Case Presentation: Partial molar Pregnancy

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

2. 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

4. First visit Presenting Symptoms Amenorrhoea 6 weeks Clinical Examination Urine pregnancy test � positive PV examination � Bulky soft uterus

5. 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

6. Second follow up visit after three days Serum Beta HCG levels- 125,000mIU/ ml, 138,000mIU/ml after 48 hrs. Repeat USG Same findings

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

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

9. 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

10. 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

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

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

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

14. Gestational Trophoblastic Diseases

15. 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

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

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

19. Pathogenesis

20. Pathogenesis

21. 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.

22. 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.

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

24. 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.

27. 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.

28. 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.

29. Serum HCG levels

30. 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.

31. 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

32. Hydropic Degeneration of placenta

33. 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.

34. Uterine Leiomyoma

35. RPOC with Hemorrhage Tissues of mixed echogenicity. No gestational sac Vesicular pattern will not be there. Low levels of HCG.

36. Choriocarcinoma No Villi Well-circumscribed echogenic lesion in myometrium

37. 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.

38. Blighted ovum The perfect interior delimitation of the embryonic sac. No evidence of any embryo

39. Ectopic pregnancy Pseudovesicles and a pseudosac The combined use of quantitative determinations of hCG and vaginal ultrasound may resolve this uncertainty.�

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

41. 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

42. 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.

43. Serum HCG levels after non trophoblastic Abortions Should fall to undetectable level by 3 weeks. Below 5mIUm/l - negative, Above 25mIU/ml -positive.

44. 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.

46. 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

47. Complete molar pregnancy, 

48. USG-Normal Pregnancy Double Decidual Sign Intradecidual Sign

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

50. Dr Haseena HamdaniAvicenna Medical ClinicMedswana House, Machel Drive, Gaboroneemail: hhamdani@rediffmail.comPh No. +267- 3188808Cell +267- 71470419