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MOLAR PREGNANCY

INTRODUCTION
INCIDENCE
EPIDEMIOLOGY
PATHOLOGY
CLINICAL PRESENTION
INVESTIGATIONS
TREATMENT
INTRODUCTION
An abn pregnancy xterized grossly by multiple
grapelike vesicles filling & distending the
uterus, usually in the absence of an intact fetus
Belong to the spectrum of diseases called GTD
(include: invasive mole, placental-site
trophoblastic tumor, chorioCA)
Most common GTD
Derived from extraembryonic trophoblast (arise
in fetal rather than maternal tissues)
2 types: complete & partial moles (3:1)
EPIDEMIOLOGY OF THE DISEASE
Incidence varies worldwide.
Common in West Africa (highest in Yorubas) &
Asia. Less common in Europe & America.
• In US 1in 1500 pregnancies
• African 1in 800 “
• In our environment – combined GTD incidences
(Hospital based figures:
• UPTH 1:707 deliveries (Annual report 2003)
• UCH 1:667 deliveries
• LUTH 1:184 deliveries
Risk factors
Racial –more commom in Orients, blacks >
Caucasians
ABO group: FxM (10x commoner in OXA > AXA)
Age: < 20 and >40yrs
Consanguinous marriages
Previous molar pregnancy (2% after one, 25% after
two)
Previous spontanous abortion (2-3x after one abortion
> nil)
Multiparity
Low social class
Diet – low protein, folic acid and vitamin A
Etiology (cytogenetics)
Due to Abnormality in fertilization.
– Complete mole (diploid Xsomal structure 46XX or
46XY)
• Unispermic Fertilization: One sperm fertilizing an empty
ovum
• Dispermic: Two sperms fertilizing an empty ovum
– Partial mole (triploid Xsomal structure 69XXX or
69XXY)
Unispermic: A sperm duplicating in a normal ovum and
fertilizing it
Diandry: Two sperms fertilizing a normal ovum
Pathology
Complete Mole:
- Marked edema of chorionic villi (hydropic villi)
- Diffused trophoblastic hyperplasia
- No fetal parts / vessels
- Karyotype is diploid DNA all of male origin
- Risk of malignant transformation 15-20%
Partial Mole
- The pathology is characterized by focal villous
Hydrops and trophoblastic hyperplasia
- There are villous stroma vessels and fetal parts
- The Kryotype is triploid with extra haploid DNA of
paternal origin
- The fetus in most cases have multiple abnormalities
and die. Early first trimester abortion
- Partial moles rarely develop to malignancy
Clinical Presentation
History:
– Amenorrhea
– Vaginal bleeding which may be painless, irregular and heavy
– Passage of vesicles
– Excessive nausia & vomiting (hyperemesis gravidarium)
Examination will reveal:
– Signs of anaemia
– Signs of Thyrotoxicosis
– Signs of PET (in 1st trimester)
– Abdomen may show uterus >date by 80%, < date by 25%,
= date by 25%
– Absent fetal parts / fetal tones
Pelvic exam:
– Some vesicles may be seen at vulva
– Uterus feels boggy
– No fetal parts
– Adnexal mass palpable (Theca luteal cyst)
Investigations:
– Urgent PCV estimation or FBC
– Blood for grouping & Xmatching
– Serum / Urinary Beta HCG estimation
(Radioimmunoassay, Pregnancy test in serial
dilution). Levels > 100 000 mIU/ml
– Pelvic Ultrasound Scan showing snow storm
appearance of vesicles
Complications
Anaemia
Hyperemesis gravidarium
PET
Thyrotoxicosis
DIC
Rupture and Torsion of theca luteal cyst.
Perforation of uterus
Sepsis
Malignant change
TREATMENT
– Wide bore canula with crystalloid infusion in-situ
– 2 – 4 pints of blood grouped and crossed matched
– Suction Evacuation in theatre under GA or TIVA
– Start suction curettage to half way then run the
oxytocin drip to contract the uterus (20-40u)
– Continue Evacuation until gritty sensation felt
– Then give ergometrine, Antibiotics
– Send all specimen to histology
– Transfuse blood as necessary
– Repeat pelvic scan to confirm complete evacuation
– Repeat B-hCG assay 1 wk post evacuation
– Contraceptive Advice (COC, barrier, progestogens)
FOLLOW UP
– HCG in urine or blood is expected to fall to
undetectable levels within 8-12 weeks
– Scheme I: Serum B-hCG assay 1wkly until
undetectable for 3 consecutive wks & monthly until
undetectable for 6 consecutive months
– Scheme 2: Urinary B-hCG assay 2wkly until
undetectable & monthly until undetectable for 6
consecutive months
– Scheme 3: Serum B-hCG assay 2wkly until
undectable & urine assay monthly until
undetectable for 6 consecutive months
– History, general examination
– Pelvic exam (Vaginal bleeding, Size of uterus and
Atfer discharge from ff-up program, in subsequent
pregnancies b/c of risk of recurrence, do USScan R/O
Mole

INDICATIONS FOR CHEMOTHERAPY


– Serum Beta HCG > 20,000 IU/L or urinary Beta HCG >
30,000 IU/day 4 weeks post evacuation
– Rising level of Beta HCG anytime post evacuation
– Positive B- hCG level 6months post evacuation
– Evidence of metastasis to lungs, vagina, brain, liver and GIT
– Persistent/irregular vaginal bleeding post evacuation with
positive B-hCG levels
– ChorioCA on histology
Normal fetus and molar pregnancy
– Counsel patient on risk of fetal congenital
malformation & fetal outcome
– Allow pregnancy to continue provided there are no
severe maternal complications
– Terminate pregnancy if not wanted.
– Commence suction evacuation after delivery and
follow up