vesicular molle 1

1. Gestational Trophoblastic DiseaseGestational Trophoblastic Disease
•Complete vesicular moleComplete vesicular mole
•Partial vesicular molePartial vesicular mole
•Invasive mole Invasive mole
•Placental-site Placental-site
trophoblastic tumortrophoblastic tumor
•Choriocarcinoma Choriocarcinoma

2. DefinitionDefinition
It is a benign neoplasm of the chorionic It is a benign neoplasm of the chorionic
villi, characterized by:villi, characterized by:
•Marked proliferation of the trophoplast,Marked proliferation of the trophoplast,bothboth the the
syncytium & cytotrophoplast are affected.syncytium & cytotrophoplast are affected.
•Oedema or hydropic degeneration of the Oedema or hydropic degeneration of the
connective tissue stroma of the villiconnective tissue stroma of the villi which leads which leads
to their distension and formation of vesicles.to their distension and formation of vesicles.
•Avascularity of the villiAvascularity of the villi:: the blood vessels the blood vessels
disappear from villi explaining early death of disappear from villi explaining early death of
the embryothe embryo

3. Incidence:Incidence:
•1:20001:2000 pregnancies in United States pregnancies in United States
and Europe, but and Europe, but 10 times10 times more in Asia. more in Asia.
•Predisposing factors includePredisposing factors include : :
Race,deficiency of protein or caroteneRace,deficiency of protein or carotene
•The incidence is higher toward the The incidence is higher toward the
beginning and more toward the end of beginning and more toward the end of
the childbearing period.the childbearing period.
•It is It is 10 times10 times more in women over 45 more in women over 45
years old.years old.

4. Pathology:Pathology:
•The uterus is distended by thin walled, The uterus is distended by thin walled,
translucent, grape-like translucent, grape-like vesiclesvesicles of of
different sizes. different sizes.
•These are These are degenerated chorionic villidegenerated chorionic villi
filled with fluid.filled with fluid.
•There is There is no vasculature in the chorionic no vasculature in the chorionic
villivilli leads to early death and absorption leads to early death and absorption
of the embryo.of the embryo.

5. •There is There is trophoblastic proliferationtrophoblastic proliferation, ,
with mitotic activity affecting both with mitotic activity affecting both
syncytial and cytotrophoblastic layers. syncytial and cytotrophoblastic layers.
•This causes This causes excessive secretion of excessive secretion of
hCG, chorionic thyrotrophin and hCG, chorionic thyrotrophin and
progesterone. progesterone.
•On the other hand, On the other hand, oestrogen oestrogen
production is lowproduction is low due to absence of due to absence of
the foetal supply of precursors.the foetal supply of precursors.
Pathology:

6. •High hCG causes High hCG causes multiple theca lutein multiple theca lutein
cystscysts in the ovaries in about 50% of in the ovaries in about 50% of
cases.cases.
•Cysts may reach a large size (10 cm or Cysts may reach a large size (10 cm or
more.more.
•Cysts disappear within few Cysts disappear within few
months(2-3), after evacuation of the months(2-3), after evacuation of the
mole. mole.
•High hCG also results in High hCG also results in exaggeration exaggeration
of the normal early pregnancy of the normal early pregnancy
symptoms and signssymptoms and signs
Pathology:Pathology:

8. •Histologic section of a complete Histologic section of a complete
hydatidiform mole stained with hydatidiform mole stained with
hematoxylin and eosin. hematoxylin and eosin.
•Villi of different sizes are present.Villi of different sizes are present.
• The large villous in the center The large villous in the center
exhibits marked edema with a exhibits marked edema with a
fluid-filled central cavity known fluid-filled central cavity known
as cisterna. as cisterna.
•Marked proliferation of the Marked proliferation of the
trophoblasts is observed.trophoblasts is observed.
• The syncytiotrophoblasts stain The syncytiotrophoblasts stain
purple, while the cytotrophoblasts purple, while the cytotrophoblasts
have a clear cytoplasm and bizarre have a clear cytoplasm and bizarre
nuclei. nuclei.
•No fetal blood vessels are in the No fetal blood vessels are in the
mesenchyme of the villi. mesenchyme of the villi.

10. (i) Complete mole:(i) Complete mole:
•The whole conceptus is transformed The whole conceptus is transformed
into a mass of vesicles. into a mass of vesicles.
•No embryoNo embryo is present. is present.
•It is the result of fertilization of It is the result of fertilization of
enucleated ovum ( has no enucleated ovum ( has no
chromosomes) with a sperm which chromosomes) with a sperm which
will duplicate giving rise to will duplicate giving rise to 46 46
chromosomeschromosomes of of paternal originpaternal origin only. only.

11. (i) Complete mole:(i) Complete mole:

12. (ii) Partial mole(ii) Partial mole
- A part of trophoblastic tissue only
shows molar changes.
- There is a foetus or at least an
amniotic sac.
- It is the result of fertilization of an
ovum by 2 sperms so the
chromosomal number is 69
chromosomes

14. (ii) Partial mole(ii) Partial mole

15. DIFFERENTIATION BETWEEN DIFFERENTIATION BETWEEN
COMPLETE AND PARTIAL MOLE COMPLETE AND PARTIAL MOLE
Rare5-10%Malignant ChangesMalignant Changes
Paternal and
maternal 69 XXY or
69 XYY
Paternal 46 XX
(96%) or 46 XY (4%)
KaryotypeKaryotype
FocalDiffuseTrophoblastic Trophoblastic
hyperplasiahyperplasia
FocalDiffuseSwelling of the villiSwelling of the villi
PresentAbsentEmbryonic or foetal Embryonic or foetal
tissuetissue
Partial MolePartial MoleComplete MoleComplete MoleFeatureFeature

17. (A) (A) SymptomsSymptoms::
•AmenorrhoeaAmenorrhoea:: usually of short usually of short
period (2-3 months).period (2-3 months).
•Exaggerated symptomsExaggerated symptoms of of
pregnancy especially vomiting.pregnancy especially vomiting.
3.Symptoms of 3.Symptoms of preeclampsiapreeclampsia
may be present as headache, may be present as headache,
and oedemaand oedema

18. 4. 4. Vaginal bleedingVaginal bleeding : :
• The main complaint, due to separation of The main complaint, due to separation of
vesicles from uterine wall, there may be a vesicles from uterine wall, there may be a
blood stained watery discharge, the watery blood stained watery discharge, the watery
part is from ruptured vesicles.part is from ruptured vesicles.
•Prune juicePrune juice disharge may occur. disharge may occur.
•The blood is brown because it has retained The blood is brown because it has retained
for sometime in the uterine cavity. for sometime in the uterine cavity.
•The The passage of vesiclespassage of vesicles is diagnostic. is diagnostic.
•The blood may be concealed causing The blood may be concealed causing
enlargment & tenderness of the uterus. enlargment & tenderness of the uterus.
(A) Symptoms:(A) Symptoms:

19. 5. 5. Abdominal painAbdominal pain : may be , : may be ,
- - dull-achingdull-aching due to rapid distension of the due to rapid distension of the
uterus by the mole or by cocealed uterus by the mole or by cocealed
haemorrhage.haemorrhage.
- - colickycolicky due to starting expulsion, due to starting expulsion,
-sudden and severesudden and severe due to perforating mole due to perforating mole
-Ovarian painOvarian pain due to stretching of the ovarian due to stretching of the ovarian
capsule or complication in the cystic ovary as capsule or complication in the cystic ovary as
torsiontorsion
(A) Symptoms:(A) Symptoms:

21. General examination:General examination:
•Pre-eclampsia develops in 20-30% of
cases, usually before 20 weeks’ gestation.
•Pallor indicating anemia may be present.
•Hyperthyroidism develops 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.

22. Abdominal examination:Abdominal examination:
•The uterus isThe uterus is larger larger than the period of than the period of
amenorrhoea amenorrhoea in 50%in 50% of cases, of cases,
corresponds to it in 25%corresponds to it in 25% and and smaller in smaller in
25%25% with inactive or dead mole. with inactive or dead mole.
•The uterus isThe uterus is doughy doughy in consistency due in consistency due
to absence of amniotic fluid and its to absence of amniotic fluid and its
distension with vesicles. distension with vesicles.
•Foetal parts and heart sound cannot be Foetal parts and heart sound cannot be
detected except in partial mole.detected except in partial mole.
•Absence of external ballottement.Absence of external ballottement.

23. Local examination :
•Passage of vesicles (sure
sign).
•Bilateral ovarian cysts in
50% of cases.
•No internal ballottement.

24. •Urine pregnancy test:Urine pregnancy test:
is positive in high dilution. is positive in high dilution.
•1/200 is highly suggestive, 1/200 is highly suggestive,
•1/500 is surely diagnostic. 1/500 is surely diagnostic.
•In normal pregnancy it is In normal pregnancy it is
positive in dilutions up to 1/100.positive in dilutions up to 1/100.
2. 2. Serum b -hCG levelSerum b -hCG level:: is highly is highly
elevated ( > 100.000 mIU/m1).elevated ( > 100.000 mIU/m1).
(C) Investigations:(C) Investigations:

25. (C) Investigations:(C) Investigations:
3. 3. UltrasonographyUltrasonography revealsreveals::
•The characteristic intrauterine The characteristic intrauterine "" snow snow
stormstorm"" appearance, appearance,
•no identifiable foetus,no identifiable foetus,
•bilateral ovarian cysts may be detected.bilateral ovarian cysts may be detected.
4. 4. X-rayX-ray to the abdomen: to the abdomen: shows no foetal shows no foetal
skeleton.skeleton.
5. 5. X-rayX-ray of the chest: of the chest: should be performed in should be performed in
every case of trophoplastic tumour. every case of trophoplastic tumour.

26. A real-time ultrasound of a hydatidiform mole.
The dark circles of varying sizes at the top
center are the edematous villi.

27. Complications:
•HaemorrhageHaemorrhage..
•Infection Infection due to absence of the amniotic sac and due to absence of the amniotic sac and
due to the large surface area left after expulsion due to the large surface area left after expulsion
or evacuation of the mole.or evacuation of the mole.
•PerforationPerforation of the uterus. Spontaneous by a of the uterus. Spontaneous by a
perforating mole or during evacuation.perforating mole or during evacuation.
•Pregnancy induced Pregnancy induced hypertensionhypertension
•HyperthyroidismHyperthyroidism..
•Subsequent development of Subsequent development of choriocarcinomachoriocarcinoma in in
about about 5%5% of cases and of cases and invasive moleinvasive mole in about in about
10%10% of cases. of cases.
•Recurrent moleRecurrent mole may occur( may occur(1-2%1-2%).).

28. Treatment:
•As soon as the diagnosis of vesicular As soon as the diagnosis of vesicular
mole is established the mole is established the uterus should be uterus should be
evacuated.evacuated.
•The selected method depends on the The selected method depends on the
sizesize of the uterus, whether of the uterus, whether partial partial
expulsionexpulsion has already occur or not, the has already occur or not, the
patient's agepatient's age and and fertility desirefertility desire..
•Cross - matched Cross - matched bloodblood should be should be
available before starting.available before starting.

29. - It is carried out under general
anaesthesia, but not that which
relax the uterus as halothane as it
may induce severe bleeding.
- An infusion of 20 units oxytocin in
500 m1 of 5% glucose should be
maintained throughout the
procedure.
(I) Suction evacuation:(I) Suction evacuation:

30. -Dilatation of the cervixDilatation of the cervix is done is done
up to a Hegar's number equal to up to a Hegar's number equal to
the period of amenorrhoea in the period of amenorrhoea in
weeks e.g. Nweeks e.g. Noo. 10 Hegar for 10 . 10 Hegar for 10
weeks’ amenorrhoea. weeks’ amenorrhoea.
-The suction canula used will be of The suction canula used will be of
the same size also. the same size also.
(I) Suction evacuation:(I) Suction evacuation:

31. (I) Suction evacuation:
- A suction canula which may be metal
or a disposable plastic (preferred) is
introduced into the uterine cavity.
-The canula is connected to a suction
pump adjusted at negative pressure of
300-500 mmHg according to the
duration of pregnancy.
-The material removed is sent for
histological examination.

32. Curettage
•After evacuation ,the uterus is After evacuation ,the uterus is
gently curettedgently curetted with a sharp with a sharp
curette.curette.
•Some advise Some advise curettage one week curettage one week
afterafter evacuation to ensure evacuation to ensure
complete removal, but the is not complete removal, but the is not
the routine practice.the routine practice.

33. Theca lutein cystsTheca lutein cysts
•They are hormone dependent.
•Disappear spontaneously after
evacuation of the mole.
•So, they are not removed
surgically unless complication
occur as torsion or rupture.

34. (II)Hysterotomy:(II)Hysterotomy:
It may be needed for It may be needed for
evacuation of a large evacuation of a large
mole to minimize and mole to minimize and
facilitate control of facilitate control of
bleeding.bleeding.

35. (III) Hysterectomy:
It should be considered in
women over 40 years who
have completed their family
for fear of developing
choriocarcinoma.

36. (IV) Medical induction:
Oxytocins and / or
prostaglandins may be used to
encourage expulsion of the
mole but must always be
followed by surgical
evacuation.

37. Follow up :Follow up :
As choriocarcinoma may As choriocarcinoma may
complicate the vesicular complicate the vesicular
mole after its evacuation, mole after its evacuation,
detection of serum ß-hCG by detection of serum ß-hCG by
radioimmunoassay is radioimmunoassay is
essentialessential

38. • ß-hCG is measured by ß-hCG is measured by
radioimmunoassay every week radioimmunoassay every week
till the test becomes negative till the test becomes negative
for 3 successive weeks, then for 3 successive weeks, then
the test is repeated every the test is repeated every
month for one year.month for one year.
•Pregnancy is allowed if the test Pregnancy is allowed if the test
remains negative for one year.remains negative for one year.
Follow up :Follow up :

39. Follow up :Follow up :
-Persistent high levelPersistent high level indicates indicates
remnants of molar tissues which remnants of molar tissues which
necessitate chemotherapy necessitate chemotherapy
( methotrexate) with or without ( methotrexate) with or without
curettage. Hysterectomy is indicated if curettage. Hysterectomy is indicated if
women had enough children.women had enough children.
-Rising hCG levelRising hCG level after disappearance after disappearance
means developing of choriocarcinoma means developing of choriocarcinoma
or a new pregnancy. or a new pregnancy.

40. It is expected that urine It is expected that urine
pregnancy test is pregnancy test is negative negative
4 weeks 4 weeks after evacuationafter evacuation
and serum b -hCG is and serum b -hCG is
undetectable undetectable 4 months4 months
after evacuation.after evacuation.
Follow up :Follow up :

41. Contraception during follow upContraception during follow up
•The combined pill is started when the The combined pill is started when the
beta-HCG becomes negative.beta-HCG becomes negative.
•Till this happens, the condom can be Till this happens, the condom can be
used.used.
•If the pill is used early the beta-HCG If the pill is used early the beta-HCG
will take a longer time to become will take a longer time to become
negative as oestrogen stimulates the negative as oestrogen stimulates the
growth of trophoplast.growth of trophoplast.

42. The The intrauterine deviceintrauterine device is is
not used because it may not used because it may
lead to irregular uterine lead to irregular uterine
bleeding which confuses bleeding which confuses
the follow upthe follow up
Contraception during Contraception during
follow upfollow up

43. Invasive Mole or Invasive Mole or
Chorioadenoma DestruensChorioadenoma Destruens
•It is a trphoplastic tumour with It is a trphoplastic tumour with
penetration of the myometrium penetration of the myometrium
by the chorionic villi.by the chorionic villi.
•It is locally malignant and rarely It is locally malignant and rarely
metastasizes.metastasizes.
•It may lead to perforation of It may lead to perforation of
uterusuterus

44. Early features suggesting
residual molar tissue
include:
2.recurrent or persistent
vaginal bleeding,
3.amenorrhoea,
4.failure of uterine involution,
5.persistence of ovarian
enlargement.