Gynecology | Hydatidiform Mole

Hi everyone, welcome back to the MedBullets Step 2 in 3 podcast. In today's episode, we cover the topic of high data deformed mole found under the gynecology section at MedBullets.com. Let's begin with a clinical snapshot. A 27-year-old female presents to the emergency department at 11 weeks of gestation with two days of uterine bleeding and pelvic pressure.

as well as multiple daily episodes of non-bloody, non-bilious emesis for 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 which demonstrates multiple anechoic spaces in the uterus with no fetus visualized. Let's continue with an introduction to hydatidiform mole.

As a general overview, remember that this is a type of gestational trophoblastic disease, or GTD. Molar pregnancies are considered premalignant. When malignant, they are termed gestational trophoblastic neoplasia, or GTN. Examples of this are choriocarcinoma. Remember that this originates in the placenta and has the potential to invade the uterus and metastasize. In terms of the classification, a complete mole is 46 XX.

or 46XY. There is an empty ovum that is fertilized by a single sperm, which results in duplication of paternal genetic material, so all DNA is from the sperm. There is a higher risk of transformation into choriocarcinoma. with about 15-20% of cases transforming. A partial mole is 69XXX, 69XXY, or 69XYY. it is a normal ovum that is fertilized by two sperm. This is less likely to transform into choriocarcinoma, with only about 1-5% of them transforming. In terms of the epidemiology,

Remember that this occurs in about 66 to 121 out of 100,000 pregnancies. Demographically, there is a higher rate in Latin American, Asian, and Middle Eastern countries. Risk factors include extremes of maternal age and a history of a previous mole. Moving on to the presentation, symptoms will include exaggeration of normal pregnancy symptoms.

due to extremely high levels of beta-HCG. Examples of this are hyperemesis gravidarum, which is extreme nausea and vomiting. Vaginal bleeding that may present as prune juice discharge due to the accumulated blood in the uterine cavity. that is oxidized and liquefied. There may also be pelvic discomfort which is described as pain or pressure. On pelvic exam, one may note that the uterus is larger than expected for gestational age.

This is more common in a complete mole. One may also note possible adnexal masses and a possible grape-like mass in the vagina. In terms of further imaging, a transvaginal ultrasound is indicated if a beta-HCG is greater than 100,000. Specific findings may include a central heterogeneous mass with numerous discrete anechoic spaces. There may be a quote-unquote snowstorm, cluster of grapes,

or honeycomb appearance on older ultrasounds. If it is a partial mole, there may be fetal parts and amniotic fluid. There may be an abnormally wide gestational sac and an abnormal looking placenta. One may also note ovarian thecalutin cysts, but these are more likely in complete moles. In terms of further studies, one will note an increase in beta-HCG that is often greater than 100,000.

and remember that the beta-HCG is greater in complete moles than in partial moles. In terms of the differential, make sure to think about a normal pregnancy, with key distinguishing factors being that the uterus will be sized appropriately for gestation. Beta HCG will be within normal pregnancy range, and the uterine pregnancy is visualized on ultrasound. Also think about a spontaneous abortion, with key distinguishing factors being that beta HCG will be normal or decreased.

The uterine pregnancy may be visualized on ultrasound. There may be an open cervical oson exam, and there may be vaginal passage of fetal parts. In terms of treatment, medical options include RhoGAM.

This is indicated in all RHD negative mothers with vaginal bleeding if the father is RHD positive or unknown. Specific modalities include a single intramuscular or intravenous dose. Surgical options include suction and curatage. This is indicated for both diagnostic and therapeutic purposes. This is the first line of treatment for a mole, and the pathology will confirm the diagnosis. For follow-up,

one should evaluate weekly beta-HCG levels. This is indicated in all patients with confirmed moles or elevated beta-HCG. If it continues to uptrend, then the patient should be worked up for choriocarcinoma. Complications related to mole pregnancies include choreocarcinoma. This is malignant production of gestational contents. It presents with very high beta-HCG that does not downtrend after surgical treatment for the mole.

It can metastasize to the lungs and brain, and it requires surgery and chemotherapy. Another complication is ovarian thecolutin cysts. These are bilateral multicystic ovaries that are often septated. It is secondary to beta-HCG stimulation. It can cause hyperandrogenism, and it is also associated with multigestational pregnancy, polycystic ovarian syndrome,

and ovulation induction due to stimulation by elevated levels of beta-HCG. Other complications include hyperthyroidism, preeclampsia, and respiratory distress, usually secondary to trophoblastic embolization.

Now that we've discussed the major points relating to high data deformed mole, let's walk through a question to apply what we've learned and get a sense of how the topic might be tested. For this question, consider the following clinical scenario. A 27-year-old G2P0A2 woman comes to the office complaining of light vaginal spotting. She received a suction curatage two weeks ago for an empty gestational sac.

Pathology reports demonstrated hyperplastic and hydropic trophoblastic villi, but no fetal tissue. The patient denies fever, abdominal pain, dysuria, dyspareunia, or abnormal vaginal discharge. She has no chronic medical conditions. Her periods are normally regular and last three to four days. One year ago, she had an ectopic pregnancy that was treated with methotrexate.

She has a history of chlamydia and gonorrhea that was treated 5 years ago with azithromycin and ceftriaxone. Her temperature is 98 degrees Fahrenheit or 36.7 degrees Celsius. Blood pressure is 125 over 71. Pulse is 82 beats per minute. On exam, hair is present on the upper lip, chin, and forearms. A pelvic exam reveals a non-tender, six-week-sized uterus and bilateral adnexal masses.

There is scant dark blood in the vaginal vault on speculum exam. A quantitative beta HCG is 101,000. Two weeks ago, her beta HCG was 63,200. A pelvic ultrasound demonstrates bilaterally enlarged ovaries with multiple thin-walled cysts between 2 to 3 centimeters in size. Which of the following is the most likely cause of this patient's adenexal masses?

And the answer choices are, choice one, corpus luteal cyst, choice two, dermoid cyst, choice three, ectopic pregnancy, choice four, endometrioma, or choice five, The best answer to this question is choice five. The patient has a markedly elevated beta-HCG following pathology that confirmed a hydatodeform mole, which is suspicious for gestational trophoblastic disease. However, given that her beta-HCG is still rising,

she may have had incomplete evacuation and may be at risk of developing gestational trophoblastic neoplasia. GTD is associated with decalutin cysts that present as bilaterally enlarged multicystic ovaries. and can cause hyperandrogenism. Thecalutin cysts are caused by hyperplasia of the theca internal cells stimulated by excessive circulating gonadotropins such as beta-HCG. Therefore,

They are associated with conditions that increase gonadotropins, including GTD, multifetal pregnancy, polycystic ovarian syndrome, and ovulation induction. They present as bilateral multicystic ovaries. and patients may have signs of hyperandrogenism, such as hirsutism, acne, and masculine appearance. Let's also discuss why the other choices are incorrect. Choice one.

Corpus luteal cysts are the failure of the corpus luteum to regress after ovum release. They are the most common pelvic mass in the first trimester of pregnancy and may result in hemorrhage or rupture. On ultrasound, they have diffusely thick walls and a peripheral ring of fire representing increased vascularity. Choice two. Dermoid cysts are also known as teratomas, which are the most common ovarian neoplasm.

They contain elements of multiple germ layers such as skin, hair, or teeth. Choice three, ectopic pregnancy presents with lower abdominal pain, adnexal tenderness, and abnormal uterine bleeding. Ectopic pregnancy would not cause multiple bilateral ovarian cysts. Choice 4. Endometrioma is endometriosis of the ovaries that is most commonly unilocular.

The hormone changes during the menstrual cycle will cause variation in size. Patients often present with dysmenorrhea, menorrhagia, dyspareunia, and or chronic pelvic pain. Finally, a bullet summary. Thecalutin cysts can cause hyperandrogenism, and they are stimulated by elevated levels of beta-HCG, such as in molar pregnancy or multiple gestation. That's all for this review about high-data deformed mole.

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