Vartika Tripathi is currently
working in the Department of
Obstetrics and Gynaecology,
Mayo Institute of Medical College,
Lucknow, as an Assistant
Professor. She has completed her
MBBS from Kasturba Medical
College, Manipal, and has
passed her M.D. with gold
medal, from KGMU, Lucknow,
in 2017. She has worked for 2
years as a senior resident at
KGMU, Lucknow. She has presented
various papers and posters
in national and state-level
conferences. High-risk pregnancy
is among the many academic interests that she has. She plans to
strive and continue her work in the field of high-risk pregnancies.
Massive subchorionic hematoma (MSH) also known as
Breus’ mole is a large placental blood clot. It has an incidence
of only about 0.03–0.08% [1]. The adverse pregnancy
outcomes reported due to this condition are mainly confined
to poor fetal prognosis, and Breus’ mole causing life-threatening
complication in the mother is extremely rare. It is not
typically familial and hence is not thought to recur. We came
across the case of a pregnancy complicated by Breus’ mole
with a history of Breus’ mole in the previous two consecutive
pregnancies. All the three pregnancies had life-threatening
hemorrhage due to hematoma requiring emergency
hysterotomy, blood transfusion, vasopressors and ventilator
support each time.
A 30-year-old lady was referred as G3P0A2 (abortions
2), 17 weeks pregnancy with placentomegaly. Her pregnancy
had been uneventful so far, and all the antenatal
investigations were within normal limits. In both her previous
pregnancies, there was history of MSH at 16–17 weeks
of gestation. The woman required life-saving emergency
hysterotomy along with blood transfusion and ventilatory
support in both the pregnancies. In the current pregnancy,
she had an ultrasonography (USG) at 17 weeks of gestation
which showed a single live fetus and placentomegaly
(placental thickness 6.5 cm) Fig. 1. She was referred to
this hospital for further evaluation and management. She was hemodynamically stable and her hemoglobin (Hb) was
10.7gm/dl. She was admitted and investigated for the cause
of placentomegaly and possible subchorionic hemorrhage.
All investigations like thrombophilia profile, toxoplasmosis,
rubella, cytomegalovirus and herpes simplex were negative.
Evaluation of MTHFR gene mutation and factor V mutation
was also done, and no abnormalities were detected. Protein
C and protein S levels were also normal.
She was kept under strict monitoring clinically. Patient
complained of acute abdominal pain on the third day of
hospital stay, and a sudden increase in fundal height was
observed. There was fall in the Hb of patient from 10.7 to
7 gm/dl over a period of few hours. Patient was considered
for termination of pregnancy on clinical suspicion of hemorrhage
and worsening of anemia. She was taken for emergency
hysterotomy. Per operatively a huge retroplacental
collection of blood of about 1200 cc was found. Placenta
weighed around 180 g, and no gross abnormality was identified
on visual inspection of the placenta. The fetus weighed
around 350 g, with no apparent malformations Fig. 2. Urgent
blood transfusion was done. Due to hemodynamic instability,
she needed ventilator support in the postoperative period.
However, within a week, she recovered fully and was later
discharged in satisfactory condition.
Similar case was reported by Szlachetka et al. in 2017
[2] where Breus’ mole had occurred in two consecutive pregnancies of a patient. Unfortunately, even they were
unable to ascertain the cause of the consecutive recurrence
of Breus’ mole in the patient.
Breus’ mole is a rare disease. Women with cardiac problems,
disorders of circulation, monosomy, hypertension
and diabetes are predisposed to Breus’ mole. Usually, the
hematoma is formed due to maternal blood; however, fetal
growth restriction and fetal demise may occur if hematoma
is near cord insertion or volume is increased significantly
[1]. Serial ultrasound and/or Doppler is indicated to monitor
the size of hematoma and well-being of fetus. This scenario
with consecutive life-threatening hematomas behind chorionic
plate with all normal investigations is intriguing. This
case highlights the need of further research regarding Breus’
mole because not only does it have the propensity to recur
in consecutive pregnancies but it can also result in severe
maternal morbidity and mortality. Subchorionic bleeding
due to vascular pathology or sudden vascular accident may
be a causative factor. A clear understanding of the process
of formation of MSH is needed to prevent its occurrence by
intervention in the early pregnancy as well as preconceptional
period, if possible. Data regarding Breus’ mole are
scarce; through this case, we hope to add further insight
into this topic by emphasizing the possibility of it being
both recurrent and life threatening. The recurrent nature of
Breus’ mole also points toward its etiology being genetic or
familial as opposed to the existing literature.
Funding None
Conflict of interest The authors declare that they have no conflict of interest.
Consent for Publication Consent was obtained from the patient for publication of the case and anonymity of the patient maintained.
Human and Animal Rights This article does not contain any studies with human participants or animals performed by any of the authors and involves no violation of human rights.
Informed Consent Consent was obtained from the patient.
