Molar Pregnancy

For medical nursing and midwifery students

1. Hydatidiform(Vesicular)Mole
Dr. Uma Gupta *Head & Prof. Obstetrics & Gynecology .
Mayo Institute of Medical Sciences, Barabanki
*M.D, MARD, FAIMER (CMCL 2012), PGDHHM, MHPE
[email protected]
5/13/2021
med-trainings.com
1

2. Learning Objectives
What is Vesicular mole
Basis of mole
Types
Symptoms
Signs
Investigation
Management
Follow up
5/13/2021
med-trainings.com
2

3. Definition
Gestational trophoblastic disease (GTD) refers to a spectrum
of interrelated but histologically distinct tumors originating
from the placenta.
Characterized by a reliable tumor marker, which is the β-
subunit of human chorionic gonadotropin (β-hCG).
5/13/2021
med-trainings.com
3

4. Gestational trophoblastic neoplasia (GTN)
refers to the subset of GTD that develops malignant sequelae.
These tumors require normal staging and typically respond
favorably to chemotherapy. Most commonly, GTN develops
after a molar pregnancy but may follow any gestation
5/13/2021
med-trainings.com
4

5. Modified WHO Classification of GTD
(2014)
Molar pregnancies
Hydatidiform mole
Complete
Partial
Invasive mole
Trophoblastic tumors
Choriocarcinoma
Placental site trophoblastic tumor
Epithelioid trophoblastic tumor
5/13/2021
med-trainings.com
5

6. Epidemiology
5/13/2021
med-trainings.com
6
•Itisabenignneoplasmofthechorionicvilli.
•Incidence:
1:2000pregnanciesinUnitedStatesandEurope,but
10timesmoreinAsia.Theincidenceishigher
towardthebeginningandmoretowardtheendof
thechildbearingperiod.Itis10timesmorein
womenover45yearsold.

7. Pathology
5/13/2021
med-trainings.com
7
•Theuterusisdistendedbythinwalled,
translucent,grape-likevesiclesofdifferent
sizes.Thesearedegeneratedchorionicvilli
filledwithfluid.
•Thereisnovasculatureinthechorionicvilli
leadstoearlydeathandabsorptionofthe
embryo.

8. The uterus is distended by
thin walled, translucent,
grape-like vesicles of
different sizes.
•These are degenerated
chorionic villi filled with fluid.
•There is no vasculature in
the chorionic villi leads to
early death of the embryo.
5/13/2021
med-trainings.com
8

9. Hydatidiform :mole
Hyperplasiaoftrophobasitccells•Hydropic
swellingofallvilli•Vesslesareusuallyabsent
5/13/2021med-trainings.com
9

10. Pathology
Thereistrophoblasticproliferation,withmitoticactivityaffecting
bothsyncytialandcytotrophoblasticlayers.Thiscausesexcessive
secretionofhCG,chorionicthyrotrophinandprogesterone.On
theotherhand,oestrogenproductionislowduetoabsenceof
thefoetalsupplyofprecursors.
5/13/2021
med-trainings.com
10

11. Pathology
HighhCGcausesmultiplethecaluteincystsin
theovariesinabout50%ofcases.
Cystsmayreachalargesize
10cmormore.
5/13/2021
med-trainings.com
11
•Cystsdisappear
withinfewmonths(2-3),
afterevacuationofthemole.

12. Pathology
5/13/2021
med-trainings.com
12
•HighhCGcausesmultiplethecaluteincystsin
theovariesinabout50%ofcases.Italso
resultsinexaggerationofthenormalearly
pregnancysymptomsandsigns.

13. Complete Mole
5/13/2021
med-trainings.com
13

14. Completemole
5/13/2021med-trainings.com
14

15. Partialmole
5/13/2021
med-trainings.com
15
-A part of trophoblastic tissue only shows molar
changes.
-There is a foetus or at least an amniotic sac.
-It is the result offertilization of an ovum by 2
sperms so the chromosomal numberis 69
chromosomes

16. Partial mole
5/13/2021
med-trainings.com
16

17. Partial mole
5/13/2021
med-trainings.com
17

18. DIFFERENTIATIONBETWEEN
COMPLETEANDPARTIALMOLE
Feature CompleteMolePartialMole
Karyotype 46XX(96%)or46
XY(4%)
69XXYor69XYY
Pathology
Embryonicorfoetal
tissue
Absent Present
SwellingofthevilliDiffuse Focal
TrophoblastichyperplasiaDiffuse Focal
p57Kip2 immunostainingNegative Positive
Karyotype 46XX(96%)or46
XY(4%)
69XXYor69XYY
5/13/2021
med-trainings.com
18

19. DIFFERENTIATIONBETWEEN
COMPLETEANDPARTIALMOLE
Feature Complete
Mole
PartialMole
Clinical
presentation
Typical diagnosis
Molar
pregnancy
Missed abortion
Postmolar
malignant sequelae15% 4-6%
MalignantChanges5-10% Rare
5/13/2021
med-trainings.com
19

20. Partial moles are optimally diagnosed when
three or our major diagnostic criteria are
demonstrated:
(1) two populations o villi,
(2) enlarged, irregular, dysmorphic villi (with
trophoblast inclusions),
(3) enlarged, cavitated villi (≥3 to 4 mm), and
(4) syncytiotrophoblasthyperplasia/atypia
5/13/2021
med-trainings.com
20

21. DIAGNOSIS
5/13/2021
med-trainings.com
21
Symptoms
•Amenorrhoea:usuallyofshortperiod(2-3months).
•Exaggeratedsymptomsofpregnancyespecially
vomiting.
•Vaginaldischarge
•Abdominalpain:maybe,
odull-achingduetorapiddistensionoftheuterus,o
colickyduetostartingexpulsion,
osuddenandsevereduetoperforatingmole.

22. Discharge
Themaincomplaint,duetoseparationofvesiclesfrom
uterinewall,theremaybeabloodstainedwatery
discharge,thewaterypartisfromrupturedvesicles.
Prunejuicedishargemayoccur.
Thebloodisbrownbecauseithasretainedfor
sometimeintheuterinecavity.
passageofvesiclesisdiagnostic.Thebloodmaybe
concealedcausing enlargement & tenderness of
uterus.
5/13/2021
med-trainings.com
22

23. Abdominal pain : may be
-dull-aching due to rapid distension of the
uterus by the mole or by concealed haemorrhage.
-Colicky due to starting expulsion,
-Sudden And Severe due to perforating mole
-Ovarianpainduetostretchingoftheovarian
capsuleorcomplicationinthecysticovaryas
torsion
5/13/2021
med-trainings.com
23

24. Pre-eclampsia in 20-30% of cases, usually before 20 weeks’ gestation.
Pallor indicating anemia may be present.
Hyperthyroidism in 3-10% of cases manifested by enlarged thyroid gland,
tachycardia (due to chorionic thyrotropin secreted by trophoplast &HCG
also has a thyroid stimulating effect.
Breast signs of pregnancy
5/13/2021
med-trainings.com
24

25. Signs
Abdominalexamination:
•Theuterusislargerthantheperiodof
amenorrhoeain50%ofcases,correspondsto
itin25%andsmallerin25%withinactiveor
deadmole.
•Theuterusisdoughyinconsistency
•Foetalpartsandheartsoundcannotbe
detectedexceptinpartialmole.
5/13/2021
med-trainings.com
25

26. Signs
*Localexamination:
>Passageofvesicles(suresign).
>Bilateralovariancysts(5-20cm)in
50%
ofcases.
5/13/2021
med-trainings.com
26

27. Investigations
5/13/2021
med-trainings.com
27
Urinepregnancytest:ispositiveinhighdilution.1/200is
highlysuggestive,1/500issurelydiagnostic.Innormal
pregnancyitispositiveindilutionsupto1/100.
Serum β-hCGlevel:ishighlyelevated(>100000mIU/ml).
*Ultrasonographyreveals:
oThecharacteristicintrauterine"snowstorm"
appearance,
onoidentifiablefoetus,
obilateralovariancystsmaybedetected.
X-ray:showsnofoetalskeleton.

28. PartialMole:Complexmasswithmany
cysticareas(betweenarrowheads)and
anembryo(arrow)inapatientwithaβ-
HCGof280,000miu/ml
5/13/2021
med-trainings.com
28

29. 5/13/2021
med-trainings.com
29
Completemole:“snowstorm”appearance
withmultiplecysticareas,nofetaltissue
present
CorrespondingT1weightedMRI(MRIcan
behelpful indeterminingextentof
trophoblasticdisease
Complete Mole

30. 5/13/2021
med-trainings.com
30

31. Complications
5/13/2021
med-trainings.com
31
•Haemorrhage.
•Infectionduetoabsenceoftheamnioticsac.
•Perforationoftheuterus.
•Pregnancyinducedhypertension
•Hyperthyroidism.
•Subsequentdevelopmentof
choriocarcinoma

32. Treatment
5/13/2021
med-trainings.com
32
•Assoonasthediagnosisofvesicularmoleis
establishedtheuterusshouldbeevacuated.
•Theselectedmethoddependsonthesizeof
theuterus,whetherpartialexpulsionhas
alreadyoccurornot,thepatient'sageand
fertilitydesire.
•Cross-matchedbloodshouldbeavailable
beforestarting.

33. Points to note
Nulliparous women are not given
prostanoids to ripen the cervixsince these
drugs can induce uterine contractions and
might increase the risk of trophoblastic
embolization to the pulmonary vasculature.
Because o the tremendous vascularity of
these placentas, blood products should be
available prior to the evacuation, and
adequate infusion lines established.
5/13/2021
med-trainings.com
33

34. Suctionevacuation
5/13/2021
med-trainings.com
34
ItiscarriedoutunderGA.
Aninfusionof20unitsoxytocinin500m1of5%glucose
shouldbemaintainedthroughouttheprocedure.
DilatationofthecervixisdoneuptoaHegar'snumber
equaltotheperiodofamenorrhoeainweekse.g.No.
10Hegarfor 10 weeks’ amenorrhoea.Thesuction
canulausedwillbeofthesamesizealso.

35. Suctionevacuation
contd…
•Asuctioncanulawhichmaybemetaloradisposableplastic
preferred)isintroducedintotheuterinecavity
•Thecanulaisconnectedtoasuctionpumpadjustedatnegative
pressureof300-500mmHgaccordingtothedurationof
pregnancy.
•Althoughsomerecommendedagentlesharpcurettagetothe
uterusafterevacuation,itispreferabletowaitoneweekforfear
ofuterineperforation.
•Following curettage, because o the possibility o partial mole and
its attendant fetal tissue, Rh immune globulin is given to
nonsensitized Rh D-negative women.
5/13/2021
med-trainings.com
35

36. Hysterotomy
5/13/2021
med-trainings.com
36
•Itmaybeneededforevacuationofalarge
moletominimiseandfacilitatecontrolof
bleeding.
Hysterectomy:Itshouldbeconsideredin
womenover40yearswhohavecompleted
theirfamilyforfearofdeveloping
choriocarcinoma.

37. Followup
5/13/2021
med-trainings.com
37
•Aschoriocarcinomamaycomplicatethe
vesicularmoleafteritsevacuation,
detectionofserumß-hCGby
radioimmunoassayfor2yearsisessential.
•About 3-5% of H.Mole develop
choriocarcinoma & 15-20% become locally
invasive.

38. Followup
5/13/2021
med-trainings.com
38
•Detectionisdoneevery:
hCG levels: obtained within 48 hrs of
evacuation,
Weekly until not detectable for three
consecutive weeks.
Monthly till 6-12 months( partial or comp)
Risk of GTN is <1% after an undectable hCG is
attained.
GTD: 5, Studd Current Progress in Obst & Gyne, 2019

39. Followup
5/13/2021
med-trainings.com
39
•Pelvic Ultrasound:
•Performed with hCG values to monitor
involution of pelvic structures and identify
persistent disease.
GTD: 5, Studd Current Progress in Obst & Gyne, 2019

40. Followup
5/13/2021
med-trainings.com
40
•Reliable contraception:
•Hormonal or Barrier recommended.
•IUCD has risk of perforation X.
•A new gestation should be avoided because it
will obscure value of monitoring hCG levels.
•If hCG remains undectable for 6-12 months
woman desirous of pregnancy may
discontinue contraception
GTD: 5, Studd Current Progress in Obst & Gyne, 2019

41. •Persistenthighlevelindicatesremnantsof
molartissueswhich necessitate
chemotherapy(methotrexate)withor
withoutcurettage.Hysterectomyisindicated
ifwomenhadenoughchildren.
5/13/2021
med-trainings.com
41

42. •RisinghCG,levelafterdisappearancemeans
developingofchoriocarcinomaoranewpregnancy.
Socombinedcontraceptivepillsshouldbeusedfor
preventionofpregnancywhichcanbemisleading.
•Itisexpectedthaturinepregnancytestisnegative4
weeks after evacuation and serum β-hCGis
undetectable4monthsafterevacuation.
*Earlyfeaturessuggestingresidualmolartissueinclude:
orecurrentorpersistentvaginalbleeding,o
amenorrhoea,
ofailureofuterineinvolution,
opersistenceofovarianenlargement.
5/13/2021
med-trainings.com
42

43. Persistent GTD
After evacuation of complete or partial mole hCG
levels show a plateau or rise over several weeks(days
1,7,14,21) more than 4 values in 3 weeks
Rise in serum hCG>10% during these weeks
Serum hCGremains detectable for 6 months or more
Histological of chorioarcinomaor invasive mole
Identification of clinical or radiological metastasis.
5/13/2021
med-trainings.com
43

44. ASSESSMENT
5/13/2021
med-trainings.com
44

45. q1
Hydatidiform mole is principally a disease of:
a. Amnion
b. Chorion
c. Uterus
d. Decidua
5/13/2021
med-trainings.com
45

46. q1
Hydatidiform mole is principally a disease of:
a. Amnion
b. Chorion
c. Uterus
d. Decidua
5/13/2021
med-trainings.com
46

47. Q 2
Follow-up in a patient of H mole is done by:
a. Serum Beta-hCG monitoring
b. Serum CEA level estimation
c. Serum amylase level
d. Serum α-fetoprotein estimation
5/13/2021
med-trainings.com
47

48. Q 2
Follow-up in a patient of H mole is done by:
a. Serum Beta-hCG monitoring
b. Serum CEA level estimation
c. Serum amylase level
d. Serum α-fetoprotein estimation
5/13/2021
med-trainings.com
48

49. q3
Snow storm appearance on USG is seen in:
a. Hydatidiform mole
b. Ectopic pregnancy
c. Anencephaly
d. None of the above
5/13/2021
med-trainings.com
49

50. q3
Snow storm appearance on USG is seen in:
a. Hydatidiform mole
b. Ectopic pregnancy
c. Anencephaly
d. None of the above
5/13/2021
med-trainings.com
50

51. q4
In a case of vesicular mole all of following are high risk
factors for the development of choriocarcinoma
Except:
a. Serum hCG levels > 100000 miu/ml
b. Uterus size larger than 16 week
c. Features of thyrotoxicosis
d. Presence of bilateral theca lutein cysts of ovary
5/13/2021
med-trainings.com
51

52. q4
In a case of vesicular mole all of following are high risk
factors for the development of choriocarcinoma
Except:
a. Serum hCG levels > 100000 miu/ml
b. Uterus size larger than 16 week
c. Features of thyrotoxicosis
d. Presence of bilateral theca lutein cysts of ovary
5/13/2021
med-trainings.com
52

53. q5
Prophylactic chemotherapy in hydatidiform mole
should preferably be given:
a. Prior to evacuation as a routine
b. Following evacuation as a routine
c. Selected cases following evacuation
d. As a routine 6 weeks postevacuation
5/13/2021
med-trainings.com
53

54. q5
Prophylactic chemotherapy in hydatidiform mole
should preferably be given:
a. Prior to evacuation as a routine
b. Following evacuation as a routine
c. Selected cases following evacuation
d. As a routine 6 weeks postevacuation
5/13/2021
med-trainings.com
54

55. Q 6
Risk of recurrence of H mole in future pregnancy is:
a. 1–4%
b. 4–8%
c. 8–10%
d. 10–12%
5/13/2021
med-trainings.com
55

56. Q 6
Risk of recurrence of H mole in future pregnancy is:
a. 1–4%
b. 4–8%
c. 8–10%
d. 10–12%
5/13/2021
med-trainings.com
56

57. Q 7
Percentage of complete moles progressing to persistent
GTN:
a. 1–4%
b. 4–8%
c. 8–12%
d. 15–20%
5/13/2021
med-trainings.com
57

58. Q 7
Percentage of complete moles progressing to persistent
GTN:
a. 1–4%
b. 4–8%
c. 8–12%
d. 15–20%
5/13/2021
med-trainings.com
58

59. Q 8
The criteria for diagnosing GTN are all except:
a. Persistently increasing b-hCG for 3 weeks
b. Plateau levels of b-hCG for 4 weeks
c. Theca lutein cyst ≥6 cm
d. Histological criteria for choriocarcinoma
5/13/2021
med-trainings.com
59

60. Q 8
The criteria for diagnosing GTN are all except:
a. Persistently increasing b-hCG for 3 weeks
b. Plateau levels of b-hCG for 4 weeks
c. Theca lutein cyst ≥6 cm
d. Histological criteria for choriocarcinoma
5/13/2021
med-trainings.com
60

61. references
Williams Gynecology, 3
rd
edition 2016.
Studd J, Tan SL, Chervenak FA: Current Progress in Obst and
Gyne, No 5, 2019, Tree Life Media Mumbai
Majhi AK: Bedside clinics in Obstetrics. Academic Publishers.
3
rd
edition 2015.
Balakrishnan S: Textbook of Gynecology. Paras
Publishers.Delhi 2010
DC Dutta’s OBSTETRICS Including Perinatology and
Contraception. 9
th
Edition. Jaypee New Delhi
Self Assessment Review Obstetrics Sakshi Arora
5/13/2021
med-trainings.com
61

62. Thank you
5/13/2021
med-trainings.com
62