A molar pregnancy is a rare complication of pregnancy. It involves unusual growth of cells called trophoblasts. These cells typically become the organ that feeds a growing fetus. That organ also is known as the placenta. There are two types of molar pregnancy — complete molar pregnancy and partial molar pregnancy. In a complete molar pregnancy, the placental tissue swells and appears to form fluid-filled cysts. There is no fetus. In a partial molar pregnancy, the placenta might have both regular and irregular tissue. There may be a fetus, but the fetus can't survive. The fetus usually is miscarried early in the pregnancy. A molar pregnancy can have serious complications, including a rare form of cancer. A molar pregnancy requires early treatment. Symptoms Molar pregnancy Molar pregnancy Enlarge image A molar pregnancy may seem like a regular pregnancy at first. But most molar pregnancies cause symptoms that can include: Dark brown to bright red bleeding from the vagina during the first three months Severe nausea and vomiting Sometimes grapelike cysts that pass from the vagina Pelvic pressure or pain Because of improved ways of detecting a molar pregnancy, most are found in the first trimester. If it is not found in the first three months, symptoms of a molar pregnancy might include: A uterus growing quickly and being too large early in the pregnancy Preeclampsia — a condition that causes high blood pressure and protein in the urine — before 20 weeks of pregnancy Ovarian cysts Overactive thyroid, also known as hyperthyroidism Request an appointment Causes An egg fertilized atypically causes a molar pregnancy. Human cells usually have 23 pairs of chromosomes. In a typical fertilization, one chromosome in each pair comes from the father, the other from the mother. In a complete molar pregnancy, one or two sperm fertilize an egg. The chromosomes from the mother's egg are missing or don't work. The father's chromosomes are copied. There's none from the mother. In a partial or incomplete molar pregnancy, the mother's chromosomes are present, but the father supplies two sets of chromosomes. The embryo then has 69 chromosomes instead of 46. This most often occurs when two sperm fertilize an egg, resulting in an extra copy of the father's genes. Risk factors Factors that can contribute to a molar pregnancy include: Earlier molar pregnancy. If you've had one molar pregnancy, you're more likely to have another. A repeat molar pregnancy happens, on average, in 1 out of every 100 people. Age of the mother. A molar pregnancy is more likely in people older than age 43 or younger than age 15. Complications After removing a molar pregnancy, molar tissue might remain and continue to grow. This is called persistent gestational trophoblastic neoplasia (GTN). GTN happens more often in complete molar pregnancies than it does in partial molar pregnancies. One sign of persistent GTN is a high level of human chorionic gonadotropin (HCG) — a pregnancy hormone —

1. GESTATIONAL
TROPHOBLASTIC DISEASE
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3. GESTATIONAL TROPHOBLASTIC
DISEASES
• GTD encompasses a spectrum of proliferative
abnormalities of trophoblasts associated with
pregnancy
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4. 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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5. PREVALANCE
• Molar pregnancy is the most common form of GTD
• Relatively rare condition, with an estimated worldwide
incidence of around 1–3 cases for every 1000 live births.
• Incidence vary significantly across different
geographical regions and racial groups,
• 1–3 cases per 1000 are reported in nearly every
worldwide series.
• Higher at the extremes of reproductive age, at
approximately 1 in 30 (under 15) and as high as 1 in 5 in
late 40s or early 50s
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6. • Gestational trophoblastic neoplasia (GTN)
Refers to the subset of GTD that develops malignant
sequel.
• 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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9. 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.

10. 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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11. Hydatidiform
• Vesicular mole
• Benign neoplasia of the chorion with malignant
potential
• Abnormal condition of the placenta where there
are partly degenerative and partly proliferative
changes in the young chorionic villi
• Hydropic swelling of all villi –formation
• Formation of clusters of small cyts
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12. Epidemiology
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• It is a benign neoplasm of the chorionic villi.
Incidence:
• Philippines:1 in 80
• Europe:1 in 752
• USA : 1:2000 pregnancies in United States
• In India 1 in 400

13. ETIOLOGY
• Unknown
• Teenage pregnancy
• Age >35yrs
• Race & ethnic
• Faculty nutrition-Low protein,animal fat,carotene
• History of previous HM
• Cytogenetic abnormality
• Disturbed maternal immune mechanism-Rise in
gammaglobulin ,Blood group
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15. 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.

16. Complete Mole
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17. Complete mole
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18. 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

19. Partial mole
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20. Partial mole
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21. 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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22. 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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23. Partial moles are optimally diagnosed when three or More
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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24. DIAGNOSIS
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Symptoms
•Amenorrhoea: usually of short period (2-3 months).
•Exaggerated symptoms of pregnancy especially
vomiting.
•Vaginal discharge
•Abdominal pain:

25. Discharge
Due to separation of vesicles from uterine wall
 There may be a blood stained watery discharge, the
watery part is from ruptured vesicles.
White currant in red currant juice
•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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26. Abdominal pain :
- 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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27. SIGNS
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
Patient looks ill
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28. ON Abdominal examination:
• Size : Uterus is larger than the period of
amenorrhoea in 50% of cases, corresponds to
it in 25% and smaller in 25% with inactive or
dead mole.
• Consistency: The uterus is firm elastic due to
absence of AF
• Foetal parts: FP,heart sound cannot be
detected except in partial mole.
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29. PER VAGINAL EXAMINATION
> Passage of vesicles (sure sign).
>Bilateral palpable ovarian cysts (5-20 cm) in
50%of cases.
Internal ballottement cannot be elicited
If os open, blood clot or vesicles present
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30. Investigations
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• Urine pregnancy test:
• 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.

31. • CBC,ABO,Grouping
• LFT,KFT Elect
• Usg pelvis,kidney ,spleen
• Chest Xray
• CT ,MRI not routine
• Definitive : histopathological examination
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33. Complications
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• Haemorrhage & Shock-massive intraperitoneal H.
• Infection due to absence of the amniotic sac.
• Perforation of the uterus.
• Pregnancy induced hypertension/preeclampsia
• Hyperthyroidism.
• Subsequent development of choriocarcinoma(late)
• Sepsis
• Acute pulmonary insufficiency –pul embolization of
trophoblastic cells
• Coagulation failure

34. MANAGEMENT
Principles:
•Suction & evacuation
•Supportive therapy-anemia & infection
•Counselling
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35. Treatment
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• As soon as the diagnosis of vesicular mole is
established the uterus should be evacuated.
• 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.

36. Suction evacuation
• Group A: Cervix favorable
• Group B : Cervix tubular & closed
• suction cannula
• Negative pressure of 200-250 mmHg
• Inj Methargine
• Antibiotics
• Rh D-negative women.
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37. Hysterotomy
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• It may be needed for evacuation of a large
mole to minimize and facilitate control of
bleeding.
Hysterectomy:
• women over 40 years
• Uncontrolled hemorrhage
• completed family
• Reduce developing choriocarcinoma.

38. Follow
Follow up
up
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• HCG level regress to normal within 3 months
• As choriocarcinoma may complicate the
vesicular mole after its evacuation,
detection of serum ß-hCG by
radioimmunoassay for 1 years is essential.
• About 3-5% of H.Mole develop
choriocarcinoma & 15-20% become locally
invasive.

39. Follow
Follow up-HCG
up-HCG
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• hCG levels
hCG levels: obtained within 48 hrs of
evacuation
• Weekly until not detectable for three
consecutive weeks.
Once Neg-
• Monthly till 6-12 months( partial or comp)
• Risk of GTN is <1% after an undectable hCG is
attained.

40. Follow
Follow up
up
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Pelvic Ultrasound:
•Performed with hCG values to monitor
involution of pelvic structures and identify
persistent disease.

41. Follow
Follow up
up
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Reliable contraception:
•Hormonal or Barrier recommended.
•IUCD has risk of perforation.
•Pregnancy should be avoided until 1 yr
because it will obscure value of monitoring hCG
levels.
•If hCG remains undectable for 6-12 months
woman desirous of pregnancy may discontinue
contraception

42. • Persistent high level indicates remnants of
molar tissues which necessitate
chemotherapy (methotrexate) with or
without curettage.
• Hysterectomy is indicated if women had
enough children.
PROPHYLACTIC CHEMOTHERAPY
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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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