From History –
- H/O amenorrhea of 8-12 weeks.
- Usually comes in 1st trimester with most common presentation – Brown bloody vaginal bleeding.
- H/O expulsion of grape like vesicles per vaginal.
- Initial features are suggestive of pregnancy but no quickening.
- Lower abdominal pain (due to expulsion/ overstretching/ hemorrhage/ infection/ perforation).
- Patient feels sick and complains of vomiting.
- Rarely with features of thyrotoxicosis/ dyspnea.
On clinical Examination –
General Features :
- Signs suggestive of early pregnancy.
- Pallor present due to hemorrhage.
- Features of Iron deficiency anemia/ Pre-eclampsia.
Per Abdominal Examination :
- Height of fundus is more than POA (Period of Amenorrhea) in most of the cases.
- The feel of uterus is firm, elastic.
- Fetal parts – Impalpable.
- Fetal Heart Sound – Not audible.
- No fetal Movement.
- External Ballotment – (-ve).
Per Vaginal Examination :
- Internal Ballotment – (-ve).
- Blood stained discharge/ Frank Bleeding.
- Unilateral/ Bilateral enlargement of ovaries.
- Vesicles may be felt if os is open.
From Investigation –
- Complete Hemogram – Hb%, TC, DC, ESR, ABO & Rh Grouping.
- USG Abdomen – Charecteristic Snowball appearance, Absence of fetal parts, Cyst in Ovary.
- Serum and Urine Beta-HCG Level – Elevated than normal level (Rising Beta-HCG >100000mIU/L is suggestive).
- Straight Xray Abdomen – To rule out fetus (-ve Fetal shadow).
- Straight CXR (PA View) – To rule out evidence of pulmonary embolization.
- Liver, Renal and Throid Function Test – When indicated.
- Histopathological Examination of the expelled vesicles – No chorion, no amnion, no fetal tissue, all villi are abnormal, degenerated with fluid filled vesicles, no blood vessels in complete mole.
THE D/D OF H. MOLE ARE –
- Threatened Abortion
- Fibroid/ Ovarian tumor with pregnancy
- Multiple Pregnancy
These are rule out by USG Abdomen and Beta-HCG Level.
- Resuscitation if needed.
- Early Diagnosis and Suction Evacuation as early as possible.
- Supportive therapy to correct anemia – IV Infusion with ringer lactate solution, Blood transfusion, Parental Antibiotic.
For further assessment, patient are grouped into 2 groups –
Group A – The mole is in the process of expulsion
Group B – The uterus is inert and closed os
FOLLOW UP IN CASE OF MOLAR PREGNANCY –
- The patient should be well counselled about the complication of molar pregnancy and the associated risk factors along with the importance of follow up in these cases.
- The disease is benign in 20-30% cases there is a chance of development of persistent trophoblastic disease which is considered malignant. The chances of choriocarcinoma is also high in these cases.
- The tumor marker in this case is Beta-HCG. The first estimate should be done immediately at evacuation and then every week still it becomes negative. This usually regress within 3 months.
- The patient is advised not to get pregnant during the whole period of follow up.
- During each follow up each things has to be noted –
– Enquiry about irregular vaginal bleeding, persistent cough, breathlessness or hemoptysis.
– Involution of uterus, Ovarian size, Malignant deposit through abdominal examination.
(The lutein cyst usually regress within 2 months)
- Investigations done are Urine/Serum HCG and CXR
- Prophylactic chemotherapy –
– HCG Level fails to become normal by 12 weeks.
– Reelevation at 4-8 weeks.
– Rising Beta HCG after normalization.
– Follow up is not possible duw to remote area.
– Evidence of metastasis.
Treatment : Methotrexate – 1 mg/kg/day IV + Folinic acid 0.1 mg/kg/day IM.
- Contraceptions like IUCD, OCP are contraindicated during this period.