Abortion, Molar

Notes
  • This is one of the diseases that belongs toGestational trophoblastic diseases. Other diseases in this group are: placental site trophoblastic tumors, choriocarcinomas, and invasive moles.
  • Hydatidiform mole is characterized by hydropic (edematous) villi and massive proliferation of trophoblastic tissues.
  • Hydatidiform moles can be complete (with no fetal tissue) or partial (with fetal tissue).
  • Development of Hydatidiform moles is associated with genetic abnormalities in either or both parent with 90% of complete moles being 46XX, and 10% being 46XY
  • It presents mostly as threatened or incomplete abortion.
  • Statistics: Global prevalence varies from 0.2 to 1% of all pregnancies; it is more common in teenage and perimenopausal periods (extremes of reproductive age); about 20% of women with a complete mole will develop a trophoblastic malignancy.

##Complications of Hydatidiform moles

  • Development of malignant trophoblastic disease
  • Hemorrhage during the evacuation
  • Perforation of the uterus during the evacuation
  • Trophoblastic embolism that could cause acute respiratory insufficiency
  • Disseminated intravascular coagulopathy (DIC) as molar tissues release factors that trigger the coagulation cascade.
Symptoms
  • Bleeding per vaginum that does not usually end within a week after bed rest. In case spontaneous abortion occurs, bleeding is usually very heavy.
  • The size of uterus is larger than the gestational period.
  • Fetus not palpable
  • Fetal movements are not evident after 18-20 wks.
  • Extended Hyperemesis gravidarum-like symptoms (such as severe nausea, vomiting, weight loss, and electrolyte disturbance) that go for > 3 months.
  • A passage of a typical grape-like vesicles when the cervix opens (confirmation of diagnosis)
  • Lower back pain
  • Abdominal cramping /pain.
  • Cervix open / dilated
  • POCs)
Diagnosis
  • hCG (quantitative levels) blood test
  • Chest x-ray
  • CT scan
  • MRI scan
  • Complete blood count (CBC)
  • Prothrombin time
  • Renal tests
  • LFTs
Differential
  • Cervical cancer
  • Cervical ectopic pregnancy
  • Dysfunctional uterine bleeding
  • Incompetent cervix
  • Tubal ectopic pregnancy
Prevention
  • None but avoiding pregnancy where possible
Management
  • First set up oxytocin drip consisting 20IU in 500mL Normal saline or 5% dextrose at a rate of 20 drops per minute until it is over (approximately after 4 hours)
  • Initiate the following: IV Crystalline penicillin 3 mega units QID PLUS IV Gentamycin 80mg TID PLUS  Tabs  Ibuprofen 400mg TID
  • Carry out suction curettage.
  • Continue with oxytocin drip until the patient is stable.
  • Discharge the patient with the following:

Caps Doxycycline 100mg BD x 1/52; Tabs  Metronidazole 400mg TID x 1/52; Tabs  Ibuprofen 400mg TID x 5/7

  • After 2 wks review the patient and carry out D & C to ensure that evacuation was complete. Also pick some tissues for histology.
  • Put the patient on an appropriate contraceptive for at least one year.
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