What finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?

The typical clinical presentation of complete molar pregnancies has changed with the advent of high-resolution ultrasonography. Most moles are now diagnosed in the first trimester before the onset of the classic signs and symptoms. [30, 31, 32]

Vaginal bleeding

The most common classic symptom of a complete mole is vaginal bleeding. Molar tissue separates from the decidua, causing bleeding. The uterus may become distended by large amounts of blood, and dark fluid may leak into the vagina. This symptom occurs in 50% of cases.

Hyperemesis

Patients may also report severe nausea and vomiting. This is due to extremely high levels of human chorionic gonadotropin (hCG). This is reported to occur in 4% of patients diagnosed at 5-9 weeks of gestation, and in 23% when the diagnosis is made after 10 weeks' gestation.

Hyperthyroidism

Signs and symptoms of hyperthyroidism can be present due to stimulation of the thyroid gland by the high levels of circulating hCG or by a thyroid stimulating substance (ie, thyrotropin) produced by the trophoblasts. [33]  Clinical hyperthyroidism has been reported in 3.7% of women with a hydatidiform mole diagnosed after the 10th week of gestation.

Partial mole

Patients with partial mole do not have the same clinical features as those with complete mole. These patients usually present with signs and symptoms consistent with an incomplete or missed abortion, including vaginal bleeding and absence of fetal heart tones.

In a retrospective study (1994-2013) at a Brazilian trophoblastic disease center, investigators evaluated the clinical presentations and incidence of postmolar gestational trophoblastic neoplasia (GTN) among 355 women with complete mole (n =186) or partial mole (n = 169), with the following findings [34] :

• Risk of vaginal bleeding, biochemical hyperthyroidism, anemia, uterine size larger than dates, and hyperemesis: Reduced risk in women with partial mole

• Preevacuation serum hCG levels: Lower in women with partial mole

• Median gestational age at evacuation: complete mole, 9 weeks; partial mole, 12 weeks

• Development of GTN:  women with complete mole, 17.7%; women with partial mole, 4.1%

Those with complete mole were diagnosed more commonly before evacuation than women with partial mole because they presented more often with signs/symptoms of molar disease. [34]

Next:

Physical Examination

Complete mole

Note the following:

• Size inconsistent with gestational age: A uterine enlargement greater than expected for gestational age is a classic sign of a complete mole. Unexpected enlargement is caused by excessive trophoblastic growth and retained blood. However, patients also present with size appropriate or smaller than expected for the gestational age.

• Preeclampsia: Pelvic ultrasonography has resulted in the early diagnosis of most cases of hydatidiform mole and preeclampsia is seen in less than 2% of cases. [31]

• Theca lutein cysts: These are ovarian cysts greater than 6 cm in diameter and accompanying ovarian enlargement. These cysts are not usually palpated on bimanual examination but are identified by ultrasonography. Patients may report pressure or pelvic pain. Because of the increased ovarian size, torsion is a risk. These cysts develop in response to high levels of beta-hCG. They are reported in 11% of cases diagnosed at  longer than10-weeks' gestational age. The cysts spontaneously regress after the mole is evacuated, but it may take up to 12 weeks for complete regression.

  
  Theca lutein cysts.

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  Complete mole.

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  Complete mole with an area of clot near cervix consistent with bleeding.

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Partial mole

Uterine enlargement and preeclampsia is reported in only 5% of patients. [35]  Theca lutein cysts, hyperemesis, and hyperthyroidism are extremely rare.

Twinning

Twinning with a complete mole and a fetus with a normal placenta has been reported (see image below). Cases of healthy infants in these circumstances have been reported. [12, 36]

Women with coexistent molar and normal gestations are at higher risk for developing persistent disease and metastasis. [20]  Termination of pregnancy is a recommended option.

The pregnancy may be continued as long as the maternal status is stable, without hemorrhage, thyrotoxicosis, or severe hypertension. The patient should be informed of the risk of severe maternal morbidity from these complications. [37]

Prenatal genetic diagnosis by chorionic villus sampling or amniocentesis is recommended to evaluate the karyotype of the fetus.

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Differential Diagnoses

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21. Vargas R, Barroilhet LM, Esselen K, et al. Subsequent pregnancy outcomes after complete and partial molar pregnancy, recurrent molar pregnancy, and gestational trophoblastic neoplasia: an update from the New England Trophoblastic Disease Center. J Reprod Med. 2014 May-Jun. 59(5-6):188-94. [QxMD MEDLINE Link].

22. Gadducci A, Cosio S, Fanucchi A, et al. Prognosis of Patients with Gestational Trophoblastic Neoplasia and Obstetric Outcomes of Those Conceiving After Chemotherapy. Anticancer Res. 2016 Jul. 36 (7):3477-82. [QxMD MEDLINE Link].

23. Joneborg U, Eloranta S, Johansson AL, Marions L, Weibull CE, Lambe M. Hydatidiform mole and subsequent pregnancy outcome: a population-based cohort study. Am J Obstet Gynecol. 2014 Dec. 211(6):681.e1-7. [QxMD MEDLINE Link].

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26. Cheung AN, Khoo US, Lai CY, et al. Metastatic trophoblastic disease after an initial diagnosis of partial hydatidiform mole: genotyping and chromosome in situ hybridization analysis. Cancer. 2004 Apr 1. 100(7):1411-7. [QxMD MEDLINE Link].

27. Menczer J, Girtler O, Zajdel L, Glezerman M. Metastatic trophoblastic disease following partial hydatidiform mole: case report and literature review. Gynecol Oncol. 1999 Aug. 74(2):304-7. [QxMD MEDLINE Link].

28. Twiggs LB, Morrow CP, Schlaerth JB. Acute pulmonary complications of molar pregnancy. Am J Obstet Gynecol. 1979 Sep 15. 135(2):189-94. [QxMD MEDLINE Link].

29. Sebire NJ, Fisher RA, Foskett M, et al. Risk of recurrent hydatidiform mole and subsequent pregnancy outcome following complete or partial hydatidiform molar pregnancy. BJOG. 2003 Jan. 110(1):22-6. [QxMD MEDLINE Link].

30. Mangili G, Garavaglia E, Cavoretto P, Gentile C, Scarfone G, Rabaiotti E. Clinical presentation of hydatidiform mole in northern Italy: has it changed in the last 20 years?. Am J Obstet Gynecol. 2008 Mar. 198(3):302.e1-4. [QxMD MEDLINE Link].

31. Soto-Wright V, Bernstein M, Goldstein DP, Berkowitz RS. The changing clinical presentation of complete molar pregnancy. Obstet Gynecol. 1995 Nov. 86(5):775-9. [QxMD MEDLINE Link].

32. Sun SY, Melamed A, Goldstein DP, et al. Changing presentation of complete hydatidiform mole at the New England Trophoblastic Disease Center over the past three decades: does early diagnosis alter risk for gestational trophoblastic neoplasia?. Gynecol Oncol. 2015 Jul. 138 (1):46-9. [QxMD MEDLINE Link].

33. Amir SM, Osathanondh R, Berkowitz RS, Goldstein DP. Human chorionic gonadotropin and thyroid function in patients with hydatidiform mole. Am J Obstet Gynecol. 1984 Nov 15. 150(6):723-8. [QxMD MEDLINE Link].

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36. Fishman DA, Padilla LA, Keh P, Cohen L, Frederiksen M, Lurain JR. Management of twin pregnancies consisting of a complete hydatidiform mole and normal fetus. Obstet Gynecol. 1998 Apr. 91(4):546-50. [QxMD MEDLINE Link].

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38. Florio P, Severi FM, Cobellis L, et al. Serum activin A and inhibin A. New clinical markers for hydatidiform mole. Cancer. 2002 May 15. 94(10):2618-22. [QxMD MEDLINE Link].

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    What are 2 signs of a hydatidiform mole pregnancy?

    Symptoms.

    Abnormal growth of the uterus, either bigger or smaller than usual..

    Severe nausea and vomiting..

    Vaginal bleeding during the first 3 months of pregnancy..

    Can you have a molar pregnancy at 10 weeks?

    The most prevalent symptoms that prompt a doctor to suspect a molar pregnancy are nausea, vomiting and palpitations that begin very early in the pregnancy. These symptoms are all normal during pregnancy, but don't begin until a woman is around 10 or 12 weeks pregnant.

    Which of the following statements is true about a hydatidiform molar pregnancy?

    Correct answer: A hydatidiform molar pregnancy is mostly a benign process that may occur due to an abnormal ovum becoming fertilized and growing into collection of cells in a cluster like formation.

    How is a hydatidiform mole pregnancy diagnosed?

    Transvaginal ultrasound A health care provider who suspects a molar pregnancy is likely to order blood tests and an ultrasound. During early pregnancy, a sonogram might involve a wandlike device placed in the vagina.