B6 M1 Case 3 TG

• Classification of Gestational Trophoblastic Disease according to FIGO

  • Hydatidiform Mole
  • Gestational Trophoblastic Neoplasia – Postmolar GRN (includes Choriocarcinoma, Invasive Mole, Placental Site, Trophoblastic Tumor)
• Hydatidiform Mole


  • Complete
  • Partial
• Gestational Trophoblastic Neoplasia – Postmolar GRN

  • Non – metastatic
  • Metastatic
• Gestational Trophoblastic Neoplasia – Postmolar GRN

  • Low risk
  • High risk
• Incidence of Hydatidiform Mole

  • Develops in approx. 1 in 1000 pregnancies in US and Europe
  • More frequent in other countries, especially in parts of Asia (Japan 2 : 1000 pregnancies; Philippines 5 : 1000)
• Low dietary intake of carotene


  May be associated with increased risk for molar pregnancy
• Areas of high incidence of molar pregnancy

  Also have high frequency of Vitamin A deficiency
• Risk factors for complete molar pregnancy


  • Maternal age >35 years
  • High frequency of H. Mole among pregnancies towards the beginning or end of the childbearing period
  • No association between maternal age and risk factor for partial mole
• Recurrence of Hydatidiform Mole

  Seen in about 1-2% of cases
• The role of gravidity, parity, other factors, estrogen status, oral contraceptives, and dietary factors in the risk of gestational trophoblastic disease is unclear
• Histologic structure of Complete Mole

  • Hydropic degeneration and swelling of villous stroma
  • Absence of blood vessels in the swollen villi
  • Proliferation of trophoblastic epithelium to varying degree
  • Absence of fetus and amnion
• Cytogenetic studies of chromosomal composition of Complete Mole


  • Diploid 46 XX with the chromosome of paternal origin (androgenesis)
  • Occasionally the chromosomal pattern may be 46XY that is heterozygous due to the dispermic fertilization
• Partial Mole


  • Fetal or embryonic tissue is present
  • Chorionic villi or varying size with focal hydatidiform swellings cavitation and trophoblastic hyperplasia
  • Marked villous shallowing
  • Prominent stromal trophoblastic inclusions
  • Karyotype is triploid in 90% - 69 chromosomes with the extra haploid set derived from the father
• Typical clinical and diagnostic features of complete hydatidiform moles

  • Uterine Bleeding
  • Uterine size
  • Pregnancy – induced hypertension
  • Hyperemesis
  • Hyperthyroidism
  • Trophoblastic embolization
  • Theca Lutein ovarian cysts
  • UTZ appearance
• Uterine Bleeding


  • Most common symptoms causing patients to seek treatment
  • May vary from spotting to profuse hemorrhage
  • It may begin just before abortion or more often
  • May occur intermittently for weeks or even months
• Uterine size


  • The growing uterus often enlarges more rapidly than usual
  • One of the classic signs of complete moles
  • Excessive uterine size is generally associated with markedly elevated levels of HCG, because uterine enlargement results partly from trophoblastic overgrowth
  • At times ovaries appreciably enlarged by multiple theca lutein cysts may be difficult to distinguish from the enlarged uterus
• Pregnancy – induced hypertension

  • Association of preeclampsia with molar pregnancies that persist into 2nd trimester
  • Preeclampsia develops almost exclusively in patients with excessive uterine size and markedly elevated HCG levels
  • H. Mole should be considered whenever preeclampsia develops early in pregnancy
• Hyperemesis


  Significant nausea and vomiting may occur as to cause dehydration and electrolyte imbalance
• Hyperthyroidism


  • Clinically apparent hyperthyroidism is unusual; if present, patients have warm skin, tremors
  • Free thyroxine (T4) and triiodothyronine (T3) elevated
  • Alpha subunit of HCG and TSH is identical
  • Develops almost exclusively in patients with very high HCG levels
• Trophoblastic embolization


  • Respiratory distress is usually diagnosed in women with excessive uterine size and markedly elevated HCG levels
  • Not a common finding in recent literature
  • Clinical: chest pain, dyspnea, tachypnea, tachycardia, during and after molar evacuation
  • Chest auscultation: diffuse rales
  • Chest Xray: bilateral pumonary infiltrates
  • Respiratory distress usually resolves in 24 hours. With cardiopulmonary support
  • Variable amounts of trophoblast with or without villous stroma escape from the uterus in venous outflow
  • The volume may be such as to produce signs and symptoms of acute pulmonary embolism and even a fatal outcome, although rare
  • Even though trophoblast with or without villous stroma embolizes to the lungs in volumes too small to produce overt blockade of the pulmonary vasculature, these can subsequently invade the pulmonary parenchyma to establish metastases that are evident radiographically
  • The lesions may consist of trophoblast alone (metastatic choriocarcinoma) or trophoblast with villous stroma (metastatic hydatidiform mole). The subsequent course of such lesions is unpredictable and some have been observed to disappear spontaneously either soon after uterine evacuation or even weeks to months later, while other proliferate and kill the woman unless she is treated effectively
• Theca Lutein ovarian cysts


  • Develop in about 50% of patients with complete mole
  • Result from high HCG levels which cause ovarian hyperstimulation
  • Regress spontaneously within 2-4 months after molar evacuation
• UTZ appearance


  • Complete moles: vesicular UTZ pattern due to diffuse hydropic swelling of villi
  • Partial moles: focal cystic spaces in placental tissue and increase in transverse diameter of gestational sac
  • "snowstorm pattern" describes both complete and partial. There is still no distinct pattern in each entity and the characteristics mentioned may point to specific entity, these are diagnostic and definite
• Clinical and diagnostic features of complete hydatidiform moles

  • Continuous or intermittent bloody discharge evident by about 12 weeks, usually not profuse and often more nearly brown rather than red
  • Uterine enlargement out of proportion to the duration of pregnancy in about half of the cases
  • Absence of fetal parts on palpation and of fetal heart sounds even though the uterus may be enlarged to the level of the umbilicus or higher
  • Characteristic ultrasonic appearance (snowstorm pattern)
  • A serum chorionic gonadotropin level higher than expected for the stage of gestation
  • Preeclampsia – eclampsia developing before 24 weeks
  • Hyperemesis gravidarum
• Natural History of Complete Moles

  • Have potential for invasion and dissemination
  • After molar evacuation, local uterine invasion occurs in 15% of patients and metastasis occurs in 4%
  • Majority of patients had the ff. signs of marked trophoblastic proliferation at the time they sought treatment: HCG level >100,000 Miu/mL, Excessive uterine enlargement, Theca lutein cysts 6cm in diameter
  • Patients with any of these signs were considered high risk; after molar evacuation, loval invasion occurred in 31% metastasis developed in 8.8%
  • For low risk patients, local invasion was only 3.4% and metastasis developed in only 0.6%
• Diagnostic evaluation in patients with suspected molar disease

  • UTZ: typical patterns of complete or partial moles may be determined
  • By curettage, for histologic diagnosis (Histologic dx is not always needed)
  • Measurements of chorionic gonadotropin
  • Chest Xray
• After molar pregnancy is diagnosed, the patient should be evaluated carefully for the presence of associated medical complications, including preeclampsia, hyperthyroidism, electrolyte imbalance and anemia
• Therapy of Molar Pregnancy

  • Surgical therapy
  • Medical Therapy
• Surgical therapy


  • Hysterectomy
  • Suction curettage
• Hysterectomy


  • May be performed if the patient desires surgical sterilization with the mole in situ
  • The ovaries may be preserved at the time of surgery, even though prominent theca lutein cysts are present
  • Large ovarian cysts may be decompressed by aspiration
  • Hysterectomy does not prevent metastasis; therefore, patients still require follow-up with assessment of HCG levels
• Suction curettage


  • Is the preferred method of evacuation, regardless of uterine size, for patients who desire to preserve fertiity
  • Oxytocin infusion – this is begun in the ORbefore the induction of anesthesia
  • Cervical dilation – uterine bleeding may be encountered, but should not deter the prompt completion of cervical dilation
  • Suction curettage – within a few minutes of starting, the uterus may decrease in size dramatically and the bleeding is generally well controlled
  • Sharp curettage – when suction curettage is believed to be complete, gentle sharp curettage is performed to remove any residual molar tissue
• Because trophoblast cells express RhD factor, patients who are Rh negative should receive Rh immune goblin at the time of the evacuation
• Prophylactic Chemotherapy


  • Its role at the time of molar evacuation is controversial. Exposing all patients to potentially toxic treatment when only about 20% are at risk of developing persistent tumor
  • In patients with complete molar pregnancy who received single course of actinomycin D at the time of evacuation, local uterine invasion developed in only 10 patients (4%) and no patients developed metastases
  • Furthermore, 10 patients with local invasion achieved remission after only one additional course of chemotherapy
  • Prophylactic chemotherapy not only prevented metastases but also reduced the incidence and morbidity of local uterine invasion
  • Prophylaxis may be particularly useful in the management of high-risk complete molar pregnancy, especially when hormonal follow-up is unavailable or unreliable
• Follow up for patients with Molar Pregnancy

  • Weekly determination of B-HCG levels until these are normal for 3 consecutive weeks
  • Followed by monthly determination until levels are normal for 6 consecutive months
  • Average time to achieve the first normal HCG level after evacuation is 9 weeks
• In patients with complete molar pregnancy who received single course of actinomycin D at the time of evacuation, local uterine invasion developed in only 10 patients (4%) and no patients developed metastases
• 10 patients with local invasion achieved remission after only one additional course of chemotherapy
• Prophylactic chemotherapy not only prevented metastases but also reduced the incidence and morbidity of local uterine invasion
• Prophylaxis may be particularly useful in the management of high-risk complete molar pregnancy, especially when hormonal follow-up is unavailable or unreliable
• Follow up for patients with Molar Pregnancy

  1. Weekly determination of B-HCG levels until these are normal for 3 consecutive weeks

  2. Followed by monthly determination until levels are normal for 6 consecutive months

  3. Average time to achieve the first normal HCG level after evacuation is 9 weeks

  4. Pregnancy may be undertaken at the completion of follow-up

  5. Patients are encouraged to use effective contraception during the entire interval of gonadotropin follow-up
• IUDs are not advisable because of the potential risk of uterine perforation
• Choice will be either oral contraceptives or barrier methods