This case presentation describes a 24-year-old woman who presented with complaints of amenorrhea for 21+ weeks, per vaginal bleeding for two days, and passage of grape-like substances for one day. Her medical history and examination findings were presented. Initial diagnosis of a molar pregnancy was made based on her history and ultrasound findings. She underwent suction and evacuation surgery, which confirmed the diagnosis of a molar pregnancy based on histopathology. She was discharged with advice for follow up, contraception, and monitoring of beta hCG levels. The case discussion then provides an overview of gestational trophoblastic diseases including classification, etiology, pathogenesis, clinical features and management of hydatidiform mole.

1. A case presentation
PRESENTED BY :
DR. MD. TANVIR ELAHI
DR. MD. ISMAIL HOSEN

2.  Mrs. Yesmin akter 24 years old muslim female house wife
hailing from gafargaon, Mymensingh came to this hospital
with the complaints of:
1. H/o Amenorrhea for 21+ weeks
2. H/O per vaginal bleeding for two days
3. H/O passage of grape like substances for one day
4. Lower abdominal pain for 15 days

3. History of present illness
 According to the statement of the patient she was a regularly
menstruating woman with normal flow and duration. Then
she developed amenorrhea for 21+ weeks. She confirmed her
pregnancy by urinary strip test. She was not a booked case
and was not on her regular ANC. Her pregnancy was
uneventful untill she developed per vaginal bleeding for 01
month which was irregular and scanty in amount but for last
two days it was moderate in amount. She also complaints
lower abdominal pain for 15 days which was mild in nature
initially then became moderate for last 2 days. She also
complaints of passage of grape like substances for one day.
She also complaints of excessive vomiting during pregnancy
period. With all these complaints she was admitted to this
hospital for better management.

4. History of past illness:
 Patient is non diabetic, normotensive, non asthmatic and has no h/o any
other diseases

5. Obstetric History
 Married for : 06 years
 Para : 2c/s+ 0ab
 gravida : 3rd
 Number of living chid : 2
 Age of last child : 1.5 years
Menstrual History
 MC : R(28 + 2 days)
 MP : 3-5 days
 LMP : May 27, 2019
 EDD : May 14, 2020
 Contraceptive history : OCP

6.  Family history: Nothing significant
 Socio economic history : Nothing significant
 Drug history : Nothing significant
 Immunization history : She was immunized as per EPI schedule
 Surgical history: she has a h/o previous two c/s

7. General Examination
 Appearance : Ill Looking
 Body built : Average
 Co-Operation Co operative
 Decubitus : supine
 Anaemia : +
 Jaundice : Absent
 Oedema : absent
 Pulse : 80 beats/min
 BP : 110/70
 Respiratory rate : 20 breaths/min
 Temp. : 980F

8. Per abdomina examination:
 On inspection:
 The lower abdomen is enlarged. There is presence of transverse scar mark in the lower
abdomen.
 On palpation:
 Height of the uterus: 24 weeks
 Feel of the uterus : Doughy feel
 Fetal parts , fetal movement : Absent
 On auscultation:
 Fetal heart sound : Absent
 All other systemic examination revealed normal

9. Per vaginal examination
 On inspection:
 Vulva and vagina was normal. Mild per vaginal bleeding was present.
 On digital examination:
 Cervical os was closed.

10. Probable diagnosis
 On the basis of history taking and clinical examination our porobable
diagnosis is Molar pregnancy

11. Differential diagnosis
1. Threatend abortion
2. Missed abortion
3. Fibroid uterus with pregnancy

12. Investigations
Ivestigations to establish
diagnosis
 Serum Beta hCG
 Uktra sonogr
 X ray chest P/A view
 Bleeding time clotting time
Routine investigations for ANC
 Complete blood count
 Urine R/M/E
 Blood grouping and cross matching
 Seeological examination
 TSH
 FBS & 2 hours after 75gm glucose
intake
 USG of pregnancy profile
HBsAg, Anti HIV 1&2,
VDRL

22. Confirmatory Diagnosis
 Our confirmatory diagnosis is Molar pregnancy

23. Treatment given
 Order on admission:
 Bed rest
 Diet: Normal
 Inj. Cephradin(1gm)-------- 1 vial I/V stat and Q6H
 Inf. Metronidazole(500mg/100mL)--------1 bottle I/V Stat and TDS
 Inj. Esomeprazole(40mg) ------- 1 vial I/V stat and BD
 Inj. Tiemonium methylsulphate(5mg)----- 1 amp. I/V stat and TDS

24. After establishment of diagnosis
patient was given following pre
operative order Bed rest
 Diet: NPO --------------TFO
 Inf. Harmann’s solution(1L) I/V running---------stat
 Inj. Cephradin(1gm)------ Ivial I/V Stat and Q6H
 Inf. Metronidazole(500mg/100mL)------1 Bottle I/V Stat and TDS
 Inj vitamin C----- iamp. I/V Stat
 Inj. Vit B complex------1 amp. I/V Stat

25. Definitive treatment- Suction and
evacuation
 Prior surgical procedure cross match was done and two units of blood
were kept preserved.
 Patient counselling was done
 Informed written conscent was taken from legal guardian
 Then patient was sent to OT

26. Operation Notes
Time: 7.20 PM
Date : Nov 01, 2019
Name of operation : Suction and Evacuation
Indication of operation: Molar pregnancy
Procedure :
With all aseptic precaution suction and evacuation has been done
under G/A. No complications occurred during the procedure.
** Height of the uterus : 24 weeks
** amount of product : Huge
** Amount of bleedong : Huge
** Specimen was sent for histopathology
Surgeon: Dr. Jinnat Sultana Assistants: Dr. Redowana Rehana
Parvin
Dr. Nisa Shifa
Anaesthesia: General anaesthesia Anaesthetist : Dr. Sharif

27. Post op. order
 Bed rest
 Diet: NPO for 6 hours
 Inf. Hartsol(1L)+ 5% DA(1L)+5% DNS (1L) + 4 amp ocin
 Inj. Avlosef(1gm)
 Inf Metryl ( 500mg)
 Inj. Maxpro(40 mg)
 Inj. Torax (30mg)
 Tab Napa (500mg)
 Tab ceevit (250mg)
 Clofenac supp

28. Post operative period
 As intra operative bleeding was huge and patient was not stable patient
was transferred to HDU.
 After improvement she was transferred to gyane ward.
 Prior discharge she was transfused with two units of blood.
 Patient has been counselled for proper follow up
 She left our hosoital on Nov 4, 2019( On 3rd pod)

30. Advice on discharge
1. Please do serum beta hCG weekly untill 3 consecutive serum beta hCG
becomes negative. then do monthly serum beta hCG for 6 months and
two monthly for next 6 months
2. Please avoid any pregnancy for at least 1 year. Better for her not to
conceive.
3. Use oral contraceptive pill or barrier method.
4. Take medicines regularly
5. Come to gynae OPD after one week with the report of serum beta hCG
and Histopathology
6. If any other complications arise withis this period of time please contact
immediately with hospital.

31. Case discussion

32. Gestational Trophoblastic Diseases
 Definition: It encompasses a spectrum of proliferative
abnormalities of trophoblast associated with pregnancy.
 Gestational trophoblastic neoplasia: Persistent GTD (ersistently
raised beta hCG) is referred as gestational trophoblastic
neoplasia(GTN)

33. Classification of gestational
trophoblastic diseases
 Hydatidiform Mole : a) Complete Mole b) Partial Mole
 Invasive Mole
 Placental site trophoblastic tumor
 Choriocarcinoma : a) Nonmetastatic ( Confined to the uterus)
b) Metastatic

34. Low Risk ( Good
Prognosis)
 Disease is present in less
than 4 months duration
 Initial serum hCG level less
than 40000 mIU/mL
 Metastasis limited to lung
and vagina
 No prior chemotherapy
 No preceding term delivery
High Risk ( Poor
Prognosis)
 Long duration of disease
 Initial serum hCG more than
40000mIU/mL
 Brain or liver metastasis
 Failure of prior
chemotherapy
 Following term pregnancy
 WHO score more than 7

35. Hydatidiform mole(Syn: Vesicular
mole)
Definition : It is an abnormal condition of the placenta where
there are partly degenerative and partly proliferative changes in
the young chorionic villi
 It is best regarded as benign neoplasia of the chorion with
malignant potential
 As there is formation of clusters of small cysts of varying size
which supeeficially resembles to hydatid cyst it is named as
hydatidiform mole
 Types: 1) Complete Mole 2) Incomplete Mole(Partial)
 However unless specified molar pregnancy relates one with
complete mole

36. Etiology
 Definite cause is not known.
 However following hypotheses and factors are the thought to be
responsible:
1) Age group: Teen Age and over 35 years of age
2) Race and Ethnicity: Common in oriental countries, Central and latin
america and africa
3) Nutrion: Inadequate intake of protein, animal fat, Low dietary
intake of carotene
4) Distubed maternal immune mechanism:
a) Rise of gamma globulin level in the absence of hepatic
disease
b) Increased association with AB blood group which
possesses no ABO antibody

37.  Cytogenetic abnormality: In general complete mole hase a chromosome
karyotype of 46 XX in 85% of cases and the molar chromisome is derived
entirely from father. The ovum nucleas may be absent or become
inactivated. It the duplicates its own chromosome after meiosis. This
phenomenon is known as androgenesis. Infrequently the chromosomal
pattern may be 46 XY or or 45X0
 Previous history of hydatidiform mole(1-4%)

38. Pathogenesis of Hydatidiform Mole
The secretion from hyperplastic cells transferred substances from
maternal blood
Accumulate in the stroma of the villi
which are devoid of blood vessels
Distension of the villi to form small vesicles
** Vesicle fluid is interstitial fluid and is almost similar to ascitic fluid but rich
in hCG

39. Naked eye appearance:
 the mass filling the uterus is made up of multiple clusters of
cysts of varying size.
 There is no trace of embryo or amniotic sac
 Hemorrhage if occurs takes place in the decidual spaces
 Microscopic appearance:
 There is maeked proliferation of the syncitial and
cytotrophoblastic epithelium
 Marked thinning of the stromal tissue due to hydropic
degeneration

40. Clinical featuresA) Patient Profile :
 Age group and parity: teenaged and erderly patient over 35
years with high parity has high prevalance
 B) Symptoms:
 Patient gives a history of amenorrhea for 8-12 weeks with
initial featues suggestive of normal pregnancy like morning
sickness etc
 Per vaginal bleeding: it is the most common oresentation.
Present in 90% cases
 It may confuse with threatened or incomplete abortion
 But in this case blood may be mixed with gelatinous fluid from
ruptired cysts giving the appearance : White currant in red
currant juice

41.  Varying degree of lower abdominal pain may be due to
Overstretching of the uterus
Concealed hemorrhage
Uterine contraction to expel out the contents
Infection
Rarely oerforation of the uterus( In case of invasive
mole)

42.  Constitutional Symptoms : a) the patient becomes sick without
any apparent reason
 Vomiting of pregnancy becomes excessive. It may be due to
excess chorionic gonadotropin
 C) Breathlessness: due to pulmonary embolization of the
trophoblastic cells
 D) thyrotoxic fearures : Tremors or tachycardia are present
ocassionally
 Probably due to increased chorionic thyrotropin
 E) Expulsion of grape like vesicles per vagina is diagnostic of
vesicular mole.
 F) No history of quickening

43.  Signs:
 Features suggestive of early moths of pregnancy are evident
 The patient looks more ill than can be accounted for.
 Pallor is present and may be unusually out of proportion to
the visible blood loss. These may be due to concealed
hemorrhage. It is mostly due iron deficiency but may be
megaloblastic due to folic acid deficiency
 Features of preclamsia: Hypertension, edema, and/or
proteinurea( In 50% cases)
 Rarely convulsion may occur

44.  On per abdominal examination:
 On Inspection
 On Palpation:
 Size of the uterus is more than that expected for the period of amenorrhea
in 70%, corresponds with the period in 20%, and smaller than the period of
amenorrhea in 10%
 The frequent finding of undue enlargement of the uterus due to exuberant
growth of the vesicles and concealed hemorrhage.
 Uterus is firm, elastic(Doughy): Due to absence of amniotic fluid sac
 Fetal parts not felt nor any fetal movement
 External ballotment can not be elicited

45.  On auscultation: Fetal heart sound absent which cannot be detected even
by the doppler effect cardioscope
 Per vaginal examination:
 Internal ballotment cannot be elicited
 Unilateral or bikateral enlargement of the ovary( Theca lutein cyst) in 25 to
50% cases
 Enlarged ovary may not be palpable due to enlarged uterus
 Finding of vesicles in vaginal discharge is oathognomonic of hydatidiform
mole
 If the cervical os is open instead of the membranes blood clot or vesicles
may be felt

46. Differential diagnosis of molar
pregnancy
Threatend abortion
Points in favor: 1. h/o
amenorrhoa for 8-12 weeks
2. Aymptoms of early
pregnancy
3.Per vaginal bleeding
Points against:
1.Expulsion of Grape like
vesicles per vagina.
2.Blood is mixed with
gelatinous fluid in case of
molar pregnancy. But in
threatened abortion blood is
dark colored
Fibroid or ovarian
tumor with
pregnancyPoints in favor: 1.
Disproportionate enlargement
of the uterus
Points against:
no Expulsion Of grape like
substance
Multiple pregnancy
Points in favor: 1. Presence Of
preeclampsia in early months
2. Disproportionate
enlargement of the uterus and
unusually high hCG titer in
urine
Points against:
1. Fetal heart sound present.
2. External ballotment
internal ballotment
positive
3. Fetal movement present
4. No expulsion of grape like
substance

47. Investigations for diagnosis
 Full blood count
 ABO and Rh grouping
 Hepatic, renal and thyroid function tests are carried out
 Ultrasonography of lowwe abdomen : Snow storm appearance
 Estimation of chorionic gonadotropin: High hCG titer in urine(Positive
pregnancy test) diluted upto 1 in 200 to 1 in 500 beyond 100days of
gestation is very much suggestive.
 Rapidly increasing value of serum hCG ( hCG is greater than
100,000mIU/mL) is usual with molar pregnancy. Normal pregnancy value
reaches a peak at about 10 to14 wekks and rarely more than 100,000
mIU/mL

48.  Plain xray of abdomen: uterine size more than 16 weeks a negative fetal
shadow may be of help.
 Straight xray of the chest should be carried out as a routine for the
evidence of pulmonary embolization even in benign mole
 Ct scan and MRI: Routinelt not done
 Histological examination of product of conception : Definitive diagnosis

49. Complications of Molar pregnancy
 Immediately: 1. Hemorrhage and shock: Due to
 A) separation of the vesicles from its attachments from the decidua may be concealed or
revealed.
 B)Mintrae intra peritoneal hemorrhage which may be the rfirst feature of perforating
mole
 C) during evacuation of the mole due to atonic uterus and uterine injury
 2. Sepsis: due to as there are no protective Membranes the vaginal organisms can creep
up into uterine cavity.
 B) presence of degenerated vesicles, sloughing decidua and old blood favors nidation of
bacterial growth.
 C) Due to increased operative Interference
 2. Perforation of the uterus: due to perforating mole which may produce massive intra
peritoneal hemorrhage b) during vaginal evacuation specially by conventional method (
d &e) or during curattege following suction and evacuation

50.  Preclampsia with convulsion or rare occasion
 Acute pulmonary insufficiency due to pulmonary embolization of
trophoblastic cells
 Coagulation failure due to pulmonary embolization of trophoblastic cells
as they cayse fibrin and platelet deposition within the vascular tree

51.  Late complications: malignant change: the development of
choriocarcinoma following hydatidiform mole occur in 2 to 10% cases.

53. Prognosis
 Risk of hemorrhage and shock is markedly diminished if there is early
diagnosis and blood transfusiin and treatment
 15-20% cases progress to persistent GTD cgaracterized by re elevation of
hCG
 5% cases metastatic disease develops
 1-4% cases recurrence of hydatidiform mole in future pregnancy
 To get good prognosis the following factors to be monitored:
 Recognition of high risk factors related to choriocarcinoma
 Careful followup of serum beta hCG
 Use of cytotoxic drug at optimum time and in the right case

54. Management
 With the use of ultrasonography and hCG tesring diagnosis is made early
in majority cases.
 The principles of management are:
1. Suction evacuation of the uterus as early as diagnosis is made
2. Correction of anaemia and infection if any
3. Counselling for regular follow up

55. Supportive therapy
 The patient usually presents with variable amount of bleeding with
associated anaemia and infection. So supportive treatment is necessary:
 I/V infusion with ringers lactate solution
 Blodd transfusion is given if patient is anaemic
 Parenteral antiobiotic is given
 Blood is kept reserved during operative procedure as there ic chance of
hemorrhage

56. Definitive therapy
 Suction and evacuation:
 Can be done under diazepam sedation or general anaesthesia
 A negative pressure is applied upto 200-250 mm Hg
 Alternatively dilatation and evacuation can also be done
 During evacuation procedure :
• Senior surgeon should be present
• Monitoring the oatient with oukse oxymeter
• 500ml ringers lactate solution iv infusion is set up
• Use of oxytocin helps the expulsion of mole and reduces blood loss but its
routine use is not recommended as it may increase the risk of embolization
• After evacuation IM Methergine 0.2 mg is given
• Following evacuation antiD Ig should be given to Rh negative woman

57. Complicarion of vaginal evacuation
 Injury to the uterus leading to hemorrhage and shock
 Acute pulmonary insufficiency(Rare but Fatal)
 Thyroid storm(Rare but fatal)
 Acute pulmonary insufficiency occur due to pulmonary embolism of
trophoblastic cells. C/F are: chest pain, tachycardia, tachypniea, dyspnoea
occuring within 4 to 6 hrs of evacuation. Medical induction by oxytocin
drip ma increase the risk of embolisation. Management: ICU support,
monitoring the arterial PO2, ventilatory assistance
 Thyroid storm: If evacuation is done under the hyperthoid state of patient
then the acute features of hyperthyroidism like hyperthermia, delirium,
covulsions, coma, even cardiovascular collapse may develop. So if patient
is also suffering from hyperthyroidism she should be given proper
treatment to make her euthyroid. Then operative procedure should be
performed.

58. Hysterectomy in case of molar
pregnancy
 Though hysterectomy reduces the risk of persistent GTD by five fold it
should bedone only in following cases:
1. Patients with age over 35 years
2. Family completed irrespective of age
3. Uncontrolled hemorrhage or perforation during surgical evacuation
4. Perforating mole
The uterus following hysterectomy should be sent to histopathology

59.  The enlarged overies (Theca lutein cyst) found during operation should be
left undisturbed as they will regress following removal of mole
 But if complications arises like rupture, torsion or infarction it should be
removed.

60. Follow up
 Even after hysterectomy following molar pregnancy there may be
persistant GTD in 305% cases. So,
 Routine followup is mandatory for all cases.