Molar pregnancy update 2020 by eMRCOG .pdf

هذا الكتاب يحمل بين طياته معلومات ثريه عن الطب و الرعاية الصحية

1. Molar
pregnancy
Update 2020
By Dr.Rabaa Abdul
.

2. GTG guideline update 2020
GTDs:
Gestational trophoblastic disease
(GTD)
comprises a group of disorders
(hydatidiform mole, invasive mole,
choriocarcinoma, PSTT)
* which can be premalignant*
*The Most common GTD is the molar
pregnancy *
GTN:
Gestational trophoblastic neoplasia (GTN) is a rare form of
cancer.
A molar pregnancy can be thought of as a precancerous
illness which can
occasionally progress to GTN.
* GTN can also happen after a miscarriage or the birth of a
baby. This is
much rarer than after a molar pregnancy, happening only
once in every
50 000 babies born*
GTN has an overall cure rate of close to 100%
* Diagnosis by persistent elevation of b-HCG after end of
pregnancy*
SBA

3. Types
complete hydatidiform mole (CHM) ?SBA partial hydatidiform mole (PHM) ?SBA

4. Hydatidiform
mole
Refers to an abnormalpregnancy
MOLAR PREGNANCY UPDATE 2020
characterised by varying degrees of
trophoblastic proliferation (both
cytotrophoblast and syncytiotrophoblast) and
vesicular swelling of placental villi(villous
hydrops)
fetus/embryo.
associated with an absent or anabnormal
Note : it can come as pathological finding of
products of conception.

6. FACTS
CHM are genetically diploid whereas the vast majorityofPartial moles are Triploid
Molar pregnancy is more common in Asian women at extremes of maternal age
in less than 15 years risk is 1 in 500
in women age above 50 risk 1 in 8
Risk of recurrence after one is less than 2%
1:80
Complete molar pregnancy is characterised by lack of
identifiable fetal tissues diffuse hydatidiform swelling of
chorionicvilli
Partial moles have characteristic focal trophoblast
hyperplasia, trophoblastic pseudoinclusions and identifiable
fetal tissues.

7. Clinical presentation
Vaginal bleeding remains the most common presenting symptom of molar pregnancy and is
associated with approximately 60% of presentations.
•Other symptoms :
A positive pregnancy test and supporting ultrasonographic evidence.
Hyperemesis
Excessive uterine enlargement.
Hyperthyroidism.
Early-onset pre-eclampsia and abdominal distension due to theca lutein cysts.
P Very rarely women can present with haemoptysis or seizures due to metastatic disease
affecting the lungs or brain.

8. How are molar pregnancies diagnosed?
The definitive diagnosis of a molar pregnancy is made by histological
examination
Do you need to perform histological examination for all miscarriages ?
Answer : No
The histological assessment of material obtained from the medical or surgical
management of all miscarriages is recommended to exclude trophoblastic neoplasia
if no fetal parts are identified at any stage of the pregnancy
So, what is the recommended practice ?
Women who receive care for a miscarriage should be recommended to do a urinary
pregnancy test 3 weeks after miscarriage

9. What is the next step if this is still positive ?
serum levels should be tracked to ensure that the level
is falling and .
if not ?
an ultrasound is arranged to look for further pregnancy
tissue.
All tissue obtained in this situation should be sent to
pathology.
The incidence of GTD, unrecognized
prior to removal, is 2.7%.

10. Investigations
uFull blood count, blood group and rhesus antibody serology(RH)
u Serum human chorionic gonadotrophin (hCG) [hCG levels are often > 100 000 iu/lwith complete hydatidiform mole (CHM) but
not partial hydatidiform mole(PHM)]
uHistopathological analysis of products of conception(POC)
uUltrasound
uCharacteristic ultrasound appearance of CHM is a placental mass containing multiple echoes (holes) (so-called snowstorm
vesicular pattern) without an associated embryo and bilateral ovarian thecal luteal cysts.( OHSS )?
uUltrasound of PHM will demonstrate the presence of an embryo butmay also show features consistent with delayed or
incompletemiscarriage.
uThe findings of multiple soft markers (including focal cystic spaces within the placenta) and an increase in the transverse
diameter of the gestational sac (transverse to anterior–posterior dimension ratio > 1.5) are consistent with a diagnosis ofPHM.
uHowever, in general, ultrasound is poorly predictive of a molar pregnancydiagnosis
(as confirmed by histopathology) , with accuracy rates of only 40–60%.SBA

11. U/Sfindings

12. GTD can occur after non-molar pregnancies. Women with abnormal
uterine bleedingfor 8 weeks after a non-molar pregnancy, including
miscarriage or term delivery, should undergo a pregnancy test to
exclude the possibility of persistent gestational trophoblastic
neoplasia (GTN).SBA
Persistent GTD or GTN should be considered in any woman
developing acute respiratory, abdominal or neurological symptoms
after any pregnancy .SBA

13. How should suspected ectopic molar pregnancy in women be managed?
Cases of women with ectopic pregnancy suspected to
be molar in nature should be managed as
any other case of ectopic pregnancy.
If there is a local tissue diagnosis of ectopic molar
pregnancy,
the tissue should be sent to a centre with appropriate
expertise for pathological review.

14. Twin pregnancy with molar pregnancy and singleton viable twin?

15. Prenatal invasive testing for fetal karyotype may be considered in cases where it is a normal twin.
There is an increased risk of early fetal loss (40%)
premature birth (36%) in a twin pregnancy of a viable fetus and coexisting molar pregnancy
pre-eclampsia is variable, with rates as high as 20%
No increase in the risk of developing GTN after such a twin pregnancy and outcome after chemotherapy was unaffected.
Chances of baby survival (51%)
**Some women may wish to continue with their pregnancy.
Increased monitoring for pre-eclampsia, and fetal and maternal wellbeing during such ongoing pregnancies is sensible.
Histological examination of the placenta is recommended and all confirmed cases of GTD registered with a GTD centre.

16. Treatment
Surgicalevacuation
The preferred treatment for women with suspected molar pregnancy who wish to
preserve their fertility is surgical evacuation of the uterus using suctioncurettage
Medicaltermination
Where possible, medical termination of molar pregnancies, including prostaglandin
cervical preparations, should be avoided. This is due to the mainly theoretical risk of
increasing trophoblastic embolisation by inducing uterine contractions.
Exception : only ( for example, if severe haemorrhage hasoccurred).
Anti-D administration
Women who are Rhesus D-negative should receive anti-D Rhesus immunoglobulin at the
time of surgical evacuation as Rhesus D antigen is expressed ontrophoblast.
SBA

17. Hysterectomy:
hysterectomy may be considered appropriateas
-Elective (e.g. women with stage 1 GTN confined to the uterus who do not seek future fertility)
or
-Emergency (e.g. life-threatening intraoperative haemorrhage)procedure.
hCG surveillance should still be continued post hysterectomy.!! WHY?
Seconduterineevacuation??? WHEN??
This decision is ideally made following discussions with the trophoblast monitoring centre and should
be performed by a senior gynaecologist. Further evacuations are usually contraindicated because they
are associated with significant risks of infection, haemorrhage and uterine perforation without
reducing the subsequent need forchemotherapy.
In general, second uterine evacuation is rarely required, however, justification may arise if:
there is plateauing or rising hCG that is less than 1500IU/l
presence of significant amount of abnormal intrauterine tissue on repeat ultrasound
and/or patient is experiencing heavy vaginalbleeding.

18. Registration for hCGsurveillance
All histopathologicallyconfirmed hydatidiform moles
should beregisteredwith a specialist centre for hCG
surveillance.
The nominated UK hCG surveillance/molar
pregnancy registration centres are.SBA
-Sheffield
-London
-Dundee
https://www.thewomens.org.au/health-professionals/oncology/gestational-
trophoblastic-disease-registry

19. hCG
estimations
& F/U
Following registration for a molar pregnancy, all women send blood or
urine samples to their nearest regional centre for hCGestimations.
Once HCG isnormalised:
If this occurred ≤56 days after evacuation, measure urine
concentrations monthly for 6 months from the date of evacuation.
More than half of all patients will have complete regression of hCG
within 56 days ofevacuation
If this occurred >56 days after evacuation, measure urine
concentrations monthly for 6 months from the date hCG became
normalised

20. •if hCG has reverted to normal within 56 days of the pregnancy
event then follow-up will be for 6 months from the date of
management
but if takes longer than 56 days .. f/u will be months
for 6 months from normalization of the hCG level.
Complete molar
pregnancy
•Is concluded once the hCG has returned to normal on two samples.
at least 4 weeks apart. Partial molar
•not need to send a post-pregnancy hCG sample.
Subsequent
pregnancies

21. Contraception:
Advice to avoidpregnancy
Women are advised not to conceive until they complete FU
but , if received Chemotherapy ttt: 1 year aftercompletion of treatment, as a
precautionary measure.
Patients are advised not to conceive and use non-hormonal barrier methods of
contraception until hCG levels revert tonormal.

22. Q: Is it safe to use HRT following molar pregnancy ?
A: Hormone replacement therapy may be used once hCG
levels have returned to normal.
(GTG 2020)
Q: Is the use of exogenous estrogens and other fertility drugs safe for women undergoing assisted reproductive
treatment after a molar pregnancy?
The use of exogenous estrogens and other fertility drugs may be used once hCG levels have returned to
normal. [New 2020]

24. What is the optimum treatment forGTN?
Treatment used is based on the FIGO 2000scoringsystem.SBA &EMQ
The need for chemotherapy following a complete mole is 15% and 0.5 % after a partial
mole.
The outlook for women treated for GTN is generally excellent with an overall cure rate close to 100%.
development of postpartum GTN requiring chemotherapy occurs at a rate of 1/50000 births.
Women with scores ≤ 6:
are at low risk and are treated with single-agent intramuscular methotrexate
alternating daily with folinicacid for 1 week followed by 6 restdays.
Women with scores ≥ 7:
are at high risk and are treated with intravenous multi-agentchemotherapy
Treatment is continued, in all cases, until the hCG level has returned to normal and then for a
further 6 consecutiveweeks.

25. Key notes :SBA
•The cure rate for women with a score ≤ 6 isalmost100%; the rate forwomen
•with a score ≥7is95%
•Placental site trophoblastic tumour is now recognised as a variant of gestational
trophoblastic neoplasia. It may be treated with surgerybecause it is less sensitive to
chemotherapy.
•Women should be advised not to conceive until their follow-up iscomplete.
•Women who undergo chemotherapy are advisednot to conceive for 1 yearafter
completion oftreatment.
•The risk of a further molar pregnancy is low(1/80)
60-80% will be of the same histologicaltype

26. Cont.ofKey notesSBA
❑Side effects of chemotherapy:
-It can bring menopause early by 1 year in case of single agent chemotherapy .
and 3 years in case of use of multi agentchemotherapy
-this is risk of develop secondry cancer in case of multiple agentchemo.
❑Contraception afterGTD
-Use of barrier contraception is recommended , however if women already on COC ,
she can continue.
-Use of IUCD is contraindicated with GTD.
❑Hormone replacement therapy may be used safely once hCG levels have returned to
normal.

27. Emq : Select the most appropriate treatment option for
the clinical situations described
.
A-A 37 -year-old woman has bleeding for 10 months following her second
vaginaldelivery.
Uterine evacuation identifies choriocarcinoma ,
Ultrasoundshows a4 -cmlesioninthemyometriumandchestx-rayshows
multiple lungnodules.
B-A41Y-Owomanhasamolarpregnancyevacuateduneventfully.
TheHCGdecreasesfrom95000to1000IU/l4weeksaftertheevacuation.but
thenpersistsat900mIU/mlfor4weeks.Clinicalexaminationshowsno
abnormalityorevidenceofmetastases.
Ultrasoundoftheuterusshowsa2-cmlesioninthemyometrium.Chestx-rayis
negative

28. Options:
1-multiple agentchemotherapy
2-hysterectomy
3-Methotrexate andhysterectomy
4-Methotrexate / folinicacid
5-Repeat suction and evacuation of RPOC.

29. Sba-Which one of the following factors is characteristically
associated with partial hydatidiform mole?
1No evidence of fetal tissue or fetal red blood cells on histology.
2Arise due to dispermic fertilisation of an ovum .
3-All cases have triploid karyotype.
4-Histology shows diffuse villous hydrops and diffuse trophoblast
hyperplasia.
5-Higher risk of requiring chemotherapy than complete hydatidiformmole.