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Hydatidiform Mole

Molar Pregnancy

A hydatidiform mole (hydatid mole, mola hydatidosa) is a placental mass resulting from the proliferation of the trophoblast, with hydropic degeneration and avascularity of the chorionic villi.


Presentation

The classic signs and symptoms of complete mole are:

  • Vaginal bleeding: Up to 50% of the cases of complete mole have vaginal bleeding, making it the most common classical symptom of this condition.
  • Nausea and vomiting: High levels of hCG (human chorionic gonadotropin) lead to severe nausea and vomiting.
  • Hyperthyroidism: hCG (human chorionic gonadotropin) as well as other thyroid stimulating substances (such as thryrotropin) produced by the trophoblast can cause the signs and symptoms of hyperthyroidism.
  • Absence of fetal heart sounds

Incomplete moles do not give rise to the above mentioned classical signs and symptoms. Vaginal bleeding and absence of fetal heart sounds mimic an incomplete or missed abortion.
The use of advanced imaging techniques such as high resolution ultrasonography routinely during the course of pregnancies has revolutionized the diagnosis of hydatidiform moles. As a result, molar pregnancies are now easily detected in the first trimester and the classical clinical presentation is rarely seen [8] [9].

Vomiting
  • The pregnancy was unremarkable except for the complaints of excessive nausea and vomiting.[ncbi.nlm.nih.gov]
  • The patient was admitted to our clinic complaining of acute abdominal pain, nausea and vomiting lasting one day.[ncbi.nlm.nih.gov]
  • A 34-year-old female in her 10th week of gestation presented with nausea, vomiting, and intermittent abdominal pain that progressively worsened.[ncbi.nlm.nih.gov]
  • Nausea and vomiting: High levels of hCG (human chorionic gonadotropin) lead to severe nausea and vomiting.[symptoma.com]
  • You cannot stop vomiting. You have changes in your vision. Your heart is beating faster than usual. You have questions or concerns about your condition or care. When should I seek immediate care or call 911? You have vaginal bleeding.[drugs.com]
Nausea
  • The pregnancy was unremarkable except for the complaints of excessive nausea and vomiting.[ncbi.nlm.nih.gov]
  • The patient was admitted to our clinic complaining of acute abdominal pain, nausea and vomiting lasting one day.[ncbi.nlm.nih.gov]
  • A 34-year-old female in her 10th week of gestation presented with nausea, vomiting, and intermittent abdominal pain that progressively worsened.[ncbi.nlm.nih.gov]
  • Nausea and vomiting: High levels of hCG (human chorionic gonadotropin) lead to severe nausea and vomiting.[symptoma.com]
  • Symptoms of a partial molar pregnancy include severe nausea, vomiting, and hypertension (high blood pressure) early in the pregnancy, often in the first trimester. Cleveland Clinic News & More Cleveland Clinic News & More[my.clevelandclinic.org]
Abdominal Pain
  • In a pregnant patient, vaginal bleeding and abdominal pain are common presentations. Molar pregnancy is an uncommon cause of abdominal pain and vaginal bleeding that should be considered.[ncbi.nlm.nih.gov]
  • The patient underwent a caesarean section at twenty eight weeks for maternal distress due to unbearable abdominal pain. The baby died after seven days.[ncbi.nlm.nih.gov]
  • A 34-year-old female in her 10th week of gestation presented with nausea, vomiting, and intermittent abdominal pain that progressively worsened.[ncbi.nlm.nih.gov]
  • A young woman presented early in her pregnancy with severe abdominal pain, tachycardia, and hypotension. She was taken emergently to the operating room with a presumed diagnosis of ruptured ectopic pregnancy.[ncbi.nlm.nih.gov]
  • We present the case of a 32-year-old female who presented with abdominal pain and vaginal bleed since 2 days of presentation. She was vitally stable. There was mild tenderness in hypogastrium and left iliac fossa.[ncbi.nlm.nih.gov]
Morning Sickness
  • The symptoms of molar pregnancy, which may include vaginal bleeding, severe morning sickness, stomach cramps, and high blood pressure, typically begin around the 10th week of pregnancy.[diseaseinfosearch.org]
  • Some women with a molar pregnancy have: vaginal bleeding or a dark discharge from the vagina in early pregnancy (usually in the first three months) – this may contain small, grape-like lumps severe morning sickness an unusually swollen tummy But some[nhs.uk]
Hypertension
  • All these signs suggest the possibility of trophoblastic embolisation during the intraoperative period leading to pulmonary artery hypertension (PAH) and pulmonary oedema rather than uncontrolled hyperthyroidism, as suggested by the author.[dx.doi.org]
  • Once the patient had been informed of the risks, it was decided to continue the pregnancy, but termination of pregnancy was necessary at week 13 5 due to maternal complications consisting of hyperthyroidism, hypertension and vaginal bleeding, followed[ncbi.nlm.nih.gov]
  • During expectant management 6 patients displayed hypertension with proteinuria, representing preeclampsia, by the 2nd trimester (11-24 weeks) and the other 9 did not (nonpreeclamptic).[ncbi.nlm.nih.gov]
Short Arm
  • To our knowledge, this is the first case report of complete hydatidiform mole with coexisting fetus diagnosed by variation of the acrocentric short arms, followed by termination with intravaginal gemeprost.[ncbi.nlm.nih.gov]
Vaginal Bleeding
  • In a pregnant patient, vaginal bleeding and abdominal pain are common presentations. Molar pregnancy is an uncommon cause of abdominal pain and vaginal bleeding that should be considered.[ncbi.nlm.nih.gov]
  • Vaginal bleeding (p 0.05), increased uterine volume (p 0.0001) and hyperemesis (p 0.05) occurred more frequently in group B.[ncbi.nlm.nih.gov]
  • Presentations of molar pregnancies include vaginal bleeding, unusually elevated β-human chorionic gonadotropin level, and preeclampsia.[ncbi.nlm.nih.gov]
  • The couple wished to continue the pregnancy and a decision to accept was taken after having consulted the available literature, but at 18 weeks gestation pregnancy termination was inevitable for severe vaginal bleeding.[ncbi.nlm.nih.gov]
  • We report a case of a 36 year old woman Para 4 0 who presented with amenorrhoea of twenty four weeks duration, vaginal bleeding, abdominal pain and pre-eclampsia.[ncbi.nlm.nih.gov]
Enlarged Uterus
  • RESULTS AND DISCUSSION: Theca lutein cysts and hydropic degeneration of villi, enlarged uterus and empty gestational sac, intrauterine hematoma significantly prevailed in the pregnant women with the molar pregnancies.[ncbi.nlm.nih.gov]
  • Ultrasonography showed an enlarged uterus including hypo/hyperechogenous cystic areas in the endometrial cavity and bilateral adnexal masses. β-HCG level was investigated and determined as 157.000 IU/l, because of the suspicion of GTN in ultrasonography[ncbi.nlm.nih.gov]
  • CT may show an enlarged uterus with areas of low attenuation, or hypoattenuating foci surrounded by highly enhanced areas in the myometrium. MRI MRI may demonstrate a heterogeneous mass with cystic spaces distending the uterine cavity.[radiopaedia.org]
  • CT may show an enlarged uterus with areas of low attenuation, or hypoattenuating foci surrounded by highly enhanced areas in the myometrium. MRI MRI can be used to determine if there is an extension of molar tissue outside the uterus.[radiopaedia.org]
  • uterus pelvic discomfort pain or pressure Evaluation β-hCG complete HM partial HM Transvaginal ultrasound complete HM transvaginal ultrasound " snow storm ," " cluster of grapes, " or " honeycomb " pattern in older sonograms partial HM transvaginal ultrasound[medbullets.com]
Vaginal Discharge

Workup

Upon physical examination, a molar pregnancy classically appears too large for gestational age. Fetal heart sounds are also absent.
A number of laboratory investigations are also helpful in establishing a diagnosis of molar pregnancy.

  • beta-hCG: beta-hCG levels are much higher in molar pregnancies as compared to normal pregnancies. hCG levels exceeding 100,000 mIU/mL are strongly suggestive of molar pregnancy.
  • Serum inhibin A and activin A: Serum inhibin A and activin A are relatively newer markers for the detection of molar pregnancies. Levels of inhibin A and activin A in the serum are 7 to 10 times higher in molar pregnancies as compared to normal pregnancies [10].
  • Complete blood count: Anemia and coagulopathy may be present in some cases of molar pregnancy.

In both complete and partial moles, ultrasonography is the criterion standard for establishing the diagnosis. The classical image of hydropic chorionic villi seen in these cases is referred to as snowstorm pattern.

Trophoblastic Cells
  • Hydatidiform mole (molar pregnancy) is a benign tumor of placental trophoblastic cells, which release human chorionic gonadotropin (hCG).[ncbi.nlm.nih.gov]
  • These results suggest that these cells exhibit characteristics of trophoblastic cells, especially cytotrophoblastic cells.[ncbi.nlm.nih.gov]
  • Expression of miR-21 in trophoblast cells and tissues was examined by quantitative real-time polymerase chain reaction.[ncbi.nlm.nih.gov]
  • A gestational disorder characterized by an abnormal placenta with marked enlargement of the chorionic villi and hyperplasia of the villous trophoblastic cells.[icd9data.com]
  • Although correct interpretation of the cytologic findings of a hydatidiform mole is difficult, our careful search revealed 3 types of trophoblastic cells, especially syncytiotrophoblastic cells, making possible the accurate diagnosis of a hydatidiform[ncbi.nlm.nih.gov]

Treatment

All molar pregnancies need to be aborted in order to prevent complications. The uterus is evacuated through dilatation and curettage.

Prognosis

If diagnosed and managed early, there is no risk of mortality in complete and partial moles.
Hydatidiform moles may give rise to malignancy (choriocarcinoma). Malignancy is more common in complete moles (15 to 20%) as compared to partial moles (2 to 3%). These malignancies however, are almost 100% curable.

Etiology

There is no specific cause for the development of hydatidiform moles. It has been suggested that low animal fat and carotene in the diet may be a risk factor.

Epidemiology

Hydatidiform moles are a very frequent complication of pregnancy. In the United States, the incidence is approximately 1 in 1200 pregnancies [1]. Molar pregnancies are more common at the extremes of reproductive age (i.e. in early teenage and close to menopause) [2] [3].

Sex distribution
Age distribution

Pathophysiology

Complete and partial moles result from slightly different pathophysiological mechanisms.
Complete moles are named so because they do not contain any fetal tissue and consist only of hyperplastic trophoblastic tissues. There is marked swelling and edema in all the chorionic villi. The genotype of the mole is either 46,XX or 46,XY, the former accounting for almost 90% of the cases [4] [5].
In most of the cases, the genetic material in a complete mole is derived paternally. Such a mole is termed androgenic complete mole and is formed when an egg that has lost its chromosomes is fertilized by either one or two sperms. The former type is known as a homozygous androgenic complete mole. After a single sperm fertilizes the egg, the haploid genetic content of that sperm is duplicated. It is the more common of the two, accounting for 80% of the cases. This type of mole is always genotypically female (46,XX). On the other hand, complete moles may be formed when two sperms fertilize an egg that has lost its chromosomes. Such a mole is termed heterozygous complete mole. These moles may be 46,XX or 46,XY genotypically and account for only 20% of the cases.
Very rarely, complete moles may be even when both maternal and paternal genes are present in the fertilized egg. Failure of maternal imprinting however, suppresses the maternal genes and they fail to express themselves. Such moles are called biparental complete moles [6].
Partial moles are formed when an egg with normal chromosomal content is fertilized by two sperms to get a triploid genotype (69,XXX or 69,XXY) [7]. Partial moles often contain fetal tissues; most commonly fetal erythrocytes and vessels. Unlike complete moles, villous edema is confined to patches of chorionic villi.

Prevention

Apart from maintaining a healthy level of animal fat and carotenes in the diet, there is no documented preventive measure against the development of molar pregnancies.

Summary

Gestational trophoblastic disease is a spectrum of tumor and tumor-like conditions in which there is proliferation of trophoblastic tissue. This includes hydatidiform moles, invasive moles, choriocarcinomas and placental-site trophoblastic tumor.

Hydatidiform mole (or hydatid mole) can be defined as abnormal conception characterized by excessive proliferation of placental trophoblastic tissue. The chorionic villi become swollen and edematous and form grapelike masses. Hydatidiform mole may be designated complete or incomplete depending upon the karyotype of the abnormal tissues, the fraction of villi involved and the presence of fetal tissues.

Patient Information

Hydatidiform mole is an abnormal pregnancy in which instead of a fetus, there is excessive growth of placental tissue. The mole grows much more rapidly than a normal fetus and it becomes necessary to abort the pregnancy and clear the uterus. Molar pregnancies are now detected very early due to advanced ultrasound imaging techniques. There is no risk for mortality. In some molar pregnancies, there is risk for the development of cancer. Such cancers however, are readily treatable.

References

Article

  1. Atrash HK, Hogue CJ, Grimes DA. Epidemiology of hydatidiform mole during early gestation. American journal of obstetrics and gynecology. Apr 1986;154(4):906-909.
  2. Bracken MB. Incidence and aetiology of hydatidiform mole: an epidemiological review. British journal of obstetrics and gynaecology. Dec 1987;94(12):1123-1135.
  3. Schorge JO, Goldstein DP, Bernstein MR, Berkowitz RS. Recent advances in gestational trophoblastic disease. The Journal of reproductive medicine. Sep 2000;45(9):692-700.
  4. Wolf NG, Lage JM. Genetic analysis of gestational trophoblastic disease: a review. Seminars in oncology. Apr 1995;22(2):113-120.
  5. Slim R, Mehio A. The genetics of hydatidiform moles: new lights on an ancient disease. Clinical genetics. Jan 2007;71(1):25-34.
  6. Fisher RA, Hodges MD. Genomic imprinting in gestational trophoblastic disease--a review. Placenta. Apr 2003;24 Suppl A:S111-118.
  7. Watson EJ, Hernandez E, Miyazawa K. Partial hydatidiform moles: a review. Obstetrical & gynecological survey. Sep 1987;42(9):540-544.
  8. Mangili G, Garavaglia E, Cavoretto P, Gentile C, Scarfone G, Rabaiotti E. Clinical presentation of hydatidiform mole in northern Italy: has it changed in the last 20 years? American journal of obstetrics and gynecology. Mar 2008;198(3):302 e301-304.
  9. Soto-Wright V, Bernstein M, Goldstein DP, Berkowitz RS. The changing clinical presentation of complete molar pregnancy. Obstetrics and gynecology. Nov 1995;86(5):775-779.
  10. Florio P, Severi FM, Cobellis L, et al. Serum activin A and inhibin A. New clinical markers for hydatidiform mole. Cancer. May 15 2002;94(10):2618-2622.

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Last updated: 2019-07-11 21:32