Cause:Gestational trophoblastic neoplasia; complete from a haploid sperm duplicating own chromosomes and inactivating ovum chromosomes, or partial w haploid karyotype
Pathophys:Molar changes seen at junction of placenta and chorionic laeve when chorion is undergoing atrophy at 8-12 wk. Embryo portion dies at 3-5 wk, chorionic villi then accumulate fluid in connective tissue spaces from maternal circulation. Fetal circulation is absent, hence fluid accumulation. Invasive mole doesn't follow a normal pregnancy unless a twin was present
Range of disease exists from benign mole to choriocarcinoma(p132)
1/1500 pregnancies; 10% of all spontaneous abortions have mole changes (A. Hertig 1967)
Increased incidence in Asians, women over age 40 yr, and in women w h/o previous spontaneous abortion
Sx:H/o recent spontaneous abortion; severe morning sickness (hyperemesis gravidarum) lasting into 2nd trimester
Si: Vaginal bleeding in 1st trimester; uterus enlarged beyond dates, although 10% may be small for gestational age
Local invasion and/or benign metastases; choriocarcinoma or persistent gestational trophoblastic tumors (20-30%); thyrotoxicosis from a TSH-like protein present in 100% of moles (Ann IM 1975;83:307); pregnancy-induced hypertension; tumor emboli
Lab:
Chem:HCG levels very high, does not decrease to normal within 6 wk of removal as a normal spontaneous abortion should
Path:Endometrial bx by D&C shows entire endometrium involved; volumes up to 3 L; translucent villi up to 1-cm diameter, appear like "grapes"; organized trophoblast (benign), to pleomorphic (potentially malignant)
Xray:CT and chest xray to look for mets; ultrasound done for abnormal bleeding detects most
Rx:
Rhogam if Rh neg
Benign moles may be rx'd with simple D&E, followed by HCG levels q 2 wk
Invasive types or mets rx'd like choriocarcinoma
Good birth control to prevent new pregnancy while follow serial HCGs to 0 to be sure benign course