MOLAR PREGNANCY (GESTATIONAL TROPHOBLASTIC

DISEASE)

These are unique tumours that developed from an abnormality at

fertilization and are entirely fetal in origin. A high index of suspicion is
needed for a prompt diagnosis and management.

Pathophysiology

 Complete moles are always euploid, of paternal origin, and sex

chromatin-positive (46XX or 46XY)
 Complete moles arise when an empty ovum is fertilized by 2 haploid
sperms
 A partial mole is triploid (69XXY- 70%; 69XXX- 27%; 69XYY- 3%) and
arises when an ovum with an active nucleus is fertilized by a
duplicated or two haploid sperm

Risk factors:

1. Extreme reproductive age

2. Previous history of GTD
3. Diet deficient in protein, folic acid and carotene

Signs and symptoms:

1. Hyperemesis
2. Thyrotoxic tremors, anxiety
3. Absence of quickening despite of growing gestation
4. Weight loss (in some cases)
5. Bleeding
6. History of passing out vesicles
7. Uterus larger than expected gestation (50-60%)

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 8. Doughy feel of uterus
9. Ovarian enlargement – unilateral (~8.5%) or bilateral (12%)
10. Signs of preeclampsia before 20th week
11. Signs of cardiac failure or thyrotoxicosis
12. Anemia not accounted by the amount of blood loss

Investigations

Ultrasound scan (TAS/TVS) : honey comb appearance is seen with or

without fetal part (snow storm appearance)

Conditions that can mimic molar pregnancy on ultrasound:

1. Septic miscarriage
2. Missed miscarriage
3. Degenerative fibroid with pregnancy

Serum BHCG dilution: suggestive when UPT positive with more than
1:3000 dilution

A full abdominal and pelvic examination should be done to exclude:

1. Vaginal causes
2. Subinvolution of uterus
3. Theca lutein cyst

Management

a. Young age wants further pregnancy

- Advise for suction and curettage
- To get consent and once available for GXM 4 pints packed cell
- Arrange for OT immediately if patient is symptomatic, i.e: bleeding,
but if patient is asymptomatic, can arrange for the nearest elective
operation date.

b. Over 40 years and completed family

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- Advise for hysterectomy, if not willing to advise for suction and
curettage and follow as above. If willing for hysterectomy, to proceed
as protocol.

1. Surgical evacuation
a. When diagnosed, the management of choice for molar
pregnancy is suction curettage. This should be done by an
experienced operator using a large 10mm or 12mm suction
curette
b. All women should have a CXR, FBC, group and save serum,
liver and renal function tests and electrolytes prior to surgery
c. Medical termination of pregnancy is not advised as there is a
theoretical risk of disseminating GTD tissue by the use of
potent oxytocic agents
d. All tissue should be sent for histology to confirm the
diagnosis

2. Complications
a. Excessive intraoperative bleeding secondary
b. Uterine perforation- all women should be made aware of the risk
of transfusion and possible hysterectomy.
c. Persistent trophoblast tissue (GTD)
d. Pulmonary edema
e. DIVC or ARDS

3. Follow-up
a. Weekly until BHCG result is below 5iu/ml
b. Monthly for 3 months
c. Three monthly for 3 times
d. Yearly till life

4. By 8- 10 weeks post initial suction and curettage, BHCG should be

< 5iu/ml, if the level failed to reach below 5iu/ml by 12 th week, patient
should be consider to be refer for chemotherapy

5. Future pregnancies

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 a. Women should be advised not to conceive for 6 months after
their serum HCG is undetectable
b. The vast majority (98%) of women who fall pregnant after one
GTD pregnancy have entirely normal reproductive and obstetric
prognosis
c. The COCP is an acceptable form of contraception after serum
HCG levels are undetectable. However, if used prior to this, it
may increase the risk of treatment failure and persistent GTD
d. Follow-up is needed after all subsequent pregnancies with urine
or blood samples for HCG.

Chemotherapy

1. Admit patient
2. Baseline investigation should include
a. LFT
b. BUSE / RP
c. FBC
3. Regime:
a. The 8-day Charing Cross regimen
i. IM methotrexate 50mg (D1,3,5,7) and T folinic acid 7.5mg
(D2,4,6,8)
b. An 8-day regimen of IM methotrexate 1mg/kg (D1,3,5,7) and IM
folinic acid 0.1mg/kg (D2,4,6,8)
c. IM Methotrexate 20mg/m2 (D1-D5), repeat every 14 days.
d. Weekly IM methotrexate 30mg/m2 – efficacy of this regimen
appears to be low for choriocarcinoma
4. BHCG should be repeat 36H post 1st dose of MTX

5. FBC should be done on D2,4,6,8,10

a. Stop chemotherapy if:
i. Hb: <8g/dl
ii. TWBC: <3000
iii. Polymorphs: <1,500
iv. PLT: <100 000
6. The number of courses will depend on level of BHCG, <5iu/ml.
7. To add another 2 courses of regime after the level <5iu/ml.

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