BACKGROUND
Traditionally preeclampsia has been defined as blood pressure over 140/90 mmHg after 20 weeks of gestation1,2 in a previously normotensive patient and any of the following characteristics: proteinuria (more than 300 mg in a 24 h urine collection or a protein/creatinine index ≥0.3 mg/mg in a random sample or ≥ 1+ in a reactive urine strip), thrombocytopenia <100,000/ɥL, creatinine elevation >1.1 mg/dL or double over the basal measure in absence of any other renal pathology.
There are other severity criteria, even in the absence of proteinuria: transaminase elevation at least doubles the superior normal limit, pulmonary edema, and neurologic symptoms such as headache, phosphenes, or blurred vision. However, it has been described as atypical preeclampsia at <20 weeks of gestation associated with molar pregnancy3.
On the other hand, trophoblastic gestational disease encompasses a wide spectrum of pathologies originating in the placenta, such as trophoblastic tumors of the placental vessels, epithelioid trophoblastic tumor, choriocarcinoma, invasive mole (chorioadenoma destruens), and hydatidiform mole, partial or complete, being the last ones the most frequent form of presentation, almost 80% of gestational trophoblastic disease4. These pathologies, although caused by separate conglomerates of different epidemiology, for example, in a systematic review, 4.6% of global pregnancies5 had a complication of preeclampsia.
There are various theories regarding the physiopathology of preeclampsia. The one that is more accepted refers to an incorrect implantation of the placenta, which causes the spiral arteries to lose their property of high blood flow, producing placental ischemia, which also produces inflammatory factors that ultimately produce a systemic response because of peripheral vascular resistance, pro-thrombotic status and endothelial dysfunction6.
There are uncommon cases of preeclampsia before 20 weeks of pregnancy, but it has been reported in molar pregnancies7 or associated with antiphospholipid syndrome8 .Early recognition is very important, even in the first trimester, when making differential diagnosis with lookalike pathologies such as lupus nephritis, thrombocytopenic purpura, and hemolytic uremic syndrome.9,10
A 26-year-old woman, at 14.1 weeks of gestation, had a familiar history of hypertension in her mother and two sisters with repetitive abortions, without any other relevant personal risk factors.
She was admitted at 14.1 weeks of gestation by the last date of menstruation, with 5-day evolution symptoms of inferior limbs and facial edema, headache, intense nausea, vomiting on various occasions, epigastralgia, phosphenes, and photophobia without any transvaginal secretions.
Her blood pressure at admission was 175/108 mmHg, heart rate was 131 bpm, respiratory rate was 24 breaths per minute, temperature was 36.3°C, oxygen saturation was 94%, 1.55 cm of height and 54.5 kg of weight.
On physical examination, the patient was found to be conscious, with hyperreflexia and anasarca, cardiac sounds augmented in frequency, low-intensity respiratory sounds in the basal areas, increased abdominal perimeter due to gestational uterus with a fundus at 22 cm (double of the expected according to the gestational age table by Fescina et al.), and no fetal heart rate. Vaginal exploration revealed mild edema of the genitalia, euthermic cavity, posterior cervix, large, semi-soft, closed, without any secretion or bleeding, limbs with correct anatomy, and edema reaching the knee.
Pelvic ultrasound was performed and a uterus of 24×18 cm with a “snowflake” image was found in the interior, as well as multiple hypoechoic images, without a fetus, also annexes were found with increased volume, with images suggestive of theca-lutein cysts, the right ovary with a cyst >3 cm.
Pregnancy was terminated by manual intrauterine aspiration. Substantial trophoblastic tissue was extracted from grape bunches (Fig 1). Subsequently, the patient started experiencing pain and abdominal distention, and a second abdominal ultrasound was performed. Approximately 2 L of free-liquid in the paracolic sulc and right subphrenic space was found, with a right annexal image (probably a plastron) and endometrial echography in the medium line of 5 mm (fig 2). This led us to think that in a broken ectopic pregnancy, exploratory laparotomy was performed in which only abundant serous liquid in the right annex was found, which corresponds with a larger theca lutein cyst reported in USG, but without any alteration in any of the ovaries.
Pulmonary USG was also performed, which revealed bilateral pleural infusion (Fig 3). Follow-up continued in the intensive care unit with hemodynamic monitoring and assessment. Routine rheumatology was performed, which included complement levels, anti-DNA antibodies, antinuclear antibodies, lupus anticoagulant, and thyroid hormones, which were normal; this was performed in order to find a specific etiology and in this case due to the suspicion of atypical preeclampsia16, 17.
Blood pressure control was achieved with nifedipine, hydralazine, and alfa-metildopa, which decreased gradually until the withdrawal of the last two. Finally, the patient was discharged to receive follow-up in outpatient care of gynecology every 2 weeks to monitor levels of B-hCG to document hormonal clearance and dismiss any malignant cause that remained elevated (fig 5).