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General Consideration
• Definition
proliferation abnormalities originating from trophoblast tissue of the placenta
• Classification :
benign (hydatidiform mole)
Malignant ( invasive mole, choriocarcinoma)
Hydatidiform mole
• Abnormal proliferation of placental trophoblastic cells tends to invade myometrium( villi) more than placenta
1. Complete mole 46 xx ( problem at time of conception)
2. Partial mole triploidy 69xxy (70%)or 69xyy(30%)
Morphology of complete mole
• Numerous odematous vesicle appear as bunch of small clear grape
no fetal tissue
• Risk of progress to persistant GTT 20%
Morphology of partial mole
• There is fetal & placental tissue ( pregnancy
is complicated by hypertension & IUGR)
Epidermiology of molar preg
• Geographical: asian
• Diet ( low protein, folic acid , carotane ),
low socioeconomic:
• Maternal age: (14-16years) , ( 40years )
• Blood group A married group O man
• Previous molar pregnancy ( 0.5-2%)
Manifestation
• 1. Clinical presentation
• Because of more proliferative activity so more
exaggeration of signs &symptoms
• . Vaginal bleeding &anaemia : 90%
• Anemia is due to bleeding ( IDA), folic acid
deficiency from( poor intake ,increase requirement
to folic acid )
• Hyperemsis gravidrum :25%, related to high
level of HCG
• Pre-eclampsia : before 24 weeks
• Thyroid dysfunction:2% ,molar preg.
Associated with high thyroxine
• Embolism: trophoblast tiss. Escape from
uterus through venous outflow lead to emboli
• DIC: emboli of troph. Tissue release
thromboplastin to circulation &stimulate
fibrin & PLT deposition ( coagulation
failure)
• 2. Abdominal examination
• A. uterine enlargement (large for date
uterus),doughy in consistancy ( no amniotic
fluid), no palpable fetal part or FH.
• B. Bilateral ovarian cyst( theca lutein cyst):
25-60% , prolong high level of HCG
stimulate ovaries. they regress after
evacuation of mole
• Diagnosis.
• U/S : echo of vesicle ( snow storm )
• Quantative measurement of HCG
treatment
• Aim: Elimination of all trophoblastic tissue
1. Proper preparation of patient prior evacuation by full investigation & chest x- ray
• Evacuation:
1. Suction curettage ( vacuum -60 mm) & send mat. For histopathology
2. uterine stimulate ( pGE2, oxytocin)
3. Hysterectomy , if patient 40 years& complete her family.
• Follow up:
• 1. serial quanatative HCG: ( 48 hr. &then
every 1 wk ) complete elimination 8-10 wk ,
until 3 consecutive weeks are normal then do
monthly for 6 month ( partial) & for 1 year to
complete mole.
• 2. pelvic examination: monthly
• To rule out any vaginal or vulval metastasis
• Size of uterus ,presence ovarian cysts &size
• 3. contraception: for at least 1 year ,barrier
method is the best, medroxy progesterone
inj. , low dose estrogen occp ( E = 30 micro
g).
• 4- chemotherapy: indication
• Raised HCG level 6 months after
evacuation
• HCG plateau in 3 consecutive serum
sample
o HCG more than 20.000 IU after 4 weeks
after evacuation
o Rising HCG in 2 consecutive serum sample
o Heavy vaginal bleeding or GI, intraperitonal
bleeding
o Pulmonary, vulval or vaginal metastasis
unless HCG level is falling
• Brain, liver, GI metastasis or lung
metastasis more than 2 cm on cxR
• Histological evidence of choriocarcinoma
• Complication of molar pregnancy
• Immediate
• Massive bleeding
• Sepsis
• Severe PE
• Remote ( metastasis & malignant 20% of
complete mole develop to persistant GTT
&4% partial)
• Persistant gestational trophoblastic
disease
• Non metastatic (invasive mole) 15% after
molar preg.
• Metastatic (distant) 5%
• Incidence& epidemiology :
• geographical:asia
• Age : in old is more
• Parity: in high parity
• Socioeconomic : in low
• Antecedent preg,: molar 50%, abortion
25%,normal term preg 25%.
• Maternal blood gr: gr.A high
• Clinical features:
• Vaginal bleeding
• Amenorrhea: producing HCG from distant
tumour metastasis
• Vaginal nodule or abdominal swelling
• Pulmonary metastasis;( dyspnea,
hemoptysis)
Staging: no. of factors influence
prognosis of persistant GTT
• Level of HCG: if it is high 100.000IU before Rx
means worse prognosis
• Metastasis: site (brain, liver) , number, size of
largest mass
• Antecedent preg: term preg is worse
• Preg/ Rx interval : prolong interval (4 months)
bad prognosis
• Previous unsuccessful chemo therapy : bad
( drug resistant , accumlating drug toxicity
Age : more than 40 yr ( bad)
Parity : high parity ( bad)
Each of the following prognostic factor is given
score ranging from ( 0-4 )
4 2 1 0 score - - more than
40
Less
than40
age
- Term abortion mole Antec
edent
preg Brain
liver
GIT Spleen
kidney
lung Site of
metastasi
s
More than
8
5-8 1-4 number
According to this score we
divide patients to
• Low risk patient :score less than or equal 6
• High risk patient : score more than or
equal 7
• Treatment:
• Chemotherapy
• Surgical
• Follow up
Low risk patients_ survival rate
100% • Methotrexate( drug of choice) bec.
Simplicity& low toxicity ( available
antidote)
• Before give chemotherapy : we should send
pat .to full Ix CBC ( WBC,PLT,Hb) LFT,
RFT ,CXR.
• It is given parentally IM/ IV
• Excreted in urine , contraindication renal
failure
methotrexate
• Methotrexate is given in alternative day
with folinic acid
• During period of therapy ,we should
montering HCG ( 2t/wk) ,WBC/ daily, ( less
than 1000 stop it), PLT/ daily ( less than
50.000 stop it)
Toxicity of methotrexate
• Mylo suppression( thrombo- cytopnea,
granulocytopnea)
• Mucus membrane inflammation( stomatitis,
conjuctivitis, vaginitis)
• Skin rash
• Nephrotoxicity
• heptotoxicity
methotrexate • After 8 days coarse of chemtherapy , 1
week rest & then 2nd coarse of Rx
• We need 2-4 courses to reach undetected
level of HCG
• 2-3 extra courses of treatment is needed (
bec. Approx. 100.000 of trophoblastic cell
may escape & undetected by HCG).
• Actinomycin (I.m for 5 days)
High risk patient/ EMA/CO chem
• D1( etoposide, methotrexate, actinomycin)
• D2( etoposide , folinic acid, actinomycin)
• 2nd wk ( D8) vincristine / cyclophosphamide
Surgical treatment
• Uterine perforation by invasive mole
• Uncontrol uterine bleeding
• Drug resistance focus ( HCG is high un
stead of chemotherapy or focal lesion
increase or plateau in size)
• Age is more than 40 years & complete her
family
Follow up
• Aim: to detect remission or relapse
• Monthly HCG in first year. Then yearly in
the next 5 years.