Obstetrics & Gynaecology
You have been asked to give a teaching session to a group of junior colleagues. The title of the session is "Early Pregnancy Complications in the Emergency Department". You are discussing molar pregnancy. Which of the following is a risk factor for molar pregnancy?
Answer:
Hydatidiform moles affect women throughout the reproductive age range but are more common at the extremes of the range. Women under 16 have a six times higher risk of developing the disease than those aged 16-40, and women who conceive aged 50 or more have a one in three chance of having a molar pregnancy.Molar Pregnancy
Obstetrics & Gynaecology
Last Updated: 12th February 2021
Gestational trophoblastic disease (GTD) comprises a group of disorders spanning the premalignant conditions of complete and partial molar pregnancies (also known as hydatidiform moles) through to the malignant conditions of invasive mole, choriocarcinoma and the very rare placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT).
Hydatidiform moles are abnormal conceptions with excessive placental, and little or no fetal, development. The two major types—complete and partial—have distinctive histological and genetic features.
Hydatidiform mole affects 1-3 in every 1000 pregnancies. About 10% of hydatidiform moles transform into one of the malignant forms of gestational trophoblastic disease, known as gestational trophoblastic neoplasia (GTN).
Hydatidiform moles affect women throughout the reproductive age range but are more common at the extremes of the range. Women under 16 have a six times higher risk of developing the disease than those aged 16-40, and women who conceive aged 50 or more have a one in three chance of having a molar pregnancy.
Clinical features
Clinicians should be aware of the symptoms and signs of molar pregnancy. The most common presentation is irregular vaginal bleeding, a positive pregnancy test and supporting ultrasonographic evidence.
Less common presentations of molar pregnancies include hyperemesis, excessive uterine enlargement, hyperthyroidism, early‐onset pre‐eclampsia and abdominal distension due to theca lutein cysts.
Very rarely women can present with haemoptysis or seizures due to metastatic disease affecting the lungs or brain.
Diagnosis
Ultrasound features suggestive of a complete molar pregnancy include a polypoid mass between 5 and 7 weeks of gestation and thickened cystic appearance of the villous tissue after 8 weeks of gestation with no identifiable gestational sac. Partial molar pregnancies are associated with an enlarged placenta or cystic changes within the decidual reaction in association with either an empty sac or a delayed miscarriage.
The definitive diagnosis of a molar pregnancy is made by histological examination. Pathological features consistent with the diagnosis of complete molar pregnancies include: absence of fetal tissue; extensive hydropic change to the villi; and excess trophoblast proliferation. Features of a partial molar pregnancy include: presence of fetal tissue; focal hydropic change to the villi; and some excess trophoblast proliferation.
Because the diagnosis of hydatidiform mole is often unsuspected until histological examination, all products of conception from non-viable pregnancies must be submitted for routine pathological evaluation. If a diagnosis is not made, malignant change will not be subsequently monitored and women will have a significantly increased risk of life threatening complications, such as uterine perforation and severe haemorrhage.
Management
- Molar pregnancy
- Suction curettage is the method of choice for removal of complete molar pregnancies. Ultrasound guidance during removal and curettage may be of use to minimise the chance of perforation and to ensure that as much tissue as possible is removed.
- Suction curettage is the method of choice for removal of partial molar pregnancies except when the size of fetal parts deters the use of suction curettage and then medical removal can be used.
- Anti‐D prophylaxis is recommended following removal of a molar pregnancy.
- Gestational trophoblastic neoplasia
- In benign disease, human chorionic gonadotrophin concentrations spontaneously return to normal, but in women who develop neoplasia the concentration plateaus or rises.
- Women with human chorionic gonadotrophin concentrations greater than 20, 000 IU/l one month after molar evacuation are at risk of uterine perforation, and chemotherapy is needed to help preserve fertility.
- Women with GTN may be treated with single‐agent (methotrexate alone) or multi‐agent chemotherapy.
- Response to treatment is assessed by measuring serum concentrations of human chorionic gonadotrophin.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
