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• Complete mole

• Partial mole

Activity and Further Outpatient Care

  • Patients may resume activity as tolerated.
  • Pelvic rest is recommended for 2-4 weeks after evacuation of the uterus, and the patient is instructed not to become pregnant for 6 months. Effective contraception is recommended during this period.
  • Serial quantitative serum beta-hCG levels should be determined.
  • Serum hCG levels are obtained weekly until the levels are within reference range for 3-4 weeks.
  • Levels should consistently drop and should never increase. Normal levels are usually reached within 8-12 weeks after evacuation of the hydatidiform mole. As long as the hCG levels are falling intervention is not needed.[35]
  • Once levels have reached the reference range for 3-4 weeks, check them monthly for 6 months.
  • If the serum hCG levels plateau or rise, the patient is considered to have malignant disease (ie, gestational trophoblastic neoplasia) and metastatic disease needs to be excluded.
  • After a hydatidiform mole, the risk of developing a second mole is 1.2-1.4%. The risk increases to 20% after 2 moles

Laboratory Studies

  • Quantitative beta-hCG: hCG levels greater than 100,000 mIU/mL indicate exuberant trophoblastic growth and raise suspicion for a molar pregnancy
  • Complete blood cell count with platelets
  • Clotting function
  • Liver function tests
  • Blood urea nitrogen (BUN) and serum creatinine
  • Thyroxine
  • Serum inhibin A and activin A have been shown to be 7- to 10-fold higher in molar pregnancies

Differential Diagnoses

• Complete mole

  • Hyperemesis Gravidarum
  • Hypertension
  • Malignant
  • Hyperthyroidism

  • Size inconsistent with gestational age that may enlarged, same or smaller.
  • Preeclampsia: most cases of hydatidiform mole and preeclampsia is seen in less than 2% of cases.
  • Theca lutein cysts: may in this cases accompanying by ovarian cyst enlargement also pt will develop pressure or pelvic pain. Because of the increased ovarian size and torsion is at risk. The cyst spontaneously regress after the mole is evacuated, but it may take up to 12 weeks

On Examination

In General

  • Uterine size is greater than expected for gestational age in 28% of complete molar pregnancies.
  • Active bleeding from the cervical os, and there may be spontaneous evacuation of vesicles from the cervix.
  • Nausea, Vomiting, pallor, tachycardia, tremor, HTN, peripheral oedema, and respiratory distress

Partial mole

Twinning

  • Uterine enlargement and preeclampsia is reported in only 5% of patients.
  • Theca lutein cysts, hyperemesis, and hyperthyroidism are extremely rare

  • Is a complete mole and a fetus with a normal placenta.
  • Women with coexistent molar and normal gestations are at higher risk for developing persistent disease and metastasis.
  • The pregnancy may be continued as long as the maternal status is stable.
  • Prenatal genetic diagnosis by chorionic villus sampling or amniocentesis is recommended to evaluate the karyotype of the fetus

The typical clinical presentation of complete molar pregnancies has changed with the advent of high-resolution ultrasonography. Most moles are now diagnosed in the first trimester before the onset of the classic signs and symptoms.

  • Vaginal bleeding: It's The most common classic symptom of a complete mole, Molar tissue separates from the decidua, causing bleeding. The uterus may become distended by large amounts of blood, and dark fluid may leak into the vagina. This symptom occurs in 50% of cases.
  • Hyperemesis: Patients may also report severe nausea and vomiting. This is due to extremely high levels of human chorionic gonadotropin (hCG).
  • Hyperthyroidism: Signs and symptoms of hyperthyroidism can be present due to stimulation of the thyroid gland by the high levels of circulating hCG or by a thyroid stimulating substance ie.thyrotropin produced by the trophoblasts

History

Epidimiology

Patients with partial mole do not have the same clinical features as those with complete mole. These patients usually present with signs and symptoms consistent with an incomplete or missed abortion.

  • Vaginal bleeding
  • Absence of fetal heart tones

  • hydatidiform moles is pathologic material from first- and second-trimester abortions were determined to occur in approximately
  • 1 in 100 pregnancies in Indonesia to 1 in 200 pregnancies in Mexico to 1 in 1200 pregnancies in United State to 1 in 5000 pregnancies in Paraguay

Hydatidiform Molar Pregnancy

partial mole

  • fetal tissue is often present. Fetal erythrocytes and vessels in the villi are a common finding.
  • The chromosomal complement is 69,XXX or 69,XXY, This results from fertilization of a haploid ovum and duplication of the paternal haploid chromosomes or from dispermy.
  • Tetraploidy may also be encountered. As in a complete mole, hyperplastic trophoblastic tissue and swelling of the chorionic villi occur.

Imaging Studies

Pathophysiology

A complete mole contains no fetal tissue. Ninety percent are 46,XX, and 10% are 46,XY. Complete moles can be divided into 2 types:

Ultrasonography The classic image:

  • older ultrasonographic technology, is of a snowstorm pattern representing the hydropic chorionic villi.
  • High-resolution ultrasonography shows a complex intrauterine mass containing many small cysts

• Androgenetic complete mole

• Biparental complete mole

o Homozygous

 These account for 80% of complete moles.

 Two identical paternal chromosome complements, derived from duplication of the paternal haploid chromosomes.

 Always female; 46,YY has never been observed.

o Heterozygous

 These account for 20% of complete moles.

 May be male or female.

 All chromosomes are of parental origin, most likely due to dispermy.

  • Maternal and paternal genes are present but failure of maternal imprinting causes only the paternal genome to be expressed.
  • The biparental complete mole is rare.
  • A recurrent form of biparental mole, which is familial and appears to be inherited as an autosomal recessive trait, has been described.
  • Mutations in NLRP7 at 19q13.4 have been identified as causative in recurrent molar pregnancies.

Chest radiograph once a molar pregnancy is diagnosed to take it as baseline because The lungs are a primary site of metastasis for malignant trophoblastic tumors

Medication

Prophylactic chemotherapy dactinomycin as one dose after evacuation of a hydatidiform mole is not routinely recommended. Only 20% of women with hydatidiform mole will develop malignant sequelae (ie, Gestational Trophoblastic Neoplasia). Prophylactic chemotherapy may be considered in patients who will not adhere to the required close follow-up

caution

  • Respiratory distress can occur at the time of surgery. This may be due to trophoblastic embolization, high-output congestive heart failure caused by anemia, or iatrogenic fluid overload.
  • Distress should be aggressively treated with assisted ventilation and monitoring, as required

Surgical Care

  • Evacuation of the uterus by dilation and curettage is always necessary.
  • Prostaglandin or oxytocin induction is not recommended because of the increased risk of bleeding and malignant sequelae.
  • Intravenous oxytocin should be started after dilation of the cervix at the initiation of suctioning and continued postoperatively to reduce the likelihood of hemorrhage. Consideration of using other uterotonic formulations (eg, Methergine)

Background

Gestational Trophoblastic disease encompasses several disease processes that originate in the placenta. These include complete and partial moles, placental site trophoblastic tumors, choriocarcinomas, and invasive moles

Treatment

Medical Care

  • Stabilize the patient.
  • Transfuse for anemia.
  • Correct any coagulopathy.
  • Treat hypertension.
  • Watch for and be prepared to treat thyroid storm

Age and Diet

GrossHistologicFindings

  • Complete mole: Complete hydatidiform moles have edematous placental villi, hyperplasia of the trophoblasts, and lack or scarcity of fetal blood vessels.
  • Partial mole: In the incomplete or partial hydatidiform mole fetal tissue is often present, as well as amnion and fetal vessels with fetal red blood cells within the mesenchyme of the villi. Like in complete hydatidiform moles, hydropic (edematous) villi and trophoblastic proliferation are present.
  • Hydatidiform mole is more common at the extremes of reproductive age. Women in their early teenage or perimenopausal years are most at risk and it's increase by age.
  • A Vitamin A deficiency, a diet in animal fat and carotene may be a risk factor

Mortality/Morbidity

  • A hydatidiform mole is considered malignant if metastases or destructive invasion of the myometrium (ie, invasive mole) occurs, or when the serum hCG levels plateau or rise during the period of follow-up and an intervening pregnancy is excluded.
  • Malignancy is diagnosed in 15-20% of patients with a complete hydatidiform mole and 2-3% of partial moles. Lung metastases are found in 4-5% of patients with a complete hydatidiform mole and rarely in cases of partial hydatidiform moles.
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