molar pregnancy, molar pregnancy

1. Molar pregnancy
Dr Rashmi Ray

2. Definition
Benign neoplasia of chorion with
malignant potential
Formation of clusters of small
cysts of varying size
Abnormal condition of placenta
partly degenerative & partly
proliferative changes in young
chorionic villi

3. Types of molar pregnancy
Complete
mole
• Mass of tissue made up of abnormal cells
• No fetus
Partial
mole
• Mass has both abnormal cells & a fetus
• Fetus has severe defects & destroyed by
growing abnormal cells very quickly
cysts
foetus

4. Genetic origin of complete mole
Monospermic complete mole - 80%
Maternal
chromosomes
are lost
23
23
Paternal chromosomes double up
46
Dispermic complete mole – 20%
Two sperms
fertilize the egg
Complete mole has only
paternal chromosomes
46XX or 46XY

5. Genetic origin of partial mole
23
Two sperm fertilize an egg
23
23
23
69
Triploid conceptus with 69 chromosomes
Partial moles are dispermic = 69XXX, 69XXY, 69XYY,
Partial mole has
maternal & paternal
chromosomes

6. Incidence
1:100 to 1:400 pregnancies in Asian countries
1: 1000-2000 pregnancies in US & Europe
Highest in Philippines (1:80).
In India its 1:400
Complete mole more common than partial mole

7. Clinical risk factors
Maternal age
<19 years, >35 years
H/o previous molar
pregnancy
Cytogenetic abnormality
More in AB blood group
7-10 times more
common in Asians
Deficient in Vit A &
proteins

8. Clinical features – complete mole
Hyperemesis due to high HCG
Vaginal bleeding with grape like vesicles
‘White currant in red currant juice’
Breathlessness due to pulmonary embolization
Thyrotoxic features - tremors & tachycardia
No foetal movement - quickening absent
Pain abdomen due to overstretching, uterine contractions,
infection, concealed hemorrhage, perforation
Nausea Bleeding High BP
Uterus > GA

9. Clinical signs
P/V: Internal ballottement absent
Theca lutein cyst may be palpable in 25 %
If cervix open vesicles may be felt
P/A: Uterine size > GA
Doughy feel ,EB absent,
No foetal part, no foetal movement & no FHS
Pallor Early Preeclampsia

10. Partial mole
Classical picture of complete mole not seen
Hyperemesis & Pre-eclampsia
Uterine enlargement > gestation
Theca lutein cysts not present
βhCG titre not markedly raised
Diagnosed only after histological exam of tissue
Diagnosed on USG & fetus not alive
If alive chance of fetal growth retardation

11. Investigations
Full blood count & coagulation profile
ABO & Rh grouping for cross matching
Hepatic, renal & thyroid function test
Sonography – snow storm appearance
hCG: high titre, later needed for follow up
TVS: “ snow storm” appearance
Xray chest for metastasis

12. Diagnosis
USG
• Classic ‘snow storm’ appearance
• Enlarged spiral arteries with low resistance
Quantitative
β-hCG
• high titre
• 1:200 – 1:400 urine
• Rapidly ↑value in blood > 100,000mIu/mL

13. Risk factors for malignant change
Advanced maternal age (>40 years)
Multiparity (≥ 3 previous births)
Initial high hCG levels (>100,000 mIU/mL)
Uterus large for date (> 20 weeks)
Bilateral theca lutein cysts > 6cm
Respiratory distress syndrome after evacuation
Previous history of molar pregnancy

14. Prognosis
Curative by evacuation
Residual Mole
Persistent trophoblastic disease
(GTD)
Complete
mole
Partial mole
Live foetus +
mole
Invasive mole Choriocarcinoma
Placental site
Trophoblastic tumor

15. Management
Evacuation of
uterus earliest
Restoration of
Blood loss
Prevention of
infection
Regular follow
up for 1 year
Suction evacuation with large bore Karman’s cannula
Gentle curettage & material sent for histopathological exam
Oxytocic infusion during & after evacuation
Blood crossmatched & kept available
Broad spectrum antibiotics
Avoid pregnancy
for 1 year

16. Contraception
Not to
become
pregnant for
1 year
IUCD
contraindicated
may cause
irregular bleeding
perforation
Barrier
contraceptives till
hCG levels
become normal
Combined oral pills
after hCG becomes
normal

17. Follow-up
Important for prompt identification of post molar GTD
At every visit
Irregular vaginal bleeding,
Persistent cough
Breathlessness,
Hemoptysis
Examination
Involution of uterus &
ovarian size
Deposits in vaginal wall
β hCG serial quantitative estimations
Xray chest
if symptomatic or
rise in hCG
Exclude
Pulmonary
metastasis

18. Follow up
Follow up for 1 year - βhCG level
βhCG level plateaus or increases
3 normal readings of βhCG
βhCG every month for 6 months Evaluate for
Gestational trophoblastic neoplasia
βhCG to be done weekly till its < 5
Avoid pregnancy
for 1 year
βhCG every 3 months for one year

19. thanks

21. Comparative Pathologic Features of
Complete and Partial Hydatidiform Mole
Features Complete mole Partial mole
Karyotype Diploid 46XX or 46XY Triploid 69XXX or 69XYY
Vessels Present but no fetal blood cells Fetal blood cells present
Villi All villi are hydropic Adjacent villi normal
Fetal tissue None present Usually present
Trophoblast Hyperplasia +nt to variable degrees Hyperplasia mild and focal

22. Comparative Pathologic Features of
Complete and Partial Hydatidiform Mole
Features Complete mole Partial mole
Karyotype Diploid 46XX or 46XY Triploid 69XXX or 69XYY
Vessels Present but no fetal blood cells Fetal blood cells present
Villi All villi are hydropic Adjacent villi normal
Fetal tissue None present Usually present
Trophoblast Hyperplasia +nt to variable degrees Hyperplasia mild and focal

23. Comparative Pathologic Features of
Complete and Partial Hydatidiform Mole
Features Complete mole Partial mole
Karyotype Diploid 46XX or 46XY Triploid 69XXX or 69XYY
Vessels Present but no fetal blood cells Fetal blood cells present
Villi All villi are hydropic Adjacent villi normal
Fetal tissue None present Usually present
Trophoblast Hyperplasia +nt to variable degrees Hyperplasia mild and focal

24. Comparative Pathologic Features of
Complete and Partial Hydatidiform Mole
Features Complete mole Partial mole
Karyotype Diploid 46XX or 46XY Triploid 69XXX or 69XYY
Vessels Present but no fetal blood cells Fetal blood cells present
Villi All villi are hydropic Adjacent villi normal
Fetal tissue None present Usually present
Trophoblast Hyperplasia +nt to variable degrees Hyperplasia mild and focal

25. Comparative Pathologic Features of
Complete and Partial Hydatidiform Mole
Features Complete mole Partial mole
Karyotype Diploid 46XX or 46XY Triploid 69XXX or 69XYY
Vessels Present but no fetal blood cells Fetal blood cells present
Villi All villi are hydropic Adjacent villi normal
Fetal tissue None present Usually present
Trophoblast Hyperplasia +nt to variable degrees Hyperplasia mild and focal

26. Differential diagnosis
Abortion
Ectopic pregnancy
Multiple
pregnancy
Polyhydramnios
fibroid/ovarian tumor with
pregnancy

27. Chemotherapy
Methotrexate 1mg/kg Body wt./day IV or IM on
alternate day (4 days in a week 1,3,5,7)
Folinic acid 0.1mg /kg/IM on alternate
day (2,4,6)
A total 3 such course
IV Actinomycin D 12mcgm/kg Body Wt. daily
for 5 days