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BEST Molar Pregnancy
BEST Molar Pregnancy
BEST Molar Pregnancy
5
Clinical presentation and management
of molar pregnancy
Shigeru Sasaki*
MD, PhD
Associate Professor
Department of Obstetrics and Gynecology, Tama-Nagayama Hospital, Nippon Medical School, 1-7-1,
Nagayama, Tama City, Tokyo 206-8512, Japan
We can now detect molar pregnancy at a much earlier gestational age than before by using high
resolution vaginal ultrasonography. As a result, the current clinical presentation of complete
hydatidiform moles has clearly changed compared to that of the classic type of mole. The
diagnosis of molar pregnancy is nearly always made by ultrasonography. Ultrasonography does
not, however, always lead to diagnosis in the very early stages of gestation, before the chorionic
villi have attained the characteristic vesicular pattern. Therefore, a histopathological examination
of the products of conception should be required in all such cases. Hydatidiform moles should be
treated by evacuating the uterus surgically as soon as possible after diagnosis. The patients must
be followed up until their serial weekly serum human chorionic gonadotrophin (hCG) titre has
fallen to an undetectable level.
Key words: clinical presentation; hydatidiform mole; management of molar pregnancy.
886 S. Sasaki
(range 16 51) and the mean estimated gestational age at evaluation was 11.8 weeks
(range 6 22). The mean uterine size at evaluation was 12.4 weeks (range 7 20) and
the mean level of pre-evacuation hCG was 345 415 mIU/ml (range 828 1 680 300).
The most common presenting symptom was vaginal bleeding, occurring in 62 out of
74 (84%) patients. Uterine size greater than that for the expected date was
observed in 21 out of 74 (28%), anaemia in 4 out of 74 (4%), pre-eclampsia in 1
(1.3%), hyperemesis in 6 (8%) and theca lutein cysts in 6 out of 69 (9%). Seven cases
(9%) were asymptomatic. They noted that the presence of excessive uterine size,
anaemia, pre-eclampsia, hyperemesis and hyperthyroidism was significantly less
common among current patients than in past cases at their centre. Gemer et al5
from Israel have also reported the changing current clinical presentation of complete
molar pregnancy in 41 patients. In their paper, the mean maternal age was 30.1
years and the mean gestational age at evacuation was 10 weeks with a range of 7
14 weeks. The mean uterine size was compatible with 10 weeks gestation. The
mean pre-evacuation b-hCG was 275 901 IU/l (range 2011 919 000). The most
common presenting symptom was vaginal bleeding, occurring in 24 out of 41 (58%)
patients. Excessive uterine size was observed in 18 (44%), anaemia in 1 (2%) and
hyperemesis in 1 (2%). No pre-eclampsia or hyperthyroidism were observed.
Although vaginal bleeding was the most common presenting symptom, 17 out of the
41 cases (41%) were asymptomatic. Furthermore, systemic manifestations such as
hyperemesis, pre-eclampsia, clinical thyrotoxicosis and respiratory distress were
exceedingly rare in this study. All ovarian cysts were small and were diagnosed only
by ultrasonography.
Lindholm and Flam6 from Sweden have reported on 75 patients with complete
moles and 60 with partial moles. In the complete mole group, the mean gestational age
at the time of sonography was 12.4 weeks. Twelve patients had experienced no
symptoms. The three most commonly occurring symptoms were vaginal bleeding
(77%), abdominal pain (23%) and hyperemesis (19%). Some of the patients experienced
several symptoms. Only one patient suffered from pre-eclampsia. The uterus was
considered to be larger than expected for a date in 20%, equal in size expected for date
in 27% and smaller in 53%. In the partial mole group, the mean gestational age at the
time of sonography was 14.3 weeks. Vaginal bleeding was seen in 62% of the patients,
abdominal pain in 15% and hyperemesis in 8%. As we can see from these reports, the
current clinical presentation of complete HMs has clearly changed compared to that of
the classic type of mole. The clinical presentation of partial moles usually includes no
typical symptoms. Rather, the signs and symptoms are those of incomplete abortion or
missed abortion.
Practice points
The current clinical presentation of hydatidiform mole includes:
vaginal bleeding
excessive uterine size
hyperemesis
abdominal pain
sometimes, presentation is asymptomatic
888 S. Sasaki
Practice points
If patient desires
Hysterectomy
Spontaneous
resolution
Persistent
trophoblastic disease
Second follow-up
Treatment
Figure 1. Algorithm for the management of hydatidiform moles. hCG, human chorionic gonadotrophin.
890 S. Sasaki
hCG (mIU/ml)
106
105
104
103
102
0.5
5
20 weeks
2nd evacuation
1st evacuation
Figure 2. Serum human chorionic gonadotrophin (hCG) level regression curve post-evacuation
(discrimination line). Reprinted, with permission, from The Japan Society of Obstetrics and Gynecology and
the Japanese Pathological Society15, p. 12.
the spontaneous resolution cases, their hCG titres decreased to under 100 mIU/ml at
the 8th week. In some patients with persistent trophoblastic disease, their hCG titres
decreased at one point to undetectable levels and then rose again by the 20th week.
These findings indicate that the hCG titres at the 5th, 8th and 20th weeks after the first
evacuation are crucial for predicting persistent trophoblastic disease. From these
observations, we conclude that when the serial hCG titre is always below this
discrimination line and reaches an undetectable level by the 20th week, resolution is
spontaneous. If the hCG titre shows a plateau for 3 weeks or rises for 2 weeks and then
crosses this discrimination line at any point during the follow up as far as the 20th week,
trophoblastic sequelae, i.e. persistent trophoblastic disease, arise in the patient.
Recently, an international consensus has been reached that it is acceptable to wait to
observe hCG regression to undetectable levels for up to 6 months (24 weeks) after
molar evacuation (data from the IXth World Congress on Gestational Trophoblastic
Diseases, Jerusalem, 1998 and the Xth World Congress on Gestational Trophoblastic
Diseases, Tbilishi, 2000).
Management of spontaneous resolution
After spontaneous resolution, the patient is subsequently seen monthly for 6 months,
then at 3-monthly intervals for a further 2 years and then at least once a year for as long
as possible for the early detection of any recurrence of gestational trophoblastic disease
and to ensure that hCG levels remain undetectable. If patients want to conceive, they
are generally advised not to become pregnant again until after the first 6 months of
follow up and are given reliable contraception, preferably in the form of the pill.
Oral contraceptives do not appear to increase the risk of post-molar trophoblastic
tumours and may, therefore, be safely prescribed after molar evacuation during the entire
interval of hCG monitoring.16 A Gynecologic Oncology Group (GOG) study17 also
supported the idea that oral contraceptives are the preferred method of contraception
after evacuation of HMs, while the Charing Cross group recommended the use of oral
contraceptives after biochemical remission.18 Palmer19 reported that the relative risk of
persistent gestational trophoblastic tumours was increased by long-term oral contraceptive use before conception, although his finding was not statistically significant.
Further study is needed on this point.
SUMMARY
Blighted ova can be detected at a much earlier gestational age than before and almost
all patients with molar pregnancy are diagnosed and treated before they develop the
classic clinical presentation. As a result, the current clinical presentation of complete
hydatidiform moles (HMs) has clearly changed compared to that of the classic type of
mole. The clinical presentation of partial moles usually includes no typical symptoms.
Rather, the signs and symptoms are those of incomplete abortion or missed
abortion.
The latest high resolution ultrasonography can reveal a vesicular pattern of complete
moles instead of the snow storm pattern. Ultrasonography does not, however, always
lead to diagnosis in the very early stages of gestation, before the chorionic villi have
attained the characteristic vesicular pattern. If all the aborted materials in early
pregnancy are not examined by a pathologist, 16% of complete moles and 70% of partial
moles will be missed in follow up. Histopathological examinations should always be
done as far as possible. Samples should be kept for DNA analysis for a final diagnosis
when histology cannot differentiate molar pregnancy from abortion. The measurement
of serum human chorionic gonadotrophin (hCG) is definitely an important tool for
reaching a diagnosis of molar pregnancy.
HMs should be treated by evacuating the uterus surgically as soon as possible after
diagnosis. The patients must be followed up until their serial weekly serum hCG titre
has fallen to undetectable levels. In cases where the serial hCG reaches an undetectable
level by the 24th week after molar evacuation, resolution is spontaneous. Patients are
generally advised not to become pregnant again until after the first 6 months of follow
up and are given reliable contraception, preferably in the form of the pill.
Practice points
Required investigations for patients with hydatidiform moles include:
clinical examination
chest X-ray
blood cell count with platelet, blood urea nitrogen (BUN), creatinine and liver
function tests on admission
blood group
thyroid function tests if necessary
Prothrombin time (PT), partial thromboplastin time(PTT), prothrombin and
fibrinogen, if clinically indicated
serum human chorionic gonadotrophin (hCG) immunoassay: a specimen of
serum for hCG should be obtained prior to and one day after the evacuation
digital oximetry, blood gases and lung scan if necessary
892 S. Sasaki
Research agenda
further study on the effect of long-term oral contraceptive use on the relative
risk of persistent gestational trophoblastic disease is needed
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