Challenges in women’s healthcare: Management of molar pregnancy in a resource-limited rural Tanzanian hospital – a case report

INTRODUCTION

This case report focuses on a molar pregnancy, also known as a hydatidiform mole, which is a rare and abnormal gestational condition characterised by the development of abnormal placental tissue. Molar pregnancies result from errors during fertilisation, leading to the formation of a mass of cysts instead of a viable foetus. Our report aims to pro-vide insights into the presentation, diagnosis, and management of molar pregnancy, highlighting the challenges encountered by medical professionals in resource-limited settings in Tanzania, where local midwives, nurses, and doctors often struggle to provide care in line with global standards.

CASE REPORT

A 30-year-old pregnant patient presented at a rural hospital in Tanzania with vaginal bleeding for an ultrasound checkup. The bleeding had started 3 days earlier. This was her third pregnancy, and she had previously had 2 normal vaginal childbirths. Her last menstruation was 3 months earlier, although she could not recall the exact date. The pregnancy had been confirmed previously by an enlarged uterus and a positive pregnancy urine test. No other pregnancy screenings had been conducted. The patient had no medical history of previous diseases or surgeries. Her blood type was A Rh positive.
The obstetrical exam revealed a slightly tender and firm uterus enlarged to the size of a 16-week pregnancy. The cervix appeared normal. The patient had moderate, dark vaginal bleeding. Transabdominal ultrasound showed the uterine cavity filled with heterogeneous masses typical of a molar pregnancy (measuring 80.4 × 75.5 × 99.3 mm) with no hypervascularisation (Figs. 1 and 2). A gestational sac was suspected, but no definite foetal structures were observed. The right ovary measured 43.2 × 20.5 mm, while the left ovary measured 57.9 × 25.5 mm. The Douglas pouch was free.
The possibility of referral to a larger medical centre was discussed. The patient mentioned that she could not afford treatment in a city and that due to the cost, she would not undergo the recommended histopathological examination. Thus, she was admitted to the local hospital and scheduled for surgical evacuation of the molar tissue. The procedure involved mechanical dilation of the cervix, followed by sharp curettage after intravenous administration of 1 g of tranexamic acid and continuous infusion of 10 IU of oxytocin. Due to limited on-site resources, the surgeon improvised an instrument for suction aspiration by utilising a perforated tube from a urine catheter bag. The surgery was successful, with estimated blood loss of less than 500 ml and the removal of a significant amount of molar tissue. One unit of whole blood was transfused.
On the first postoperative day, the patient was feeling well with some vaginal spotting. The follow-up ultrasound ex-amination showed findings consistent with the performed procedure. The patient was discharged and advised to re-turn for a follow-up visit. So far, months after the hospitalisation, the patient has not attended the recommended check-up.

DISCUSSION OF CHARACTERISTIC SYMPTOMS, TREATMENT RESULTS, ETC.

Gestational trophoblastic disease (GTD) encompasses a cytogenetically and clinically heterogeneous group of disorders characterised by abnormal differentiation and/or proliferation of trophoblast epithelium [1].
The morphological classification is based on the World Health Organisation (WHO) classification, which distinguishes between villous and non-villous GTD [2]. Both groups include benign and malignant conditions, as well as those that can progress from benign to malignant, such as in the case of post-molar trophoblast persistence. The most common forms of GTD are partial and complete hydatidiform moles. According to Asian studies, partial and complete moles account for 80.3% of all GTD [3, 4].
Gestational trophoblastic disease occur in most cases as sporadic diseases. In rare instances, repeated so-called familial cases of complete hydatidiform moles are observed [5]. Additionally, women with molar pregnancies also appear to have a predisposition for aneuploid early miscarriages [6].
The incidence of hydatidiform mole exhibits significant geographic variation, ranging from 0.57 to 2 per 1000 pregnancies [7]. An increased incidence of GTD is found in young women (ages 10-19 years) and older women (ages 40-54 years), and also depends on ethnic background [8]. For example, Black American women are overrepresented in national registries, and Asian women have been shown to have twice the incidence compared to European women.
The risk stratification of GTD, which also forms the basis for the indication for chemotherapy, should be performed according to the current Fédération Internationale de Gynécologie et d’Obstétrique (FIGO) risk score [9].
The determination of human chorionic gonadotropin (hCG) in serum, alongside the histological confirmation of a trophoblastic disease, is the most important parameter for establishing the therapy, determining its duration, and assessing the therapeutic effect [10, 11].
The diagnostic process begins with a detailed medical history focusing on childbirth, miscarriages, abortions, ectopic pregnancy, and symptoms such as vaginal bleeding, nausea and vomiting, hypertension, dyspnoea, gastrointestinal bleeding, haematuria, and clinical signs of hyperthyroidism such as sweating, tachycardia, and palpitations [11, 12]. The clinical examination should include a general assessment of the patient’s overall condition. During the gynaecological examination, attention must be paid to nodules in the vagina and the introitus, bleeding, and adnexal findings. If material is found in the cervical canal, no biopsy should be performed due to the high risk of bleeding [11].
The ultrasound examination should include measurement of the uterus, identification of the gestational sac with or without embryo, and assessment of the endometrium (thickness, echo pattern, and borders). The vascularisation of pathological findings must be examined using colour Doppler. Potential adnexal tumours, which can arise due to high hCG levels, and ascites must be ruled out [10].
A blood laboratory test should include not only hCG but also thyroid function tests, electrolytes, creatinine, liver function tests, complete blood count, blood type, and coagulation including prothrombin time (PT) and fibrinogen. Urine analysis is recommended. In cases suspicious for a hydatidiform mole, a chest X-ray is obligatory. Further imaging studies such as magnetic resonance imaging (MRI) of the central nervous system and computed tomography (CT) of the abdomen, pelvis, and thorax should only be conducted upon histologically confirmed diagnosis of GTD or in the presence of clinical symptoms such as dyspnoea.
Prior to the surgical procedure in the form of suction curettage, comprehensive informed consent must be obtained [11, 12]. The patient must be informed about the risk of transfusion-requiring bleeding and even the necessity of a hysterectomy. Because the risk of uterine perforation is higher in GTD, consent for laparoscopy or laparotomy must be obtained. It must be made clear that after the operation, repeated hCG monitoring and effective contraception for 6 to 12 months are necessary. The risk of persistent GTD must also be addressed.
The suction curettage itself should ideally be performed after priming with a single vaginal administration of prostaglandin E1 [10]. An oxytocin drip should be initiated before the surgery and continued postoperatively. Cross-matched blood and sulprostone should be available on-site. Perioperative antibiotic prophylaxis is mandatory.
The procedure must be performed by the most experienced physician, optimally using a 12-14 mm suction cannula, under intraoperative ultrasound guidance and with readiness for hysterectomy if necessary [10, 11]. Tissue samples should be reserved for both pathological and cytogenetic examination. If necessary, postoperative intensive monitoring should be ensured. For Rh-negative patients, it is necessary to administer anti-Rh D immunoglobulin after the evacuation of molar tissue to prevent serological conflict in subsequent pregnancies [10, 11].
Routine follow-up for partial mole involves weekly monitoring of serum hCG until 3 consecutive negative values are obtained [10]. For partial mole, after hCG normalisation, an additional single check-up is necessary after 4 weeks. For complete mole, after hCG normalisation, 2 more weeks of weekly monitoring, followed by 4-weekly checks for 6 months, are recommended. Effective contraception for 6 months after hCG normalisation is mandatory in all cases of molar pregnancy.

SUMMARY

In Tanzania medical professionals working in the Reproductive and Child Health (RCH) section of healthcare ser-vices, including nurses, midwives, and doctors, are involved in providing a range of maternal and child health services. These services include prenatal care, emergency obstetric care, postnatal and newborn care, management of sexually transmitted diseases, family planning, and immunisations for children under 5 years old, and are crucial, particularly in rural and resource-limited settings, because they play a vital role in reducing maternal and child mortality rates. The healthcare workers in this field often face challenges such as limited resources, stockouts of essential medicines, and inadequate equipment, but they continue to provide essential care to improve health outcomes for mothers and children.
All pregnant women in Tanzania are required to attend antenatal clinics with their partners. During the perinatal period, they receive care from trained RCH midwives and doctors. Special attention is given to women with specific conditions, such as features suggestive of pre-eclampsia, history of multiple pregnancy losses, chronic illnesses, including sickle cell disease, diabetes mellitus, hypertension, and heart failure during pregnancy. Midwives alone are often the primary caregivers during the perinatal period, especially in remote areas. They provide antenatal care, assist with de-liveries, and offer postnatal care. In urban areas and more equipped healthcare facilities, obstetricians, general doctors, and nurses are more commonly involved in perinatal care, and they handle more complicated cases and emergencies.
However, local healthcare workers encounter several challenges while providing care during the perinatal period, including financial constraints because many pregnant women from low socioeconomic backgrounds struggle to afford basic investigations and treatments, delayed clinic attendance due to poor road infrastructure in remote areas, cultural beliefs where persistent local beliefs in shamans and traditional medicine lead some pregnant women to prefer traditional birth attendants over formal antenatal clinics, and urban-rural disparity where obstetric care is more accessible in urban areas with a higher concentration of government, private, and religious health facilities compared to rural areas. This is compounded by shortages of medical supplies and equipment that further hinders access to adequate healthcare. Another critical issue is the significant shortage of trained midwives and doctors, particularly in rural areas, resulting in overburdened staff and high patient-to-provider ratios. The challenges in training and education are evident, as continuing education and training opportunities for healthcare providers are limited. This limitation adversely affects their ability to manage complications and emergencies effectively.
In light of the above, meeting all the standards of care for GTD to ensure its adequate diagnosis, treatment, and control is unattainable in rural areas of Tanzania. In the described case, the first problem arose right at the beginning: the patient was uninsured and could not afford medical services. The pregnancy was initially diagnosed solely based on a positive urine pregnancy test result, and the woman had not been previously examined by a medical professional. Her first ultrasound was performed by volunteer physicians during a medical mission at around 12 weeks of gestation only because she was symptomatic. Suspicion of GTD was raised based solely on physical examination findings, which revealed a uterus larger than expected for the gestational age and a characteristic image of tissue filling the uterine cavity on ultrasound.
Secondly, the local staff faced significant challenges due to the lack of proper equipment. The facility only had the capability to perform qualitative hCG testing in urine, without the option for quantitative serum testing. Due to financial constraints, the patient agreed only to essential tests and procedures necessary for the surgical intervention. A make-shift vacuum aspiration kit for evacuating molar tissue from the uterus had to be improvised using available materials – urinary catheters. The only available uterotonic was oxytocin. Due to bleeding, whole blood from the local blood bank – the only available blood product in the region – was administered.
Despite the difficulties, thanks to the dedication of the local midwifes, nurses, and doctors, the procedure and peri-operative care were successful, and the patient was discharged home in good general and local condition, with instructions to attend a follow-up appointment in a week.
Lastly, a significant issue was the lack of compliance from the patient, who failed to attend the scheduled follow-up appointment.
Working in rural conditions in low-income to lower-middle-income countries demands significant physical and psychological effort from healthcare workers. Procedures that are easy and safe with appropriate equipment require additional preparation and adaptation of medical staff to local conditions. Awareness of the inability to provide care to patients in line with global standards can be frustrating for professionals. This highlights the need for improved infra-structure and increased healthcare resources in rural and remote areas to ensure equitable access to maternal healthcare services across Tanzania and neighbouring countries.

ACKNOWLEDGEMENTS

We thank the entire “Doctors Africa” and “Centrum Dobroczynności Lekarskiej” (www.dobroczynnosc.org) team for their commitment to medical aid projects and the organisation of missions in Tanzania and other countries in need of various forms of support.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The manuscript includes clinical data and ultrasound images obtained during the patient’s hospitalisation. After a thorough review, the hospital’s director has granted permission for the publication. This consent is contingent upon maintaining the patient’s full anonymity. It has been emphasised that all personal data must be appropriately anonymised and that the ultrasound images should not contain any identifiable information.
The authors declare no conflict of interest.

References