BENIGN GESTATIONAL

TROPHOBLASTIC DISEASE

BASEEL ABU-HILAL
COMPLETE MOLAR
PREGNANCIES
PATHOGENESIS
Although the cause of molar pregnancy is unknown, it is believed that most complete
moles result from the fertilization of an empty egg, by one normal sperm that then
replicates itself .
The placental abnormality is characterized by abnormal proliferation of the
syncytiotrophoblasts that produce hCG And diffuse swelling of the chorionic villi.
This hydropic degeneration gives the complete mole the appearance of grape-like
vesicles filling the uterus in the absence of an embryo .
History
The most common presenting symptom of molar pregnancy is irregular or heavy
.vaginal bleeding in the setting of a positive pregnancy test (97%)
The bleeding is caused by separation of the tumor from the underlying decidua,
.resulting in disruption of the maternal vessels
Many of these symptoms can be attributed to the high hCG levels, including severe
nausea and vomiting (from hyperemesis gravidarum); irritability, dizziness, and
photophobia (from preeclampsia); or nervousness, anorexia, and tremors (from
hyperthyroidism although subclinical hyperthyroidism is more common than overt
.hyperthyroidism)
Physical Examination
In complete molar pregnancy, the physical examination may show sequelae of
.preeclampsia (hypertension) or hyperthyroidism (tachycardia and tachypnea)
The abdominopelvic examination in molar pregnancy may be remarkable for the
absence of fetal heart sounds because there is no associated embryo in a complete
.molar pregnancy
Fifty percent of women with complete molar pregnancies will measure large for
gestational age because of the presence of large amounts of proliferative tissue,
.hemorrhage, and/or clot in the uterus
The pelvic examination may reveal the expulsion of grape-like molar clusters into the
.vagina or blood in the cervical os
Occasionally, the provider may palpate large bilateral theca lutein cysts
DIAGNOSTIC EVALUATION
In the presence of a molar pregnancy, quantitative serum hCG levels can be
.extremely high (>100,000 mIU/mL)
The hCG level reflects the amount of tumor volume and can be used for diagnosis and
.assessment of treatment effectiveness
Suspicion of GTD is usually confirmed using pelvic ultrasound. In the case of a
.complete mole, no embryo or gestational sac is present
Instead, the intrauterine environment appears as a “snowstorm” pattern due to
. swelling of chorionic villi
The scan may also reveal bilateral theca lutein cysts (15% to 25% of cases), which
.appear as large (>6 cm) multilocular cysts on both ovaries
The definitive diagnosis of molar pregnancy is made on pathologic examination of
.the intrauterine tissue once the uterus is evacuated
DIFFERENTIAL DIAGNOSIS

The differential diagnosis for GTD includes conditions that can result in
,abnormally high hCG levels, vaginal bleeding in pregnancy, and/or enlarged placentas
: Such as
Multiple gestation pregnancy
Erythroblastosis fetalis
Intrauterine infection
Uterine fibroids
Threatened abortion
Ectopic Pregnancy
.Normal intrauterine pregnancy
 TREATMENT
.Suction D&C is the definitive treatment for most patients with complete molar pregnancy
Prior to evacuation of the uterus, laboratory examination should include a baseline hCG level, a complete blood count (CBC)
.coagulation studies, along with renal, thyroid, and liver function tests
.A chest X-ray (CXR) is not routinely necessary, but can be used in the event that metastasis is suspected
.If a patient is demonstrating signs of preeclampsia, antihypertensives may be used to decrease risk of maternal stroke
Patients with sequelae of hCG-induced hyperthyroidism benefit from the use of B blockers such as propranolol to avoid
.precipitation of thyroid storm by anesthesia and/or stress of the surgical procedure
.In general, the cysts will spontaneously involute as the Hcg levels decrease following the procedure
.In patients who have completed childbearing, hysterectomy is an alternative therapy
Although this will eliminate the risk of local invasion, hysterectomy does not prevent metastasis of
.the disease
FOLLOW-UP
.The prognosis for molar pregnancy is excellent
Persistent postmolar GTD will develop in 6% to 32% of patients with complete moles but <5% of
.patients with partial moles. For this reason, close follow-up is essential even after hysterectomy
Serum levels are typically measured 48 hours after evacuation and then every 1 to 2 weeks until
.negative for 3 consecutive weeks
The levels are then followed monthly for an additional 6 months as most persistent disease will occur
.within 6 months of the evacuation
.The average time to normalization of levels is 14 weeks for a complete mole
A plateau or rise in hCG levels during surveillance or the presence of hCG several weeks to months
.after the D&C is indicative of malignant postmolar GTD
Patients at highest risk for persistent trophoblastic disease are those with β-hCG levels >100,000
.mIU/mL, those with ovaries >6 cm, and those with large uterine sizes (14 to 16 weeks)
In patients with these “high-risk moles,” a single dose of prophylactic chemotherapy
has been found to greatly lower the rate of persistent GTD without significant
.increase in morbidity or mortality

Reliable contraception is recommended during the surveillance period to avoid a

.new pregnancy that would interfere with interpretation of the hCG levels
However, all subsequent pregnancies should be closely monitored with early ultrasound
.to rule out recurrent GTD
Following delivery in a subsequent pregnancy, an hCG level should be checked at the 6-
.week postpartum visit
It is no longer necessary to send the placenta for pathologic examination, but any tissue
.obtained from a miscarriage or termination should be evaluated for molar tissue
PARTIAL MOLAR
PREGNANCY
PATHOGENESIS
A partial or incomplete mole is formed when a normal ovum is fertilized by two
.sperm simultaneously
The placental abnormality in a partial mole is characterized by focal hydropic villi
.and trophoblastic hyperplasia primarily of the cytotrophoblast
Partial moles are the only histologic type of GTD associated with the presence of an
embryo. In fact, a gestational sac and fetal heart rate may also be present. These
embryos often have multiple anomalies such as syndactyly and hydrocephalus and
.are often growth restricted
Most embryos associated with partial moles survive only several weeks in utero
.before being spontaneously aborted in the late first or early second trimester
History
Ninety percent of patients with partial moles present with vaginal bleeding from miscarriage
.or incomplete abortion in late first trimester or early second trimester
.The hCG levels are normal or only slightly elevated

.Diagnosis is often made on pathologic examination of the products of conception

PHYSICAL EXAMINATION

.In partial molar pregnancy, the physical examination is typically normal

Given the relatively normal hCG levels, hyperemesis, hyperthyroidism, and
.preeclampsia are rarely seen in women with partial moles
Fetal heart sounds may be present because there is a coexistent fetus in partial
.molar pregnancies
These pregnancies are often complicated by a uterine size that measures small for
.gestational age and for intrauterine growth restriction (IUGR)
DIAGNOSTIC EVALUATION

Quantitative serum hCG levels are likely to be relatively normal

Pelvic ultrasound may reveal a fetus with cardiac activity, congenital malformations,
.and/or IUGR
Amniotic fluid is usually present but reduced, and these patients generally do not
.have theca lutein cysts associated with complete molar pregnancy
The intrauterine tissue may contain anechoic spaces juxtaposed against chorionic
villi, giving the tissue a “Swiss-cheese” appearance. The definitive diagnosis of
partial molar pregnancy is made on pathologic examination of the intrauterine
.tissue once the uterus is evacuated
TREATMENT

.Treatment is immediate removal of the uterine contents via suction D&C

Less than 5% of patients with partial moles will develop persistent malignant disease
FOLLOW-UP

.Surveillance with serial hCG levels, is critical to the treatment of this disease
The average time to normalization of levels is 8 weeks for a partial mole compared with
14 weeks for a complete mole and 2 to 4 weeks following a normal pregnancy,
.miscarriage, or termination
Reliable contraception is also important to prevent pregnancy and allow accurate hCG
.surveillance