Molar Pregnancy

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