VESICULAR MOLE

FEATURE Age Karyotype hCG Pathology 1. Fetus 2. Amnion, fetal RBCs 3. Villous edema 4. Trophoblast proliferation Clinical presentation 1. Uterine size 2. Theca lutein cysts 3. Symptoms of PET, hyperemesis, hyperthyroidism 4. Postmolar disease N/E PARTIAL Not age related 69 XXX or 69 XXY (triploidy) 1 maternal & 2 paternal Rarely elevated above pregnancy level Present Present Variable, focal Focal, moderate COMPLETE Great risk > 40 years 46 XX or 46 XY All are paternal >100,000 mIU/ml

Absent Absent Diffuse Diffuse, severe

Small for date Rare Rare

Large for date in 50% Present in 25-30% Frequent

4%

M/E

-marked sweeling & edema of villi -presence of normal villi

US

Picture of missed abortion

20% -uterus enlarged > amenorrhea -distended with grape like vesicles & filled with clear watery fluid -vesicles may invade deciduas & myometrium - some cases into metastasis mole -Hydropic degeneration & sweeling of villous stroma -absence of blood vessels in swollen villi -no malignant criteria Snow storm appearance with no fetal part

SECONDARY POST PARTUM HEMORRHAGE

1. 2. 3. 4. 5. 6. 7. Retained placental tissue/ membranes Subinvolution Submucous fibroid Choriocarcinoma Puerperal inversion of uterus Cancer cervix General as hypertensive heart failure

CHORIOCARCINOMA
LOW RISK (Good prognosis) HIGH RISK (Poor prognosis) Short duration : <4 months Long duration : >4 months Pre-treatment hCG titre : <40,000 mIU/ml Pre-treatment hCG titre : >40,000 mIU/ml No previous chemotherapy Brain / liver metastasis Failure of previous chemotherapy When the disease follows full term pregnancy

INVASIVE MOLE 15% of vesicular mole invades myometrium by direct invasion and venous channel 15% of invasive mole show benign distant metastasis. Commonly in lungs, liver, vagina and CNS CHORIOCARCINOMA Gross appearance Microscopic pictures Circumscribed soft dark red nodule Sheets of malignant trophoblast with hemorrhage and necrosis interspersed with blood lakes Polypoidal mass with hemorrhagic Both cyto and syncitiotrophoblast appearance should be identified Diffuse mass affecting the whole There is variable degree of myometrial uterine cavity invasion Infiltrative lesion that invades Absence of intact villi (pathognomonic) myometrium Areas of Arias Stella reaction maybe present

METHOTREXATE
Mechanism of action It is antimetabolite that inhibits dihydrofolate reductase enzyme required for processing folic acid to folinic acid This result in arrested synthesis of DNA, RNA and proteins (folic acid antagonist) Dose 1mg/kg body weight for 5 days course Courses are repeated every other week Repeat courses till hCG is negative and then add 3 courses after negative titre Side effects Ulceration of mouth & GIT mucosa Nausea, vomiting and diarrhea Alopecia Myelosuppression : decrease in platelets, WBCs and RBCs Pneumonitis Hepatotoxicity Nephrotoxicity ACTINOMYCIN D It is antibiotic that intercalates DNA strands It is effective as a single agent in non metastatic GTT COMBINED REGIMENS M-EA Methotrexate etoposide OR Methotrexate Actinomycin D EMA-C Etoposide - Methotrexate Actinomycin D Cyclophosphamide OR Etoposide - Methotrexate Actinomycin D - Vincristine