1. MOLAR PREGNANCYMOLAR PREGNANCY
Dr. NADIA NAZEERDr. NADIA NAZEER

2. INTRODUCTION:INTRODUCTION:
Molar pregnancy is a premalignant form of Gestational trophoblasticMolar pregnancy is a premalignant form of Gestational trophoblastic
diseases that occur after abnormal fertilization.diseases that occur after abnormal fertilization.
Risk FactorsRisk Factors
Age < 15->40Age < 15->40
Previous history of hydatidiform molePrevious history of hydatidiform mole
Previous miscarriagePrevious miscarriage
Excessive smokingExcessive smoking
Reduce carotene intakeReduce carotene intake

3. TYPES OF HYDATIDIFORMTYPES OF HYDATIDIFORM
MOLEMOLE
 Complete hydatidiform moleComplete hydatidiform mole
 Partial hydatidiform molePartial hydatidiform mole

4. PATHOLOGYPATHOLOGY
 Complete mole:Complete mole:
CHMs develop without the formation of fetal tissue. On pathologic evaluation,CHMs develop without the formation of fetal tissue. On pathologic evaluation,
CHMs demonstrate swollen chorionic villi with a grapelike appearance andCHMs demonstrate swollen chorionic villi with a grapelike appearance and
with hyperplasic trophoblastic tissue.with hyperplasic trophoblastic tissue.
Transverse endovaginal sonogram of a second-trimester complete
hydatidiform mole (CHM) demonstrates a distended endometrial cavity
containing innumerable, variably sized anechoic cysts with intervening
hyperechoic material.

5. Partial Hydatidiform mole:Partial Hydatidiform mole:
Fetal tissue is often present in PHMs, but the fetus is nonviable, it is severelyFetal tissue is often present in PHMs, but the fetus is nonviable, it is severely
growth restricted, or it has multiple anomalies. On pathologic analysis, PHMsgrowth restricted, or it has multiple anomalies. On pathologic analysis, PHMs
show unpronounced swelling of chorionic villi and unpronounced trophoblasticshow unpronounced swelling of chorionic villi and unpronounced trophoblastic
hyperplasia.hyperplasia.
Transverse transpelvic sonogram of a partial hydatidiform mole (PHM) at 16 weeks.
The major imaging feature is the presence of fetal tissue on the left side of the image
and the many small cysts that replace the placental tissue on the right side. This
finding has a distribution more focal than that typically found in CHM.

6. Genetics.Genetics.
 Complete mole:Complete mole:
CHMs have a diploid chromosomal pattern, with all chromosomesCHMs have a diploid chromosomal pattern, with all chromosomes
being derived from the father by means of either monospermic orbeing derived from the father by means of either monospermic or
dispermic fertilization.dispermic fertilization.
 Partial Mole:Partial Mole:
Partial hydatidiform moles (PHMs) usually have a triploidPartial hydatidiform moles (PHMs) usually have a triploid
karyotype (69XXX, 69XXY, or 69XYY) resulting fromkaryotype (69XXX, 69XXY, or 69XYY) resulting from
fertilization of a normal egg by 2 sperm. Therefore, triploidfertilization of a normal egg by 2 sperm. Therefore, triploid
PHMs consist of 2 sets of paternal chromosomes and 1 setPHMs consist of 2 sets of paternal chromosomes and 1 set
of maternal chromosomes.of maternal chromosomes.

7. CLINICAL FEATURESCLINICAL FEATURES
 Vaginal Bleeding.There is passage of grapeVaginal Bleeding.There is passage of grape
like vesicles in vaginal bleeding.like vesicles in vaginal bleeding.
 Uterine Enlargement more than of dates.Uterine Enlargement more than of dates.
 Hyperemesis GravidarumHyperemesis Gravidarum
 Theca Lutein Cyst.It is usually bilateral andTheca Lutein Cyst.It is usually bilateral and
due to hyperstumulation of ovaries by betadue to hyperstumulation of ovaries by beta
hCGhCG
 Pre-eclampsiaPre-eclampsia
 Hyperthyroidism.It is due to TSH LIKEHyperthyroidism.It is due to TSH LIKE
function alpha subunits of beta hCGfunction alpha subunits of beta hCG

8. COMPLICATIONSCOMPLICATIONS
 Immediate Complications:Immediate Complications:
1.1. Uterine perforationUterine perforation
2.2. HaemorrhageHaemorrhage
3.3. Pelvic sepsisPelvic sepsis
 Long Terms Complications:Long Terms Complications:
1.1. Invasive moleInvasive mole
2.2. ChoriocarcinomaChoriocarcinoma

9. INVESTIGATIONSINVESTIGATIONS
 Human Chronic Gonadotrophin:Human Chronic Gonadotrophin: TheThe
syncytiotrophoblast is responsible for producing beta-syncytiotrophoblast is responsible for producing beta-
human chorionic gonadotropin (hCG).human chorionic gonadotropin (hCG).
 Ultra SonoGraphy:Ultra SonoGraphy:
Sonography is the imaging investigation of choice forSonography is the imaging investigation of choice for
hydatidiform mole. The most common sonoghraphic picturehydatidiform mole. The most common sonoghraphic picture
is the snow storm or granular appearance which representis the snow storm or granular appearance which represent
the hyperechoic central urterine mass with hypoechoicthe hyperechoic central urterine mass with hypoechoic
cystic spaces with no fetal parts in case of complete mole.cystic spaces with no fetal parts in case of complete mole.
In 25% cases a typical appearance.In 25% cases a typical appearance.
1.1. Large hyperechoic area.Large hyperechoic area.
2.2. Single large central fluid collection with hyperechoic rimSingle large central fluid collection with hyperechoic rim
resembling and anembryonic gestation.resembling and anembryonic gestation.
3.3. Bilateral theca lutein cysts are visualized in 50% of theBilateral theca lutein cysts are visualized in 50% of the
cases.cases.

10.  MRI:MRI:
MRI has no established role in the initial diagnosisMRI has no established role in the initial diagnosis
of hydatidiform moles. It is useful in malignant formsof hydatidiform moles. It is useful in malignant forms
of gestational trophoblastic neoplasm (GTN) toof gestational trophoblastic neoplasm (GTN) to
characterize the degree of myometrial and/orcharacterize the degree of myometrial and/or
parametrial invasion and to assess the treatmentparametrial invasion and to assess the treatment
response.response.

11. Complete Mole.Complete Mole. Transabdominal and transvaginal sonographs show an enlargedTransabdominal and transvaginal sonographs show an enlarged
uterusuterus
containing a large echogenic mass (yellow dotted line) with innumerable anechoiccontaining a large echogenic mass (yellow dotted line) with innumerable anechoic
(cystic) spaces (green arrows). (cystic) spaces (green arrows).
Vascular flow is seen during systole (open red arrow) and diastole (closed red arrow),Vascular flow is seen during systole (open red arrow) and diastole (closed red arrow),
representing low resistance flow within this mass. No intrauterine gestation is seen.representing low resistance flow within this mass. No intrauterine gestation is seen.
In combination with an extremely elevated beta-hCG, these findings are concerningIn combination with an extremely elevated beta-hCG, these findings are concerning
for a complete molar pregnancy.for a complete molar pregnancy.

16. DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
 Anembronic gestational sacAnembronic gestational sac
 Pseudo gestational sac of EctopicPseudo gestational sac of Ectopic
pregnancypregnancy
 Hydropic degeneration of placentaHydropic degeneration of placenta
associated with incomplete / missedassociated with incomplete / missed
abortionabortion
 Degenerating leiomyomaDegenerating leiomyoma
 ChoriocarcinomaChoriocarcinoma

17. TREATMENTTREATMENT
 Suction CurettageSuction Curettage
Dilation and curettage are curative in 84% of CHMs andDilation and curettage are curative in 84% of CHMs and
99.5% of PHMs.99.5% of PHMs.
 HysterectomyHysterectomy

18. FOLLOW UPFOLLOW UP
 Serial quantitative beta-HCG levels areSerial quantitative beta-HCG levels are
followed up every 2 weeks until the level isfollowed up every 2 weeks until the level is
in the reference range (<5 mIU/mL). Afterin the reference range (<5 mIU/mL). After
normalization occurs, monthly serum beta-normalization occurs, monthly serum beta-
hCG surveillance is recommended for 3-6hCG surveillance is recommended for 3-6
months in patients with partial hydatidiformmonths in patients with partial hydatidiform
mole (PHM) and for 12 months in patientsmole (PHM) and for 12 months in patients
with CHM.with CHM.

19. Prophylactic ChemotherapyProphylactic Chemotherapy
Post evacuation prophylactic chemotherapy isPost evacuation prophylactic chemotherapy is
controversial.controversial.
It is recommended in patients with high riskIt is recommended in patients with high risk
criteria serum hCG level >100,000 mIU/mL, uteruscriteria serum hCG level >100,000 mIU/mL, uterus
larger than usual for the date of pregnancy,larger than usual for the date of pregnancy,
ovaries > 6 cm in diameter, and/or associatedovaries > 6 cm in diameter, and/or associated
medical conditions and epidemiologic factors (eg,medical conditions and epidemiologic factors (eg,
previous molar pregnancy or trophoblastic tumor,previous molar pregnancy or trophoblastic tumor,
maternal age >40 y, toxemia, coagulopathy,maternal age >40 y, toxemia, coagulopathy,
trophoblastic embolization, hyperthyroidism).trophoblastic embolization, hyperthyroidism).