Vesicular Mole

Question 1

What is the clinical classification of gestational trophoblastic diseases (GTD)?

Answer 1

Benign
- vesicular mole: Hydatidiform mole (partial or complete)

Malignant
- invasive mole
- choriocarcinoma

Question 2

What is the difference between the karyotype of a complete & partial mole?

Answer 2

COMPLETE
- 46-XX: entirely paternal in origin due to haploid sperm fertilizing anucleated or inactivated ovum
- 46-XY: paternal in origin with dispermatic fertilization
- no fetal tissue or blood vessels
- bilateral theca-lutein cysts

PARTIAL
one maternal & 2 paternal haploid complements
- 69-XXX
- 69-XXY
- 69-XYY
- some fetal tissue or amniotic sac
- only part of the placenta is affected

Question 3

Which type of vesicular mole has a risk of malignancy?

Answer 3

Complete hydatidiform mole has a 20% risk
- 15% locally invasive
- 5% metastatic choriocarcinoma

Question 4

What are theca-lutein cysts & what is their cause?

Answer 4

25-60% of complete mole -> bilateral theca lutein cysts in ovaries
- smooth yellowish, lined with lutein cells
- caused by large amounts of B-hCG secreted by the proliferating trophoblasts -> ovarian hyperstimulation

Question 5

What are the complications of theca-lutein cysts?

Answer 5

very large cysts undergo
- infarction
- torsion
- hemorrhage

OR regress spontaneously within 2-4 months after molar evacuation

Question 6

What is the prognosis of partial vesicular mole?

Answer 6

4 - 8 % progress to locally invasive non metastatic trophoblastic tumors

Question 7

What are the risk factors for vesicular moles?

Answer 7

1- women in east asia
2- low dietary intake of carotene (Vitamin A deficiency)
3- maternal age <20 & >40
4- previous mole: recurrence 1-2%

Question 8

What is the pathogenesis of moles?

Answer 8

1- excess trophoblastic proliferation
2- excess hCG, chorionic thyrotropin, & progesterone
3- avascularity of villi
5- hydropic degeneration
6- formation of grape like vesicles
7- early death & absorption of the embryo

Question 9

What is the clinical picture of a complete hydatidiform mole?

Answer 9

• amenorrhea (8-12 weeks)
• vaginal bleeding (PAINLESS) -> anemia
• prune juice discharge
• spontaneous expulsion of hydatid vesicles resembling grapes
• hyperemesis gravidarum
• trophoblastic embolization -> dyspnea, chest pain, tachypnea, severe respiratory distress

Question 10

What is found in general examination of patient with suspected complete mole?

Answer 10

• signs of pregnancy
• signs of anemia
• signs of pre-eclampsia: hypertension & edema
• hyperthyroidism: tachycardia, warm skin, tremors

Question 11

What is found in abdominal examination of patient with suspected complete mole?

Answer 11

• large to date uterus in 50%
• uterus is doughy (due to absent amniotic fluid)
• absence of fetal parts & fetal heart sounds
• no external ballotement

Question 12

What is found in pelvic examination of patient with suspected complete mole?

Answer 12

• cystic ovaries in 25-600% of cases due to theca-lutein cysts
• discharge of vesicles
• no internal ballotement

Question 13

What is found in general examination of patient with suspected partial mole?

Answer 13

like incomplete or missed abortion
diagnosis only made after histopathological review of curettage biopsy

Question 14

What are the complications of vesicular moles?

Answer 14

• bleeding
• perforation of uterus: in invasive
• infection (absent membranes)
• invasive mole or choriocarcinoma
• pre-eclampsia & eclampsia (high hCG)
• hyperthyroidism: excess TSH -> heart failure
• recurrence

Question 15

What investigations should be preformed to diagnose vesicular moles?

Answer 15

1- urine pregnancy test: 1/500 diagnostic
2- serum B-hCG: higher than expected (>100 000 in complete)
3- Ultrasound: snow-storm appearance, honey-comb appearance, theca-lutein, anechoic cystic spaces
- multiple cystic spaces in placenta + fetus -> partial mole
4- x-ray abdomen: no fetal skeleton
5- x-ray chest: to exclude canon-ball metastasis

Question 16

How are molar pregnancies managed?

Answer 16

as soon as diagnosis is made -> evacuate uterus
1- cross match blood
2- suction curettage: oxytocin infusion -> dilation of cervix -> suction -> sharp curettage to remove residual molar tissue
3- send all tissue to histopathology

4- hysterotomy:
- incase of severe bleeding with closed cervix
- uterus is > 16 weeks & suction is not available

5- hysterectomy: if patient desires sterilization & over 40

Question 17

What are the complications of suction curettage?

Answer 17

• profuse bleeding
• perforation of uterus because its soft
• incomplete evacuation
• thyroid storm
• acute respiratory distress syndrome

Question 18

What are the indications for prophylactic chemotherapy?

Answer 18

• hCG > 100 000 mlU/ml
• excessive uterine enlargement >24 weeks
• theca lutein cysts > 6cm in diameter

Question 19

How many times should patients follow up after evacuation of molar pregnancies?

Answer 19

1- weekly until B-hCG is very low for 3 consecutive weeks
2- monthly until B-hCG is normal for 6 consecutive months
3- every 2 months for a total of 1 year

if B-hCG plateauted, rising, elevated after disappearing, or do not return to undetectable levels by 12 weeks of evacuation -> metastatic work up & contraception

Question 20

What method of contraception should be used?

Answer 20

combined oral pill only after B-hCG becomes negative
- it slows down its decrease