Updated: 12/31/2019

Hydatidiform Mole

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Snapshot
  • A 27-year-old female presents to the emergency department at 11 weeks of gestation with 2 days of uterine bleeding and pelvic pressure, as well as multiple daily episodes of nonbloody, nonbilious emesis over the past week. The patient states that the bleeding is like heavy spotting with dark, purplish-colored blood. On exam, the uterus is larger than expected for gestational age. An ultrasound is performed and shows multiple anechoic spaces in the uterus with no fetus visualized. 
Introduction
  • Overview
    • a type of gestational trophoblastic disease (GTD)
      • molar pregnancies are considered premalignant
        • when malignant, are termed gestational trophoblastic neoplasia (GTN)
          • e.g., choriocarcinoma
        • originates in the placenta
          • has the potential to invade the uterus and metastasize
  • Epidemiology
    • incidence
      • 66-121 per 100,000 pregnancies
    • demographics
      • higher rates in Latin American, Asian, and Middle Eastern countries
    • risk factors
      • extremes of maternal age
      • history of previous mole
Classification
  • Complete mole
    • 46,XX or 46,XY
    • an empty ovum fertilized by a single sperm
      • results in duplication of paternal genetic material (all DNA is from sperm)
    • higher risk of transformation into choriocarcinoma
      • 15-20% transform
  • Partial mole
    • 69,XXX, 69,XXY, or 69,XYY
    • a normal ovum is fertilized by 2 sperm
    • less likely to transform into choriocarcinoma
      • 1-5% transform
Presentation
  • Symptoms
    • exaggeration of normal pregnancy symptoms due to extremely high β-hCG
      • hyperemesis gravidarum 
        • extreme nausea and vomiting
      • vaginal bleeding
        • "prune juice" discharge
          • due to accumulated blood in uterine cavity that has oxidized and liquified
      • pelvic discomfort
        • pain or pressure
  • Physical Exam
    • pelvic exam
      • uterus larger than expected for gestational age
        • more common in complete mole
      • possible adnexal mass
      • possible grape-like mass in vagina
Imaging
  • Transvaginal ultrasound (TVUS)
    • indications
      • β-hCG > 100,000 mIU/mL
    • findings
      • central heterogeneous mass with numerous discrete anechoic spaces
      • “snowstorm,” “cluster of grapes,” or “honeycomb” appearance on older ultrasounds
      • if partial mole
        • fetal parts and amniotic fluid
        • abnormally wide gestational sac
        • abnormal-looking placenta
      • ovarian theca-lutein cysts
        • more likely in complete mole
Studies
  • ↑ β-hCG (> 100,000 mIU/mL)
    • complete mole > partial mole
Differential
  • Normal pregnancy
    • key distinguishing factors
      • uterus sized appropriately for gestation
      • β-hCG will be within normal pregnancy range
      • uterine pregnancy visualized on ultrasound
  • Spontaneous abortion 
    • key distinguishing factors
      • β-hCG will be normal or decreased
      • uterine pregnancy visualized on ultrasound
      • +/- open cervical os on exam
      • +/- vaginal passage of fetal parts
Treatment
  • Medical
    • RhoGAM
      • indications
        • all Rh(D)-negative mothers with vaginal bleeding if father is Rh(D)-positive or unknown
      • modalities
        • single intramuscular or intravenous dose
  • Surgical
    • suction and curettage
      • indications
        • both diagnostic and therapeutic
          • first line treatment for mole
          • pathology confirms diagnosis
  • Follow-Up
    • trend weekly β-hCG levels
      • indications
        • all patients with confirmed mole and/or elevated β-hCG
      • if continues to uptrend
        • workup for choriocarcinoma
Complications
  • Choriocarcinoma
    • malignant product of gestational contents
    • very high β-hCG that does not downtrend after surgical treatment for mole
    • can metastasize to lungs and brain
    • requires surgery and chemotherapy
  • Ovarian theca-lutein cysts 
    • bilateral, multicystic ovaries, often septated
    • secondary to β-hCG stimulation
    • can cause hyperandrogenism
    • also associated with multigestational pregnancy, polycystic ovarian syndrome (PCOS), and ovulation induction due to stimulation by elevated levels of β-hCG
  • Hyperthyroidism
  • Preeclampsia
  • Respiratory distress
    • usually secondary to trophoblastic embolization
 

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Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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