7. Partial Hydatidiform Mole
Approximately 1% of pregnancies have
a triploid karyotype and resolve in
spontaneous abortion.
8.
9. fetal parts or amniotic membranes
normal and hydropic villi
focal mild hyperplasia
Scalloping of the hydropic villi
trophoblastic inclusions in the stroma
Fetal vessels are frequently observed with nucleated
fetal erythrocytes within the vessels
Normal amniotic membranes are often identified,
even if a fetus is not found.
13. invasive mole (IM),develops in 15 to 20 percent
of women with complete mole and 1 t o 5
percent of women following partial mole
14. Incidence and Epidemiology
rates 5- to 15-fold higher in the Far East and
Southeast Asia than in the Western industrialized
nations
Latin American, Asian, and Middle Eastern nations report
a wide range, including high rates (23 to 1299 per 100,000
pregnancies) .
This geographic difference in incidence, however, is based
upon older studies, and subsequent data suggest that the
incidence in Southeast Asia is much lower, and in fact may
be similar to that seen in the Western Hemisphere
15. Incidence and Epidemiology
complete mole was significantly more common in Asians and significantly less common in
Hispanics, but only marginally less common in blacks. Compared with whites, partial mole
was significantly less common in Asians, Hispanics, and blacks
In the United Kingdom, the incidence of complete mole is around 1 per 1000 pregnancies,
and the incidence of partial mole is 3 per 1000
16. risk factors
Nutritional factors may also be important in the development
of hydatidiform mole, including deficiencies of protein or
animal fat and fat-soluble carotene
• Global regions with a high incidence of vitamin A deficiency
correspond to areas with a high frequency of complete molar
pregnancy. However, partial mole has not been related to
dietary factors .
• decreasing levels of consumption of dietary carotene (vitamin A precursor)
Known risk factors for hydatidiform mole include
previous molar pregnancies and maternal age.
The main risk factors for HM are extremes of maternal age and
a history of previous mole
17. Prior molar pregnancy
reported to range from 11 to 25 percent .
In recurrent mole, one type of molar pregnancy can be
followed by the same or a different type in any combination
(eg, complete mole after complete mole, complete mole after
partial mole).
18. Extremes of maternal age
The risk of complete mole is highest at extremes of maternal age
(≤15 and >35 years).
These data suggest that ova from older women may be more
susceptible to abnormal fertilizations that result in HM.
In addition, women age 40 or older with HM may have a higher
rate of severe complications.
Most cases of HM, however, still occur in women under age 35
because of the greater number of pregnancies in this age group
The risk for molar pregnancy and its relation to maternal age is
much greater in complete mole than partial mole .
19. The risk for both complete mole and partial mole is increased
in women with a history of prior spontaneous abortion and
infertility. Compared with women with no previous history of
miscarriage
20. CLINICAL FEATURES
Women with HM typically present to their obstetric clinician
with missed menstrual periods, a positive pregnancy test, and
signs and symptoms consistent with early pregnancy or early
pregnancy complications (bleeding, pelvic discomfort,
hyperemesis gravidarum)
Molar pregnancy may be suspected based upon unusually
high human chorionic gonadotropin (hCG) levels or only after
pathology evaluation of a failed pregnancy.
In many cases, particularly in partial mole, a patient is
presumed to have a spontaneous abortion, and a molar
pregnancy is detected only after pathology evaluation of a
uterine curettage sample.
21. The clinical presentation of complete HM began to change
substantially in the 1980s. Prior to this time, complete mole
typically presented with late effects (hyperthyroidism,
preeclampsia). The availability of both ultrasonography and
sensitive quantitative measurement of serum hCG has led to
earlier diagnosis of complete mole .
Globally, complete mole is now diagnosed more frequently in
the first rather than the second trimester. Thus, there are
fewer late onset symptoms.
However, there has been no change in risk for post-molar
tumor.
22. Common features
Vaginal bleeding, pelvic pressure or pain, an enlarged uterus, and
hyperemesis gravidarum are common presenting symptoms.
Vaginal bleeding — Vaginal bleeding, which results from separation of the
molar villi from the underlying decidua, is common (occurring in 84
percent of patients in one study )
In complete mole, the classic appearance of the blood is characterized as a
"prune juice" discharge. This appearance is due to accumulated blood in
the uterine cavity, which has undergone oxidation and liquefaction.
Historically, when complete mole typically presented at later gestational ages, vaginal
bleeding was often heavy and prolonged and resulted in anemia. Anemia is now
uncommon. At early gestational ages, the timing, volume, or pattern of bleeding in
HM does not differ from other pregnancy-associated etiologies (spontaneous
abortion, ectopic pregnancy).
23. Anemia is now uncommon. At early gestational ages, the
timing, volume, or pattern of bleeding in HM does not differ
from other pregnancy-associated etiologies (spontaneous
abortion, ectopic pregnancy).
Pelvic pressure or pain — Similar to vaginal bleeding, pelvic
pain and pressure are common, nonspecific symptoms in
molar pregnancy due to the enlarging uterus and/or enlarged
cystic ovaries.
Uterine size greater than gestational age — Pelvic examination
or ultrasound may reveal a uterine size larger than the
estimated gestational age.
24. Uterine enlargement is more likely with a complete mole than partial mole.
Although in complete mole there is no fetus, the enlargement is due to
both large volumes of molar tissue and retained blood and is usually
associated with hCG levels >100,000 mIU/mL.
In fact, women with a partial mole may have a uterine size that is small for
gestational age, due to slow growth of a fetus with triploidy.
Hyperemesis gravidarum — Hyperemesis gravidarum was present in
approximately 8 percent of patients in one study. Nausea and vomiting may
develop earlier than in a nonmolar pregnancy and/or be more severe.
Less common or late features — HM may also be associated with other
clinical features. These are less common and some develop only later in
the course if the molar pregnancy presents in the second trimester.
25. • In complete mole, sequelae associated with the high
hCG levels include theca lutein cysts,
hyperthyroidism, and early onset of preeclampsia.
For complete mole diagnosed in the first trimester,
the risk of complications such as preeclampsia or
significant hyperthyroidism is low
• hCG levels are typically far lower in partial mole.
Thus, partial mole is less likely to be associated with
sequelae of hCG stimulation
26. Hyperthyroidism
Clinical hyperthyroidism is present in HM primarily at later gestational
ages
The development of hyperthyroidism requires the elevation of hCG
>100,000 mIU/mL for several weeks. These patients may present with
tachycardia, warm skin, and tremor. Laboratory evidence of
hyperthyroidism is commonly detected in asymptomatic patients with HM
Hyperthyroidism may be accompanied by thyroid storm when the patient
undergoes anesthesia, due to the release of catecholamines from the
adrenal gland.
The source of the thyrotropic factor in patients with complete mole
remains elusive. Some investigators have suggested that hCG is the thyroid
stimulator because of the homology between hCG and thyroid stimulation
hormone and because positive correlations have been observed between
serum hCG and total T4 or T3 concentrations
27. Ovarian theca lutein cysts
• Theca lutein cysts are a form of ovarian hyperstimulation
resulting from high circulating levels of hCG and prolactin .
These cysts are multiloculated, often bilateral, and resolve a few
weeks or months after treatment of HM.
• Bilateral theca lutein ovarian cysts may develop due to hCG
stimulation and may be noted on pelvic examination or pelvic
ultrasound. When the uterus is markedly enlarged, theca lutein
cysts are difficult to palpate and are usually detected by
ultrasonography.
• Theca lutein cysts may develop in infertile patients treated with
ovulation induction or in patients with a multiple gestation. In
other patients, a finding of theca lutein cysts should raise a high
suspicion of gestational trophoblastic disease (GTD).
28. Preeclampsia <20 weeks of gestation — Preeclampsia
(pregnancy-induced hypertension and proteinuria or end-
organ dysfunction) typically develops after 34 weeks of a
normal gestation. When it occurs at <20 weeks, complete
mole should be suspected.
Historically, when complete mole typically presented at later
gestational ages, preeclampsia was a more common
presentation.
29. Other features — Women with HM may also develop:
●Anemia – HM may be associated with significant bleeding at
later gestational ages, resulting in iron deficiency anemia.
Anemia is uncommon when HM is diagnosed in the first
trimester .
●Passage of hydropic vesicles from the vagina may occur
spontaneously, usually in patients with rapidly enlarging
complete moles.
30. CLINICAL FEATURES
Women with HM typically present to their obstetric
clinician with missed menstrual periods, a positive
pregnancy test, and signs and symptoms consistent
with early pregnancy or early pregnancy
complications (bleeding,pelvic discomfort,
hyperemesis gravidarum)
31. Less common or late
features
Hyperthyroidism
Theca lutein cysts
Preeclampsia
anemia
32. DIAGNOSTIC EVALUATION
History — An obstetric history is taken, including a history of prior
gestational trophoblastic disease (GTD). The obstetric history
should include the dates, duration, and outcome of all
pregnancies.
A medical, gynecologic, and surgical history should also be taken.
The patient should be asked about symptoms associated with HM.
If the clinical presentation suggests HM, malignant disease,
gestational trophoblastic neoplasia (GTN), must be excluded.
Patients should be asked about symptoms of metastatic disease.
The lungs (symptoms include dyspnea or chest pain) and vagina
(vaginal bleeding) are the most common metastatic sites, but
other potential sites include the central nervous system or liver.
33. Physical examination — A complete pelvic examination should be
performed. On speculum examination, the vagina should be
examined for metastases.
On bimanual examination, the uterus in women with complete
mole may be larger than the expected gestational age.
Bilateral adnexal masses may be present if ovarian theca lutein
cysts have developed due to hCG stimulation. A unilateral adnexal
mass suggests another type of adnexal mass.
A focused general physical examination should be performed to
exclude metastases. In GTN, common sites of metastases include
the lungs, vagina, liver, and central nervous system.
34. Laboratory evaluation
hCG — A quantitative serum hCG should be measured. The
serum hCG concentration in women with HM is usually higher
than that observed with intrauterine or ectopic pregnancies of
the same gestational age.
If the initial hCG level is high (>100,000 mIU/mL), a
transvaginal ultrasound should be performed and will likely
demonstrate molar disease if present.
35. Blood type and antibody screen — An RhD typing and antibody screen
should be drawn if not previously performed during the current pregnancy.
Women with bleeding in pregnancy who are RhD-negative should be given
anti-D immune globulin.
Other tests — Further testing depends upon the likelihood of
complications and the clinical assessment. For molar pregnancies that
present in the first trimester, the risk of complications such as
preeclampsia or significant hyperthyroidism is low
For women who present in the second trimester, there is a higher risk of
these complications. In such cases, testing should include: complete blood
count, renal panel, liver function tests, urine protein, and thyroid function
tests.
If significant bleeding has occurred, a complete blood count should be
ordered.
36. Pelvic ultrasound — If molar pregnancy is suspected, a
transvaginal ultrasound should be performed. However, the
ultrasound may be indeterminate. In particular, partial molar
pregnancies are frequently misdiagnosed as incomplete or missed
abortion.
The diagnostic performance of ultrasound appears to be better for
complete than partial mole and at later rather than earlier
gestations
Ultrasound is preferred to other imaging studies (eg, computed
tomography, magnetic resonance imaging) because it provides
high resolution images of the female reproductive tract and is cost
effective.
37. Complete mole — Sonographic features suggestive of a
complete mole include :
●Absence of an embryo or fetus.
●Absence of amniotic fluid.
●Central heterogeneous mass with numerous discrete
anechoic spaces – This has classically been described as a
"snowstorm or Swiss cheese pattern" on older ultrasounds
●Ovarian theca lutein cysts
38.
39.
40. Partial mole — Sonographic features suggestive of a partial molar
pregnancy include :
●A fetus may be identified, may be viable, and is often growth restricted.
●Amniotic fluid is present, but the volume may be reduced.
●Placenta with one or more abnormal findings – Enlarged, cystic spaces
("Swiss cheese pattern") and/or increased echogenicity of chorionic villi.
●Increased transverse diameter of the gestational sac – These changes in
the shape of the gestational sac may be part of the embryopathy of
triploidy.
●Theca lutein cysts are usually absent.
41. Chest radiograph — When patients present with HM, a chest
radiograph is performed only if the patient has pulmonary
symptoms such as dyspnea or chest pain.
Uterine evacuation — Suction evacuation of the uterus is both
diagnostic and therapeutic for molar pregnancy. There is no
role for endometrial biopsy in the evaluation of molar
pregnancy, since complete uterine evacuation will eventually
be required.
42. Evaluation of the patient before
evacuation of the hydatidiform mole
Complete physical and pelvic examinations
Complete blood count
Blood chemistries, including renal, hepatic, and thyroid
function tests
Baseline serum hCG level
Type and screen
Chest radiograph
Pelvic ultrasound.
43. DIFFERENTIAL DIAGNOSIS
differential diagnosis for HM includes nonmolar pregnancy,
spontaneous abortion with hydropic change, and other etiologies
of an enlarged uterus, hyperthyroidism, or ovarian theca lutein
cysts..
Hydropic chorionic villi can develop in any nonviable conception
where the villi degenerate and become edematous. Hydropic villi
can be identified both on ultrasound and the gross appearance of
the products of conception.
Bleeding or pelvic discomfort may occur during a nonmolar
pregnancy, including a normal pregnancy, spontaneous abortion,
or ectopic pregnancy.
An enlarged uterus may be due to benign or malignant pathology,
including leiomyomas, adenomyosis, or uterine malignancy.
44. Ovarian theca lutein cysts may also occur in ovarian
hyperstimulation syndrome during ovulation induction for
assisted reproduction.
Hyperthyroidism symptoms should be evaluated and the
etiology determined.
45.
46. Multiple gestation
Multiple gestation may be complicated by HM, either a complete or
partial mole and a viable fetus. A multiple conception with a normal co-
twin with a complete or partial mole is a rare occurrence, developing in
only 1 per 20,000 to 100,000 pregnancies .
It is possible that the incidence will increase with increased use of
ovulation induction in older women and an increased rate of multiple
gestation .
Multiple gestations that include HM can usually be detected by pelvic
ultrasound, but amniocentesis and chromosome analysis is occasionally
required. Patients should be advised of the potential risks, including: (1)
severe complications such as preeclampsia, hemorrhage, and
thyrotoxicosis, which typically develop in the second trimester; (2) preterm
delivery; and/or (3) malignancy, gestational trophoblastic neoplasia (GTN) .
47. Multiple gestation
Patients with complete mole and co-existent normal co-twin
should be counseled regarding the increased risk of medical
complications, including post-molar GTN.
These patients may continue the pregnancy under careful
monitoring. They should be evaluated and managed by a
gynecologic oncologist with expertise in gestational
trophoblastic disease (GTD) and a maternal-fetal medicine
specialist, if possible.
48. Familial recurrent molar
pregnancy
Patients with recurrent molar pregnancies can have
biparental molar rather than typical androgenetic disease, and
is typically familial . Genetic studies in such families showed
that the related genes are at chromosome 19q13.3-13.4, and
subsequent analysis noted NLRP7 mutations in this region .
The function of the normal protein and the mechanism by
which mutations are associated with imprinting abnormalities
and GTD are unknown.
49. Management
The basic principles in
management of the patient
with hydatidiform mole include
establishment of the diagnosis,
evacuation of the molar
gestation, and close
surveillance of hCG level after
evacuation.
50. CHOICE OF PROCEDURE FOR
REMOVAL OF MOLAR TISSUE
Surgical removal of the HM is the central component of treatment and can be
accomplished by either uterine evacuation or hysterectomy. We suggest
surgical uterine evacuation for most women because it is effective, preserves
childbearing capacity, and is less morbid.
Hysterectomy is a reasonable alternative for women who have completed
childbearing, particularly those with a known or presumptive complete mole
and the following risk factors for gestational trophoblastic neoplasia (GTN)
●Signs of trophoblastic proliferation (uterine size greater than gestational age,
serum human chorionic gonadotropin [hCG] levels >100,000 milli-international
units/mL, ovarian theca lutein cysts >6 cm in diameter)
●Age >40 years
51. Suction D&C
low complication rate in patients with uterine sizes
corresponding to <16 weeks gestation. Oxytocic agents
are administered after cervical dilation and partial
evacuation to aid in postoperative hemostasis. Patients
with excessive uterine enlargement have a higher risk
of pulmonary complications associated with D&C, which
may be related to trophoblastic deportation,
preeclampsia, fluid overload, anemia, and
hyperthyroidism
52. PATIENT PREPARATION
●RhD-negative women – Patients who are RhD-negative should
receive anti-D immune globulin at the time of treatment. A complete mole
does not contain fetal red cells, but prophylaxis after evacuation is
suggested because fetal red cells are present in partial molar
pregnancies; sometimes it is initially difficult to determine whether the
patient had a molar pregnancy, a missed abortion, or a partial mole with
fetal absorption; and there is some evidence that the RhD antigen is
expressed on trophoblast
In recent years, complete mole is usually first detected with ultrasound in
the first trimester, so potentially serious signs and symptoms, such as
hyperthyroidism and preeclampsia, which primarily occur in the second
trimester, are now infrequently seen.
53. Symptomatic
hyperthyroidism
●Although hyperthyroidism due to gestational trophoblastic disease resolves with treatment
of the HM and subsequent normalization of human chorionic gonadotropin levels,
symptomatic women require treatment with a beta blocker prior to surgery. T
he longer acting beta blockers (eg, atenolol) are preferred because an oral dose taken one
hour before surgery will usually maintain adequate beta blockade until the patient is able to
take oral medications postoperatively. We typically start with atenolol 25 to 50 mg daily and
increase the dose, as needed, to maintain the pulse rate below 80 beats/minute; up to 200
mg daily may be needed for the symptomatic treatment of hyperthyroidism and control of
tachycardia.
Intravenous propranolol (0.5 to 1 mg over 10 minutes followed by 1 to 2 mg over 10 minutes
every few hours) can be used to control fever, hypertension, and tachycardia
intraoperatively.
Beta blockers should be continued until the patient's thyroid disease is under control.
Some patients may require thionamides.
54. Preeclampsia
Preeclampsia associated with HM resolves promptly
after molar evacuation and usually does not require
medical management, unless severe features of the
disease are present. For example, severe hypertension,
if present, should be treated to reduce the risk of stroke.
Eclampsia is rare; the decision to administer
magnesium sulfate for seizure prophylaxis should be
individualized
55. PROCEDURES
Uterine evacuation — Uterine evacuation consists of mechanical dilation of the cervix, followed by
electric suction aspiration (regardless of uterine size), and then sharp curettage to help assure complete
evacuation of molar tissue. Electric and manual suction evacuation are comparable in terms of their
effectiveness for complete evacuation and in side effects
. The technique is the same as for pregnancy termination.
We do not use osmotic dilators, but some clinicians insert them in nulliparas on the day before the
procedure to facilitate dilation. Medications (eg, prostaglandins) are not used for cervical ripening
because their use delays the procedure, they are associated with side effects, they may increase the
risk of complications, and they do not confer proven benefit
At the time of anesthesia induction, an oxytocin infusion (10 units in 1 L Ringer lactate solution at 50
drops/minute) is begun to promote myometrial contraction and thus decrease blood loss.
Mechanical dilation of the cervix is performed gradually until a cannula diameter appropriate for the
uterine size can be inserted. Most clinicians choose a diameter equal to or 1 mm smaller than the
number of weeks of gestation of a similarly sized normal intrauterine pregnancy.
56. PROCEDURES
Disruption of the HM can cause brisk bleeding. Although the uterus
generally shrinks rapidly as the contents are aspirated and oxytocin
is infused, which diminishes blood loss, bleeding is typically
substantially more than that encountered during evacuation of a
pregnancy. Transabdominal fundal massage can facilitate uterine
contraction if the uterus is sufficiently above the pelvic brim (≥14
week size). However, hysterectomy or uterine artery embolization
may be needed for emergency management of acute hemorrhage
When suction evacuation is believed to be complete, gentle sharp
curettage should be performed to remove any residual molar tissue.
Intraoperative sonography can be used to monitor the procedure and
help determine when evacuation is complete.
57. Hysterectomy
can be safely performed by either an abdominal or laparoscopic approach; the choice is
influenced by technical issues such as uterine size and the clinician's familiarity with the
techniques.
Preoperative issues (eg, thromboprophylaxis, prophylactic antibiotics, elective oophorectomy)
are similar to those before any abdominal or laparoscopic hysterectomy for benign uterine
disease, except for administration of anti-D immune globulin in D-negative patients and
greater consideration of a supracervical procedure. Due to the highly vascular nature of the
gravid uterus, supracervical hysterectomy may be performed to reduce blood loss and avoid
ureteral injury
If prominent ovarian theca lutein cysts are present and symptomatic (large cysts can cause
troublesome pressure symptoms), they can be aspirated to reduce the volume and patient
discomfort.
The ovaries may be left in situ since ovarian metastases are rarely encountered.
58. Hysterectomy reduces the incidence of
malignant sequelae after evacuation of
hydatidiform mole from approximately 20%
after suction D&C to <5% after hysterectomy.
59. POSTEVACUATION
COMPLICATIONS Cardiopulmonary symptoms — In women treated in the first trimester, postoperative
cardiopulmonary symptoms are rare . In the second trimester, approximately 2 percent of
patients treated by evacuation develop cardiopulmonary symptoms, including chest pain,
dyspnea, tachypnea, and tachycardia .
Respiratory distress after uterine evacuation is usually attributed to trophoblastic
embolization
. Respiratory problems can also be due to massive fluid replacement, complications of
thyroid storm, or preeclampsia and can develop in patients who undergo hysterectomy.
Auscultation of the chest usually reveals diffuse rales, and the chest radiograph often
demonstrates bilateral pulmonary infiltrates, which have been misinterpreted as
metastases. With standard cardiopulmonary support, the infiltrates resolve in most cases
over 48 to 72 hours as the human chorionic gonadotropin (hCG) level decreases since
complications of complete mole (eg, hyperthyroidism, preeclampsia) are strongly
associated with marked trophoblastic proliferation and high hCG values
60. Ovarian theca lutein cysts
Theca lutein cysts usually regress slowly over two
to four months following evacuation as hCG levels
decline. Large cysts causing troublesome pressure
symptoms can be aspirated transabdominally under
ultrasound guidance.
Theca lutein cysts may cause adnexal torsion, or,
rarely, they rupture spontaneously. In such cases,
they can be managed laparoscopically
61. POSTOPERATIVE
MONITORING
Postoperative human chorionic gonadotropin (hCG)
monitoring is performed to detect development of gestational
trophoblastic neoplasia (GTN), which is indicated by an hCG
level that does not return to undetectable.
Patient education is crucial to help patients understand and
comply with surveillance protocols. Internet resources can
substantially contribute to a patient's understanding of
gestational trophoblastic disease (GTD) and support
compliance with treatment recommendations .
62. Protocol for serial hCG
measurements
After surgical treatment of HM (evacuation or
hysterectomy), measurements of serum hCG levels are
obtained weekly in all patients until either the level
remains undetectable or criteria are met for an increasing
or plateaued level, as described below
63. The recommendations for postmolar follow-up include
determination of serum β-hCG levels every 1 to 2 weeks
after evacuation until the hCG level is normal;
determination of the hCG level 2 weeks after first
normal level to confirm spontaneous hCG regression;
and hCG surveillance every 1 to 2 months for 6 months
after the first normal hCG level
64. Increasing hCG levels — An increasing hCG is defined as a level that
progressively increases >10 percent across three values during at least a
two week period (eg, on days 1, 7, and 14) . Patients with this pattern
meet criteria for postmolar GTN and typically require chemotherapy to
achieve remission. The diagnostic evaluation, classification, staging, and
treatment of postmolar GTN are discussed in detail separately.
Plateaued hCG levels — A plateaued hCG level is defined as four
measurements that remain within ±10 percent over at least a three week
period (eg, days 1, 7, 14, and 21) . Patients with this pattern meet criteria
for postmolar GTN and typically require chemotherapy to achieve
remission. The diagnostic evaluation, classification, staging, and
treatment of postmolar GTN are discussed in detail separately.
65. Low-level plateaued hCG
(quiescent GTN)
On very rare occasions following molar evacuation, plateauing is
due to quiescent GTN, which is defined as a low level (<200 milli-
international units/mL) of hCG that persists for at least three
months after evacuation of an HM in the absence of any clinical or
radiologic evidence of GTN. This condition is thought to be due to
the presence of a small focus of highly differentiated, noninvasive
syncytiotrophoblast cells that produce small amounts of hCG and
usually do not progress to invasive disease as long as
cytotrophoblast or intermediate cells are absent
Patients with quiescent GTN do not require therapy but do require
close follow-up because 6 to 10 percent will eventually develop
active GTN, requiring treatment . They should be monitored with
monthly hCG testing and advised to avoid pregnancy .
66. Low-level plateaued hCG
(quiescent GTN)
●Measurement of hyperglycosylated hCG (hCG-h) has
been proposed for surveillance in patients with
quiescent GTN , but the test is not commercially
available.
There are several other etiologies of a persistent low-
level hCG, including pituitary gland hCG production
particularly in perimenopausal women. The differential
diagnosis of persistent low hCG is discussed in detail
separately
67. OUTCOME
Frequency of gestational trophoblastic neoplasia after
molar pregnancy
After a complete mole —nother high-risk factor for
development of GTN. In women over age 40, the risk may be 30
to 60 percent . In women over age 50, risks of 53 and 56
percent have been reported . The reason that older age is a risk
factor may be because complete moles are more commonly
aneuploid in older women, and aneuploidy may be a risk factor
for GTN ,In comparison, adolescents (<20 years of age) appear
to have a low risk of developing GTN
First-trimester versus second-trimester diagnosis does not
impact the incidence of postmolar GTN .
68. After a partial mole — After a partial mole, 3.5 to 4.5
percent of women develop GTN
No risk factors for GTN after partial mole have been
identified
69. Frequency of repeat molar
pregnancy
Women with a prior HM are at increased risk of developing
subsequent HM compared with the general population
Estimates of the risk of subsequent HM are:
●After one molar pregnancy: 1 to 1.9 percent
●After two molar pregnancies: 15 to 17.5 percent
A Patients with repeat molar pregnancy are at an increased risk of
developing GTN. One study reported a threefold increased risk of
postmolar tumor in patients with a repeat molar pregnancy
70. Obstetric outcomes of
subsequent pregnancies
In general, patients with either a complete or partial mole
can anticipate normal future reproductive outcomes.
71. OBSTETRIC MANAGEMENT OF
SUBSEQUENT PREGNANCIES
Due to the risk of recurrent HM, in our practice, we do the following
in patients with a prior HM who become pregnant:
●First-trimester ultrasound to confirm normal gestational
development.
●After delivery, carefully examine the placenta and send to
pathology for histologic examination if any gross abnormalities are
present.
●Measure serum human chorionic gonadotropin six weeks after the
completion of any type of future pregnancy (eg, term delivery,
miscarriage, pregnancy termination) to exclude choriocarcinoma.
●Send all products of conception from miscarriages and pregnancy
72. Medication-only methods of uterine evacuation (misoprostol,
mifepristone, oxytocin) should not be used, although data
are limited. The only study that evaluated this approach
reported that 20 of 77 cases (26 percent) subsequently
required surgical evacuation (suction or sharp curettage) for
persisting symptoms, persistently raised hCG levels, or a
combination of symptoms and raised hCG .
In addition, medical evacuation was associated with a higher
rate of subsequent need for chemotherapy than was surgical
evacuation (9.1 versus 3.8 to 5.9 percent).
73. Hysterotomy or induction of
labor for molar evacuation is
not recommended
75. IUD
theoretical risk for perforation, infection, and
hemorrhage .An IUD may be used in women with
undetectable hCG levels.
76. PROPH YLACTIC
CHEMOTHERAPY
We rarely administer prophylactic chemotherapy around
the time of molar evacuation. Prophylactic
chemotherapy has been evaluated as a method to
reduce the risk of development of gestational
trophoblastic neoplasia (GTN), but supporting data are
weak, and prophylactic chemotherapy may increase
drug resistance and is associated with toxicities
77. USE OF PROPHYLACTIC
CHEMOTHERAPY
We only consider it in patients who have complete moles, who are being
treated by evacuation rather than hysterectomy, who are at high risk of
developing GTN (ie, they have signs of trophoblastic proliferation, uterine
size greater than gestational age, serum human chorionic gonadotropin
[hCG] levels >100,000 milli-international units/mL, and ovarian theca
lutein cysts >6 cm in diameter, and are age >40 years), and in whom hCG
follow-up is either unavailable or unreliable, which is a particular
consideration in global areas that are resource-limited
Both methotrexate and actinomycin D have been used for
chemoprophylaxis; no data are available to suggest whether one is
superior to the other. At our center, we generally administer actinomycin D
when prophylaxis is indicated. Chemoprophylaxis does not appear to
impact future fertility potential
78. False-Positive
absence of urine hCG and failure
to detect hCG in an alternative
laboratory hCG test, the initial
suspected test is likely a false
positive Heterophillic antibody
79. the following in patients
with a prior HM who become
pregnant:
First-trimester ultrasound to confirm normal gestational
development.
After delivery, carefully examine the placenta and send
t o pathology for histologic examination if any gross
abnormalities are present.
Measure serum human chorionic gonadotropin six weeks
after the completion of any type of future pregnancy
(eg, term delivery, miscarriage, pregnancy termination)
to exclude choriocarcinoma.
