Unintended consequences of vaginal misoprostol use in a patient with hydatidiform mole: A case report.
Hyung Joon Yoon, Yong Jung Song, Dong Soo Suh et al.
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Case in brief
A 49-year-old woman presented with vaginal bleeding, imaging suspicious for hydatidiform mole, and serum β-hCG of 589,830 mIU/mL. Partial hydatidiform mole was confirmed histologically. Although hysterectomy was planned, 400 μg vaginal misoprostol was given for cervical ripening; uterine contractions followed, with complete expulsion of molar tissue the next morning. β-hCG initially fell markedly but rose at 9 to 10 weeks. Hysterectomy was performed, but persistent low-level β-hCG led to methotrexate treatment. Levels plateaued, and she was considered to have methotrexate-resistant disease; multi-agent EMA-CO chemotherapy was then administered.
What made this case unusual
Misoprostol was given for preoperative cervical ripening rather than intended molar evacuation, yet triggered complete expulsion. The apparently complete expulsion did not prevent subsequent persistent or recurrent trophoblastic disease and escalation to multi-agent chemotherapy.
Diagnostic / clinical pearl
Complete expulsion of molar tissue and an initial marked β-hCG decline do not exclude subsequent postmolar trophoblastic disease; continued β-hCG surveillance is important.
Why it matters
The report cautions against misoprostol for cervical ripening when hysterectomy is planned as primary treatment for molar pregnancy, given the potential for unintended expulsion and a complicated subsequent course.