Hydatidiform

(Vesicular) Mole
Dr.Ashraf Fouda
Ob/ Gyn. Specialist
Domiatte General Hospital
Gestational Trophoblastic Disease

• Complete vesicular mole

• Partial vesicular mole
• Invasive mole
• Placental-site
trophoblastic tumor
• Choriocarcinoma
 Definition
It is a benign neoplasm of the chorionic
villi, characterized by:
• Marked proliferation of the trophoplast,both the
syncytium & cytotrophoplast are affected.
• Oedema or hydropic degeneration of the
connective tissue stroma of the villi which leads
to their distension and formation of vesicles.
• Avascularity of the villi: the blood vessels
disappear from villi explaining early death of
the embryo
 Incidence:
• 1:2000 pregnancies in United States
and Europe, but 10 times more in Asia.
• Predisposing factors include :
Race,deficiency of protein or carotene
• The incidence is higher toward the
beginning and more toward the end of
the childbearing period.
• It is 10 times more in women over 45
years old.
 :Pathology
• The uterus is distended by thin walled,
translucent, grape-like vesicles of
different sizes.
• These are degenerated chorionic villi
filled with fluid.
• There is no vasculature in the chorionic
villi leads to early death and absorption
of the embryo.
 :Pathology
• There is trophoblastic proliferation,
with mitotic activity affecting both
syncytial and cytotrophoblastic layers.
• This causes excessive secretion of
hCG, chorionic thyrotrophin and
progesterone.
• On the other hand, oestrogen
production is low due to absence of
the foetal supply of precursors.
 :Pathology
• High hCG causes multiple theca lutein
cysts in the ovaries in about 50% of
cases.
• Cysts may reach a large size (10 cm or
more.
• Cysts disappear within few months(2-
3), after evacuation of the mole.
• High hCG also results in exaggeration
of the normal early pregnancy
symptoms and signs
• Histologic section of a complete
hydatidiform mole stained with
hematoxylin and eosin.
• Villi of different sizes are present.
• The large villous in the center
exhibits marked edema with a
fluid-filled central cavity known
as cisterna.
• Marked proliferation of the
trophoblasts is observed.
• The syncytiotrophoblasts stain
purple, while the cytotrophoblasts
have a clear cytoplasm and bizarre
nuclei.
• No fetal blood vessels are in the
mesenchyme of the villi.
 :i) Complete mole)
• The whole conceptus is transformed
into a mass of vesicles.
• No embryo is present.
• It is the result of fertilization of
enucleated ovum ( has no
chromosomes) with a sperm which
will duplicate giving rise to 46
chromosomes of paternal origin only.
:i) Complete mole)
 (ii) Partial mole
- A part of trophoblastic tissue only
shows molar changes.
- There is a foetus or at least an
amniotic sac.
- It is the result of fertilization of an
ovum by 2 sperms so the
chromosomal number is 69
chromosomes
(ii) Partial mole
 DIFFERENTIATION BETWEEN
COMPLETE AND PARTIAL MOLE
Feature Complete Mole Partial Mole
Embryonic or foetal Absent Present
tissue
Swelling of the villi Diffuse Focal

Trophoblastic Diffuse Focal

hyperplasia
Karyotype Paternal 46 XX Paternal and
(96%) or 46 XY (4%) maternal 69 XXY or
69 XYY
Malignant Changes 5-10% Rare
 (A) Symptoms:
• Amenorrhoea: usually of short
period (2-3 months).
• Exaggerated symptoms of
pregnancy especially vomiting.
3.Symptoms of preeclampsia
may be present as headache,
and oedema
 (A) Symptoms:
4. Vaginal bleeding :
• The main complaint, due to separation of
vesicles from uterine wall, there may be a
blood stained watery discharge, the watery
part is from ruptured vesicles.
• Prune juice disharge may occur.
• The blood is brown because it has retained
for sometime in the uterine cavity.
• The passage of vesicles is diagnostic.
• The blood may be concealed causing
enlargment & tenderness of the uterus.
 (A) Symptoms:
5. Abdominal pain : may be ,
- dull-aching due to rapid distension of the
uterus by the mole or by cocealed
haemorrhage.
- colicky due to starting expulsion,
- sudden and severe due to perforating mole
- Ovarian pain due to stretching of the ovarian
capsule or complication in the cystic ovary as
torsion
 :General examination
• Pre-eclampsia develops in 20-30% of
cases, usually before 20 weeks’ gestation.
• Pallor indicating anemia may be present.
• Hyperthyroidism develops in 3-10% of
cases manifested by enlarged thyroid
gland, tachycardia (due to chorionic
thyrotropin secreted by trophoplast
&HCG also has a thyroid stimulating
effect.
• Breast signs of pregnancy.
 Abdominal examination:
• The uterus is larger than the period of
amenorrhoea in 50% of cases,
corresponds to it in 25% and smaller in
25% with inactive or dead mole.
• The uterus is doughy in consistency due
to absence of amniotic fluid and its
distension with vesicles.
• Foetal parts and heart sound cannot be
detected except in partial mole.
• Absence of external ballottement.
Local examination :
• Passage of vesicles (sure
sign).
• Bilateral ovarian cysts in
50% of cases.
• No internal ballottement.
 (C) Investigations:
• Urine pregnancy test:
is positive in high dilution.
• 1/200 is highly suggestive,
• 1/500 is surely diagnostic.
• In normal pregnancy it is
positive in dilutions up to 1/100.
2. Serum b -hCG level: is highly
elevated ( > 100.000 mIU/m1).
 (C) Investigations:
3. Ultrasonography reveals:
• The characteristic intrauterine " snow
storm" appearance,
• no identifiable foetus,
• bilateral ovarian cysts may be detected.
4. X-ray to the abdomen: shows no foetal
skeleton.
5. X-ray of the chest: should be performed in
every case of trophoplastic tumour.
A real-time ultrasound of a hydatidiform mole.
The dark circles of varying sizes at the top
center are the edematous villi.
 Complications:
• Haemorrhage.
• Infection due to absence of the amniotic sac and
due to the large surface area left after expulsion
or evacuation of the mole.
• Perforation of the uterus. Spontaneous by a
perforating mole or during evacuation.
• Pregnancy induced hypertension
• Hyperthyroidism.
• Subsequent development of choriocarcinoma in
about 5% of cases and invasive mole in about
10% of cases.
• Recurrent mole may occur(1-2%).
 :Treatment
• As soon as the diagnosis of vesicular
mole is established the uterus should be
evacuated.
• The selected method depends on the
size of the uterus, whether partial
expulsion has already occur or not, the
patient's age and fertility desire.
• Cross - matched blood should be
available before starting.
 (I) Suction evacuation:
- It is carried out under general
anaesthesia, but not that which
relax the uterus as halothane as it
may induce severe bleeding.
- An infusion of 20 units oxytocin in
500 m1 of 5% glucose should be
maintained throughout the
procedure.
 (I) Suction evacuation:
- Dilatation of the cervix is done
up to a Hegar's number equal to
the period of amenorrhoea in
weeks e.g. No. 10 Hegar for 10
weeks’ amenorrhoea.
- The suction canula used will be of
the same size also.
 :I) Suction evacuation)
- A suction canula which may be metal
or a disposable plastic (preferred) is
introduced into the uterine cavity.
- The canula is connected to a suction
pump adjusted at negative pressure of
300-500 mmHg according to the
duration of pregnancy.
- The material removed is sent for
histological examination.
 Curettage
• After evacuation ,the uterus is
gently curetted with a sharp
curette.
• Some advise curettage one week
after evacuation to ensure
complete removal, but the is not
the routine practice.
 Theca lutein cysts
• They are hormone dependent.
• Disappear spontaneously after
evacuation of the mole.
• So, they are not removed
surgically unless complication
occur as torsion or rupture.
(II)Hysterotomy:
It may be needed for
evacuation of a large
mole to minimize and
facilitate control of
bleeding.
(III) Hysterectomy:
It should be considered in
women over 40 years who
have completed their family
for fear of developing
choriocarcinoma.
:IV) Medical induction)
Oxytocins and / or
prostaglandins may be used to
encourage expulsion of the
mole but must always be
followed by surgical
evacuation.
 : Follow up
As choriocarcinoma may
complicate the vesicular
mole after its evacuation,
detection of serum ß-hCG by
radioimmunoassay is
essential
 : Follow up
• ß-hCG is measured by
radioimmunoassay every week
till the test becomes negative
for 3 successive weeks, then
the test is repeated every
month for one year.
• Pregnancy is allowed if the test
remains negative for one year.
 Follow up :
- Persistent high level indicates
remnants of molar tissues which
necessitate chemotherapy
( methotrexate) with or without
curettage. Hysterectomy is indicated if
women had enough children.
- Rising hCG level after disappearance
means developing of choriocarcinoma
or a new pregnancy.
 Follow up :
It is expected that urine
pregnancy test is negative
4 weeks after evacuation
and serum b -hCG is
undetectable 4 months
after evacuation.
 Contraception during follow up

• The combined pill is started when the

beta-HCG becomes negative.
• Till this happens, the condom can be
used.
• If the pill is used early the beta-HCG
will take a longer time to become
negative as oestrogen stimulates the
growth of trophoplast.
 Contraception during
follow up
The intrauterine device is
not used because it may
lead to irregular uterine
bleeding which confuses
the follow up
 Invasive Mole or
Chorioadenoma Destruens
• It is a trphoplastic tumour with
penetration of the myometrium
by the chorionic villi.
• It is locally malignant and rarely
metastasizes.
• It may lead to perforation of
uterus
 Early features suggesting
residual molar tissue
include:
2. recurrent or persistent
vaginal bleeding,
3. amenorrhoea,
4. failure of uterine involution,
5. persistence of ovarian
enlargement.