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Key Features

Essentials of Diagnosis

  • Hydatidiform mole

    • Amenorrhea

    • Irregular uterine bleeding

    • Serum human chorionic gonadotropin (hCG) β-subunit > 40,000 milli-units/mL

    • Passage of grape-like clusters of enlarged edematous villi per vagina

    • Ultrasound of uterus shows characteristic heterogeneous echogenic image and no fetus or placenta

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

  • Choriocarcinoma: Presence of detectable β-hCG after mole evacuation

General Considerations

  • Gestational trophoblastic disease is a spectrum of disorders, including

    • Hydatidiform mole (partial and complete)

    • Invasive mole (local extension into the uterus or vagina)

    • Choriocarcinoma (malignancy often complicated by distant metastases)

    • 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

Demographics

  • Highest rates of gestational trophoblastic neoplasia occur in Asians

  • Risk factors include prior spontaneous abortion, a history of mole, and age below 21 or above 35

Clinical Findings

Symptoms and Signs

  • Hydatidiform mole

    • Excessive nausea and vomiting may occur

    • Uterine bleeding beginning at 6–16 weeks is usual

    • In some cases, the uterus appears larger than would be expected

    • Bilaterally enlarged cystic ovaries may be palpable

    • Less commonly, preeclampsia-eclampsia may develop during the second trimester

  • Choriocarcinoma may be manifested by continued or recurrent bleeding

    • After evacuation of a mole

    • Following delivery, abortion, or ectopic pregnancy

    • An ulcerative vaginal tumor, pelvic mass, or distant metastases may be the presenting manifestation

Differential Diagnosis

  • Similarly elevated levels of serum β-hCG subunit are seen in multiple gestation

    • Spontaneous abortion

    • Ectopic pregnancy

    • Prolapsed uterine fibroid

    • Uterine leiomyomas (fibroids), endometrial polyp, or adenomyosis (uterine endometriosis)

    • Ovarian tumor

    • Cervical neoplasm or lesion

Diagnosis

Laboratory Tests

  • High serum β-hCG subunit values

    • Can range from high normal to the millions

    • Levels are higher with complete moles than with partial moles

    • Can cause the release of thyroid hormone, and rarely, symptoms of hyperthyroidism will be present

  • Serum β-hCG values are more helpful in managing response to treatment than they are for diagnosis

  • Hematocrit, creatinine, blood type, liver chemistries, and thyroid function tests

Imaging Studies

  • Preoperative diagnosis is made with ultrasonography

  • Placental vesicles can be easily seen on transvaginal ultrasound

  • Preoperative chest radiograph is required to evaluate for pulmonary metastases of trophoblast

Treatment

Medications

  • Chemotherapy is indicated for mole if malignant tissue is discovered at surgery or during follow-up examination (Table 39–3)

  • For low-risk patients with a good prognosis, give

    • Methotrexate, 0.4 mg/kg intramuscularly over a 5-day period, or

    • Actinomycin, 10–12 mcg/kg/day intravenously over a 5-day period

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