DISCUSSION
The Complications in the third trimester of pregnancy, although well
described, can be fatal, and any abnormality requires an integral
assessment, especially with the first appearance of hypertension,
associated or not with proteinuria1.The
ultrasonographic exam of the uterus in the 1st trimester and in
particular the colour Doppler vaginal echography has made it possible to
detect anomalies in the early pregnancy like the hydatidiform mole, that
even when the diagnosis is made mostly by this technique, the histologic
exam of the evacuated material (fig. 4) is vital to confirm the
diagnosis11. This disease has to be considered as
pre-malignant, because it has been described that 15-20% of complete
mole and 1% of incomplete moles can generate malignant degradation of
the invasive mole type, choriocarcinoma, and in rare cases,
trophoblastic tumors of the placental vessels. After the evacuation of
the mole, the patients should be closely monitored with quantification
of the B-hCG at least every 2 weeks until non-detectable measures are
obtained. Subsequently, normal values should persist and be evaluated
monthly for a minimum of 6 months12. In 10-20% of
patients in whom the B-hCG levels remain high, various courses of
chemotherapy may be required, depending on the FIGO and WHO
stratification for gestational trophoblastic
neoplasia13. In general, patients are no longer
required to receive prophylactic chemotherapy in the diagnosis of mole;
this produces an unnecessary exposure in 80% of the cases and should
only be offered in patients who would not receive the appropriate
follow-up12.The complications of molar pregnancy are
another topic that should be considered in addition to the risk of
neoplasia evolution. First, one of the most relevant is hyperthyroidism
(because of the similarities between the α subunits of HCG and TSH), in
which a beta-adrenergic blockade could be required to prevent and revert
metabolic and cardiovascular complications of a thyroid storm14. Second,
the thecal-lutein ovarian cysts, secondary to the ovarian
hyperstimulation, could be twisted or spontaneously broken (this might
have been the cause of the abdominal syndrome that the patient presented
posterior to the evacuation of the mole; however, this was not evidenced
in the moment of rupture with laparotomy). Finally, cardiopulmonary
symptoms are associated with trophoblastic
emboly13.All the afore mentioned studies showed a
general trend of resolution according to the decrease in B-hCG levels.
Patients with hyperemesis related to pregnancy in 8-28% generally in
earlier stages of gestation and with more severity because of the high
levels of these hormones related to different isoforms or mutations in
the receptors of this hormone7.The total level of hCG
is crucial for the follow-up of patients with gestational trophoblastic
disorders. The chemical exams should measure all the portions of the
molecule in particular the free- beta subunit, the hCG
hyperglycosylated, hCG “nicked” and the hCG without the terminal
carboxyl segment, because these segments in particular are higher in
neoplasia than the total hCG.Other clinical entity, although not very
frequent that clinicians should also considered is the ghost hCG where
the patients contain heterophilic antibodies that react with antibodies
of certain analysis kits which generates a false positive result of
hCG15,In general, the patients with history of molar
pregnancy either partial or complete can have other reproductive
successful attempts, they only posses a higher risk of recurrence
between 1-1.9% and after 2 or more molar pregnancies it increases to
15-17.5%16. Lastly, it can result fatal not to
maintain a suspicious of preeclampsia in an early pregnancy before 20
weeks in a clinical context that results relevant, although the
prevalence is low, like it could have been in the case of this patients
that coursed with severity criteria preeclampsia.