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Vesicular Mole

Vesicular Mole. Dr. Sally Mary Abraham Professor. It is a benign neoplasm of the chorionic villi with malignant. Incidence. 1:2000 pregnancies in United States and Europe 1:200 in Asia 1:400 in India. 1 in 80 Philippines.

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Vesicular Mole

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  1. Vesicular Mole Dr. Sally Mary Abraham Professor

  2. It is a benign neoplasm of the chorionic villi with malignant

  3. Incidence • 1:2000 pregnancies in United States and Europe • 1:200 in Asia 1:400 in India. • 1 in 80 Philippines. • The increasing use of ultrasound in early pregnancy has probably led to the earlier diagnosis of molar pregnancy

  4. ETIOLOGY • Maternal age : Teenage &age above 35 • Women who have had a previous molar gestation • Race &ethnic origin • Immune mechanism- Women with blood type A B may be more likely to develop hydatidiform mole • Faulty nutrition- lack of protein , dietary carotene. • Cytogenetic abnormality

  5. What Is A Hydatidiform Mole? A hydatidiform mole is an abnormality of fertilization

  6. Differentiation Between Complete And Partial Mole

  7. Pathology • There is trophoblastic proliferation, with mitotic activity affecting both syncytial and cytotrophoblastic layers. This causes excessive secretion of hCG,chorionic thyrotrophin and progesterone. • microscopic evaluation shows trophoblastic hyperplasia

  8. Pathology • (hydropic) villi The uterus is distended by thin walled, translucent, grape-like vesicles of different sizes. • Uniformly edematous (hydropic) villi with dissolution of central stroma (cavitation/ciste

  9. Pathology • There is no vasculature in the chorionic villi leads to early death and absorption of the embryo.

  10. Pathology • High hCG causes: • multiple theca lutein cysts in the ovaries in about 50% of cases. • exaggeration of the normal early pregnancy symptoms and signs

  11. Pathology • Uniformly edematous (hydropic) villi with dissolution of central stroma (cavitation/cistern) • Villous vessels absent (usually) • Trophoblastic hyperplasia – circumferential, haphazard. • Trophoblasticatypia

  12. CLINICAL FEATURES - Teenage pregnancy - More than 35 years multipara - Hypermesisgravidarum - Sick looking - Thyrotoxic features – tremors and tachycardia – 2% - Breathlessness – pulmonary embolism of trophoblastic cells – 2%

  13. - Vaginal bleeding – 90% - Abdominal pain - Passage of grape like vesicles -50%-diagnostic - Uterine size more than period of amenorrhoea - Early onset of pre-eclmpsia - Features of hyper thyrodism - Absent fetus

  14. D/D : The following conditions are often confused with molar pregnancy. • Threatened abortion • Fibroid or ovarian tumour in pregnancy • Multiple pregnancy • Serum β HCG and USG is diagnostic

  15. Complications of molar pregnancy : Immediate • Haemorrhage and shock • Sepsis • Perforation of uterus • Preeclampsia and eclampsia – rarely • Acute pulmonary insufficiency • Coagulation failure (DIC) • Development of choriocarcinoma 2 to 10%

  16. Risk factor for malignant change : • Age - >40 or <20yrs irrespective of parity • Serum β HCG >1 lakh miu/ml • Size of uterus > 20 weeks • Previous history of molar pregnancy • Theca lutein cyst – large (>6 cmts.)

  17. PROGNOSIS : • 15 to 20% of complete mole progress to persistent GTD • Metastastic disease in 5% • Recurrence of hydatidiform mole is subsequent pregnancy 1 to 4% (Chances of foetal malformation is not increased in pregnancies following chemotherapy)

  18. Management Investigation • Blood group Rh • LFT • TFT • RFT • PIH Profile • USG – classical snow storm appearance • Quantitative estimation of chorionic gonadotrophin high HCG titre in urine diluted upto 1 to 200 to 1 in 500 dilution +ve. • Rapidly increasing serum β HCG > 1 lakh miu/ml

  19. Chest x-ray – • to rule out lung metastases (choriocarinoma) • to rule out pulmonary embolism even in benign mole • HPE of products on conception is a must to rule out choriocarcinoma

  20. Management • With use of USG and sensitive HCG testing diagnosis is made early in majority of the cases. Principles in the management : • Suction evacuation of the uterus as early as possible. • Supportive therapy – correction of anemia and infection. • Counselling for regular follow up.

  21. Management of molar pregnancy • Group A – mole in the process of expulsion less common. Treatment – Suction evacuation under G.A. or sedation : • Under close observation • 500ml R.L. with 10 units oxytocin drip • After evacuation if BP is normal .2mg methergine IM given

  22. Group B – uterus is enert cervix is tubular and closed • Treatment – prior slow dilatation of cervix with PGE 400mg (misoprostol) 3 hrs. before suction evacuation.

  23. Complications during evacuation : Haemorrhage and shock injury to uterus + 2 rare but fetal complications • Pulmonary embolism – acute pulmonary insufficiency • Symptoms of acute chest pain, tachycardia tachypnoea may develop with in 4 to 6hrs. Following evacuation. • Thyroid storm – is presence of hyperthyroid state when evacuation is done decrease G.A. the acute features such as hyperthermia, delirium, convulsions coma and CVS collapse Rx with B blockers.

  24. Hysterectomy is indicated in – • Patients age >35yrs. • Completed her family • Uncontrolled bleeding or perforation during surgical evacuation • Theca leutin cysts of ovary should be left undisturbed as they will regress following removal of mole within 2 months. • Uterus sent for HPE Note : GTD observed in 3 to 5% cases even after hysterectomy and so follow up is necessary.

  25. Rh-negative non-immunised patient – Anti D to be given following evacuation of mole. • Routine curettage following evacuation of mole not recommended

  26. FOLLOW UP PROTOCOL – UP TO 1 YEAR HCG ASSAY • Initial every week till serum B HCG becomes negative (4-8 weeks) • Once negative monthly x 6 months • Women who undergo chemotherapy follow up for 1 year after HCG has become normal. • No pregnancy during the period of follow up.

  27. FOLLOW UP PROTOCOL INCLUDES – • History – irregular bleeding P/V persistent cough, breathlessness & haemoptysis nausea vomiting. • Abdominal pelvic examination to note • Involution of uterus. • Ovarian size • Anterior vaginal wall deposits (suburethral nodule)

  28. Investigation : • HCG assays – initially urine pregnancy test once negative to serum β HCG till neg. • Chest X-ray – when preevacuation chest x-ray is normal, it is repeated only when HCG titres rises or plateaus. • If preevacuation chest x-ray shows metastasis – repeat at 4 weeks interval post chemotherapy until remission is confirmed.

  29. Prophylactic chemotherapy : • 80% patients undergo spontaneous remission Indications : • HCG fails to come to normal (in 10-12 weeks) • HCG plateaus or rises • Rising HCG after reaching normal levels • Recurrence of bleeding P/V or persistence of post-evacuation bleeding P/V – provided you are sure that the 1st time evacuation was complete. • Cases where malignant sequelae was high and poor patient compliance for follow up.

  30. REGIMEN OF PROPHYLACTIC CHEMOTHERAPY : • Methotrexate – 1mg/kg/day IV or IM one day 1,3,5,7, with • Folinic acid – 1 mg/kg/day IM one day 2,4,6,8 • Repeated every 7 days for 3 courses. • Serum B HCG should decrease by a least 15% by 4 to 7 days after methotrexate Alternatively • IV actinomycin D 12mg/kg/daily x 5 days • Less toxic

  31. Contraception : • Traditionally patient advised not to be pregnant for at least 1 year. But if she so desires she may become pregnant 6 months following negative HCG titre. • Pregnancy delayed for 1 year for GTN • For 2 years if there is metastases

  32. Use of contraception : • IUD is contraindicated because of irregular bleeding P/V • Barrier method • DMPA • Combined O.C. pills after HCG has come to normal • Surgical sterilization if she has completed family. • Serum B HCG checked 3 weeks after the end of any pregnancy, subsequent to a molar one.

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