Molar PregnancyMolar Pregnancy

Mohammed khairyMohammed khairyAssisted lecture of Assisted lecture of

obstetric and gynecologyobstetric and gynecologyAssiut university- EgyptAssiut university- Egypt

m_khairy2001@yahoo.comm_khairy2001@yahoo.com

IntroductionIntroduction

Case report of partial molar pregnancyCase report of partial molar pregnancy Brief discussion about molar pregnancyBrief discussion about molar pregnancy Diagnostic role of Human Chorionic Diagnostic role of Human Chorionic

Gonadotropin Gonadotropin

Case ReportCase Report(Partial mole)(Partial mole)

32 years old woman32 years old woman G2 + P1+ 0 G2 + P1+ 0 Combined oral pills user before pregnancyCombined oral pills user before pregnancy

First visitFirst visit

Presenting SymptomsPresenting Symptoms

Amenorrhea of pregnancy Amenorrhea of pregnancy 13 weeks13 weeks , minimal , minimal vaginal bleeding. vaginal bleeding.

Clinical ExaminationClinical Examination

General examination → General examination → BP 120/90 mmhgBP 120/90 mmhg

Abdominal examination → Abdominal examination → Fundal level 18 wksFundal level 18 wks PV examination → PV examination → Cervix closed with minimal vaginal Cervix closed with minimal vaginal

bleedingbleeding

First visitFirst visit

Abdominal U/S Abdominal U/S a live fetus a live fetus 13 weeks13 weeks

of gestation. of gestation. Separate multiple cystic Separate multiple cystic

massmass was found in the placenta .was found in the placenta .

Provisional diagnosisProvisional diagnosis

? Partial mole. ? Partial mole.

Follow upFollow up

Our planOur plan

Second visitSecond visit(2 week later)(2 week later)

Presenting SymptomsPresenting Symptoms Amenorrhea Amenorrhea 15 weeks15 weeks , minimal vaginal bleeding. , minimal vaginal bleeding. Clinical ExaminationClinical Examination

General examinationGeneral examination → → BP 190/110BP 190/110 mmhg mmhg Abdominal examinationAbdominal examination → → Fundal level 34wksFundal level 34wks PV examination PV examination →→ Cervix closed with minimal vaginal bleeding Cervix closed with minimal vaginal bleeding . .

Second visitSecond visit (2 week later)(2 week later)

Abdominal U/S Abdominal U/S a live fetus consistent a live fetus consistent

with 15 weeks of with 15 weeks of gestation. There was no gestation. There was no evidence of growth evidence of growth retardation or fetal retardation or fetal anomaly. anomaly.

a well-defined and a well-defined and separate multiple cystic separate multiple cystic mass mass (honey-comb (honey-comb appearance) appearance) was found in was found in the upper uterine segment. the upper uterine segment.

Laboratory InvestigationsLaboratory Investigations

Serum Beta HCG levelsSerum Beta HCG levels..

3,000,000 mIU/ ml, 3,000,000 mIU/ ml, Albumin in urine.Albumin in urine.Albumin ++++ Albumin ++++ SPET SPET Thyroid function →Normal Thyroid function →Normal

ConclusionConclusion

• Clinical impression Clinical impression Partial mole Partial mole

• PlanPlan Termination of pregnancy followed by Termination of pregnancy followed by

histological analysis.histological analysis. Follow up by serum HCG estimationFollow up by serum HCG estimation ..

TreatmentTreatment

Hystrotomy was done.Hystrotomy was done. Antihypertensive drugs and Antihypertensive drugs and

Magnesium sulphate were were given.given.

Post-evacuation abdominal Post-evacuation abdominal U/SU/S

Bilateral theca Bilateral theca

lutin cysts 7x5cm .lutin cysts 7x5cm .

(RCOG 2010)RCOG 2010) Medical evacuation of molar pregnancies by oxytocin should be avoided because of the potential to embolise and disseminate trophoblastic tissue through the venous system .

(RCOG 2010)(RCOG 2010) Prolonged cervical Prolonged cervical preparation, particularly with preparation, particularly with prostaglandins, should be avoided prostaglandins, should be avoided where possible to reduce the risk of where possible to reduce the risk of embolization of trophoblastic cells.embolization of trophoblastic cells.

Post-evacuation planPost-evacuation plan

Post evacuation single-agent chemotherapy Post evacuation single-agent chemotherapy ,, 25mg methotrexate IM for 5 days25mg methotrexate IM for 5 days . .

Contraception by back up method till Contraception by back up method till hCG level became negative . hCG level became negative .

Follow up for HCG levels .Follow up for HCG levels .

Post-evacuation HCGPost-evacuation HCG(7 days later)(7 days later)

7300073000 mIU/ mlmIU/ ml

Brief Discussion about molar Brief Discussion about molar pregnancy.pregnancy.

Molar pregnancy

Complete molar pregnancy

Partial molar Pregnancy

Incidence of molar pregnancy (RCOG 2010)

• 1/714 live births.

•Asian women .

The true incidence of the disease is under-represent because of problems with reporting, particularly with partial moles.

Predisposing factorsPredisposing factors

1. Maternal age 1. Maternal age > 40 years> 40 years < 15 years< 15 years 2. Paternal age 2. Paternal age > 45 years > 45 years 3. Previous hydatidiform mole. 3. Previous hydatidiform mole. 4. Vitamin A deficiency.4. Vitamin A deficiency. 5. Smoking.5. Smoking.

Complete Mole

Duplication of the haploid sperm following fertilization of an ‘empty’ ovum .

Some complete moles arise after dispermic fertilization of an “empty’ ovum (dispermy).

Emptyovum

Emptyovum

46XX

46XX or 46XY

23X or Y

23X

23X

Complete Mole (46XX diploid)

Complete Mole (46XX or 46XY, diploid)

Complete Mole

COMPLETE HYDATIFORM MOLE

CLINICAL FEATURES

Vaginal bleeding (anemia) 97%

Excessive uterine size 50%

Theco-lutein ovarian cysts 50%

Preeclampsia 27%

Hyperemesis 25%

Hyperthyroidism 7%

Trophoblastic embolization 2%

Partial Molar Pregnancy

Triploid in origin (two paternal and one maternal).Dispermic fertilization of an active ovum.

23X

23XDyspermy 23X/23Y or 23X/23X

23Y

Partial Mole (69XXY, or 69XXX, or 69XYY

triploid)

23X

23X23Y69XXY

Partial Molar Pregnancy

Complete mole

Partial mole

Karyotype 46XX ,46XY Triploid (69 XXY)Fetal or embryonic tissue absent present

Hydatiform swelling of chorionic villi extensive focal

Trophoblastic hyperplasia extensive focal

 Theca-lutein cysts 25–30%  less common

 Medical complications Frequent   less common

Gestational trophoblastic neoplasia 20% <5–10%

HCG level very high Slight raised

Differance between COMPLETE AND PARTIAL MOLE

Ultrasonographic D/DUltrasonographic D/D

Hydropic degeneration of placentaHydropic degeneration of placenta Complete mole with co-existent fetusComplete mole with co-existent fetus Degenerated leiomyoma of uterusDegenerated leiomyoma of uterus Retained products of conceptionRetained products of conception ChoriocarcinomaChoriocarcinoma Missed AbortionMissed Abortion

Hydatidiform Mole with co-existent foetusHydatidiform Mole with co-existent foetus(RCOG 2010)(RCOG 2010)

The outcome for a normal pregnancy with a The outcome for a normal pregnancy with a coexisting complete mole is poor, with coexisting complete mole is poor, with approximately a 25% chance of achieving a live approximately a 25% chance of achieving a live birth. There is an increased risk of early fetal loss birth. There is an increased risk of early fetal loss (40%) and premature delivery (36%). The (40%) and premature delivery (36%). The incidence of pre-eclampsia is variable, with rates incidence of pre-eclampsia is variable, with rates as high as 20% reported.as high as 20% reported. Prenatal invasive testing for fetal karyotype Prenatal invasive testing for fetal karyotype should be considered in these cases.should be considered in these cases.

GTD and Twin PregnancyGTD and Twin Pregnancy

Human chorionic Human chorionic GonadotropinGonadotropin

Diagnostic Implications of Serum HCG levels

Single HCG value –Not very informative Rate of increase in HCG levels varies as a pregnancy

progresses. An HCG that does not double every two to three days does

not necessarily indicate a problem with the pregnancy. Some normal pregnancies will have quite low levels of

HCG, and result in perfect babies.

Correlation between HCG level, and Correlation between HCG level, and sonography findingssonography findings

Serum HCG levels 1500 IU/L-Gestational sac Serum HCG levels 1500 IU/L-Gestational sac should be visible by USGshould be visible by USG

Serum HCG levels 5000IU/L-Cardiac Serum HCG levels 5000IU/L-Cardiac pulsation should be visible.pulsation should be visible.

More than 5000 IU/L rules out Ectopic More than 5000 IU/L rules out Ectopic pregnancy.pregnancy.

Serum HCG levels after non Serum HCG levels after non trophoblastic Abortionstrophoblastic Abortions

Should fall to undetectable level by 3 weeks.Should fall to undetectable level by 3 weeks. Below 5mIUm/l - negative.Below 5mIUm/l - negative. Above 25mIU/ml -positive.Above 25mIU/ml -positive.

HCG Levels –after trophoblastic HCG Levels –after trophoblastic abortionsabortions

Greater than 500mIU/ml frequently for 3 Greater than 500mIU/ml frequently for 3 weeks and usually for 6 weeks.weeks and usually for 6 weeks.

HCG titer should fall to a non-detectable HCG titer should fall to a non-detectable level by 15 weeks.level by 15 weeks.

HCG levels -Management

• Indications of chemotherapySerum hCG> 20, 000 IU/L at >4 weeks. Rising hCG. i.e. 2 consecutive rising serum

samples.hCG plateau. i.e. 3 consecutive serum samples

not rising or falling significantly.hCG still abnormal at 6 months post

evacuation.

Thank You