molar pregnancy.pptx

molar pregnancy/ hydatidiform mole

1. Molar Pregnancy Prepared by : Shiksha khanal

2. Hydatidiform mole / Molar pregnancy Hydatiform mole is gestational trophoblastic disease. It is an abnormal condition of the placenta where there are partly degenerative and partly proliferative change in the young chorionic villi. It result in the formation of cluster of small cysts of varying sizes form a pinhead to small grape , this shapeless mass measuring a mm to more than a cm. Looks like bunch of grapes. The embryo dies and absorbed. Because of its superficial resemblance to hydatid cyst,it is named as hydatidiform mole . Best regarded as benign neoplasis of chorian with malignant potential.

3. Etiology The etiology is unknown although there may be an ovular defect or a nutritional deficiency. However the following factors are hypothesized . Prevalence is highest in teenage pregnancy in those women over 35 years of age. Faulty nutrition caused by inadequate intake of protein, animal fat. Low carotein intake in diet is associated with increased risk. · Woman at higher risk for hydatidiform mole formation are those who have undergone ovulation stimulation with Clomiphene.

4. Cytogenic abnormality; complete mole have 46 XX, the molar chromosomes are derived entirely from the father. The ovum nucleus may be either absent (empty ovum) or inactivated which has been fertilized by haploid sperm . History of prior hydatidiform mole increases the chance of recurrence.

5. Types Partial mole Complete mole

6. Partial mole A partial mole often has embryonic or fetal part and an amniotic sac present congenital anomalies are usually present. The potential for malignant transformation. is much less than that associated with complete hydatiform mole . A part of trophoblastic tissue only shows molar change. There is a fetus or at least an amniotic sac.

7. 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 and absorption of the embryo . There is trophoblastic proliferation, with mitotic activity affecting both syncytial and cytotrophobalstic layers. This causes excessive secretion of hCG , chronic thyrotrophin and progesterone. On the other hand, oestrogen production is low due to absence of the fetal supply of precursors.

8. Complete mole:

9. The whole conceptus is transformed into a mass of vesicles. No embryo is present. The complete mole results from fertilization of an egg whose nucleus has been lost or inactivated. The mole resembles a bunch of white grapes. The fluid filled vesicles grow rapidly ,causing the uterus to be larger then expected for the duration of the pregnancy. Usually, the complete mole contains no fetus, placenta, amniotic membranes, or fluid. Maternal blood has no placenta to receive it ,hemorrhage into the uterine cavity and vaginal bleeding ,therefore occurs. In approximately 20% of cases of complete mole,progressin toward choriocarcinoma occurs.

10. Cytogenic studies have demonstrated that complete moles usally have a 46xx karyotype,and the molar chromosomes are entire of paternal origin. Complete mole appers to arise from an ovum that has been fertilized by a haploid sperm, which then duplicates its chromosomes ,and the ovum nucleus may be either absent or inactivated. Although most complete moles have a 46xx chromosomal pattern, approximately 10% have a 46xy karyotype. Chromosomes in 46xy complete mole als appear to be entire of paternal origin but in this circumstance ,an empty egg is fertilized by two sperm.

11. Difference between partial mole and complete mole Features Partial mole Complete mole karyotype Tripliod (69xxy) Diploid (46xx/ xy ) Fetus Present Absent Trophoblastic proliferation Focal Diffuse Trophoblastic scalloping Present Absent Inclusion bodies Present Absent USG Missed abortion Snow storming appearance Uterine size Size<POG Size >POG Beta HCG <10 5 IU <10 5 IU Theca lutein cysts Rare Common Post molar malignant sequelae <5% 20% Immuno staining Positive Negative

12. Clinical Features Symptoms: Vaginal bleeding is the commonest presentation. It may be preceeded by a brownish or watery discharge . Varying degree of lower abdominal pain may be due to ; over distention of the uterus concealed hemorrhage rarely perforation of the uterus by the invasive mole. Infection or Uterine contractions to expel out

13. Expulsion of grape like vesicle per vagina is diagnostic of vesicular mole. History of quickening is absent Other symptoms are ; the woman become sick without any apparent reason . vomiting of pregnancy becomes excessive to the stage of hyperemesis. breathlessness due to pulmonary embolism of trophoblastic cells.

14. Signs: Features sugestive of early months of pregnancy are evident. Woman looks more ill Pallor Features of pre- eclampsia (hypertension, edema, or proteinuria) between 9 and 12 weeks.

15. Per-abdomen The size of the uterus is more than expected period of amenorrhea (50% of case). The feel of the uterus is firm elastic (doughy). This is due to absence of amniotic fluid sac . Fetal parts are not felt, nor any fetal movement. Absence of fetal heart sound.

16. Vaginal Examination Internal ballottement can not be elicited . Unilateral or bilateral enlargement of ovary . Findings of vesicles in the vaginal discharge If the cervical os is open, instead of membranes, blood clot or the vesicles may be felt. 

17. Investigation Full blood count, ABO and Rh grouping. Hepatic, renal, and thyroid function test Sonography , characteristics of molar pregnancy is snow storm appearance. Estimation of serum chorionic gonadotrophin . Urine pregnancy test is positive in high dilution, 1/200 is highly suggestive, 1/500 is surely diagnostic. In normal pregnancy it is positive in dilutions up to 1/100.

18. Straight x-ray abdomen, if the uterus is more than 16 weeks. Straight x-ray chest should also be carried out for evidence of pulmonary embolization. CT and MRI

19. C omplications Immediate 1. Hemorrhage and shock : The cause of hemorrhage are; Separation of vesicles from its attachment to the decidua. The hemorrhage may be concealed or revealed . Massive intra peritoneal hemorrhages which may be first feature of perforation mole . During evacuation of the mole due to atonic uterus or uterine injury.

20. 2. Sepsis : Increased risk of sepsis is due to ; There is no protective membrane Presence of degenerated vesicles, sloughing decidua and old blood . Increased operative interference 3 . Perforation of uterus due to ; perforating mole during vaginal evacuation by D and E 4. Pre- eclampsia 5. Acute pulmonary insufficiency due to pulmonary embolization of the trophoblastic cell. 6. Coagulation failure due to pulmonary embolization of trophoblastic cells 

21. Late: Development of choriocarcinoma following hydatidiform mole

22. M anagement Nursing assessment during prenatal visits should include observation for signs of molar pregnancy during the first 24 weeks. If hydatiform mole is suspected, ultrasound and serial ß- hCG immunoassays are used to confirm the diagnosis. The sonographic pattern of molar pregnancy is characterized by diffuse " snowstrom " pattern. A -B- hCG titer will remain high or rise above normal peak after the time at which it is normal drops (70 to 100 days)

23. Principles of management 1. Supportive therapy to restore the blood loss and to prevent infection. 2. Evacuate the uterus as soon as diagnosis is made 3. Regular follow up for early detection of persistent trophoblastic disease.

24. Supportive therapy : Woman usually presents with variable amount of bleeding. Therefore ; Start ringer's lacted solution IV infusion Arrangement is made for blood transfusion . Blood should also be kept ready prior to elective evacuation of the uterus.

25. 2. Evacuation of uterus Although most moles abort spontaneously, suction/vacuum aspiration is safe, rapid, and effective method of evacuation of hydatidiform mole if necessary. The risk of perforation using metal curette is high . Digital exploration and removal of the mole by ovum forceps may be done to evacuate them . Infuse oxytocin 20 units in 1 liter IV fluids (NS or RL) at 60 drops per minute to prevent hemorrhage once evacuation is under way. Induction of labor with oxytocin or prostaglandins is not recommended because of the increased risk of embolization of trophoblastic tissue .

26. Administration of Rho (D) immune globulin to women who are Rh negative is necessary to prevent isoimmunization . The nurse provides information to the woman and her family about the disease process, necessity for long course of follow up, and the possible consequences of the disease.

27.   3.Follow up management Include frequent physical and pelvic examinations and biweekly measurement of ß- hCG level until the level drops to normal and remains normal for 3 weeks . Monthly measurements are taken for 6 month and then every 2 months for a total of one year . A rising titer and an enlarging uterus may indicate choriocarcinoma . To nurse help the woman to understand and cope with pregnancy loss and recognize that the pregnancy was abnormal.

28. Explanation about importance of the need to postpone a subsequent pregnancy and contraceptive counselling are provided for consistent and reliable method of family planning . The avoid confusion with sign of pregnancy, pregnancy should be avoided for one year. Any contraceptive method except intrauterine device is acceptable, oral contraceptives are highly effective.