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vesicular molle 1

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vesicular molle 1

  1. 1. Gestational Trophoblastic Disease <ul><li>Complete vesicular mole </li></ul><ul><li>Partial vesicular mole </li></ul><ul><li>Invasive mole </li></ul><ul><li>Placental-site trophoblastic tumor </li></ul><ul><li>Choriocarcinoma </li></ul>
  2. 2. Definition <ul><li>It is a benign neoplasm of the chorionic villi, characterized by: </li></ul><ul><li>Marked proliferation of the trophoplast, both the syncytium & cytotrophoplast are affected. </li></ul><ul><li>Oedema or hydropic degeneration of the connective tissue stroma of the villi which leads to their distension and formation of vesicles. </li></ul><ul><li>Avascularity of the villi : the blood vessels disappear from villi explaining early death of the embryo </li></ul>
  3. 3. Incidence: <ul><li>1:2000 pregnancies in United States and Europe, but 10 times more in Asia. </li></ul><ul><li>Predisposing factors include : </li></ul><ul><li>Race,deficiency of protein or carotene </li></ul><ul><li>The incidence is higher toward the beginning and more toward the end of the childbearing period. </li></ul><ul><li>It is 10 times more in women over 45 years old. </li></ul>
  4. 4. Pathology: <ul><li>The uterus is distended by thin walled, translucent, grape-like vesicles of different sizes. </li></ul><ul><li>These are degenerated chorionic villi filled with fluid. </li></ul><ul><li>There is no vasculature in the chorionic villi leads to early death and absorption of the embryo. </li></ul>
  5. 5. <ul><li>There is trophoblastic proliferation , with mitotic activity affecting both syncytial and cytotrophoblastic layers. </li></ul><ul><li>This causes excessive secretion of hCG, chorionic thyrotrophin and progesterone. </li></ul><ul><li>On the other hand, oestrogen production is low due to absence of the foetal supply of precursors. </li></ul>Pathology:
  6. 6. <ul><li>High hCG causes multiple theca lutein cysts in the ovaries in about 50% of cases. </li></ul><ul><li>Cysts may reach a large size (10 cm or more. </li></ul><ul><li>Cysts disappear within few months(2-3), after evacuation of the mole. </li></ul><ul><li>High hCG also results in exaggeration of the normal early pregnancy symptoms and signs </li></ul>Pathology:
  7. 8. <ul><li>Histologic section of a complete hydatidiform mole stained with hematoxylin and eosin. </li></ul><ul><li>Villi of different sizes are present. </li></ul><ul><li>The large villous in the center exhibits marked edema with a fluid-filled central cavity known as cisterna. </li></ul><ul><li>Marked proliferation of the trophoblasts is observed. </li></ul><ul><li>The syncytiotrophoblasts stain purple, while the cytotrophoblasts have a clear cytoplasm and bizarre nuclei. </li></ul><ul><li>No fetal blood vessels are in the mesenchyme of the villi. </li></ul>
  8. 9. Complete mole Partial mole Types:
  9. 10. (i) Complete mole: <ul><li>The whole conceptus is transformed into a mass of vesicles. </li></ul><ul><li>No embryo is present. </li></ul><ul><li>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. </li></ul>
  10. 11. (i) Complete mole:
  11. 12. (ii) Partial mole <ul><li>- A part of trophoblastic tissue only shows molar changes. </li></ul><ul><li>- There is a foetus or at least an amniotic sac. </li></ul><ul><li>- It is the result of fertilization of an ovum by 2 sperms so the chromosomal number is 69 chromosomes </li></ul>
  12. 14. (ii) Partial mole
  13. 15. DIFFERENTIATION BETWEEN COMPLETE AND PARTIAL MOLE Rare 5-10% Malignant Changes Paternal and maternal 69 XXY or 69 XYY Paternal 46 XX (96%) or 46 XY (4%) Karyotype Focal Diffuse Trophoblastic hyperplasia Focal Diffuse Swelling of the villi Present Absent Embryonic or foetal tissue Partial Mole Complete Mole Feature
  14. 16. Diagnosis
  15. 17. (A) Symptoms : <ul><li>Amenorrhoea : usually of short period (2-3 months). </li></ul><ul><li>Exaggerated symptoms of pregnancy especially vomiting. </li></ul><ul><li>3.Symptoms of preeclampsia may be present as headache, and oedema </li></ul>
  16. 18. <ul><li>4. Vaginal bleeding : </li></ul><ul><li>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. </li></ul><ul><li>Prune juice disharge may occur. </li></ul><ul><li>The blood is brown because it has retained for sometime in the uterine cavity. </li></ul><ul><li>The passage of vesicles is diagnostic. </li></ul><ul><li>The blood may be concealed causing enlargment & tenderness of the uterus. </li></ul>(A) Symptoms:
  17. 19. <ul><li>5. Abdominal pain : may be , </li></ul><ul><li>- dull-aching due to rapid distension of the uterus by the mole or by cocealed haemorrhage. </li></ul><ul><li>- colicky due to starting expulsion, </li></ul><ul><li>sudden and severe due to perforating mole </li></ul><ul><li>Ovarian pain due to stretching of the ovarian capsule or complication in the cystic ovary as torsion </li></ul>(A) Symptoms:
  18. 20. (B) Signs
  19. 21. General examination: <ul><li>Pre-eclampsia develops in 20-30% of cases, usually before 20 weeks’ gestation. </li></ul><ul><li>Pallor indicating anemia may be present. </li></ul><ul><li>Hyperthyroidism develops 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. </li></ul><ul><li>Breast signs of pregnancy. </li></ul>
  20. 22. Abdominal examination: <ul><li>The uterus is larger than the period of amenorrhoea in 50% of cases, corresponds to it in 25% and smaller in 25% with inactive or dead mole. </li></ul><ul><li>The uterus is doughy in consistency due to absence of amniotic fluid and its distension with vesicles. </li></ul><ul><li>Foetal parts and heart sound cannot be detected except in partial mole. </li></ul><ul><li>Absence of external ballottement. </li></ul>
  21. 23. Local examination : <ul><li>Passage of vesicles (sure sign). </li></ul><ul><li>Bilateral ovarian cysts in 50% of cases. </li></ul><ul><li>No internal ballottement. </li></ul>
  22. 24. <ul><li>Urine pregnancy test: </li></ul><ul><li>is positive in high dilution. </li></ul><ul><li>1/200 is highly suggestive, </li></ul><ul><li>1/500 is surely diagnostic. </li></ul><ul><li>In normal pregnancy it is positive in dilutions up to 1/100. </li></ul><ul><li>2. Serum b -hCG level : is highly elevated ( > 100.000 mIU/m1). </li></ul>(C) Investigations:
  23. 25. (C) Investigations: <ul><li>3. Ultrasonography reveals : </li></ul><ul><li>The characteristic intrauterine &quot; snow storm &quot; appearance, </li></ul><ul><li>no identifiable foetus, </li></ul><ul><li>bilateral ovarian cysts may be detected. </li></ul><ul><li>4. X-ray to the abdomen: shows no foetal skeleton. </li></ul><ul><li>5. X-ray of the chest: should be performed in every case of trophoplastic tumour. </li></ul>
  24. 26. A real-time ultrasound of a hydatidiform mole. The dark circles of varying sizes at the top center are the edematous villi.
  25. 27. Complications: <ul><li>Haemorrhage . </li></ul><ul><li>Infection due to absence of the amniotic sac and due to the large surface area left after expulsion or evacuation of the mole. </li></ul><ul><li>Perforation of the uterus. Spontaneous by a perforating mole or during evacuation. </li></ul><ul><li>Pregnancy induced hypertension </li></ul><ul><li>Hyperthyroidism . </li></ul><ul><li>Subsequent development of choriocarcinoma in about 5% of cases and invasive mole in about 10% of cases. </li></ul><ul><li>Recurrent mole may occur( 1-2% ). </li></ul>
  26. 28. Treatment: <ul><li>As soon as the diagnosis of vesicular mole is established the uterus should be evacuated. </li></ul><ul><li>The selected method depends on the size of the uterus, whether partial expulsion has already occur or not, the patient's age and fertility desire . </li></ul><ul><li>Cross - matched blood should be available before starting. </li></ul>
  27. 29. <ul><li>- It is carried out under general anaesthesia , but not that which relax the uterus as halothane as it may induce severe bleeding. </li></ul><ul><li>- An infusion of 20 units oxytocin in 500 m1 of 5% glucose should be maintained throughout the procedure. </li></ul>(I) Suction evacuation:
  28. 30. <ul><li>Dilatation of the cervix is done up to a Hegar's number equal to the period of amenorrhoea in weeks e.g. N o . 10 Hegar for 10 weeks’ amenorrhoea. </li></ul><ul><li>The suction canula used will be of the same size also. </li></ul>(I) Suction evacuation:
  29. 31. (I) Suction evacuation: <ul><li>- A suction canula which may be metal or a disposable plastic (preferred) is introduced into the uterine cavity. </li></ul><ul><li>The canula is connected to a suction pump adjusted at negative pressure of 300-500 mmHg according to the duration of pregnancy. </li></ul><ul><li>The material removed is sent for histological examination. </li></ul>
  30. 32. Curettage <ul><li>After evacuation ,the uterus is gently curetted with a sharp curette. </li></ul><ul><li>Some advise curettage one week after evacuation to ensure complete removal, but the is not the routine practice. </li></ul>
  31. 33. Theca lutein cysts <ul><li>They are hormone dependent. </li></ul><ul><li>Disappear spontaneously after evacuation of the mole. </li></ul><ul><li>So, they are not removed surgically unless complication occur as torsion or rupture. </li></ul>
  32. 34. (II)Hysterotomy: <ul><li>It may be needed for evacuation of a large mole to minimize and facilitate control of bleeding. </li></ul>
  33. 35. (III) Hysterectomy: <ul><li>It should be considered in women over 40 years who have completed their family for fear of developing choriocarcinoma. </li></ul>
  34. 36. (IV) Medical induction: <ul><li>Oxytocins and / or prostaglandins may be used to encourage expulsion of the mole but must always be followed by surgical evacuation. </li></ul>
  35. 37. Follow up : <ul><li>As choriocarcinoma may complicate the vesicular mole after its evacuation, detection of serum ß-hCG by radioimmunoassay is essential </li></ul>
  36. 38. <ul><li>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. </li></ul><ul><li>Pregnancy is allowed if the test remains negative for one year. </li></ul>Follow up :
  37. 39. Follow up : <ul><li>Persistent high level indicates remnants of molar tissues which necessitate chemotherapy </li></ul><ul><li>( methotrexate) with or without curettage. Hysterectomy is indicated if women had enough children. </li></ul><ul><li>Rising hCG level after disappearance means developing of choriocarcinoma or a new pregnancy. </li></ul>
  38. 40. <ul><li>It is expected that urine pregnancy test is negative 4 weeks after evacuation and serum b -hCG is undetectable 4 months after evacuation. </li></ul>Follow up :
  39. 41. Contraception during follow up <ul><li>The combined pill is started when the beta-HCG becomes negative. </li></ul><ul><li>Till this happens, the condom can be used. </li></ul><ul><li>If the pill is used early the beta-HCG will take a longer time to become negative as oestrogen stimulates the growth of trophoplast. </li></ul>
  40. 42. <ul><li>The intrauterine device is not used because it may lead to irregular uterine bleeding which confuses the follow up </li></ul>Contraception during follow up
  41. 43. Invasive Mole or Chorioadenoma Destruens <ul><li>It is a trphoplastic tumour with penetration of the myometrium by the chorionic villi. </li></ul><ul><li>It is locally malignant and rarely metastasizes. </li></ul><ul><li>It may lead to perforation of uterus </li></ul>
  42. 44. <ul><li>Early features suggesting residual molar tissue include: </li></ul><ul><li>recurrent or persistent vaginal bleeding, </li></ul><ul><li>amenorrhoea, </li></ul><ul><li>failure of uterine involution, </li></ul><ul><li>persistence of ovarian enlargement. </li></ul>
  43. 45. Thank you