MOLAR PREGNANCYMOLAR PREGNANCY

Dr. NADIA NAZEERDr. NADIA NAZEER

INTRODUCTION:INTRODUCTION:

Molar pregnancy is a premalignant form of Gestational trophoblastic Molar pregnancy is a premalignant form of Gestational trophoblastic

diseases that occur after abnormal fertilization.diseases that occur after abnormal fertilization.

Risk FactorsRisk FactorsAge < 15->40Age < 15->40

Previous history of hydatidiform molePrevious history of hydatidiform mole

Previous miscarriagePrevious miscarriage

Excessive smokingExcessive smoking

Reduce carotene intakeReduce carotene intake

TYPES OF HYDATIDIFORM TYPES OF HYDATIDIFORM MOLEMOLE

Complete hydatidiform moleComplete hydatidiform mole Partial hydatidiform molePartial hydatidiform mole

PATHOLOGYPATHOLOGY Complete mole:Complete mole:

CHMs develop without the formation of fetal tissue. On pathologic CHMs develop without the formation of fetal tissue. On pathologic evaluation, CHMs demonstrate swollen chorionic villi with a evaluation, CHMs demonstrate swollen chorionic villi with a grapelike appearance and with hyperplasic trophoblastic tissue. grapelike appearance and with hyperplasic trophoblastic tissue.

Transverse endovaginal sonogram of a second-trimester complete hydatidiform mole (CHM) demonstrates a distended endometrial cavity containing innumerable, variably sized anechoic cysts with intervening hyperechoic material.

Partial Hydatidiform mole:Partial Hydatidiform mole:

Fetal tissue is often present in PHMs, but the fetus is nonviable, it is Fetal tissue is often present in PHMs, but the fetus is nonviable, it is severely growth restricted, or it has multiple anomalies. On severely growth restricted, or it has multiple anomalies. On pathologic analysis, PHMs show unpronounced swelling of chorionic pathologic analysis, PHMs show unpronounced swelling of chorionic villi and unpronounced trophoblastic hyperplasia. villi and unpronounced trophoblastic hyperplasia.

Transverse transpelvic sonogram of a partial hydatidiform mole (PHM) at 16 weeks. The major imaging feature is the presence of fetal tissue on the left side of the image and the many small cysts that replace the placental tissue on the right side. This finding has a distribution more focal than that typically found in CHM.

Genetics.Genetics. Complete mole:Complete mole:

CHMs have a diploid chromosomal pattern, with all CHMs have a diploid chromosomal pattern, with all chromosomes being derived from the father by means of chromosomes being derived from the father by means of either monospermic or dispermic fertilization.either monospermic or dispermic fertilization.

Partial Mole:Partial Mole: Partial hydatidiform moles (PHMs) usually have a Partial hydatidiform moles (PHMs) usually have a

triploid karyotype (69XXX, 69XXY, or 69XYY) triploid karyotype (69XXX, 69XXY, or 69XYY) resulting from fertilization of a normal egg by 2 resulting from fertilization of a normal egg by 2 sperm. Therefore, triploid PHMs consist of 2 sets of sperm. Therefore, triploid PHMs consist of 2 sets of paternal chromosomes and 1 set of maternal paternal chromosomes and 1 set of maternal chromosomes. chromosomes.

CLINICAL FEATURESCLINICAL FEATURES Vaginal Bleeding.There is passage of grape Vaginal Bleeding.There is passage of grape

like vesicles in vaginal bleeding.like vesicles in vaginal bleeding. Uterine Enlargement more than of dates.Uterine Enlargement more than of dates. Hyperemesis GravidarumHyperemesis Gravidarum Theca Lutein Cyst.It is usually bilateral and Theca Lutein Cyst.It is usually bilateral and

due to hyperstumulation of ovaries by beta due to hyperstumulation of ovaries by beta hCG hCG

Pre-eclampsiaPre-eclampsia Hyperthyroidism.It is due to TSH LIKE Hyperthyroidism.It is due to TSH LIKE

function alpha subunits of beta hCGfunction alpha subunits of beta hCG

COMPLICATIONSCOMPLICATIONS

Immediate Complications:Immediate Complications:1.1. Uterine perforationUterine perforation

2.2. HaemorrhageHaemorrhage

3.3. Pelvic sepsisPelvic sepsis

Long Terms Complications:Long Terms Complications:1.1. Invasive moleInvasive mole

2.2. ChoriocarcinomaChoriocarcinoma

INVESTIGATIONSINVESTIGATIONS Human Chronic Gonadotrophin: Human Chronic Gonadotrophin: The The

syncytiotrophoblast is responsible for producing beta-syncytiotrophoblast is responsible for producing beta-human chorionic gonadotropin (hCG).human chorionic gonadotropin (hCG).

Ultra SonoGraphy:Ultra SonoGraphy: Sonography is the imaging investigation of choice for Sonography is the imaging investigation of choice for

hydatidiform mole. The most common sonoghraphic hydatidiform mole. The most common sonoghraphic picture is the snow storm or granular appearance which picture is the snow storm or granular appearance which represent the hyperechoic central urterine mass with represent the hyperechoic central urterine mass with hypoechoic cystic spaces with no fetal parts in case of hypoechoic cystic spaces with no fetal parts in case of complete mole.complete mole.

In 25% cases a typical appearance.In 25% cases a typical appearance.

1.1. Large hyperechoic area.Large hyperechoic area.

2.2. Single large central fluid collection with hyperechoic Single large central fluid collection with hyperechoic rim resembling and anembryonic gestation. rim resembling and anembryonic gestation.

3.3. Bilateral theca lutein cysts are visualized in 50% of Bilateral theca lutein cysts are visualized in 50% of the cases. the cases.

MRI:MRI:

MRI has no established role in the initial MRI has no established role in the initial diagnosis of hydatidiform moles. It is useful in diagnosis of hydatidiform moles. It is useful in malignant forms of gestational trophoblastic malignant forms of gestational trophoblastic neoplasm (GTN) to characterize the degree of neoplasm (GTN) to characterize the degree of myometrial and/or parametrial invasion and myometrial and/or parametrial invasion and to assess the treatment response.to assess the treatment response.

Complete Mole. Complete Mole. Transabdominal and transvaginal sonographs show an enlarged uterus Transabdominal and transvaginal sonographs show an enlarged uterus containing a large echogenic mass (yellow dotted line) with innumerable anechoic containing a large echogenic mass (yellow dotted line) with innumerable anechoic (cystic) spaces (green arrows).   (cystic) spaces (green arrows).   Vascular flow is seen during systole (open red arrow) and diastole (closed red arrow), Vascular flow is seen during systole (open red arrow) and diastole (closed red arrow), representing low resistance flow within this mass. No intrauterine gestation is seen. representing low resistance flow within this mass. No intrauterine gestation is seen. In combination with an extremely elevated beta-hCG, these findings are concerning In combination with an extremely elevated beta-hCG, these findings are concerning for a complete molar pregnancy.for a complete molar pregnancy.

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Anembronic gestational sacAnembronic gestational sac Pseudo gestational sac of Ectopic Pseudo gestational sac of Ectopic

pregnancypregnancy Hydropic degeneration of placenta Hydropic degeneration of placenta

associated with incomplete / missed associated with incomplete / missed abortion abortion

Degenerating leiomyomaDegenerating leiomyoma Choriocarcinoma Choriocarcinoma

TREATMENTTREATMENT

Suction CurettageSuction Curettage Dilation and curettage are curative in 84% of CHMs Dilation and curettage are curative in 84% of CHMs

and 99.5% of PHMs.and 99.5% of PHMs.

HysterectomyHysterectomy

FOLLOW UPFOLLOW UP

Serial quantitative beta-HCG levels are Serial quantitative beta-HCG levels are followed up every 2 weeks until the followed up every 2 weeks until the level is in the reference range (<5 level is in the reference range (<5 mIU/mL). After normalization occurs, mIU/mL). After normalization occurs, monthly serum beta-hCG surveillance is monthly serum beta-hCG surveillance is recommended for 3-6 months in recommended for 3-6 months in patients with partial hydatidiform mole patients with partial hydatidiform mole (PHM) and for 12 months in patients (PHM) and for 12 months in patients with CHM.with CHM.

Prophylactic Chemotherapy Prophylactic Chemotherapy

Post evacuation prophylactic chemotherapy is Post evacuation prophylactic chemotherapy is controversial.controversial.

It is recommended in patients with high risk It is recommended in patients with high risk criteria serum hCG level >100,000 mIU/mL, criteria serum hCG level >100,000 mIU/mL, uterus larger than usual for the date of uterus larger than usual for the date of pregnancy, ovaries > 6 cm in diameter, pregnancy, ovaries > 6 cm in diameter, and/or associated medical conditions and and/or associated medical conditions and epidemiologic factors (eg, previous molar epidemiologic factors (eg, previous molar pregnancy or trophoblastic tumor, maternal pregnancy or trophoblastic tumor, maternal age >40 y, toxemia, coagulopathy, age >40 y, toxemia, coagulopathy, trophoblastic embolization, hyperthyroidism). trophoblastic embolization, hyperthyroidism).