Hydatidiform mole/ VESICULAR MOLE

Hydatidiform mole

1. Hydatidiform (vesicular ) M ole

2. HYDATIDIFORM MOLE HYDATIDIFORM MOLE IS A BENIGN NEOPLASM OF THE CHORION WITH MALIGNANT POTENTIAL Incidence more common among asians in india 1 in 400 pregnancies increased incidence in women at the extremes of reproductive ages, especially above 35 Other risk factor is previous molar pregnancy-recurrence in 1-2% cases

3. PATHOLOGY Villous pattern maintained Marked proliferation of both syncytiotrophoblasts and cytotrophoblasts Marked edema of stromal tissue Trophoblast secrete more hCG than in normal pregnancy Ovaries contain multiple theca lutein cysts

4. TYPES COMPLETE HYDATIDIFORM MOLE PARTIAL HYDATIDIFORM MOLE

5. COMPLETE HYDATIDIFORM MOLE No evidence of existence of fetus Fetal blood vessels are not seen in the villi There is hydropic degeneration,swelling of the villous stroma and trophoblastic proliferation Diploid and completely paternal in origin-arise due to duplication of haploid sperm following fertilisation of an empty ovum and are 46XX- androgenesis In some,46XY due to dispermic fertilisation of an empty ovum Marked increase in circulating hCG

6. PARTIAL HYDATIDIFORM MOLE There is focal trophoblastic proliferation with cystic degeneration mixed with areas of normal chorionic villi A normal or abnormal fetus may present Karyotype typically triploid(69XXX or 69XXY),with two sets of paternal haploid genes and one set of maternal haploid genes and is due to dispermic fertilisation of an ovum

7. DIFFERENCE B/W COMPLETE AND PARTIAL MOLE FEATURES COMPLETE MOLE PARTIAL MOLE Karyotype 46XX or 46XY 69XXX or 69XXY Pathology Embryo/fetus absent present Hydropic degeneration of villi pronounced and diffused variable and focal Trophoblastic hyperplasia diffuse focal Fetal RBC absent present Scalloping of chorionic villi absent present Stromal inclusions absent present P57KIP2 immunostaining negative present

8. Clinical features Uterine size usually more less Theca lutein cysts common uncommon Medical complications common uncommon Serum beta hCG very high slight increase Persistent GTD 20%;local invasion is <5% and usually 15% and metastasis 5% nonmetastatic

9. CLINICAL FEATURES Clinical presentation of hydatidiform mole has changed over last few decades with the advent of sonography . Many moles are today diagnosed by routine ultrasound. Vaginal bleeding is a common symptom. Clinical features include certain symptoms and signs .

10. SYMPTOMS Amennorrhea of varying duration followed by bleeding. Passage of vesicles per vaginum . Hyperemisis is common due to high levels of circulating hCG Pre- eclampsia Thyrotoxicosis Respiratory symptoms Trophoblastic embolization Thyroid strom Pre- eclampsia

11. SIGNS Utreus is more than period of amenorrhea in 50% cases .In 35% cases ,it will correspond to the gestational perod and in rest it may be smaller. Fetal parts will not be felt,fetal heart sound will not be heard Theca lutein cysts may be felt in about 50%. Cysts are due to over stimulation of luteal elements by large amounts of circulating hCG Larger moles are associated with cysts Presistent trophoblastic disease is more likely in women with theca lutein cysts Early onset of preeclampsia ,so if hypertension appears before 20 weeks,it is important to rule out hydatidiform mole. signs of preeclampsia include- Elevated blood pressure Proteinuria Thyrotoxicosis ,due to thyrotropin like effect of hCG .Signs include Tachycardia Tremor Respiratory distress due to embolization is very rare

12. Partial mole may not present with classic features of a complete mole It may present as an incomplete or missed abortion and diagnosed after histopathological examination If featus present,it may have the stigmata of triploidy like early onset IUGR and hydrocephalous A twin fetus can coexist with a molar pregnancy and is difficult to differentiate from a partial mole

13. DIAGNOSIS INVESTIGATIONS The ultrasound appearance is diagnostic described as “snow strom appearance” It may show the presence of theca lutein cysts in the ovaries In a partial mole,ultrasound may show featus

14. Ultrasound, early diagnosis of most cases of molar pregnancy In partial mole,there may be focal cystic spaces in the placenta Serum beta hCG level are very high Complete blood count Renal function test Liver function test Coagulation profile

15. DIFFERENTIAL DIAGNOSIS Threatened abortion Acute hydraminos Multiple pregnancy Tumors complicating pregnancy

16. VESICULAR MOLE -MANAGEMENT

17. Two stages immediate evacuation Follow-up Before evacuation,serum beta hCG level is estimated. A chest X-ray is taken & looked for pulmonary metastasis.

18. Evacuation Suction evacuation is done irrespective of the size of uterus. Misoprostol-to dilate cervix before evacuation. Compatible blood has to be arranged,curettage is done after evacuation. Importance of oxytocin infusion. Intra or post evacuation ultrasound. All products of conception should undergo histopathological examination. Role of Anti-D to an Rh negative mother.

19. Follow-up Objective-to detect any malignant change & prompt institution of chemotherapy. Serum beta hCG levels are evaluated in follow-up. Pregnancy is avoided in the first 6 months as the chances of developing GTN are high. Clinical examination is done at each visit & if needed sonography also done, pregnancy can be allowed only after the period of follow-up is over.

20. Risk of GTN About 80% of complete moles regress,while 20% may progress to GTN. Of these,15% may be monmetastatic & 5% metastatic. In case of partial moles, the risk is much less(.5-4%) & is usually nonmetastatic .

21. The main risk factors of postmolar GTN are; Advanced maternal age. Preevacuation high hCG >100000mIU/ml. Uterus large for dates. Bilateral theca lutein cysts. Respiratory distress after evacuation. Eclampsia or hyperthyroidism. Uterine subinvolution with post evacuation bleeding.

22. Contraception Barrier contraception is safest until serum beta hCG levels become normal. Hormonal contraceptives may interfere with rate of decline of beta hCG. An IUD shouldn’t be used until serum beta hCG levels become normal.

23. Subsequent pregnancy Pregnancy can be allowed after 6 months, provided the serum beta hCG level has become normal. If still elevated,follow -up should continue for 2 yrs. There is 1-2% of recurrence of moles ,so it’s important to carry out USG in next pregnancy to rule out molar pregnancy. After delivery, placenta & products of conception should be sent for histopathological study.

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