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Molar pregnancy• is characterized histologically by abnormalities of thechorionic villi that consist of trophoblastic proliferation andedema of villous stroma.• complete or partial
Epidemiology• vary dramatically in different regions of the world• molar pregnancy in Japan (2 per 1,000 pregnancies)• in Europe or North America (about 0.6 to 1.1 per 1,000 pregnancies)
Risk Factors• Age• adolescents and women aged 36 - 40 years have a 2-fold riskand those > 40 years have 10-fold risk• Prior Molar Pregnancy• recurrent moles was 1.3 %, 1.5 % complete mole and 2.7 %partial mole• 2 prior molar pregnancies third mole 23 %
Complete versus Partial Hydatidiform Mole• Gross morphology• Histopathology• Karyotype
Complete Hydatidiform Mole• Grossly• mass of clearvesicles• vary in size frombarely visible to afew centimeters• hang in clustersfrom thin pedicles.• Histologically• hydropic degeneration andvillous edema• absence of villous blood vessels• absence of embryonic fetus andamnion.
Complete Hydatidiform Mole• usually diploid and of paternal origin• 85 % are 46,XX with both of chromosomes paternal origin• androgenesis, ovum is fertilized by a haploid sperm, which duplicatesits own chromosomes after meiosis, ovum chromosomes absent orinactivated.• other complete moles, may be 46,XY due to dispermic fertilization
Complete Hydatidiform MoleMalignant Potential• higher incidence of malignant sequela• 15 - 20 % had evidence of persistent trophoblastic disease
Partial Hydatidiform Mole• fetal tissue and Hydatidiform changes that are focal and lessadvanced• avascular chorionic villi and vascular villi• typically is triploid—69, XXX, 69,XXY, or much lesscommonly, 69,XYY
Partial Hydatidiform Mole• Grossly• Smaller volume of tissue• Mixture of grosslyvesicular and normal villi• Fetus / embryo isusuallypresent, although oftenabnormal• syndactyly of digits 3 &4 of both hands andfeet• Histologically• Mixture edematous villi & normalvilli• Less conspicuous central cisternformation (internal clefting)• Mild focal trophoblasthyperplasia without atypia• Villous scalloping
Partial Hydatidiform Mole• Malignant Potential• lower than complete molar• Seckl and associates (2000) documented 3 of 3000 ofpartial moles to be choriocarcinoma• Growdon and co-workers (2006) higher hCG levelsincreased risk for persistent disease• levels 200 mIU/mL in the third through 8 week postevacuation at least a 35-% risk of persistent disease
Twin Molar Pregnancy• not rare• Vejerslev (1991) found that of 113 such pregnancies, 45 %progressed to 28 weeks, and 70 % neonates survived
Terminaton of pregnancy• Suction & curettage• Hysterectomy• Prophylactic chemotherapy
Suction Curettageregardless of uterine size & preserve fertility following steps:• Oxytocin infusion before the induction of anesthesia.• Cervical dilation• Suction curettage the uterus may decrease dramatically in size, and the bleedingis well controlled. The use of a 12-mm cannula is strongly advised to facilitateevacuation. If the uterus is larger than 14 weeks of gestation, one hand shouldbe placed on top of the fundus, and the uterus should be massaged to stimulateuterine contraction and reduce the risk of perforation.• Sharp curettage When suction evacuation is believed to be complete, gentlesharp curettage is performed to remove any residual molar tissue
Hysterectomy• If no further pregnancies are desired• aged > 40 yr.• Uterine perforate
Prophylactic Chemotherapy• Prophylactic chemotherapy not only prevented metastasisbut also reduced the incidence and morbidity ofchoriocarcinoma• But• can’t absolutely to prevent choriocarcinoma• After TOP 80-90 % of Molar pregnancy are cure• and choriocarcinoma are cure by currently chemotherapyActinomycin D, Methotrexate
Follow-up• Human Chorionic Gonadotropin• Contraception• Chemotherapy
Human Chorionic Gonadotropin• monitored q weekly B-hCG levels until normal for 3consecutive weeks• followed q monthly until normal for 6 consecutive months
Contraception• Prevent pregnancy for a minimum of 1 yr. using hormonalcontraception• oral contraceptives safely after molar evacuation during theentire interval of hormonal follow-up
chemotherapy• If• B-hCG level rising or plateau• Rising = increase B-hCG > 2-fold• Plateau = no change or increase < 2-fold
Further of pregnancy• Recurrent 5 - 10-fold of pregnancy• Reassurance women if desire pregnancy but early ANC
Reference• Berek, Jonathan S. Gestational Trophoblastic Disease. Berek & NovaksGynecology, 14th Edition.• Chapter 11. Gestational Trophoblastic Disease. Williams Obstetrics, 23Edition