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Hydatidiform (vesicular) mole
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Hydatidiform mole

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Hydatidiform mole

  1. 1. Hydatidiform Mole Extern Sarawut Hongyim
  2. 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. 3. History • CC : • PI : 1d PTA ultrasound • • •
  4. 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. 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. 6. Ultrasound
  7. 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 bilirubin 0.15, ALP 70, AST 8, ALT 29
  8. 8. Diagnosis • Molar pregnancy
  9. 9. Molar pregnancy Hydatidiform Mole
  10. 10. Molar pregnancy • is characterized histologically by abnormalities of the chorionic villi that consist of trophoblastic proliferation and edema of villous stroma. • complete or partial
  11. 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. 12. Risk Factors • Age • adolescents and women aged 36 - 40 years have a 2-fold risk and 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. 13. Complete versus Partial Hydatidiform Mole • Gross morphology • Histopathology • Karyotype
  14. 14. Complete Hydatidiform Mole • Grossly • mass of clear vesicles • vary in size from barely visible to a few centimeters • hang in clusters from thin pedicles. • Histologically • hydropic degeneration and villous edema • absence of villous blood vessels • absence of embryonic fetus and amnion.
  15. 15. Complete Hydatidiform Mole
  16. 16. Normal chorionic villi http://radiology.uchc.edu/eAtlas/Images/GYN/5801b.gif
  17. 17. Complete Hydatidiform Mole http://www.webpathology.com/image.asp?case=585&n=2
  18. 18. Complete Hydatidiform Mole http://www.webpathology.com/image.asp?n=3&Case=585
  19. 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 duplicates its own chromosomes after meiosis, ovum chromosomes absent or inactivated. • other complete moles, may be 46,XY due to dispermic fertilization
  20. 20. Complete Hydatidiform Mole Malignant Potential • higher incidence of malignant sequela • 15 - 20 % had evidence of persistent trophoblastic disease
  21. 21. 85 % androgenesis Complete Hydatidiform Mole
  22. 22. Partial Hydatidiform Mole • fetal tissue and Hydatidiform changes that are focal and less advanced • avascular chorionic villi and vascular villi • typically is triploid—69, XXX, 69,XXY, or much less commonly, 69,XYY
  23. 23. Partial Hydatidiform Mole • Grossly • Smaller volume of tissue • Mixture of grossly vesicular and normal villi • Fetus / embryo is usually present, although often abnormal • syndactyly of digits 3 & 4 of both hands and feet • Histologically • Mixture edematous villi & normal villi • Less conspicuous central cistern formation (internal clefting) • Mild focal trophoblast hyperplasia without atypia • Villous scalloping
  24. 24. Partial Hydatidiform Mole
  25. 25. Partial Hydatidiform Mole
  26. 26. Partial Hydatidiform Mole
  27. 27. Partial Hydatidiform Mole
  28. 28. Partial Hydatidiform Mole • Malignant Potential • lower than complete molar • Seckl and associates (2000) documented 3 of 3000 of partial moles to be choriocarcinoma • Growdon and co-workers (2006) higher hCG levels increased risk for persistent disease • levels 200 mIU/mL in the third through 8 week post evacuation at least a 35-% risk of persistent disease
  29. 29. Twin Molar Pregnancy • not rare • Vejerslev (1991) found that of 113 such pregnancies, 45 % progressed to 28 weeks, and 70 % neonates survived
  30. 30. Twin Molar Pregnancy
  31. 31. Clinical Presentation • Vaginal Bleeding 84% • Theca Lutein Ovarian Cysts 46 % • Excessive Uterine Size 28% • Hyperemesis Gravidarum 8% • Preeclampsia 1 % • Hyperthyroidism rarely • Trophoblastic Embolization rarely Complete Mole Partial Mole • incomplete or missed abortion 91.3% • vaginal bleeding 72.8% • Excessive uterine size 3.7%
  32. 32. Diagnosis • History & physical exam • Mole pass in vagina • pregnancy testing and sonography
  33. 33. Sonography • complete mole • complex, echogenic uterine mass with numerous cystic spaces and no fetus or amnionic sac • partial mole • thickened, hydropic placenta with fetal tissue Snow storm appearance
  34. 34. complete mole
  35. 35. Partial Hydatidiform Mole http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-39842010000200014&lng=en&nrm=iso&tlng=en
  36. 36. Management • Evaluation • Termination of pregnancy • Follow up
  37. 37. evaluation • Evaluated medical complications • Preeclampsia • Hyperthyroidism • electrolyte imbalance • Anemia • Lab investigation • CXR • CBC • UA • BUN, Cr • Electrolyte • LFT • PT, PTT
  38. 38. Terminaton of pregnancy • Suction & curettage • Hysterectomy • Prophylactic chemotherapy
  39. 39. Suction Curettage regardless 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 bleeding is well controlled. The use of a 12-mm cannula is strongly advised to facilitate evacuation. If the uterus is larger than 14 weeks of gestation, one hand should be placed on top of the fundus, and the uterus should be massaged to stimulate uterine contraction and reduce the risk of perforation. • Sharp curettage When suction evacuation is believed to be complete, gentle sharp curettage is performed to remove any residual molar tissue
  40. 40. Hysterectomy • If no further pregnancies are desired • aged > 40 yr. • Uterine perforate
  41. 41. Prophylactic Chemotherapy • Prophylactic chemotherapy not only prevented metastasis but also reduced the incidence and morbidity of choriocarcinoma • But • can’t absolutely to prevent choriocarcinoma • After TOP 80-90 % of Molar pregnancy are cure • and choriocarcinoma are cure by currently chemotherapy Actinomycin D, Methotrexate
  42. 42. Follow-up • Human Chorionic Gonadotropin • Contraception • Chemotherapy
  43. 43. Human Chorionic Gonadotropin • monitored q weekly B-hCG levels until normal for 3 consecutive weeks • followed q monthly until normal for 6 consecutive months
  44. 44. Contraception • Prevent pregnancy for a minimum of 1 yr. using hormonal contraception • oral contraceptives safely after molar evacuation during the entire interval of hormonal follow-up
  45. 45. chemotherapy • If • B-hCG level rising or plateau • Rising = increase B-hCG > 2-fold • Plateau = no change or increase < 2-fold
  46. 46. Further of pregnancy • Recurrent 5 - 10-fold of pregnancy • Reassurance women if desire pregnancy but early ANC
  47. 47. Reference • Berek, Jonathan S. Gestational Trophoblastic Disease. Berek & Novak's Gynecology, 14th Edition. • Chapter 11. Gestational Trophoblastic Disease. Williams Obstetrics, 23 Edition
  • KILILIDEBOROY

    Apr. 9, 2021
  • mahmoudkareem1

    Dec. 13, 2017
  • Sanjays38

    Aug. 2, 2016
  • HMelaome

    Aug. 18, 2015
  • ssuserc18503

    Apr. 29, 2014

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