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Follow up of vesicular mole…… 
VISHNU AMBAREESH M S
This mole???
This one???
cabernet-sauvignon
Follow up of vesicular mole
Follow up of vesicular mole…… 
VISHNU AMBAREESH M S
Management – 2 phases 
Immediate evacuation 
Subsequent follow up 
aim of treatment is to eliminate all trophoblastic tissue from the maternal systems
Why??? 
• Risk of malignancy after a complete and 
partial mole is 15-20% and 1-5% 
respectively 
• invasive tendencies and the ability to make 
hCG hormone
IN BETA HCG WE TRUST 
SENSITIVITY & SPECIFICITY OF VIRTUALLY 100%
• hCG is a placental glycoprotein composed of 2 dissimilar subunits: an 
alpha subunit resembling that of the pitutary glycoprotein hormones and 
a beta subunit that is unique to plaacental production.Several forms of 
hCG exist, including atleast 6 major variants that can be detected in serum 
• hyperglycosylated 
• nicked 
• absent c-terminal of beta subunit 
• free beta subunit 
• nicked free beta subunit 
• free alpha unit
• the hCg molecules in GTD are more heterogenous and 
degraded than those in normal pregnancy,therefore, an assay 
that will detect all main forms of hCG and its multiple 
fragments should be used to follow up patients with GTD. 
• rapid automated radiolabeled monoclonal antibody sandwich 
assays that measure different mixtures of hCG related 
molecules
• It is expected that urine pregnancy test is 
negative 4 weeks after evacuation and 
serum β-hCG is undetectable 4 months after 
evacuation 
• Followed up for at least 6 months 
Nl serum level < 4 IU/L NL urine level <24 IU/L
• Weekly beta hCG until normal for 3 
consecutive weeks 
• Then monthly until normal for 6 months 
• The follow-up is recommended for 2 years 
in cases of complete moles, and 6 months of 
cases of partial moles after the evacuation of 
uterus.
Follow up of vesicular mole
Diagnosis of persistent GTD (FIGO) 
4 values or more of hCG documenting a plateau over at 
least 3 weeks 
A rise in hCG of 10% or more for 3 values or longer over 
at least 2 weeks 
HPE evidence of choriocarcinoma 
Persistence of hCG 6 months after mole evacuation 
This does not address the issue of metastatic disease or 
PSTT
phantom hCG 
• some lab assays may yield false positive hCG results. These so 
called phantom hCG resuts, with levels reported as high as 
800 mIU/mL, have led to treatment of healthy patients with 
unnecessary surgery and chemotherapy. 
• cause - proteolytic enzymes that produce nonspecific protein 
interference and heterophile(human antimouse) antibodies. 
in 3-4% of health people and can mimic hCG 
immunoreactivity by linking and capturing tracer mouse IgG...
3 ways to determine if false positive 
1. urine hCG level neg as interfering substances 
are not excreted in urine 
2.serial dilution of serum would not show a 
parallel decrease in dilution 
3.send serum and urine of patient to an hCG 
reference labortary
also some cross reactivity with LH. measure LH. 
supress with OCP
• "Quiescent gestational trophoblastic disease" is a term for that is 
characterized by persistant,unchanging low levels(<200 mIU/mL) of "real" 
hCG for atleast 3 months associated with a history of GTD or spontaneous 
abortion, but without clinically detectable disease. the hCg levels do not 
change with chemotherapy or surgery.Follow up of these patients reveals 
subsequent development of active GTN in 1/4th, heralded by an increse in 
both glycosylated hCG and total hCG.Acc INTL society for the study of 
trophoblastic disease 2001 recommendations for managing this condition, 
false positive hCG resulting from heterophile antibodies, or LH 
interference should be excluded, the patient should be thoroughly 
investigated for evidence of disease, immediate chemotherapy or surgery 
should be avoided, and the patient should be monitored long term with 
periodic hCG testing while avoiding pregnancy.treat only when substancial 
rise or overt clinical diesase.
What to do at each visit? 
Symptoms like irregular bleeding, persistent cough, 
haemoptysis and dyspnoea 
Cl exam for uterine size, theca lutein cysts and 
suburethral mets 
USS if any suspicion 
Xray chest in some cases
Early features suggesting residual molar tissue 
include: 
recurrent or persistent vaginal bleeding, 
• amenorrhoea, 
• failure of uterine involution, 
• persistence of ovarian enlargement.
Metastases in GTT 
Lung 80%- resp symptoms and Xray findings mimicking 
primary pul disease Pulmonary hypertension sec to pul artery 
occlusion by tropho emboli 
Vagina 30% (suburethral or fornices) can bleed profusely 
Pelvis 20% 
Liver 10% epigastric pain, hepatic rupture 
Brain 10% focal neuro deficits or cerebral haemorrhage
Follow up of vesicular mole
Follow up of vesicular mole
Follow-up 
• Indication of chemotherapy after 
the evacuation of the hydatidiform 
mole in: 
Serum hCG >20000 i.u/L , at any 
time after evacuation of mole. 
 Raised hCG at 4 to 6 weeks after 
evacuation of mole.
Evidence of metastases 
,hepatic,brain,and pulmonary. 
Persistent uterine hemorrhage 
after evacuation of mole with 
raised hCG levels.
Follow-up 
• Pregnancy is not allowed except after one 
year of negative follow up but with danger 
of : 
Molar pregnancy (4-5 times greater risk). 
 Spontaneous abortion. 
Premature delivery.
Pregnancy after hydatidiform mole 
Usually normal reproductive function 
Recurrence of mole in 1-2% 
Hence early USS to rule out a molar pregnancy and for dates 
Placenta or products to be sent for HPE for occult 
trophoblastic disease 
hCG level 6 weeks post evacuation or delivery
Contraception 
• Contraception is recommended for 6 months after the first 
normal HCG result to distinguish a rising hCG because of 
persistent or recurrent disease from a rising hCG associated 
with a subsequent pregnancy. 
• the use of OCP is preferrrable because they have the 
advantage of supressing endogenous LH, which may interfere 
with the measurement of hCG at low levels and studies have 
shown that they do not increase the risk of postmolar 
trophoblastic neoplasia
Future pregnancy 
• If a further molar pregnancy 
does occur,in 68–80% of cases 
it will be of the same 
histological type
Merci !!

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Follow up of vesicular mole

  • 1. Follow up of vesicular mole…… VISHNU AMBAREESH M S
  • 6. Follow up of vesicular mole…… VISHNU AMBAREESH M S
  • 7. Management – 2 phases Immediate evacuation Subsequent follow up aim of treatment is to eliminate all trophoblastic tissue from the maternal systems
  • 8. Why??? • Risk of malignancy after a complete and partial mole is 15-20% and 1-5% respectively • invasive tendencies and the ability to make hCG hormone
  • 9. IN BETA HCG WE TRUST SENSITIVITY & SPECIFICITY OF VIRTUALLY 100%
  • 10. • hCG is a placental glycoprotein composed of 2 dissimilar subunits: an alpha subunit resembling that of the pitutary glycoprotein hormones and a beta subunit that is unique to plaacental production.Several forms of hCG exist, including atleast 6 major variants that can be detected in serum • hyperglycosylated • nicked • absent c-terminal of beta subunit • free beta subunit • nicked free beta subunit • free alpha unit
  • 11. • the hCg molecules in GTD are more heterogenous and degraded than those in normal pregnancy,therefore, an assay that will detect all main forms of hCG and its multiple fragments should be used to follow up patients with GTD. • rapid automated radiolabeled monoclonal antibody sandwich assays that measure different mixtures of hCG related molecules
  • 12. • It is expected that urine pregnancy test is negative 4 weeks after evacuation and serum β-hCG is undetectable 4 months after evacuation • Followed up for at least 6 months Nl serum level < 4 IU/L NL urine level <24 IU/L
  • 13. • Weekly beta hCG until normal for 3 consecutive weeks • Then monthly until normal for 6 months • The follow-up is recommended for 2 years in cases of complete moles, and 6 months of cases of partial moles after the evacuation of uterus.
  • 15. Diagnosis of persistent GTD (FIGO) 4 values or more of hCG documenting a plateau over at least 3 weeks A rise in hCG of 10% or more for 3 values or longer over at least 2 weeks HPE evidence of choriocarcinoma Persistence of hCG 6 months after mole evacuation This does not address the issue of metastatic disease or PSTT
  • 16. phantom hCG • some lab assays may yield false positive hCG results. These so called phantom hCG resuts, with levels reported as high as 800 mIU/mL, have led to treatment of healthy patients with unnecessary surgery and chemotherapy. • cause - proteolytic enzymes that produce nonspecific protein interference and heterophile(human antimouse) antibodies. in 3-4% of health people and can mimic hCG immunoreactivity by linking and capturing tracer mouse IgG...
  • 17. 3 ways to determine if false positive 1. urine hCG level neg as interfering substances are not excreted in urine 2.serial dilution of serum would not show a parallel decrease in dilution 3.send serum and urine of patient to an hCG reference labortary
  • 18. also some cross reactivity with LH. measure LH. supress with OCP
  • 19. • "Quiescent gestational trophoblastic disease" is a term for that is characterized by persistant,unchanging low levels(<200 mIU/mL) of "real" hCG for atleast 3 months associated with a history of GTD or spontaneous abortion, but without clinically detectable disease. the hCg levels do not change with chemotherapy or surgery.Follow up of these patients reveals subsequent development of active GTN in 1/4th, heralded by an increse in both glycosylated hCG and total hCG.Acc INTL society for the study of trophoblastic disease 2001 recommendations for managing this condition, false positive hCG resulting from heterophile antibodies, or LH interference should be excluded, the patient should be thoroughly investigated for evidence of disease, immediate chemotherapy or surgery should be avoided, and the patient should be monitored long term with periodic hCG testing while avoiding pregnancy.treat only when substancial rise or overt clinical diesase.
  • 20. What to do at each visit? Symptoms like irregular bleeding, persistent cough, haemoptysis and dyspnoea Cl exam for uterine size, theca lutein cysts and suburethral mets USS if any suspicion Xray chest in some cases
  • 21. Early features suggesting residual molar tissue include: recurrent or persistent vaginal bleeding, • amenorrhoea, • failure of uterine involution, • persistence of ovarian enlargement.
  • 22. Metastases in GTT Lung 80%- resp symptoms and Xray findings mimicking primary pul disease Pulmonary hypertension sec to pul artery occlusion by tropho emboli Vagina 30% (suburethral or fornices) can bleed profusely Pelvis 20% Liver 10% epigastric pain, hepatic rupture Brain 10% focal neuro deficits or cerebral haemorrhage
  • 25. Follow-up • Indication of chemotherapy after the evacuation of the hydatidiform mole in: Serum hCG >20000 i.u/L , at any time after evacuation of mole.  Raised hCG at 4 to 6 weeks after evacuation of mole.
  • 26. Evidence of metastases ,hepatic,brain,and pulmonary. Persistent uterine hemorrhage after evacuation of mole with raised hCG levels.
  • 27. Follow-up • Pregnancy is not allowed except after one year of negative follow up but with danger of : Molar pregnancy (4-5 times greater risk).  Spontaneous abortion. Premature delivery.
  • 28. Pregnancy after hydatidiform mole Usually normal reproductive function Recurrence of mole in 1-2% Hence early USS to rule out a molar pregnancy and for dates Placenta or products to be sent for HPE for occult trophoblastic disease hCG level 6 weeks post evacuation or delivery
  • 29. Contraception • Contraception is recommended for 6 months after the first normal HCG result to distinguish a rising hCG because of persistent or recurrent disease from a rising hCG associated with a subsequent pregnancy. • the use of OCP is preferrrable because they have the advantage of supressing endogenous LH, which may interfere with the measurement of hCG at low levels and studies have shown that they do not increase the risk of postmolar trophoblastic neoplasia
  • 30. Future pregnancy • If a further molar pregnancy does occur,in 68–80% of cases it will be of the same histological type