4. Physical exam
• Vital sign : BP 100/70 mmHg, PR 86 bmp, RR 18 /min, Temp 37 oC
• Wt. 52 kg Ht. 155 cms
• General appearance : thai teenage women, good consciousness
• HEENT : not pale, no icteric sclera
• Lymph node : no lymphadenopathy
• Heart : normal s1 s2, no murmur
• Lung : normal breath sound, no adventitious sound
• Abdomen : BS +ve, not tender
• Neuro : E4V5M6 pupil 3 mm RTL BE
5. Physical exam
• Affected part
• Uterus 12 wk size
• PV exam
• NIUB normal
• Vagina normal discharge
• Cervix no abnormal lesion, os closed, not tender
• Adnexa no adnexa mass, not tender
10. Molar pregnancy
• is characterized histologically by abnormalities of the
chorionic villi that consist of trophoblastic proliferation and
edema of villous stroma.
• complete or partial
11. 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)
12. Risk Factors
• Age
• adolescents and women aged 36 - 40 years have a 2-fold risk
and 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 %
14. Complete Hydatidiform Mole
• Grossly
• mass of clear
vesicles
• vary in size from
barely visible to a
few centimeters
• hang in clusters
from thin pedicles.
• Histologically
• hydropic degeneration and
villous edema
• absence of villous blood vessels
• absence of embryonic fetus and
amnion.
19. 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 duplicates
its own chromosomes after meiosis, ovum chromosomes absent or
inactivated.
• other complete moles, may be 46,XY due to dispermic fertilization
20. Complete Hydatidiform Mole
Malignant Potential
• higher incidence of malignant sequela
• 15 - 20 % had evidence of persistent trophoblastic disease
22. Partial Hydatidiform Mole
• fetal tissue and Hydatidiform changes that are focal and less
advanced
• avascular chorionic villi and vascular villi
• typically is triploid—69, XXX, 69,XXY, or much less
commonly, 69,XYY
23. Partial Hydatidiform Mole
• Grossly
• Smaller volume of tissue
• Mixture of grossly
vesicular and normal villi
• Fetus / embryo is
usually present,
although often abnormal
• syndactyly of digits 3 &
4 of both hands and
feet
• Histologically
• Mixture edematous villi & normal
villi
• Less conspicuous central cistern
formation (internal clefting)
• Mild focal trophoblast
hyperplasia without atypia
• Villous scalloping
28. Partial Hydatidiform Mole
• Malignant Potential
• lower than complete molar
• Seckl and associates (2000) documented 3 of 3000 of
partial moles to be choriocarcinoma
• Growdon and co-workers (2006) higher hCG levels
increased risk for persistent disease
• levels 200 mIU/mL in the third through 8 week post
evacuation at least a 35-% risk of persistent disease
29. Twin Molar Pregnancy
• not rare
• Vejerslev (1991) found that of 113 such pregnancies, 45 %
progressed to 28 weeks, and 70 % neonates survived
39. Suction Curettage
regardless 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 bleeding
is well controlled. The use of a 12-mm cannula is strongly advised to facilitate
evacuation. If the uterus is larger than 14 weeks of gestation, one hand should
be placed on top of the fundus, and the uterus should be massaged to stimulate
uterine contraction and reduce the risk of perforation.
• Sharp curettage When suction evacuation is believed to be complete, gentle
sharp curettage is performed to remove any residual molar tissue
40. Hysterectomy
• If no further pregnancies are desired
• aged > 40 yr.
• Uterine perforate
41. Prophylactic Chemotherapy
• Prophylactic chemotherapy not only prevented metastasis
but also reduced the incidence and morbidity of
choriocarcinoma
• But
• can’t absolutely to prevent choriocarcinoma
• After TOP 80-90 % of Molar pregnancy are cure
• and choriocarcinoma are cure by currently chemotherapy
Actinomycin D, Methotrexate
43. Human Chorionic Gonadotropin
• monitored q weekly B-hCG levels until normal for 3
consecutive weeks
• followed q monthly until normal for 6 consecutive months
44. Contraception
• Prevent pregnancy for a minimum of 1 yr. using hormonal
contraception
• oral contraceptives safely after molar evacuation during the
entire interval of hormonal follow-up
45. chemotherapy
• If
• B-hCG level rising or plateau
• Rising = increase B-hCG > 2-fold
• Plateau = no change or increase < 2-fold
46. Further of pregnancy
• Recurrent 5 - 10-fold of pregnancy
• Reassurance women if desire pregnancy but early ANC
47. Reference
• Berek, Jonathan S. Gestational Trophoblastic Disease. Berek & Novak's
Gynecology, 14th Edition.
• Chapter 11. Gestational Trophoblastic Disease. Williams Obstetrics, 23
Edition
Editor's Notes
Villous scalloping (invaginations of trophoblast tissue into villous stroma, appears circular in cross section and resembles “coast of Norway” or inclusions)
