1) Hydatidiform (Vesicular) Mole is a benign neoplasm of the chorionic villi that is characterized by trophoblastic proliferation. 2) It is diagnosed through elevated hCG levels, ultrasound showing the characteristic "snowstorm" appearance, and histological examination of tissue. 3) Follow up of patients involves regular monitoring of hCG levels to check for resolution or development of gestational trophoblastic neoplasia, as molar pregnancies have a risk of developing into choriocarcinoma or invasive mole.

1. Hydatidiform (Vesicular) Mole
Dr. Uma Gupta *Head & Prof. Obstetrics & Gynecology .
Mayo Institute of Medical Sciences, Barabanki
*M.D, MARD, FAIMER (CMCL 2012), PGDHHM, MHPE
umankgupta@gmail.com
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2. Learning Objectives
 What is Vesicular mole
 Basis of mole
 Types
 Symptoms
 Signs
 Investigation
 Management
 Follow up
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3. Definition
 Gestational trophoblastic disease (GTD) refers to a spectrum
of interrelated but histologically distinct tumors originating
from the placenta.
 Characterized by a reliable tumor marker, which is the β-
subunit of human chorionic gonadotropin (β-hCG).
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4.  Gestational trophoblastic neoplasia (GTN)
refers to the subset of GTD that develops malignant sequelae.
These tumors require normal staging and typically respond
favorably to chemotherapy. Most commonly, GTN develops
after a molar pregnancy but may follow any gestation
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5. Modified WHO Classification of GTD
(2014)
 Molar pregnancies
 Hydatidiform mole
Complete
Partial
 Invasive mole
 Trophoblastic tumors
 Choriocarcinoma
Placental site trophoblastic tumor
Epithelioid trophoblastic tumor
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6. Epidemiology
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• It is a benign neoplasm of the chorionic villi.
• Incidence:
1:2000 pregnancies in United States and Europe, but
10 times more in Asia. The incidence is higher
toward the beginning and more toward the end of
the childbearing period. It is 10 times more in
women over 45 years old.

7. Pathology
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• The uterus is distended by thin walled,
translucent, grape-like vesicles of different
sizes. These are degenerated chorionic villi
filled with fluid.
• There is no vasculature in the chorionic villi
leads to early death and absorption of the
embryo.

8. The uterus is distended by
thin walled, translucent,
grape-like vesicles of
different sizes.
•These are degenerated
chorionic villi filled with fluid.
•There is no vasculature in
the chorionic villi leads to
early death of the embryo.
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9. Hydatidiform :mole
Hyperplasia of trophobasitc cells • Hydropic
swelling of all villi • Vessles are usually absent
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10. Pathology
 There is trophoblastic proliferation, with mitotic activity affecting
both syncytial and cytotrophoblastic layers. This causes excessive
secretion of hCG, chorionic thyrotrophin and progesterone. On
the other hand, oestrogen production is low due to absence of
the foetal supply of precursors.
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11. Pathology
High hCG causes multiple theca lutein cysts in
the ovaries in about 50% of cases.
Cysts may reach a large size
10 cm or more.
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• Cysts disappear
within few months(2-3),
after evacuation of the mole.

12. Pathology
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• High hCG causes multiple theca lutein cysts in
the ovaries in about 50% of cases. It also
results in exaggeration of the normal early
pregnancy symptoms and signs.

13. Complete Mole
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14. Complete mole
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15. Partial mole
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- A part of trophoblastic tissue only shows molar
changes.
- There is a foetus or at least an amniotic sac.
- It is the result of fertilization of an ovum by 2
sperms so the chromosomal numberis 69
chromosomes

16. Partial mole
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17. Partial mole
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18. DIFFERENTIATION BETWEEN
COMPLETE AND PARTIAL MOLE
Feature Complete Mole Partial Mole
Karyotype 46 XX (96%) or 46
XY (4%)
69 XXY or 69 XYY
Pathology
Embryonic or foetal
tissue
Absent Present
Swelling of the villi Diffuse Focal
Trophoblastic hyperplasia Diffuse Focal
p57Kip2 immunostaining Negative Positive
Karyotype 46 XX (96%) or 46
XY (4%)
69 XXY or 69 XYY
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19. DIFFERENTIATION BETWEEN
COMPLETE AND PARTIAL MOLE
Feature Complete
Mole
Partial Mole
Clinical
presentation
Typical diagnosis
Molar
pregnancy
Missed abortion
Postmolar
malignant sequelae 15% 4-6%
Malignant Changes 5-10% Rare
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20.  Partial moles are optimally diagnosed when
three or our major diagnostic criteria are
demonstrated:
 (1) two populations o villi,
 (2) enlarged, irregular, dysmorphic villi (with
trophoblast inclusions),
 (3) enlarged, cavitated villi (≥ 3 to 4 mm), and
 (4) syncytiotrophoblast hyperplasia/atypia
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21. DIAGNOSIS
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Symptoms
•Amenorrhoea: usually of short period (2-3 months).
•Exaggerated symptoms of pregnancy especially
vomiting.
•Vaginal discharge
•Abdominal pain: may be,
o dull-aching due to rapid distension of the uterus, o
colicky due to starting expulsion,
o sudden and severe due to perforating mole.

22. Discharge
The main complaint, due to separation of vesicles from
uterine wall, there may be a blood stained watery
discharge, the watery part is from ruptured vesicles.
Prune juice disharge may occur.
The blood is brown because it has retained for
sometime in the uterine cavity.
passage of vesicles is diagnostic. The blood may be
concealed causing enlargement & tenderness of
uterus.
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23. Abdominal pain : may be
- dull-aching due to rapid distension of the
uterus by the mole or by concealed haemorrhage.
- Colicky due to starting expulsion,
- Sudden And Severe due to perforating mole
- Ovarian pain due to stretching of the ovarian
capsule or complication in the cystic ovary as
torsion
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24. Pre-eclampsia in 20-30% of cases, usually before 20 weeks’ gestation.
Pallor indicating anemia may be present.
Hyperthyroidism in 3-10% of cases manifested by enlarged thyroid gland,
tachycardia (due to chorionic thyrotropin secreted by trophoplast &HCG
also has a thyroid stimulating effect.
Breast signs of pregnancy
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25. Signs
Abdominal examination:
• The uterus is larger than the period of
amenorrhoea in50% of cases, corresponds to
it in 25% and smaller in 25% with inactive or
dead mole.
• The uterus is doughy in consistency
• Foetal parts and heart sound cannot be
detected except in partial mole.
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26. Signs
* Local examination:
> Passage of vesicles (sure sign).
>Bilateral ovarian cysts (5-20 cm) in
50%
of cases.
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27. Investigations
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Urine pregnancy test: is positive in high dilution. 1/200 is
highly suggestive, 1/500 is surely diagnostic. In normal
pregnancy it is positive in dilutions up to 1/100.
Serum β-hCG level: is highly elevated (>100000 mIU/ml).
* Ultrasonography reveals:
o The characteristic intrauterine "snow storm"
appearance,
o no identifiable foetus,
o bilateral ovarian cysts may be detected.
X-ray: shows no foetal skeleton.

28. Partial Mole: Complex mass with many
cystic areas (between arrowheads) and
an embryo (arrow) in a patient with a β-
HCG of 280,000 miu/ml
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Complete mole: “snowstorm” appearance
with multiple cystic areas, no fetal tissue
present
Corresponding T1 weighted MRI (MRI can
be helpful in determining extent of
trophoblastic disease
Complete Mole

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31. Complications
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• Haemorrhage.
• Infection due to absence of the amniotic sac.
• Perforation of the uterus.
• Pregnancy induced hypertension
• Hyperthyroidism.
• Subsequent development of
choriocarcinoma

32. Treatment
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• As soon as the diagnosis of vesicular mole is
established the uterus should be evacuated.
• The selected method depends on the size of
the uterus, whether partial expulsion has
already occur or not, the patient's age and
fertility desire.
• Cross- matched blood should be available
before starting.

33. Points to note
Nulliparous women are not given
prostanoids to ripen the cervix since these
drugs can induce uterine contractions and
might increase the risk of trophoblastic
embolization to the pulmonary vasculature.
Because o the tremendous vascularity of
these placentas, blood products should be
available prior to the evacuation, and
adequate infusion lines established.
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34. Suction evacuation
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It is carried out under GA.
An infusion of 20 units oxytocin in 500 m1 of 5% glucose
should be maintained throughout the procedure.
Dilatation of the cervix is done up to a Hegar's number
equal to the period of amenorrhoea in weeks e.g. No.
10 Hegar for 10 weeks’ amenorrhoea. The suction
canula used will be of the same size also.

35. Suction evacuation
contd…
• A suction canula which may be metal or a disposable plastic
preferred) is introduced into the uterine cavity
• The canula is connected to a suction pump adjusted at negative
pressure of 300-500 mmHg according to the duration of
pregnancy.
• Although some recommended a gentle sharp curettage to the
uterus after evacuation, it is preferable to wait one week for fear
of uterine perforation.
• Following curettage, because o the possibility o partial mole and
its attendant fetal tissue, Rh immune globulin is given to
nonsensitized Rh D-negative women.
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36. Hysterotomy
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• It may be needed for evacuation of a large
mole to minimise and facilitate control of
bleeding.
Hysterectomy:It should be considered in
women over 40 years who have completed
their family for fear of developing
choriocarcinoma.

37. Follow up
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• As choriocarcinoma may complicate the
vesicular mole after its evacuation,
detection of serum ß-hCG by
radioimmunoassay for 2 years is essential.
• About 3-5% of H.Mole develop
choriocarcinoma & 15-20% become locally
invasive.

38. Follow up
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• Detection is done every:
hCG levels: obtained within 48 hrs of
evacuation,
Weekly until not detectable for three
consecutive weeks.
Monthly till 6-12 months( partial or comp)
Risk of GTN is <1% after an undectable hCG is
attained.
GTD: 5, Studd Current Progress in Obst & Gyne, 2019

39. Follow up
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• Pelvic Ultrasound:
• Performed with hCG values to monitor
involution of pelvic structures and identify
persistent disease.
GTD: 5, Studd Current Progress in Obst & Gyne, 2019

40. Follow up
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• Reliable contraception:
• Hormonal or Barrier recommended.
• IUCD has risk of perforation X.
• A new gestation should be avoided because it
will obscure value of monitoring hCG levels.
• If hCG remains undectable for 6-12 months
woman desirous of pregnancy may
discontinue contraception
GTD: 5, Studd Current Progress in Obst & Gyne, 2019

41. • Persistent high level indicates remnants of
molar tissues which necessitate
chemotherapy (methotrexate) with or
without curettage. Hysterectomy is indicated
if women had enough children.
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42. • Rising hCG, level after disappearance means
developing of choriocarcinoma or a new pregnancy.
So combined contraceptive pills should be used for
prevention of pregnancy which can be misleading.
• It is expected that urine pregnancy test is negative 4
weeks after evacuation and serum β-hCG is
undetectable 4 months after evacuation.
* Early features suggesting residual molar tissue include:
o recurrent or persistent vaginal bleeding, o
amenorrhoea,
o failure of uterine involution,
o persistence of ovarian enlargement.
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43. Persistent GTD
 After evacuation of complete or partial mole hCG
levels show a plateau or rise over several weeks(days
1,7,14,21) more than 4 values in 3 weeks
 Rise in serum hCG >10% during these weeks
 Serum hCG remains detectable for 6 months or more
 Histological of chorioarcinoma or invasive mole
 Identification of clinical or radiological metastasis.
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44. ASSESSMENT
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45. q1
 Hydatidiform mole is principally a disease of:
a. Amnion
b. Chorion
c. Uterus
d. Decidua
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46. q1
 Hydatidiform mole is principally a disease of:
a. Amnion
b. Chorion
c. Uterus
d. Decidua
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47. Q 2
 Follow-up in a patient of H mole is done by:
a. Serum Beta-hCG monitoring
b. Serum CEA level estimation
c. Serum amylase level
d. Serum α-fetoprotein estimation
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48. Q 2
 Follow-up in a patient of H mole is done by:
a. Serum Beta-hCG monitoring
b. Serum CEA level estimation
c. Serum amylase level
d. Serum α-fetoprotein estimation
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49. q3
 Snow storm appearance on USG is seen in:
a. Hydatidiform mole
b. Ectopic pregnancy
c. Anencephaly
d. None of the above
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50. q3
 Snow storm appearance on USG is seen in:
a. Hydatidiform mole
b. Ectopic pregnancy
c. Anencephaly
d. None of the above
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51. q4
 In a case of vesicular mole all of following are high risk
factors for the development of choriocarcinoma
Except:
a. Serum hCG levels > 100000 miu/ml
b. Uterus size larger than 16 week
c. Features of thyrotoxicosis
d. Presence of bilateral theca lutein cysts of ovary
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52. q4
 In a case of vesicular mole all of following are high risk
factors for the development of choriocarcinoma
Except:
a. Serum hCG levels > 100000 miu/ml
b. Uterus size larger than 16 week
c. Features of thyrotoxicosis
d. Presence of bilateral theca lutein cysts of ovary
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53. q5
 Prophylactic chemotherapy in hydatidiform mole
should preferably be given:
a. Prior to evacuation as a routine
b. Following evacuation as a routine
c. Selected cases following evacuation
d. As a routine 6 weeks postevacuation
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54. q5
 Prophylactic chemotherapy in hydatidiform mole
should preferably be given:
a. Prior to evacuation as a routine
b. Following evacuation as a routine
c. Selected cases following evacuation
d. As a routine 6 weeks postevacuation
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55. Q 6
 Risk of recurrence of H mole in future pregnancy is:
a. 1–4%
b. 4–8%
c. 8–10%
d. 10–12%
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56. Q 6
 Risk of recurrence of H mole in future pregnancy is:
a. 1–4%
b. 4–8%
c. 8–10%
d. 10–12%
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57. Q 7
 Percentage of complete moles progressing to persistent
GTN:
a. 1–4%
b. 4–8%
c. 8–12%
d. 15–20%
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58. Q 7
 Percentage of complete moles progressing to persistent
GTN:
a. 1–4%
b. 4–8%
c. 8–12%
d. 15–20%
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59. Q 8
 The criteria for diagnosing GTN are all except:
a. Persistently increasing b-hCG for 3 weeks
b. Plateau levels of b-hCG for 4 weeks
c. Theca lutein cyst ≥ 6 cm
d. Histological criteria for choriocarcinoma
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60. Q 8
 The criteria for diagnosing GTN are all except:
a. Persistently increasing b-hCG for 3 weeks
b. Plateau levels of b-hCG for 4 weeks
c. Theca lutein cyst ≥ 6 cm
d. Histological criteria for choriocarcinoma
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61. references
 Williams Gynecology, 3rd edition 2016.
 Studd J, Tan SL, Chervenak FA: Current Progress in Obst and
Gyne, No 5, 2019, Tree Life Media Mumbai
 Majhi AK: Bedside clinics in Obstetrics. Academic Publishers.
3rd edition 2015.
 Balakrishnan S: Textbook of Gynecology. Paras
Publishers.Delhi 2010
 DC Dutta’s OBSTETRICS Including Perinatology and
Contraception. 9th Edition. Jaypee New Delhi
 Self Assessment Review Obstetrics Sakshi Arora
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62. Thank you
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