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