SIGNS AND SYMPTOMS 
- Usually exaggerated subjective symptoms of pregnancy
- Complete mole:
- Vaginal bleeding, most common (97%):
- Late 1st trimester
- Usually painless and like "prune juice"
- May also have vaginal tissue passage:
- Often described as grapelike vesicles
- Usually occurs in 2nd trimester < 20 wk
- Hyperemesis from high levels β-hCG
- Preeclampsia (27%):
- Hyperthyroidism (7%):
- Marked tachycardia, tremor
- Due to high levels of β-hCG or thyroid stimulating substance (thyrotropin)
- Acute respiratory distress (2%):
- Tachypnea, diffuse rales, tachycardia, mental status changes
- Possible embolism of trophoblastic tissue
- May also be due to cardiopulmonary changes from preeclampsia, hyperthyroidism, or iatrogenic fluid replacement
- Partial mole:
- Usually does not exhibit dramatic clinical features of complete mole
- Frequently presents with symptoms similar to patients with threatened or spontaneous abortion:
- Vaginal bleeding
- May have fetal heart tones
- Often presents at more advanced gestational age
History
Similar to that of pregnancy:
- Missed menstrual periods
- Positive pregnancy test
- Nausea, vomiting, vaginal bleeding
Physical Exam
- Uterine size/date discrepancy occurs in 50–66% of cases
- Complete mole usually larger than dates would indicate
- Partial mole can be smaller than dating suggests
- Ovarian masses:
- Present in complete moles, rarely in partial moles
- Usually from ovarian enlargement
- Multiple bilateral theca lutein cysts due to high levels of β-hCG, usually found by US
ESSENTIAL WORKUP
- hCG
- Complete mole β-hCG > 100,000 mIU/mL, but can be normal
- Partial mole: Usually lower than that seen with normal pregnancy
- β-hCG > 40,000 mIU/mL carries poor prognosis
- US:
- Complete mole:
- Characteristic "snowstorm" vesicular pattern
- Absence of fetal tissue and swelling of chorionic villi with anechoic spaces
- No amniotic fluid
- Theca lutein cysts
- Bilateral, multiloculated
- Large at 6–12 cm
- Partial mole:
- "Swiss-cheese" appearance
- Cystic changes in placenta with scalloping of villa and in shape of gestational sac
- Fetus may be present
DIAGNOSIS TESTS & INTERPRETATION
Lab
- β-hCG
- Blood type, Rh, and cross-match
- CBC to assess for anemia and thrombocytopenia
- Coagulation profile to assess for disseminated intravascular coagulation
- Electrolytes with BUN and creatinine
- LFTs
- TSH and thyroxin (free T4) if hyperthyroidism suspected
- Urinalysis to evaluate for protein if preeclampsia suspected
Imaging
- US:
- May be performed at bedside
- CXR:
- Assess for pulmonary edema in acute respiratory distress
- Check for metastatic disease
- For baseline study
Diagnostic Procedures/Surgery
Pathology/histology:
- All conception products should be sent for formal evaluation
- Products may be the only way to diagnose a partial molar pregnancy
- Complete mole:
- Edematous chorionic villi
- Hyperplasia of trophoblasts
- Partial mole:
- Fetal tissue and vessels
- Amnion
- Edematous chorionic villi
DIFFERENTIAL DIAGNOSIS
[Outline]
PRE-HOSPITAL
- Ensure patent airway, provide oxygen
- IV access
- Treat convulsions appropriately with benzodiazepine
- Save passed tissue for histologic evaluation
INITIAL STABILIZATION/THERAPY
- IV access
- Cardiac monitoring
- Type and cross-match for blood, especially if patient requires uterine extraction
ED TREATMENT/PROCEDURES
- Acute respiratory distress:
- Intubation and mechanical ventilation
- CXR
- Hyperthyroidism:
- β-adrenergic blockers:
- Administer before molar evacuation
- Stress of anesthesia or surgery may precipitate thyroid storm
- Preeclampsia/eclampsia:
- Convulsions
- Hypertension:
- Coagulopathy:
- Transfuse with blood products as needed
- Human anti-D immunoglobulin (RhoGAM):
- Although fetal blood not present in complete mole, may be delay in distinguishing partial vs. complete
- Suction curettage:
- Done by obstetrician, possibly in ED
- Curative in 80% of cases
- Method of choice in women wishing to preserve fertility
- Oxytocin infusion to induce myometrial tone, may require other uterotonic formulations
- Chemoprophylaxis:
- Very controversial
- Prescribed by obstetrician only for patients with follow-up
- Usually used in high-risk complete mole or if hormonal monitoring is unavailable
- Hysterectomy:
- Patients in older age group
- Patients not interested in keeping fertility
- High-risk disease
- Does not prevent possible metastasis
MEDICATION
- Diazepam: 0.2–0.4 mg/kg IV, or 0.3–0.5 mg PR, up to 5–10 mg, for max. 30 mg
- Hydralazine: 5–10 mg IV q20min, up to 60 mg.
- Labetalol: 20 mg IV with doubled dosing q10m for max. 300 mg
- Magnesium sulfate: 4–6 g IV over 15–20 min then maintain 1–2 g/h
- Oxytocin: Postpartum bleeding, 10 U IM
- Propranolol: 1 mg IV increments q2m
- RhoGAM: 300 µg within 72 hr
[Outline]
DISPOSITION
Admission Criteria
- Enlargement of uterus beyond 16 wk of gestation size:
- The larger the uterus, the greater the risk for uterine perforation during suction curettage, hemorrhage, and pulmonary complications due to embolism
- Clinical evidence of preeclampsia hyperthyroidism, respiratory distress
- Hysterectomy
- Partial molar pregnancy
- Hemodynamic instability
Discharge Criteria
- Uncomplicated dilation and curettage of low-risk and small-size mole in reliable patient
- Stress importance of follow-up
- Pelvic rest for 4–6 wk after uterine evacuation
- Recommend no pregnancies for 12 mo
- Future pregnancies should have early sonographic evaluation due to increased risk in future pregnancies
FOLLOW-UP RECOMMENDATIONS
- Close follow-up and monitoring by OB-GYN
- Serial hCG levels:
- Obtained weekly for at least 4 wk, then monthly intervals
- Levels should consistently drop and never increase
- If increase is noted, evaluation for metastatic disease should ensue
- Use contraception
- US:
- Early in all future pregnancies
- Increased risk for future molar pregnancies (1–1.5% with 2nd, 20% after 2 moles)
[Outline]
- Hydatidiform Mole. Emedicine. Available at http://emedicine.medscape.com/article/254657-overview
- Sebire NJ, Seckl MJ. Gestational trophoblastic disease: Current management of hydatidiform mole. BMJ. 2008;337:a2076.
- Soper JT, Mutch DG, Schink JC, et al. Diagnosis and treatment of gestational trophoblastic disease: ACOG Practice Bulletin No. 53. Gynecol Oncol. 2004;93:575–585.
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