Gestational trophoblastic disease (GTD) includes a spectrum of abnormal pregnancies associated with trophoblastic proliferation. The most common form is a hydatidiform mole, which occurs when a fertilized egg implants abnormally in the uterus. Complete moles have only paternal chromosomes, while partial moles have both maternal and paternal chromosomes. Symptoms include vaginal bleeding, abdominal pain, and high hCG levels. Treatment involves uterine evacuation followed by chemotherapy for high-risk cases to prevent malignant changes. Long-term monitoring of hCG levels is needed due to the risk of persistent trophoblastic disease.

1. By Ms. Parijat S
Masters in OBG Nursing
HYDATIDIFORM MOLE /VESICULAR
MOLE

2. Hemorrhage in
Early Pregnancy
The causes of bleeding in early pregnancy are
broadly divided into two groups:
Those related to the pregnant state
Those associated with the pregnant state

3. Those related to the pregnant state:
 Abortion (95%),
 Ectopic pregnancy,
 Hydatidiform mole and
 Implantation bleeding.

4. Those associated with the pregnant state:
 Cervical lesions such as vascular ectopy
(erosion), polyp, ruptured varicose veins and
malignancy are important causes.
 The lesions are unrelated to pregnancy—
either pre-existing or aggravated during
pregnancy.

5. Cervical ectropion

6. Gestational Trophoblastic Disease
(GTD)
 Gestational Trophoblastic Disease (GTD)
originates from placental tissue and is
among the rare human tumors that can be
cured even in the presence of widespread
metastases.
 Gestational trophoblastic disease (GTD)
encompasses a spectrum of proliferative
abnormalities of trophoblasts associated
with pregnancy.

7. types of gestational trophoblastic
diseases :
Hydatidiform mole (benign)
Invasive mole;
Choriocarcinoma; (rare case likely to spread
quickly)
Placental site trophoblastic tumor ( PSTT).
 The most common form of GTD is
hydatidiform mole, also known as molar
pregnancy.

8. HYDATIDIFORM
MOLE

9.  Molar pregnancy is an abnormal form
of pregnancy in which a non-viable fertilized
egg implants in the uterus and will fail to come to
term.

10. DEFINITION
 Hydatidiform mole is the abnormal condition of
the trophoblast (placenta) in which partly
degenerative and partly proliferative changes
occurs in the young chorionic vili.

11.  Hydatids means “watery vesicles”
 Cells degenerate and get filled with the fluid
which resemble the hydatid cyst so its called
hydatidiform mole.
 Hydatidiform mole is also called as “benign
neoplasia of the chorion with malignant
potential”

12. INCIDENCE
 The highest incidence is in Philippines being 1 in
80 pregnancies and lowest in European
countries 1 in 752 and USA being about 1 in
2,000.
 The incidence, in India, is about 1 in 400.

13. Risk factors
 Teenage and elderly pregnancy with high parity
 Race and ethnic group
 Low intake of carotene
 Low intake of protein & animal fat
 Disturbed maternal immune response
 Cytogenic abnormality
 History of previous hydatidiform mole

14. TYPES
A. Complete hydatidiform mole
B. Incomplete/partial hydatidiform mole
 Partial and complete mole is identified through
chromosomal analysis

15. COMPLETE HYDATIDIFORM MOLE
 Complete mole usually have 46 no. of
chromosomes but of paternal origin only. It
means no maternal chromosomes. Haploid
sperm cells get fertilized with empty ovum and
paternal chromosomes get duplicated.
 + + duplication=
sperm ovum zygote
23 46

16. Features of complete mole:
 This type of mole shows no evidence of embryo,
cord or membrane
 Embryo forms and dies earlier without
development of placental circulation
 Chorionic vili alter to form clear fluid filled bunch of
grapes of varying sizes.
 Hyperplasia affects the syncytiotrophoblast and
cytotrophoblast layers. Mass occupies the uterine
cavity and uterus gets enlarged.

17. PARTIAL HYDATIDIFORM MOLE
Chromosomal analysis shows 69 chromosomes
with 3 sets of chromosomes, 1 maternal and 2
paternal
Sperm ovum zygote
23
23
23
69

18. Features of partial mole
 There is presence of embryo, fetus or amniotic fluid.
Fetus dies in early 1st trimester
 Hyperplasia is confined to single layer of
syncytiotrophoblast.
 Uterus is not large for dates and potential for
malignancy is low.

19. Etiology
 Idiopathic
 Its related to ovular defect.

20. Clinical symptoms
The patient gives history of amenorrhea of 8–12
weeks with initial features suggestive of normal
pregnancy but subsequently presents with the
following manifestations:
Symptoms
 Vaginal bleeding (90%)
The blood may be mixed with a gelatinous fluid
from ruptured cysts giving the appearance of
discharge “white currant in red currant juice”.

22.  Lower abdominal pain
It is due to:
o Over distention of uterus
o Concealed hemorrhage
o Perforation of uterus by invasive mole
o Infection

23.  Constitutional symptoms
 Patient is sick without apparent reason
 Nausea and vomiting
 Thyrotoxic features-tremors, tachycardia
 Breathlessness( due to pulmonary embolisation of
trophoblastic cells)
 Expulsion of grape like vesicles per vaginum
 No H/O quickening

24. Signs
 Patient looks more ill
 Pallor
 Feature of preeclampsia may be present

25. Examination
1. Per abdomen
 Size of uterus is more than period of
amenorrhoea in 70%, corresponds with the
period of amenorrhea in 20% and smaller than
the period of amenorrhea in 10%.
 On palpation uterus is doughy or elastic
 Fetal parts are not felt
 No fetal movements
 No fetal heart sound
 External ballottement cannot be elicited

26. Per vaginum
 Vesicles in vaginal discharge
 Internal ballottement cannot be elicited.

27.  The ovaries often contain multiple large
theca-lutein cysts as a result of increased
ovarian stimulation by excessive beta-hCG
 In women with a complete mole, the
quantitative serum beta-hCG level is higher
than expected, often exceeding 100,000 IU/L.

28.  In case of a partial mole, the level of beta-hCG is
often within the wide range associated with
normal pregnancy and the symptoms are usually
less pronounced.

29. Investigations
1. Full blood count, ABO and Rh grouping
2. Hepatic, renal and thyroid function test
3. USG
 USG of abdomen shows snow-storm
appearance
 USG of liver, kidney and spleen is also done

31. 4. Serum HCG level/ urine test of HCG
5. Radiography
-Xray of abdomen shows –ve fetal shadow.
6. CT scan and MRI

32. Complications
 Immediate
 Late
 IMMEDIATE COMPLICATIONS
I. Haemorrhage
II. Shock
III. Sepsis
IV. Perforation of uterus

33. v. Preeclampsia
vi. Acute pulmonary insufficiency
Symptoms usually begins within 4–6 hours
following evacuation.
vii. Coagulation failure
LATE COMPLICATIONS
 Choriocacinoma

34. Risk Factors for Malignant Change
 Patient’s age ≥ 40 or < 20 years irrespective of
parity
 Parity ≥ 3. Age is more important than the parity
 Serum hCG > 100,000 mIU/mL
 Uterine size > 20 weeks
 Previous history of molar pregnancy
 Theca lutein cysts: large (>6 cm diameter)

35. Management
Principles in the management
 Supportive therapy to restore the blood loss and
to prevent infection
 To evacuate the uterus as soon as diagnosis is
made.
 Counseling for regular follow up

36. Supportive therapy
(i) IV infusion with Ringer’s solution is started.
(ii) Blood transfusion is given if the patient is
anemic.
(iii) Parenteral antibiotic is given if there is
associated infection.
(iv) Blood is kept reserved during the evacuation as
there is risk of hemorrhage.

37. Definitive management
 Evacuation of the uterus is done as soon as the
diagnosis is made. Suction evacuation can safely
be done even when the uterus is of 28 weeks of
gestation

39. Vaginal evacuation
Cervix is favourable
 Suction evacuation is done in which a –ve
pressure of 200-250 mmHg pressure is applied.
 This procedure is done under diazepam sedation
or general anaesthesia .
 Oxytocin infusion (20 units) in 500 ml ringer’s
solution is started at 30 drops per min when there
is risk of haemorrhage.

40. Cervix is tubular and closed
 Slow dilatation of cervix is done by introducing
Laminaria tent which is followed by suction and
evacuation
 Alternatively, vaginal misoprostol (PGE1) 400
µg, 3 hours before surgery may be used.
 Digital exploration and removal of mole it may
done by ovum forceps which is alternative.

41.  After completion of evacuation methergin of 0.2
mg is given IM.

42. Laminaria tent
 It is a cylinder about 5-
10 cm long made from
the dried stalk of the
marine plant Laminaria
digitata.
 They are inserted into
the cervical canal when
they are dry and slowly
expand as they absorb
water, dilating the
cervix.

43. Hysterotomy
 Cervix is unfavourable
 Bleeding is ++

44. Abdominal
hysterectomy
 Patient is above 35yrs
 Family is completed
 Perforating
hydatidiform mole
 Patient is high risk for
developing
malignancy.

45.  Uterus is send for histopathological examination
 Following examination anti D immunoglobulin is
given to patient who are Rh –ve.
Prophylactic chemotherapy
 About 80% of patients undergo spontaneous
remission.
 It is given to those patients who are at risk to
develop malignancies
 Either methotrexate or actinomycin is given orally or
IM or IV

46.  Methotrexate, 1 mg/kg/day IV or IM is given on
days 1, 3, 5 and 7 with folinic acid 0.1 mg/kg IM
on days 2, 4, 6 and 8.
 It is to be repeated every 7 days. A total three
courses are given.
 beta-hCG level should decrease by at least
15%, 4–7 days after methotrexate.
 Alternatively, intravenous actinomycin D 12 µg/kg
body weight daily for 5 days may be given. It is
less toxic than methotrexate.

47. Follow up
 Routine follow-up is mandatory for all cases for
at least 1 year.
 The prime objective is to diagnose persistent
trophoblastic disease (20–30%) that is
considered malignant. However, hCG levels
following evacuation should regress to normal
within 3 months time.

48. Follow up protocols
 Maternal serum or urine hCG level is measured
 Relevant symptoms are enquired such as vaginal
bleeding, persistant cough, breathlessness, etc
 Chest X-ray, CTscan/ MRI for brain, chest and
pelvis is done
 Abdomino-vaginal examination is done to note
involution of uterus, ovarian size, malignant
deposit if any in anterior vaginal wall.

49. Contraceptive advise is given.
 If patient wants to be pregnant she can but after 6
month if her serum hCG titre is –ve.
 women who is under chemotherapy should wait
for 1 year.
 Oral pills or barrier method is used
 IUD should be avoided.