MOLAR PREGNANCY November 2018

JIs Dungca, Delos Santos,

Crisostomo
 GENERAL DATA
• 19 years old
• Gravida 2 Para 1 (1-0-0-1)
• Single
• Filipino
• Roman Catholic
• Manila
• Admitted for the 1st time at OMMC last October 21,
2018
 CHIEF COMPLAINT

Vaginal Bleeding of
10 days duration
 HISTORY OF PRESENT PREGNANCY
LMP: July 29, 2018
PMP: June 29, 2018
AOG: 12 weeks
EDC: May 5, 2019
 1 ST TRIMESTER
• (+) Cessation of menses ( August to September)
• Pregnancy tests
• First (June) : Negative
• Second (July) : Negative
• (-) spotting
• (+) Nausea and vomiting
• (-) Fever, cough, colds
• No medications taken or prenatal check up done
 HISTORY OF PRESENT PREGNANCY
• 10 days PTC
• (+) first episode of vaginal bleeding ( using 1 per day
per day moderately soaked)
• (+) Nausea/vomiting
• (+) Occasional hypogastric pain
• (-) Medications taken/Consultation done
HISTORY OF PRESENT PREGNANCY
On the interim, there is persistence of vaginal
bleeding however there were no consult done
and medications taken up until
 HISTORY OF PRESENT PREGNANCY
• 3 hours PTC,
• (+) Profuse vaginal bleeding using 4-6 pads fully
soaked with passage of vesicular tissue “sago- sago”
on her napkin
• (+) hypogastric pain (7-8/10)
•No fever
•No dizziness
• Consultation at OMMC and eventually was admitted
 PAST MEDICAL HISTORY
• Immunization history – unrecalled
• No childhood illness
• No PTB, HPN, DM, BA, Goiter
• No allergy to foods or drugs
• No cancer
• No previous hospitalization
• No previous surgery done
 FAMILY MEDICAL HISTORY
• (+) Hypertension (maternal)
• (-) Cerebrovascular disease
• (-) Diabetes Mellitus
• (-) Bronchial Asthma
• (-) Cervical cancer
• (-) Goiter
• (-) Pulmonary Tuberculosis
 PERSONAL SOCIAL HISTORY
• Nonsmoker
• Nonalcoholic beverage drinker
• Denies illicit drug use
• High school undergraduate
• Saleslady
 GYNECOLOGIC HISTORY
A.
• Menarche: 14 years old
MENSTRUAL HISTORY
• Interval : Regular
• Days : lasted for 4 days
• Amount: Consumed 5 pads per day, moderately soaked
• Symptoms: no dysmenorrhea

Subsequent menses:
 Interval: Regular (30 days)
 Days: Lasting for 3-4 days
 Amount: 3- 5 pads/day, moderately soaked
 Symptoms : No dysmenorrhea
 GYNECOLOGIC HISTORY
B. SEXUAL HISTORY
• Age of 1st coitus: 16 years old
• # of Sexual Partner: 1
• (-) OCP use
• (-) PCB
• (-) Dyspareunia
 GYNECOLOGIC HISTORY
C. OB HISTORY
GRAVIDA YEAR SEX OUTCOME PROCEDURE PLACE OF FMC BIRTHWEIGHT
DELIVERY

1 2017 F FT NSD Batangas (-) 3.0 kgs

Medical
Center
2 2018 PRESENT PREGNANCY
 REVIEW OF SYSTEMS
• General: no weight loss
• HEENT: no headache, no blurring of vision, no tinnitus
• Respiratory: no cough, no colds,
• Cardiovascular: no palpitations, no orthopnea, no easy fatigability
• Abdominal: no change in bowel movement, no melena
• Genitourinary Tract: no dysuria, no hematuria, no incontinence
• Endocrinologic: no polydypsia, no polyphagia, no polyuria
• Hematologic: no easy bruising, no prolonged bleeding, no cyanosis
 PHYSICAL EXAMINATION

General: Conscious, coherent, ambulatory, not

in cardiorespiratory distress

Vital signs
BP: 110/80 mmHg
HR: 88 beats/min
RR: 17 cycles/min
Temp: 36.4 oC
 PHYSICAL EXAMINATION
HEENT: Anicteric sclerae, pink palpebral conjunctiva, no nasoaural
discharge, no tonsillopharyngeal congestion
Neck: No cervical lymphadenopathy, no palpable mass
Breast: Symmetric, No skin discoloration, No discharge,
Nontender, no mass
Heart: Adynamic Precordium, Normal rate, Regular rhythm, no
murmurs
Chest and Lungs: Symmetric chest expansion, no retractions,
clear breath sounds
Abdomen: Soft, non-tender, no appreciable FHT
o Leopold’s Maneuver: None palpated
Extremities:
Grossly normal, with full and equal pulses, no edema, no cyanosis
 PELVIC EXAMINATION

• Inspection:
• Grossly normal external genitalia
• Speculum Exam
• Cervix violaceous, open with vesicular tissue fragment
plugging at the OS and with moderate bleeding per OS
• Internal Examination:
•parous introitus admits two fingers with ease, cervix soft,
with vesicular tissue from the OS, Uterus enlarged to 18
weeks size, no adnexal mass, no adnexal tenderness
 ASSESSMENT
19 years old
Gravida 2 Para 1 (1-0-0-1), Molar pregnancy,
12 weeks AOG
PLAN
For suction curettage
For serial beta HCG monitoring
For work- up
For chemotherapy
PLAN
Admit the patient
NPO temporarily
IVF: PNSS IL x KVO
Diagnostics:
 For baseline serum beta hcg
 For work- up (BUN, CREA, AST, ALT, CHEST XRAY, thyroid function test)
Medications: None
To secure and transfuse 2 units of packed RBC properly typed and crossmatched, Please hook the first
unit of blood prior to suction curettage
Book to anesthesia for suction curettage
Watch out for profuse bleeding, signs of hypotension, severe abdominal pain
VSq1
For serial beta hcg monitoring thereafter
LABORATORY RESULT (CBC) (OCTOBER 21,
2018)

WBC 9.0 5.2-12.4 MCV 13 80-99

Neutrop
86.7 40-74 MCH 36.7 27-31
hils
Monocyt
4.6 3-15% MCHC 30.5 33-37
es
Lympho
8.7 19-48 % PLT 183 150-450
cytes
Hgb 10.4 12-18
Hct 31.2 33-52
LABORATORY RESULT (URINALYSIS) (OCTOBER 21,
2018)
PHYSICAL CHEMICAL
Color Yellow Albumin Negative
Transparency Clear Sugar Negative
MICROSCOPIC Specific gravity 1.030
Epithelial cells Few pH 6.0
Mucus Threads Few MICROSCOPIC
Amorphous Urates Few Bacteria Few
Amorphous
Calcium Oxalate
Phosphates
WBC 0-1 Uric acid
RBC 0-2 Yeast Cells
 BLOOD TYPING
Blood Type: A+
 DILUTED ΒHCG
(OCTOBER 21,18)
Result Reference Range
458,000 mIU/mL Cyclic = <4
Menopause = <13
 LABORATORIES
October 21, 2018 RESULT

BUN 3.07 Normal

CREATININE 72.6 Nornal

ALT 15.6 Normal

AST 21.0 Normal

CXRAY Normal chest findings

 CLINICAL CHEMISTRY

TEST RESULT REFERENCE RANGE

Na 136 mmol/L 135.0-145.0
K 3.8 mmol/L 3.4-5.0
Cl 105.1 mmol/L 93.0-109.0
 TEST Result
FT3 2.05 (Normal)
FT4 1.09 (Normal)
TSH 0.16 (Normal)
 CLOTTING TIME/ BLEEDING TIME
Clotting time = 3 minutes and 30 seconds (normal)
Bleeding time = 1 minute (normal)
PT =15.1 (normal)
99 % activity
APTT= 30.3 (normal)
INR= 1.15
 CHEST X-RAY
Radiologic Report: Normal Chest Findings
OPERATIVE TECHNIQUE
Patient is placed in a supine position
Povidone iodine scrub and antiseptic used for the vaginal and perineal skin preparation
Sterile drapes placed
Bladder drained aseptically
Pelvic examination under anesthesia done
Posterior vaginal retractor applied
Cervix visualized
Anterior lip of the cervix grasped with tenaculum forceps
Evacuation of uterine contents by suction curettage approximately 2 cups of vesicular tissue admixed with tissues and blood clots
Proceeded with careful blunt curettage followed by sharp curettage
Final Hysterometry is 10 cm
Removal of insturments in succession
Hemostasis observed
Antisepsis
Internal examination done
Drapes removed
Patient tolerated the procedure well
Estimated blood loss of 1200cc
 POST OPERATIVE ORDERS
o S/P Suction Curettage
o To RR now then to OB wards once stable
o NPO
o IVF: D5LR 1L + 10 units oxytocin to run for 8 hrs then
consume
o Continue blood transfusion
o For post BT CBC with PC 6 hours after transfusion of blood
o For repeat serum beta HCG
 POST OPERATIVE ORDERS
o Medications:
oCo-Amoxiclav 625 mg Q8 x 7 days
oMultivitamins tablet OD
oFerrous Sulfate tablet OD
oMefenamic Acid 500 mg Q6 x PRN
o Daily body and perineal hygiene
o VSq15 on the 1st hour, then VSq1
o Refer
 FINAL DIAGNOSIS
19 years old
Gravida 2 Para1(1-0-1-1) Molar Pregnancy 12 weeks
AOG
S/P suction curettage (OMMC 2018)
 1 ST POST-CURETTAGE DAY
(OCTOBER 22,2018)
S O A P

(-) fever Vital Signs: Gravida 2 Para 1 (1-0-1-1) • Diet as tolerated, increase oral fluid
(-) Difficulty of 110/70 mmHg, Molar Pregnancy 12 weeks intake
breathing Heart Rate 73 bpm AOG by LMP • Labs: follow up repeat serum beta
(-) Chest pain Respiratory Rate 16 cpm S/P Suction Curettage hcg post suction curettage
Freely voiding Temperature 36.3° (OMMC, 2018) • For referral to Trophoblastic disease
(-) Profuse 98% specialist
vaginal • Meds:
bleeding Anicteric Sclerae • Co-Amoxiclav 625 mg Q8 x 7 days;
Pink palpebral conjunctiva • Multivitamins tablet OD,
Clear breath sounds • Ferrous Sulfate BID,
• Mefenamic acid 500 mg Q6 x PRN
Repeat CBC • Daily body and perineal hygiene
Hgb: 10.9 • VSq1
Hct 24.8% • Refer
Neutrophils: 84.3
WBC: 10.3
 2 ND POST-CURETTAGE DAY
(OCTOBER 23,2018)
S O A P
(-) fever Vital Signs: Gravida 2 Para • Diet as tolerated, increase oral fluid intake
(-) Difficulty of 110/70 mmHg, • Labs: for repeat serum βhCG – 1 week post
1 (1-0-1-1) evacuation (10/28/18)
breathing Heart Rate 73 bpm
(-) Chest pain Respiratory Rate 16 cpm
Molar Pregnancy • Meds:
12 weeks AOG • Methotrexate 0.7 ml TIM OD x 5 doses,
Freely voiding Temperature 36.3°
• NAHCO3 625 mg TID,
(-) Profuse 98% by LMP • Leucovorin 0.6mL PRN for methotrexate
vaginal bleeding S/P Suction toxicity,
Anicteric Sclerae Curettage • Co-Amoxiclav 625 mg Q8 x 7 days,
Pink palpebral conjunctiva Multivitamins OD,
Clear breath sounds
(OMMC, 2018) • Ferrous Sulfate BID,
• Mefenamic acid 500 mg Q6 x PRN
βhCG = 108827.48 mIU/mL • Daily body and perineal hygiene
• VSq4
• WOF for mouth sores, fever
• Advise to wear mask all the time
• Avoid sun exposure
• Refer
 3RD POST-CURETTAGE DAY
(OCTOBER 24,2018)
S O A P
(-) fever Vital Signs: Gravida 2 Para • Diet as tolerated, increase oral fluid intake
(-) Difficulty of 110/70 mmHg, • Labs: for repeat serum βhCG – 1 week post
1 (1-0-1-1) evacuation (10/28/18)
breathing Heart Rate 73 bpm
(-) Chest pain Respiratory Rate 16 cpm
Molar Pregnancy • Meds:
12 weeks AOG • Methotrexate 0.7 ml TIM OD x 5 doses,
Freely voiding Temperature 36.3°
• NAHCO3 625 mg TID,
(-) Profuse 98% by LMP • Leucovorin 0.6mL PRN for methotrexate
vaginal bleeding S/P Suction toxicity,
Anicteric Sclerae Curettage • Co-Amoxiclav 625 mg Q8 x 7 days,
Pink palpebral conjunctiva Multivitamins OD,
Clear breath sounds
(OMMC, 2018) • Ferrous Sulfate BID,
• Mefenamic acid 500 mg Q6 x PRN
Day 1 of methotrexate • Daily body and perineal hygiene
• VSq4
• WOF for methotrexate toxicity
• Avoid sun exposure
• Refer
 4 TH POST-CURETTAGE DAY
(OCTOBER 25,2018)
S O A P
(-) fever Vital Signs: Gravida 2 Para • Diet as tolerated, increase oral fluid intake
(-) Difficulty of 110/70 mmHg, • Labs: for repeat serum βhCG – 1 week post
1 (1-0-1-1) evacuation (10/28/18)
breathing Heart Rate 73 bpm
(-) Chest pain Respiratory Rate 16 cpm
Molar Pregnancy • Meds:
12 weeks AOG • Methotrexate 0.7 ml TIM OD x 5 doses,
Freely voiding Temperature 36.3°
• NAHCO3 625 mg TID,
(-) Profuse 98% by LMP • Leucovorin 0.6mL PRN for methotrexate
vaginal bleeding S/P Suction toxicity,
Anicteric Sclerae Curettage • Co-Amoxiclav 625 mg Q8 x 7 days,
Pink palpebral conjunctiva Multivitamins OD,
Clear breath sounds
(OMMC, 2018) • Ferrous Sulfate BID,
• Mefenamic acid 500 mg Q6 x PRN
Day 2 of methotrexate • Daily body and perineal hygiene
• VSq4
• WOF for methotrexate toxicity
• Avoid sun exposure
• Refer
 5 TH POST-CURETTAGE DAY
(OCTOBER 26, 2018)
S O A P
(-) fever Vital Signs: Gravida 2 Para • Diet as tolerated, increase oral fluid intake
(-) Difficulty of 110/70 mmHg, • Labs: for repeat serum βhCG – 1 week post
1 (1-0-1-1) evacuation (10/28/18)
breathing Heart Rate 73 bpm
(-) Chest pain Respiratory Rate 16 cpm
Molar Pregnancy • Meds:
12 weeks AOG • Methotrexate 0.7 ml TIM OD x 5 doses,
Freely voiding Temperature 36.3°
• NAHCO3 625 mg TID,
(-) Profuse 98% by LMP • Leucovorin 0.6mL PRN for methotrexate
vaginal bleeding S/P Suction toxicity,
Anicteric Sclerae Curettage • Co-Amoxiclav 625 mg Q8 x 7 days,
Pink palpebral conjunctiva Multivitamins OD,
Clear breath sounds
(OMMC, 2018) • Ferrous Sulfate BID,
• Mefenamic acid 500 mg Q6 x PRN
Day 3 of methotrexate • Daily body and perineal hygiene
• VSq4
• WOF for methotrexate toxicity
• Avoid sun exposure
• Refer
 6 TH POST-CURETTAGE DAY
(OCTOBER 27, 2018)
S O A P
(-) fever Vital Signs: Gravida 2 Para • Diet as tolerated, increase oral fluid intake
(-) Difficulty of 110/70 mmHg, • Labs: for repeat serum βhCG – 1 week post
1 (1-0-1-1) evacuation (10/28/18)
breathing Heart Rate 73 bpm
(-) Chest pain Respiratory Rate 16 cpm
Molar Pregnancy • Meds:
12 weeks AOG • Methotrexate 0.7 ml TIM OD x 5 doses,
Freely voiding Temperature 36.3°
• NAHCO3 625 mg TID,
(-) Profuse 98% by LMP • Leucovorin 0.6mL PRN for methotrexate
vaginal bleeding S/P Suction toxicity,
Anicteric Sclerae Curettage • Co-Amoxiclav 625 mg Q8 x 7 days,
Pink palpebral conjunctiva Multivitamins OD,
Clear breath sounds
(OMMC, 2018) • Ferrous Sulfate BID,
• Mefenamic acid 500 mg Q6 x PRN
Day 4 of methotrexate • Daily body and perineal hygiene
• VSq4
• WOF for methotrexate toxicity
• Avoid sun exposure
• Refer
 7 TH POST-CURETTAGE DAY
(OCTOBER 28, 2018)
S O A P
(-) fever Vital Signs: Gravida 2 Para • May go home
(-) Difficulty of 110/70 mmHg, • Diet as tolerated, increase oral fluid intake
1 (1-0-1-1) • Labs: for repeat serum βhCG – 1 week post
breathing Heart Rate 73 bpm
(-) Chest pain Respiratory Rate 16 cpm
Molar Pregnancy evacuation (10/28/18)
12 weeks AOG • Meds:
Freely voiding Temperature 36.3°
• Meds:
(-) Profuse 98% by LMP • Co-Amoxiclav 625 mg Q8 x 7 days
vaginal bleeding S/P Suction • Multivitamins OD,
Anicteric Sclerae Curettage • Ferrous Sulfate BID,
Pink palpebral conjunctiva • Mefenamic acid 500 mg Q6 x PRN
Clear breath sounds
(OMMC, 2018) • Daily body and perineal hygiene
• VSq4
Day 5 of methotrexate • WOF for methotrexate toxicity
• Avoid sun exposure
• Refer
REPEAT SERUM BETA HCG 1 WEEK POST
CURETTAGE
8, 203.00 mIU/ml
HISTOPATHOLOGIC REPORT
OMS- 18 -3473

Complete Hydatidiform Mole

 SALIENT FEATURES
19 years old
Gravida 2 Para 1 (1-0-0-1)
History of Vaginal bleeding
AOG: 12 weeks AOG
(+) Hypogastric pain radiating to the back
(+) passage vesicular like tissue material
Speculum Exam
Cervix violaceous, open with vesicular tissue fragment plugging at the OS
and with moderate bleeding per OS
Internal Exam
parous introitus admits two fingers with ease, cervix soft, with vesicular tissue
from the OS, Uterus enlarged to 18 weeks size, no adnexal mass, no adnexal
tenderness
Serum Beta HCG of 458, 000 mIU/ml
GESTATIONAL TROPHOBLASTIC DISEASE
WHO Classification

Malformations of the
chorionic villi that are Benign entities that
Malignant neoplasms
predisposed to develop can be confused with
of various types of
trophoblastic with these other
trophoblast
malignacies lesions

Choriocarcinoma Hydatidiform moles Exaggerated placental site

Placental site
Complete Partial Placental site nodule
trophoblastic tumor
Epithelioid trophoblastic
tumors Invasive
HYDATIDIFORM MOLE (HM)
• Abnormal conception with excessive placental, and little
or no fetal development
• Grossly resembles “bunch of grapes”, with or without
fetal components
• Subdivided based on morphologic, cytogenetic and
clinicopathologic features into:
•A) Complete Hydatidiform Mole (CHM)
•B) Partial Hydatidiform (PHM)
 HYDATIDIFORM MOLE (HM): CLASSIFICATION
Feature Partial Mole Complete Mole
Karyotype 69, XXX or 69, XXY 46, XX
Clinical Presentation
• Preliminary diagnosis Missed abortion Molar gestation
• Uterine size Small for dates Large for dates
• Theca-lutein cysts Rare 25-30% of cases
• Initial hCG levels <100,000 mIU/mL >100,000 mIU/mL
• Medical complications Rare uncommon
• Rate of subsequent 1-5% of cases 15-20% of cases
GTN
 HYDATIDIFORM MOLE (HM): CLASSIFICATION
Feature Partial Mole Complete Mole
Pathology
• Embryo fetus Often present absent
• Amnion, fetal erythrocytes Often present absent
• Villous edema Focal widespread
• Trophoblastic proliferation Focal, slight to moderate Slight to severe
• Trophoblastic atypia Mild Marked
• P57 KIP2 immuno-staining Positive Negative
HYDATIDIFORM MOLE (HM): INCIDENCE
• Reported worldwide incidence: 1-2 per 1,000 pregnancies
• 7-10x Southeast Asia > Europe or North America
• Indonesia: one of the highest reported incidence rates with 1
in 77 pregnancies (1 in 57 deliveries)
• Prevalence Rate in Philippines (2002-2008): 2.3/1000
pregnancies
• Prevalence Rate in UP-PGH: 14/1,000 pregnancies
HYDATIDIFORM MOLE (HM): RISK FACTORS
• AGE AND PRIOR HYDATIDIFORM MOLE:
• strongest risk factors
• MATERNAL AGE
• Teenagers and reproductive women of 40 years or older have
higher incidence rates (our patient is 19 years old)
• Age of 36-40 years: twofold risk
• >40 years old: tenfold risk
HYDATIDIFORM MOLE (HM): RISK FACTORS
• PATERNAL AGE
• >45 years old was related to the risk of complete mole but not
to partial mole
• PRIOR HYDATIDIFORM MOLE
• CM: risk of another mole is 0.9%
• After 2 CM: 20% of women have 3rd mole
• PM: 0.3%
• DIET AND NUTRITION
•Decreased dietary carotene and animal fat
HYDATIDIFORM MOLE (HM): RISK FACTORS
• REPRODUCTIVE AND OBSTETRIC HISTORY
• History of previous HM: second molar pregnancy occurs
in 0.6-2.6% of pregnancies
• Increased risk in nulliparous women with history of
miscarriage and have conceived twin pregnancies
• RACIAL FACTORS
• Differences in geographical distribution, race or
ethnicity
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
Based on:
a. Clinical presentation
b. Typical UTZ findings
c. Elevated β-hCG titer
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
CLINICAL PRESENTATION
• Complete Hydatidiform Mole
• Amenorrhea
•Varying amounts of vaginal bleeding (89-97%)
• Uterine size more than the AOG (40-50%)
• Absence of fetal heart tones
All of these are present in our patient
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
Other classical signs and symptoms:
• Presence of theca lutein cyst (20%)
• Hyperemesis (15-25%)
• Pre-eclampsia (12-27%)
• Hyperthyroidism (2-7%)
• Respiratory Insufficiency (2%)
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
• Partial Hydatidiform Mole
• Less prominent clinical features
• Initially managed as cases of incomplete or missed
abortion
• Diagnosis made after histologic examination of the
curettage specimen
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
PELVIC ULTRASOUND (Overall sensitivity: 50-86%)
Most accurate non-invasive imaging modality for the
hydatidiform mole
• Complete Mole
• complex, echogenic intra-uterine mass containing many small
cystic spaces
• Diagnosed during 2nd trimester: grape-like or hydropic villous
change
• “snowstorm-like appearance” appearance
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
• Complete Hydatidiform
Mole
• “snowstorm appearance
due to echogenic uterine
mass that has numerous
anechoic cystic spaces
• Fetus and amniotic sac
are absent
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
• Partial Hydatidiform Mole
•Less accurate and nearly 70% of cases will be missed
•Findings:
1. Focal cystic changes in the placenta
2. Ratio of the transverse to antero-posterior dimension of
the gestational sac >1.5
• Show presence of a growth retarded fetus with multiple
congenital anomalies attached to a hydropic placenta
• Partial Hydatidiform Mole
• Fetus is seen above
multicystic placenta
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS

Correlation of the ultrasonographic findings with β-hCG

levels can further improve the recognition of a molar
pregnancy to surgical evacuation.
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
β-hCG
•CM: elevated above those expected for gestational age
• Advanced moles: high values can lead to erroneous false-negative urine
pregnancy test results
• “hook effect”: excessive β-hCG hormone levels oversaturate assay’s
targeting antibody creating falsely low reading

• PM: significantly elevated but concentrations fall into

ranges expected for gestational age
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
• Complete Hydatidiform mole patients
• markedly elevated pre-evacuation β-hCG with a titer
of >100,000 U/mL
• PHM patients
• less commonly present with markedly elevated β-hCG
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
• Histological confirmation is mandatory for the
diagnosis of hydatidiform mole
• Immunostaining with p57kip2: used to
differentiate CHM and PHM
•P57kip2: positive in PM and hydropic abortions,
negative in complete moles
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
• P57 KIP2 : nuclear protein whose gene is paternally
imprinted and maternally expressed
• The gene product is produced only in tissues
containing a maternal allele
• This protein is absent in complete mole, since it only
contains paternal allele.
HYDATIDIFORM MOLE (HM):
PRESENTATION AND DIAGNOSIS
• Cytogenetic examination
• Recommended when the diagnosis based
on histology and immunostaining are
inconclusive
HYDATIDIFORM MOLE:
HISTOPATHOLOGIC FINDINGS
Complete Mole Partial Mole
• Lack of fetal or embryonic tissue • Presence of fetal or embryonic
• Hydropic or swollen villi tissues
• Diffuse trophoblastic hyperplasia • Less diffuse, focal hydropic swelling
• Marked atypia of trophoblasts at of villi
the implantation site • Focal trophoblastic hyperplasia
• Absence of trophoblastic stromal • Less pronounced trophoblastic
inclusions atypia at the molar implantation
site
• Presence of trophoblastic scalloping
and stromal inclusions
COMPLETE HYDATIDIFORM MOLE: PATHOGENESIS
Paternal
chromosomes
Empty ovum
only

Duplication 46XX

23X

Diandric diploidy
Androgenesis
COMPLETE HYDATIDIFORM MOLE: PATHOGENESIS
Paternal
chromosomes
Empty ovum
only

23X 23X
46XX
23X

23X

Dispermic diploidy
PARTIAL HYDATIDIFORM MOLE: PATHOGENESIS
Paternal extra
Normal ovum set

23Y 23X
23X 69XXY
23Y 23X

23X

Dispermic triploidy
HYDATIDIFORM MOLE: PATHOPHYSIOLOGY
NORMAL PREGNANCY H. MOLE
• 4th week after LMP: chorionic • Embryonic development stops
cavity and secondary yolk sac soon after the formation of the
are visible under transvaginal germ disc just after the
UTZ secondary yolk sac has started
to form
• 5th week: fetal pole
• 34-35 days after LMP: fetal • Supported by AFP inside molar
cardiac activity vesicles and of yolk sac tissue in
early CHM miscarriage
 HYDATIDIFORM MOLE: PATHOPHYSIOLOGY
NORMAL PREGNANCY H. MOLE
• Implantation → primitive placenta • (5-7 weeks of gestation) → primitive
formation → primary villi formation placenta villous tissue → proliferate
→ (13-15 days postconception) to form a heterogeneous mainly
invaded by cytotrophoblastic dense often polypoid mass (dense
columns and extraembryonic mesenchymal tissue surrounded by
mesoderm → secondary villi hyperplastic trophoblast)
• Mesodermal cells → invade • (end of 2nd month of pregnancy)
trabeculae → hemangioblast → progressive edema of villous
fetal capillaries mesenchyme → cystic molar changes
 HYDATIDIFORM MOLE: PATHOPHYSIOLOGY
NORMAL PREGNANCY H. MOLE
• Syncytiotrophoblast → • EVT migration almost
allows normal transfer of completely absent in CHM →
water from the maternal molar villous tissue loosely
blood intervillous → no attach to the uterine wall,
development for embryonic unplugged tips of the arteries
circulation → water → vaginal bleeding
accumulation → generalized
hydropic macroscopic
changes
HYDATIDIFORM MOLE (HM):
PLAN AND MANAGEMENT
• Complete History and Physical Examination
• Observation/Diagnostic
• Medical and Surgical Care
MANAGEMENT: HISTORY AND PHYSICAL
EXAMINATION
The following medical complaints should be promptly recognized
and treated:
 Anemia
 Hyperthyroidism
 Preeclampsia
 Electrolyte Imbalance
 Hyperemesis Gravidarum
 Pulmonary Insufficiency
 Disseminated Intravascular Coagulopathy
MANAGEMENT: HISTORY AND PHYSICAL
EXAMINATION
The following medical complaints should be promptly recognized
and treated:
 Anemia
 Hyperthyroidism
 Preeclampsia
 Electrolyte Imbalance
 Hyperemesis Gravidarum
 Pulmonary Insufficiency
 Disseminated Intravascular Coagulopathy
LABORATORY RESULT (CBC) (OCTOBER 21,
2018)

WBC 9.0 5.2-12.4 MCV 13 80-99

Neutrop
86.7 40-74 MCH 36.7 27-31
hils
Monocyt
4.6 3-15% MCHC 30.5 33-37
es
Lympho
8.7 19-48 % PLT 183 150-450
cytes
Hgb 10.4 12-18
Hct 31.2 33-52
MANAGEMENT: HISTORY AND PHYSICAL
EXAMINATION
The following medical complaints should be promptly recognized
and treated:
 Anemia
 Hyperthyroidism
 Preeclampsia
 Electrolyte Imbalance
 Hyperemesis Gravidarum
 Pulmonary Insufficiency
 Disseminated Intravascular Coagulopathy
 TEST Result
FT3 2.05 (Normal)
FT4 1.09 (Normal)
TSH 0.16 (Normal)
MANAGEMENT: HISTORY AND PHYSICAL
EXAMINATION
The following medical complaints should be promptly recognized
and treated:
 Anemia
 Hyperthyroidism
 Preeclampsia
 Electrolyte Imbalance
 Hyperemesis Gravidarum
 Pulmonary Insufficiency
 Disseminated Intravascular Coagulopathy
 LABORATORIES
OCTOBER 21, 2018 RESULT
BUN 3.07 NORMAL
CREATININE 72.6 NORMAL
ALT 15.6 NORMAL
AST 21.0 NORMAL
MANAGEMENT: HISTORY AND PHYSICAL
EXAMINATION
The following medical complaints should be promptly recognized
and treated:
 Anemia
 Hyperthyroidism
 Preeclampsia
 Electrolyte Imbalance
 Hyperemesis Gravidarum
 Pulmonary Insufficiency
 Disseminated Intravascular Coagulopathy
 CLINICAL CHEMISTRY

TEST RESULT REFERENCE RANGE

Na 136 mmol/L 135.0-145.0
K 3.8 mmol/L 3.4-5.0
Cl 105.1 mmol/L 93.0-109.0
MANAGEMENT: HISTORY AND PHYSICAL
EXAMINATION
The following medical complaints should be promptly recognized
and treated:
 Anemia
 Hyperthyroidism
 Preeclampsia
 Electrolyte Imbalance
 Hyperemesis Gravidarum
 Pulmonary Insufficiency
 Disseminated Intravascular Coagulopathy
 CHEST X-RAY
Radiologic Report: Normal Chest Findings
MANAGEMENT: HISTORY AND PHYSICAL
EXAMINATION
The following medical complaints should be promptly recognized
and treated:
 Anemia
 Hyperthyroidism
 Preeclampsia
 Electrolyte Imbalance
 Hyperemesis Gravidarum
 Pulmonary Insufficiency
 Disseminated Intravascular Coagulopathy
 CLOTTING TIME/ BLEEDING TIME
Clotting time = 3 minutes and 30 seconds (normal)
Bleeding time = 1 minute (normal)
PT =15.1 (normal)
99 % activity
APTT= 30.3 (normal)
INR= 1.15
MANAGEMENT
Surgical evacuation of molar products is the definitive
management of hydatidiform moles.
A. Suction curettage: preferred method to evacuate molar
products
B. All tissues obtained during molar evacuation should be
submitted for histologic evaluation
C. 2 units of blood should be immediately available
D. Prostanoids: avoided, Laminaria tent
E. Use of hysterometer
MANAGEMENT
F. Patients who are Rh negative should receive Rh
immune globulin at the time of evacuation because
the Rh D factor is expressed on the trophoblast
G. Routine repeat curettage after the diagnosis of a
molar pregnancy is not warranted
H. Hysterectomy with mole in situ
I. Theca Lutein cyst
GENERAL GUIDELINES FOR SUCTION CURETTAGE
Induction of anesthesia (SAB)
Placed in a semi-fowler’s dorsolithotomy position
Mechanical cervical dilatation
Oxytocin infusion
During suctioning: the surgeon’s other hand should be
positioned on the uterine fundus to continuously assess the
uterine size and tone
Sharp Curettage
CHEMOPROPHYLAXIS
o For patients at high risk of post molar GTD and when post
evacuation surveillance is doubtful
o Methotrexate is the drug of choice for chemoprophylaxis
o Dosage: 0.3-0.4 mg/kg body weight/day IM for 5 days
o Given prior to or within 2 weeks post evacuation
o Actinomycin: alternative, given 10-12 ug/kg BW
o Chemoprophylaxis does not obviate the need for post evacuation
hCG surveillance
 INDICATIONS
 Uterine size larger than AOG of more than 6 weeks
 Serum HCG greater than or equal to 100 000
 Theca lutein cyst greater than or equal to 6cm
 Maternal age greater than or equal to 35
 Gravidity of at least 4
 Recurrent molar pregnancy
 Medical complications arising from trophoblastic proliferation
CONTRAINDICATIONS TO CHEMOPROPHYLAXIS
 Hemoglobin < 100 mg/dl or Hct < 0.30
 WBC count < 3 x 109
 Absolute neutrophil count ≤ 1.5
 Platelet count <100
 Any active infection
 Presence of liver or renal dysfunction (increased renal or
liver function test)
FOLLOW UP
o Serial B-hCG monitoring to detect malignant
degeneration (Done at 08/19/18, 1 week post
suction curettage: 9102.85)
o Measured 1 week after molar evacuation then every 2
weeks until levels become normal (≤ 5 mIU/ml)
o After 3 consecutive biweekly normal levels
o Monitoring is every month for 6 mos
o Then at 2 monthly intervals for the next 6 months
FOLLOW UP
o Use of reliable contraception during entire follow
up period
o Eliminate potential confusion that arises in
interpretation of a rising hCG.
o Low dose COC pill: preferred
CLINICAL FEATURES OF PATIENT AT RISK OF POST
MOLAR TROPHOBLASTIC DISEASE
o Advance maternal age greater than or equal to 35 y/o
o Gravidity of ≥ 4
o Uterine size larger than gestation by ≥ 6 weeks
o Serum B-hCG ≥ 100,000 mIU/ml
o Theca Lutein cyst ≥ 6 cm
o Presence of any medical complication associated with increased
trophoblastic proliferation
o Repeat molar pregnancy
PREGNANCY AFTER A MOLAR PREGNANCY
o Pregnancy may be allowed after 6 months of normal
serum B-hCG level
o Early ultrasound should be performed because of the risk
of another molar pregnancy
o B-hCG should be monitored at 6 weeks post partum
o Placenta in subsequent pregnancies should be submitted
for histopathologic examination
IN THE PRESENCE OF THE FOLLOWING, IMMEDIATE
REFERRAL TO A TROPHOBLASTIC DISEASE SPECIALIST
SHOULD BE DONE
o High levels of B-hCG > 4 weeks post evacuation
o A rise of B-hCG of 10% or greater
o Plateauing B-hCG values (<10% decline or rise) at any time
after evacuation
o Clinical or histologic evidence of metastasis at any site
o Persistently elevated B-hCG titer at 14 weeks post evacuation
o Elevation of a previously normal B-hCG titer after evacuation
provided the diagnosis of pregnancy is excluded
Thank you!