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Hydatidiform mole

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  • Villous scalloping (invaginations of trophoblast tissue into villous stroma, appears circular in cross section and resembles “coast of Norway” or inclusions)

Transcript

  • 1. Hydatidiform MoleExtern Sarawut Hongyim
  • 2. History•• Menache 14 yr.• LMP 9 day pad 1-2 no dysmenorrhea• SI 1st 15 yr. single partner• Oral contraception 2 yr• No Hx. STD, dyspareunia, post coital bleeding, abortion
  • 3. History• CC :• PI : 1d PTAultrasound•••
  • 4. Physical exam• Vital sign : BP 100/70 mmHg, PR 86 bmp, RR 18 /min, Temp 37 oC• Wt. 52 kg Ht. 155 cms• General appearance : thai teenage women, good consciousness• HEENT : not pale, no icteric sclera• Lymph node : no lymphadenopathy• Heart : normal s1 s2, no murmur• Lung : normal breath sound, no adventitious sound• Abdomen : BS +ve, not tender• Neuro : E4V5M6 pupil 3 mm RTL BE
  • 5. Physical exam• Affected part• Uterus 12 wk size• PV exam• NIUB normal• Vagina normal discharge• Cervix no abnormal lesion, os closed, not tender• Adnexa no adnexa mass, not tender
  • 6. Ultrasound
  • 7. Lab investigation• CBC : Hct 36.2 % Platelet 233,000 WBC 6,220 cu.mm.• UA : protein & sugar –ve, RBC 2-3, WBC 1-2, Epi 5-10• Urine BHCG : 1,600 – 3,200• Serum BHCG :• BUN 12 mg/dl, cr 0.61 mg/dl• LFT : total protein 7.6, alb 4.6, total bilirubin 1.02, direct bilirubin0.15, ALP 70, AST 8, ALT 29
  • 8. Diagnosis• Molar pregnancy
  • 9. Molar pregnancyHydatidiform Mole
  • 10. Molar pregnancy• is characterized histologically by abnormalities of thechorionic villi that consist of trophoblastic proliferation andedema of villous stroma.• complete or partial
  • 11. Epidemiology• vary dramatically in different regions of the world• molar pregnancy in Japan (2 per 1,000 pregnancies)• in Europe or North America (about 0.6 to 1.1 per 1,000 pregnancies)
  • 12. Risk Factors• Age• adolescents and women aged 36 - 40 years have a 2-fold riskand those > 40 years have 10-fold risk• Prior Molar Pregnancy• recurrent moles was 1.3 %, 1.5 % complete mole and 2.7 %partial mole• 2 prior molar pregnancies third mole 23 %
  • 13. Complete versus Partial Hydatidiform Mole• Gross morphology• Histopathology• Karyotype
  • 14. Complete Hydatidiform Mole• Grossly• mass of clearvesicles• vary in size frombarely visible to afew centimeters• hang in clustersfrom thin pedicles.• Histologically• hydropic degeneration andvillous edema• absence of villous blood vessels• absence of embryonic fetus andamnion.
  • 15. CompleteHydatidiformMole
  • 16. Normalchorionic villihttp://radiology.uchc.edu/eAtlas/Images/GYN/5801b.gif
  • 17. CompleteHydatidiformMolehttp://www.webpathology.com/image.asp?case=585&n=2
  • 18. CompleteHydatidiformMolehttp://www.webpathology.com/image.asp?n=3&Case=585
  • 19. Complete Hydatidiform Mole• usually diploid and of paternal origin• 85 % are 46,XX with both of chromosomes paternal origin• androgenesis, ovum is fertilized by a haploid sperm, which duplicatesits own chromosomes after meiosis, ovum chromosomes absent orinactivated.• other complete moles, may be 46,XY due to dispermic fertilization
  • 20. Complete Hydatidiform MoleMalignant Potential• higher incidence of malignant sequela• 15 - 20 % had evidence of persistent trophoblastic disease
  • 21. 85 %androgenesisCompleteHydatidiformMole
  • 22. Partial Hydatidiform Mole• fetal tissue and Hydatidiform changes that are focal and lessadvanced• avascular chorionic villi and vascular villi• typically is triploid—69, XXX, 69,XXY, or much lesscommonly, 69,XYY
  • 23. Partial Hydatidiform Mole• Grossly• Smaller volume of tissue• Mixture of grosslyvesicular and normal villi• Fetus / embryo isusuallypresent, although oftenabnormal• syndactyly of digits 3 &4 of both hands andfeet• Histologically• Mixture edematous villi & normalvilli• Less conspicuous central cisternformation (internal clefting)• Mild focal trophoblasthyperplasia without atypia• Villous scalloping
  • 24. PartialHydatidiformMole
  • 25. PartialHydatidiformMole
  • 26. PartialHydatidiformMole
  • 27. PartialHydatidiformMole
  • 28. Partial Hydatidiform Mole• Malignant Potential• lower than complete molar• Seckl and associates (2000) documented 3 of 3000 ofpartial moles to be choriocarcinoma• Growdon and co-workers (2006) higher hCG levelsincreased risk for persistent disease• levels 200 mIU/mL in the third through 8 week postevacuation at least a 35-% risk of persistent disease
  • 29. Twin Molar Pregnancy• not rare• Vejerslev (1991) found that of 113 such pregnancies, 45 %progressed to 28 weeks, and 70 % neonates survived
  • 30. Twin MolarPregnancy
  • 31. Clinical Presentation• Vaginal Bleeding 84%• Theca Lutein Ovarian Cysts 46 %• Excessive Uterine Size 28%• Hyperemesis Gravidarum 8%• Preeclampsia 1 %• Hyperthyroidism rarely• Trophoblastic Embolization rarelyComplete Mole Partial Mole• incomplete or missedabortion 91.3%• vaginal bleeding 72.8%• Excessive uterine size 3.7%
  • 32. Diagnosis• History & physical exam• Mole pass in vagina• pregnancy testing and sonography
  • 33. Sonography• complete mole• complex, echogenic uterine mass with numerous cysticspaces and no fetus or amnionic sac• partial mole• thickened, hydropic placenta with fetal tissueSnow stormappearance
  • 34. completemole
  • 35. Partial Hydatidiform Molehttp://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-39842010000200014&lng=en&nrm=iso&tlng=en
  • 36. Management• Evaluation• Termination of pregnancy• Follow up
  • 37. evaluation• Evaluated medical complications• Preeclampsia• Hyperthyroidism• electrolyte imbalance• Anemia• Lab investigation• CXR• CBC• UA• BUN, Cr• Electrolyte• LFT• PT, PTT
  • 38. Terminaton of pregnancy• Suction & curettage• Hysterectomy• Prophylactic chemotherapy
  • 39. Suction Curettageregardless of uterine size & preserve fertility following steps:• Oxytocin infusion before the induction of anesthesia.• Cervical dilation• Suction curettage the uterus may decrease dramatically in size, and the bleedingis well controlled. The use of a 12-mm cannula is strongly advised to facilitateevacuation. If the uterus is larger than 14 weeks of gestation, one hand shouldbe placed on top of the fundus, and the uterus should be massaged to stimulateuterine contraction and reduce the risk of perforation.• Sharp curettage When suction evacuation is believed to be complete, gentlesharp curettage is performed to remove any residual molar tissue
  • 40. Hysterectomy• If no further pregnancies are desired• aged > 40 yr.• Uterine perforate
  • 41. Prophylactic Chemotherapy• Prophylactic chemotherapy not only prevented metastasisbut also reduced the incidence and morbidity ofchoriocarcinoma• But• can’t absolutely to prevent choriocarcinoma• After TOP 80-90 % of Molar pregnancy are cure• and choriocarcinoma are cure by currently chemotherapyActinomycin D, Methotrexate
  • 42. Follow-up• Human Chorionic Gonadotropin• Contraception• Chemotherapy
  • 43. Human Chorionic Gonadotropin• monitored q weekly B-hCG levels until normal for 3consecutive weeks• followed q monthly until normal for 6 consecutive months
  • 44. Contraception• Prevent pregnancy for a minimum of 1 yr. using hormonalcontraception• oral contraceptives safely after molar evacuation during theentire interval of hormonal follow-up
  • 45. chemotherapy• If• B-hCG level rising or plateau• Rising = increase B-hCG > 2-fold• Plateau = no change or increase < 2-fold
  • 46. Further of pregnancy• Recurrent 5 - 10-fold of pregnancy• Reassurance women if desire pregnancy but early ANC
  • 47. Reference• Berek, Jonathan S. Gestational Trophoblastic Disease. Berek & NovaksGynecology, 14th Edition.• Chapter 11. Gestational Trophoblastic Disease. Williams Obstetrics, 23Edition