follow up of vesicular mole

Follow up of vesicular mole……

VISHNU AMBAREESH M S

This mole???

This one???

cabernet-sauvignon

Follow up of vesicular mole……

VISHNU AMBAREESH M S

Management – 2 phases

Immediate evacuation

Subsequent follow up

aim of treatment is to eliminate all trophoblastic tissue from the maternal systems

Why???

• Risk of malignancy after a complete and partial mole is 15-20% and 1-5% respectively

• invasive tendencies and the ability to make hCG hormone

IN BETA HCG WE TRUST

SENSITIVITY & SPECIFICITY OF VIRTUALLY 100%

• hCG is a placental glycoprotein composed of 2 dissimilar subunits: an alpha subunit resembling that of the pitutary glycoprotein hormones and a beta subunit that is unique to plaacental production.Several forms of hCG exist, including atleast 6 major variants that can be detected in serum

• hyperglycosylated• nicked• absent c-terminal of beta subunit• free beta subunit• nicked free beta subunit• free alpha unit

• the hCg molecules in GTD are more heterogenous and degraded than those in normal pregnancy,therefore, an assay that will detect all main forms of hCG and its multiple fragments should be used to follow up patients with GTD.

• rapid automated radiolabeled monoclonal antibody sandwich assays that measure different mixtures of hCG related molecules

• It is expected that urine pregnancy test is negative 4 weeks after evacuation and serum β-hCG is undetectable 4 months after evacuation

• Followed up for at least 6 months

Nl serum level < 4 IU/L NL urine level <24 IU/L

• Weekly beta hCG until normal for 3 consecutive weeks

• Then monthly until normal for 6 months

• The follow-up is recommended for 2 years in cases of complete moles, and 6 months of cases of partial moles after the evacuation of

uterus.

Diagnosis of persistent GTD (FIGO)

4 values or more of hCG documenting a plateau over at least 3 weeks

A rise in hCG of 10% or more for 3 values or longer over at least 2 weeks

HPE evidence of choriocarcinoma

Persistence of hCG 6 months after mole evacuation

This does not address the issue of metastatic disease or PSTT

phantom hCG

• some lab assays may yield false positive hCG results. These so called phantom hCG resuts, with levels reported as high as 800 mIU/mL, have led to treatment of healthy patients with unnecessary surgery and chemotherapy.

• cause - proteolytic enzymes that produce nonspecific protein interference and heterophile(human antimouse) antibodies. in 3-4% of health people and can mimic hCG immunoreactivity by linking and capturing tracer mouse IgG...

3 ways to determine if false positive

1. urine hCG level neg as interfering substances are not excreted in urine2.serial dilution of serum would not show a parallel decrease in dilution3.send serum and urine of patient to an hCG reference labortary

also some cross reactivity with LH. measure LH.

supress with OCP

• "Quiescent gestational trophoblastic disease" is a term for that is characterized by persistant,unchanging low levels(<200 mIU/mL) of "real" hCG for atleast 3 months associated with a history of GTD or spontaneous abortion, but without clinically detectable disease. the hCg levels do not change with chemotherapy or surgery.Follow up of these patients reveals subsequent development of active GTN in 1/4th, heralded by an increse in both glycosylated hCG and total hCG.Acc INTL society for the study of trophoblastic disease 2001 recommendations for managing this condition, false positive hCG resulting from heterophile antibodies, or LH interference should be excluded, the patient should be thoroughly investigated for evidence of disease, immediate chemotherapy or surgery should be avoided, and the patient should be monitored long term with periodic hCG testing while avoiding pregnancy.treat only when substancial rise or overt clinical diesase.

What to do at each visit?

Symptoms like irregular bleeding, persistent cough, haemoptysis and dyspnoea

Cl exam for uterine size, theca lutein cysts and suburethral mets

USS if any suspicion

Xray chest in some cases

Early features suggesting residual molar tissue include:

recurrent or persistent vaginal bleeding,• amenorrhoea,• failure of uterine involution,• persistence of ovarian enlargement.

Metastases in GTT

Lung 80%- resp symptoms and Xray findings mimicking primary pul disease Pulmonary hypertension sec to pul artery occlusion by tropho emboli

Vagina 30% (suburethral or fornices) can bleed profusely

Pelvis 20%

Liver 10% epigastric pain, hepatic rupture

Brain 10% focal neuro deficits or cerebral haemorrhage

Follow-up• Indication of chemotherapy after

the evacuation of the hydatidiform mole in:

Serum hCG >20000 i.u/L , at any time after evacuation of mole.

Raised hCG at 4 to 6 weeks after evacuation of mole.

Evidence of metastases ,hepatic,brain,and pulmonary.

Persistent uterine hemorrhage after evacuation of mole with raised hCG levels.

Follow-up

• Pregnancy is not allowed except after one year of negative follow up but with danger of :

Molar pregnancy (4-5 times greater risk). Spontaneous abortion.Premature delivery.

Pregnancy after hydatidiform mole Usually normal reproductive function

Recurrence of mole in 1-2%

Hence early USS to rule out a molar pregnancy and for dates

Placenta or products to be sent for HPE for occult trophoblastic disease

hCG level 6 weeks post evacuation or delivery

Contraception

• Contraception is recommended for 6 months after the first normal HCG result to distinguish a rising hCG because of persistent or recurrent disease from a rising hCG associated with a subsequent pregnancy.

• the use of OCP is preferrrable because they have the advantage of supressing endogenous LH, which may interfere with the measurement of hCG at low levels and studies have shown that they do not increase the risk of postmolar trophoblastic neoplasia

Future pregnancy• If a further molar pregnancy

does occur,in 68–80% of cases it will be of the same histological type

Merci !!