Case Presentation Partial molar Pregnancy Dr Haseena Hamdani

Case Presentation: Partial molar Pregnancy Dr Haseena Hamdani Avicenna Medical Centre

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

Case Report § § § Asian woman 27 years old Nulliparous Consanguineous marriage Combined oral pills for puberty menorrhagia

First visit § Presenting Symptoms Ø Amenorrhoea 6 weeks § Clinical Examination Ø Urine pregnancy test – positive Ø PV examination – Bulky soft uterus

Follow up visit after 4 weeks § Ø Ø Ø Ø Presenting Symptoms Amenorrhea 10 weeks Abdominal USGGestational sac present. Ill defined fetal echo present. Cardiac pulsation not seen. Few small cisterns in part of placenta

Second follow up visit after three days § Ø Ø § Ø Serum Beta HCG levels 125, 000 m. IU/ ml, 138, 000 m. IU/ml after 48 hrs. Repeat USG Same findings

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

Treatment § Ø Suction Evacuation done. Curetted material sent for Histo-pathology.

Histo-pathology report § Findings Ø 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 Ø Ø •

Post-evacuation follow up Irregular scanty bleeding P/V for 3 weeks § HCG levels Ø After 4 weeks-543 m. IU/ml Ø After 6 weeks- 58. 73 m. IU/ml Ø After 8 weeks- 11. 67 m. IU/ml Ø After 10 weeks- 3. 16 m. IU/ml §

Post-evacuation follow up Advice Ø use combined oral pills for next 6 months, Ø follow up for HCG levels every month for 6 months. §

Brief Discussion Gestational trophoblastic Diseases. § Molar pregnancy Ø Complete molar pregnancy Ø Partial molar Pregnancy § Invasive Mole § Chorio-carcinoma § Placental-site trophoblastic tumor

Characteristics of GTD § § Arise from fetal chorion Secrete HCG Good response to chemotherapy Variable Malignant Potential

Gestational Trophoblastic Diseases Incidence ØAsians 1 in 200 - 300 ØAfricans 1 in 800 ØCaucasians 1 in 2000 ØMaximum in Indonesia, Japan, and Philippine

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 5 years H/O infertility

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

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

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

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

Pathogenesis 69 xxx 69 xxy 69 xyy 46 xxy

Diagnostics in management § Ø Ø Ø § § § Tumor markers Serum HCG Alpha feto-protein. Others like PAPP, Pregnancy specific protein, CA 125 Ultrasound examination. Histo-pathological Analysis. Genetic Karyotyping, Flow cytometry, ploidy analysis etc.

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.

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

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.

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.

Correlation between HCG level, and sonography findings § § § Serum HCG levels 1800 IU/L-Gestational sac should be visible by USG Serum HCG levels 5000 IU/L-Cardiac pulsation should be visible. More than 5000 IU/L rules out Ectopic pregnancy.

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.

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

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

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

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.

Serum HCG levels after non trophoblastic Abortions § Ø Ø Should fall to undetectable level by 3 weeks. Below 5 m. IUm/l - negative, Above 25 m. IU/ml -positive.

HCG Levels –after trophoblastic abortions § § Greater than 500 m. IU/ml frequently by 3 weeks and usually by 6 weeks. HCG titer should fall to a non-detectable level by 15 weeks.

HCG levels -Management • Indications of chemotherapy ØSerum h. CG> 20, 000 IU/L at >4 weeks. Ø Rising h. CG. i. e. 2 consecutive rising serum samples. Øh. CG plateau. i. e. 3 consecutive serum samples not rising or falling significantly. Øh. CG still abnormal at 6 months post evacuation.

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

Complete molar pregnancy,

USG-Normal Pregnancy § § Double Decidual Sign Intradecidual Sign

Blighted Ovum § § The perfect interior delimitation of the embryonic sac. No evidence of any embryo

Thank You Dr Haseena Hamdani Avicenna Medical Clinic Medswana House, Machel Drive, Gaborone email: hhamdani@rediffmail. com Ph No. +267 - 3188808 Cell +267 - 71470419