1. Associated professor of Ob& Gyn fellowship of Gynecology oncology
Molar Pregnancy GTD
T Allameh MD
Associated professor of Ob& Gyn
fellowship of Gynecology oncology

2. GTD Complete hydatidiform mole Partial hydatidiform mole
Benign & premalignant

3. Gestational Ttophoblastic neoplasia (GTN)
Invasive mole
Choriocarcinoma
Placental site trophoblastic tumor
Epithelioid trophoblastic tumor

4. Hydatidiform mole Originate in villous trophoblast
Abnormal chorionic villi
Trophoblastic hyperplasia
Overexpression of paternal genes

6. Complete hydatidiform mole
80% homozygous 46XX( duplication of single sperm following fertilization of an ovum in which the maternal chromosomes are lost)
20% 46XX or 46 XY (dispermic fertilization )
Rarely biparental , autosomal recessive condition ( recurrent HMS, ovum donation )

7. Partial hydatidiform mole
Triploid (fertilization of an normal ovum by two sperm 69XXX or 69XXY or 69 XYY)
Presence of a fetus
Amniotic fluid is present
Placenta in enlarged and cystic
Increased transverse diameter of gestational sac
Theca lutein cyst are usually absent
hCG levels of generally lower than complete mole

8. Epidemiology
North American & European countries /100,000 pregnancy
Latin American ,Asian and Middle East / 100,000 pregnancy

9. Risk factors Maternal age < 15 and > 35pr Prior molar pregnancy
*After the first mole 1 to 1.5% (10 to 15 times ↑ )
*After two mole %
Decreasing levels of dietary carotene

10. Clinical features High hCG Vaginal bleeding Pelvic pressure or pain
Uterine size greater than gestational age
Hyperemesis gravidarum
Hyperthyroidism
Ovarian theca lutein cyst
Preeclampsia <20 weeks
Anemia
Passage of hydropic vesicles

11. Diagnostic evaluation
History
Physical examination (vagina should be examined for metastases - common sites of metastases include the vagina, lungs, liver, CNS)
Pelvic ultrasound (snow storm or Swiss cheese pattern )

15. Theca lutein cysts

16. Laboratory evaluation
hCG if more than 100,000 TVS should be performed – if apparently normal singleton gestation , sono and hCG should be repeated in1 week( normal fetus and co-existent molar pregnancy)
Blood type and antibody screen
Chest radiograph if the patient has pulmonary symptoms

17. Multiple gestation
Normal co-twin with a mole(1/20000 to 1/ pregnancy)
Detected by pelvic sono
Preeclampsia , hemorrhage , thyrotoxicosis
Preterm delivery ,GTN
- 57% delivered alive baby at 34 weeks
- 26.7% GTN developed
These patients may continue the pregnancy under careful monitoring

18. Familiar recurrent molar pregnancy
Biparental molar
Typically familial
Related genes are at choromosoms 19q

19. Management of hydatidiform mole
Surgical uterine evacuation
Medical uterine evacuation
Hystrectomy

20. Surgical uterine evacuation
* suction curettage * Laminaria * fundal massage if uterus is larger than 14 weeks * We do not use prostaglandins for cervical ripening * starting at the time of anesthesia induction ,oxytocin infusion (10 units in1 liter ringer lactate solution at50 drops/min )

21. Medical uterine evacuation
medication –only methods , misoprostol, mifepristone, oxytocin are
controversial because of increase risk of trophoblastic
embolization and obtaining a specimen for pathology
26% required uterine curettage
9% required chemotherapy ( 4-6% after uterine curettage)

22. Hysterectomy
For women with HM who are > 40 y and have completed child bearing.
In one study GTN developed in 54% women treated with dilatation and evacuation and in non of the hysterectomy patients
If hCG levels > (ultra high risk )
Prophylactic chemo or TAH
Eliminate local invasion and reduce GTN
The ovaries may be preserved ( ovarian metastases are rare )
Large theca lutein cyst can be aspirated

23. Prophylactic chemotherapy
High risk women
Hormonal follow up unavailable or unreliable
Do not impact future fertility
Methotrexate or actinomyycin D
63% reduction in the risk of GTN ( delay in diagnosis of GTN ? )

24. Management of complication
Hyperthyroidism (antithyroid )
Beta adrenal blocking agent may be required before the induction of anesthesia
Ovarian theca lutein cyst ( regress over 2-4 months, may need aspiration )
Preeclampsia (resolves promptly after molar evacuation )
Cardiopulmonary symptoms ( resolve within 72h after evacuation)

25. Follow up
Serial hCG
*Every week until non detectable for 3 weeks ,then
*Every month for 6 months
*Trying to become pregnant

26. Shorter duration of monitoring
Allow patients to become pregnant after achieving 3 consecutive weekly
Followed by 3 consecutive monthly undetectable hCG level

27. Diagnosis of GTN
hCG levels plateau ( remain within + percent of the previous result)
Over a 3 weeks period( days 1,7, 14 and 21)
hCG level increases > 10% over a 2 weeks duration(days 1,7 and 14)
Persistence of detectable hCG for more than 6 months after molar evacuation

28. Persistent low hCG(quiescent GTN)
Will fail to normalize and remain elevated at low levels ( <200 at least 3months)
Absence of any clinical or radiological evidence of GTN
May develop after partial mole , invasive mole or choricarcinoma
Small focus of highly differentiated non invasive syncytiotrophoblast

29. Quiescent GTN Foci of disease are not readily identifiable clinically
hCG level is unresponsive to therapy
The measurement of hyper glycosylated hCG ( hCG-H) has been proposed in patients with quiescent GTN.
hCG- H is produced by cytotrophoblast and is associated with trophoblast invasion growth of cytotrophoblast cells and promotion of placental implantation
hCG- H is a promoter of choriocarcinoma ,tumorigenesis and is the main form of hCG produced in active GTN

30. hCG - H Low level indicate quiescent GTN
Increasing levels indicate the development of active GTN that requires GTN
Patients with quiescent GTN should be monitored with monthly hCG and avoid pregnancy
Active GTN should be diagnosed and treated If hCG –H rises to greater than 20 % of total hCG or if total hCG has 2 doublings

31. Contraception Hormonal contraception Barrier methods
IUD should not be used before the hCG normalizes (uterine perforation )

32. Gestational trophoblastic neoplasia GTN
Complete mole (15-20 %)
Partial mole (1-5 %)

33. Risk factors for GTN
Complete mole with signs of trophoblastic proliferation ( uterine size greater than gestational age , hCG> )
Ovarian theca lutein cysts > 6 cm
Age >35-40 y

34. Subsequent pregnancy
Patients with MH can anticipate normal reproductive outcomes
Repeat molar pregnancy
* After 1 molar pregnancy %
* After 2 molar pregnancy %

35. Obstetric management
First trimester ultrasound to confirm normal pregnancy
Measurement of hCG at 6 weeks after the completion of pregnancy ( term or abortion) , to exclude choriocarcinoma
Placenta should be examined and sent to pathology
Product of conception from abortions should be examined pathologically