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Vesicular mole for undergraduate

Undergraduate course lectures in Obstetrics&Gynecology .Faculty of medicine,Zagazig University .Prepared by DR Manal BEHERY

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Vesicular mole for undergraduate

  1. 1. GestationalTrophoblastic Disease
  2. 2. DefinitionA clinical spectrum including all neoplasm derived from abnormal trophoblastic proliferation
  3. 3. Classification1. Hydatidiform (vesicular )mole Complete and Partial2. Invasive mole3. Choriocarcinoma4. Placental-site trophoblastic tumor
  4. 4. Vesicular moleVesicular moleVesicular moleVesicular mole
  5. 5. It is a benign neoplasm of the chorionic villi characterized by1. Marked proliferation of the trophoplast,both the syncytium & cytotrophoplast are affected.2. Oedema or hydropic degeneration of the connective tissue stroma of the villi which leads to their distension and formation of vesicles.3. Avascularity of the villi: the blood vessels disappear from villi explaining early death of the embryo
  6. 6. The microscopic appearance of hydatidiform: moleHyperplasia of trophobasitc cells •Hydropic swelling of all villi •Vessles are usually absent •
  7. 7. Incidence• 1:2000 pregnancies in United States and Europe, but 10 times more in Asia.• Predisposing factors include : Race, deficiency of protein or carotene• The incidence is higher toward the beginning and more toward the end of the childbearing period.• It is 10 times more in women over 45 years old.
  8. 8. PathologyThe uterus is distended by thin walled, translucent,grape-like vesicles ofdifferent sizes.• These are degenerated chorionic villi filled with fluid.• There is no vasculature in the chorionic villi leads to early death of the embryo.
  9. 9. Pathology• High hCG causes multiple theca lutein cysts in the ovaries in about 50% of cases.• Cysts may reach a large size (10 cm or more.• Cysts disappear• within few months(2-3),• after evacuation of the mole.
  10. 10. :i) Complete mole(• The whole conceptus is transformed into a mass of vesicles.• No embryo is present.• It is the result of fertilization of enucleated ovum ( has no chromosomes) with a sperm which will duplicate giving rise to 46 chromosomes of paternal origin only.
  11. 11. :i) Complete mole(
  12. 12. Complete mole
  13. 13. (ii) Partial mole- A part of trophoblastic tissue only shows molar changes.- There is a foetus or at least an amniotic sac.- It is the result of fertilization of an ovum by 2 sperms so the chromosomal number is 69 chromosomes
  14. 14. Partial mole
  15. 15. (ii) Partial mole
  16. 16. Differentiation between complete and partial mole Feature Complete Mole Partial MoleEmbryonic or Absent Present foetal tissueSwelling of the Diffuse Focal villiTrophoblastic Diffuse Focal hyperplasia Karyotype Paternal 46 XX Paternal and (96%) or 46 XY (4%) maternal 69 XXY or 69 XYY Malignant 5-10% Rare
  17. 17. Diagnosis
  18. 18. (A) Symptoms1.Amenorrhoea: usually of short period (2-3 months).2.Exaggerated symptoms of pregnancy especially vomiting.3.Symptoms of preeclampsia may be present as headache, and oedema
  19. 19. (A) Symptoms4. Vaginal bleeding :• The main complaint, due to separation of vesicles from uterine wall, there may be a blood stained watery discharge, the watery part is from ruptured vesicles.• Prune juice disharge may occur.• The blood is brown because it has retained for sometime in the uterine cavity.• passage of vesicles is diagnostic.• The blood may be concealed causing enlargment & tenderness of the uterus.
  20. 20. (A) Symptoms5. Abdominal pain : may be- dull-aching due to rapid distension of the uterus by the mole or by cocealed haemorrhage.- Colicky due to starting expulsion,- Sudden And Severe due to perforating mole- Ovarian pain due to stretching of the ovarian capsule or complication in the cystic ovary as torsion
  21. 21. Signs
  22. 22. General examination1.Pre-eclampsia in 20-30% of cases, usually before 20 weeks’ gestation.2.Pallor indicating anemia may be present.3.Hyperthyroidism in 3-10% of cases manifested by enlarged thyroid gland, tachycardia (due to chorionic thyrotropin secreted by trophoplast &HCG also has a thyroid stimulating effect.4.Breast signs of pregnancy.
  23. 23. Abdominal examination1.The uterus is >the period of amenorrhoea in 50% of cases, corresponds to it in 25% and smaller in 25% with inactive or dead mole.2.The uterus is doughy in consistency due to absence of amniotic fluid and its distension with vesicles.3.Fetal parts and heart sound cannot be detected except in partial mole.
  24. 24. Local examination1. Passage of vesicles (sure sign).2. Bilateral ovarian cysts in 50% of cases.3. No internal ballottement.
  25. 25. (C) Investigations1.Urine pregnancy test: is positive in high dilution.• 1/200 is highly suggestive,• 1/500 is surely diagnostic.• In normal pregnancy it is positive in dilutions up to 1/100.2. Serum b -hCG levelis highly elevated ( > 100.000 mIU/m1).
  26. 26. (C) Investigations3. Ultrasonography reveals:• The characteristic intrauterine " snow storm" appearance,• no identifiable foetus,• bilateral ovarian cysts may be detected.4. X-ray to the abdomen: shows no foetal skeleton.5. X-ray of the chest: should be performed in every case of trophoplastic tumour.
  27. 27. Partial Mole: Complex mass with manycystic areas (between arrowheads) andan embryo (arrow) in a patient with a β- HCG of 280,000 mIU/ml
  28. 28. Complete MoleComplete mole: “snowstorm” Corresponding T1 weightedappearance with multiple MRI (MRI can be helpfulcystic areas, no fetal tissue in determining extent ofpresent )trophoblastic disease
  29. 29. A real-time ultrasound of a hydatidiform mole. The dark circles of varying sizes at the top center are the edematous villi.
  30. 30. Complications1. Haemorrhage.2. Infection due to absence of the amniotic sac and due to the large surface area left after expulsion or evacuation of the mole.3. Perforation of the uterus. Spontaneous by a perforating mole or during evacuation.4. Pregnancy induced hypertension5. Hyperthyroidism.6. Subsequent development of choriocarcinoma in about 5% of cases and invasive mole in about 10% of cases.7. Recurrent mole may occur(1-2%).
  31. 31. Treatment When the diagnosis of hydatidiform mole is established, the molar pregnancy should be evacuated. Suction dilation and curttage to remove benign hydatidiform mole An oxytocic agent 20 units oxytocin in 500 m1 of 5% glucose should be infused intravenously after the start of evacuation and continued for several hours to enhance uterine urettage :contractility
  32. 32. (I) Suction evacuationDilatation of the cervix is done up to a Hegars number equal to the period of amenorrhoea in weeks e.g. No. 10 Hegar for 10 weeks’ amenorrhoea- The suction canula used will be of the same size also.
  33. 33. I) Suction evacuation(- A suction canula which may be metal or a disposable plastic (preferred) is introduced into the uterine cavity.- The canula is connected to a suction pump adjusted at negative pressure of 300-500 mmHg according to the duration of pregnancy
  34. 34. The material removed is sent for histological examination to exclude malignancy .
  35. 35. Curettage• After evacuation ,• the uterus is gently curetted with a sharp curette.• Some advise curettage one week after evacuation to ensure complete removal, but the is not the routine practice.
  36. 36. Theca lutein cysts• They are hormone dependent.• Disappear spontaneously after evacuation of the mole.• So, they are not removed surgically unless complication occur as torsion or rupture.
  37. 37. LargeLarge bilateral theca lutein cysts resembling ovarian germ cell bilateral theca lutein cysts resembling ovarian germ celltumors. With resolution of the human chorionic gonadotropin(HCG) tumors. With resolution of the human chorionic .stimulation, theygonadotropin(HCG) stimulation,return to normal-appearing ovaries they return to normal-.appearing ovaries
  38. 38. (II)HysterotomyIt may be needed for evacuation of a large mole to minimize and facilitate control of bleeding.
  39. 39. (III) HysterectomyIt should be considered in women over 40 years who have completed their family for fear ofdevelopingchoriocarcinoma.
  40. 40. IV) Medical induction(Oxytocins and / or prostaglandins may be used to encourage expulsion of the mole but must always be followed by surgical evacuation.
  41. 41. Follow up As choriocarcinoma may complicate the vesicular mole after its evacuation, detection of serum ß- hCG by radioimmunoassay is essential Normally B –subunit reach normal level 8-12 wks after evacuation
  42. 42. Follow up• ß-hCG is measured by• radioimmunoassay every week till the test becomes negative for 3 successive weeks, then the test is repeated every month for one year.• Pregnancy is allowed if the test remains negative for one year.
  43. 43. Follow up- Persistent high level indicates remnants of molar tissues which necessitate chemotherapy ( methotrexate) with or without curettage. Hysterectomy is indicated if women had enough children.- Rising hCG level after disappearance means developing of choriocarcinoma or a new pregnancy.
  44. 44. Follow upIt is expected that urine pregnancy test is negative 4 weeks after evacuation* Serum B-hCG is undetectable 4 months after evacuation.
  45. 45. Contraception during follow up• The combined pill is started when the beta-HCG becomes negative.• Till this happens, the condom can be used.• If the pill is used early the beta-HCG will take a longer time to become negative as oestrogen stimulates the growth of trophoplast.
  46. 46. IUD during follow upThe intrauterine device is not used because it may lead to irregular uterine bleeding which confuses the follow up
  47. 47. Invasive mole orChorioadenoma Destruens
  48. 48. Definition• It is a trphoplastic tumour with penetration of the myometrium by the chorionic villi.• It is locally malignantand rarely metastasizes.It may lead to perforation of uterus
  49. 49. A case of invasive mole: inside the uterine cavity the typicalsnow storm” appearance can be detected, The location of “ .blood flow suggest an invasive mole
  50. 50. . The same patient owing to the myometrial invasion.Reduced vascular resistance is detected in the uterine artery
  51. 51. Early features suggesting persistant GTN or post molar syndrome include1. Recurrent Or Persistent Vaginal Bleedig2. Subinvoluation3. Amenorrhoea4. Persistence of ovarian enlargement.5. No malignancy in endometrial biopsy
  52. 52. ChemotherapyStarted if persistant or malignant disease •developThe level of serum HCG doubles in 2 weeks), after exclusion of a new pregnancy plateaus failure HCG to decrease over 3 weeks) or the test for the hormone becomes positive after being negative or If metastases appear.
  53. 53. DefinitionA malignant form of GTD which candevelop from a hydatidiform mole or fromplacental trophoblast cells associated witha healthy fetus ,an abortion or an ectopic.pregnancy
  54. 54. Symptoms and signs• Bleeding• Infection• Abdominal swelling• Vaginal mass• Lung symptoms• Symptoms from other metastases
  55. 55. Doppler image of choriocarcinoma

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Undergraduate course lectures in Obstetrics&Gynecology .Faculty of medicine,Zagazig University .Prepared by DR Manal BEHERY


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