25. Molar pregnancy.Chorionepithelioma.Diagnosis and treatment. Flashcards
what are types of molar pregnancy ?
complete mole
partial mole
what is the pathoetiology of bot types of molar pregnancy ?
complete
results from fertilisation of an anucleated ovum (no chromosomes) with a sperm which will duplicate giving rise to 46 chromosomes of paternal origin only
partial
It is the result of fertilisation of an ovum by 2 sperms so the chromosomal number is 69 chromosomes
what is the karytoptyping o these two molar pregnancies ?
complete - Paternal 46 XX (96%) xy
partial
paternal and maternal 69xxy or 69xyy
which molar pregnancy has a higher risk of malignancy ?
complete - 5-10 percent
morphologically in the uterus how do we distinguish between complete and partial mole ?
in partial - embryonic and fetal tissue or atleast amniotic tissue is present
the swelling of chorionic villi - is focal
trophoblastic hyperplasia - focal
complete -whole conceptus is turned into mass of diffused swollen villi
with diffused trophoblastic hyperplasia
symptoms in molar pregnancy
Vaginal bleeding during the first trimester - dark brown
Uterus size greater than normal for gestational age
Pelvic pressure or pain
- dull-aching due to rapid distension of the uterus, - colicky due to starting expulsion,
- sudden and severe due to perforating mole.
Passage of vesicles
Endocrine symptoms (due to ↑ β-hCG level)
Preeclampsia (before the 20th week of gestation)
Hyperemesis gravidarum
Ovarian theca lutein cysts: bilateral, large, cystic, adnexal masses that are tender to the touch
Hyperthyroidism
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Partial mole
Less severe symptoms than in complete mole
Vaginal bleeding
Pelvic tenderness
diagnosis of molar pregnancy
abdominal examination
in complete
>uterus is doughy in consistency
> Foetal parts and heart sound cannot be detected except in partial mole.
> chest X-ray always done for PE even in partial mole
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Laboratory tests:
β-hCG level measurement higher than expected for the gestational age
serum hcg
Transvaginal ultrasound:
Complete
Bilateral ovarian Theca lutein cysts
Echogenic mass interspersed with many hypoechogenic cystic spaces that represent hydropic villi -“bunch of grapes”, or “snowstorm”
No amniotic fluid
No fetal parts
Lack of fetal heart tones
Partial hydatidiform mole Fetal parts Fetal heart tones may be detectable Amniotic fluid is present. Increased placental thickness
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Definitive diagnosis is made by histological examination of the products of conception
what is the treatment of molar pregnancy ?
cervix favourable - Suction evacuation (curettage not recommended!)
- It is carried out under general anaesthesia,
After the evacuation is completed, methergine given
risk of hemorrhage is high especially when the uterus is large. Use of oxytocin drip helps the expulsion of moles and reduces blood loss but its routine use is not recommended due to the risks of embolization if used intravenous oxytocin should be started at the initiation of the suctioning
gentle sharp curettage to the uterus after evacuation, it is preferable to wait one week for fear of uterine perforation and only done in selective cases
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cervix unfavourable
slow dilatation of the cervix is done by introducing laminaria tent or misoprostol3 hrs before surgery followed by suction and evacuation.
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(II)Hysterectomy:
Uncontrolled hemorrhage or perforation during surgical evacuation.
It should be cosidered in women over 40 years who have completed their family for fear of developing choriocarcinoma.
methotrexate if refectory
theca lutein cysts should be left undisturbed as they will regress following removal of mol
why is the follow up of molar pregnancy necessary important ?
- As choriocarcinoma may complicate the vesicular mole after its evacuation, detection of serum ß-hCG by radioimmunoassay for 2 years is essential.
- Persistent high level indicates remnants of molar tissues which necessitate chemotherapy ( methotrexate) with or without curettage.
Hysterectomy is indicated if women had enough children.
Rising hCG, level after disappearance means developing of choriocarcinoma or a new pregnancy.
So combined contraceptive pills should be used for prevention of pregnancy which can be misleading for atleast one year is recommended .
if the patient so desires, she may be pregnant after a minimum of 6 months, following the negative hCG titer.
UD is contraindicated, because of its frequent association of irregular bleeding—a feature often coexists with choriocarcinoma.
Combined oral pills
Injection DMPA
Barrier method
Early features suggesting residual molar tissue include?
● recurrent or persistent vaginal bleeding,
● amenorrhoea,
● failure of uterine involution,
● persistence of ovarian enlargement due to theca lutein cyst
what is choriocarcinoma ?
Highly aggressive, malignant tumor consisting of trophoblastic tissue
choriocarcinoma has a tendency to what ?
to metastasize early-common sites of metastases are lungs (80%), anterior vaginal wall (30%), brain (10%)
aetiology of choriocarcinoma ?
Hydatidiform mole (50%) Miscarriages or ectopic pregnancy (25%) Normal pregnancy (25%)
what are the clinical features of choriocarcinoma ?
bleeding associated with uterine
subinvolution after molar evacuation
or pregnancy or abortion
bleeding may be continuous or intermittent, with sudden and sometimes
massive hemorrhage
Pallor of varying degrees
pelvic pain
ovarian enlargement: Bilateral lutein cysts are multiple theca lutein cyst
hcg - continuous amneorhea
dyspnea , chest pain , hemoptyses- lung metastasis
neuolgcal - dizziness - in brain metastasis
why is there bleeding in choriocarcinoma?
involves the endometrium, then bleeding, sloughing, and infection of the surface
usually occur earl
