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1. Hydatidiform (vesicular ) M ole

2. H ydatidiform moles are excessively edematous immature placentas . These include the benign complete hydatidiform mole and partial hydatidiform mole and the malignant invasive mole.

3. A complete mole has abnormal chorionic villi that grossly appear as a mass of clear vesicles. These vary in size and often hang in clusters from thin pedicles. A partial molar pregnancy has focal and less advanced hydatidiform changes and contains some fetal tissue Invasive mole is deemed malignant due to its marked penetration into and destruction of the myometrium as well as its ability to metastasize

4. HYDATIDIFORM MOLE Incidence more common among asians , Hispanics and American Indians in india 1 in 400 pregnancies increased incidence in women at the extremes of reproductive ages ( adolescents and women aged 36 to 40 years have a twofold risk, but those older than 40 have an almost tenfold risk ) previous molar pregnancy-recurrence in 1-2% cases

5. PATHOLOGY chrom o somally abnormal fertilizations Complete moles - diploid chromosomal composition ( 46,XX ) and result from androgenesis ( both sets of chromosomes are paternal in origin ) Partial moles usually have a triploid karyotype—69,XXX, 69,XXY—or 69,XYY. These are each composed of two paternal haploid sets of chromosomes and one maternal haploid set

6. 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 Marked increase in circulating hCG

7. PARTIAL HYDATIDIFORM MOLE There is focal trophoblastic proliferation with cystic degeneration mixed with areas of normal chorionic villi These triploid zygotes result in some embryonic development, however, it ultimately is a lethal fetal condition. Fetuses that reach advanced ages have severe growth restriction, multiple congenital anomalies,or both.

8. SYMPTOMS Amennorrhea of varying duration Passage of vesicles per vaginum /bleeding p/v. Hyperemisis is common due to high levels of circulating hCG Respiratory symptoms in case of embolism

9. SIGNS Ut er us 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 absent Doughy consistency of uterus Multiple Theca lutein cysts in about 50%. Early onset of preeclampsia Thyrotoxicosis

10. DIAGNOSIS Elevated Bhcg values: more than usual pregnancy values * With more advanced moles, values in the millions are not unusual. Importantly, these high values can lead to erroneous false-negative urine pregnancy test results because of oversaturation of the test assay by excessive β-hC G

11. The ultrasound appearance is diagnostic described as “snow strom appearance” It may show the presence of multiple theca lutein cysts in the ovaries In a partial mole,ultrasound may show f oe tus The most common misdiagnosis is incomplete or missed abortion. Occasionally, molar pregnancy may be confused for a multifetal pregnancy or a uterine leiomyoma with cystic degeneration

12. DIFFERENTIAL DIAGNOSIS Threatened abortion Multiple pregnancy Tumors complicating pregnancy

13. MANAGEMENT

14. Evacuation Suction evacuation is done irrespective of the size of uterus. Compatible blood has to be arranged As evacuation is begun, oxytocin is infused to limit bleeding. All products of conception should undergo histopathological examination. Anti-D to be given to an Rh negative mother.

15. Hysterectomy with ovarian preservation may be preferable for women who have completed childbearing. (>40 years - 1/3rd will develop GTN and hysterectomy markedly reduces this risk. Chest radiograph following the procedure

16. Follow-up The initial β-hCG level is obtained within 48 hours after evacuation. This serves as the baseline, which is compared with β-hCG quantification done thereafter every 1 to 2 weeks until levels progressively decline to become undetectable. The median time for such resolution is 7 weeks for partial moles and 9 weeks for complete moles. Once β-hCG is undetectable, this is confirmed with monthly determinations for another 6 months. After this, surveillance is discontinued and pregnancy allowed.

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

18. The main risk factors of postmolar GTN are; Advanced maternal age. Preevacuation high hCG >100000mIU/ml. Uterus large for gestational age . theca lutein cysts >6cm slow decline in Bhcg levels

19. Contraception Barrier contraception is safest until serum beta hCG levels become normal. combination hormonal contraception or injectabl e medroxyprogesterone acetate can be used An IUD shouldn’t be used until serum beta hCG levels become normal (risk of perforation in invasive mole)

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