DESCRIPTION

This is a pregnancy-related disorder that includes hydatidiform mole, invasive mole (chorioadenoma destruens), and choriocarcinoma. Hydatidiform mole, the most common, is a tumor of the placenta that is usually benign. It develops from placental tissue during an early pregnancy in which the embryo fails to develop normally. The tumor consists of many small vesicles (sacs) and resembles a large cluster of grapes. Although the condition is fairly rare in the USA, it is common in the Orient and other parts of the world. Hydatidiform molar pregnancy occurs up to 1 in 100 pregnancies in Indonesia. In the United States, molar pregnancy occurs in 1 of every 1,000-1,200 pregnancies. Other types of GTD are more rare. Invasive mole is a hydatidiform mole that spreads to adjacent structures; choriocarcinoma is a malignant tumor preceded by hydatidiform mole (50 percent of cases), abortion or term pregnancy (each about 25 percent of cases).

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TYPES OF HYDATIDIFORM MOLES

COMPLETE MOLES

This is a complete hydatidiform mole. A molar pregnancy may result from abnormal fertilization of an empty ovum (egg) by two sperms (a process called androgenesis). A complete hydatidiform mole, shown here, occurs when the ovum is lacking a maternal complement of chromosomes and is fertilized by a haploid sperm, usually containing an X chromosome. Duplication of this chromosome set yields a 46, XX karyotype that is paternally derived (DNA is purely paternal in origin since all chromosomes are derived from the sperm and is diploid meaning there are two copies of every chromosome). Ninety percent are 46XX and 10 percent are 46XY. In a complete mole, no fetus develops, thus on gross examination there are no signs of fetal tissue, but there is an abnormal placenta consisting of a mass of tissue with grape-like enlarged swollen chorionic villi ("cluster of grapes" or "honeycombed uterus" or "snow-storm"). The main complication of the complete mole is a 2 percent chance of progression to a cancer called choriocarcinoma.

PARTIAL MOLES

This is a partial hydatidiform mole. Note that there are only scattered grape-like villi. Such a partial mole occurs when a normal ovum (egg) is fertilized by two haploid sets of paternal chromosomes. This may occur with diploid sperm fertilizes an ovum, or if a haploid sperm fertilizes a diploid ovum. Thus their DNA is both maternal and paternal in origin. The result is triploidy with 69 chromosomes (e.g. 69XXX, 69XXY). A normal fertilized egg contains 46 chromosomes. Since a maternal set of chromosomes is present, a fetus develops, but it is malformed, and the pregnancy rarely goes to term. Only some of the villi are grape-like. There is also an increased risk of choriocarcinoma, but the risk is lower than with the complete mole and is considered relatively rare.

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FREQUENT SIGNS & SYMPTOMS

In early pregnancy, there may be no unusual symptoms.

Extremely high levels of human chorionic gonadotropin (HCG) are suggestive, but not diagnostic.

Painless vaginal bleeding, which may be dark brown in color, in the fourth to fifth month of pregnancy.

Uterus larger than expected, or the ovaries may be enlarged.

Morning sickness that is frequently excessive.

Passage of vesicle (small sac).

Abnormally large or small fetus (in partial mole only).

No fetal movement or heart tone detected.

Sometimes there is an increase in blood pressure along with protein in the urine.

Abdominal cramping.

MoonDragon's Pregnancy Information: Morning Sickness

MoonDragon's Pregnancy Information: Hyperemesis Gravidarum

MoonDragon's Pregnancy Information: Hyperemesis Gravidarum - Medical Management

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CAUSES

Exact cause is unknown. The etiology of this condition is not completely understood. Genetic factors may be involved.

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RISK INCREASES WITH

Oriental race.

Egg defects or abnormalities.

Mother over 40 or under age 20.

Nutritional deficiencies. Diet lacking in protein, folic acid, and possibly, carotene.

Uterine abnormalities.

History of previous hydatidiform mole or other gestational trophoblastic disease (GTD).

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PREVENTIVE MEASURES

No specific preventive measures.

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EXPECTED OUTCOME

With early diagnosis and treatment of an uncomplicated hydatidiform, the outlook is excellent. More than 80 percent of hydatidiform moles are benign. Close follow-up is essential. Highly effective means of contraception are recommended to avoid pregnancy for at least 6 months, although most health care providers highly recommend waiting a year or longer before attempting to get pregnant again. Any birth control method is considered acceptable with the exception of an intrauterine device (IUD).

In 10 to 15 percent of cases, hydatidiform moles may develop into invasive moles. These may intrude so far into the uterine wall that hemorrhage or other complications develop. It is for this reason that a post-operative full abdominal and chest x-ray will often be requested.

In 2 to 3 percent of cases, hydatidiform moles may develop into choriocarcinoma, which is a malignant, rapidly-growing, and metastatic (spreading) cancer, remission remains at 75 to 80 percent, although the ability to have children is usually lost.

Feelings of loss and grief for the terminated pregnancy are common. Feelings of guilt may also be present. Although the removal of a molar pregnancy is not the termination of a developing child, it is still a loss. Even when an embryo is present, it does not have the opportunity to develop into a child. Most women discover that they are dealing with a molar pregnancy after the discovery and anticipation of being pregnant. Dreams, plans, and hopes are canceled all at once; it is still a significant loss.

• There will have to be healing time for all involved, and grief will be experienced.



• Recognize that people may try to console you with statements like, "Well at least it wasn't a baby." This does not help, but at least know that they are trying. Let them know what you need.



• What makes this type of loss further different from a "normal miscarriage" or loss is the continued concern of the mother's health. Make sure that you stick with your follow-up appointments.



• Support groups and counseling may prove beneficial.

Reproductive function is generally not affected. A normal subsequent pregnancy is usual, and complications are similar to those in the general population. If you have had a molar pregnancy without complications, your risk of having another molar pregnancy is about 1 to 2 percent. Genetic counseling prior to conceiving again is helpful for some couples.

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POSSIBLE COMPLICATIONS

Excessive bleeding and/or pulmonary problems following the uterine evacuation procedure (more likely to occur with an extra large uterus).

There is a small risk that a malignant tumor may later develop (choriocarcinoma). Follow-up testing is usually necessary for a year to monitor for this possibility. If tumor does occur, treatment with chemotherapy (anti-cancer drugs) is uniformly successful.

The risk of having a recurrent hydatidiform mole with a future pregnancy is slightly increased.

TREATMENT

GENERAL MEASURES

DIAGNOSIS

A pelvic exam may reveal a larger or smaller uterus, enlarged ovaries, and abnormally high levels of the pregnancy hormone hCG.

Diagnostic tests may include ultrasound to assess uterine contents; laboratory studies of blood and/or urine levels of beta-human chorionic gonadotropin (B-hCG - a hormone produced by the placenta); x-ray and amniocentesis.

Sometimes symptoms of hyperthyroidism are seen, due to the extremely high levels of hCG, which can mimic the normal Thyroid-stimulating hormone (TSH).

TREATMENT

Most molar pregnancies will spontaneously end and the expelled tissue will appear grape-like.

Treatment normally involves suction curettage (surgical curettage) to evacuate the contents of the uterus, or sometimes through medication. This is performed as soon as possible after diagnosis. General anesthesia is normally used during these procedures. Blood loss is usually moderate and transfusion is rarely necessary.

Removal of the mole done very carefully or excessive bleeding and blood clots to the lungs can occur. The placental tissue is sent to the pathologist, who looks under the microscope to make the final diagnosis. An HCG level, and sometimes a thyroid level, are also obtained. In unusual cases, where the patient has completed her childbearing, a hysterectomy may be preferable. Although most cases of molar pregnancy occur after a miscarriage, some occur after ectopic pregnancies or a normal pregnancy. Therefore, women with abnormal bleeding or a persistent cough (especially if it produces blood) should see their health care provider for an HCG level to make sure they do not have a molar pregnancy.

Approximately 90 percent of women who have a mole removed require no further treatment.

Hysterectomy is a treatment option for women not desirous of future pregnancy or for older women (who might be more likely to develop a malignancy).

FOLLOW-UP

Regardless of method of treatment, follow-up care is essential to monitor blood and urine levels for the hormone B-hCG that can indicate a malignancy. These tests will be done weekly at first, and then monthly for at least 6 months to a year until the hCG titer levels have fallen and become undetectable. Invasive or metastatic moles often respond well to methotrexate. The response to treatment is nearly 100 percent.

Follow-up usually consists of a baseline chest x-ray, review of the pathology specimen, physical examination of the vagina and uterus every 2 weeks until the uterus returns to normal and then every 3 months for a year. There will be frequent visits to your health care provider's office and laboratory to have your blood hCG levels checked.

A new pregnancy must be delayed for a minimum of 1 year, possibly longer, if the blood and urine tests indicate the hormone levels are still not within normal range. The chances of having another molar pregnancy are approximately 1 percent. Effective contraception methods should be implemented and maintained throughout this time period (a IUD should not be used).

Follow-up is done to ensure that the mole has been removed completely. Traces of the mole can begin to grow again and may progress to a cancerous-type threat to other parts of the body. When they come back the patient may need chemotherapy to prevent the microscopic placental cells from spreading to other organs like cancer. Fortunately, this only occurs in about 20 percent of complete molar pregnancies; it is even more uncommon with partial molar pregnancies. Many women are frustrated when their health care provider recommends waiting one year to become pregnant. This is actually important, because a rise in HCG levels may indicate a normal pregnancy when the patient is trying to get pregnant, or a recurrent molar pregnancy, which requires chemotherapy. To avoid this confusion your health care provider requests a 1 year period without becoming pregnant.

Psychological and emotional support are important following diagnosis, during treatment and the follow-up time period of the disorder.

TREATMENT FOR RECURRENT MOLAR PREGNANCY

When the HCG levels drop then increase again it means that the molar pregnancy has grown from microscopic cells in the wall of the uterus to larger cells. These cells can act like a cancer, and metastasize (spread) to other organs, like the lungs, brain, bones, and vagina. Treatment for recurrent molar pregnancy, called gestational trophoblastic neoplasia, or GTN, in medical terms, usually consists of a chemotherapy medication called methotrexate. Fortunately, methotrexate is a pretty "easy" chemotherapy on the system, and can be given as an intramuscular shot. Sometimes only 1 shot is necessary. In other cases, multiple shots, or even the addition of other medications, is necessary. Also, when GTN is suspected, the patient usually gets a CT scan of the brain, lungs, and abdomen, and a battery of blood tests. Again, weekly HCG tests are obtained until they fall to zero, then careful follow-up is undertaken for a year. Patients can expect an almost 100 percent cure rate using chemotherapy.

FUTURE PREGNANCY PLANS

Fortunately, the risk of having another molar pregnancy is about 1 percent (1 in 100). Most health care providers will perform an ultrasound to make sure the pregnancy is normal when a patient has had a prior molar pregnancy. It is also a good idea to send the placenta to the pathologist after the delivery just to make sure there are not abnormal areas.

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COPING WITH LOSS

For many women, emotional healing takes a good deal longer than physical healing. Even if the pregnancy ended very early, the sense of bonding between a mother and her fetus can be very strong. The feelings of loss can be intense for some women.

Grief can involve a wide range of feelings. You may find yourself searching for the reason your pregnancy ended. You may wrongly blame yourself. You may have headaches, loose your appetite, feel tired, or have trouble concentrating or sleeping.

Your feelings of grief may differ from those of your partner. You are the one who has felt the physical changes of pregnancy. Your partner also may grieve, but he may not express his feelings in the same way you do. He may feel he has to be strong for both of you and may not share his hurt and disappointment. This may create tensions between the two of you when you need each other the most.

If either of you is having trouble handling the feelings that go along with this loss, talk to your midwife or health care provider. You may also find it helps to talk with a counselor or therapist.

Do not blame yourself for the pregnancy loss. In most cases it is not likely that it could have been prevented. Reach out to those closest to you. As for their understanding, comfort, and support.

Most early pregnancy losses cannot be prevented. Losing a pregnancy often does not mean that a woman cannot have more children or that there is something wrong with her health. Most women who miscarry have a healthy pregnancy later.

Emotional healing is as vital as physical healing. Grieving allows you to accept this painful loss and go on with your life. Counseling can help both you and your partner if you cannot deal with these feelings alone. You should allow enough time for physical and emotional healing before trying to get pregnant again. Your midwife or health care provider may be able to give you some guidance.

MoonDragon's Pregnancy Information: Intrauterine Fetal Demise

MoonDragon's Pregnancy Information: Miscarriage

March of Dimes: Pregnancy & Newborn Loss

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MEDICATION

Medicines as needed for the selected treatment plan.

Oral contraceptives are usually the chosen method for contraceptive purposes.

In some women who may be more at risk for malignancy, chemotherapy may be recommended as a form of preventive therapy.

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ACTIVITY

Any restrictions will be determined by the treatment method.

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DIET

No special diet. However, a poor nutritional diet increases the risk of having a molar pregnancy. Follow a diet with sufficient folic acid, protein and carotene.

MoonDragon's Nutrition Information Index

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NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER IF...

You or a family member has symptoms of hydatidiform mole or other GTD.

You are pregnant and any unusual symptoms occur.

After treatment, you have excessive vaginal bleeding or any other unusual symptoms. Medications and oral contraceptives may have side effects.

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GESTATIONAL TROPHOBLASTIC DISEASE LINKS

Baby Zone - Molar Pregnancy

MyMolarPregnancy.com: Support Group, Information, Links, Personal Stories

PaternityAngel.com: Molar Pregnancy, Early Pregnancy Loss

CancerLink: Gestational Trophoblastic Disease

MoonDragon's Ectopic & Molar Pregnancy Overview

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PREGNANCY RELATED LINKS

MoonDragon's Pregnancy Information & Survival Tips

MoonDragon's Pregnancy Information Index

MoonDragon's Pediatric Information Index

MoonDragon's Parenting Information Index

MoonDragon's Nutrition Information Index

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