MOLAR PREGNANCY

DR. M. ANUPAMA
 Molar Pregnancy

 Defined as abnormal condition of placenta

where partly proliferation and partly
degeneration of the Chorionic Villi occurs.
 A benign neoplasm of the Chorion with
malignant potential.
 15% will develop malignancy requiring
chemotherapy
 1 : 2000 pregnancies western countries

 Higher incidence in Far East countries (1:80 in

Philipines).
• India : 1/400

• More often is the younger or older mother

(before 20y and after 40yr)
• GTD is a group of disease originated from
placental villose trophoblastic cells, including
hydatidiform mole, invasive mole,
choriocarcinoma and a kind of less common
trophoblastic cell tumor in placenta(PSTT)
• GTT is all GTD except hydatidiform mole
• GTN : comprises of a spectrum of proliferative
abnormalities of trophoblast asociated with
pregnancy.
– Benign mole is considered to be abnormal
formation of placenta accompanied by the
special abnormal proliferation.
– Invasive mole results from benign mole
– Choriocarcinoma and the trophoblastic cell
tumor in placenta may result from benign
mole, term pregnancy, abortion and ectopic
pregnancy
 Etology
• Basic :Ovular defect
• Low SES with low protein diets
• Disturbed maternal immunity(rise of gamma
globulin/ABO association)
• Cytogenetic abnormality(85%-46XX/ 15%-
46XY)
• Higher ratio of paternal/maternal chromosome
• H/o prior molar pregnancy
• Low Vit-A /Beta-Carotine/ Folic acid inatke
Pathogenesis
Pathology
• Secretions from hyperplastic cells accumulates
in stroma of villi which are deviod of blood
vessels.
• Vesicles fluid is interstitial fluid rich in HCG
• No trace of embryo or amniotic sac
• B/L Theca Lutein Cysts
• Microscopic
– Proliferation of Cyto & Syncytiotrophoblast
– Thinning of Stromal tissue due to hydrophic
degeneration
– Absence of blood vessels in Villi
– Villous Pattern maintained
– Irregular proliferation of epithelial cells with
hyperchromatic & mititic nuclei
 Complete
• History of amenorrhea
• Most common symptom is vaginal bleeding:
brownish (prune juice) or expulsion of molar
vesicles
• Lower abdominal pain
– Over distention
– Concealed bleeding
– Infection
– Contraction
– Perforation
• Discharge with Grape-like vesicles
• H/o Quickening Absent
• Asymptomatic-1%
• Usually needs to abortion between 3 rd and 6th
month of Pregnancy
• Anemia out of proportion to visible blood loss
• Diagnosed as Missed Abortions (early USG
without Symptoms)
• PIH(50%)
• Hyperthyroidism(2%)
• Hyperemesis gravidarum (25%)
P/A
• Size of Uterus(>70%,=20%,<10%)
• Doughy consistency of Uterus(due to absence amniotic fluid)
• Absence of fetal parts & FHS
P/V
• Internal ballottement-absent
• 15–25% of patients will have theca lutein cysts with ovarian
enlargement of more than 6 cm
• Finding of grape like vesicles
• DIC
 Investigations
• CBC, Grouping & Rh typing
• USG : Used to diagnose a mole and find out if it
is invading local tissues.“Snow-Storm”
• Serum beta-HCG(>100000 mIU/ml)
• LFT& RFT
• TFT
• Serum HPL
• X-ray Abdomen & Chest
• Maternal serum AFP( )
• CT/MRI
The Snow storm appearance
Differential diagnosis
• Threatened Abortion
• Fibroid/Ovarian tumor with pregnancy
• Twin pregnancy
• Polyhydramnios

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 Complications
• Immediate
hemorrhage and shock(Anemia)
sepsis
perforation
preeclampsia
acute pulmonary edema
Embolisation
thyroid Storm
DIC
• Late : Choriocarcinoma
Reurrence
 Risk factors for malignancy

 Age > 40 yrs

 Previous 3 or more births
 Initial serum hCG > 100000
mIU/ml
 Uterine Size > 20 wks
 Previous h/o molar pregnancy
 Large lutein cysts(> 6 cm)
15% of complete moles progresses to persistent GTN
 TREATMENT
Aim
Restoration of blood loss & prevention of
infection
Evacuation of Uterus
Follow up
 Suction & evacuation
 Hysterotomy
(Bleeding with unfavorable Cx)
Hysterectomy
Elderly(>40 yrs)
Completed their family
Hemorrhage
Perforation
High risk factors
β-HCG>100000IU/L
Size is over 14 gestational weeks
 S&E
• Under GA/Spinal .
• Cervical Preparation prior to S & E
• Cervix Dilatation till 12mm and S&C induced to
the uterine cavity.
• Uterine Stimulation : I.V Oxytocin
• S & C started by pressure of about 400-600 mm
of Hg.
• Curette is genteelly rotated to ovoid perforation
of the soft uterus
• Anti-D IG

Molar tissue/Uterus is to be sent for HP study

 FOLLOW-UP
85% of cases, the trophoblastic tissue die
15% of cases the trophoblastic tissue does not die
out completely and may persist or recur as :
invasive mole or choriocarcinoma.
 Regular measurement of the beta-HCG
 Baseline Chest x-ray
 Physical Examination, including Pelvic exam
 Effective contraception (Between 6-12 months)

Even after hysterectomy chance of malignancy is 5%

• Serum beta-HCG, returned to non pregnant levels
by 6 weeks after evacuation.
• Mandatory follow up for Six months(monthly)
• Patient getting Chemotherapy should be followed
up for 1 yr
• Follow up
– Warning symptoms
– Clinical examinations
– Investigations

Check HCG level 3 Wks after end of any pregnancy

subsequent to molar pregnancy
 Indication of Prophylactic Chemotherapy
a) If Serum beta HCG fails to become
normal by 6 wks.
b) Serum HCG >20000 mIU/ml at any
time after evacuation of mole.
c) Evidence of Metastasis irrespective
of HCG level
d) High Risk Factors

Dose
a) Methotrexate : 1 mg/kg 5 days/3 cycles with2
wks gap in each
b) Actinomycin : 12 mcg/kg
 Partial
 Is developed as the result of fertilization of a normal egg by
two spermatozoa.
 The Chorionic epithelial cells are always triploid (69XXY).
 Serum HCG level is less elevated.
 Triploid Karyotype – extra haploid set paternal
 Focal affection of villi, there is either fetus or amniotic sac.
 Usually triploid growth restricted/multiple anomalies/
dies in Utero
 Average GA of detection is 24-26 wks
Pathology differs from complete:
focal hydatidiform swelling
varying size of chorionic villi
marked villous scalloping
focal trophoblastic hyperplasia
identifiable embryonic or fetal tissues
Rarely progresses to Choriocarcinoma
Low level of HCG
Does not require chemotherapy
 M/E : hyperplasia of Syncytiotrophoblast and
presence of fetal blood vessel with fetal RBC
 Usually presented as threatened or missed abortion
 If continue, IUGR
 Excessive uterine enlargement / PET very rare
 No hyperemesis / hyperthyroidism / theca-lutein cysts
 Diagnosis:
a) U/S may detect focal cystic spaces of varying
diameter
b) Histology of Curetting
 GESTATIONAL TROPHOBLASTIC DISEASE:
COMPLETE VERSUS PARTIAL HYDATIDIFORM MOLE
FEATURES COMPLETE PARTIAL

Karyotype 46, XX 69, XXY

Embryo Absent Present

Villous edema All Villi Some Villi

Proliferation Diffuse; circumferential Partial

Atypia Often Absent

Theca Cyst Common Uncommon

Serum HCG Elevated Less elevated

HCG in tissue ++++ +

Behavior 15% 5%
 Complete mole Partial mole
– A sperm has fertilized an – Two sperm fertilize a
“empty” egg (contains no normal egg.
nucleus or DNA). – These contain some
– All the genetic material fetal tissue mixed in
comes from the father’s with the
sperm. Therefore, there is trophoblastic tissue,
no fetal tissue. No viable fetus is
– Up to 15% of patients with being formed.
complete moles will need – Only a small(5%)
additional surgery or percentage of
chemotherapy after their patients with partial
initial surgery. moles need further
– A small percentage of treatment after initial
complete moles may surgery.
develop into – Com/Partial moles
choriocarcinoma, a rarely develop into
malignant form of GTD malignant GTD.
 Partial mole

Complete mole

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37
 Follow up : As of Complete mole(6 months)

Recurrent Molar Pregnancy : 2%

Maximum No of Consecutive molar Pregnancy :9
Risk of Subsequent Pregnancy :20X
 Prognosis

The risks:
 Immediate : hemorrhage , sepsis, or pre-clampsia,
torsion
 Delayed : Molar metastases(10%)
Invasive mole = Non-metastatic form.
Choriocarcinoma = Metastatic form
 Prognosis
• Complete mole has the latent risk of local invasion
• The high-risk factors includes
– Serum beta-HCG> 1lakh IU/ml
– uterine size is obviously larger than that with the same
gestational time.
– the luteinizing cyst is >6cm
– If >40 years old, the risk of invasion and metastasis may be
37%,
– If >50 years old, the risk of invasion and metastasis may be
56%.
– repeated mole : the morbidity of invasion and metastasis
increase 3~4 times

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 F0llow-up
Evidence of metastases : Liver, Brain and
Lungs
Persistent uterine hemorrhage after
evacuation of mole with raised hCG levels.
Pregnancy is better to be avoided ,and also
the use of oral contraceptive pills until the
hCG levels returns to normal after the
evacuation of the mole.
• When titer gets negative, measurements are
done every month
a) 2 years : Complete moles
b) 6 months : Partial moles
Contraception:
Oral /Injectables/ barrier / permanent

No IUCD until hCG normal (perforation)

 INVASIVE MOLE
-It is intermediate between a
benign mole and
choriocarcinoma.
-It is invasive locally but have
no metastatic potential.
-Invasive mole have
edematous villi penetrating
the uterine wall deeply
causing severe haemorrhage.
-Erosion occurs into
peritoneal cavity or broad
• Diagnosis of invasive moles or
“Chorioadenoma Destruens” is applied to
the moles characterized by :
 Abnormal peneterativeness
 Extensive local invasion, along with
 Excessive trophoblastic proliferation
 With preserved villous pattern .
• The proliferative villi may invade the
myomatrum ,paramatrum or the vaginal wall
• Morbidity and mortality of this disease results
from the penetration of the tumar through the
myomatrum and to the pelvic vessels with the
resultant hemorrhage “the morbidity and
mortality rate 10 %”
.
Cliniacal Feature
• Most Common : Abnormal bleeding(1st trimester)
• Absent Fetal Heart sounds
• Hyperemesis Gravidarum
• Abnormally high level of hCG for gestational age
• Uterine Subinvolution
• Theca Lutein Cyst does not disappear after emptying uterus
• Abdominal Pain
• Metastatic focus manifestation
INVASIVE MOLE
Invasive mole vs Choriocarcinoma
if we see villi, it must be invasion mole;
(<6 months Abortion/Molar)
if we can’t see villi, it is choriocarcinoma.
(>6 months Abortion/Molar)

Trophoblastic tumor following FT

Pregnancy is always a
Choriocarcinoma but it may be
invasive mole or choriocarcinoma if
follows Abortion or Molar
Pregnancy)
Persistent mole: if the HCG is still positive 3
months after the mole is completely emptied,
called persistent mole
Prognosis depends upon
-high risk factors
-Serials beta-HCG
-Cytotoxic drugs
 PSTT

• Develops from placental bed trophoblast &

invades myometrium
• Follows term delivery(95%) or mole(5%)
• Benign course
• Contains mainly Cytotrophoblast
• Lower level of HCG(<3000 IU/L)
• High value of HPL
• Treatment : Hysterectomy
 PERSISTENT TROPHOBLASTIC
DISEASE(PTD)

• 15% of molar patients shows persistence of tumor

in uterus following S & E.
• C/F
a) Enlarged cyst
b) Vaginal bleeding
c) Static/raised beta HCG in Serum & Urine.
• Look for local metastasis(Pelvic USG)
• Look for distant metastasis(X-ray Chest/CT brain &
Liver)
Chemotherapy
 Methotrexate-1 mg/kg wt
 Actinomycin-10mcg/kg wt
Criteria
a) Hb >8-10gm%
b) TLC >3000/cmm
c) TPC > 1lakh/cmm
d) Normal LFT & RFT
THANK U