Molar pregnancy

Question 1

Molar pregnancy

Answer 1

Hydatidiform mole is a type of tumour that grows like a pregnancy inside the uterus. This is called a molar pregnancy. There are two types of molar pregnancy: a complete mole and a partial mole.

Question 2

What is a complete mole?

Answer 2

Occurs when two sperm cells fertilise an ovum that contains no genetic material (an “empty ovum”).

These sperm then combine genetic material, and the cells start to divide and grow into a tumour called a complete mole. No foetal material will form.

Question 3

What is a partial mole?

Answer 3

Occurs when two sperm cells fertilise a normal ovum (containing genetic material) at the same time.

The new cell now has three sets of chromosomes (it is a haploid cell). The cell divides and multiplies into a tumour called a partial mole. In a partial mole, some foetal material may form.

Question 4

Gestational trophoblastic disease

Answer 4

A term used to describe a group of pregnancy-related tumours.

Question 5

What are examples of pre-malignant conditions in Gestational trophoblastic disease?

Answer 5

More common = such as partial molar pregnancy and complete molar pregnancy.

Question 6

What are examples of malignant conditions in Gestational trophoblastic disease?

Answer 6

Such as invasive mole, choriocarcinoma, placental trophoblastic site tumour and epithelioid trophoblastic tumour.

Question 7

Choriocarcinoma

Answer 7

A malignancy of the trophoblastic cells of the placenta. It commonly, but not exclusively, co-exists with a molar pregnancy.

This type of GTT characteristically metastasises to the lungs.

Question 8

Placental site trophoblastic tumour

Answer 8

A malignancy of the intermediate trophoblasts, which are normally responsible for anchoring the placenta to the uterus.

Question 9

Epithelioid trophoblastic tumour

Answer 9

A malignancy of the trophoblastic placental cells, which can be very difficult to distinguish from choriocarcinoma. It mimics the cytological features of squamous cell carcinoma

Question 10

Clinical presentation for molar pregnancies

Answer 10

Vaginal bleeding, abdominal pain early in pregnancy.

On examination, the uterus can be larger than expected for gestation, and of a soft, boggy consistency.

Later symptoms - Hyperemesis , Hyperthyroidism and Anaemia

Question 11

Investigations for molar pregnancy

Answer 11

Urine B-hCG
Blood B-hCG levels
Ultrasound Scan
Histological examination of the products of conception

Question 12

Management of molar pregnancy

Answer 12

Suction curettage

However, if the partial mole is of a greater gestation, and is not conducive to surgery, medical evacuation should be recommended – with a urinary B-hCG measurement performed 3 weeks post-treatment.

In all cases, anti-D prophylaxis is recommended post-evacuation if the mother is Rhesus negative.

Question 13

What is Hyperemesis Gravidarum?

Answer 13

The severe form of nausea and vomiting in pregnancy is called hyperemesis gravidarum.

Nausea and vomiting are normal during early pregnancy.

Symptoms usually start from 4 – 7 weeks, are worst around 10 – 12 weeks and resolve by 16 – 20 weeks. Symptoms can persist throughout pregnancy.

Question 14

What causes nausea and vomiting in pregnancy?

Answer 14

The placenta produces hCG during pregnancy. This hormone is thought to be responsible for nausea and vomiting.

Theoretically, higher levels of hCG result in worse symptoms.

Question 15

Criteria for diagnosis of Hyperemesis gravidarum

Answer 15

• More than 5 % weight loss compared with before pregnancy
• Dehydration
• Electrolyte imbalance

Question 16

What anti emetics are used for the management of hyperemesis gravidarum?

Answer 16

1. Prochlorperazine (stemetil)
2. Cyclizine
3. Ondansetron
4. Metoclopramide

Question 17

Ovarian hyperstimulation syndrome (OHSS)

Answer 17

A complication of ovarian stimulation during IVF infertility treatment.

It is associated with the use of hCG to mature the follicles during the final steps of ovarian stimulation.

Question 18

Psychophysiology of Ovarian hyperstimulation syndrome (OHSS)

Answer 18

An increase in vascular endothelial growth factor (VEGF) released by the granulosa cells of the follicles.

VEGF increases vascular permeability, causing fluid to leak from capillaries. Fluid moves from the intravascular space to the extravascular space. This results in oedema, ascites and hypovolaemia.

The use of gonadotrophins (LH and FSH) during ovarian stimulation results in the development of multiple follicles.

OHSS is provoked by the “trigger injection” of hCG 36 hours before oocyte collection. HCG stimulates the release of VEGF from the follicles.

There is also activation of the renin-angiotensin system.

Question 19

What system is activated in Ovarian hyperstimulation syndrome (OHSS)?

Answer 19

Renin-angiotensin system

Question 20

Risk factors for Ovarian hyperstimulation syndrome (OHSS)

Answer 20

	Younger age
	Lower BMI
	Raised anti-Müllerian hormone 
	Higher antral follicle count
	Polycystic ovarian syndrome
	Raised oestrogen levels

Question 21

What is anti-Müllerian hormone useful for?

Answer 21

Useful marker of ovarian function. Granulosa cells of growing follicles secrete AMH, and its serum levels reflect the remaining follicular pool and thus the remaining length of a woman’s reproductive lifespan.

Question 22

Women are individually assessed for their risk of developing OHSS, how are the patients monitored for OHSS?

Answer 22

1. Serum oestrogen levels (higher levels indicate a higher risk)
2. Ultrasound monitor of the follicles (higher number and larger size indicate a higher risk)

Question 23

Features of OHSS

Answer 23

	Abdominal pain and bloating
	Nausea and vomiting
	Diarrhoea
	Hypotension
	Hypovolaemia
	Ascites
	Pleural effusions
	Renal failure
	Peritonitis 
	Prothrombotic state (risk of DVT and PE)

Question 24

Difference between early & late OHSS.

Answer 24

Early OHSS presents within 7 days of the hCG injection.

Late OHSS presents from 10 days onwards.

Question 25

What are the 4 classifications for the severity of OHSS based on symptoms?

Answer 25

1. Mild
2. Moderate
3. Severe
4. Critical

Question 26

What is the symptoms of mild OHSS?

Answer 26

Abdominal pain and bloating

Question 27

What is the symptoms of Moderate OHSS?

Answer 27

Nausea and vomiting with ascites seen on ultrasound

Question 28

What is the symptoms of Severe OHSS?

Answer 28

Ascites, low urine output (oliguria), low serum albumin, high potassium and raised haematocrit (>45%)

Question 29

What is the symptoms of Critical OHSS?

Answer 29

Tense ascites, no urine output (anuria), thromboembolism and acute respiratory distress syndrome (ARDS)

Question 30

Management of OHSS

Answer 30

1. Oral fluids
2. Monitoring of urine output
3. LMWHs (to prevent thromboembolism)
4. Ascitic fluid removal if required
5. IV colloids

Question 31

Haematocrit

Answer 31

Is the concentration of red blood cells in the blood.

When the haematocrit goes up, this indicates less fluid in the intravascular space, as the blood is becoming more concentrated. Raised haematocrit can indicate dehydration.

Question 32

What does a raised haematocrit suggest?

Answer 32

can indicate dehydration