Presentation on molar pregnancy

1. DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
MASENO UNIVERSITY
Presentation on
HYDATIDIFORM MOLE
30th April 2020
Dr. Edward Owilah

2. CASE
 Name: YY
 Age: 20yrs
 IP NO: 3151/37
 DOA: 20.04.2020
 LNMP: 16.12.2019
 GBD: 18 wks
 EDD: 23.09.2020
 Parity: 0 + 0

3. Contd.
Patient was a 20 year old Para 0 + 0 who presented with complaints of:
-
 Bleeding per vaginum for 2 weeks
• Bleeding was described as light and did not necessitate the use
of a pad
• Bleeding mostly noted during morning hours after waking up
• There was no associated lower abdominal pain
 She had no nausea/vomiting

4. Contd.
 There was no history of dizziness, irritability or photophobia
 She denied having anorexia or tremors
Social History: -
 Patient is a single lady who is the 2nd born in a family of 2.
 Lives with the mother and her sibling all of who are alive and well
 She denied to having any allergies, denied drinking alcoholic
beverages and denied being an active smoker
 Denied use of any recreational drugs

5. Contd.
Obstetric/Gynecological History: -
 She experienced her menarche at 14 years
 Has regular periods that last 2 – 3 days and uses 2 sanitary pads per
day
 Reports to having dysmenorrhea
 Denied history of having suffered from STI/UTI

6. Contd.
 No history of any abortions/pregnancy
 Negative for Family Planning (FP) use
 Has had no cervical cancer screening
Medical/Surgical History: -
 Had no previous hospital admissions prior to incident admission
 No history of any surgical procedures
 Had not been transfused before/No blood dyscrasias

7. Examination
 The patient was alert, oriented and not in any obvious distress or pain
 Was not pale, not jaundiced and was clinically afebrile
 She had no pedal edema
 Vital Signs –
 BP – 122/85 mmHg
 PR – 81 bpm
 Temperature – 36.7 degrees centigrade

8. Examination contd.
 Abdominal Examination: -
 Soft, non – tender
 No hepatosplenomegaly
 FH – 16 weeks
 The Central Nervous System, Respiratory System, Gastrointestinal System,
Musculoskeletal System and the Cardiovascular System were all normal at
examination
 Vaginal Examination –
 Normal external genitalia.
 The cervix was smooth
 External cervical OS admitted the tip of a finger
 There was blood on the examining fingers.

9. Contd.
Diagnosis
- Hydatidiform Mole
Plan of Management
- Pelvic ultra sound done at the casualty – a bulky uterus with a homogeneous
mixed echomass with “lily” appearance
Laboratory Investigations done: -
 Complete Blood Count (CBC) –
 Hemoglobin (Hb) – 10.3 gm/dl
 Platelets (PLT) – 204
 White Blood Cell Count (WBC) – 5.7

10. Contd.
 Beta human chorionic gonadotropin (b-hCG) – 21/4/20 – 352,499.4
mIU/ml
 Urea/Electrolyte and Creatinine (UECs) – within normal limits
 Blood Group – A positive (+ve)– cross matched
 Intravenous Fluids (IVF) (Normal Saline)
 Transfused – 1 pint/Hematinics/Antibiotics/Analgesics
 Suction Curettage – 24/4/20 – 200 milliliters (mls) of vesicular like
particles mixed with dark blood suctioned

11. Outcome and Follow up
 Patient did well post curettage and was subsequently discharged
home on 25/04/2020
 Follow up
 Family Planning advice given and need to avoid pregnancy
stressed
 To come again after 1 week for review
 Patient asked to come with b-hCG test results

12. DISCUSSION
 Definition : - Hydatidiform mole (HM) is an abnormal
pregnancy characterized by varying degrees of
trophoblastic proliferation and vesicular swelling of
placental villi associated with an absent or abnormal
fetus/embryo.
 Etiology: - the etiology of HM remains unclear but it
appears to be due to abnormal gametogenesis and
fertilization

13. Gestational Trophoblastic Disease (GTD)
 Hydatidiform mole (Molar Pregnancy) is the most common type of a spectrum of
illnesses called gestational trophoblastic disease, which include
 Invasive mole.
 Choriocarcinoma.
 Placental-site trophoblastic tumor and
 Epithelioid trophoblastic tumor.
 It is considered a benign form of GTD but with malignant potential

14. INCIDENCE
 Increased prevalence in Asians, Hispanics, and American
Indians (Drake, 2006; Lee, 2011; Smith, 2006) – suggests
ethnic predisposition
 Indonesia – 1:100. Mexico – 1:200 (American Journal of
Obstetrics and Gynaecology 1984)
 The incidence in the United States and Europe has
been relatively constant at 1 to 2 per 1000 deliveries
(Lee; Lybol; Salehi, 2011).

15. Incidence contd.
 Africa – Data from Africa is scarce
 Nigeria – Jos – 1:357, (Amaka N. Ocheke, Jonah Musa, Alexander O.
Uamai, 2005)
• Ibadan – 1:175, Lagos – 1:184, Ile-Ife – 1:588
 Uganda - 6.1% (11/181) – (Olivier Mulisya et al, 2017)
 Tanzania – 12.8% (M. City, 2013)
 Kenya – Not much data on incidence

16. Contd.
 The higher trend in some populations has been attributed to
“nutritional and socioeconomic status” (R. S. Berkowitz and D. P.
Goldstein)
 Rather than true incidence differences, reported differences may be
related to: -
• lack of standardization of data collection
• Issues to do with reporting
• Hospital center versus population studies – (Kim, 2004; Matsui, 2003)

17. RISK FACTORS
 Age (extremes of reproductive years)
 < 20 years
 > 40 years
 Reproductive history
 Prior HM - For those with a prior complete mole, the risk of another mole is
1.5%. Previous partial mole – 2.7% (Garret, 2008)
 Prior spontaneous abortion – (previous spontaneous abortion at least
doubles the risk of molar pregnancy (Parazzini, 1991)

18. Risk factors contd.
 Diet - Vitamin A deficiency and low dietary intake of carotene are
associated with an increased risk of complete moles (Berkowitz, 1985;
Parazzini, 1988).
 Excessive Smoking
 Blood type –
• A or AB are slightly at higher risk than those with type B or O

19. Risk Factors Contd.
 Genetic factors - A rare autosomal recessive disorder known as
familial recurrent HM has been identified on chromosome 19q
(Wang, 2009; Murdoch, 2006).*
 Partial moles have been linked to
 higher educational levels,
 smoking,
 irregular menstrual cycles, and
 obstetric histories in which only male infants are among the prior
live births (Berkowitz, 1995; Parazzini, 1986).

20. TYPES
 The
 degree of histological changes,
 gross characteristics,
 karyotypic differences, and
 the absence or presence of embryonic elements are used to classify them as either: -
 Complete Hydatidiform Mole (CHM) or
 Partial/Incomplete Hydatidiform Mole (PHM)
 Other classifications: -
 Non-Invasive –
 CHM
 PHM
 Invasive – Destructive and penetrates/perforates the uterine wall – Chorioadenoma
deutrens

21. Types Contd.
Features of Partial and Complete Hydatidiform Moles
Feature Partial Complete
Karyotype Triploid i.e. 69,XXX/69,XXY or
tetraploid. Has both paternal &
maternal genes
Diploid i.e. 46XX/or rarely 46XY
(From Father) No maternal genes
Clinical presentation
Uterine size Small for dates Large for dates
Diagnosis Missed abortion Molar pregnancy
Vaginal bleeding Mild Marked

22. Contd.
Feature Partial Complete
Initial serum b-hCG levels < 100,000 mIU/mL > 100,000 mIU/mL
Tissue b-hCG Mild Marked
Theca-lutein cysts Rare 25 – 30 % of cases
Medical complications Rare Uncommon
Rate of subsequent GTN 1 – 5 of cases 15 – 20 % of cases

23. Contd.
Feature Partial Complete
Pathology
Embryo/fetus Present Absent
Fetal erythrocytes Present Absent
Villous size Variable Uniform
Hydropic villi Some Widespread/All
Vesicles Smaller and Irregular Large and Regular
Trophoblastic proliferation Focal – only syncytiotrophoblast Circumferencial – all 3 types of
trophoblastic tissue

24. Contd.
Feature Partial Complete
P57 immunohistochemichal
staining
+ve -ve
Implantation-site Trophoblast Mild atypia Marked atypia
Blood vessels Present Generally absent
Necrosis Generally absent Absent
Persistence after initial therapy 7% 20%

25. PATHOGENESIS
Complete Hydatidiform Mole (CHM): - Usually arise when
an ovum without maternal chromosomes is fertilized by one sperm
which then duplicates its DNA after meiosis, resulting in a 46, XX
(90%) androgenic karyotype in which all the chromosomes are
paternally derived (androgenesis)
 About 10% of complete moles are 46, XY or 46, XX arising from
fertilization of an “empty ovum” by two sperm
 The mechanism for production of the empty ovum is unknown.

26. Trophoblast proliferation

27. Pathogenesis contd.

28. Pathogenesis contd.

29. Picture - CHM

30. Pathogenesis contd. -
Partial Hydatidiform Mole (PHM) – They have a triploid
karyotype, usually 69, XXY or 69, XXX or much less commonly 69, XYY
resulting from dispermic fertilization of an apparently normal ovum
 These are each composed of two paternal haploid sets of
chromosomes contributed by dispermy and one maternal haploid set

31. Pathogenesis contd.

32. Picture – PHM

33. PRESENTATION - CHM
 Most molar pregnancies are currently detected when they are small
and before complications ensue - early prenatal care and widespread
availability of sonography (Kerkmeijer, 2009; Mangili, 2008).**
 There is typically amenorhhea of 1 to 2 months before discovery
 Vaginal bleeding with or without the passage of grape like cysts – this
varies from spotting to profuse haemorrhage
 Anemia - can ensue without heavy bleeding due to occult
hemorrhage

34. Presentation contd.
Per Abdomen: -
• A uterus which is large for dates (70%) – (uterus is usually full of
hydropic chorionic villi/tissues in a molar pregnancy also grow
faster than they should)
 Uterus feels doughy (firm and elastic)
 Fetal parts are not palpable
 Absence of fetal movements and fetal heart sound
 Varying degrees of abdominal pain

35. Presentation contd.
 Nausea/Vomiting – (raised HCG)
 1st trimester associated hypertension
 Occasionally, a bilateral enlargement of the ovaries, secondary to
lutein cyst - (b-hCG is homologous to luteinizing hormone (LH),
causing ovarian stimulation)*

36. Contd.
• Anorexia and tremors – (b-hCG shares a sub-unit wth TSH, (Fares FA,
Gruener N, Kraiem Z, 1996)*
• Dizziness, irritability and photophobia – (preeclamptic like
symptoms)**
• Respiratory distress from trophoblastic emboli to the lungs

37. Diagnosis – CHM
• Location - Complete hydatidiform moles usually occupy the uterine
cavity and are rarely located in fallopian tubes or ovaries
• A positive pregnancy diagnostic test
• Pelvic sonography –
• The typical finding is a “snow storm” pattern
• Theca-lutein cysts are frequent findings

38. Diagnosis contd.
• However based on sonography correct diagnosis can be suspected in
only 84% of patients with complete HM (Lindholm and Flam, 1999)
 The accuracy of sonography is gestational age dependent: -
 In complete HM 100% of cases can be diagnosed at a gestational age of 13
weeks or more
 50% of cases can be diagnosed in earlier pregnancies (Lazarus et al, 1999)

39. Diagnosis contd. - The snow storm appearance of a
complete HM

40. Diagnosis contd. - Theca-lutein cysts

41. Diagnosis contd.
• Beta-hCG
• Serum β-hCG levels are commonly elevated above those expected for
gestational age,
• With more advanced moles, values in the millions are not unusual*
• Serum hCG levels of greater than 92000 IU/ml are associated with absent
fetal heart and indicate a diagnosis of complete HM (Romero et al, 1985)
• Serum hCG levels decreases quickly if the patient has an abortion but it does
not in molar pregnancy

42. Baseline Investigations – CHM
• Complete Blood Count –
• Haemoglobin levels
• Blood counts
• A comprehensive metabolic panel with Renal and Liver Function Tests
• Prothrombin Time (PT) -
• Partial Thromboplastin Time (PTT) -
• To rule out any sub-clinical blood disorders like Von Willebrand disease –
Curretage is a bloody process*

43. Baseline Investigations contd.
• Thyroid Function Tests (TFT) – need for beta-blockers in case of
hyperthyroidism
• Blood type/screen – Rhesus –ve patients should be given Rho D
immunoglobulin; need for follow up in subsequent pregnancies
• Chest radiograph

44. Digital Vaginal Examination
Finding of vesicles in the vaginal discharge
Unilateral/bilateral enlargement of the ovaries (25 – 50%)
Open cervical os
Blood on examining fingers

45. PRESENTATION – PHM
• Partial HM usually presents incidentally following histopathologic
examination of the products of conception from uterine evacuation of
a suspected missed or therapeutic abortion.
• Presents as missed or spontaneous abortion around the late first to
early second trimester in 91% of cases
• There is abnormal uterine bleeding in 75% of the cases
• Nausea/Vomiting

46. Presentation PHM contd.
• Medical complications such as: -
• hyperthyroidism,
• theca lutein cysts, and
• respiratory distress are rare – presentations associated with these conditions
are rarely seen
• Preeclampsia occurs with lower incidence (2.5%) and presents much
later with PHM than with CHM but can be equally severe
• There is a low clinical suspicion for Partial HM, under-diagnosis is a
risk, reflecting the importance of a thorough histopathologic
examination of curettage specimens to ensure quality care.

47. Diagnosis PHM
• Physical examination: - Typically unremarkable, one may see a uterine
size that is generally small for gestational date; excessive uterine size
is observed in only 4% of patients
• Ultrasonography - Definitive diagnosis by ultrasound is often difficult.
• Described sonographic features include: -
• Abnormal gestational sac*
• The classic vesicular sonographic findings of a CHM are usually not seen
• Oligohydramnios is not uncommon

48. Diagnosis PHM contd.
• Focal sonographic cystic/and or hydropic changes in the placenta are
significantly associated with the diagnosis of a PHM
• presence of a well-formed but growth-retarded fetus, either dead or alive
with hydropic degeneration of fetal parts being frequently present
• Enlarged placenta with “Swiss cheese” like appearance
• Serum b-hCG - . With a partial mole, β-hCG levels may also be significantly
elevated, but more commonly concentrations fall into ranges expected for
gestational age. - < 100000 IU/ml

49. Diagnosis contd.- Fetus and placenta with cheese like
appearance - PHM

50. Baseline Investigations
• Complete Blood Count
• PT
• PTT
• Blood type and screen

51. DIFFERENTIAL DIAGNOSIS
• Threatened abortion
• Fibroid or ovarian tumor with pregnancy
• Multiple pregnancy
• Mistaken date
• Acute hydramnios

52. MANAGEMENT
 The primary treatment for HM is suction curettage*
 The following steps should be taken before curettage is done: -
 Stabilization of all medical complications
 Determination of active blood type and screening
 Large bore intravenous access
 Counseling and informed consent

53. Management contd.
 Post operatively – Antibiotics/Analgesics/Intravenous fluids
 Rh-negative blood type should receive Rh immune globulin at the
time of evacuation of the uterus**
• Effective contraception is recommended for the entire interval of b-
hCG follow-up testing,,,,,,,,,which type and reasons

54. Follow up
 After the surgical evacuation of the HM, patients should be
monitored as follows: -
 B-hCG levels should be measured after 48 hours
 B-hCG levels should be determined weekly until results are normal
for 3 consecutive weeks, then monthly until results are normal for
6 to 12 consecutive months
 Consider invasive disease when b-hCG plateaus or rises up
 Pelvic examinations - to monitor the involution of pelvic structures
(ovaries/tubes) and to aid in early detection of metastases)

55. Follow up of HM pregnancy

56. COMPLICATIONS
 Anemia – due to excessive bleeding and seen in 50% of cases
 Pre-eclampsia – in 25% of cases (hypertension; proteinuria; oedema)
 Hyperthyroidism – in 7% of CHM (tachycardia; hypertension;
tachypnea)
 Pulmonary complications** - rare (2%) - **Embolization of
trophoblastic tissue)
 HM and co-existent fetus – rare – there is increased risk for post
molar gestational trophoblastic disease

57. Complications contd.
 Hemorrhage and shock
 Uterine perforation
 Sepsis
 Disseminated Intravascular Coagulopathy (DIC) - Factors released by
the molar tissue could trigger the coagulation cascade
 Gestational Trophoblastic Neoplasia –Choriocarcinoma*

58. Prognosis
• > 80% are benign
• About 15 to 20% of cases may develop into persistent gestational
trophoblastic disease
• In 2 to 10% of cases it may change into Choriocarcinoma
• > 90% of women with malignant, non-spreading cancer are able to
survive
• In those with metastatic cancer, remission remains at 75 to 85%

59. WHO RISK SCORE
Prognostic Factor 0 1 2 4
Age < 40 years > 40 years- -
Previous pregnancy H.Mole Abortion Full term pregnancy -
Months since last
pregnancy
< 4 4 – 6 7 – 12 > 12
Pretreatment hCG < 10000 10000 – 100000 > 100000 – 1000000 > 1000000
Largest tumor size
including uterus
< 3 cm 3 – 5 cm > 5 cm -
Site of spread Lungs Spleen or Kidney GIT Brain & Liver
No. of tumors that
have spread
0 1 – 4 5 – 8 > 8
No. of drugs used to
treat the tumor that
have not worked
None None 1 > 2

63. THANK YOU