Gynaecology

1. CASE
• 32 years , G2+P1 presented in ER with
complain of amenorrhoea for 3 months
followed by PV bleeding for 2 days, on
examination uterus was 24 weeks in size and
vitals stable and hemoglobin 8gm /dl %.

2.  Abdominal U/S
a live fetus 12
weeks of gestation.
 Separate multiple cystic mass
was found in the placenta

3. Laboratory Investigations
Serum Beta HCG levels
 3,000,000 mIU/ ml,
 Albumin in urine.
 Albumin ++++  SPET
 Thyroid function→ Normal
What could be the diagnosis?

4. Molar Pregnancy

6. CONTENTS
• DEFINITION
• INCIDENCE
• TYPES
• CLINICAL FEATURES
• INVESTIGATIONS
• DIAGNOSIS
• MANAGEMENT
• COMPLICATIONS

7. Hydatidiform Moles (H.M.)
• Hydatidiform moles are abnormal pregnancies
characterized histologically by :
 Trophoblastic proliferation (Both
syncitiotrophoblast & cytotrophoblast)
 Edema of the villous stroma (Hydropic) .
• Based on the degree and extent of these tissue
changes, hydatidiform moles are categorized as either
 Complete hydatidiform mole.
 Partial hydatidiform mole.

8. FEATURE
Karyotype
Partial mole
Most commonly
69, XXX or - XXY
Complete mole
Most commonly
46, XX or -,XY
Pathology
Fetus
Amnion, fetal RBC
Villous edema
Trophoblastic proliferation
Often present
Usually present
Variable, focal
Focal, slight-moderate
Absent
Absent
Diffuse
Diffuse, slight-severe
Clinical presentation
Diagnosis
Uterine size
Theca lutein cysts
Medical complications
Missed abortion
Small for dates
Rare
Rare
Molar gestation
50% large for dates
25-30%
10-25%
Partial V/S Complete Hydatidiform Moles

9. Bilateral theca lutin cysts
7x5cm .

10. INCIDENCE
• The reported incidence of GTD varies widely
worldwide, from a low of 23 per 100,000
pregnancies (Paraguay) to a high of 1,299 per
100,000 pregnancies (Indonesia).
• The malignant potential of GTD is also higher
in South Asia (10-15%) compared to western
countries (2-4%)

11. Types
• Gestational trophoblastic disease
– Molar pregnancy (hydatidiform mole) or
premalignant
• Complete mole
• Incomplete or partial mole
– Gestational trophoblastic neoplasia or malignant
• Invasive mole
• Choriocarcinoma
• Placental site trophoblastic tumor
• Epitheloid trophoblastic tumor

12. .
Predisposing factor
1. Age(>40 yrs)
2. Previous hydatidiform mole.
3. Vitamin A deficiency.
4. Smoking

13. Complete Molar pregnancy
• Duplication of the haploid sperm following
fertilization of an ‘empty’ ovum .
• Some complete moles arise after dispermic
fertilization of an “empty’ ovum (dispermy).

14. Homozygous 90%
Pathogenesis of complete H. Mole
Karyotype

15. Pathogenesis of complete H. Mole
Heterozygous 10%
Karyotype

16. Complete H. Mole
Microscopically,Enlarged, edematous villi and abnormal
trophoblastic proliferation that diffusely involve the
entire villi
No fetal tissue, RBCs or amnion are produced
Macroscopically, these microscopic changes transform the
chorionic villi into clusters of vesicles with variable
dimensions “ like bunch of grapes"
No fetal or embryonic tissue are produced
Uterine enlargement in excess of gestational age .
Theca-lutein cyst associated in 30%

17. Complete hydatidiform mole: Macroscopically, these
microscopic changes transform the chorionic villi into clusters of
vesicles with variable dimensions the name hydatidiform mole
stems from this "bunch of grapes"

18. Complete Molar Pregnancy

19. Complete hydatidiform mole. The classic "snowstorm"
appearance is created by the multiple placental vesicles.

20. Partial molar pregnancy
 Triploid in origin (two paternal and one
maternal).
Dispermic fertilization of an active ovum.

21. Pathogenesis of Partial H. Mole
Karyotype

22. Partial H. Mole
Microscopically: The enlarged, edematous villi and
abnormal trophoblastic proliferation are slight and
focal and did not involve the entire villi.
There is a scalloping of chorionic villi
Fetal or embryonic or fetal RBCs
Macroscopically: The molar pattern did not involve
the entire placenta.
Uterine enlargement in excess of gestational age is
uncommon.
Theca-lutein cysts are rare
Fetal or embryonic tissue or amnion

23. Partial Hydatiform Mole
Vesicles
Maternal side

24. Partial H. mole.

25. Clinical features
• Vaginal bleeding
• Excessive uterine growth
• Hyperemesis gravidarum
• Preeclampsia
• Embolization of trophoblastic tissue
• Hyperthyroidism
• Theca lutein cyst

26. • Metastatic features
Pulmonary Cough, chest pain, hemoptysis,
dyspnoea, chest x ray finding -80%
Vaginal  Irregular vaginal bleeding
Hepatic Epigastric pain, jaundice
CerebralHeadache, convulsion, paralysis or
coma

27. Diagnosis
• Clinical features
• History
• Physical examination
• Investigation
– Lab investigation – Beta-hCG, LFT, RFT, CBC, urine R/E
– USG abdomen and pelvis
– Chest x ray
– CT scan
– Histopathological examination

28. VAGINAL METASTASIS

29. LUNG METASTASIS
• Cannon ball shadow in the left apical and midregion of
the lung with pleural effusion in choriocarcinoma

30. USG Showing snow strom patttern

31. Staging of GTN
• Stage I
• Stage II
• Stage III
• Stage IV
- Disease confined to uterus
-GTN extending outside uterus but limited
to genital structures (adnexa, vagina,
broad ligament)
-GTN extending to lungs with or without
known genital tract involvement
-All other metastatic sites

32. WHO PROGNOSTIC SCORING
SCORES 0 1 2 4
AGE IN YRS <40 >40 - -
ANTECEDENT
PREGNANCY
H.MOLE ABORTION TERM -
INTERVAL(months)* <4 MONTHS 4-6 7-12 >12
BHCG <1000 1000-10000 10000-100000 >100000
LARGE SIZE TUMOR <3 3-4 >5 -
SITE OF
METATSTASIS
Lung,pelvis SPLEEN,KIDNEY GI tract, liver LIVER, BRAIN
NUMBER OF
METASTASIS
1-4 5-8 >8
PREVIOUS FAILED
CHEMO
SINGLE DRUG TWO OR MORE
DRUG
Adapted from FIGO
Low risk score <6 ,High risk score >7
Interval- time between antecedent
pregnancy and start of chemotherapy

33. Management of gestational trophoblastic disease
Hydatidiform mole
Evacuation
Serial hCG levels
FIGO scoring
GTN
LOW RISK
SINGLEAGENT
CHEMO
HIGH RISK
COMBINATION OF CHEMO
SERAIL hCG MONITORING
6 months HCG
follow up
LIFE LONG
Hcg follow up
RELAPLSED AND RESISTANT DIEASE SECOND LINE CHEO THARAPY

35. Indications for chemotherapy in
GTD
• Histological evidence of choriocarcinoma
• Evidence of metastases in brain, liver or
gastrointestinal tract or radiological opacities
>2 cm on chest x ray.
• Pulmonary , vulval or vaginal metastates unless
hcg falling
• Heavy Vaginal Bleeding Or Evidence Of
Gastrointestinal Or Intraperitoneal Hemorrhage

36. Contd…
• Rising hCG After Evacuation
• Serum hCG >20,000 mIU/L More Than 4weeks
After Evacuation, Because Of Risk Of Uterine
Perforation.
• Elevated hCG 6months after evacuation even if
still falling.

39. High risk treatment regimen
• EMA/CO
– Etoposide
– Methotrexate
– Actinomycin d
– Cyclcophosphamide
– Oncovin/vincristine
• Week 1, Days 1-2: EMA With Folinic Acid Rescue.
• Week 2, Day 8: CO

40. (RCOG 2010) Medical evacuation of
molar pregnancies by oxytocin
should be avoided because of the
potential to embolise and disseminate
trophoblastic tissue through the
venous system .

41. COMPLICATIONS
• IMMEDIATE
– Massive hemorrhage
– Early onset preeclampsia and Eclampsia
– Hyperemesis Gravidarum
– Pulmonary embolism
– Uterine perforation
– IUGR of viable pregnancy
– Still birth
– Preterm birth
• REMOTE
– Choriocarcinoma

42. Questions
• Define types of molar pregnancy and write
difference between complete hydatidiform
mole and partial mole?
• What are the clinical features of molar
pregnancy how will you manage a case of
molar pregnancy?
• Write complications of molar pregnancy.