2. LEARNING OUTCOMES:
By the end of presentation, the participants should
be able to:
Diagnose a case of gestational trophoblastic
disease.
Plan treatment for a case of hydatidiform mole.
3. INTRODUCTION
Abnormal proliferation of gestational
trophoblastic tissue that forms a spectrum of
diseases from the benign partial hydatidiform
mole to the malignant choriocarcinoma and
placental site trophoblastic tumours.
5. INCIDENCE
Geographical and racial variation
Higher in Africa and Asia
In Europe and North America 0.2-1.5 / 1000 LB.
Extremes of reproductive age. Higher in
teenage pregnancies (1.3 fold) & above 40yrs
(10 fold)
Complete mole – 1:1000
Partial mole – 3:1000.
6. PARTIAL MOLE
In this form of hydatidiform mole, embryo or
fetus co-exist with placental abnormality.
Though it tends to die at earlier gestation i.e at
8-9 wks.
Less hydropic swelling of chorionic villi & focal
changes.
7. PARTIAL MOLE
Genetics:
Partial moles are triploid with two sets of
paternal and one set of maternal
chromosomes i.e. 2 sperms fertilize an egg.
This results in triploid. i.e. 69 Chromosomes.
8. PARTIAL MOLE
Clinical presentation :
Irregular bleeding
Large for dates uterus
Detection on routine USG
Hyperemesis gravidarum
Pre-eclampsia
Hyperthyroidism
DIC
9. COMPLETE MOLE:
Abnormal pregnancy which consists of placental
tissue only and there is no embyo in it.
There is cytotrophoblastic and syncytiotrophoblastic
hyperplasia. Placental villi are swollen resulting in
cistern formation.
10. COMPLETE MOLE:
Genetics:
In complete mole all of the genetic material is
paternal in origin and results from fertilization of
an empty egg lacking maternal DNA.
Chromosomes count is 46XX, 46XY.
12. COMPLETE MOLE
Macroscopically:
No fetal pole visible. Bunch of grapes.
Microscopically:
Some embryonic cells present.
Histologically :
It shows oedematous villous stroma .
USG: Snow-storm appearance .
Clinical presentation: Same as partial mole
14. INVESTIGATIONS: Serum β hCG
Ideal tumour marker --- useful in diagnosis and follow up.
Produced by synchtiotrophoblastic cells of placenta. Two
subunits alpha & βeta.
β hCG level are higher in hydatidiform mole than in singleton
pregnancy.
hCG can be measured in serum and urine.
17. TREATMENT
Suction evacuation in majority of the
cases.
Hysterectomy if life threatning
hemorrhage during suction evacuation.
Chemotherapy if indicated.
18. FOLLOW UP
Once suction evacuation done, 90% of patient
require no treatment.
Among 10% patients, 3% develop choriocarcinoma
& 7% invasive mole.
Follow up done by measurement of hCG level at
regular intervals.
19. FOLLOW UP
In full term normal delivery, hCG level became
undetectable with in 10-20 days.
Takes longer time after non-molar abortion.
Takes longer time after evacuation of hydatidiform
mole i.e. 8wks up to 6 months.
20. FOLLOW UP
Measure hCG level every 2wks till it becomes undetectable.
If hCG reverted to normal within 56 days then follow up will
be for 6 months from the date of uterine evacuation.
If hCG has not reverted to normal within 56 days then
folllow up for 6 months from normalization of hCG level.
21. FOLLOW UP
Monthly during 1st yr.
Three monthly during 2nd yr.
Measure hCG after every pregnancy.
22. PREGNANCY / CONTRACEPTION
Avoid pregnancy until follow-up is complete.
Women undergoing chemotherapy should not
conceive for one year after completion of
treatment.
23. CONTRACEPTION
Contraception by barrier methods until hCG levels
are normal
COCs may be used once hCG levels are normal
IUCDs should not be used until hCG levels are normal
to reduce risk of uterine perforation.
24. INDICATIONS FOR CHEMOTHERAPY
Raised hCG level 6 months after evacuation
hCG plateau in 3 consecutive serum samples
hCG >20,000iu/l > 4 weeks after evacuation
Rising hCG in 2 consecutive serum samples
25. INDICATIONS FOR CHEMOTHERAPY
Pulmonary, vulval or vaginal mets unless hCG
level is falling
Heavy PV bleeding or GI/ intraperitoneal
bleeding
Histological evidence of choriocarcinoma
Brain, liver, GI mets or lung metastasis >2 cm
on CXR.
26. CHORIOCARCINOMA
Common in Asia
Incidence: 1:250 to 1:6000
Epidemiology : 50% : after complete mole
25% : term pregnency
25% : non molar abortion
30. Classification (scoring)
Age of pt
Antecedent pregnancy
Months from index pregnancy
Pre-treatment hcg
Largest tumour size
Size of mets
Number of mets
Previous chemotherapy.
31.
32. Low Risk…≤ 6
Treatment:
Single agent chemotherapy
METHOTREXATE 50 mg IM
+
FOLINIC ACID after 30 hours 6 mg IM.
33. High risk: ≥ 7
Combination of multiple drugs.
EMA/CO regimen.
Continue treatment until hCG are normal and
for a further 6 cosecutive weeks.
Follow up by serial beta hCG levels.
35. SUMMARY:
Suction evacuation is the mainstay of treatment for
hydatiform mole.
Follow up with beta hCG is very essential.
Indications for chemotherapy should be followed.
Avoid pregnancy until the follow up is complete.