Molar pregnancy

Question 1

How would you manage a patient with a molar pregnancy?

Answer 1

D&C or hyst if done with childbearing

Question 2

What is a complete molar pregnancy?

Answer 2

46XX/XY, completely paternally derived

Question 3

What is an incomplete molar pregnancy?

Answer 3

69 XXX, ovum fertilized by 2 sperm

Question 4

What is the risk of GTN with a complete mole?

Answer 4

15-20%

Question 5

What is the WHO prognostic scoring system?

Answer 5

including age of diagnosis, type of antecedent pregnancy, interval from evacuation to presentation of elevated hcg, level of hcg. If score <6, low risk of resistance to single agent MTX. If high score, would need more chemo

Question 6

What is the risk of a repeat molar pregnancy?

Answer 6

Risk of repeat mole after 1 mole is 1-2%, after 2nd mole, 15-18%.

Question 7

What is the risk of GTN with a partial mole?

Answer 7

5%

Question 8

When are you concerned for GTN?

Answer 8

Hcg increase <10% over 2 week period or plateau of hcg -> require chemo.

Question 9

Describe a partial vs complete mole

Answer 9

PARTIAL
- karyotype 69 XXX or 69 XXY
- maybe fetus present
- uterine size SGA
- rare theca-lutein cysts
- GTN risk rare (<5%)

COMPLETE
- karyotype 46 XX or 46 XY
- absent fetus (on villi w/ POCs)
- LGA uterine size
- common theca lutein cysts (2/2 high hCG levels0
- GTN risk 15-20%

*molar pregnancies associated w/ associated w/ anemia, infection, hyperthyroid and coagulopathy

Question 10

What is treatment of molar pregnancy?

Answer 10

• Suction D&C + sharp curettage or hyst if no desired fertility
• HYST if: age <40, S>D, hCG >100K, bilateral theca lutein cysts >6cm (bc all incr risk GTN)
• early US for all future pregnancies (recurrence risk 1% after 1 and 15% after 2 prior moles)

Post-op follow up:
- reliable contraception
- weekly HCG until negative (for partial stop when first negative obtained, for complete once neg, do monthly x 3 mo)

Question 11

When is there concern for post molar GTN?

If post evacuation HCG levels plateau at 10-20 mIU/ml. What is your management?

Answer 11

increasing hcg >10% across 3 values
Plateauing hcg 4 measurements within 10% of each other across 3 weeks.

Plateau at low levels is consistent with “phantom HCG”, which are nonspecific heterophilic antibodies. They are not excreted in the urine, so check a UPT to exclude a false + HCG before subjecting patient to chemotherapy for GTN.

Question 12

What is GTN?

Answer 12

gestational trophoblastic neoplasia: abnormal proliferation of trophoblastic tissue

• invasive mole, choriocarcinoma, placental site trophoblastic tumor, epithelioid trophoblastic tumor
• FIGO staging system (first 3 are indicators of hcg level)
• age
• duration from prior pregnancy
• type of prior pregnancy (abortion vs full term)
• pre-treatment HCG level
• largest tumor size
• site/number of mets
• history of failued chemo

Need chemo and gyn onc referral.

Treatment:
- single agent MTX vs. actinomycin d for low-risk disease.
- multiagent EMACO (etoposide, MTX, actinomycin d, cyclophosphamide, vincristine) for high risk

Question 13

How do you evaluate extent of disease for GTN prior to therapy?

Answer 13

• history assessing risk factors (interval from pregnancy, type of pregnancy
• Labs: CMP for renal and liver function, CBC, HCG levels
• CT chest, CTAP, brain MRI

Question 14

What would a molar pregnancy look like on US?
What is the differential for LGA?

Answer 14

• heterogenous mass w/ hydropic placenta
• larger than expected for EGA

Differential for LGA:
- incorrect dating
- multiple gestation
- uterine mass like fibroid
- molar pregnancy