The diagnosis of molar pregnancy is now easy based upon a triple clinical, laboratory and ultrasonographic approach. Histology provides final confirmation. However treatment is more difficult since uterine evacuation may be very hemorrhagic or traumatic. A clinical case forms the basis here for a review of the main features concerning the diagnosis and treatment of hydatidiform mole.
PIP: Molar pregnancy, which results from an anomaly in the development of the trophoblastic tissue, is now easy to diagnose based on clinical evidence, beta hCG level, and sonography, although it must be histologically confirmed. Treatment remains difficult because of the danger of hemorrhage or trauma during uterine evacuation. Hydatidiform mole was diagnosed in the 1st pregnancy of a 27-year-old woman on the basis of a routine 1st trimester sonogram. Clinical examination revealed a voluminous uterus and a long, closed, very tonic cervix. Sulprostone was administered to aid cervical dilatation. An initial intramuscular injection of sulprostone caused uterine contractions without cervical modifications. 5 hours later an intravenous perfusion of sulprostone was started, during which significant contractions and cervical modifications were observed. An aspiration curettage was performed, in which numerous vesicles typical of the hydatidiform mole were evacuated. There was no need for further cervical dilatation and the curettage was rapid and nonhemorrhagic. The postoperative course was uneventful, and a test of beta hCG levels 6 weeks later was negative. The patient complained of pain during uterine contractions despite use of high doses of pethidine. The frequency of hydatidiform mole varies in different countries. It has been estimated at 1/85 in Indonesia and 1/2000 in the US. The clinical picture of hydatidiform mole includes vomiting often nonresponsive to treatment and metrorrhagia of varying volume, a large uterus for the gestational age, and often bilateral ovarian cysts. A vasculorenal syndrome may also begin at 13-16 weeks of amenorrhea. Beta hCG levels are high for the gestational age. Sonography reveals no embryonic structures. Biopsy shows a complete absence of embryo and amniotic sac. The karyotype is diploid and almost always XX. The mechanism is fertilization of an ovocyte whose nucleus is absent or inactive. The 2 chromosome sets are contributed by the father, a circumstance incompatible with embryonic development. Trophoblastic proliferation occurs without embryonic development. Hydatidiform moles may be transformed to invasive moles or chorioepithelioma. Treatment includes uterine evacuation by aspiration under sonographic control if possible. Many authors recommend oxytocin and antibiotic cover. The use of prostaglandin analogs to facilitate uterine evacuation is controversial, with some authors citing the increased risk of trophoblastic embolism. The mole should be histopathologically and cytogenetically studied, and postmolar follow-up is essential.