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Irregular uterine bleeding Serum hCG -subunit > 40,000 mU/mL Passage of grape-like clusters of enlarged edematous villi per vagina Ultrasound of uterus with characteristic heterogeneous echogenic image and no fetus or placenta Cytogenetic composition is 46,XX (85%), completely of paternal origin
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Gestational trophoblastic disease is a spectrum of disorders that includes hydatidiform mole, invasive mole, and choriocarcinoma Partial moles generally show evidence of an embryo or gestational sac; are polyploid, slower-growing, and less symptomatic; and often present clinically as a missed abortion Partial moles tend to follow a benign course, while complete moles have a greater tendency to become choriocarcinomas The highest rates of gestational trophoblastic disease occur in some developing countries, with rates of 1:125 pregnancies in certain areas of Asia In the United States, the frequency is 1:1500 pregnancies Risk factors include low socioeconomic status, a history of mole, and age below 18 or above 40 Approximately 10% of women require further treatment after evacuation of the mole; 5% develop choriocarcinoma
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Excessive nausea and vomiting occur in over one-third of patients with hydatidiform mole Uterine bleeding, beginning at 6 8 weeks, is observed in virtually all instances In about one-fifth of cases, the uterus is larger than would be expected in a normal pregnancy of the same duration Bilaterally enlarged cystic ovaries are sometimes palpable They are the result of ovarian hyperstimulation due to excess of hCG Preeclampsia-eclampsia, frequently of the fulminating type, may develop during the second trimester of pregnancy, but this is unusual Choriocarcinoma may be manifested by continued or recurrent uterine bleeding after evacuation of a mole or following delivery, abortion, or ectopic pregnancy The presence of an ulcerative vaginal tumor, pelvic mass, or evidence of distant metastatic tumor may be the presenting observation The diagnosis is established by pathologic examination of curettings or by biopsy
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GESTATIONAL TROPHOBLASTIC DISEASE (HYDATIDIFORM MOLE & CHORIOCARCINOMA)
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A serum hCG -subunit value above 40,000 mU/mL or a urinary hCG value in excess of 100,000 units/24 h increases the likelihood of hydatidiform mole
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ESSENTIALS OF DIAGNOSIS
Hydatidiform Mole
Amenorrhea
C Imaging
Ultrasound has virtually replaced all other means of preoperative diagnosis of hydatidiform mole A preoperative
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chest film is indicated to rule out pulmonary metastases of trophoblast
Prognosis
Five years survival after courses of chemotherapy, even when metastases have been demonstrated, can be expected in at least 85% of cases of choriocarcinoma
Smith HO et al Choriocarcinoma and gestational trophoblastic disease Obstet Gynecol Clin North Am 2005 Dec;32(4):661 84 [PMID: 16310678] Soper JT Gestational trophoblastic disease Obstet Gynecol 2006 Jul;108(1):176 87 [PMID: 16816073]
Treatment
A Specific (Surgical) Measures
The uterus should be emptied as soon as the diagnosis of hydatidiform mole is established, preferably by suction Ovarian cysts should not be resected nor ovaries removed; spontaneous regression of theca lutein cysts will occur with elimination of the mole If malignant tissue is discovered at surgery or during the follow-up examination, chemotherapy is indicated Thyrotoxicosis indistinguishable clinically from that of thyroid origin may occur While hCG usually has minimal TSH-like activity, the very high hCG levels associated with moles result in the release of T3 and T4 and cause hyperthyroidism Patients thyrotoxic on this basis should be stabilized with -blockers prior to induction of anesthesia for their surgical evacuation Surgical removal of the mole promptly corrects the thyroid overactivity
THIRD-TRIMESTER BLEEDING
Five to 10 percent of women have vaginal bleeding in late pregnancy The clinician must distinguish between placental causes (placenta previa, placental abruption, vasa previa) and nonplacental causes (infection, disorders of the lower genital tract, systemic disease) The approach to bleeding in late pregnancy should be conservative and expectant unless fetal distress or risk of maternal hemorrhage occurs The patient should be hospitalized and placed at bed rest with continuous fetal monitoring A complete blood count (including platelets) should be obtained and two to four units of blood typed and cross-matched Coagulation studies should be ordered as clinically indicated Ultrasound examination should be performed to determine placental location Speculum and digital pelvic examinations are done only after ultrasound study has ruled out placenta previa Continuous electronic fetal monitoring is required to exclude fetal distress While uterine contractions, pain, or tenderness often indicate associated abruptio placentae, an ultrasound negative for retroplacental clot does not exclude it If the patient is at less than 36 weeks of gestation, continued hospitalization and bed rest may be necessary, especially with placenta previa during the initial 7 10 days following vaginal bleeding If the patient has close proximity to the hospital and immediate access, can be on strict bed rest, and has complete resolution of bleeding and uterine contractions, home management may be considered She must be well instructed and counseled regarding the risks Patients with vaginal bleeding at less than 36 weeks of gestation should also be considered for amniocentesis to test for fetal lung maturity Corticosteroid therapy (betamethasone 12 mg intramuscularly, two doses 12 24 hours apart) is indicated if fetal lung immaturity is present
Usta IM et al Placenta previa-accreta: risk factors and complications Am J Obstet Gynecol 2005 Sep;193(3 Pt 2):1045 9 [PMID: 16157109]
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