Gestational Trophoblastic Disease:

Hydatidiform Mole
April 7, 2022

Moderator:
Angelica Ann Chua MD, FPOGS

ROTATORS:
Joanna Rose C. Janoras
Angelle C. Valenciano
 ROD 48yo
Chief complaint: vaginal spotting

Consulted at Private Clinic.

1 week PTC
TVS Revealed (3/19):
Slightly enlarged uterus
(+) vaginal spotting
Markedly thickened, hyperechoic,
multicystic endometrium, consistent with
(-) passage of meaty Molar pregnancy
materials, Normal ovaries

(-) abdominal pain

Past Medical History:
Unremarkable

OB History: G7P5 (5015)

G1 1995 NSD Bicol

G2 2007 NSD QMMC

G3 2010 NSD QMMC

G4 2011 NSD QMMC

G5 2012 NSD QMMC

G6 2019 Complete abortion

G7 Present pregnancy
 PHYSICAL EXAM
Awake, coreherent, not in distress

VS:
BP: 100/80
HR: 89
RR: 20
T: 36.5

Abdomen: soft, non tender

Speculum Exam: cervix pink, smooth, (-) lesions, (-) erosions, (+) minimal vaginal bleeding per os

Internal Exam: Cervix closed, (-) cervical motion tenderness, Uterus enlarged to 16weeks size, (-)
adnexal mass nor tenderness
 Ultrasound

TVS done by Dr. Banal at QMMC (3/25/2022)

>Slightly enlarged anteverted Uterus (10x7.26 x 6.19cm)

>There is a multicystic structure within the EM cavity measuring
7.8x6.82x3.49cm (vol 91cc)
>Endometrial mass consistent with molar gestation
>Normal ovaries
 Diagnostics

Na 136 Urinalysis BHCG 180, 450

CBC
K 4.3 LY
Hgb 131
Cl 107 6
Hct 0.40 Chest Xray:
AST 36.16 1.005 Clear Lungs
Wbc 10.8
ALT 34.99 Negative sugar
Plt 365
BUN 2.48 Negative
albumin

WBC 0-1
Crea 56.06
RBC 0-1
 Admitting Diagnosis

G7P5 (5015) Molar Pregnancy at 14 weeks 2 days AOG,

Grandmultipara
Total Abdominal Hysterectomy with Bilateral
Salpingectomy with Mole-In-Situ

The uterus measures 7x8x4 cm, with

smooth outer surface. On cut section,
endometrium is thin. There are
vesicular tissues occupying the
endometrial cavity.

The cervix measures 4x4 cm. On cut

section, no polyps/masses/nodules
noted.

The bilateral fallopian tubes are

grossly normal. There is a 1.5x1.5 cm
cystic structure attached on the right
fallopian tube and a 0.5x0.5 cm cystic
structure attached on the left fallopian
tube.
DISCUSSION
GESTATIONAL TROPHOBLASTIC DISEASE
● Are abnormal conceptions with excessive placental and little or no fetal development
● Excessively edematous immature placentas

Source: Clinical Practice Guidelines for the Diagnosis and Management of Gestational Trophoblastic Diseases (Nov 2016)
Williams Obstetrics 26th edition
 INCIDENCE

World wide: incidence of 1-2 per 1,000 pregnancies.

Philippines (2002-2008): 2.4/1000 pregnancy

UP PGH: prevalence rate of 14 in every 1,000 pregnancies

Source: Clinical Practice Guidelines for the Diagnosis and Management of Gestational Trophoblastic Diseases (Nov 2016)
Pathogenesis

Williams Obstetrics 26th edition

HYDATIDFORM MOLE

Williams Obstetrics 26th edition

 RISK FACTORS
● MATERNAL AGE
○ ‘J Curve’
○ Teenagers <15yo (20x higher)
○ >40yo (10x higher)
○ >50yo (200x higher)

● PATERNAL AGE
○ 45yo

● REPRODUCTIVE AND OBSTETRIC HISTORY

○ Previous history of Molar pregnancy (0.6-2.6%)

● RACIAL FACTORS

● DIET AND NUTRITION

○ Decrease dietary carotene and animal fat

Source: Clinical Practice Guidelines for the Diagnosis and Management of Gestational Trophoblastic Diseases (Nov 2016)
 PRESENTATION
CLINICAL PRESENTATION + ULTRASOUND FINDING + ELEVATED BHCG

● Amenorrhea
● Positive Pregnancy test
● Vaginal bleeding (89-97% of cases)
● Uterine size more than age of gestation (40-50% of cases)
● Absence of fetal heart tones

● Presence of Theca Lutein Cysts (20%)

● Hyperemesis (15-25%)
● Pre-eclampsia (12-27%)
● Hyperthyroidism (2-7%)
● Respiratory insufficiency (2%)

Source: Clinical Practice Guidelines for the Diagnosis and Management of Gestational Trophoblastic Diseases (Nov 2016
 DIAGNOSTICS
PELVIC ULTRASOUND
- Most accurate non-invasive imaging modality of hydatidiform mole
- Overall sensitivity 50-86%

Complete Hydatidiform Mole:

● Grape-like or hydropic villous
● Snowstorm-like appearance

Partial Hydatidiform Mole:

● Less accurate, nearly 70% will be missed
● Focal cystic changes in the placenta
● Ratio of transverse to antero-posterior diameter dimension of the gestational sac >1.5
● Growth retarted fetus with multiple congenital anomalies

Source: Clinical Practice Guidelines for the Diagnosis and Management of Gestational Trophoblastic Diseases (Nov 2011)
A. Snow Storm appearance B. partial hydatidiform mole,
the fetal head (arrow) lies adjacent to an
enlarged, multicystic placenta.
 DIAGNOSTICS

BETA HCG
● Above expected for the gestational age
● COMPLETE H.MOLE: >100,000 mIU/L
● PARTIAL H.MOLE: Less elevated BHCG levels

Source: Clinical Practice Guidelines for the Diagnosis and Management of Gestational Trophoblastic Diseases (Nov 2011)
 BASELINE LABORATORY

● Complete Blood Count

● AST
● ALT
● BHCG
● Chest Xray
● Thyroid Function Test
 MANAGEMENT
Suction Curettage Hysterectomy
● Preferred method regardless ● Option for patients with
of the patient’s age and completed family size
uterine size ● For patients with life
threatening hemorrhage
● Decrease the risk for local
invasion (3-5%)
● Does not eliminate the the
need for post-evacuation
monitoring

PSSTD CPG 2016, RCOG 2010

Committee on Practice Bulletins--Gynecology American College of Obstetricians and Gynecologists, ACOG Practice Bulletin #53. Diagnosis
and Treatment of Gestational Trophoblastic Disease. Obstet Gynecol 2004; 103:1365

RCOG Guideline # 38, The management of Gestational Trophoblastic Disease February 2010
 ROLE OF CHEMOPROPHYLAXIS
● Reduce the risk of progression of GTN, and who are at high risk for malignant transformation

● METHOTREXATE is the drug of choice (0.3-0.4 mg/kg/day for 5 days)

● Does not remove the need for post-evacuation hCG surveillance

May be useful in some situations where:

● Patients are high risk of postmolar GTD
● When post-evacuation surveillance is doubtful

Clinical Practice Guidelines for the Diagnosis and Management of Gestational Trophoblastic Diseases, November 2016
Lurain JR, AJOG, 2010
 INDICATIONS TO CHEMOPROPHYLAXIS

● Age ≥ 40 y.o
● Uterine size ≥6 weeks larger than AOG
● Theca Lutein Cysts ≥ 6cm
● Medical Complications
● Recurrent Mole
● Serum bHCG ≥ 100,000 mIU/I
● Poor Follow-up

Level I, Grade B
Clinical Practice Guidelines for the Diagnosis and Management of Gestational Trophoblastic Diseases, November 2016
CONTRAINDICATION TO CHEMOPROPHYLAXIS

● Hemoglobin < 100mg/dl, hematocrit <0.30

● WBC count < 3 x 109
● Absolute neutrophil count (ANC) < 1.5
● Platelet count <100
● Any active infection
● Presence of liver or renal dysfunction

Clinical Practice Guidelines for the Diagnosis and Management of Gestational Trophoblastic Diseases, November 2016
 SURVEILLANCE
● Serum beta-hCG level is measured 1 week after molar evacuation then
every 2 weeks until level becomes normal (< 5 mIU/mL)

● After 2 consecutive biweekly normal levels, beta-hCG monitoring is done

every month for 6 months

● As per the June 2020 PSSTD Guidelines, laboratory results may be

discussed via telemedicine and patients should be advised to monitor
symptoms such as bleeding, severe hypogastric pain or signs of malignant
degeneration

Clinical Practice Guidelines for the Diagnosis and Management of Gestational Trophoblastic Diseases, November 2016
Clinical Practice Guidelines for the Diagnosis and Management of Gestational Trophoblastic Diseases, November 2016
Williams Obstetrics 26th edition
Thank you