Hydatidiform mole

Gestational Trophoblastic Neoplasia (GTN)

• Gestational trophoblastic neoplasia refers to a

spectrum of proliferative abnormalities of the
trophoblast associated with pregnancy.
• GTN is classified as:
Histological classification:
1. Hydatidiform mole
2. Invasive mole
3. Placental site trophoblastic tumour
4. Choricarcinoma
 Cont…
Clinical classification:
• Gestational trophoblastic disease
• Gestational trophoblastic tumour
 Non-metastatic
 Metastatic
Hydatidiform Mole
• It is the most common form of Gestational
trophoblastic disease and also called molar
pregnancy. The term hydatid means watery
vesicles, mole means mass.
DEFINITION:
• It is the abnormal condition of the placenta
where there is partly degenerative and partly
proliferative changes in the young chorionic
villi. These result in the formation of clusters
of small cysts of varying sizes.
• It is best regarded as the benign neoplasm of
the chorion with the malignant potential.
• Because of its superficial resemblance to
hydatid cyst, it is named as hydatidiform mole.
• A hydatidiform mole is growth of an abnormal
fertilized egg or an overgrowth of tissue from
the placenta. Women appear to be pregnant,
but the uterus enlarges much more rapidly
than in a normal pregnancy.
INCIDENCE:
 Incidence is varied.
 The highest incidence is in Philippines being 1
in 86 and in India about 1 in 400 but lowest in
USA about 1 in 2000.
Types :
• The type of hydatidiform mole are :
a. Complete mole
b. Partial mole
Complete mole:

• It is present in 75% of the cases.

• It develops when the sperm has fertilized an
empty egg (the egg without nucleus and
DNA).All the genetic material comes from the
father’s sperm. So, there is no fetal tissue. It
may develop into choriocarcinoma.
Partial mole:
It occurs in 25% of the cases. It develops when
the two sperm fertilizes a normal egg. These
contain some fetal tissues but the tissue is
mixed with trophoblastic tissue. No viable
fetus is being formed. Partial moles rarely
develop into choriocarcinoma.
 DIFFERENCE:
SN TOPIC COMPLETE MOLE PARTIAL MOLE

1 Fetus absent Present ,malformed

2. Fetal vessel absent present

3 Trophoblastic marked Mild to moderate

hyperplasia
4. Beta HCG level high Comparatively low

5 karyotype 46XX mostly 69XXY

paternally derived
6 Malignancy 15% to 20% rare
CAUSES:
• The cause is not definitely known
• Its prevalence is highest in teenage pregnancy
and in those women over 35 years of age.
• Faulty nutrition caused by the inadequate
intake of protein, high carbohydrate, deficient
in folic acid and other vitamins.
• Genetic and chromosomal abnormalities.
• Disturbed maternal immune mechanism.
• History of previous hydatidiform mole
increases the chance of recurrence.
 Cont…
• Genetic and chromosomal abnormalities.
• Disturbed maternal immune mechanism.
• History of previous hydatidiform mole
increases the chance of recurrence.
CLINICAL FEATURES:
The clinical features of hydatiform mole are:
The patient gives the history of amenorrhea for
8-12 weeks with initial features suggestive of
normal pregnancy but subsequently presents
with following manifestations-
Symptoms
Vaginal bleeding is the commonest
presentation (90% cases).It may be preceded
by brownish or watery discharge.
Varying degree of lower abdominal pain

Constitutional symptoms includes:

 The patient becomes sick without any
apparent reason .
 Vomiting of pregnancy becomes excess to a
state of hyperemesis in 15% of the cases.
 Breathlessness due to pulmonary
embolization of trophoblastic cells.
 Thyrotoxic features of tremors ,tachycardia is
present.
Expulsion of grape like
vesicles per vaginum is
the pathogmonic of
vesicular mole.
History of quickening is
absent.
Signs
Features suggestive of early months of
pregnancy is evident.
The patient looks more ill.
Pallor usually prominent
Features of preeclampsia ( hypertension,
edema and proteinurea) is present in 50% of
the cases.
Per abdomen
 The size of the uterus is more than the period
of amenorrhea in 70%of the cases.
 The feel of the uterus is firm and elastic
(doughy)due to absence of amniotic fluid.
 Fetal parts are not felt, nor any fetal
movements.
 Absence of fetal heart sound.
Vaginal examination
 Finding of vesicle in vaginal discharge.
 If cervical os is open instead of membranes,
blood clot or vesicles may be felt.
Investigations

 Full blood count, ABO and RH grouping

 Hepatic ,renal and thyroid function test
 Ultrasonography: ‘snow-storm appearance’
 Quantitative estimation of chorionic
gonadotropin (hCG>100,000 mIU/ml)
 Straight X-Ray abdomen
 CT scan, MRI
 Management
The principles of management are;
• Supportive therapy to restore blood loss and
to prevent infection.
• To evacuate the uterus as soon as the
diagnosis is made.
• To take appropriate steps to minimize
infection.
• Regular follow up for early detection of the
persistent trophoblastic disease.
The patient are grouped in two phases;
Group A:The mole is in process of expulsion.

Group B:The uterus remains inert.

Group A:The patient usually presents with variable
amount of bleeding.
• To start Ringer’s lactate solution .
• Blood should be also kept ready prior to the
elective evacuation of the uterus.

Group B: Blood should be kept ready prior to the

elective evacuation of the uterus.
 DEFINITIVE MANAGEMENT:
Group A
Supportive therapy: Ringer’s Lactate solution,
IV Infusion, blood transfusion. To prevent
hemorrhage oxytocin 20 units in 1 litre IV
fluids at 60 drops/min may be added once the
evacuation is under way.
a. Suction evacuation is the best.
b. Digital exploration and removal of mole by
ovum forceps, after evacuation methergin
0.2mg is given IM.
Group B
After diagnosis is made, evacuation is done as
soon as possible.
1. Vaginal evacuation:
• Cervix is favourable the preferred method is
suction evacuation
• If cervix is closed prior, slow dilation by using
misoprostol then suction and evacuation is
done.
2. Hysterotomy : Incase of profuse vaginal
bleeding and cervix unfavourable for
immediate vaginal evacuation.
3. Hysterectomy: Indicated in patients over 35
years and those who have completed their
family.
• Prophylactic chemotherapy: 85% of the
patient undergo spontaneous remission.
It is indicated in
1. If HCG level fails to become normal by 4-6
weeks or there is re-elevation.
2. Evidence of metastasis irrespective of level
of HCG.
3. Where malignant sequelae is higher.
• Follow up: routine follow up should be done in
all cases for at least 6 months.
• Initially check-up at every one week till serum
HCG level becomes negative.
• Once negative, follow up at one month
interval for 6 months.
• Women on chemotherapy should follow up
for one year after hCG has become normal.
NURSING MANAGEMENT:
1. Assess the general condition of the patient.
2. Send the blood for grouping and other
investigations.
3. Start IV fluid and monitor oxytocin drip.
4. Give prophylactic antibiotics as prescribed.
5. Assess the nutritional condition.
6. It is an emotionally overwhelming condition
so, psychological support should be given.
7. As there is more amount of blood loss food
with high value of iron should be
recommended.
8. Follow up advice
4.Initially the check up should be at the interval
of one week till HCG titres in the urine
becomes negative, once negative the patient
should follow up at every one or two month
interval for one year ,the patient is advised
not to be pregnant for 2 years and if the
patient has extreme need only after 12
months. Barrier method is the best
contraceptive method.
COMPLICATIONS:
1. Hemorrhage
2. Shock
3. Perforation of the uterus
4. Coagulation disorder
5. Pre-eclampsia
6. Chorio carcinoma
7. Recurrent in subsequent pregnancy
P. The fullmoon