宫内妊娠合并葡萄胎十例临床分析

Clinical analysis of 10 cases of hydatidiform mole with coexistent intrauterine pregnancy

目的:探讨宫内妊娠合并葡萄胎的诊断及处理。方法:回顾性分析2009年9月至2019年5月广州医科大学附属第三医院收治的10例宫内妊娠合并葡萄胎的临床资料。采用描述性方法对数据进行分析。结果:(1)同期本院产科分娩65960例,宫内妊娠合并葡萄胎的发生率为1/6596。10例中,完全性葡萄胎与胎儿共存(complete hydatidiform mole and coexisting fetus,CHMCF)和部分性葡萄胎与胎儿共存(partial hydatidiform mole and coexistent fetus,PHMCF)分别为4例和6例。10例患者年龄(30.9±4.1)岁,范围为26~35岁;妊娠2.5(1~4)次。9例在22周+3(12周+3~32周+3)发现,1例于孕9周+发现。(2)6例妊娠期反复阴道出血,3例出现妊娠呕吐,2例妊娠中晚期出现甲状腺功能亢进症,1例发生子痫前期,1例发生重度二尖瓣反流伴轻度肺动脉高压。(3)10例血清β-hCG最高值为139935(16990~546033)U/L,其中CHMCF和PHMCF患者分别为212500(200000~546033)U/L和60768(16990~225000)U/L。(4)5例超声提示胎盘蜂窝状暗区,2例超声仅提示胎盘增厚,1例B超示双侧卵巢巨大黄素化囊肿、胸部CT见左肺下叶多个转移瘤、肺部MRI提示左侧肺部胸膜壁多个结节、盆腔MRI提示妊娠合并完全性葡萄胎,1例超声提示胎盘水泡样,1例超声提示胎儿腹壁连续中断、可见包块、其内可见胃泡、肝脏、部分肠管回声以及脐膨出,1例为胚胎停育。(5)1例羊水胎儿染色体核型为46,XX,未发现异常,染色体微阵列分析技术检测结果为arr[hg19](1-22)×2。其余病例拒绝产前诊断。(6)10例患者中,3例予依沙吖啶羊膜腔内注射引产术,2例行药物流产+清宫术,2例发生自然流产行清宫术、妊娠物可见胎儿及葡萄胎样组织,1例葡萄胎局部侵犯子宫、行全子宫切除术,1例因孕妇左下肺转移瘤行剖宫取胎术,1例孕33周+4发生子痫前期、行剖宫产获得两早产儿;4例病理提示妊娠合并完全性水泡状胎块、免疫组织化学P57(-),6例病理提示妊娠合并部分性水泡状胎块、P57(+)。(7)10例患者按葡萄胎术后随访,2例CHMCF发生持续性滋养细胞疾病并予以化疗,8例未发生持续性滋养细胞疾病。结论:产前发现宫内妊娠合并葡萄胎后,应立即鉴别PHMCF或CHMCF。CHMCF可能存在更高的流产、胎儿宫内死亡、早产、子痫前期等妊娠并发症风险,是否继续妊娠,应采取个体化原则。PHMCF患者胎儿畸形或胎儿丢失风险较高,建议及时终止妊娠。

Objective To investigate the diagnosis and management of partial or complete hydatidiform mole with coexistent intrauterine pregnancy.Methods Clinical data of 10 cases of hydatidiform mole with coexistent intrauterine pregnancy admitted to the Third Affiliated Hospital of Guangzhou Medical University,from September 2009 to May 2019 were retrospectively described.Results(1)During the same period,65960 women were delivered at our hospital,and hydatidiform mole with coexistent intrauterine pregnancy was accounted for 1/6596,among which complete hydatidiform mole and coexisting fetus(CHMCF)and partial hydatidiform mole and coexistent fetus(PHMCF)were found in four and six cases,respectively.The mean age of the ten patients were(30.9±4.1)years old,ranging from 26 to 35 years old,with 2.5(1-4)times of pregnancies.Nine cases were identified at 22+3(12+3-32+3)gestational weeks and one at 9+weeks.(2)Recurrent vaginal bleeding during pregnancy occurred in six cases,nausea and vomiting in three cases,and hyperthyroidism in mid-and late pregnancy in two cases.One patient developed preeclampsia and one case of severe mitral regurgitation with mild pulmonary hypertension.(3)In the 10 patients,the summit serumβ-hCG level was 139935(16990-546033)U/L,and CHMCF and PHMCF patients were 212500(200000-546033)U/L and 60768(16990-225000)U/L,respectively.(4)The ultrasound results revealed a dark honeycomb area of the placenta in five cases,placental thickening in two cases,and vesicular placenta in one case.One case was found with bilateral giant luteinized ovarian cyst by ultrasound,multiple metastases in the left lower lobe of the lung by chest CT,multiple nodules in the pleural wall of the left lung by lung MRI,and CHMCF by pelvic MRI.In one case,ultrasound at 14 weeks of gestation showed interrupted fetal abdominal wall,visible mass,gastric bubble,liver,part of the intestinal echoes,and omphalocele.One case was found with embryo arrest.(5)The karyotype analysis of one case through amniocentesis was 46,XX with no anomalies,and chromosome microarray analysis was arr[hg19](1-22)×2.Prenatal diagnosis was refused in the remaining cases.(6)Among the ten patients,three were terminated by rivanol intra-amniotic injection,two received drug abortion,and uterine evacuation,and two with spontaneous abortion followed by curettage with a visible fetus and hydatidiform tissue.Total hysterectomy was performed in one patient due to partial invasion of the uterus by hydatidiform mole.One patient underwent a cesarean section on account of the left lower lung metastasis.One case developed preeclampsia at 33+4 weeks of gestation and delivered two premature infants by cesarean section.Pathology examination found a complete and partial vesicular fetal mass in four and six cases,with P57(-)and P57(+),respectively.(7)During the follow-up,two women developed the persistent trophoblastic disease and received chemotherapy,while the remaining eight cases did not.Conclusions When hydatidiform mole with coexistent intrauterine pregnancy is found,a timely differential diagnosis between CHMCF and PHMCF is needed.CHMCF is at a higher risk of abortion,intrauterine death,premature delivery,preeclampsia,and other maternal complications.Therefore,termination of CHMCF should be individualized.Most PHMCF patients have fetal malformation or fetal loss;thereby,timely termination is recommended.