**12.1. Hydatidiform mole**

Hydatidiform mole (HM), called also a *molar pregnancy*, represents a subcategory of gestational trophoblastic disease. The origin of the entity is the gestational tissue. The character of HM is usually benign, but it has a known potential to become malignant and invasive. The incidence of a HM is 1:1000–2000 [67]. Risk factors include extremes of maternal age (greater than 35 years old and less than 20 years old), a previous molar pregnancy, women with previous spontaneous abortions or infertility, dietary factors, and smoking [68]. The HM can be a *complete mole*, with the absence of the fetus, or a *partial mole* with an abnormal fetus or a fetal demise; rarely, a mole coexists with a normal pregnancy. In complete HM, 90% of cases the karyotype are 46XX diploid, while in partial HM, the karyotype is usually triploid 69XX [1]. The histopathological event of HM is considered to be a proliferation of the villous trophoblast, accompanied by swelling of the chorionic villi, resulting in high levels of human chorionic gonadotrophin (hCG) production (e.g., **Figure 7**) [68]. The location of the HM is the uterine cavity, with exceptionally rare cases located in the fallopian tubes or ovaries. Clinically, the most common symptom is the vaginal bleeding in the first trimester. Sometimes an association of hyperemesis (severe nausea and vomiting) or passage of vaginal tissue described as "grape-like clusters" or "vesicles" can be encountered. If not early diagnosed, other significant complications may appear, such as hyperthyroidism, including tachycardia and tremors and preeclampsia. Usually, on a physical exam, there is a uterine size discrepancy compared with the amenorrhea period, the uterus being larger in complete mole and smaller in partial mole [69]. The ultrasound exam finding is a heterogeneous mass in the uterine cavity, with multiple anechoic spaces

• Toxoplasmosis implies a risk of placental colonization, depending on the volume of uteroplacental blood flow, on the maternal immunocompetence, and parasitemia. Placental infection, described by granulomatous villitis, cysts, plasma cell deciduitis, villous sclerosis, and chorionic vascular thrombosis, is more common with advancing gestational

• *Chlamydia psittaci*: can infect the placenta and can cause significant feto-maternal morbidity and mortality by an intense, acute intervillositis, perivillous fibrin deposition with villous necrosis, and large irregular basophilic intracytoplasmic inclusions within the syncytiotro-

The fetal membranes (chorion, amnion) represent the interface between the fetal graft and the maternal host [1]. Infection may also pass the fetal membranes, especially in the area overlying the cervix. It provides direct access to pathogens, ascending from the vagina and the cervix [62]. Less commonly, infectious agents enter the uterus as a result of invasive procedures (e.g., amniocentesis, fetoscopy, cordocentesis, and chorionic villus sampling) or via

Chorioamnionitis is the most frequent histopathological result of ascending transcervical infection and occurs with both symptomatic and silent infections [63]. The histologic diagnosis of chorioamnionitis is allowed if the inflammatory infiltrate involves either or both the chorion and the amnion. The acute chorioamnionitis is more common than the chronic form [64]. As clinical symptoms, chorioamnionitis is characterized by maternal fever, tachycardia, uterine tenderness, or foul-smelling amniotic fluid. However, cultures of the amniotic fluid or membranes fail to document the bacterial infection in 25–30% of placentas with histologic chorioamnionitis [65]. The infection of the membranes is often polymicrobial, with the most commonly seen bacteria: *Streptococcus* sp., *Escherichia coli*, *Ureaplasma* sp., *Fusobacterium* sp., *Mycoplasma* sp., and anaerobes [63]. The correct diagnosis and treatment of chorioamnionitis are paramount, as it is an important cause of perinatal and maternal morbidity and mortality [66]. The major pathological consequences of chorioamnionitis may include premature rupture of membranes, preterm labor, prolonged labor, premature delivery, fetal and newborn

Hydatidiform mole (HM), called also a *molar pregnancy*, represents a subcategory of gestational trophoblastic disease. The origin of the entity is the gestational tissue. The character

the fallopian tubes from an infectious process in the peritoneal cavity.

age at the time of maternal parasitemia [59].

336 Congenital Anomalies - From the Embryo to the Neonate

phoblast [60, 61].

**11.1. Chorioamnionitis**

infection, and endomyometritis.

**12.1. Hydatidiform mole**

**12. Gestational trophoblastic disease.**

**11. Placental membranes**

**Figure 7.** Image of post-hysterectomy uterus invaded by a hydatidiform mole in a 48-year-old patient.

**Figure 8.** Ultrasound image of the case of hydatidiform mole.

(e.g., **Figure 8**). The "snow storm" or "bunch of grapes" appearance is no longer seen with nowadays equipment. In complete moles the embryo is absent, and no amniotic fluid is present [70]. In the first trimester, the diagnosis of complete mole can be difficult; bilateral theca lutein cyst may be seen [71]. In partial mole, the molar placenta may not always be seen; the amniotic cavity is either empty or contains a well-formed but growth-retarded fetus, either dead or alive, with hydropic degeneration of fetal parts [72]. Occasionally, the differential diagnosis between partial moles, complete moles, and missed abortion [73] may be difficult. In molar pregnancy the first step after the diagnosis is the chest X-ray to determine metastasis. Computer tomography and magnetic resonance imaging can add valuable additional information for the final diagnosis. After careful counseling of the patient, including genetic testing, the best treatment option remains suction and curettage for evacuation. Hysterectomy, however, is an option if preservation of the fertility is not necessary. When hCG levels remain elevated after a proper evacuation of the uterine cavity, a gynecology oncology consultation is required to guide the therapy and consider chemotherapy [68].

#### **12.2. Choriocarcinoma**

Choriocarcinoma is a rare aggressive tumor, with highly malignant potential and widespread dissemination metastases [74]. It is considered part of the spectrum of gestational trophoblastic disease and is called *gestational* choriocarcinoma. The high mortality is due to lack of early diagnosis and appropriate chemotherapy [75]. Approximately 5% of cases of complete HM can be complicated with choriocarcinoma. Only about half the cases of choriocarcinoma arise from a complete HM. The imaging diagnosis of choriocarcinoma includes a discrete, central, infiltrative mass enlarging the uterus, with a possible invasion of the myometrium and beyond (e.g., **Figures 9** and **10**). The ovaries may be enlarged, due to cysts secondary to increased levels of hCG [76]. If choriocarcinoma arises from a complete HM, the prognosis is usually favorable after proper chemotherapy. On the contrary, other cases of choriocarcinoma have a less favorable prognosis.

**Author details**

myometrium and beyond.

intense vascularization.

Cristian Marinaș2

Craiova, Romania

Timișoara, Romania

Roxana Cristina Drăgușin<sup>1</sup>

Dominic Gabriel Iliescu1

\*, Maria Șorop-Florea<sup>1</sup>

1 Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy,

2 Department of Anatomy, University of Medicine and Pharmacy, Craiova, Romania 3 Department of Obstetrics and Gynaecology, University of Medicine and Pharmacy,

, Bogdan Virgiliu Șorop<sup>3</sup>

\*Address all correspondence to: roxy\_dimieru@yahoo.com

, Ciprian Laurențiu Pătru<sup>1</sup>

and

, Răzvan Căpitănescu<sup>1</sup>

**Figure 9.** Ultrasound image in gray and color Doppler scale showing a rare case of choriocarcinoma of the cervix with

**Figure 10.** Ultrasound image in gray and color Doppler scale showing a case of choriocarcinoma with invasion of the

, Lucian Zorilă<sup>1</sup>

Abnormalities of the Placenta

339

http://dx.doi.org/10.5772/intechopen.75985

,

**Figure 9.** Ultrasound image in gray and color Doppler scale showing a rare case of choriocarcinoma of the cervix with intense vascularization.

**Figure 10.** Ultrasound image in gray and color Doppler scale showing a case of choriocarcinoma with invasion of the myometrium and beyond.
