Vesicular Mole

Dr. MOHAMMED ABDALLA EGYPT, DOMIAT G. HOSPITAL

It is a benign neoplasm of the chorionic villi

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

RISK FACTORS:
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);

What Is A Hydatidiform Mole?

A hydatidiform mole is an abnormality of fertilization
COMPLETE MOLE PARTIAL MOLE

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

Differentiation Between Complete And Partial Mole

Feature
Embryonic or foetal tissue

Complete Mole
Absent

Partial Mole
Present

Swelling of the villi

Trophoblastic hyperplasia Karyotype

Diffuse
Diffuse Paternal 46 XX (96%) or 46 XY (4%)

Focal
Focal Paternal and maternal 69 XXY or 69 XYY Rare

Malignant Changes 5-10%

Three components make up the trophoblast:

cytotrophoblast, intermediate trophoblast syncytiotrophoblast

The cytotrophoblast is a stem cell with high mitotic activity but without hormonal synthesis.

The intermediate trophoblast has features of the other two components and is responsible for endometrial invasion and implantation

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.

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

microscopic evaluation shows trophoblastic

hyperplasia

Pathology
hydropic) villi

The uterus is distended by thin walled, translucent, grape-like vesicles of different sizes.

At histologic analysis,
Uniformly edematous (hydropic) villi with dissolution of central stroma (cavitation/cistern

Pathology
There is no vasculature in the chorionic villi leads to early death and absorption of the embryo.

At histologic analysis Occasionally, necrosis is seen

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

Pathology
1.Uniformly edematous (hydropic) villi with dissolution of central stroma (cavitation/cistern)
2.Villous vessels absent (usually) 3.Trophoblastic hyperplasia circumferential, haphazard, involves CT/ST/IT 4.Trophoblastic atypia

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%).

MOST COMMON:
invasive mole,

GTD

complete hydatidiform mole,

choriocarcinoma.

LESS COMMON:
Partial hydatidiform moles placental site trophoblastic tumor

Complete Hydatidiform Mole

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

Complete Hydatidiform Mole

U/S evaluation.
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.

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)

Partial Hydatidiform Mole

U/S evaluation.
Ultrasound has limited value in detecting partial molar pregnancies. Grade C recommendations
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.
RCOG/Fine C, Bundy A L, Berkowitz R S et al. Sonographic diagnosis of partial hydatidiform mole. Obstet Gynecol 1989; 73:414-8.

In twin pregnancies with a viable fetus and a molar pregnancy, the pregnancy can be allowed to proceed.

(Grade C recommendation

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. */**

1.

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.

2.

Partial Hydatidiform Mole

U/S evaluation.
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

 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.

RCOG Recommendations
1. 2. 3. 4. 5. 6. 7. 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

Evacuation of Molar Pregnancies Suction curettage is the method of choice of evacuation for complete molar pregnancies.

1.

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.

Evacuation of Molar Pregnancies

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.
1. 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

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.
1. Bagshawe K D, Dent J, Webb J. Hydatidiform mole in England and Wales 1973-1983. Lancet 1986; 2:673-7.

Evacuation of Molar Pregnancies

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.

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.

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.

SO
all patients are followed up with successive serum beta-hCG measurements to allow early detection of persistent gestational trophoblastic neoplasia

Avoid pregnancy
IF serial testing shows progressive decrease in the serum beta-hCG level

The clinical diagnosis of complete hydatidiform mole is reached.

Clinical management of persistent low level hCG elevation 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

Evacuation of Molar Pregnancies

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

Bagshawe K D, Dent J, Webb J. Hydatidiform mole in England and Wales 19731983. Lancet 1986; 2:673-7.

Evacuation of Molar Pregnancies

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)
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.