Fetomaternal hemorrhage caused by an intraplacental choriocarcinoma

Abstract

Intraplacental choriocarcinoma is rare, and occasionally results in massive feto-maternal hemorrhage. We describe a case of an intraplacental choriocarcinoma diagnosed postpartum after a preterm cesarean delivery of a severely anemic newborn. The microscopic examination showed that clusters of malignant trophoblasts arose from residual normal chorionic villi and infi ltrated into the intervillous spaces, confirmed as intraplacental choriocarcinoma. Fetomaternal hemorrhage is a rare complication of choriocarcinoma but its presence should always warrant detailed examination of placenta, mother, and infant.Keywords: Fetomaternal hemorrhage; Fetal distress; Intraplacental choriocarcinoma CASE REPORT Received: 2011. 8.18. Revised: 2011. 9.21. Accepted: 2011 Gestational trophoblastic disease encompasses a spectrum of interrelated tumors, including the hydatidiform moles, either partial or complete, to the more malignant forms, the invasive mole, the placental site and epithelioid trophoblastic tumors and choriocarcinoma [1]. Intraplacental choriocarcinoma, defi ned as choriocarcinoma in the placenta, is a rare variant of gestational choriocarcinoma accounting for no more than approximately 0.04% of gestational trophoblastic disease [2]. Older than 35 years or very young age of mother can be risk factors of gestational trophoblastic disease [3]. As fetomaternal hemorrhage can cause fetal distress and death, the possibility of intraplacental choriocarcinoma should be considered in these cases [4]. In this report, we present a case of an incidental intraplacental choriocarcinoma that was discovered when the placenta was examined in order to identify the cause of a newborn's anemia. Case ReportA 27-year-old woman, gravida 1, was referred to our institution for evaluation of fetal cardiomegaly and ascites at 31+4 weeks' gestation. Her past history was uneventful, and the results of antenatal laboratory tests and examinations were normal. The mother presented with decreased fetal movement from around 31 weeks of gestation. A transabdominal ultrasound scan with 3.5-5 MHz trasducers (Accuvix XQ, Medison, Seoul, Korea) revealed a severely dilatated heart, skin edema, pleural effusion and ascites, suggesting fetal hydrops. Cardiotocography was severely pathologic, showing a repeatitive late decerelation and decreased variability (Fig. 1). Emergency cesarean delivery was performed because of fetal hydrops and fetal distress. At delivery, the newborn baby weighed 2,020 g and had Apgar scores of 3 at 1 minute and 5 at 5 minutes. The baby was immediately intubated due to weak respiratory movement and was mechanically ventilated in the neonatal intensive care unit. He was markedly anemic and edematous. Initial chest X-ray showed a total white out pattern on the both lung fi elds. After admission, the baby's condition deteriorated

Intraplacental Choriocarcinoma: Rare or Underdiagnosed? Report of 2 Cases Diagnosed after an Incomplete Miscarriage and a Preterm Spontaneous Vaginal Delivery

“…In some of these cases, this was certainly due to the lack of placental examination. Massive transplacental fetal haemorrhage has also been reported [ 3 , 5 , 6 , 9 , 10 ]. Thus, some authors consider it more accurate to use the term “intraplacental choriocarcinoma” because of this possibility of distant metastases.…”

“…The prevalence of choriocarcinoma is low but it is most often seen in women aged less than 15 or more than 45 years old, as well as in multiparous women [ 2 , 3 , 5 ]. However, due to the subtle nature of the gross appearance of these lesions, it is likely that many cases go undiagnosed and the real incidence is higher than documented.…”

“…The maternal symptoms, when present, are also nonspecific. The most common presentation is the vaginal bleeding but the symptoms related to metastasis like haemoptysis or cough have been reported [ 1 , 3 , 11 ]. However, in the majority of the cases, the disease is clinically silent and the diagnosis is based on the pathological placental or RPOC examination.…”

“…However, as the placenta's histological examination is not routinely performed and the lesions have an inconspicuous appearance, the real incidence is probably underestimated [ 3 ]. In some case reports, the diagnosis followed the first trimester abortions, in others it followed hydatidiform moles and preterm or term pregnancies [ 1 , 5 , 6 ], with most cases identified in the third trimester in asymptomatic women [ 4 ].…”

“…In some cases, the authors describe fatal outcomes associated with maternal or fetal/infant metastatic disease (particularly to the lungs) [ 6 , 7 ], while in others there were no implications for the mother and infant [ 8 ]. Complications as intrauterine growth restriction, premature birth, fetal anaemia, and transplacental haemorrhage have also been reported [ 1 – 3 ].…”