History

Fact Explanation
Vaginal bleeding in the first trimester Intermittent or irregular vaginal bleeding in the first trimester is the commonest presentation of hydatidiform mole.[1][2][5][6]
Abdominal pain Pain arises due to large benign theca-lutein cysts in the ovaries[1]
Vaginal passage of grape-like vescicles Can be the presenting feature in some patients with molar pregnancies [1]
Severe nausea and vomiting Women with molar pregnancies tend to have severe nausea and vomiting which are attributed to the elevated hCG levels seen in such pregnancies.[3][5]
Thyrotoxicosis Features of thyrotoxicosis or hyperthyroidism is seen in some patients with a molar pregnancy. It is considered to be related to the high circulating levels of hCG.[2][4][5]
References
  1. Cavaliere A. Ermito S. Dinatale A. Pedata R. Management of molar pregnancy.Journal of Prenatal Medicine[online] 2009 Jan-Mar; 3(1): 15–17.[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094/#__ffn_sectitle
  2. Abdulaziz A. Al-Mulhim. Hydatidiform mole: Astudy of 90 cases. Journal of Family & Community Medicine [online] 2000 Sep-Dec; 7(3): 57–61[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437081/#__ffn_sectitle
  3. Lee N.M. Saha S. Nausea and Vomiting of Pregnancy. Gastroenterol Clin North Am.[[online] 2011 June ; 40(2): 309–vii. [viewed on 13 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3676933/pdf/nihms458269.pdf
  4. Robson A. Hydatidiform mole and hyperthyroidism.British Medical Journal. [online] Jul 17, 1971; 3(5767): 187.[viewed on 13 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1800249/
  5. The management of gestational trophoblastic disease. Royal College of Obstetricians and Gynecologists. Green-top Guideline No. 38. [online] Feb 2010[viewed on 13 May 2014] Available from; http://www.rcog.org.uk/files/rcog- corp/GT38ManagementGestational0210.pdf
  6. Diagnosis of Vaginal bleeding in Early Pregnancy. World Health Organization publications.[online] 2004 reformatted. 2007.[viewed on 11 May 2014] Available from; http://www.who.int/surgery/publications/Obstetricsafetyprotocols.pdf?ua=1

Examination

Fact Explanation
Uterus large for dates This is considered a classic feature of a molar pregnancy.[1][2][3][4]
Distended abdomen Occurs due to presence of large theca lutein cysts in the ovaries[1]
Dilated cervix May be seen during vaginal examination[2]
Uterus softer than normal Can be detected during bi-manual examination[2]
Partial expulsion of products of conception which resemble grapes, are seen on vaginal examination May be detected during vaginal examination[2]
Elevated blood pressure Early onset pre-eclampsia is seen in some women with molar pregnancies[1][3][4]
References
  1. The management of gestational trophoblastic disease. Royal College of Obstetricians and Gynecologists. Green-top Guideline No. 38. [online] Feb 2010[viewed on 13 May 2014] Available from; http://www.rcog.org.uk/files/rcog- corp/GT38ManagementGestational0210.pdf
  2. Diagnosis of Vaginal bleeding in Early Pregnancy. World Health Organization publications.[online] 2004 reformatted. 2007.[viewed on 11 May 2014] Available from; http://www.who.int/surgery/publications/Obstetricsafetyprotocols.pdf?ua=1
  3. Abdulaziz A. Al-Mulhim. Hydatidiform mole: Astudy of 90 cases. Journal of Family & Community Medicine [online] 2000 Sep-Dec; 7(3): 57–61[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437081/#__ffn_sectitle
  4. Cavaliere A. Ermito S. Dinatale A. Pedata R. Management of molar pregnancy.Journal of Prenatal Medicine[online] 2009 Jan-Mar; 3(1): 15–17.[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094/#__ffn_sectitle

Differential Diagnoses

Fact Explanation
Ectopic pregnancy May present with bleeding in the first trimester[1]
Hyperthyroidism Human chorionic gonadotrophin is secreted excessively in molar pregnancies. It is considered a thyroid stimulator so that some patients with hydatidiform mole may develop hyperthyroidism features[1][2]
Subchorionic hemorrhage Is a common cause for first trimester bleeding. It may also be an incidental finding in an uncomplicated pregnancy.[1]
Spontaneous abortion May present with first trimester bleeding.[1]
Hyperemesis gravidarum Causes severe nausea and vomiting. Can also arise as a result of hydatidiform mole[2]
Hypertension Patients with hydatidiform mole may present with pregnancy associated hypertension[2][4]
Choriocarcinoma Is an important differential diagnosis. Can arise as a complication of hydatidiform mole.[3]
References
  1. Deutchman M. Tubay A.T. Turok D.K.First Trimester Bleeding. American Family Physician.[online] 2009 Jun 1;79(11):985-992.[viewed on 10 May 2014 ] Available from; http://www.aafp.org/afp/2009/0601/p985.html
  2. Abdulaziz A. Al-Mulhim. Hydatidiform mole: Astudy of 90 cases. Journal of Family & Community Medicine [online] 2000 Sep-Dec; 7(3): 57–61[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437081/#__ffn_sectitle
  3. Wei-Cheng Xue. Kelvin Y.K. Chan. Hui-Chen Feng. Pui-Man Chiu. Hextan Y.S. Ngan. Sai-Wah Tsao. Annie N.Y. Cheung. Promoter Hypermethylation of Multiple Genes in Hydatidiform Mole and Choriocarcinoma.The Journal of molecular diagnostics[online] Nov 2004; 6(4): 326–334.[viewed on 11 May 2014]Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1867494/#!po=3.33333
  4. The management of gestational trophoblastic disease. Royal College of Obstetricians and Gynecologists. Green-top Guideline No. 38. [online] Feb 2010[viewed on 13 May 2014] Available from; http://www.rcog.org.uk/files/rcog- corp/GT38ManagementGestational0210.pdf

Investigations - for Diagnosis

Fact Explanation
Urine beta human chorionic gonadotrophin (beta-hCG) Performed for diagnosis of pregnancy.[4][5]
Quantitative serum beta-hCG Beta-hCG is secreted mainly by syncytiotrophoblast cells of the chorionic villi. In hydatidiform mole, increased proliferation of syncytiotrophoblast cells occurs, so that large amounts of beta- hCG is secreted by them. In a complete mole, serum beta-hCG level often exceeds 100,000 IU/L but in a partial mole it can be within the normal pregnancy range.[1][2][3][4][5]
Ultrasound scan of pelvis 'Snow storm' appearance of mixed echogenic structures in the placenta, the absence of a gestational sac and the absence of fetal heart activity are typical findings of a complete mole. Fetus may be viable in a partial mole but may have features of early growth restriction or developmental abnormalities. [1][2][3][4][5] Ovaries may contain multiple large theca-lutein cysts.[1][2][3][4]
Histopathological tests On histological examination, complete mole often displays circumferential trophoblastic proliferation affecting most chorionic vili and does not contain extra-embryonic membranes or any fetal tissue. Partial mole displays mild and focal trophoblastic proliferation that can be observed on some chorionic villi and may contain extra-embryonic membranes and embryonic tissues (cartilage, bones, etc.), or even a normal or an abnormal complete fetus. [1][2][3][4][5]
Karyotyping Complete hydatidiform mole is usually diploid. Most have 46,XX karyotype; a few have a 46,XY karyotype. Partial hydatidiform mole is usually triploid. (69XXX/69XXY/69XYY)[2][3][4]
Serum TSH and free T4 level Thyroid function tests are done to diagnose hyperthyroidism[3]
References
  1. Abdulaziz A. Al-Mulhim. Hydatidiform mole: Astudy of 90 cases. Journal of Family & Community Medicine [online] 2000 Sep-Dec; 7(3): 57–61[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437081/#__ffn_sectitle
  2. Rima S. Wallace. E.P. NLRP7 and the Genetics of Hydatidiform Moles: Recent Advances and New Challenges.Frontiers in Immunology. Published online Aug 20, 2013.[viewed on 11 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3747449/
  3. Cavaliere A. Ermito S. Dinatale A. Pedata R. Management of molar pregnancy.Journal of Prenatal Medicine[online] 2009 Jan-Mar; 3(1): 15–17.[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094/#__ffn_sectitle
  4. Collins S. Arulkumaran S. Hayes K. Jackson S. Impey L. Oxford handbook of Obstetrics and Gynecology. Second edition. Oxford university press. First published 2008. Reprinted 2011.
  5. The management of gestational trophoblastic disease. Royal College of Obstetricians and Gynecologists. Green-top Guideline No. 38. [online] Feb 2010[viewed on 13 May 2014] Available from; http://www.rcog.org.uk/files/rcog- corp/GT38ManagementGestational0210.pdf

Investigations - Fitness for Management

Fact Explanation
Complete blood count Done to detect anemia which can result from irregular vaginal bleeding[1][2]
Serum creatinine Done to assess baseline renal function[2]
Serum electrolytes Done to assess renal function[2]
Liver function tests Done to assess baseline liver function[2]
References
  1. Abdulaziz A. Al-Mulhim. Hydatidiform mole: Astudy of 90 cases. Journal of Family & Community Medicine [online] 2000 Sep-Dec; 7(3): 57–61[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437081/#__ffn_sectitle
  2. Cavaliere A. Ermito S. Dinatale A. Pedata R. Management of molar pregnancy.Journal of Prenatal Medicine[online] 2009 Jan-Mar; 3(1): 15–17.[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094/#__ffn_sectitle

Investigations - Followup

Fact Explanation
Quantitative serum beta-hCG Done to confirm the success of treatment and to identify persistent or malignant gestational trophoblastic disease. [1][2][3]
Ultrasound scan of pelvis Also done to confirm the success of treatment and to identify persistent or malignant gestational trophoblastic disease. [1][2]
References
  1. Abdulaziz A. Al-Mulhim. Hydatidiform mole: Astudy of 90 cases. Journal of Family & Community Medicine [online] 2000 Sep-Dec; 7(3): 57–61[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3437081/#__ffn_sectitle
  2. The management of gestational trophoblastic disease. Royal College of Obstetricians and Gynecologists. Green-top Guideline No. 38. [online] Feb 2010[viewed on 13 May 2014] Available from; http://www.rcog.org.uk/files/rcog- corp/GT38ManagementGestational0210.pdf
  3. AGARWAL R, TEOH S, SHORT D, HARVEY R, SAVAGE PM, SECKL MJ. Chemotherapy and human chorionic gonadotropin concentrations 6 months after uterine evacuation of molar pregnancy: a retrospective cohort study Lancet [online] 2012 Jan 14, 379(9811):130-135 [viewed 13 May 2014] Available from: doi:10.1016/S0140-6736(11)61265-8

Investigations - Screening/Staging

Fact Explanation
Chest X-ray postero-anterior view Is done when there are symptoms that suggest pulmonary metastases[1]
References
  1. Cavaliere A. Ermito S. Dinatale A. Pedata R. Management of molar pregnancy.Journal of Prenatal Medicine[online] 2009 Jan-Mar; 3(1): 15–17.[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094/#__ffn_sectitle

Management - General Measures

Fact Explanation
Family planing Women are advised not to conceive until their followup is complete. Women who receive chemotherapy are advised not to conceive for 1 year after completion of treatment.Barrier methods of contraception should be used until hCG levels become normal.Once hCG level are normal, combined oral contraceptive pill can be used.[1]
Anti-D immunoglobulin Anti-D prophylaxis should be given for partial moles, but it is not required for complete moles[1][2]
References
  1. The management of gestational trophoblastic disease. Royal College of Obstetricians and Gynecologists. Green-top Guideline No. 38. [online] Feb 2010[viewed on 13 May 2014] Available from; http://www.rcog.org.uk/files/rcog- corp/GT38ManagementGestational0210.pdf
  2. Cavaliere A. Ermito S. Dinatale A. Pedata R. Management of molar pregnancy.Journal of Prenatal Medicine[online] 2009 Jan-Mar; 3(1): 15–17.[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094/#__ffn_sectitle

Management - Specific Treatments

Fact Explanation
Surgical management- Suction curettage This is the treatment of choice for uterine evacuation in molar pregnancies, especially when the female has further fertility wishes. In a partial molar pregnancy when the size of fetal parts does not allow for successful suction curettage, medical evacuation is used.[1][2][5]
Medical uterine evacuation Medical evacuation of products of contraception using potent oxytocic agents is done for some partial molar pregnancies. This is avoided in case of complete mole due to the theoretical risk to embolize and disseminate trophoblastic tissue through the venous system.[1]
Chemotherapy The need for chemotherapy following evacuation is determined based on the FIGO 2000 scoring system. Women with high risk are treated with multi agent chemotherapy, (i.e.combinations of methotrexate, dactinomycin, etoposide, cyclophosphamide and vincristine). Women with low risk are treated with single-agent chemotherapy,(i.e.intramuscular methotrexate alternating daily with folinic acid). Treatment is continued until the hCG level has returned to normal and then for a further 6 consecutive weeks.[1][2][3][4]
References
  1. The management of gestational trophoblastic disease. Royal College of Obstetricians and Gynecologists. Green-top Guideline No. 38. [online] Feb 2010[viewed on 13 May 2014] Available from; http://www.rcog.org.uk/files/rcog- corp/GT38ManagementGestational0210.pdf
  2. Cavaliere A. Ermito S. Dinatale A. Pedata R. Management of molar pregnancy.Journal of Prenatal Medicine[online] 2009 Jan-Mar; 3(1): 15–17.[viewed on 10 May 2014] Available from; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094/#__ffn_sectitle
  3. Skubisz M.M, Tong S. The Evolution of Methotrexate as a Treatment for Ectopic Pregnancy and Gestational Trophoblastic Neoplasia: A Review ISRN Obstet Gynecol [online] :637094 [viewed 13 May 2014] Available from: doi:10.5402/2012/637094
  4. AGARWAL R, TEOH S, SHORT D, HARVEY R, SAVAGE PM, SECKL MJ. Chemotherapy and human chorionic gonadotropin concentrations 6 months after uterine evacuation of molar pregnancy: a retrospective cohort study Lancet [online] 2012 Jan 14, 379(9811):130-135 [viewed 13 May 2014] Available from: doi:10.1016/S0140-6736(11)61265-8
  5. HANNA RK, SOPER JT. The Role of Surgery and Radiation Therapy in the Management of Gestational Trophoblastic Disease Oncologist [online] 2010 Jun, 15(6):593-600 [viewed 13 May 2014] Available from: doi:10.1634/theoncologist.2010-0065