Molar pregnancy: Difference between revisions
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*''Non-viable'' fertilized egg implants in uterine wall | *''Non-viable'' fertilized egg implants in uterine wall | ||
**Complete: all chorionic villi are vesicular, swollen, with no embryonic development | **Complete: all chorionic villi are vesicular, swollen, with no embryonic development | ||
***46, XX karyotype | |||
**Partial: some vesicular chorionic villi, +/- (nonviable) embryonic development | **Partial: some vesicular chorionic villi, +/- (nonviable) embryonic development | ||
***69, XXX or 69, XXY | |||
==Clinical Features== | ==Clinical Features== | ||
Due primarily to elevated levels of hCG | Due primarily to elevated levels of hCG<ref>Cavaliere A et al. Management of molar pregnancy. J Prenat Med. 2009 Jan-Mar; 3(1): 15–17.</ref> | ||
*[[Vaginal bleeding in pregnancy (less than 20wks)|Vaginal bleeding]] (75-95%) | *[[Vaginal bleeding in pregnancy (less than 20wks)|Vaginal bleeding]] (75-95%) | ||
*[[Hyperemesis gravidarum]] ( | *[[Hyperemesis gravidarum]] (10-25%) | ||
**Suspect molar pregnancy when pregnancy-induced hypertension occurs at <24 weeks | **Suspect molar pregnancy when pregnancy-induced hypertension occurs at <24 weeks | ||
*Larger than usual uterine size | *Larger than usual uterine size (25%) | ||
* | *[[Vaginal discharge]] of grape-like vesicles (10%) | ||
*[[Hyperthyroidism]] (5%) | |||
*Early [[preeclampsia]] (5%) | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*Vaginal bleeding | *[[Vaginal bleeding]] | ||
**[[Ectopic Pregnancy]], heterotopic pregnancy | **[[Ectopic Pregnancy]], heterotopic pregnancy | ||
**[[First Trimester Abortion]] (complete, threatened, incomplete, septic, etc.) | **[[First Trimester Abortion]] (complete, threatened, incomplete, septic, etc.) | ||
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==Evaluation== | ==Evaluation== | ||
[[File:Molar pregnancy.jpg|thumb|Molar pregnancy on ultrasound]] | [[File:Molar pregnancy.jpg|thumb|Molar pregnancy on ultrasound (transvaginal)]] | ||
*Serum hCG | [[File:Molar pregnancy 0001.jpg|thumb|Molar pregnancy on ultrasound (transabdominal)]] | ||
[[File:Blasenmole Computertomographie sagittal.jpg|thumb|Hydatidiform mole on CT, sagittal view (not study of choice)]] | |||
*Serum hCG > 100,000 mIU/mL suggest excessive trophoblastic growth<ref>Diagnosis and treatment of gestational trophoblastic disease: ACOG Practice Bulletin No. 53. Soper JT, Mutch DG, Schink JC, American College of Obstetricians and Gynecologists. Gynecol Oncol. 2004 Jun; 93(3):575-85.</ref> | |||
**Normal hCG level does not exclude molar pregnancy | |||
**Partial molar pregnancies are more likely to produce lower hCG levels | |||
*Evaluate for other causes of or electrolyte derangements due to [[vomiting]] | *Evaluate for other causes of or electrolyte derangements due to [[vomiting]] | ||
* | *Other serum lab workup | ||
**CBC | |||
**BUN/Cr/Electrolytes | |||
**[[LFTs]] | |||
**Thyroid function tests | |||
*Consider [[CXR]] or CT chest if there is suspicion of pulmonary metastases<ref>Initial management of hydatidiform mole. Schlaerth JB, Morrow CP, Montz FJ, d'Ablaing G. Am J Obstet Gynecol. 1988 Jun; 158(6 Pt 1):1299-306.</ref> | |||
*[[Pelvic ultrasound]] | |||
**Complete mole - enlarged uterus with interspersed lucent and brighter areas ("snowstorm" appearance) | |||
**Before 12 weeks, may show a fine vascular or honeycomb appearance | |||
**Ovaries may contain multiple large theca-lutein cysts due to excessive beta-hCG | |||
**Partial mole - more difficult to diagnose, with the fetus possibly being viable | |||
***Scattered cystic spaces within placenta | |||
***Ovarian cystic changes less pronounced than in complete mole | |||
==Management== | ==Management== | ||
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*Resuscitate if severe bleeding | *Resuscitate if severe bleeding | ||
*Treat [[preeclampsia]] | *Treat [[preeclampsia]] | ||
*Symptomatic | *Symptomatic treatment of [[nausea/vomiting]] | ||
==Disposition== | ==Disposition== | ||
Latest revision as of 19:35, 17 September 2020
Background
- Type of gestational trophoblastic disease
- Neoplasm of placental hCG-producing trophoblast cells
- Non-invasive (invasive form is choriocarcinoma, can metastasize to brain, liver, lung)
- Non-viable fertilized egg implants in uterine wall
- Complete: all chorionic villi are vesicular, swollen, with no embryonic development
- 46, XX karyotype
- Partial: some vesicular chorionic villi, +/- (nonviable) embryonic development
- 69, XXX or 69, XXY
- Complete: all chorionic villi are vesicular, swollen, with no embryonic development
Clinical Features
Due primarily to elevated levels of hCG[1]
- Vaginal bleeding (75-95%)
- Hyperemesis gravidarum (10-25%)
- Suspect molar pregnancy when pregnancy-induced hypertension occurs at <24 weeks
- Larger than usual uterine size (25%)
- Vaginal discharge of grape-like vesicles (10%)
- Hyperthyroidism (5%)
- Early preeclampsia (5%)
Differential Diagnosis
- Vaginal bleeding
- Ectopic Pregnancy, heterotopic pregnancy
- First Trimester Abortion (complete, threatened, incomplete, septic, etc.)
- Implantation bleeding
- Fibroids
- Cervicitis
- Gestational trophoblastic disease
Nausea and vomiting in pregnancy
- Hyperemesis gravidarum
- Gastroenteritis
- Biliary disease
- Ectopic pregnancy
- Gastroenteritis
- Pancreatitis
- Appendicitis
- Hepatitis
- Peptic ulcer disease
- Pyelonephritis
- Acute fatty liver of pregnancy
- HELLP syndrome
- Gestational trophoblastic disease (may present with intractable vomiting)
- Thyrotoxicosis (may present with intractable vomiting)
Evaluation
- Serum hCG > 100,000 mIU/mL suggest excessive trophoblastic growth[2]
- Normal hCG level does not exclude molar pregnancy
- Partial molar pregnancies are more likely to produce lower hCG levels
- Evaluate for other causes of or electrolyte derangements due to vomiting
- Other serum lab workup
- CBC
- BUN/Cr/Electrolytes
- LFTs
- Thyroid function tests
- Consider CXR or CT chest if there is suspicion of pulmonary metastases[3]
- Pelvic ultrasound
- Complete mole - enlarged uterus with interspersed lucent and brighter areas ("snowstorm" appearance)
- Before 12 weeks, may show a fine vascular or honeycomb appearance
- Ovaries may contain multiple large theca-lutein cysts due to excessive beta-hCG
- Partial mole - more difficult to diagnose, with the fetus possibly being viable
- Scattered cystic spaces within placenta
- Ovarian cystic changes less pronounced than in complete mole
Management
- Ob/gyn consult
- Suction curettage as inpatient (due to risk of bleeding)
- Resuscitate if severe bleeding
- Treat preeclampsia
- Symptomatic treatment of nausea/vomiting
Disposition
- Admit
See Also
External Links
References
- ↑ Cavaliere A et al. Management of molar pregnancy. J Prenat Med. 2009 Jan-Mar; 3(1): 15–17.
- ↑ Diagnosis and treatment of gestational trophoblastic disease: ACOG Practice Bulletin No. 53. Soper JT, Mutch DG, Schink JC, American College of Obstetricians and Gynecologists. Gynecol Oncol. 2004 Jun; 93(3):575-85.
- ↑ Initial management of hydatidiform mole. Schlaerth JB, Morrow CP, Montz FJ, d'Ablaing G. Am J Obstet Gynecol. 1988 Jun; 158(6 Pt 1):1299-306.