Dr. Sally Mary Abraham Professor Vesicular Mole Dr. Sally Mary Abraham Professor

It is a benign neoplasm of the chorionic villi with malignant

Incidence 1:2000 pregnancies in United States and Europe 1:200 in Asia 1:400 in India. 1 in 80 Philippines. The increasing use of ultrasound in early pregnancy has probably led to the earlier diagnosis of molar pregnancy

ETIOLOGY Maternal age : Teenage &age above 35 Women who have had a previous molar gestation Race &ethnic origin Immune mechanism- Women with blood type A B may be more likely to develop hydatidiform mole Faulty nutrition- lack of protein , dietary carotene. Cytogenetic abnormality

What Is A Hydatidiform Mole? A hydatidiform mole is an abnormality of fertilization COMPLETE MOLE PARTIAL MOLE It is the result of fertilisation of anucleated ovum ( has no chromosomes) with a sperm which will duplicate giving rise to 46 chromosomes of paternal origin only. It is the result of fertilisation of an ovum by 2 sperms so the chromosomal number is 69 chromosomes

Differentiation Between Complete And Partial Mole Complete Mole Feature Present Absent Embryonic or foetal tissue Focal Diffuse Swelling of the villi Trophoblastic hyperplasia Paternal and maternal 69 XXY or 69 XYY Paternal 46 XX (96%) or 46 XY (4%) Karyotype Rare 5-10% Malignant Changes

Pathology There is trophoblastic proliferation, with mitotic activity affecting both syncytial and cytotrophoblastic layers. This causes excessive secretion of hCG,chorionic thyrotrophin and progesterone. microscopic evaluation shows trophoblastic hyperplasia

Pathology (hydropic) villi The uterus is distended by thin walled, translucent, grape-like vesicles of different sizes. Uniformly edematous (hydropic) villi with dissolution of central stroma (cavitation/ciste

Pathology There is no vasculature in the chorionic villi leads to early death and absorption of the embryo.

Pathology High hCG causes: multiple theca lutein cysts in the ovaries in about 50% of cases. exaggeration of the normal early pregnancy symptoms and signs

Pathology Uniformly edematous (hydropic) villi with dissolution of central stroma (cavitation/cistern) Villous vessels absent (usually) Trophoblastic hyperplasia – circumferential, haphazard. Trophoblastic atypia

CLINICAL FEATURES - Teenage pregnancy - More than 35 years multipara - Hypermesis gravidarum - Sick looking - Thyrotoxic features – tremors and tachycardia – 2% - Breathlessness – pulmonary embolism of trophoblastic cells – 2%

- Vaginal bleeding – 90% - Abdominal pain - Passage of grape like vesicles -50%-diagnostic - Uterine size more than period of amenorrhoea - Early onset of pre-eclmpsia - Features of hyper thyrodism - Absent fetus

D/D : The following conditions are often confused with molar pregnancy. Threatened abortion Fibroid or ovarian tumour in pregnancy Multiple pregnancy Serum β HCG and USG is diagnostic

Complications of molar pregnancy : Immediate Haemorrhage and shock Sepsis Perforation of uterus Preeclampsia and eclampsia – rarely Acute pulmonary insufficiency Coagulation failure (DIC) Development of choriocarcinoma 2 to 10%

Risk factor for malignant change : Age - >40 or <20yrs irrespective of parity Serum β HCG >1 lakh miu/ml Size of uterus > 20 weeks Previous history of molar pregnancy Theca lutein cyst – large (>6 cmts.)

PROGNOSIS : 15 to 20% of complete mole progress to persistent GTD Metastastic disease in 5% Recurrence of hydatidiform mole is subsequent pregnancy 1 to 4% (Chances of foetal malformation is not increased in pregnancies following chemotherapy)

Management Investigation Blood group Rh LFT TFT RFT PIH Profile USG – classical snow storm appearance Quantitative estimation of chorionic gonadotrophin high HCG titre in urine diluted upto 1 to 200 to 1 in 500 dilution +ve. Rapidly increasing serum β HCG > 1 lakh miu/ml

Chest x-ray – to rule out lung metastases (choriocarinoma) to rule out pulmonary embolism even in benign mole HPE of products on conception is a must to rule out choriocarcinoma

Principles in the management : With use of USG and sensitive HCG testing diagnosis is made early in majority of the cases. Principles in the management : Suction evacuation of the uterus as early as possible. Supportive therapy – correction of anemia and infection. Counselling for regular follow up.

Management of molar pregnancy Group A – mole in the process of expulsion less common. Treatment – Suction evacuation under G.A. or sedation : Under close observation 500ml R.L. with 10 units oxytocin drip After evacuation if BP is normal .2mg methergine IM given

Group B – uterus is enert cervix is tubular and closed Treatment – prior slow dilatation of cervix with PGE 400mg (misoprostol) 3 hrs. before suction evacuation.

Complications during evacuation : Haemorrhage and shock injury to uterus + 2 rare but fetal complications Pulmonary embolism – acute pulmonary insufficiency Symptoms of acute chest pain, tachycardia tachypnoea may develop with in 4 to 6hrs. Following evacuation. Thyroid storm – is presence of hyperthyroid state when evacuation is done decrease G.A. the acute features such as hyperthermia, delirium, convulsions coma and CVS collapse Rx with B blockers.

Hysterectomy is indicated in – Patients age >35yrs. Completed her family Uncontrolled bleeding or perforation during surgical evacuation Theca leutin cysts of ovary should be left undisturbed as they will regress following removal of mole within 2 months. Uterus sent for HPE Note : GTD observed in 3 to 5% cases even after hysterectomy and so follow up is necessary.

Rh-negative non-immunised patient – Anti D to be given following evacuation of mole. Routine curettage following evacuation of mole not recommended

Initial every week till serum B HCG becomes negative (4-8 weeks) FOLLOW UP PROTOCOL – UP TO 1 YEAR HCG ASSAY Initial every week till serum B HCG becomes negative (4-8 weeks) Once negative monthly x 6 months Women who undergo chemotherapy follow up for 1 year after HCG has become normal. No pregnancy during the period of follow up.

FOLLOW UP PROTOCOL INCLUDES – History – irregular bleeding P/V persistent cough, breathlessness & haemoptysis nausea vomiting. Abdominal pelvic examination to note Involution of uterus. Ovarian size Anterior vaginal wall deposits (suburethral nodule)

Investigation : HCG assays – initially urine pregnancy test once negative to serum β HCG till neg. Chest X-ray – when preevacuation chest x-ray is normal, it is repeated only when HCG titres rises or plateaus. If preevacuation chest x-ray shows metastasis – repeat at 4 weeks interval post chemotherapy until remission is confirmed.

Prophylactic chemotherapy : 80% patients undergo spontaneous remission Indications : HCG fails to come to normal (in 10-12 weeks) HCG plateaus or rises Rising HCG after reaching normal levels Recurrence of bleeding P/V or persistence of post- evacuation bleeding P/V – provided you are sure that the 1st time evacuation was complete. Cases where malignant sequelae was high and poor patient compliance for follow up.

REGIMEN OF PROPHYLACTIC CHEMOTHERAPY : Methotrexate – 1mg/kg/day IV or IM one day 1,3,5,7, with Folinic acid – 1 mg/kg/day IM one day 2,4,6,8 Repeated every 7 days for 3 courses. Serum B HCG should decrease by a least 15% by 4 to 7 days after methotrexate Alternatively IV actinomycin D 12mg/kg/daily x 5 days Less toxic

Contraception : Traditionally patient advised not to be pregnant for at least 1 year. But if she so desires she may become pregnant 6 months following negative HCG titre. Pregnancy delayed for 1 year for GTN For 2 years if there is metastases

Use of contraception : IUD is contraindicated because of irregular bleeding P/V Barrier method DMPA Combined O.C. pills after HCG has come to normal Surgical sterilization if she has completed family. Serum B HCG checked 3 weeks after the end of any pregnancy, subsequent to a molar one.