Molar pregnancies are the premalignant forms of gestational trophoblastic neoplasia ( GTN ) , a group of illnesses that also includes the rare but aggressive malignancies of choriocarcinoma and placental site trophoblastic tumours

1. Molar pregnancy
Done by : Ibrahim Al-Hedirbi
Batch 25 ( OIU )

2. Definition:-
■ Molar pregnancies are the premalignant forms of
gestational trophoblastic neoplasia ( GTN ), a group of
illnesses that also includes the rare but aggressive
malignancies of choriocarcinoma and placental site
trophoblastic tumours .
■ Charactrized by abnormal proliferation of placental trophpoblast
(cytotrophoblast and synctiotrophoblast) and villous oedema

3. ■ Divided into :-
■ A) benign disorder called hydatiform mole pregnancy which include :-
1- complete mole pregnancy.
2- partial (incomplete )mole pregnancy .
B) Malignant disorder :-
divided into Metastatic ( good prognosis or poor prognosis ) and non metastatic
1-invasive trophoblastic disease
2-choriocarcinoma
3-placental sit trophoblast

5. Hydatiform mole :
■ Abnormal proliferation of the syncitiotrophoblast and replacement of the placental trophpoblast
by hydropic placental villi.
 Complete mole:-
It is the most common GTD and result from fertilization of an empty egg with single(haploid) sperm
which replicate to restore the diploid number this process is called androgensis.This process lead
to formation of uterus filled with the grape like vesicle composed of edematous avascular villi and
there is no fetus and no amniotic fluid formation
 Most common karyotype is 46XX (90 % ) the 46 XY is rare (10%)
 Have high tendency to malignant transformation by 20%.

6.  Partial mole :-
 It is less common GTD, result from fertilization of normal egg with two
sperm
Resulting in triploid karyotype ( 69 XXY or 69 XXX) and rarely by three sperm
(92XXX).
 A fetus , amniotic fluid and umbilical cord is seen .
 Progression to malignancy is 10 % .

8. ■ Clinical presentation
1. Amenorrhea and exaggerated sign and symptoms of pregnancy.
2. vaginal bleeding prior to 16 weeks gestation :- It the most common
presentation start as brownish and scanty then it become red and severe .
3. hyperemesis gravidarum.
4. hypertension .
5. Hyperthyroidism ( rare )
6. early preeclampsia ( rare )
7. abdominal pain due to rapid distension of the uterus.
8. Acute respiratory failure (v.rare )
9. Seizure ( v.rare )

9. ■ On examination :-
1. Fundal level more than date
2. no fetal part
3. no fetal heart sound
4. grape like vesicle when perform PV examination
5. pouch of Douglas is free
6. sign of hyperthyroidism (sweating , tachycardia , tachypnea , etc)
7. doughy abdomen.
8. bilateral cystic enlargement called theca lutein cysts
9. Fundscopy examination show retinal sheen

10. ■Investigation :-
1- US :- snowstorm appearance (multiple cyst structure)
no fetal active heart beat
2- blood or urine test of B-HCG increase above 500,000 IU
3- pelvic arteriography.
4- biopsy.
5- chest x-ray .

11. ■ Management
 Preoperative evaluation:- b-HCG titer , baseline chest X-ray , CBC ,
blood type and coagulation studies, thyroid function test.
 Evacuation of uterine contents by dilation and suction curettage
followed by gentle sharp curettage.
 Uterotonic administration after uterine evacuation and blood
transfusion if needed.
 Hysterectomy for women who have no interest in further
childbearing.
 Theca lutein cysts do not require removal and will likely regress
unless it rupture.

12. ■ Post operative management:-
1. Quantitative hCG within 48 hours following evacuation and every 1-2 weeks while
elevated and at 1-2 months thereafter for a total of 6 -1 2 months
2. Give Rh immune globulin if Rh negative
3. Use reliable contraception to prevent pregnancy in the first 6 -1 2 months
monitoring hCG
4. Risk of recurrence after 1 year <1%

13. Follow up
■ Via HCG level :
1-if return to the normal level before the 56 day of evacuation pregnancy is prevented for
6 month from the day of evacuation.
2- if return to the normal after 56 day of evacuation then the pregnancy is prevented for 6
month from day of normalization of HCG.

14. Complication of H-mole :
■ perforation
■ infertility
■ DIC
■ PIH
■ septic abortion
■ malignancy develop into choriocarcinoma

15. A. Invasive mole:-
It Invades myometrium and histologically similar to molar pregnancy
Diagnosed months after evacuation of complete mole when hCG levels do not fall
appropriately as persistent metastatic or nonmetastatic gestational trophoblastic
neoplasia.

17. B. Choriocarcinoma:-
■ Can follow molar pregnancy, normal-term pregnancy, abortion, or ectopic pregnancy.
■ Rapid systemic metastasis results from hematogenous embolization
■ Sites of metastasis: lungs, vagina, central nervous system (CNS), kidney, liver.

18. ■ Sensitive to chemotherapy
■ Single-agent chemotherapy (for treating nonmetastatic disease)
Methotrexate or actinomycin D
EMA/CO chemotherapy
■ Combined chemotherapy for treatment of metastatic disease
International Federation of Gynecology and Obstetrics (FIGO) score more than or
equal 7.
■ Adjunctive radiotherapy is used for patients with brain metastasis

19. EMA/CO chemotherapy
■ Week 1
Day 1 dactinomycin 0.5 mg IV
etoposide 100 mg/m2 IV
methotrexate 300 mg/m2 IV
Day 2 dactinomycin 0.5 mg IV
etoposide 100 mg/m2 IV
folinic acid 15 mg orally 12hourly 4 doses,
starting 24 hours after commencing methotrexate
Week 2
Day 8 vincristine 1.4 mg/m2 (maximum 2mg)
cyclophosphamide 600 mg/m2
IM = intramuscularly; IV = intravenously

20. ■ Placental site tumors :-
■ Intermediate cytotrophoblastic cells that invade locally at site of
placental implantation
■ Secretes small amounts of hCG and a more of HPL
■ Rarely metastatic
■ Resistant to standard chemotherapy
■ Hysterectomy is often curative

21. • A 24-year-old 2nd Gravida ,Para 1 woman at 8 Ws , GA (Blood group: O,
negative) complains of:
1-Worsening nausea, and vomiting over the last 2 weeks which is
unlike her prior pregnancy .
2-Irregular vaginal bleeding over the last 7 days She denies any
abdominal or back cramps.
-What does the differential diagnosis include for
this patient?
-Which Diagnostic Test Would Be
Most Useful?
-What Is The Plan of Management?
Case Scenario

22. Case Scenario
A 24-year-old 2nd Gravida ,Para 1 woman at 8 Ws , GA (Blood group: O,
negative) complains of:
1-Worsening nausea, and vomiting over the last 2 weeks which is unlike
her prior pregnancy .
2-Irregular vaginal bleeding over the last 7 days She denies any
abdominal or back cramps.
What does the differential diagnosis include for
this patient?
Multiple pregnancy.
Hydatidiform mole.
Threatened abortion.
Ectopic pregnancy.
Which Diagnostic Test Would Be
Most Useful?
u/s
What Is The Plan of Management?
There are 2 important basic lines :
1-Evacuation of the mole
2-Regular follow-up to detect
persistent trophoblastic disease