vesicularmole-abdalla

8/8/2019 VesicularMole-abdalla

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Vesicular Mole

Dr. MOHAMMED ABDALLA

EGYPT, DOMIAT G. HOSPITAL


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It is a benign neoplasm

of the chorionic villi


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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 hasprobably led to the earlier diagnosis of molar pregnancy


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1-Maternal age :

Young mothers (under age 20 years) have a slightly

higher prevalence of GTD, although not nearly so greatas those mothers over age 35 years.

2-Women who have had a previous molar gestation

3-The risk increases with the number of spontaneousabortions.

4- Women with blood type A may be more likely to

develop choriocarcinoma (but not hydatidiform mole);

RISK FACTORS:


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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 sothe chromosomal

number is 69

chromosomes

COMPLETE MOLEPARTIAL MOLE


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Differentiation Between Complete And Partial

Mole

Partial MoleComplete MoleFeature

PresentAbsentEmbryonic or

foetal tissue

FocalDiffuseSwelling of the villi

FocalDiffuseTrophoblastic

hyperplasia

Paternal and maternal

XX or X

Paternal XX ( %)

or X ( %)aryotype

Rare5-10%Malignant Changes


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Three components make up the trophoblast:

cytotrophoblast, syncytiotrophoblastintermediate trophoblast

The cytotrophoblast is

a stem cell with high

mitotic activity but

without hormonalsynthesis.

The syncytiotrophoblast,

which constitutes the

villous trophoblast, has low

mitotic activity. Thesyncytiotrophoblast is

responsible for the

synthesis of the (beta-hCG)

and can be identified with

immunohistochemicalstains.

The intermediate

trophoblast has features

of the other two

components and is

responsible for

endometrial invasion and

implantation


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There is trophoblastic proliferation, with mitoticactivity affecting both syncytial andcytotrophoblastic layers. This causes excessive

secretion of hCG,chorionic thyrotrophin andprogesterone.

.

Pathology

microscopic evaluation shows trophoblastic

hyperplasia


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(hydropic) villi The uterus is distendedby thin walled, translucent, grape-likevesicles of different sizes.

At histologic analysis,

Uniformly edematous (hydropic) villi with

dissolution of central stroma (cavitation/cistern

Pathology


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There is no vasculature in the

chorionic villi leads to earlydeath and absorption of theembryo.

At histologic analysis Occasionally, necrosis is seen

Pathology


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High hCG causes:

multiple theca luteincysts in the ovariesin about 50% of

cases.

exaggeration of the

normal early

pregnancy symptoms

and signs

Pathology


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1.Uniformly edematous (hydropic) villi

with dissolution of central stroma

(cavitation/cistern)

2.Villous vessels absent (usually)

3.Trophoblastic hyperplasia

circumferential, haphazard, involvesCT/ST/IT

4.Trophoblastic atypia

Pathology


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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 ).


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GTDMOST COMMON:complete hydatidiform mole,

invasive mole,

choriocarcinoma.

Partial hydatidiform moles

placental site trophoblastic tumor

LESS COMMON:


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U/S evaluation.

Complete Hydatidiform Mole

allows identification of numerous,discrete, anechoic (cystic) spaces

within a central area ofheterogeneous echotexture


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The coexistence of a fetus with a complete

hydatidiform mole is uncommon (incontrast to the partial hydatidiformmole), occurring in 1 -2 of cases .as a

result of dizygotic twinning; thus, thefetus is chromosomally normal. but, fetalsurvival until term is unlikely because ofthe maternal complications of the mole

itself


U/S evaluation.


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Theca lutein cysts multiloculated,

often bilateral

resolve after treatment of theintrauterine process

Occasionally seen in twin gestations, fetal hydrops,

pharmacologic stimulation (especially with human

maternal gonadotropin)

U/S evaluation.


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the ultrasound diagnosis of a complete mole is often reliable, thediagnosis of a partial molar pregnancy is more complex. Thefinding of multiple cystic spaces in the placenta is suggestive of apartial molar pregnancy. *

When there is diagnostic doubt about the possibility of acombined molar pregnancy with a viable fetus then ultrasoundexamination should be repeated before intervention.

Partial Hydatidiform Mole

RCOG/Fine C, Bundy A L, Berkowitz R S et al. Sonographic diagnosis of partial hydatidiformmole. Obstet Gynecol 1989; 73:414-8.

Ultrasound has limited value in detecting partial molar

pregnancies.

Grade C recommendations

U/S evaluation.


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In twin pregnancies with

a viable fetus and amolar pregnancy, the

pregnancy can beallowed to proceed.

(Grade C recommendation


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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.

2. 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.


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The clues for the sonographer in thisdiagnosis are the presence of afetus (although usually with severe,but nonspecific, abnormalities) incombination with a formedplacenta containing numerouscystic spaces

U/S evaluation.

Partial Hydatidiform Mole


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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,P

riestJH

, Macmahon WC, FernhoffP

M, Elsas LJ.P

renatal ascertainment oftriploidy by maternal serum alpha-fetoprotein screening. Prenat Diagn 1989;9:339-47.


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RCOG Recommendations

1. Ultrasound has limited value in detecting partial molar pregnancies.

2. In twin pregnancies with a viable fetus and a molar pregnancy, the

pregnancy can be allowed to proceed.3. Surgical evacuation of molar pregnancies is advisable.

4. Routine repeat evacuation after the diagnosis of a molar pregnancy is

not warranted.

5. Registration of any molar pregnancy is essential.

6. The combined oral contraceptive pill and hormone replacement therapyare safe to use after hCG levels have reverted to normal.

7. 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


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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.


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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.



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oxytocic infusions are onlycommenced once evacuation hasbeen completed. If the patient is

experiencing significanthaemorrhage prior to evacuation andsome degree of control is requiredthen use of these agents will be

necessary according to the clinicalcondition.

1. Bagshawe K D, Dent J, Webb J. Hydatidiform mole in England and Wales

1973-1983. Lancet 1986; 2:673-7.



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In partial molar pregnancies where the size

of the fetal parts deters the use of suction

curettage, medical termination can beused.(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 subsequentdevelopment 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.


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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


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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 patientscarefully 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 ofpersistent low levels of hCG in patients suspected of having gestational trophoblastic disease

Clinical management of persistent low level hCG

elevation


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Because persistent trophoblastic disease may

develop after any pregnancy it is recommended

that all products of conception obtained afterrepeat 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 1973-

1983. Lancet 1986; 2:673-7.



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There is no clinical indication for the routine use of a seconduterine evacuation in the management of molarpregnancies.

In cases where there are persisting symptoms after initialevacuation, consultation with the Screening Centreshould be sought before surgical intervention. (Grade Crecommendation)

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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