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ESSENTIALS OF DIAGNOSIS

Hydatidiform mole

  • Amenorrhea.

  • Irregular uterine bleeding.

  • Serum beta-hCG greater than 40,000 milli-units/mL.

  • Passage of grapelike clusters of enlarged edematous villi per vagina.

  • Uterine ultrasound shows characteristic heterogeneous echogenic image and no fetus or placenta.

  • Cytogenetic composition is 46,XX (85%), of paternal origin.

Choriocarcinoma

  • Persistence of detectable beta-hCG after mole evacuation.

GENERAL CONSIDERATIONS

Gestational trophoblastic disease is a spectrum of disorders that includes hydatidiform mole (partial and complete), invasive mole (local extension into the uterus or vagina), choriocarcinoma (malignancy often complicated by distant metastases), and placental site trophoblastic tumor. Complete moles show no evidence of a fetus on ultrasonography. The majority are 46,XX, with all chromosomes of paternal origin. Partial moles generally show evidence of an embryo or gestational sac; are triploid, 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 choriocarcinoma.

In North America, the frequency of gestational trophoblastic disease is 1:1500 pregnancies. The highest rates occur in Asians. Risk factors include prior spontaneous abortion, a history of mole, and age younger than 21 or older than 35. Approximately 10% of women require further treatment after evacuation of the mole; choriocarcinoma develops in 2–3% of women.

CLINICAL FINDINGS

A. Symptoms and Signs

Uterine bleeding, beginning at 6–16 weeks, is observed in most instances. In some cases, the uterus is larger than would be expected in a normal pregnancy of the same duration. Excessive nausea and vomiting may occur. Bilaterally enlarged cystic ovaries are sometimes palpable (eFigure 19–6). They are the result of ovarian hyperstimulation due to excess beta-hCG.

eFigure 19–6.

Trophoblastic disease. Transverse scan of the pelvis with a hydatidiform mole (M) and ovarian theca-lutein cysts (arrowheads). (Reproduced, with permission, from Krebs CA, Giyanani VL, Eisenberg RL. Ultrasound Atlas of Disease Processes. Originally published by Appleton & Lange. Copyright © 1993 by The McGraw-Hill Companies, Inc.)

Preeclampsia-eclampsia may develop during the second trimester of an untreated molar pregnancy, but this is unusual because most are diagnosed early.

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 distant metastases may be the presenting manifestation.

B. Laboratory Findings

Hydatidiform moles are generally characterized by high serum beta-hCG values, which can range from high normal to the millions. Levels are higher with complete moles than with partial moles. Serum beta-hCG values, if extremely high, can assist in making the diagnosis, but they are more helpful in managing response to treatment. Hemoglobin/hematocrit, creatinine, blood type, liver biochemical tests, and thyroid function tests ...

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