Hi XXXXX,
Thanks for writing in.

From your query, I understand that you are a 36 years old lady with hypothyroidism and on treatment with levothyroxine 150 mg, presently having got an ultrasound scan with findings as mentioned.

From the descriptions of findings, it is observed that you have conceived a pregnancy in which the size of the gestation sac is 27 mm (which corresponds to an age of approximately 7 weeks) and apart from this sac there is some complex material which is suggestive of placenta tissue with cystic changes within.

The above report findings indicate the possibility of a Molar pregnancy. This type of a pregnancy is a failed pregnancy. You must get yourself investigated further by estimation of levels of beta human chorionic gonadotropin (HCG).


A molar pregnancy happens when there are certain problems with the genetic information (the chromosomes) in the fertilized egg at conception. The result is that the egg may develop into a growth with no embryo (this is called a complete mole) or an abnormal embryo (a partial mole).

With this suspicion your gynecologist might decide to get another ultrasound done to re confirm findings, if felt necessary. Only after it is clinically highly suspicious and in the light of ultrasound reports and HCG levels will your doctor go ahead with any further procedures.

You will be explained the problem in detail and may need to follow up with your gynecologist regularly for a while.

Hope your query is answered.
Further questions are welcome.

Wishing you good health,
Dr Vivek

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Hi XXXXX,
Welcome and thanks for writing in again.

I have gone through each word in report findings mentioned in your query. However, I could not find any images or report files attached separately with your question.

The molar pregnancy is either a partial mole or complete mole depending on its features. This must be evacuated from the uterus totally (all attempts must be made to do this by your doctor). In few patients, very little amount of this mole remains in the uterus and starts growing by itself and may bury into the uterus. This can enter the blood circulation and spread to other parts of the body. This is known as Gestational trophoblastic disease. In extremely rare occurrences, it can develop into a focal cancer like mass inside the uterus and this is known as choriocarcinoma. This may require chemotherapy for treatment.

The above is just a summary of information related to molar pregnancy and with proper guidance the associated problems can be averted.

Treatment may be a medical evacuation (tablets are inserted into the vagina and taken orally) or a dilatation and curettage (D & C, or "scrape") to remove as much of the molar tissue from the womb as possible. This is a minor operation which is carried out after most miscarriages under anaesthesia. In most cases, one or two of these minor operations will be enough to remove the mole permanently. The purpose behind treating molar pregnancy is to remove every bit of molar material from the uterus.

Following mole removal, the HCG levels are regularly assessed for decrease. This requires testing at frequent intervals and may continue for 6 weeks to 3 months, until the HCG level is negative. Further you will be put on watch for 3 to 6 months and require serial ultrasound scans to look for any complications and to rule out the possibility of gestational trophoblastic disease. Please discuss with your doctor on the correct time to plan your next pregnancy and this may be suggested after 6 to 12 months.

Hope your query is answered.
Wishing you good health.

Regards
Dr Vivek

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Hi XXXXX,
Welcome and thanks for writing in again.

Thanks for sending in images and reports in mail. After having gone through them, I would like to make few observations.

1.     As per ultrasound scan report 27 XXXXXXX 2013, there was an embryo measuring 23mm but unfortunately heartbeat was absent. Mention of a second clot like area is there.
2.     On ultrasound scan done 04 July 2013, there is a larger complex mass (nothing about the embryo is mentioned).
3.     The ultrasound scan done on 06 July 2013 shows the complex area with a sac like area within and the mention of possible placental tissue with cyst like appearance.

I am sorry to state that from what the reports mention, this is no longer a viable pregnancy. Please take it as a passing phase in your life.

Possibility of a delayed miscarriage persists. Still, the mention about cystic changes in placenta makes one think of molar pregnancy, something we have been talking in detail about in our earlier discussions. While a delayed miscarriage is something less worrisome, a molar pregnancy requires close observation.

Your doctors are doing regular ultrasound monitoring before being certain about the condition. I would have suggested serial HCG level monitoring for you alongside. In most cases of miscarriage HCG levels fall.

Hoping for the best outcome.

Regards
Dr Vivek

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Hi XXXXX,

Welcome and thanks for writing in again.

I do agree that there might have been some lack of communication and insensitivity in not reporting about the embryo in the second scan.

Hoping for the best.

Wishing you good health.

Regards,
Dr Vivek

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Hi XXXXX,
Welcome and thanks for writing in again.

I know that you are looking forward to answers for a few important questions and whether any action taken by your doctors is entirely justified. I will try my best to clear all your doubts.

Discussing about the fetal heart activity, in few women, the fetal heart activity can be appreciated by the 6th week (better seen by transvaginal scan) and in most women it can be seen by the 8th week. As you have said irregular periods, calculating the age of the fetus becomes difficult in that situation. The last menstrual period need not technically be the last one sometimes. This results in discordant or wrong dates. In such a situation, the fetal age as measured during scan may be less than the age calculated from the last menstrual period. Going by this, if there is a mixup between dates by last menstrual period and scan report by upto 4 weeks, then the fetal heart activity can appear late (as per last menstrual period age). Might be this was what you came across on another website discussion forum.

I have made note of this in your last scan report. The age by your dates is 13 weeks 6 days and by your scan the sac size corresponds to 9 weeks 1 day. As they have clearly mentioned (in the last scan report) that fetus is not seen, the possibility of heart activity being present in your earlier scan was less likely.

Further questions welcome.
Wishing you good health.

Regards
Dr Vivek

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Hi XXXXX,
Welcome and hope I have been able to answer your queries.

Wishing you a good health.

Regards
Dr Vivek

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Hi XXXXX,
Welcome and thanks for writing in again.

Let me clarify your queries.

1.     Is hcg level important in predicting molar pregnancy or not?

In a normal pregnancy, the level of hCG will reach its peak in the first 8 – 11 weeks of pregnancy and then will decline and level off for the remainder of the pregnancy. Yes, unusually high HCG levels for gestational age by last menstrual period, HCG level monitoring and its increase even after fetal demise/ non visualisation of fetus in a pregnancy are important predictors of molar pregnancy.

A high hCG level can indicate:
a.     Miscalculation of pregnancy dating
b.     Molar pregnancy
c.     Multiple pregnancy


2.     Whats the interval of redoing the test?

Most doctors recommend redoing the test after an interval of two weeks in the initial days. Further follow ups can take place once a month for six months or as the gynecologist decides.

3.     What is the normal level for hcg levels for my case?

For gestational age by last menstrual period
9– 12 weeks LMP: Normal HCG values are 25,700 – 288,000 mIU/ml
13 – 16 weeks LMP: Normal HCG values are 13,300 – 254,000 mIU/ml

4.     0000 was the level of the blood testbi did on monday. Does this makes sense?

If your value is 0000, then this is somewhere in the normal range. So it surely makes sense in that its not unusually high and hence less likely pointing towards a molar pregnancy.
Please remember this value serves only as guidance to the doctors.

Hope your queries have been answered.
Further questions welcome.

Wishing you good health.

Regards
Dr Vivek

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Hi XXXXX,
Welcome and thanks for writing in again.

In the report of second scan, the gestation sac measures 9 weeks in age while as per dates, you were supposed to be 13 weeks pregnant. Therefore due to stop in fetal growth, you were told that the baby died sometime at nine weeks.

The hCG levels are not fixed and lie in a variable range. As mentioned earlier, the normal HCG values are 25,700 – 288,000 mIU/ml during 9 – 12 weeks. Considering this normal range, if we assess your present (0000) hCG levels, it is below that found in a normal viable pregnancy of same age. However, your next hCG result will give a better picture.

Hope your queries have been answered.
Further questions welcome.

Wishing you good health.

Regards
Dr Vivek

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