Hydatidiform Mole

PGI Sia, Kevin

PGI Tan, Sheila
General Data

• Name: R. F.
• Age: 19
• Nationality: Filipino
• Address: Tondo, Manila
• Religion: Roman Catholic
• Date of Admission: August 11, 2018
• LMP: February 26, 2018 (sure, regular)
• PMP: January 24, 2018
• AOG: 23 weeks 5 days
• Obstetric Index: Gravida 2 Para 1 (1-0-0-1)
Chief Complaint

Vaginal bleeding
History of Present Illness

Noted amenorrhea

NO pregnancy test done

NO consult sought

NO ultrasound done
History of Present Illness

Still with vaginal bleeding

No abdominal pain, no nausea and

vomiting, no fever, no dysuria

No pregnancy test done

No consult sought

No medications taken
History of Present Illness
(+) vaginal bleeding, consuming 2-3 pads
of napkin per day, mildly soaked

No abdominal pain, no nausea and

vomiting, no fever, no dysuria

No pregnancy test done

No consult sought

No medications taken
History of Present Illness
(+) profuse vaginal bleeding 3-5 pads/day, fully
soaked

(+) sudden onset of abdominal pain, 10/10,

hypogastric, “aching”, non-radiating

(+) uterine contractions

(-) nausea and vomiting, fever, change in

bowel movement

Consult done at a public hospital and

ultrasound was performed
 Transvaginal Ultrasound
(August 11, 2018)

• Anteverted uterus is ENLARGED measuring

17.7 x 14.5 x 10.3 cm (L x W x AP) with
homogenous parenchymal echopattern.
• The endometrial cavity is filled with echogenic
mass containing VESICLES.
• Both ovaries are obscured and cannot be
properly evaluated.
IMPRESSION: Consider molar pregnancy
History of Present Illness

(+) passage of blood clots with “sago” like

material per vagina

(+) hypogastric pain, 1-2/10 in PAS

(-) fever (-) nausea and vomiting (+)

dizziness (+) loss of consciousness

Consult to our institution

Laboratory Findings

August 11
Spot Urine Pregnancy Test POSITIVE

7-Fold Serial Dilution POSITIVE

Past Medical History
• Childhood illnesses and immunizations -
unrecalled
• No history of asthma, diabetes mellitus,
hypertension, liver, kidney, or heart diseases or
cancer
• No known allergies to food and medications
• No previous hospitalizations
• No prior surgeries
• No maintenance medications
 Family History

• (+) hypertension - maternal side

• No history of asthma, diabetes mellitus, liver,
kidney, or heart diseases or cancer
Personal and Social History

• Nonsmoker
• Nonalcoholic beverage drinker
• Denies illicit drug use
• Occupation: Saleslady
Menstrual History

• Menarche- 14 years old

• Interval- Irregular
• Duration – 5 days
• Amount – 2 pads per day, moderately soaked
• No dysmenorrhea noted
 Sexual History

• Age of 1st coitus – 16 years old

• Number of sexual partners: 2
• (+) OCP 2017, for 1 month
• No postcoital bleeding
• No Dyspareunia
Obstetric History
• Gravida 2 Para 1 (1-0-0-1)

G1 2017, Female Full Term via Carmen, No

Normal Bohol fetomaternal
Spontaneous complications
Delivery
G2 Present Pregnancy
Review of Systems
• General: no weight loss
• HEENT: no headache, no blurring of vision, no tinnitus
• Respiratory: no cough, no colds,
• Cardiovascular: no palpitations, no orthopnea, no easy
fatigability
• Abdominal: no change in bowel movement, no melena
• Genitourinary Tract: no dysuria, no hematuria, no
incontinence
• Endocrinologic: no polydypsia, no polyphagia, no
polyuria
• Hematologic: no easy bruising, no cyanosis
 Physical Examination

• Awake, ambulatory, not in distress

VS: 100/60 mmHg 70 bpm 17 bpm 36.5oC
• Anicteric sclerae, pink palpebral conjunctivae,
no nasoaural discharge no tosillopharyngeal
congestion, no lymphadenopathies
• Symmetric chest expansion, no retractions,
clear breath sounds
Physical Examination
• Adynamic precordium, normal rate, regular
rhythm, no murmurs appreciable
• Globular, normoactive bowel sounds, soft, (+)
hypogastric tenderness, no guarding

(-) FHT

• Grossly normal extremities, no cyanosis, no

edema
Physical Examination
Pelvic examination
• Inspection: grossly normal external genitalia, no
masses seen at the introitus
• Speculum: Cervix violaceous, open with grape
like tissue fragment plugging at the OS and with
moderate bleeding per OS
• Internal exam: Parous introitus, vagina admits
two fingers easily, smooth vagina, cervix open
with vesicular tissue from the os, uterus
enlarged to 18-20 weeks size, no adnexal mass
or adnexal tenderness
 ASSESSMENT

Gravida 2 Para 1 (1-0-0-1) Hydatidiform mole,

23 weeks and 5 days AOG
Anemia, mild secondary to acute blood loss
Pre-Operative Plan
• NPO temporarily
• IVF: D5LR 1L to run for 8 hours
• Labs:
 CBC with PC
 Blood typing with Rh
 Urinalysis with pregnancy test
 Serum B-hCG
 Serum TSH, fT3, fT4
 Serum BUN, Creatinine, AST, ALT, LDH
 Serum Na, K, Cl
 Chest X-ray PA
• Secure and transfuse 1 unit PRBC properly type and crossmatched
• Book to anesthesia for Suction curettage
• Secure OR and anes needs
• For referral to Trophoblastic service
Laboratory Findings

Put CBC and Urinalysis Blood type

 DILUTED βhCG
(August 11, 2018)

Result Reference Range

More than 300,000 Cyclic = <4
mIU/mL Menopause = <13
Intra-Operative Findings

Evacuated a total of 115 cc of vesicular

tissues, admixed with placental tissues and
blood clots
Post-Operative Plan
• Diet: NPO temporarily, DAT once fully awake
• Increased oral fluid intake
• IVF: D5LR 1L + 10 units oxytocin to run for 8 hours
• Secure and transfuse 1 more unit PRBC properly typed and crossmatched
• Diagnostics:
 Post BT CBC with PC
 Repeat B-HCG 1 week postevacuation
 Ff-up previously ordered labs (Na, K, Cl, TSH, FT3, FT4, AST, ALT)
• Meds:
– Co-Amoxiclav 625 mg/tab, Q8, x 7days
– Multivitamins, OD
– Ferrous Sulfate, BID
– Mefenamic Acid 500 mg/tab, Q6 PRN for pain
• Send specimen for Histopathological Examination
• For referral to Trophoblastic service for possible chemoprophylaxis
2nd Post-operative Day (11/6/17 2PM)

S O A P
(+) difficulty of breathing Awake, conscious, in Acute respiratory failure Type I S/P Intubation
(+) desaturation distress probably secondary to: For ICU admission
(+) fever 1) Multiple transfusion Labs:
(+) cough BP: 130/60mmHg 2) Sepsis -rpt CBC with PC
Tranfusion-related Acute Lung
decreased jaundice HR: 134 bpm -rpt BUN, Crea, Na, K, Cl, AST, ALT
Injury
slightly icteric sclerae RR: 26 cpm -For Ca, Mg, TPAG, D-dimer
Cornual pregnancy, 15 weeks and 1
(-) hypotension T: 38.9 day AOG, left, ruptured -rpt CXR PA post-intubation
O2 sat: 91-96% To consider Acute Hemolytic -ABG
Transfusion reaction
>slightly pinkish palpebral Anemia secondary to acute blood Meds:
conjunctivae loss -Clindamycin 900mg IV q8
>(+) crackles, all over S/P Exploratory laparotomy, -Metronidazole 500 mg IV q8
bilateral lung fields evacuation of hemoperitoneum, -Gentamycin 240mg IV OD
salpingectomy, left with cornual -Furosemide 40 mg IV q8
wedge resection, enterolysis, -Salbutamol + Ipratropium neb q8
omentectomy (OMMC, 2017)
-Omeprazole 40 mg IV OD
Gravida 2 Para 1 (1-0-1-1)
-Paracetamol 300 mg IV q4 RTC
-Hold transfusion
 LABS

11/3/17 11/3/17 11/4/17 11/5/17 11/6/17

(after 2 (after 4 (Transfusion (Post-
units pre- units post- reaction) intubation)
op) op)
Hemoglobin 5.5 8.9 8.9 7.7 9.0

Hematocrit 17.0 25.4 25.1 21.7 25.8

WBC 18.0 16.3 25.5 13.3 12.8

Neutrophils 93.9 92.4 91.8 94.7 82.0

Lymphocytes 4.3 5.5 4.4 3.4 14.5

Platelet 175 170 155 121 195

 LABS:
11/5/17 11/6/17 Normal values
BUN 5.58 10.08 1.7-8.30 mmol/L
Crea 117.1 142.0 69.0-104.0 umol/L
Na 141.4 140.5 135-145 mmol/L
K 3.53 2.9 3.4-5.00 mmol/L
Cl 109.8 108.4 93-109 mmol/L
Mg 0.54 0.77-1.03 mmol/L
ALT 111.7 42.7 <35 U/L
AST 78.8 27.0 <32 U/L
TB 398.46 (18.95x) 195.23 2.00-21.00 umol/L
B1 135.4 (8.5x) 48.8 2.0-15.9 umol/L

B2 263.03 (51x) 146.44 <5.10umol/L

LDH 723.4 944.0 <247 U/L

Course in the Wards

• 1st Hospital Day

– Stable vital signs
– (-) vaginal bleeding (-) hypogastric pain
– Serum B-hCG (8/11/18) = >300, 000 mUI/mL
– Medications continued
 Beta-HCG
8/11/18

Result >300,000 mIU/mL

Course in the Wards

• 2nd Hospital Day

– Stable vital signs
– (-) vaginal bleeding (-) hypogastric pain
– Serum B-hCG (8/14/18) = 108, 827 mUI/mL
– Medications continued
 Beta-HCG
8/11/18 8/14/18
(post-
evacuation)
Result >300,000 108, 827 mUI/mL
mIU/mL
Course in the Wards

• 3rd Hospital Day

– Stable vital signs
– (-) vaginal bleeding (-) hypogastric pain
– Medications
1. Methotrexate was started at 0.7 mL TIM OD x 5 days
2. NaHCO3 625 mg TID
3. Leucovorin 0.6 mL TIM PRN for Methotrexate toxicity
Course in the Wards

• 4th Hospital Day

– Stable vital signs
– (-) vaginal bleeding (-) hypogastric pain
– Medications
1. Methotrexate was started at 0.7 mL TIM OD x 5 days
2. NaHCO3 625 mg TID
3. Leucovorin 0.6 mL TIM PRN for Methotrexate toxicity
Course in the Wards
• Histopathology Results (8/16/18)
– Gross: Several fragments dark-brown, irregular meaty
tissue with an aggregate diameter of 10.0 cm
– Microscopic: Edematous chorionic villi with prominent
central acellular space and focal trophoblastic
proliferation
– IMPRESSION: Hydatidiform molar pregnancy, probably
considering a complete mole. Suggest
Immunohistochemistry for P57 for a more definitive
diagnosis”
Course in the Wards

• 5th Hospital Day

– Stable vital signs
– (-) vaginal bleeding (-) hypogastric pain
– Medications continued
Course in the Wards

• 6th Hospital Day

– Stable vital signs
– (-) vaginal bleeding (-) hypogastric pain
– Medications continued
– Thyroid function test (8/17/18)
Value Reference Range
TSH 0.16 (Normal) 0.4 – 6.2 UIu/mol
fT3 2.05 (Normal) 1.23 – 3.08 nmol/L
Course in the Wards

• 7th Hospital Day

– Stable vital signs
– (-) vaginal bleeding (-) hypogastric pain
– Medications continued
– Serum B-hCG (8/19/18) = 9, 102.95 mUI/mL
 Beta-HCG
8/11/18 8/14/18 8/19/18
(post- (1 weeks
evacuation) postevacuat
ion)
Result >300,000 108, 827 9, 102.95
mIU/mL mUI/mL mUI/mL
Course in the Wards

• 8th Hospital Day

– Stable vital signs
– (-) vaginal bleeding (-) hypogastric pain
– Patient may go home
 Discharge Orders
• May go home
• Diet as tolerated, Adequate oral fluid intake
• Diagnostics:
– Repeat B-hCG after 2 weeks
• Medications:
1. Sodium Bicarbonate tablet 625 mg TID for 7 days
2. Co-Amoxiclav 625 mg/tab, Q8, x 7days
3. Multivitamins OD
4. Ferrous Sulfate, OD
5. Mefenamic Acid 500 mg/tab, Q6 PRN for pain
 FINAL DIAGNOSIS

Gravida 2 Para 1 (1-0-1-1) Complete Hydatidiform

mole, 23 weeks and 5 days AOG
S/P Suction Curettage (OMMC, 2018)
 Salient Features
• 19 years old
• Filipino
• Gravida 2 Para 1(1-0-0-1)
• Amenorrheic
• (+) vaginal bleeding with passage of vesicular tissue material
• (+) Hypogastric pain
• Enlarged uterus
• No fetal heart tones
• “snow storm pattern” ultrasound without evidence of fetal parts
• Baseline Serum B-hCG = >300,000 mUI/mL
• Internal exam: Parous introitus, vagina admits two fingers easily,
smooth vagina, cervix open with vesicular tissue from the os, uterus
enlarged to 18-20 weeks size, no adnexal mass or adnexal
tenderness
GESTATIONAL TROPHOBLASTIC DISEASES

HYDATIDIFORM MOLE
 Complete hydatidiform
mole
Gestational Trophoblastic Diseases
Partial hydatidiform
Hydatidiform moles
mole

Invasive mole

Choriocarcinoma

Non-molar trophoblastic Placental site

neoplasms trophoblastic tumor

Epithelioid trophoblastic
tumor
 Hydatidiform Mole

• Hydatidiform Mole— Molar pregnancy

– Under Gestational trophoblastic disease (GTD)
– Histologically characterized by the presence of villi
– “Excessively edematous immature placentas”
(Benirschke, 2012)
 Hydatidiform Mole

• Classic histological finding include “villous

stromal edema and trophoblast proliferation”
• Associated with elevated hCG levels
• Sonographic finding:
– In complete moles, “snow storm pattern”
– In incomplete moles, “thickened multicystic
placenta along with fetal tissue”
 Epidemiology

• Asians, Hispanics, and American Indians

• Incidence worldwide: 1 - 2 per 1000 deliveries
• In the Philippines: 2.4/1000 pregnancy (2004-
2008)
• In PGH: 14/1000
 Risk Factors

• Maternal Age
– Teenagers
– Reproductive-age women ≥40 years
• Paternal Age
– Paternal age greater than 45
• History of prior molar pregnancy
– Complete (1.5%)
– Partial (2.7%)
 Pathogenesis
• Arise from abnormal fertilizations.
 PRESENTATION AND DIAGNOSIS OF MOLAR
PREGNANCY

1. The clinical diagnosis of hydatidiform mole

• clinical presentation
• ultrasonographic findings
• elevated BHCG titer
 Clinical Diagnosis
• Amenorrhea • Presence of theca lutein cyst
(20%)
• Positive pregnancy test • hyperemesis (15 -25%)
• Vaginal bleeding (89-97%) • preeclampsia (12-27%)
• Uterine size more than the • hyperthyroidism (2 – 7%)
age of gestation (40 – 45%) • respiratory insufficiency (2%)

• Absence of FHT.
2. Pelvic ultrasound
 the most accurate noninvasive imaging
modality for hydatidiform mole
– Overall sensitivity (50 – 86%)
– Factors that influence
the diagnosis:
• Gestational age
• Operator expertise
 Complete vs Incomplete Mole

Feature Partial Mole Complete Mole

Karyotype 69, XXX or 69 XXY 46, XX
Clinical Presentation
Diagnosis Missed abortion Molar gestation
Uterine size Small for dates Large for dates
Theca-lutein cysts Rare 25-30%
Initial hCG levels <100, 000 mIU/ mL >100, 000 mIU/mL
Medical Complications Rare Uncommon
Rate of subsequent GTN 1-5% of cases 15-20%
 Complete vs Incomplete Mole

Feature Partial Mole Complete Mole

Pathology
Emryo-fetus Often present Absent
Amnion, fetal erythrocytes Other present Absent
Villous edema Focal Widespread
Trophoblastic proliferation Focal, slight to moderate Slight to severe
Trophoblast atypia Mild Marked
p57KIP2 immunostaining Positive Negative
 Complete vs Incomplete Mole
Feature Partial Mole Complete Mole
Sonography

fetus is seen above a multicystic Sagittal view

placenta “snowstorm” appearance
Fetus and amniotic sac are absent
 Complete vs Incomplete Mole
Feature Partial Mole Complete Mole
Grossly

scattered grape-like villi (fewer) scattered grape-like villi.

Fetal parts and gestational sac No fetal parts or gestational sac
may be present present
 Algorithm for the Diagnosis and
Management of H. Mole
Clinical History and
Pelvic Ultrasound Serum BhCG titer
Physical Examination

Hydatidiform Mole

Completed Family Size

TAHBSO Suction Curettage

(+) Risk Factors (-) Risk Factors

Chemoprophylaxis
(under supervision of Suction Curettage
Trophoblastic disease specialist)
 Algorithm for the Diagnosis and
Management of H. Mole
Chemoprophylaxis
(under supervision of Suction Curettage
Trophoblastic disease specialist)

Spontaneous Gestational Trophoblastic

Resolution Neoplasia

REFER TO A
TROPHOBLASTIC DISEASE
SPECIALIST
 Diagnosis

• Clinical presentation
• Serum B-hCG measurements
• Sonography
• Pathological diagnosis
– Histological immunostaining: p57KIP2
• POSITIVE in partial moles and hydropic abortions
• NEGATIVE in complete moles
– Cytogenetic examination
 MANAGEMENT
1. The following medical complications should be
promptly recognized and treated.
• Anemia
• Preeclampsia
• Hyperthyroidism
• Electrolyte imbalance
• Hyperemesis gravidarum
• Pulmonary insufficiency
• Disseminated intravascular coagulopathy
2. Initial evaluation
• Baseline Hcg titer
• Chest Xray
• CBC with platelet count
• Liver function test (ALT & AST)
• Renal function test (BUN & Crea)
• Thyroid function test (FT3, FT4, TSH)
• Urinalysis

• Pre-operative evaluation  BT, Crossmatching, serum

hCG and ECG if appropriate
3. Surgical evacuation of molar products is the
definitive management of hydatidiform
moles.
A. SUCTION CURETTAGE
• Preferred method to evacuate molar products
 GENERAL GUIDELINES FOR SUCTION
CURETTAGE
• Prepare at least 2 units of blood should be immediately
available especially when the uterus is more than 16-
weeks’ gestational size.
• Induction of anesthesia (general anesthesia is preferred)
• Placed in a semi-Fowler’s dorsolithotomy position.
• Oxytocin infusion (10 units of oxytocin incorporated into
1L of Lactated Ringer’s solution) after induction of
anesthesia
• Use of hysterometer for measurement of pre- and post-
uterine depth is avoided since it may lead to uterine
perforation.
 GENERAL GUIDELINES FOR SUCTION
CURETTAGE
• During suctioning, the surgeon’s other hand should be
positioned on the uterine fundus to continuously assess
the uterine size and tone.
• Sharp curettage is done to ensure complete removal of
all chorionic tissues
• All tissues obtained during molar evacuation should be
submitted for histologic evaluation. Specimens obtained
from suction curettage are submitted separately from
tissues obtained by sharp curettage.
• Observe for signs of respiratory distress and treat
agressively
• Patients who are Rh negative should receive Rh
immune globulin at the time of evacuation because
the Rh D factor is expressed on trophoblast.

• Routine repeat curettage after the diagnosis of a

molar pregnancy is not warranted.
Hysterectomy with mole in-situ
– may be considered for patients who have completed the
desired family size or have life threatening hemorrhage.

Theca lutein csyts

– best left alone during laporotomy.
– regress spontaneously within
8 -12 weeks post-evacuation.
 THE ROLE OF CHEMOPROPHYLAXIS
1. Useful in situations where patients are at
high risk of postmolar GTD and when post-
evacuation surveillance is doubtful.

• Risk of malignancy after complete or partial mole is

15 -25% and 0.5 -4 %, respectively
CLINICAL FEATURES OF PATIENT AT RISK OF POSTMOLAR
TROPHOBLASTIC DISEASE:

a) Advance maternal age ≥40 years

b) Uterine size larger than gestation by ≥ 6 weeks
c) Serum B hCG titer > 100, 000 mIU/mL
d) Theca lutein cysts ≥ 6 cm
e) Presence of any medical complication associated
with increased trophoblastic proliferation
f) Recurrent hydatidiform mole
g) Documented hydatidiform mole with coexisting
normal twin
2. METHOTREXATE is the drug of choice for
chemoprophylaxis.

• Methotrexate  administered Intramuscularly, and not

in oral form
• Actinomycin D – given in the presence of hypersensitivity
to Methotrexate or liver toxicity.
• For chemoprophylaxis, only 1 course is given.
 CONTRAINDICATION TO CHEMOPROPHYLAXIS

• Hemoglobin <100mg/dl or Hct < 0.30

• WBC count < 3 x 109
• Absolute neutrophil count (ANC) ≤ 1.5
• Platelet count < 100
• Any active infection
• Presence of liver or renal dysfunction
3. Chemoprophylaxis does not obviate the need
for post-evacuation HCG surveillance.
 FOLLOW-UP
1. Serial BHCG Monitoring to detect malignant
degeneration

• Measured 1 week after molar evacuation

• every 2 weeks until with 2 consecutive normal values
• Monthly for 6 months
2. Use of reliable contraception during entire
follow-up period.

• Eliminate potential confusion that arises in

interpretation of a rising HCG
• Low-dose COC pill  preferred
– Advantage: suppressing endogenous LH.
 POSTMOLAR EVACUATION
CONTRACEPTION
1. Pregnancy maybe allowed after 6 months of normal serum
ß HCG level.

2. Ovulation resumes at around 9 weeks post-evacuation

3. Most menses are ovulatory; ovulation can occur at <10-

100mIU/mL
 Post-evacuation Surveillance

• Close biochemical surveillance for persistent

gestational neoplasia
– serial measurements of serum β-hCG
• Reliable contraception is imperative
Combination hormonal contraception or
injectable medroxyprogesterone acetate.