M olar pregnancy

 Gestational trophoblastic disease

 Partial mole
 Complete mole

 Gestational trophoblastic neoplasia

 Invasive mole
 Choriocarcinoma
 Placental site trophoblastic tumor PSTT
 Epithelial trophoblastic tumor ETT

 Molar diseases
 Partial mole
 Complete mole
 Invasive mole
 On Histopathological examination  chorionic villi
are present
 Rest of molar diseases:
 Choriocarcinoma
 PSTT
 ETT
 On Histopathological examination  chorionic villi
are absent

H mole
 It is benign disease of chorion with malignant
potential.
 They are more common in developing countries.
 MC seen in Philippines

 Risk factor:
 Increased maternal age:
(> 35 years – 2 times chances
> 40 years – 7 times changes)
 Asian population
 Dietary factors – deficiency of vit A
 Previous history of H mole
 Use of smoking
 Use of OCP
 AB blood group

 Pathology:
 Undue proliferation of trophoblast

 There might be enough space for development of fetal

body parts or there might be no any space for
development of fetal body parts.

 Some fetal parts are present: called partial mole.

 No fetal parts are present: called as complete mole.

1) Because of undue proliferation of trophoblast:

1. High level of HCG.
2. PIH: < 20 weeks of pregnancy
 3. Increase in height of uterus more than
gestational age
2) Hydropic degeneration

 Due to increase HCG:

1. Excessive nausea and vomiting: hyperemesis
gravidarum
2. α subunit of HCG similar to TSH: thyrotoxicosis
3. HCG is similar to LH: leads to theca lutein
cysts.
 On USG: you will get snow storm appearance

Partial mole Complete mole

Triploid Diploid
69XXX or 46 XX
69 XXY
Monospermic (90%)
Dispermic
1 empty ova + 2 sperm
1 ova + 2 sperm
The entire genetic
The extra genetic
Material is paternal
Material is
Origin  called
Paternal in origin
Androgenesis
10% cases – dispermic

Hydropic degeneration
Hydropic Is more
Degeneration is less No fetal parts are
Some fetal parts Present
Are present

All symptoms are more in

Trophoblastic Complete mole
Scalloping present e.g.
Inclusion bodies PIH – 27% cases
Present Hyperemesis gravidarum –
All symptoms are less or 25%
Absent Thyrotoxicosis
Respiratory distress – due
To embolisation of
trophoblastic tissue.
Snow storm appearance
On USG
It resembles  missed
abortion HCG: >105

HCG: <105 Present

Theca lutein cysts absent

12-20 %
Progression to gestational
4%
trophoblastic neoplasia
3-5%
Negative staining
Chances of
Choriocarcinoma <1%
Immuno staining with:
P57 kip2
 P57: it’s a maternal gene.
Positive staining

 Symptoms:
 It is not a normal pregnancy
 It has to end
 MC presenting symptom – bleeding PV
 Typical history: grape like vesicles coming out

 IOC: TVS/USG
 IOC for follow up in molar pregnancy: HCG
 Gold standard : Histopathological examination

 HCG: used for follow up of molar pregnancy after

suction and evacuation.

 Management of molar pregnancy:

 Suction evacuation is treatment of choice –
irrespective of gestational age of molar pregnancy.
 After suction and evacuation, if needed, do a
currettage
 And send tissue for histopatho examination.

 Other points:
 Oxytocin drip should not be started before evacuation
 As there are chances of embolisation
 Size of the cannula: use for suction evacuation: 10-12
 After evacuation in all Rh negative female –
give anti D
 Management of theca lutein cysts: do not need any
management after suction evacuation they will
spontaneously regress. (This is in contrast to the
chocolate cyst of endometriosis.)

 Indication for hysterectomy in molar pregnancy:

 Female is > 40 years with completed family
 Uncontrollable hemorrhage following suction and
evacuation
 Invasive mole
 After suction evacuation and after hysterectomy 
follow up molar pregnancy by doing HCG levels.
Because there is chances of Choriocarcinoma.

 How to do follow up?

 By measuring HCG weekly  till 3 conservative
normal values
 Then, monthly * 6 months.

 Pregnancy is contraindicated for 6 months after

evacuation of mole. Because HCG level again raise
then it will difficult to follow up for HCG.

 Contraception of choice in molar pregnancy:

 OCP
 After evacuation of partial mole: HCG is not detected
after 7 weeks usually.
 After evacuation of complete mole: HCG is not
detected by 9 weeks usually.

 Prophylactic chemotherapy in mole:

 It is not given to all patients after evacuation of mole.
 Given only to high risk patients.
 Age of patient > 40 years
 HCG levels > 105 IU/L
 Large uterine size prior to evacuation
 If there are bilateral theca lutein cysts > 6cm

 Prophylactic chemotherapy of choice: methotrexate

 Jaundice is present then gives - actinomycin D.