Case Presentation: Partial molar Pregnancy

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Case Presentation Partial molar Pregnancy

• Dr Haseena Hamdani
• Avicenna Medical Centre

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Introduction

• Case Report of Partial molar pregnancy.
• Brief discussion about partial molar pregnancy.
• Role of Diagnostics in Management.

3
Case Report

• Asian woman
• 27years old
• Nulliparous
• Consanguineous marriage
• Combined oral pills for puberty menorrhagia

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First visit

• Presenting Symptoms
• Amenorrhoea 6 weeks
• Clinical Examination
• Urine pregnancy test positive
• PV examination Bulky soft uterus

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Follow up visit after 4 weeks

• Presenting Symptoms
• Amenorrhea 10 weeks
• Abdominal USG-
• Gestational sac present.
• Ill defined fetal echo present.
• Cardiac pulsation not seen.
• Few small cisterns in part of placenta

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Second follow up visit after three days

• Serum Beta HCG levels-
• 125,000mIU/ ml,
• 138,000mIU/ml after 48 hrs.
• Repeat USG
• Same findings

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Second follow up visit

• Clinical impression
• ? Partial mole
• Plan
• suction evacuation followed by histological
  analysis.
• Follow up by serum HCG estimation.

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Treatment

• Suction Evacuation done.
• Curetted material sent for Histo-pathology.

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Histo-pathology report

• Findings
• Fetal tissue with fetal vessels present.
• Hydropic degeneration of chorionic villi
• Trophoblastic hyperplasia seen at few places.
• Conclusion
• ? Missed abortion with hydropic degeneration of
  placenta
• ? Partial mole ( Correlate clinically).
• Advice serum HCG level after 4 weeks

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Post-evacuation follow up

• Irregular scanty bleeding P/V for 3weeks
• HCG levels
• After 4 weeks-543mIU/ml
• After 6 weeks- 58.73mIU/ml
• After 8 weeks- 11.67mIU/ml
• After 10 weeks- 3.16mIU/ml

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Post-evacuation follow up

• Advice
• use combined oral pills for next 6 months,
• follow up for HCG levels every month for 6
  months.

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Brief Discussion

• Gestational trophoblastic Diseases.
• Molar pregnancy
• Complete molar pregnancy
• Partial molar Pregnancy
• Invasive Mole
• Chorio-carcinoma
• Placental-site trophoblastic tumor

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Characteristics of GTD

• Arise from fetal chorion
• Secrete HCG
• Good response to chemotherapy
• Variable Malignant Potential

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Gestational Trophoblastic Diseases

• Incidence
• Asians 1 in 200- 300
• Africans 1 in 800
• Caucasians 1 in 2000
• Maximum in Indonesia, Japan, and Philippine

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Predisposing factors

• Race
• Deficiency of Protein or carotene
• Age- Higher towards the beginning, or end of
  childbearing age.
• HLA-B locus antigen compatibility with Husband
• Smoking
• Oral contraceptives for more than 5years
• H/O infertility

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Partial Mole

• Differs from Complete mole
• Morphology
• Clinical picture
• Pathogenesis
• Genetics
• Synonyms-Triploidy, partial hydatidiform mole,
  partial molar pregnancy.
• Undiagnosed
• Unreported

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• Partial Mole is common, but unawared,
  underdiagnosed, and underreported.

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Importance of Diagnosis

• 4-12 develop in persistent gestational
  trophoblastic diseases, and require chemotherapy.
• Recurrence -3
• Chorio-carcinoma-1

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Pathogenesis

• Two sperms fertilize a single ovum,
• Development of certain or all fetal parts
• Triploid karyotype of 69XXX, 69XXY, OR 69XYY.
• Diploid or tetraploid karyotype may exist.

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Pathogenesis
69xxx
69xxy
46xxy
69xyy
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Diagnostics in management

• Tumor markers
• Serum HCG
• Alpha feto-protein.
• Others like PAPP, Pregnancy specific protein,
  CA125
• Ultrasound examination.
• Histo-pathological Analysis.
• Genetic Karyotyping, Flow cytometry, ploidy
  analysis etc.

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Diagnostic Challenges

• Clinical presentation is like normal pregnancy
  before 12 weeks.
• HCG levels may be normal or slightly raised.
• USG is usually confusing, specially in first
  trimester.
• Histology is also not conclusive most of the time.

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Clinical presentation

• Symptoms of missed, anembryonic or incomplete
  abortion
• Usually asymptomatic, but may present with
  hyperemesis gravidarum or pre-eclampsia

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Human chorionic Gonadotropin

• Secreted by active trophoblast of the placenta.
• Detected in the blood 7-9 days after ovulation.
• A concentration of 100mIU/ml is reached 2 days
  after the date of an expected menses.
• Peak level of HCG ( app. 100,000mIU/ml ) - 10
  weeks of gestations
• Declining and remaining at app 10,000-
  20,000mIU//ml by 12-14 weeks of gestation.

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Rate of HCG rise
Below 1200 IU/L Doubles every 48-72hrs
From 1200 to 6000IU/L Doubles every 72-96 hrs
Above 6000IU/L Doubles every 4 days
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Diagnostic Implications of Serum HCG levels

• Single HCG value Not very informative
• rate of increase in HCG levels varies as a
  pregnancy progresses.
• Normal HCG values vary up to 20 times between
  different pregnancies,
• An HCG that does not double every two to three
  days does not necessarily indicate a problem with
  the pregnancy.
• Some normal pregnancies will have quite low
  levels of HCG, and result in perfect babies.

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Challenges USG

• As the vesicular degeneration is only partial,
  and delayed, USG findings are not clear as in
  complete mole.
• Gestational sac is not measured routinely.
• High resolution Transvaginal USG, and doppler
  flow study is not available widely.

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Correlation between HCG level, and sonography
findings

• Serum HCG levels 1800 IU/L-Gestational sac should
  be visible by USG
• Serum HCG levels 5000IU/L-Cardiac pulsation
  should be visible.
• More than 5000 IU/L rules out Ectopic pregnancy.

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Serum HCG levels
From conception From Lmp IU/L
7days 3weeks 0to5
14days 28days 3to426
21days 35days 18 to 7,340
28days 42days 1080 to56,500
35-42days 49-56days 7,650 to 229,000
43-64days 57-78days 25,700 to 288,200
57-78days 79-100days 13,300 to 253,000
17-24weeks 2nd trimester 4060 to 65,400
After several days postpartum Non-pregnant levels

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Diagnostic criteria by USG

• Enlarged and cystic placenta with ill-defined
  fetal echoes, surrounded by a strongly refringent
  ring.
• Transverse diameter is 1.5 times more than of AP
  diameter.

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Ultrasonographic D/D

• Hydropic degeneration of placenta
• Complete mole with co-existent fetus
• Leiomyoma of uterus
• Retained products of conception
• Choriocarcinoma
• Missed Abortion
• Blighted ovum
• Ectopic pregnancy

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Hydropic Degeneration of placenta

• sonographic similarity of a hydropic placenta
  with marked swelling of the villi to molar
  tissue.
• Vesicles, cysts, fetal remains, and an abnormal
  placenta can be seen.
• The clinical history of the patient -diabetes,
  isoimmunization, and intragestational infection -
  should be considered
• Beta HCG Generally lower

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Hydatidiform Mole with co-existent foetus

• Echogenic Intra-uterine tissue that is
  interspersed with numerous punctuated
  sonolucencies.
• 8-12 weeks -Homogenously echogenic intraluminal
  tissue ( Max. Diam of villi 2mm) with separate
  normal placenta, and fetus.
• 18-20 weeks Cystic spaces ( Max. diam. Of villi
  10mm). Molar tissue can cover normal placenta,
  thus difficult to differentiate from partial mole.

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Uterine Leiomyoma

• Areas of Hyaline degeneration can simulate the
  appearance of hemorrhage within mole.
• Whorled internal consistency distinctly different
  than Vesicular pattern in mole.
• Lack the cystic appearance of mole.

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RPOC with Hemorrhage

• Tissues of mixed echogenicity.
• No gestational sac
• Vesicular pattern will not be there.
• Low levels of HCG.

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Choriocarcinoma

• No Villi
• Well-circumscribed echogenic lesion in myometrium

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Missed Abortions

• Echo-refringent and non-homogeneous chorionic
  tissue remains either located inside the cavity
  or attached to the uterine wall.
• Low or negative hCG levels.

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Blighted ovum

• The perfect interior delimitation of the
  embryonic sac.
• No evidence of any embryo

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Ectopic pregnancy

• Pseudovesicles and a pseudosac
• The combined use of quantitative determinations
  of hCG and vaginal ultrasound may resolve this
  uncertainty. 

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Histopathology

• Two populations of villi
• Enlarged villi ( gt or 3-4mm) with central
  captivation
• Irregular villi with geographic, scalloped border
  with trophoblastic inclusions
• Trophoblast hyperplasia, usually focal.

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Differential histopathology diagnosis

• Beckwith-wiedeman syndrome
• Twin gestation with complete mole, and
  co-existent fetus
• Early complete hydatidiform mole
• Hydropic spontaneous abortion
• Placental Angiomatous malformation

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Cytoflowmetry

• Study of DNA content of curetted material.
• Confirmation of Diagnosis specially when cofusion
  in diagnosis, or unnatural behaviour.
• For Scientific reports
• For research purpose.

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Serum HCG levels after non trophoblastic Abortions

• Should fall to undetectable level by 3 weeks.
• Below 5mIUm/l - negative,
• Above 25mIU/ml -positive.

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HCG Levels after trophoblastic abortions

• Greater than 500mIU/ml frequently by 3 weeks and
  usually by 6 weeks.
• HCG titer should fall to a non-detectable level
  by 15 weeks.

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HCG levels -Management

• Indications of chemotherapy
• Serum hCGgt 20, 000 IU/L at gt4 weeks.
• Rising hCG. i.e. 2 consecutive rising serum
  samples.
• hCG plateau. i.e. 3 consecutive serum samples not
  rising or falling significantly.
• hCG still abnormal at 6 months post evacuation.

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Conclusion

• Partial Mole is a common, but under-diagnosed
  gestational trophoblastic disease.
• combine use of serum HCG and ultrasonography in
  early pregnancy leads to suspicion of partial
  mole, and histology can confirm the diagnosis.
• Early diagnosis, and use of prophylactic
  chemotherapy if indicated can prevent the
  development of chorio-carcinoma

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Complete molar pregnancy,
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USG-Normal Pregnancy

• Double Decidual Sign
• Intradecidual Sign

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Blighted Ovum

• The perfect interior delimitation of the
  embryonic sac.
• No evidence of any embryo

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Dr Haseena HamdaniAvicenna Medical
ClinicMedswana House, Machel Drive,
Gaboroneemail hhamdani_at_rediffmail.comPh No.
267- 3188808Cell 267- 71470419
Thank You