Molar Pregnancy Complete Vs Incomplete Hydatidiform Mole.pptxpptx

Complete And Incomplete Hydatidiform Mole.pptxpptx

1. Dr.Massam MOLAR PREGNANCY

2. Objectives Definitions Risk factors Clinical features Complications Investigations Treatments Follow up plans

3. Definitions Molar pregnancy is one of the disease conditions originating from the trophoblast (placenta ). These disease conditions are collectively called the Gestational trophoblastic disease (GTD) Apart from molar pregnancy, other GTD are :- Placental site trophoblastic tumours Choriocarcinomas Invasive mole

4. Definitions Molar pregnancy- abnormal form of pregnancy in which a non viable fertilized egg implants in the uterus and will fail to come to term. Is a gestational trophoblastic disease (GTD) Occurs when a fertilized egg does not contain an original maternal nucleus i.e. an empty egg + sperm

5. Modified WHO classification of GTD Molar pregnancies: Hydatidiform mole - Complete mole -Partial mole 2 . Invasive mole Trophoblastic tumors: Choriocarcinoma Placenta site trophoblastic tumor (PSTT) Epithelioid trophoblastic tumor (ETT)

6. MOLAR PREGNANCY/HYDATIDIFORM MOLE Molar pregnancy as hydatidiform mole is divided into two types:- Complete moles Partial moles

7. Complete moles A single sperm ( abt 90%) or two sperms (10%)..combining with an egg which has lost its DNA. No fetal tissue present 46,XX (Diploid), 46,XY (Diploid). 46 ,YY (diploid) is not observed

8. Complete Mole Empty ovum + 23X sperm → 23X →duplicate→ 46XX (90%) Empty ovum + 23X → 46XX 23X Empty ovum + 23X → 46XY 23Y

9. Complete mole

10. Partial moles Partial moles occurs when a haploid egg is fertilized by two sperms or by one sperm which reduplicates itself yielding the genotype of 69,XXY (triploid) OR 92,XXXY ( tetraploid ) Fetal tissue is present (fetal erythrocytes +blood vessels)

11. Partial Mole 23X ovum +23X sperm = 69XXX 23X 23X ovum +23Y sperm =69XYY 23Y 23X ovum +23X sperm =69XXY 23Y

12. Partial mole

13. Complete Partial COMPLETE MOLE PARTIAL MOLE KARYOTYPE 46,XX 46,XY 69,XXY hCG Uterine Size __ Fetal parts No YES Components 2 sperms + empty egg 2 sperms + 1 egg Risk of complications 15-20% malignant trophoblatic disease Low risk of malignancy (<5%)

14. COMPLETE MOLE PARTIAL MOLE KARYOTYPE 46XX, 46XY 69XXX, 69XXY, 69YYX HISTOLOGY FETAL EMBRYO ABSENT PRESENT VILLI EDEMATOUS DIFFUSED FOCAL TROPHOBLASTIC PROLIFERATION MAY BE MARKED FOCAL MINIMAL p57KIP2 NEGATIVE POSITIVE CLINICAL DIAGNOSIS MOLAR GESTATION INCOMPLETE ABORTION POST MOLAR GTN 15% 4-6% DIFFERENCE BETWEEN COMPLETE AND PARTIAL MOLE

15. ETIOLOGY AND RISKS FACTORS The exact etiology is not well understood . Risk factors: Maternal age (extremes <15 & >45) Older paternal age Previous hx of GTD & Hx of spontaneous abortion Nutritional deficiency of carotene, folic acid, proteins and vitamin A and high carbohydrates. AB blood group of the parents Smoking

16. CLINICAL FEATURES - Complete moles Vaginal bleeding-uterus may become distended by large amount of blood + dark fluid may leak into the vagina-50% Hyperemesis –severe nausea +vomiting Thyrotoxic features of tremors or tachycardia (2%). It is probably due to increased chorionic thyrotropin Varying degree of lower abdominal pain

17. Clinical features - Complete mole Breathlessness due to pulmonary embolization of the trophoblastic cells (2%). Expulsion of grape like vesicles per vagina is diagnostic of vesicular mole. Actually, in approximately 50% of cases the mole is not suspected until it is expelled in part or whole. History of quickening is absent.

18. Generally

19. Clinical features - Partial moles Usually mimic the symptoms of incomplete /missed abortion Vaginal bleeding + absence of fetal heart beats

20. Physical examination Complete moles Large uterus than expected GA - excessive trophoblastic growth + retained blood Pre eclampsia _2% Theca lutein cyst – ovarian cyst > 6 cm in diameters, increased hCG , GA > 10 Weeks.Presents with pressure or pelvic pain, regress after evacuation – up to 12 weeks.

21. Physical examination con't... Features suggestive of early months of pregnancy are evident. The patient looks more ill than can be accounted for. Pallor The feel of the uterus is firm elastic (doughy). Fetal parts are not felt, nor any fetal movements. Absence of fetal heart sound

22. Physical examination – PARTIAL MOLES Uterine enlargement than GA PRE ECLAMPSIA

23. COMPLICATIONS Perforation of the uterus Hemorrhage Disseminated intravascular coagulation Acute respiratory distress- trophoblastic embolism esp with a large uterus than gestation age.

24. Complications con't ... Pre- eclampsia Sepsis as no protective layer the vaginal organisms can invade the uterus The development of choriocarcinoma in 2 -10%

25. DIFFERENTIAL DIAGNOSIS Hyperemesis gravidarum Hypertension Hyperthyroidism/Thyrotoxicosis Abortion

26. INVESTIGATIONS NB: Most of the investigations are done at hospital level, consider referral Quantitative beta –Hcg levels , hCG >100,000 mIU/mL, may indicates trophoblastic growth. Full blood picture- Hb - anemia??, platelets –coagulopathy?? Ultrasound – bunch of grapes or honeycombed uterus or snow storm appearance, (intrauterine mass containing many small cysts)

27. Chest X ray- lungs primary site of metastatis Histology Complete moles - oedematous placenta villi , hyperplasia of trophoblast , no fetal tissue Incomplete moles - oedematous villi , trophoblastic proliferation.

28. TREATMENT Also consider referral when at dispensary or health center level Blood transfusion, if anaemic Fresh frozen plasma - DIC Contraception for 6 month

29. TREATMENT SURGICAL CARE Evacuation of the uterus by dilation and curettage IV Oxytocin is used after the dilation of the cervix at the initiation of suctioning and postoperatively to reduce likelyhood of hemorrhage

30. PROGNOSIS Complete hydatidiform mole - 15-20% risk of developing into choriocarcinoma and 15% to invasive mole. Accounts for 50% of all cases of choriocarcinoma . Incomplete moles can become invasive (<5%) but not choriocarcinoma One percent of women with molar pregnacy may have recurrence

31. MONITORING Serial quantitative beta hCG Weekly until levels are within reference range for 3-4 weeks hCG levels should consistently drop,never increase, and should get back to normal (8-12 weeks) after evacuation Once reference range reached (3-4 weeks) , continue checking monthly for 6 month

32. MONITORING If the level of hCG plateau or rise ,think of malignant transformation. Effective contraception- if IUD was chosen , to avoid perforation and bleeding , insertion should wait for uterus involution to occur and normalization of serum hCG levels

33. Key points Molar pregnancy is one among the diseases called the Gestational Trophoblastic Diseases (GTD) A doctor has to diagnose proparly and provide appropriate management.

34. Evaluation How a molar pregnancy is formed? What are the clinical features of a complete molar? What are the risk factors for a molar pregnancy to turn into malignancy?

35. Reference DC Dutta's Textbook of Obstetrics 7th Edition