Hydatidiform Mole.pptx.pptx

Vesicular Mole

1. Hydatidiform Mole Dr Rachna Jaju Dr Anant Mugale Dr Deepa More Dr Parveen Palla Dr Anjali Jamma Dr LaxmiKant Marda

2. What is Gestational Trophoblastic Disease? Define Hydatidiform Mole?

3. GESTATIONAL TROPHOBLASTIC DISEASE (GTD) HYDATIFORM MOLE – benign –premalignant can become malignant and invasive GESTATIONAL CHORIOCARCINOMA –extremely malignant and invasive PLACENTAL SITE TROPHOBLaSTIC TUMOUR

4. Introduction A Hydatiform mole (also known as a molar pregnancy) is a gestational trophoblastic disease (GTD), which originates from the placenta and can metastasize at the beginning of pregnancy. Results from abnormal fertilization of oocyte (Egg) It arises from gestational tissue rather than maternal tissue

5. Describe pathological changes in hydatidiform mole ? Enumerate types of Hydatidiform Mole?

6. Mole with a typical vesicular structure and normal placenta. It is abnormal condition of placenta where there are partly degenerative and proliferative changes in chorionic villi and result in formation of cluster of cyst which vary in sizes. (like bunch of grape)

7. Types of Hydatidiform Mole Two types of HM Complete Hydatidiform Mole 2.Incomplete or partial Hydatidiform Mole

8. Etiology Of Complete Hydatidiform Mole?

9. Etiology Complete Hydatidiform Mole (CHM) Complete moles are usually DIPLOID & tend to cause higher levels of the human chorionic gonadotropin (HCG) which is one of the main clinical features of this process. In complete moles, the karyotype is 46XX, 90% of the time and 46XY 10% of the time. Fetus is absent It occurs when enucleated egg is fertilized by two sperms or haploid sperm Only paternal DNA is expressed CHD Specimen

10. Etiology Of Partial Hydatidiform Mole?

11. Etiology Incomplete OR Partial Hydatidiform mole (PHM)  In partial moles, the karyotype is 90% of the time triploid and either 69,XXX or 69,XXY. In partial moles, both maternal and paternal DNA is expressed. There is formation of fetus but will not survive Normal sperm fertilizes haploid ovum duplicates or when two sperms fertilizes a haploid ovum

12. Schematic of the different karyotypes of complete and partial Hydatidiform moles.

13. Describe Incidence & High risk Factors for Vesicular Mole?

14. Incidence Asia (~1 in 500) The Middle east and Africa (~1 in 1000) In Europe and north America (~1 in 1500)

15. RISK FACTORS Extremes of maternal age: Greater than 35 years old carries a  five to ten-fold increased risk  Early teenage years, usually less than 20 years old Previous molar pregnancy increases the risk in future pregnancies Women with previous spontaneous abortions or infertilities Dietary factors including patients that have diets deficient in carotene (vitamin A precursor) and animal fats Smoking

16. Pathophysiology In complete Hydatidiform mole, there is no fetal tissue present; in partial Hydatidiform moles, there is some residual fetal tissue. Several studies reveal a severe vasculogenic deficit in trophoblastic diseases, with significantly retarded angiogenesis in early complete mole progressive accumulation of fluids, and subsequent formation of cystic spaces. Hydatidiform mole is characterized by chromosomal abnormalities In brief, complete moles are diploid (46,XX; 46,XY) while most partial moles are triploid  (69,XXY; XXX; XYY).

17. Pathogenesis of Complete Hydatidiform mole

18. Pathogenesis of partial Hydatidiform mole

19. Describe Clinical features of Hydatidiform Mole?

20. Clinical Features Dark Brown to bright red Vaginal bleeding( prune juice appearance) in the first trimester. Hyperemesis (severe nausea and vomiting), which is due to the high level of the HCG hormone circulating in the bloodstream. Some patients also endorse passage of vaginal tissue described as grape-like clusters or vesicles. Advance stage possibility of Respiratory Distress Syndrome

21. Late finding of disease (after the first trimester around 14 to 16 weeks of pregnancy) Symptoms of Hyperthyroidism, including tachycardia and tremors, again caused by the high levels of circulating hCG Pre-eclampsia Partial Mole presents with symptoms S/o Threatened or Spontaneous Abortion Clinical Features

22. On physical examination In a complete mole, the uterus is usually larger than the expected gestational date of the pregnancy, In partial moles, the uterus can be smaller than the suggested date. Clinical Presentation

23. What Investigations to be done?

24. EVALUATION Serum HCG level (greater than 100,000 mIU /ml) Blood Group Complete blood count Thyroid function test Liver function test Coagulation profile including PT/INR

25. Describe imaging modalities for vesicular mole?

26. Pelvic ultrasound ( IMAGING OF CHOICE) This Photo by Unknown Author is licensed under CC BY COMPLETE MOLE Heterogenous Mass in uterine cavity with multiple Anechoic spaces SNOW STORM APPERANCE Absence of Fetus Absence of amniotic fluid

27. Partial MOLe USG findings This Photo by Unknown Author is licensed under CC BY-SA-NC FOETUS is present, may be viable . Presence of amniotic fluid Enlarged placenta with cystic spaces SWISS CHEESE appearance CT SCAN PET SCAN XRAY FOR LUNG Metastates

28. What are principles of management of vesicular mole? Suction & Evacuation-as early as diagnosis is done Supportive therapy-correction of fluid and blood loss Counselling for regular follow up

29. What cervical ripening agents to be used? Which Anesthesia to be preferred? Which is Uterotonic of choice? Is there role of Curettage following evacuation? Which is preferred contraceptive?

30. TREATMENT OPTION Uterine Evacuation should be performed by surgical procedure. Significant risk of bleeding and perforation are there ,hence to be performed by senior surgeon with cross match available. SGA preferred anesthesia Medical evacuation may be tried for partial mole. Oxytocin/methergine to be used for uterotonic. Misoprostol 600mcg to be used for making cx favorable. Barrier contraceptive is preferred

31. How will you advice Follow up?

32. Follow up after molar pregnancy Weekly till HCG levels falls to normal . This usually occurs within 2mnths. Then monthly till 6mnths Current advice is f/u is needed for 6mnths from time of evacuation or 6mnths from first normal HCG level. Contraception to be advised for 6mnths.

33. What are Complications of molar pregnancy?

34. Complications of molar pregnancy Hemorrhage & Shock-separation of decidua, intraperitoneal bleed of invasive mole, atonic uterus ,uterine injury Sepsis Perforation of uterus-invasive mole, during surgical evacuation Preeclampsia Acute pulmonary insufficiency choriocarcinoma

35. What are indications for chemotherapy treatment?

36. Indications for chemotherapy treatment after molar pregnancy Brain liver or GI tract metastases or lung metastases >2cm on Xray Histological evidence of choriocarcinoma Heavy vaginal bleeding or GI bleeding Pulmonary ,vaginal or vulval metastases unless hCG levels are falling Rising hCG in two consecutive serum samples hCG >20,000IU/L more than 4 weeks After Evacuation hCG plateau in Three consecutive Samples Raised hCG levels 6mnths after evacuation(even if falling)