Complete And Incomplete Hydatidiform Mole.pptxpptx

1. Dr.Massam
MOLAR PREGNANCY

2. Objectives
• Definitions
• Risk factors
• Clinical features
• Complications
• Investigations
• Treatments
• Follow up plans

3. Definitions
• Molar pregnancy is one of the disease conditions
originating from the trophoblast (placenta).
• These disease conditions are collectively called the
Gestational trophoblastic disease (GTD)
• Apart from molar pregnancy, other GTD are:-
– Placental site trophoblastic tumours
– Choriocarcinomas
– Invasive mole

4. Definitions
• Molar pregnancy- abnormal form of pregnancy in
which a non viable fertilized egg implants in the
uterus and will fail to come to term.
• Is a gestational trophoblastic disease (GTD)
• Occurs when a fertilized egg does not contain an
original maternal nucleus i.e. an empty egg + sperm

5. Modified WHO classification of
GTD
Molar pregnancies:
1. Hydatidiform mole
-Complete mole
-Partial mole
2. Invasive mole
Trophoblastic tumors:
1. Choriocarcinoma
2. Placenta site
trophoblastic tumor
(PSTT)
3. Epithelioid trophoblastic
tumor (ETT)

6. MOLAR PREGNANCY/HYDATIDIFORM MOLE
• Molar pregnancy as hydatidiform mole is divided into
two types:-
1. Complete moles
2. Partial moles

7. Complete moles
• A single sperm (abt 90%) or two sperms
(10%)..combining with an egg which has lost its DNA.
• No fetal tissue present
• 46,XX (Diploid), 46,XY (Diploid).
• 46 ,YY (diploid) is not observed

8. Complete Mole
• Empty ovum +23X sperm →23X
→duplicate→ 46XX (90%)
• Empty ovum + 23X →46XX
23X
• Empty ovum + 23X →46XY
23Y

9. Complete mole

10. Partial moles
• Partial moles occurs when a haploid egg is fertilized
by two sperms or by one sperm which reduplicates
itself yielding the genotype of 69,XXY (triploid) OR
92,XXXY (tetraploid)
• Fetal tissue is present (fetal erythrocytes +blood
vessels)

11. Partial Mole
• 23X ovum +23X sperm = 69XXX
23X
• 23X ovum +23Y sperm =69XYY
23Y
• 23X ovum +23X sperm =69XXY
23Y

12. Partial mole

13. Complete Partial
COMPLETE MOLE PARTIAL MOLE
KARYOTYPE 46,XX
46,XY
69,XXY
hCG
Uterine Size __
Fetal parts No YES
Components 2 sperms + empty egg 2 sperms + 1 egg
Risk of complications 15-20% malignant
trophoblatic disease
Low risk of malignancy
(<5%)

14. COMPLETE MOLE PARTIAL MOLE
KARYOTYPE 46XX, 46XY 69XXX, 69XXY, 69YYX
HISTOLOGY
FETAL EMBRYO ABSENT PRESENT
VILLI EDEMATOUS DIFFUSED FOCAL
TROPHOBLASTIC
PROLIFERATION
MAY BE MARKED FOCAL MINIMAL
p57KIP2 NEGATIVE POSITIVE
CLINICAL DIAGNOSIS MOLAR GESTATION INCOMPLETE
ABORTION
POST MOLAR GTN 15% 4-6%
DIFFERENCE BETWEEN COMPLETE AND PARTIAL MOLE

15. ETIOLOGY AND RISKS FACTORS
• The exact etiology is not well understood.
• Risk factors:
– Maternal age (extremes <15 & >45)
– Older paternal age
– Previous hx of GTD & Hx of spontaneous abortion
– Nutritional deficiency of carotene, folic acid, proteins and
vitamin A and high carbohydrates.
– AB blood group of the parents
– Smoking

16. CLINICAL FEATURES - Complete moles
• Vaginal bleeding-uterus may become distended by
large amount of blood + dark fluid may leak into the
vagina-50%
• Hyperemesis –severe nausea +vomiting
• Thyrotoxic features of tremors or tachycardia (2%).
It is probably due to increased chorionic thyrotropin
• Varying degree of lower abdominal pain

17. Clinical features - Complete mole
• Breathlessness due to pulmonary embolization of
the trophoblastic cells (2%).
• Expulsion of grape like vesicles per vagina is
diagnostic of vesicular mole. Actually, in
approximately 50% of cases the mole is not
suspected until it is expelled in part or whole.
• History of quickening is absent.

18. Generally

19. Clinical features - Partial moles
• Usually mimic the symptoms of incomplete /missed
abortion
• Vaginal bleeding + absence of fetal heart beats

20. Physical examination
Complete moles
• Large uterus than expected GA - excessive
trophoblastic growth + retained blood
• Pre eclampsia _2%
• Theca lutein cyst – ovarian cyst > 6 cm in diameters,
increased hCG , GA > 10 Weeks.Presents with
pressure or pelvic pain, regress after evacuation – up
to 12 weeks.

21. Physical examination con't...
• Features suggestive of early months of
pregnancy are evident.
• The patient looks more ill than can be
accounted for.
• Pallor
• The feel of the uterus is firm elastic (doughy).
• Fetal parts are not felt, nor any fetal
movements.
• Absence of fetal heart sound

22. Physical examination – PARTIAL MOLES
• Uterine enlargement than GA
• PRE ECLAMPSIA

23. COMPLICATIONS
• Perforation of the uterus
• Hemorrhage
• Disseminated intravascular coagulation
• Acute respiratory distress- trophoblastic embolism
esp with a large uterus than gestation age.

24. Complications con't...
• Pre-eclampsia
• Sepsis as no protective layer the vaginal organisms
can invade the uterus
• The development of choriocarcinoma in 2 -10%

25. DIFFERENTIAL DIAGNOSIS
• Hyperemesis gravidarum
• Hypertension
• Hyperthyroidism/Thyrotoxicosis
• Abortion

26. INVESTIGATIONS
NB: Most of the investigations are done at hospital level,
consider referral
• Quantitative beta –Hcg levels , hCG >100,000 mIU/mL, may
indicates trophoblastic growth.
• Full blood picture- Hb- anemia??, platelets –
coagulopathy??
• Ultrasound – bunch of grapes or honeycombed uterus or
snow storm appearance, (intrauterine mass containing
many small cysts)

27. • Chest X ray- lungs primary site of metastatis
• Histology
 Complete moles - oedematous placenta villi,
hyperplasia of trophoblast, no fetal tissue
 Incomplete moles - oedematous villi, trophoblastic
proliferation.

28. TREATMENT
• Also consider referral when at dispensary or health
center level
• Blood transfusion, if anaemic
• Fresh frozen plasma - DIC
• Contraception for 6 month

29. TREATMENT
• SURGICAL CARE
 Evacuation of the uterus by dilation and curettage
 IV Oxytocin is used after the dilation of the cervix at
the initiation of suctioning and postoperatively to
reduce likelyhood of hemorrhage

30. PROGNOSIS
• Complete hydatidiform mole - 15-20% risk of
developing into choriocarcinoma and 15% to invasive
mole. Accounts for 50% of all cases of
choriocarcinoma.
• Incomplete moles can become invasive (<5%) but not
choriocarcinoma
• One percent of women with molar pregnacy may
have recurrence

32. MONITORING
• Serial quantitative beta hCG
 Weekly until levels are within reference range for 3-4
weeks
 hCG levels should consistently drop,never increase,
and should get back to normal (8-12 weeks) after
evacuation
 Once reference range reached (3-4 weeks) , continue
checking monthly for 6 month

33. MONITORING
 If the level of hCG plateau or rise ,think of malignant
transformation.
 Effective contraception- if IUD was chosen , to avoid
perforation and bleeding , insertion should wait for
uterus involution to occur and normalization of
serum hCG levels

34. Key points
• Molar pregnancy is one among the diseases called
the Gestational Trophoblastic Diseases (GTD)
• A doctor has to diagnose proparly and provide
appropriate management.

35. Evaluation
• How a molar pregnancy is formed?
• What are the clinical features of a complete molar?
• What are the risk factors for a molar pregnancy to
turn into malignancy?

36. Reference
• DC Dutta's Textbook of Obstetrics 7th Edition