Molar Ectopic Pregnancy : A Case Study from the Maternity Unit of the Bobo-Dioulasso Teaching Hospital

The authors reported a case of molar ectopic pregnancy seen and managed at the maternity unit of the Bobo-Dioulasso Teaching Hospital. The frequency of the molar ectopic pregnancy is difficult to assess. Besides, the histopathological examination of surgical specimen of the salpingectomy is not usual in our setting. For the management, we realized a total left salpingectomy with a histopathological examination of surgical specimens in association with serum β HCG follow up. During post operations period, the patient was put on estro-progestin contraception for a year, a regular checkup of the biological marker of the molar pregnancy till negativation, a clinical, ultrasound and radiological checkup. No anomaly was noticed at the end of the follow up.


Introduction
Clinical anatomic entity within the scope of trophoblastic diseases, molar pregnancy remains prevalent in low socioeconomic countries among the majority of the population.
Data from the literature indicate the occurrence of the tubal, ovarian and heterotopic location of molar pregnancy [1] [2] [3] [4].Histopathological examination of surgical specimens of salpingectomy and serum β HCG assay provides the diagnosis and allows the monitoring of the disease which has an evolutionary potential to choriocarcinoma.We report a clinical case observed at the maternity unit of the Bobo-dioulasso Teaching Hospital.

Case Study
Mrs S. S, 23 year-old, Gravida 4, Para 3, 3 live children.She was referred from a health center within the locality to us on the 24/10/2013 on account of suspected ectopic pregnancy.
On examination, she reported a 2-month delay in menses, pelvic pain and per vagina bleeding.
The Clinical examination found a picture of peritoneal irritation (abdominal defense with rebound tenderness at the umbilicus, shifting dullness at the flanks, shock, and heart rate at 140 beats per minute).
Speculum examination noted a normal looking cervix, endo-uterine bleeding of black blood and at the vaginal examination, the posterior fornix was bulging.The tapping of the Douglas pouch brought some dark blood which was not clotting.
A laparotomy was performed in conjunction with emergency resuscitation using macromolecules and cross-matched blood.
At the abdominal entry, we find some hemoperitoneum about 500mls and a ruptured left ampular ectopic pregnancy.
We performed a total left salpingectomy.The ipsilateral adnexa was apparently normal, the abdominal walls was closed in three planes.
At the dissection of the surgical sample, macroscopically we noted some clusters of vesicles with appearance of trophoblastic tissue.The sample was sent for histopathological examination.

Comments Epidemiology Classification: [5]
The gestational trophoblastic disease include: 1) Benign entities, complete hydatidiform and partial mole.Hydatidiform mole is most common in developing countries including Africa, South East Asia, the Caribbean and Latin America.
The molar pregnancy is usually intrauterine and diagnose in the first trimester in aclinical picture of incomplete miscarriage.Cases of giant moles are still found in our regions with low obstetric coverage.
Ectopic localization is rare according to data in the literature.
In 1941, Petit [8] from his personal observation had identified 13 cases worldwide.
In 1980, 39 years after Smith [9] reported a total of 25 cases published worldwide.
Diouf in 1995 [6] in Senegal has reported two cases in 16 years.
From 2000 to 2012, 30 publications have been reported on ectopic mole.
The cases of molar ectopic pregnancies are underreported in our context for the following reasons:  The high incidence of hydatidiform mole in our under-equipped setting.
 The prevalence and spread of sexually transmitted infections to the upper genital tract creating risk factors for ectopic pregnancy. The lack of systematic histopathological study of samples from salpingectomy in case of ruptured ectopic pregnancy.
According to Leung [3] the incidence of ectopic molar pregnancies mole is potentially underestimated in developing countries due to the lack of systematic histopathological examination of surgical specimens of salpingectomy.
A diet low in vitamin A and animal fats, maternal age over 40 years and a history of recurrent spontaneous abortions appears to be associated with an increased risk of developing a molar pregnancy [10] [11].

Diagnostic
In practice ectopic molar pregnancy presents a typical picture of ectopic cyesiswith the same biological characteristics of hydatidiform mole [12].
The pre-operative diagnosis of unruptured ectopic molar pregnancy is exceptional in our context, as most of ectopic uterine pregnancies are admitted at a late stage of rupture with hemoperitoneum in most cases.
For histopathological diagnosis of surgical specimens of salpingectomy, we have very few specialists in pathology and the cost of the investigation is very expensive for the majority of patients (38 US$).
The Histopathological examination of surgical specimens of salpingectomy, as well the products of abortion, could result in a higher incidence of the molar ectopiccyesis.
Radioimmunoassay of serum βHCG, early transvaginal ultrasound scan before rupture, laparoscopy in the absence of abundant hemoperitoneum can help diagnose where the setting allows their realization.

Prognosis
In the postoperative period of the molar ampullary ectopic pregnancy, we conducted a clinical and Para clinical monitoring with measurement of plasma βHCG till it became negative.The monitoring also included pelvic ultrasounds and chest x-ray.
The outcome of molar pregnancy always carry a risk of degeneration to choriocarcinoma [13].The risk of onset is 1/15,386 in the case of miscarriage, 1/5333 in case of ectopic pregnancy and 1/40 in case of hydatidiform mole [14].

Conclusions
The occurrence of ectopic molar pregnancy is a rare event.
The realization of a systematic histopathological examination of surgical specimens of salpingectomy remains difficult in our work environment.
The risk of degeneration to choriocarcinoma requires more vigilance from practitioners.
The immediate postoperative period was uneventful.The first measurement of plasma β HCG realized the day after surgery showed a level of 900 IU/l.The histopathological report of surgical specimens H464 of the 8 th November 2013 made the diagnosis of histological appearance of ruptured tubalectopic pregnancy containing a partialhydatidiform mole.After discharge, she benefited from clinical and biological follow up under Progestin (stédéril) contraception for one year.Serial serum β HCG follow up showed: 25 th October 2013: 909 IU/l.23 rd December 2013: 15 IU/l.15 th March 2014: 6, 35UI/l.