Molar pregnancy


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Molar pregnancy

  1. 1. Molar Pregnancy Mohammed khairy Assisted lecture of obstetric and gynecology Assiut university- Egypt [email_address]
  2. 2. Introduction <ul><li>Case report of partial molar pregnancy </li></ul><ul><li>Brief discussion about molar pregnancy </li></ul><ul><li>Diagnostic role of Human Chorionic Gonadotropin </li></ul>
  3. 3. Case Report (Partial mole) <ul><li>32 years old woman </li></ul><ul><li>G2 + P1+ 0 </li></ul><ul><li>Combined oral pills user before pregnancy </li></ul>
  4. 4. First visit <ul><li>Presenting Symptoms </li></ul><ul><li>Amenorrhea of pregnancy 13 weeks , minimal vaginal bleeding. </li></ul><ul><li>Clinical Examination </li></ul><ul><li>General examination -> BP 120/90 mmhg </li></ul><ul><li>Abdominal examination -> Fundal level 18 wks </li></ul><ul><li>PV examination -> Cervix closed with minimal vaginal bleeding </li></ul>
  5. 5. First visit <ul><ul><ul><ul><li>Abdominal U/S </li></ul></ul></ul></ul><ul><ul><ul><ul><li>a live fetus 13 weeks </li></ul></ul></ul></ul><ul><ul><ul><ul><li>of gestation. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Separate multiple cystic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>mass was found in the placenta . </li></ul></ul></ul></ul>
  6. 6. Provisional diagnosis <ul><ul><ul><ul><li>? Partial mole. </li></ul></ul></ul></ul>
  7. 7. <ul><ul><ul><li>Follow up </li></ul></ul></ul>Our plan
  8. 8. Second visit (2 week later) <ul><li>Presenting Symptoms </li></ul><ul><li>Amenorrhea 15 weeks , minimal vaginal bleeding. </li></ul><ul><li>Clinical Examination </li></ul><ul><li>General examination -> BP 190/110 mmhg </li></ul><ul><li>Abdominal examination -> Fundal level 34wks </li></ul><ul><li>PV examination -> Cervix closed with minimal vaginal bleeding . </li></ul>
  9. 9. Second visit (2 week later) <ul><li>Abdominal U/S </li></ul><ul><li>a live fetus consistent with 15 weeks of gestation. There was no evidence of growth retardation or fetal anomaly. </li></ul><ul><li>a well-defined and separate multiple cystic mass (honey-comb appearance) was found in the upper uterine segment. </li></ul>
  10. 10. Laboratory Investigations <ul><li>Serum Beta HCG levels . </li></ul><ul><li>3,000,000 mIU/ ml, </li></ul><ul><li>Albumin in urine. </li></ul><ul><li>Albumin ++++  SPET </li></ul><ul><li>Thyroid function ->Normal </li></ul>
  11. 11. Conclusion <ul><li>Clinical impression </li></ul><ul><li>Partial mole </li></ul><ul><li>Plan </li></ul><ul><li>Termination of pregnancy followed by histological analysis. </li></ul><ul><li>Follow up by serum HCG estimation . </li></ul>
  12. 12. Treatment <ul><li>Hystrotomy was done. </li></ul><ul><li>Antihypertensive drugs and Magnesium sulphate were given. </li></ul>
  13. 13. Post-evacuation abdominal U/S <ul><li>Bilateral theca </li></ul><ul><li>lutin cysts 7x5cm . </li></ul>
  14. 14. <ul><li>( RCOG 2010)  Medical evacuation of molar pregnancies by oxytocin should be avoided because of the potential to embolise and disseminate trophoblastic tissue through the venous system . </li></ul>
  15. 15. <ul><li>(RCOG 2010)  Prolonged cervical preparation, particularly with prostaglandins, should be avoided where possible to reduce the risk of embolization of trophoblastic cells. </li></ul>
  16. 16. Post-evacuation plan <ul><li>Post evacuation single-agent chemotherapy , 25mg methotrexate IM for 5 days . </li></ul><ul><li>Contraception by back up method till hCG level became negative . </li></ul><ul><li>Follow up for HCG levels . </li></ul>
  17. 17. Post-evacuation HCG (7 days later) <ul><li>73000 mIU/ ml </li></ul>
  18. 18. <ul><li>Brief Discussion about molar pregnancy. </li></ul><ul><li>Molar pregnancy </li></ul><ul><li>Complete molar pregnancy </li></ul><ul><li>Partial molar Pregnancy </li></ul>
  19. 19. Incidence of molar pregnancy (RCOG 2010) <ul><li>• 1/714 live births. </li></ul><ul><li>• Asian women . </li></ul><ul><li>The true incidence of the disease is under-represent because of problems with reporting, particularly with partial moles. </li></ul>
  20. 20. Predisposing factors <ul><li>1. Maternal age > 40 years </li></ul><ul><li> < 15 years </li></ul><ul><li>2. Paternal age > 45 years </li></ul><ul><li>3. Previous hydatidiform mole. </li></ul><ul><li>4. Vitamin A deficiency. </li></ul><ul><li>5. Smoking. </li></ul>
  21. 21. Complete Mole <ul><li>Duplication of the haploid sperm following fertilization of an ‘empty’ ovum . </li></ul><ul><li>Some complete moles arise after dispermic fertilization of an “empty’ ovum (dispermy). </li></ul>
  22. 22. Empty ovum Empty ovum 46XX 46XX or 46XY 23X or Y 23X 23X Complete Mole (46XX diploid) Complete Mole (46XX or 46XY, diploid) Complete Mole
  23. 23. COMPLETE HYDATIFORM MOLE CLINICAL FEATURES Vaginal bleeding (anemia) 97% Excessive uterine size 50% Theco-lutein ovarian cysts 50% Preeclampsia 27% Hyperemesis 25% Hyperthyroidism 7% Trophoblastic embolization 2%
  24. 24. Partial Molar Pregnancy <ul><li>Triploid in origin (two paternal and one maternal). </li></ul><ul><li>Dispermic fertilization of an active ovum. </li></ul>
  25. 25. 23X 23X Dyspermy 23X/23Y or 23X/23X 23Y Partial Mole (69XXY, or 69XXX, or 69XYY triploid) 23X 23X 23Y 69XXY Partial Molar Pregnancy
  26. 26. Complete mole Partial mole Karyotype 46XX ,46XY Triploid (69 XXY) Fetal or embryonic tissue absent present Hydatiform swelling of chorionic villi extensive focal Trophoblastic hyperplasia extensive focal   Theca-lutein cysts 25–30%  less common   Medical complications Frequent   less common Gestational trophoblastic neoplasia 20% <5–10% HCG level very high Slight raised Differance between COMPLETE AND PARTIAL MOLE
  27. 27. Ultrasonographic D/D <ul><li>Hydropic degeneration of placenta </li></ul><ul><li>Complete mole with co-existent fetus </li></ul><ul><li>Degenerated leiomyoma of uterus </li></ul><ul><li>Retained products of conception </li></ul><ul><li>Choriocarcinoma </li></ul><ul><li>Missed Abortion </li></ul>
  28. 28. Hydatidiform Mole with co-existent foetus (RCOG 2010) <ul><li>The outcome for a normal pregnancy with a coexisting complete mole is poor, with approximately a 25% chance of achieving a live birth. There is an increased risk of early fetal loss (40%) and premature delivery (36%). The incidence of pre-eclampsia is variable, with rates as high as 20% reported. </li></ul><ul><li>Prenatal invasive testing for fetal karyotype should be considered in these cases. </li></ul>
  29. 29. GTD and Twin Pregnancy
  30. 30. Human chorionic Gonadotropin
  31. 31. Human chorionic Gonadotropin <ul><li>Secreted by active trophoblast of the placenta. </li></ul><ul><li>Detected in the blood 7-9 days after ovulation. </li></ul><ul><li>A concentration of 100mIU/ml is reached 2 days after the date of an expected menses. </li></ul><ul><li>Peak level of HCG (100,000mIU/ml ) - 10 weeks of gestations </li></ul><ul><li>Declining and remaining at app 10,000- 20,000mIU//ml by 12-14 weeks of gestation. </li></ul>
  32. 32. Diagnostic Implications of Serum HCG levels <ul><li>Single HCG value –Not very informative </li></ul><ul><li>Rate of increase in HCG levels varies as a pregnancy progresses. </li></ul><ul><li>An HCG that does not double every two to three days does not necessarily indicate a problem with the pregnancy. </li></ul><ul><li>Some normal pregnancies will have quite low levels of HCG, and result in perfect babies. </li></ul>
  33. 33. Correlation between HCG level, and sonography findings <ul><li>Serum HCG levels 1500 IU/L-Gestational sac should be visible by USG </li></ul><ul><li>Serum HCG levels 5000IU/L-Cardiac pulsation should be visible. </li></ul><ul><li>More than 5000 IU/L rules out Ectopic pregnancy. </li></ul>
  34. 34. Serum HCG levels after non trophoblastic Abortions <ul><li>Should fall to undetectable level by 3 weeks. </li></ul><ul><li>Below 5mIUm/l - negative. </li></ul><ul><li>Above 25mIU/ml -positive. </li></ul>
  35. 35. HCG Levels –after trophoblastic abortions <ul><li>Greater than 500mIU/ml frequently for 3 weeks and usually for 6 weeks. </li></ul><ul><li>HCG titer should fall to a non-detectable level by 15 weeks. </li></ul>
  36. 36. HCG levels -Management <ul><li>Indications of chemotherapy </li></ul><ul><ul><li>Serum hCG> 20, 000 IU/L at >4 weeks. </li></ul></ul><ul><ul><li>Rising hCG. i.e. 2 consecutive rising serum samples. </li></ul></ul><ul><ul><li>hCG plateau. i.e. 3 consecutive serum samples not rising or falling significantly. </li></ul></ul><ul><ul><li>hCG still abnormal at 6 months post evacuation. </li></ul></ul>
  37. 37. Thank You