A vesicular mole, or hydatidiform mole, is a benign tumor resulting from abnormal fertilization. It has a higher incidence in Asia and in women over age 45. Complete moles have no fetal or placental tissue and are more likely to develop into gestational trophoblastic disease, while partial moles contain some fetal tissue. Ultrasound and serum markers can help differentiate between types of molar pregnancies. Surgical evacuation is usually recommended for treatment.

1. Vesicular Mole Dr. MOHAMMED ABDALLA EGYPT, DOMIAT G. HOSPITAL

2. It is a benign neoplasm of the chorionic villi

3. Incidence: 1:2000 pregnancies in United States and Europe 1:200 in Asia 10 times more in women over 45 years old. The increasing use of ultrasound in early pregnancy has probably led to the earlier diagnosis of molar pregnancy

4. 1 -Maternal age : Young mothers (under age 20 years) have a slightly higher prevalence of GTD, although not nearly so great as those mothers over age 35 years. 2- Women who have had a previous molar gestation 3- The risk increases with the number of spontaneous abortions . 4- Women with blood type A may be more likely to develop choriocarcinoma (but not hydatidiform mole); RISK FACTORS:

5. What Is A Hydatidiform Mole? A hydatidiform mole is an abnormality of fertilization It is the result of fertilisation of anucleated ovum ( has no chromosomes) with a sperm which will duplicate giving rise to 46 chromosomes of paternal origin only. It is the result of fertilisation of an ovum by 2 sperms so the chromosomal number is 69 chromosomes COMPLETE MOLE PARTIAL MOLE

6. Differentiation Between Complete And Partial Mole Rare 5-10% Malignant Changes Paternal and maternal 69 XXY or 69 XYY Paternal 46 XX (96%) or 46 XY (4%) Karyotype Focal Diffuse Trophoblastic hyperplasia Focal Diffuse Swelling of the villi Present Absent Embryonic or foetal tissue Partial Mole Complete Mole Feature

7. Three components make up the trophoblast: cytotrophoblast, syncytiotrophoblast intermediate trophoblast The cytotrophoblast is a stem cell with high mitotic activity but without hormonal synthesis. The syncytiotrophoblast, which constitutes the villous trophoblast, has low mitotic activity. The syncytiotrophoblast is responsible for the synthesis of the (beta-hCG) and can be identified with immunohistochemical stains. The intermediate trophoblast has features of the other two components and is responsible for endometrial invasion and implantation

8. There is trophoblastic proliferation, with mitotic activity affecting both syncytial and cytotrophoblastic layers. This causes excessive secretion of hCG,chorionic thyrotrophin and progesterone. . Pathology microscopic evaluation shows trophoblastic hyperplasia

9. hydropic) villi The uterus is distended by thin walled, translucent, grape-like vesicles of different sizes. Pathology At histologic analysis , Uniformly edematous (hydropic) villi with dissolution of central stroma (cavitation/cistern

10. There is no vasculature in the chorionic villi leads to early death and absorption of the embryo. Pathology At histologic analysis Occasionally, necrosis is seen

11. High hCG causes: Pathology multiple theca lutein cysts in the ovaries in about 50% of cases. exaggeration of the normal early pregnancy symptoms and signs

12. Uniformly edematous (hydropic) villi with dissolution of central stroma (cavitation/cistern) Villous vessels absent (usually) Trophoblastic hyperplasia – circumferential, haphazard, involves CT/ST/IT Trophoblastic atypia Pathology

13. Symptoms and Signs Usually occur in first 20 ­ 24 weeks of gestation. Bleeding. pain. toxemia (25% ). hyperemesis (25%) . absent fetus, LGA, SGA. hyperthyroidism (7%). passage of tissue with vesicles. bilateral thecalutein cysts (30%).

14. GTD MOST COMMON: complete hydatidiform mole, invasive mole, choriocarcinoma. Partial hydatidiform moles placental site trophoblastic tumor LESS COMMON:

15. U/S evaluation . Complete Hydatidiform Mole allows identification of numerous, discrete, anechoic ( cystic ) spaces within a central area of heterogeneous echotexture

16. The coexistence of a fetus with a complete hydatidiform mole is uncommon (in contrast to the partial hydatidiform mole), occurring in 1%-2% of cases .as a result of dizygotic twinning; thus, the fetus is chromosomally normal. but, fetal survival until term is unlikely because of the maternal complications of the mole itself Complete Hydatidiform Mole U/S evaluation .

17. Complete Hydatidiform Mole Theca lutein cysts multiloculated, often bilateral resolve after treatment of the intrauterine process Occasionally seen in twin gestations, fetal hydrops, pharmacologic stimulation (especially with human maternal gonadotropin) U/S evaluation .

18. the ultrasound diagnosis of a complete mole is often reliable, the diagnosis of a partial molar pregnancy is more complex. The finding of multiple cystic spaces in the placenta is suggestive of a partial molar pregnancy. * When there is diagnostic doubt about the possibility of a combined molar pregnancy with a viable fetus then ultrasound examination should be repeated before intervention. Partial Hydatidiform Mole RCOG/ Fine C, Bundy A L, Berkowitz R S et al. Sonographic diagnosis of partial hydatidiform mole. Obstet Gynecol 1989; 73 :414-8. Ultrasound has limited value in detecting partial molar pregnancies. Grade C recommendations U/S evaluation .

19. In twin pregnancies with a viable fetus and a molar pregnancy, the pregnancy can be allowed to proceed. (Grade C recommendation

20. twin pregnancies with a viable fetus and a molar pregnancy are associated with: reduced live birth rate of 25% risk from complications such as pre-eclampsia and haemorrhage. The subsequent need for chemotherapy, about 20%, is the same whether the pregnancy is terminated, or allowed to proceed to term. */** Evans A C Jr, Soper J T, Hammond C B. Clinical features of molar pregnancies and gestational trophoblastic tumours. In: Hancock B W, Newlands E S, Berkowitz R S, editors. Gestational Trophoblastic Disease . London: Chapman and Hall 1997: 109-25. Foskett M A, Seckl M J, Paradinas F J, et al. A review of 126 cases registered at Charing Cross Hospital as twin-multiple pregnancies complicated by a complete hydatidiform mole (CHM) IX World Congress of Gestational Trophoblastic Disease, Jerusalem, November 1998.

21. The clues for the sonographer in this diagnosis are the presence of a fetus (although usually with severe, but nonspecific, abnormalities) in combination with a formed placenta containing numerous cystic spaces Partial Hydatidiform Mole U/S evaluation .

22. When Sonography alone is not sufficient.To differentiate between twin pregnancy with a normal fetus and a coexistent complete mole, AND partial molar pregnancy, In twin pregnancy with a normal fetus and a coexistent complete mole maternal serum AFP levels are within the normal range. in partial molar pregnancy, elevated levels of AFP are found in the maternal serum and normal levels of AFP in the amniotic fluid Jauniaux E, Campbell S. Placenta and Cord. In: Dewbury K, Meire H, Cosgrove D, eds. Ultrasound in Obstetrics and Gynecology. London, United Kingdom. Churchill Livingstone 1993;448-9. Freeman SB, Priest JH, Macmahon WC, Fernhoff PM, Elsas LJ. Prenatal ascertainment of triploidy by maternal serum alpha-fetoprotein screening. Prenat Diagn 1989;9:339-47.

23. RCOG Recommendations Ultrasound has limited value in detecting partial molar pregnancies. In twin pregnancies with a viable fetus and a molar pregnancy, the pregnancy can be allowed to proceed. Surgical evacuation of molar pregnancies is advisable. Routine repeat evacuation after the diagnosis of a molar pregnancy is not warranted. Registration of any molar pregnancy is essential. The combined oral contraceptive pill and hormone replacement therapy are safe to use after hCG levels have reverted to normal. Women should be advised not to conceive until the hCG level has been normal for six months or follow-up has been completed (whichever is the sooner). Grade C recommendation

24. Evacuation of Molar Pregnancies Suction curettage is the method of choice of evacuation for complete molar pregnancies. Stone M, Bagshawe K D. An analysis of the influence of maternal age, gestational age, contraceptive method and mode of primary treatment of patients with hydatidiform moles on the incidence of subsequent chemotherapy. Br J Obstet Gynaecol 1979; 86 :782-92.

25. Medical termination of complete molar pregnancies, including cervical preparation prior to suction evacuation should be avoided where possible. because of the potential to embolise and disseminate trophoblastic tissue through the venous system. Evacuation of Molar Pregnancies Gillespie A M, Tidy J, Bright N, Radstone C R, Coleman R E and Hancock B W. Primary gynaecological management of gestational trophoblastic tumours and the subsequent development of persistent trophoblastic disease. Br J Obstet Gynaecol 1998; 107(suppl 17) Abs. No. 287, p. 95.

26. oxytocic infusions are only commenced once evacuation has been completed. If the patient is experiencing significant haemorrhage prior to evacuation and some degree of control is required then use of these agents will be necessary according to the clinical condition. Evacuation of Molar Pregnancies Bagshawe K D, Dent J, Webb J. Hydatidiform mole in England and Wales 1973-1983. Lancet 1986; 2 :673-7.

27. In partial molar pregnancies where the size of the fetal parts deters the use of suction curettage, medical termination can be used. (Grade C recommendation. Gillespie A M, Tidy J, Bright N, Radstone C R, Coleman R E and Hancock B W. Primary gynaecological management of gestational trophoblastic tumours and the subsequent development of persistent trophoblastic disease. Br J Obstet Gynaecol 1998; 107(suppl 17) Abs. No. 287, p. 95. Evacuation of Molar Pregnancies Newlands E S. Presentation and management of persistent gestational trophoblastic disease and gestational trophoblastic tumours in the UK. In: Hancock B W, Newlands E S, Berkowitz R S, editors. Gestational Trophoblastic Disease . London: Chapman and Hall 1997; 143-56.

28. Therapy: dilatation and suction curettage ( at which time the diagnosis is confirmed ). 15% of women with complete hydatidiform mole will develop recurrent disease in the form of invasive mole or choriocarcinoma . all patients are followed up with successive serum beta - hCG measurements to allow early detection of persistent gestational trophoblastic neoplasia SO IF serial testing shows progressive decrease in the serum beta - hCG level The clinical diagnosis of complete hydatidiform mole is reached. Avoid pregnancy

29. At the Eleventh World Congress on Gestational Trophoblastic Disease 2001, over 70 cases of persistent low level hCG elevation were reported from four Trophoblast Centres. The majority view of an expert panel was to refrain from immediate chemotherapy and/or surgery but to monitor such patients carefully and repeatedly (even over many years) looking for evidence of tumour or for a definite rise in hCG values. Hancock BW, Everard JE, Drew D. Quiescent gestational trophoblastic disease (FTD): how common is it and what is its outcome? XIth World Congress on Gestational Trophoblastic Diseases, Santa Fe, 2001, abstract. Kohorn EI. Persistent low level hCG: a clinical enigma. XIth World Congress on Gestational Trophoblastic Disease, Santa Fe, 2001, abstract. Newlands ES, Seckl MJ, Foskett M, Short D, Fuller S and Mitchell H. Problems of interpretation of persistent low levels of hCG in patients suspected of having gestational trophoblastic disease (GTD). XIth World Congress on Gestational Trophoblastic Diseases, Santa Fe, 2001, abstract. Clinical management of persistent low level hCG elevation

30. Because persistent trophoblastic disease may develop after any pregnancy it is recommended that all products of conception obtained after repeat evacuation, performed because of persisting symptoms, should undergo histological examination. (Grade C recommendation Evacuation of Molar Pregnancies Bagshawe K D, Dent J, Webb J. Hydatidiform mole in England and Wales 1973-1983. Lancet 1986; 2 :673-7.

31. There is no clinical indication for the routine use of a second uterine evacuation in the management of molar pregnancies. In cases where there are persisting symptoms after initial evacuation, consultation with the Screening Centre should be sought before surgical intervention. (Grade C recommendation) Evacuation of Molar Pregnancies Newlands E S. Presentation and management of persistent gestational trophoblastic disease and gestational trophoblastic tumours in the UK. In: Hancock B W, Newlands E S, Berkowitz R S, editors. Gestational Trophoblastic Disease . London: Chapman and Hall 1997; 143-56.

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