CASE REPORT Cerebral Metastases of a Choriocarcinoma During Pregnancy O. Picone, MD, V. Castaigne, MD, C. Ede, MD, and H. Fernandez, MD From the Department of Obstetric Gynecology Hospital Antoine Be ´cle `re, Clamart, France; and the Polyvalent Critical Care Department, Institute Gustave Roussy, Villejuif, France. BACKGROUND: Cerebral metastasis of choriocarcinoma dur- ing pregnancy is rare. Described is the fourth case in the literature. CASE: A pregnant women at 28 weeks’ gestation sought care for headaches followed by loss of consciousness. The diagnosis of choriocarcinoma metastases was made on the basis of the combination of cerebral and pulmonary le- sions, all suspected to be metastatic, and a high  human chorionic gonadotropin level. A premature cesarean deliv- ery was performed to improve the mother’s prognosis; the responsiveness of choriocarcinoma to chemotherapy made it important for treatment to begin as rapidly as possible. The outcome has been on balance favorable, even though her sequelae include paraplegia. The child has no apparent sequelae. CONCLUSION: The diagnosis of choriocarcinoma must be considered when acute neurological signs appear in a pregnant patient. (Obstet Gynecol 2003;102:1380 –3. © 2003 by The American College of Obstetricians and Gynecologists.) The development and diagnosis of cerebral metastases during pregnancy is very rare. We made this diagnosis in a patient at 28 weeks’ gestation. Gestational trophoblas- tic neoplasia is a malignant proliferation of syncytial trophoblast cells that do not form placental villi. Al- though most choriocarcinomas are observed after a mo- lar pregnancy, 1 it has been recently shown that even a partial mole can be transformed into choriocarcinoma. 2 CASE This 20-year-old patient had had a previous pregnancy and no deliveries. The first pregnancy had been marked by bleeding at 6 weeks, in December 2000. The patient underwent a laparoscopy for suspected ectopic preg- nancy (blood -human chorionic gonadotropin [-hCG] 25,000 UI/L and a 1-cm heterogeneous intrauterine im- age); the findings were normal, and uterine curettage revealed no chorionic villi. The -hCG level decreased from 30,000 IU/L on the sixth day after laparoscopy to 49 IU/L 1 month later, the last day of monitoring. A month afterward, this patient sought treatment for pelvic pain. An ultrasound examination revealed a left ovarian cyst 4 cm in diameter, suggestive of a dermoid cyst. No hormone assay was performed. An intraperitoneal cys- tectomy was performed by laparoscopy. Analysis of histologic serial sections confirmed the diagnosis of a mature dermoid cyst of the ovary; it contained no ele- ments of histologic choriocarcinoma. In June 2001, 5 months after the curettage, the patient became pregnant again. Two blood -hCG assays found levels of 5200 and 9500 IU/L, consistent with the term of pregnancy. The first trimester was unremarkable, with normal sonogram at 12 weeks. The pregnancy contin- ued without problems until 28 weeks, when the patient consulted her physician about intense headaches, fol- lowed rapidly by loss of consciousness. At arrival in the neurosurgery department, she was in a coma and re- quired assisted ventilation. Magnetic resonance imaging (MRI) revealed a bulky intracerebral hematoma in the right parietal region. Angiography with gadolinium re- vealed no evidence of vascular malformation, thrombo- phlebitis, or tumor blush. Clinical improvement fol- lowed emergency drainage of hematoma by open craniotomy. The hematoma was examined, but no tu- mor cells were found. The situation was aggravated again at day 10 after admission. Cerebral MRI revealed lesions suggestive of secondary injuries (hemispheric, cerebellar, and cerebral trunk) (Figures 1 and 2). Lung radiography revealed diffuse pulmonary opacities. The plasma -hCG level was very high: 400,000 IU/L (mean at this term is 14,000 IU/L). 3 The diagnosis of choriocarcinoma metastases was based on this combination of cerebral and pulmonary lesions, all suspected to be metastatic, and an extremely high -hCG level. In view of the seriousness of her condition, the obstetric, pediatric, and oncology staff decided on a premature cesarean delivery of the new- born at 28 weeks, after a corticoid treatment (to acceler- ate fetal pulmonary maturation). The cesarean was per- formed under general anesthesia, and a 1260-g girl was delivered. The neonate had an Apgar score of 3 at 1 minute, 7 at 3 minutes, and 10 at 5 minutes; she was Address reprint requests to: Professor H. Fernandez, MD, Service de Gyne ´cologie Obste ´ trique (Pr. Frydman), Ho ˆ pital Antoine Be ´cle `re, 157, rue de la porte de Trivaux, 92140 Clamart, France; E-mail: herve. fernandez@abc.ap-hop-paris.fr. 1380 VOL. 102, NO. 6, DECEMBER 2003 0029-7844/03/$30.00 © 2003 by The American College of Obstetricians and Gynecologists. Published by Elsevier. doi:10.1016/S0029-7844(03)00865-2