Partial hydatidiform moles: a review

Differential expression of leukemia inhibitory factor and insulin like growth factor-1 between normal pregnancies, partial hydatidiform moles and complete hydatidiform moles

INTRODUCTION

Leukemia inhibitory factor (LIF) and insulin like growth factor-1 (IGF-1) are two of the most important growth factors mediating trophoblast actions. We hypothesized that the localization and expression patterns of LIF and IGF-1 in partial and complete hydatidiform moles (HM) compared with normal first trimester placentas may provide an understanding of the proliferative processes in HMs.

METHODS

The study population included curettage material of women diagnosed as complete or partial HM as a result of histopathological and immunohistochemical examination (complete HM group, n = 8; partial HM group, n = 8) and women undergoing dilatation&curettage for unwanted pregnancies (control group, n = 8). Expression of LIF and IGF-1 among placental cell groups was evaluated immunohistochemically and given a score depending on immunostaining intensity.

RESULTS

In normal chorionic villi strong expression of LIF and IGF-1 was present. Both LIF and IGF-1 expressions were weaker in the chorionic villi of complete HMs. In complete mole decidua there was a significant decrease in glandular and endothelial IGF-1 expression along with a decrease in decidual cell LIF expression compared to normal first trimester decidua. LIF expression in extravillous trophoblasts was stronger in complete molar placentas compared to normal placentas.

DISCUSSION

LIF and IGF-1 are important regulators of trophoblast proliferation and invasion. Differential expression of LIF and IGF-1 in molar trophoblasts and chorionic villi might have a role in regulation of trophoblasts in complete moles. Decreased expression of glandular IGF-1 and decidual LIF might be related to the decidual changes during trophoblastic proliferation and invasion of decidua in complete HMs.

Differences in current clinical features of diploid and triploid hydatidiform mole

OBJECTIVE

To describe and compare the current clinical features of diploid and triploid molar pregnancy and to evaluate whether the presenting clinical features can predict the ploidy of a molar pregnancy.

DESIGN

A retrospective study of the clinical features and ploidy of hydatidiform moles.

SETTING

The Departments of Clinical Genetics and Pathology, Aarhus University Hospital and 13 gynaecological wards, Jutland, Denmark.

POPULATION

A total of 259 women with molar pregnancy diagnosed between April 1986 and June 2003.

METHODS

A review of medical records of consecutively collected, clinically suspected cases of molar pregnancy was performed. The molar ploidy was determined by karyotyping, flow cytometry, and/or analysis of polymorphic DNA markers.

MAIN OUTCOME MEASURES

Maternal characteristics, presenting symptoms, initial human chorionic gonadotrophin (hCG), and molar ploidy.

RESULTS

In a multiple logistic regression model, initial hCG of > or = 100,000 iu/l (P < 0.001), first-trimester gestational age (P < 0.001), vaginal bleeding (P < 0.001), and maternal age of > or = 40 years (P = 0.03) were independent predictors of diploid mole. Women with excessive uterine size more frequently had a diploid than a triploid mole (P < 0.001). Fifty-four percent of the women with triploid mole and 27% of the women with diploid mole were diagnosed before onset of symptoms (P < 0.001).

CONCLUSIONS

The current clinical features of diploid mole are different from those of triploid mole. The presenting clinical profile of a molar pregnancy may be used as an early predictor of the molar ploidy and thus of the prognosis.

Partial molar pregnancy and coexisting fetus with diploid karyotype

OBJECTIVES

To evaluate cases of partial hydatidiform mole coexisting with a live fetus, including an observation of our own, and to discuss the proper antenatal management of women wishing to continue with a partial molar pregnancy.

METHOD

A PubMed search was then undertaken, extending over the time period from 1975 to 2006, using the keywords 'partial hydratidiform mole', 'hydatidiform mole' and 'coexisting fetus'.

RESULTS

At 16 weeks of gestation, an ultrasonographic examination revealed a normal fetus with an extremely large, multicystic placenta. The woman was informed of future risks but wished to continue with the pregnancy. The pregnancy progressed until 28 weeks without any complication but ended spontaneously with a vaginal delivery; the fetus had died in utero. Pathologic examination of the placenta revealed areas of hydropic degeneration and necrosis. Including our own observation, 17 cases of partial hydatidiform mole associated with a fetus of normal karyotype have been documented.

CONCLUSION

Although the rate of adverse perinatal outcome is high, we still believe that if amniocentesis or fetal blood sampling reveals a normal karyotype, then continuing the affected pregnancy with close follow-up in tertiary centers is a feasible choice.

The Placenta Revisited: Radiologic–Pathologic Correlation

The placenta is the central support organ for the developing fetus. Recognition of placental variants and insignificant findings is important so as not to suggest an abnormality when one is not present. However, the degree of abnormality, as well as the clinical implications of the findings, must be understood to help guide management of the pregnancy. This article reviews the normal sonographic appearance of the placenta and some anatomic variants, in addition to illustrating various common pathological conditions of the placenta and correlating with gross pathologic and histologic specimens.

Partial mole, triploidy and proteinuric hypertension: two case reports

We present two cases of proteinuric hypertension in the early second trimester of pregnancy, associated with partial mole and triploidy karyotyping. This demonstrates the complementary nature of ultrasound in the diagnosis and management of this rare association.

Gestational trophoblastic disease following the evacuation of partial hydatidiform mole: a review of 66 cases

OBJECTIVE

The current study was undertaken in order to identify the clinical characteristics and natural history, as well as methods of investigation and available therapy, of persistent gestational trophoblastic disease (GTD) following the evacuation of partial hydatidiform mole (PM).

METHODS

Case reports of persistent GTD following the evacuation of partial mole, were searched using the Medline computerized retrieval system. There were 66 such cases (including 4 cases treated at our department), representing 2.9% of GTD following PM.

RESULTS

The mean age of the women at diagnosis was 28.4 years and mean gravidity was 2.99. The mean gestational age at diagnosis was 15.5 weeks and the mean uterine size was 13.6 weeks. The most common presenting symptom was vaginal bleeding. In the majority of the patients, the pre-evacuation diagnosis was incomplete or missed abortion.

CONCLUSIONS

Although the malignant potential of PM is low, persistent GTD may develop after PM and may even metastasize, it is usually responsive to single agent chemotherapy but may require combination chemotherapy. Therefore, after evacuation of PM, these women should be followed with serial serum b-hCG. Further research is needed to enable earlier identification of PM that eventually will develop persistent GTD.

Persistent gestational trophoblastic tumour with partial hydatidiform mole as the antecedent pregnancy

OBJECTIVE

A 16 year review of persistent gestational trophoblastic tumour when the antecedent pregnancy was a partial hydatidiform mole.

DESIGN

Cases of persistent gestational trophoblastic tumour with partial hydatidiform mole as the antecedent pregnancy were reviewed for the period 1976 to 1992. DNA ploidy was analysed by flow cytometry.

SETTING

A University Hospital which is a reference centre for gestational trophoblastic tumour.

SUBJECTS

The case notes of 207 women with persistent gestational trophoblastic tumour were reviewed.

MAIN OUTCOME MEASURES

A rise (or failure to fall) of beta hCG titre, or sign of metastasis.

RESULTS

Six (2.9%) women had partial hydatidiform mole as the antecedent pregnancy and all were initially judged to be low risk. However, two developed pulmonary metastasis; one woman developed persistent gestational trophoblastic tumour shortly after a hysterotomy, and none developed choriocarcinoma. The geometric mean of serum beta hCG concentrations at the initiation of chemotherapy was 868 mIU/ml (95% CI 114-1524). Of the six women, one achieved remission after total abdominal hysterectomy, and five after chemotherapy. The mean interval from starting treatment to remission was 68 days (95% CI 27.9-108.0). The initial beta hCG titre and interval were not statistically different from those found in cases of persistent gestational trophoblastic tumour when the antecedent pregnancy was not partial hydatidiform mole. Of the six, the DNA content was triploid in three and diploid in two. One of the two diploid cases required multiple courses of chemotherapy to achieve remission.

CONCLUSION

Partial hydatidiform mole can have malignant sequelae and can develop very soon after treatment. Its DNA content can be either diploid or triploid, the lungs being the most common site of metastasis. After evacuation of partial hydatidiform mole, immediate chest X-ray and regular follow up of the serum beta hCG level is necessary.

Successful resolution of persistent trophoblastic disease after partial mole with the EMA-CO regimen

A 29-year-old nullipara with partial hydatidiform mole at 8 weeks had pre-evacuation hCG levels of 275,000 mIU/ml. Free beta-hCG levels were measured as 3% (normal value below 4%). The patient developed persistent gestational trophoblastic disease, failed to respond to methotrexate and actinomycin D, but has responded to combination chemotherapy with EMA-CO. Such a response to EMA-CO was not reported previously.

High levels of maternal serum alpha-fetoprotein and human chorionic gonadotrophins leading to the diagnosis of combined neural tube defect and partial mole

A case of combined partial mole and neural tube defect is presented. The detection of high levels of both maternal serum (MS) alpha-fetoprotein (AFP) and human chorionic gonadotrophin (hCG) during the second trimester led to the ultrasonic demonstration of anencephaly, omphalocele, and partial mole. This is the first report of combined elevation of MSAFP and MShCG.

Persistent gestational trophoblastic disease following evacuation of a tetraploid partial hydatidiform mole

A 31-year-old woman at 11 weeks gestation with ultrasonographic demonstration of partial mole had markedly elevated serum bHCG levels (458,000 mIU/ml). The patient underwent a vacuum curettage with pathological confirmation of the diagnosis, and cytogenetic analysis revealed a tetraploid karyotype (92,XXXX). The patient developed persistent gestational trophoblastic disease and was successfully treated with two courses of actinomycin D. Persistent trophoblastic disease after evacuation of a tetraploid partial mole was not reported previously.