Molar or Hydatidiform Pregnancy: Double or triple DNA

This patient had uterine adhesions that were caused by two molar pregnancies, a chromosomal defect that occurs when the egg or sperm contains more genetic information than usual. They are very complicated cases but #KnowledgeIsSuccess and Dr. Otto Paredes, Creafam fertility expert, explains to us how this case is diagnosed and resolved.

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What is Hydatidiform Mole or Molar Pregnancy?

We are going to present a particular case, we have a patient who had 2 uterine curettages. They will say why 2 uterine degrees? Were they repeat abortions? No, think that it was a very interesting or very particular case. There is an obstetric disease called “Hydatidiform mole”, it is a degeneration of pregnancy in which the fetus does not develop and what was going to give rise to the placenta ends up having an abrupt, exaggerated growth, we cannot say that it is a cancer but the behavior is similar in the sense of the invasive capacity it can have.

The mole is a disorder derived from the trophectoderm, when we have an embryo originally in the blastocyst stage, from the blastocyst we can identify the trophyectoderm and what is the internal cell mass that is what actually gives rise to the embryo, the fetus. The trophyectoderm would be what will give rise to the placenta and the ovular membranes. In the case of the mole, it has been identified that the trophectoderm has an abnormal development, a development that is too invasive, with hypercellularity and ends up invading not only the endometrium but even In some cases it can even invade the uterine muscle, that is, an absolutely abnormal behavior, aberrant to the origin of the pregnancy.

Most of the experience that exists in relation to this type of pathology is reaching the conclusion that the origin is genetic. When germ cells are generated, that is, both the egg and the sperm, these cells have a process called meiosis by which the chromosomal information is divided, that is, each gamete has half of the information. If you have an egg with half the information and a sperm with half the information, when they join together, the full information is restored. If one of these gametes did not have that stage well developed and has complete information, then you have a gamete with complete information plus half of the other, because you already have something abnormal, you have extra information. So, the chromosomal studies that have been carried out on this type of disease, called molar disease or trophoblast diseases, have found that genetically they have double or even triple chromosomal information.

There are incomplete moles, in which the embryo does develop, it looks very small, it does not have the capacity to evolve and the rest of the tissue had this behavior that I tell you. So, there are complete moles, incomplete moles and in some cases, fortunately much less frequent than this, there is also the more aggressive behavior which is the one that invades the uterine muscle, it is usually called choriocarcinoma and there is also another called tumor of the uterus. placental site, but well, they are histological variants within the same problem but with much more aggressive behavior. Generally we follow it up by measuring the same pregnancy hormone, hCG, which is ultimately what it releases. It serves as a marker and the solution involves not only curettage to extract all this tissue but, in many cases, receiving some type of chemotherapy to be able to do so. destroy those tissues that are in such extensive proliferation.

What are uterine synechiae?

Well yes, this patient had the experience of experiencing pregnancies with a mole twice and the curettage or two curettages that were performed ended up being very strong, very exhaustive, since the level of invasion that she had in her cavity was quite important. After a while, now it turns out that the situation she is facing is that she does not get pregnant, so when she did not get pregnant, she finally ended up going to the consultation. I told her to perform… At first we performed an ultrasound and taking into account the history it seemed to me that the uterine cavity looked reduced in size, so we performed a hysterosonography.

On other occasions we have presented videos on this topic, we placed a little physiological solution inside the cavity and through ultrasound right there in the office we can have a better view of the cavity, and yes, we saw that the cavity did not extend well, there were an area in which it was seen that both sides of the uterus were joined. We continue with the diagnostic level and indicate a hysterosalpingography, the hysterosalpingography, the radiologist places a solution inside the uterus that is radio opaque and they perform the x-ray. The x-ray clearly shows the cavity space that was occupied by the synechiae. In this case in the x-rays the image is different, an image of the effect is observed, we see a white space which is what the contrast medium occupies occupying the cavity and black, which is the area that does not pass the contrast, corresponds to the synechia, in it it is clearly seen as a free corridor between the synechia and the uterine cavity. In this way, the first clinical and ultrasound suspicion is confirmed with a radiological imaging study and, indeed, the solution is to go to a hysteroscopy.

Hysteroscopy or surgery to remove uterine adhesions

When performing the hysteroscopy, in principle I confirm the diagnosis, we evaluate the synechiae and the way to solve this type of problem, let’s say, we have two types of tools: The types of solutions that are called “cold”, that is, using scissors or small tweezers and there is also the strategy of using electrosurgery, some call it “hot” surgery, because it obviously generates a little local heat. The difference between both techniques is relatively little in terms of resolution capacity, both can perfectly be used, the use of electrosurgery, there are those who point out that the use of heat can generate a greater risk of injuries to the uterine wall or that they can eventually favor the appearance of new synechiae, which is why in general terms I prefer the cold approach with the scissors first, if the synechiae is very hard, very firm, then I would need to go to plan B, but well, in this case with the With scissors we were able to solve it, we cut the base of the synechia, later as it was quite extensive I was able to cut the upper part, so not only did I free it but we were able to extract the scar completely.

Once the synechiae is removed we see that on that side, the uterine horn on the right side was also sealed by fibrosis and then I proceeded to cut that entire area to free and further expand the cavity. Because the idea is… It is not only to free the synechia, but to leave a uterine cavity that is larger, which can allow the development of the pregnancy. Currently, the patient has already seen her first menstruation after surgery and the first comment was that It was totally different, a more abundant menstruation than usual, which is an expression of the fact that having freed this entire healing process effectively freed the uterus.

How to achieve a healthy pregnancy after having a hydatidiform mole?

Now in this case it also lends itself to something very interesting, a different approach. If we have told you that the origin of molar disease is related to chromosomal alterations, then obviously the ideal scenario for it would be not only to generate embryos to be placed but also for them to be healthy embryos. In parallel, we also performed a semen diagnosis; not only the basic diagnostic REM study was performed, but also a sperm FISH. When performing sperm FISH we have the opportunity to evaluate the percentage of disomic sperm, that is, those that have the complete chromosome load and not half as it should be. So, if he had a greater amount of disomic sperm than usual, that could guide us to the origin of the mole problem, the fact that his sperm had this type of alteration. We performed the sperm FISH, it gave us a normal result, the percentage of disotomous sperm is the usual or normal one that men can have, therefore, we think that the risk factor of the mole recurring is not so high , even so with the history of two molar pregnancies, well yes, the indication is definitely to perform the genetic diagnosis on the embryos now in order to establish the risk or eliminate the risk of experiencing this type of problems again.

Can you avoid having synechiae or adhesions?

Uterine synechiae end up being a pathology that is a “consequence of”, that is, it is a consequence of some type of alteration that the endometrium received. The most common thing is that it is after pregnancies that were interrupted for some reason, whether spontaneous abortions of genetic origin, of endocrinological origin, perhaps of immunological origin, the fact is that there was an interruption of the pregnancy.

When there are uterine curettages, it is called MVA type or any of the existing techniques, since when scraping the endometrial cavity a local inflammatory process is generated and this inflammatory process can lead to or favor the appearance of this type of synechiae. There may also be cases of endometritis, postpartum endometritis, for example, is a very old, widely described pathology. If you have an infectious inflammatory process of bacteria in the endometrium, well, when the endometrium is reacting, an inflammatory process is generated, scars are generated and that is how synechiae appear. The most severe case of these synechiae is definitely the so-called Asherman syndrome, on another occasion we have mentioned it where the level of obstruction of the cavity can be very, very, very severe and obviously that implies that it is much more difficult to resolve. So, the spectrum can be very wide, from very mild, very lax synechiae, to very severe synechiae that compromise practically the entire cavity.

“If you have had one or two curettages and you notice that the volume of your menstruations decreased or you had a gynecological infection and your menstrual pattern also changed, it is important to consider the possibility that you may have an intrauterine pathology such as synechiae or adhesions and that you go for a procedure. a good evaluation. Remember that knowledge is success”

Dr. Otto Paredes
Dr. Otto Paredes
Fertility Expert

Reproductive medicine and gynecological endocrinology
Instituto Valenciano de Infertilidad, Spain.

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