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]] (26%)
*[[Hyperemesis gravidarum]] (10-25%)
*[[Hypertension]], [[preeclampsia]]
**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%)
*Signs/symptoms of [[hyperthyroidism]] (rarely)
*[[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]]
*Ultrasound: enlarged uterus with interspersed lucent and brighter areas ("snowstorm" appearance)
*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 resuscitation of nausea/vomiting
*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

Clinical Features

Due primarily to elevated levels of hCG[1]

Differential Diagnosis

Nausea and vomiting in pregnancy

Evaluation

Molar pregnancy on ultrasound (transvaginal)
Molar pregnancy on ultrasound (transabdominal)
Hydatidiform mole on CT, sagittal view (not study of choice)
  • 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

  1. Cavaliere A et al. Management of molar pregnancy. J Prenat Med. 2009 Jan-Mar; 3(1): 15–17.
  2. 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.
  3. 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.