One of the rare, and at the same time, severe complications of pregnancy is partial hydatidiform mole. This condition is characterized by an abnormal course of pregnancy, in which the fetus stops developing, and the chorionic villi turn into fluid-filled vesicles.
Vesicular drift, being one of the most common forms of trophoblastic disease, occurs with a frequency of 1 case per 1000-1500 pregnancies, and is divided into complete and incomplete, or partial. In the first case, embryonic tissues are completely absent, while in case of incomplete hydatidiform mole, there are separate parts of the embryo.
What is a partial hydatidiform mole?
Already five days after meeting with the sperm, the fertilized egg is ready for implantation in the uterine wall for further growth and development. For penetration into the wall of the uterus and reliable fixation in it, the fetal egg has an embryonic membrane - the chorion, which has villi that grow into the thickness of the endometrium with subsequent fusion with blood vessels. The chorion in the first trimester supplies the fetal egg with blood, as does the placenta in the future. In the case of the development of cystic drift, instead of transforming the chorion into the placenta, its villi turn into fluid-filled vesicles. At the same time, edema of the stroma of the villi develops, the number of bubbles increases, they merge with each other, resembling a bunch of grapes during ultrasound scanning. Yellowish fluid in vesicles a large number of hCG ( chorionic gonadotropin a person), the level of which, with a partial hydatidiform drift in a woman, is increased tenfold.
Due to the compression of the villi due to edema, there is a violation of the blood supply to the fetal egg, as a result of which the embryo does not receive nutrition, therefore, it is deprived of the opportunity to fully grow, and dies in the early stages of gestation, at about 10 weeks.
Abnormal proliferating chorionic tissue (chorionadenoma) sometimes penetrates deep into the uterus, penetrating into its muscular layer, and can also grow into the abdominal cavity, provoking the development of massive bleeding - we are talking about invasive, destructive hydatidiform mole. With cystic drift, malignant degeneration of chorionadenoma is also possible.
Why does a partial hydatidiform mole develop?
Normally, a fetal egg carries 23 female and paternal chromosomes, that is, a total of 46, while with complete hydatidiform mole, a fertilized egg contains a duplicated set of male genes in the complete absence of female genetic material. In the case of an incomplete hydatidiform mole, the fetal egg may have a duplicate set of papa's chromosomes - 46, and a set of mom's chromosomes - 23, which is a total of 69 chromosomes. This phenomenon most often occurs when two sperm enter the same egg.
Predisposing factors for the development of hydatidiform mole include:
- Hormonal disorders: thyrotoxicosis, as well as a decrease in the level of estrogens in the blood (hypoestrogenism)
- Complicated obstetric history(the presence of multiple births, medical abortions, habitual miscarriage, ectopic pregnancy)
- Weakened immunity
- Age under 16 and over 35
How to suspect a partial hydatidiform mole?
The clinic with partial cystic drift very remotely resembles a normal pregnancy, so this pathology can be diagnosed at an early stage. The primary symptom is severe toxicosis, which is characterized by severe nausea and repeated vomiting, while there is not a decrease, but, on the contrary, an increase in blood pressure in a pregnant woman. In addition, in the presence of incomplete hydatidiform mole, there is a rapid growth of the uterus that does not correspond to the gestational age. With a positive pregnancy test, a woman notes the presence of bloody discharge from the genital tract, which may contain drift tissue in the form of small bubbles, followed by the development of moderate and severe anemia against this background. Both with complete and partial mole, the fetal heartbeat is not audible, there is no motor activity.
IMPORTANT! Bleeding from the vagina, indomitable vomiting, and the absence of fetal movements in due time are the main clinical signs of hydatidiform mole, the appearance of which should immediately seek medical attention.
How to treat a partial hydatidiform mole?
The diagnosis of hydatidiform mole is confirmed both serologically (an increase in the level of hCG by several tens of times) and by ultrasound examination of the uterus (“bunch of grapes”, a picture of a “snow storm”, the absence of heart sounds, parts of the fetus). The earlier the diagnosis is established, the more favorable the prognosis of the disease.
Due to the fact that with cystic drift the embryo is doomed to death, the treatment consists in removing the fetal egg and abnormal chorion tissues from the body of the uterus. In the early stages of pregnancy, removal of trophoblastic tissues is performed by vacuum aspiration of the contents of the uterine cavity, while at later stages, uterine curettage may be required.
Cystic drift, although it does not belong to the category of true neoplasms, is included in the group of trophoblast pathologies and is inextricably linked with the pregnancy process. In fact, this disease is a complication of pregnancy, including ectopic, although it is quite rare. On average, based on statistical data, such a pathology is recorded in 1 case per 1000 pregnancies.
Epidemiology
Prevalence this disease depends on race and geographic location. For example, in North America, such a pathology is diagnosed only in 1 case for every 1200 pregnancies, in the countries of South America and the Far East (China, Japan) such a disease occurs much more often - 1 episode for every 120 pregnancies, in the territory Russian Federation pathology is diagnosed in one case for every 820-3000 pregnancies.
Separately, chorionepithelialoma should be singled out, which is diagnosed in 2 cases per 100,000 births.
Types of hydatidiform mole
By cystic drift, one should mean the pathology of the fetal egg (chorion), which, during development, should be transformed into the placenta. The villous membrane of the embryo or chorion undergoes a transformation, during which the villi are reborn into cysts (cluster-shaped formations) that range in size from lentils to grapes and resemble grapes in their shape. The diameter of such bubbles is about 25 mm, inside they are filled with a transparent opalescent liquid, which contains various amino acids, globulins, albumins and, of course, hCG.
The disease is directly related to pregnancy, so it can develop against the background of pregnancy, after delivery, miscarriage or medical abortion. It is also possible to develop a cystic drift against the background of the presence of a tubal (ectopic) pregnancy.
It is customary to distinguish several types of cystic drift:
Depending on the area of damage to the fetal egg:
partial, or incomplete, hydatidiform mole;
complete blistering.
Depending on the histological structure of the pathology:
chorioncarcinoma;
invasive or destructive;
a simple form of hydatidiform mole.
Based international classification 1992 (Singapore), if the disease has a malignant course, here we are talking about invasive mole, it is customary to determine its stage:
zero stage - hydatidiform mole with high or low risk (0B or 0A);
the first stage - the tumor is located within the uterus;
the second stage - there are foci of metastasis in the vagina and pelvic organs;
the third stage - the presence of metastases in the lungs;
fourth stage - distant metastases (liver, brain) are diagnosed.
Characteristics of the main types of cystic drift
With the development of the disease in the first 12 weeks of gestation, all the primary villi of the fetal egg degenerate, and pronounced hyperplasia is present in the layers of the trophoblast, so it is worth talking about the presence of a complete form of pathology. Some patients call this form of pathology early cystic drift (this is due to the timing of occurrence). Morphologically, this type of disease is characterized by:
proliferation of trophoblasts that line the villi from the inside;
the villi are enlarged (dilated) and edematous;
the epithelium of the chorionic villi has either undergone dystrophic changes or is not defined;
there are no blood vessels in the villi;
the embryo is missing (resorbed).
The onset of the disease at later gestational ages (from 3 months to 34 weeks inclusive) and the degeneration of only part of the chorionic villi is known as incomplete hydatidiform mole. At the same time, intact villi have a normal appearance, vascularization and blood supply are preserved in them. In this case, the fetus is present, but its death occurs due to the spread of pathology to a third or more of the placenta.
If the pregnancy is multiple and the pathology develops in one of the placentas, the second one can remain in its normal form and functionality.
Invasive hydatidiform mole can occur both in the presence of a complete (most often) and in the presence of a partial one. The distinguishing features are:
villi, growing through the serous cover of the uterus and myometrium, penetrate into the blood vessels and lymphatic network, thus spread throughout the body and affect the internal organs;
the trophoblast is hyperplastic, but retains the placental structure of the villi;
bubbles begin to grow into the muscular layers of the uterus.
The destructive form of pathology occurs in 5-6% of cases and is the most severe.
Causes and mechanism of development of pathology
The mechanism of the development of the disease is the presence of a pathological set of chromosomes of the embryo, when only a double set of father's chromosomes is present as a result of the initial complete absence or loss of maternal chromosomes.
In the presence of the full form of the disease, the karyotype of the embryo has a set of 46XX, if the cell loses maternal chromosomes and the paternal haploid genome is duplicated. However, it is possible to fertilize an initially empty egg with two sperm at the same time, this leads to the emergence of a 46XX or 46 XY karyotype. As a result, the embryo dies for another early stages development, before the formation of the placental circulation, while the chorionic villi continue to grow and develop.
An incomplete form of pathology is caused by triplodia - the fertilization of an egg by two sperm with a delay in the maternal haploid set of chromosomes. The karyotype of the embryo in such cases may contain 69XYU, 69XXX, 69XXY chromosomes. In such cases, the embryo dies at the 10th week of pregnancy due to multiple developmental anomalies, but in very rare cases, a viable fetus may develop.
The causes that lead to hydatidiform drift have not been determined to this day, however, there are a number of theories that can be used to explain the occurrence of chromosomal abnormalities after the egg is fertilized:
lack of protein - with a deficiency, there is a shortage of genes in the chromosome of a fertilized egg;
enzymatic theory - based on an increase in the level of the enzyme hyaluronidase, which is able to dissolve the vascular walls;
immunological theory - the embryo and later the fetus are antigens to female body therefore, in the presence of an insufficiently pronounced immune response, degeneration of the chorionic villi occurs, when a miscarriage should normally occur;
decidual theory - the development of endometritis in the decidua, which subsequently leads to the degeneration of chorionic villi;
defeat of the egg in the ovary - the maturation of an inferior egg in the follicle;
viral theory (viruses, including toxoplasmosis, damage the sets of chromosomes of both the father and the mother).
Factors that increase the likelihood of the disease:
consanguineous marriages;
thyrotoxicosis;
malnutrition (deficiency of vitamin A, animal proteins);
weakened immunity;
repeated miscarriages and abortions;
numerous genera;
age (pregnant women under 18 or over 40).
Clinical picture of pathology
Symptoms of the disease are not always clearly expressed in the early stages. A woman feels that she is pregnant, as there are signs of early toxicosis, a pregnancy test is positive and there is a delay in menstruation. Quite often, the detection of pathology occurs by chance during a medical abortion.
A characteristic feature is early toxicosis, which is very difficult with vomiting, sometimes indomitable, profuse salivation, which leads to the development of dehydration, electrolyte imbalance and significant lethargy and weakness. Early severe toxicosis is diagnosed in 20-35% of patients. In 27% of cases, the symptoms of early toxicosis are combined with signs of late toxicosis and preeclampsia. Edema occurs, increases blood pressure, in the study of urine, the presence of a large amount of protein, of fetal origin, is noted. Eclampsia may develop as early as 3-4 months of gestation. Preeclampsia is more typical for the full form of pathology and develops in the presence of a significant size of the uterus and a high level of β-hCG subunits in the blood. Accordingly, the development of preeclampsia in the early stages should alert the gynecologist and make him suspect the presence of a hydatidiform mole.
Mole is indicated by such signs as periodic bleeding from the vagina, which are present in 90-100% of cases, as well as the size of the uterus, which exceed the estimated gestational age. Uterine bleeding occurs most often early and is disguised as a spontaneous abortion. In some cases, the appearance of spotting coincides in time with the onset of menstruation. In 68% of patients, the asymptomatic period lasts less than two months. A clear sign of the presence of such a pathology is the detection of vesicles characteristic of the disease in the secretions.
If germination of the villi of the serous membrane (destructive hydatidiform mole) and uterine myometrium develops, intra-abdominal bleeding with symptoms of an acute abdomen may occur. Invasive forms of pathology are dangerous with the risk of developing profuse bleeding, which requires emergency hospitalization.
Prolonged and massive spotting leads to the development of anemia in the patient with a risk of death.
With the destructive form of the disease, the spread of metastases to the brain, lungs, vulva and vaginal walls is quite often observed. In some cases, metastatic foci are diagnosed after removal of the drift. Most often, the disappearance of metastases occurs spontaneously, after removal of the pathological focus, however, there is a possibility of developing severe complications that lead to the death of the patient.
About 15% of all patients complain of pain in the lumbar and lower abdomen. The nature and intensity of pain are different, and the manifestation of pain syndrome is often a precursor of blood discharge. Pressing, dull or aching pains occur due to the germination of the walls of the uterus to the serous cover or as a result of compression of neighboring organs by large thecalutein cysts. The manifestation of paroxysmal, acute pain is the result of rupture or torsion of thecalyutein cysts or the occurrence of intra-abdominal bleeding.
Thyrotoxicosis develops in 7% of patients with a complete pathology, which is characterized by tremor, tachycardia, increased levels of thyroid hormones and an enlarged thyroid gland, warm and moist integuments. The development of thyrotoxicosis is explained by an increase in the content of peat blastic β-globulin, which has a stimulating effect on thyrotropic receptors.
In the presence of a complete mole, embolism (blockage) of the branches of the pulmonary artery and the occurrence of respiratory failure may occur (about 2% of cases). This complication is characterized by the occurrence of chest pain, shortness of breath, tachypnea and tachycardia, cough and cyanosis. Disseminated rales are heard, X-ray examination of the lungs allows to establish the presence of bilateral focal opacification.
Diagnostics
This disease requires differential diagnosis with multiple pregnancy, acute polyhydramnios, pregnancy against the background of the presence of fibroids, ectopic pregnancy and spontaneous abortion.
After collecting complaints and anamnesis, the doctor performs a gynecological examination, during which the following is diagnosed:
the presence of tumor-like formations in the vulva and vagina;
in 50% of cases, luteal bilateral ovarian cysts are palpated (in case of an increase in the ovaries over 6 cm), which occur during the first two weeks and are unfavorable signs for the prognosis of pathology;
heterogeneous structure of the uterus: with a general softening, nodal seals are determined;
the size of the uterus does not correspond to the size of the expected gestational age (exceed).
In the presence of a large abdomen, the most reliable signs of pregnancy (palpation of large parts of the child, palpitations) are not determined.
Among the additional research methods used:
histological method - allows you to determine the morphological type of the disease (the material is obtained by scraping from the uterine cavity);
immunochemical method - is to determine the trophoblastic β-globulin in the blood. In the presence of pathology, the level is 76-93%;
a study on the level of hCG in the blood - in the absence of pregnancy, hCG in the woman's blood is absent. During pregnancy, it appears in the blood on the eighth day from the moment of conception, and the peak of 5000-10000 units falls on the 60th day. With a high level of hCG after 12 weeks, a mole should be suspected;
diagnostic hysteroscopy, laparoscopy - performed if necessary;
hysterosalpingography - used to clarify the diagnosis and control the effect of chemotherapy. In the invasive form on the hysterogram, the contour penetration of the contrast agent in the zone of introduction into the myometrium of the villi is determined;
X-ray examination chest- to detect metastases in the lungs;
ultrasound examination - a significant size of the uterus is determined against the background of the absence of a fetus or embryo, a characteristic feature is the presence of homogeneous fine-grained tissue, luteal cysts. The diagnostic value of ultrasound is 100%.
Treatment
In the presence of cystic drift, therapy consists in removing the pathology, which is performed by the following methods:
extriptation of the uterus and preservation of the appendages (lutenin cysts are not excised, since their regression is observed within 3 months after removal of the underlying pathology);
initiation of labor with the help of prostaglandins, if the size of the uterus is more than 20 weeks and the invasive form of the disease has been excluded (in case of ineffectiveness or the development of profuse bleeding, a small cesarean section with further curettage of the uterine cavity);
digital removal requiring curettage and vacuum aspiration;
vacuum excochleation (more preferable due to low trauma);
curettage of the uterus by penetration through the dilated cervical canal.
After surgery, means for uterine contraction, cold on the lower abdomen and antibiotics are indicated. After the pathology has been eliminated, the patient is discharged with obligatory dispensary observation in the antenatal clinic.
The second stage of therapy consists in performing treatment with chemotherapeutic drugs. Indications for its appointment are:
long-term steel indicator or increase in hCG titer;
detection of metastases during the removal of cystic mole;
invasive form of pathology after surgical treatment.
The first choice is the drug "Dactomycin", which is administered intravenously, the number of courses is determined on an individual basis. Metatrexate can also be used, but is more nephrotoxic. Metastases, after the focus of pathology is removed, either disappear on their own or are destroyed by chemotherapy.
The most popular questions on the topic
What methods of contraception are acceptable for use after treatment?
After treating the pathology, doctors recommend preventing pregnancy for one year after the disappearance of hCG in the urine and blood. It is best to use oral combined contraceptives, however, protection with barrier means is also allowed. Introduction intrauterine device not recommended as there is a high risk of uterine perforation.
What is dispensary observation and how long does it last?
After elimination of the mole, it takes about 73 days for the complete disappearance of hCG. The observation is:
MRI of the brain for 2 years with a frequency of 6 months, in case of detection of cerebral metastases;
annual lung x-ray;
Ultrasound of the pelvic organs every two weeks until the onset of remission, and after - quarterly;
weekly determination of the level of hCG in the blood, until 2 negative results are obtained;
monthly determination of the hCG level for six months, then after 2 months during the year, quarterly in the 2nd year and once every 6 months in the third.
When is it allowed to plan a pregnancy?
In the presence of a simple form of pathology, it is allowed to become pregnant one year after treatment and normalization of hCG, if there was an invasive form with chemotherapy, pregnancy can be planned after 2 years.
Why is such a pathology dangerous?
In 29% of patients after treatment, infertility occurs, in 14% of cases amenorrhea develops, in 4% of women the malignancy of the process occurs. Pregnancy that occurs earlier than 2 years after chemotherapy is dangerous with a high risk of chromosomal mutations and fetal abnormalities. Complications during childbirth can also develop: anomalies of the birth forces, bleeding.
What is the prognosis after treatment?
Modern methods of therapy allow achieving a 100% cure, in 90% of cases it is possible to restore the menstrual cycle. Get pregnant and carry healthy baby 70-80% of patients succeed.
- pathology of the fetal egg, characterized by the transformation of the villi of the outer germinal membrane (chorion) into cysts - fluid-containing vesicles, the growth of the epithelium of the villi, and the death of the fetus. Bubble drift is manifested by early toxicosis, bleeding, an increase in the size of the uterus compared to the gestational age. A mole is detected using a vaginal examination, ultrasound, determination of the content of β-CHG, fetal PCG. Treatment consists of removing the mole by vacuum aspiration, curettage of the uterine cavity, and sometimes a hysterectomy.
ICD-10
O01
General information
Cystic drift is included in the group of so-called trophoblastic diseases. Under the term "trophoblastic disease", gynecology unites various forms trophoblast pathologies: simple and invasive hydatidiform mole, choriocarcinoma, placental bed tumor and epithelioid trophoblastic tumor. Malignant tumors of the trophoblast can develop during pregnancy, after an abortion, ectopic pregnancy, childbirth, but more often they are the result of hydatidiform mole.
Vesicular mole develops in 0.02-0.8% of all pregnancies. With this pathology, there is a sharp edema of the stroma and the growth of chorionic villi with the formation of bubble-like extensions resembling bunches of grapes. Vesicles (cysts) reach a size of 25 mm, contain an opalescent or yellowish liquid, which contains amino acids, globulins, albumins, chorionic gonadotropin. As a rule, cysts are devoid of vessels; occasionally they are determined by single formed capillaries. Microscopically, the elements of hydatidiform mole are characterized by cystic and edematous degeneration of the stroma, the absence of signs of vascularization, hypertrophy of the trophoblast epithelium (syncytium, Langhans layer).
Classification of hydatidiform mole
According to the degree of degeneration of the chorionic villi, a complete and partial cystic skid is distinguished. With the full form of cystic drift, the transformation affects all the villous elements of the chorion; with partial - only a certain part of them. In both cases, the fetus dies, but the development of hydatidiform drift continues, which is accompanied by rapid increases in the size of the uterus.
Complete hydatidiform mole is usually detected at 11-25 weeks of gestation, often contains a diploid chromosome set 46XX, while both X chromosomes are paternal. In 3-13% of cases, a combination of 46XY with all paternal chromosomes occurs. With complete hydatidiform mole, there are no signs of the development of the embryo and the embryo, vesicles and edematous villi of the chorion are visualized. Clinically, complete hydatidiform drift is manifested by an increase in the size of the uterus compared with the gestational age. In 20% of cases, hydatidiform drift undergoes malignant transformation and the development of metastatic trophoblastic tumors.
The timing of the development of partial hydatidiform mole is variable: pathology can be diagnosed at a period of 9-34 weeks of gestation. Partial cystic drifts are triploid (69ХХХ, 69ХХУ, 69ХУУ), their set contains one maternal chromosome, macroscopically there are fragments of an unchanged embryo and placenta, edematous chorionic villi. Clinically, the size of the uterus corresponds to or less than the gestational age. The probability of malignant transformation is up to 5%.
In addition, there is a destructive (invasive) form of hydatidiform mole, characterized by the germination of villi into the depth of the myometrium and tissue destruction. Proliferating villus invasion into the myometrium may be accompanied by severe intraperitoneal bleeding. According to the histotype, depending on the ratio of the cellular structures of the trophoblast, a mixed, syncytial, cytotrophoblastic hydatidiform mole is distinguished.
Causes and risk factors for hydatidiform mole
A cystic drift develops as a result of chromosomal gestational disorders. Full version cystic drift (uniparental disomy) occurs when the maternal genes are lost and the haploid set of paternal genes is duplicated (zygote karyotype 46XX) or when two spermatozoa simultaneously fertilize an inferior non-nuclear egg (zygote karyotype 46XY, 46XX). A partial variant of hydatidiform mole is characterized by triplodia, which is the result of dispermy or fertilization of the egg by a sperm with a diploid set of chromosomes (karyotype 69XXY, 69XYY or 69.XXX). With partial hydatidiform drift, the fetus often has multiple malformations (hydrocephalus, syndactyly, etc.).
Due to the rapid growth of drift bubbles, a relatively rapid increase in the uterus occurs, in which its size does not correspond to the expected gestational age. With cystic drift, toxicosis is often noted, accompanied by nausea, repeated vomiting, salivation, exhaustion, increasing liver failure, symptoms of preeclampsia, preeclampsia and eclampsia already in the first trimester.
Since the fetus usually dies in hydatidiform mole, early dates, then there are no reliable signs of pregnancy - parts of the fetus are not determined by palpation and with the help of ultrasound, the heartbeat is not heard and is not recorded by hardware methods, there are no fetal movements. At the same time, biological and immunological pregnancy tests give a positive result.
In 30-40% of cases, bilateral thecalutein cysts are detected in patients, which spontaneously regress after removal of the hydatidiform mole. The greatest danger of cystic drift is due to the possibility of malignant gestational trophoblastic tumors that metastasize to the walls of the vulva and vagina, lungs, brain, organs abdominal cavity.
Diagnosis of hydatidiform mole
When diagnosing, cystic drift is differentiated with multiple pregnancies, polyhydramnios, pregnancy against the background of uterine fibroids, spontaneous miscarriage. Distinguishing features include the presence of spotting vesicles, usually observed before the expulsion of the hydatidiform mole. In a gynecological examination, the dense elastic consistency of the uterus is determined with areas of excessive softening, the excess of the size of the uterus over the gestational age.
Ultrasound reveals an increase in the uterus in the absence of a fetus in it, homogeneous small-cystic tissue (a symptom of a “snow storm”), the presence of tecalutein ovarian cysts with a diameter of more than 6 cm. During fetal phonocardiography, the heartbeat is not recorded. According to the indications for cystic drift, ultrasound, hysteroscopy, laparoscopic echography, diagnostic laparoscopy can be performed.
If you suspect the development of cystic drift, the content of chorionic gonadotropin (hCG) is necessarily examined; if necessary, biochemical tests of the liver, determination of creatinine and coagulograms are performed. To exclude metastatic screenings of hydatidiform mole, an x-ray of the chest, abdominal cavity, CT or MRI of the brain is performed. After removal of the cystic drift, a histological examination and determination of the karyotype are performed.
Treatment of hydatidiform mole
When a cystic drift is detected medical tactics is to remove it. The cystic drift is removed by vacuum aspiration with control curettage after preliminary dilatation of the cervix. For better contraction of the uterus, oxytocin or pituitrin is prescribed. Sometimes there is an independent expulsion of cystic drift from the uterine cavity. With the development of threatening bleeding or the reproductive function performed, a hysterectomy is performed - removal of the uterus without appendages. The removed tissue without fail subject to histological examination.
After the evacuation of the hydatidiform mole over the next 2 months, the patient undergoes a weekly determination of hCG in the blood serum, ultrasound of the small pelvis once every 2 weeks, radiography of the lungs. In the absence of signs of developing chorionepithelioma, subsequent chemotherapy is not indicated. Dispensary observation of an oncogynecologist after a hydatidiform mole is carried out for 2 years. For this period, protection from pregnancy with oral contraception is recommended.
Complications of hydatidiform mole
A threatening complication of cystic drift can be the development of chorionepithelioma (chorioncarcinoma) - a malignant form of trophoblastic disease. Chorioepithelioma is characterized by invasive germination of the uterus, massive metastasis to the lungs, liver, brain, and can be fatal. Often, after cystic drift, intrauterine infections, metrothrombophlebitis, thrombosis, septicemia develop. In 30% of women after hydatidiform drift, infertility is noted, in 14% - amenorrhea.
Forecast and prevention of hydatidiform mole
Prophylactic chemotherapy is indicated if, after the evacuation of the mole, there is no decrease in the hCG titer, as well as in case of detection of metastases. In 80% of women who have had a hydatidiform mole, spontaneous remission occurs without the need for additional treatment. Systematic monitoring of hCG and observation by a gynecologist help to detect developing chorionic carcinoma in a timely manner and take active measures.
Adequate treatment of hydatidiform mole allows you to preserve the reproductive potential of a woman with the possibility of a subsequent normal pregnancy.
One of the unpleasant and, moreover, formidable complications of pregnancy is hydatidiform mole. Some consolation for women who are already "in position" can be the fact that this pathology is not so common and is approximately 1 case per 1000 births. The researchers noted that the prevalence of the disease is directly related to geographic and racial origin. For example, in the United States, there are 0.6 - 1.1 cases of hydatidiform mole per 1000 of all pregnancies, while in Asia (not all) and South America it is diagnosed approximately 10 times more often.
What is a blister?
Cystic drift is the pathology of the trophoblast, as a result of which the stroma swells, and the chorionic villi grow. At the ends of the chorionic villi, expansions are formed in the form of bubbles, similar to bunches of grapes. Vesicles or cysts increase to 0.25 cm, inside they contain a yellowish liquid with a high level of human chorionic gonadotropin (CG).
The described pathology is included in the group of trophoblastic diseases, the development of which is associated with pregnancy. Trophoblast tumors are the only ones of all cancerous tumors that originate from the trophoblast, which is a derivative of the female and male germ cells. A hydatidiform mole can develop during an ongoing pregnancy, after childbirth, and even after an ectopic pregnancy.
Types of hydatidiform mole
Depending on the area of regenerated chorionic villi, there are full and partial hydatidiform mole. With complete cystic drift, the embryo dies even in the early stages of pregnancy, and all the villi are involved in the pathological process. With partial mole, only part of the chorionic villi is reborn, it usually develops in the second half of pregnancy, but can occur earlier or later, in terms of 9 to 34 weeks. It is possible to have a live fetus in the case of an almost full-term pregnancy.Also, hydatidiform mole can be simple and destructive or invasive. The destructive form is characterized by the fact that chorionic villi sprout (introduce) into the muscular wall of the uterus, which is fraught with internal bleeding. This is the most severe form of the disease.
Causes of hydatidiform mole
To date, the exact causes of the pathology have not been established. There are several theories for the development of hydatidiform mole:
- theory of viral transformation (important viral nature diseases);
- disease of the egg in the ovary (a pathological egg that has matured in the follicle causes the death of the embryo);
- decidual theory (decidual endometrium causes the degeneration of the chorion);
- immunological theory;
- enzymatic theory (increased content of hyaluronidase, which destroys the vascular wall);
- protein deficiency (lack of genes in the chromosomes of a fertilized egg).
The full form of hydatidiform drift is caused either by the loss of maternal genes, in which case the father's genes are duplicated, or by the simultaneous fertilization of an egg without a nucleus by two sperm. Partial hydatidiform mole occurs when there is an existing pathology of spermatozoa (dyspermia or a spermatozoon that has fertilized an egg has a diploid set (doubled) of chromosomes). In this case, the zygote will not contain 46 chromosomes, but 69.
Predisposing factors for the development of hydatidiform mole include:
- age (20 - 24 years and 40 - 49 years);
- parity (large number of births);
- multiple abortions;
- thyrotoxicosis;
- immunodeficiency;
- lack of vitamin A or carotene in food;
- consanguineous marriages.
Symptoms of hydatidiform mole
The clinical picture of cystic drift is not always clearly expressed. It is possible to diagnose the disease during an abortion, which is often an accidental finding. In most cases, a woman considers herself pregnant, she has a delay in menstruation. There are early signs (nausea, vomiting, dizziness, fatigue, and others) in the first trimester of pregnancy and severe symptoms (up to) in the second half of pregnancy.
Also a symptom of cystic skidding are uterine bleeding, which occurs early. Sometimes in bloody secretions, bubbles can be found that have come off the chorionic villi. Bleeding can also be internal, into the abdominal cavity, which indicates a destructive form. Blood loss leads to anemia in the patient with all the ensuing consequences (weakness, fainting, increased fatigue, etc.).
When conducting a gynecological examination, the doctor often determines that the size of the uterus does not correspond to the gestational age. A significant increase in the size of the uterus (for example, pregnancy 8 weeks, and the uterus is palpated as 12 weeks old) is characteristic of a complete mole. The consistency of the fruit-place is heterogeneous, in some places strongly softened areas are palpated, which alternate with dense elastic ones. If the pregnancy has exceeded 20 weeks, the fetus and its large parts are not detected. The baby's heartbeat is also not audible.
In half of the cases with cystic drift, bilateral luteal ovarian cysts are diagnosed. Their sizes exceed 6 cm in diameter and can reach 15 cm.
Treatment of hydatidiform mole
At the first stage of treatment, it is necessary to remove the cystic drift. To do this, use the following methods:
- curettage of the uterine cavity;
- vacuum excochleation;
- finger removal followed by curettage;
- labor induction after 20 weeks of gestation with prostaglandins, in the absence of effect - caesarean section with curettage;
- extirpation of the uterus without appendages (luteal cysts disappear on their own within 3 months after removal of the cystic mole).
In the postoperative period, cold is shown on the lower abdomen (for 2 hours), reducing drugs (oxytocin), antibiotics and infusion therapy (if indicated). After being discharged from the hospital, the woman is registered in the dispensary at the antenatal clinic. Restoration of regular menstrual cycle and the absence of spotting is a favorable sign in terms of prognosis.
If spotting continues, the uterus does not contract well, grows, or remains the same level chorionic gonadotropin, this indicates a malignant course of the disease. In this case, it shows:
- weekly monitoring of hCG levels until negative results are obtained;
- after that, hCG is examined every month for two years;
- Pelvic ultrasound every 14 days until recovery, then quarterly for 12 months;
- x-ray of the lungs, if hCG does not decrease (exclusion of metastases);
- hormonal contraception for 2 years.
The second stage is chemotherapy. Indications for her:
- an increase in the titer of hCG or its stabilization;
- destructive hydatidiform mole after surgery;
- detection of metastases after removal of the hydatidiform mole.
Of the chemotherapy drugs, preference is given to dactinomycin. Perhaps the use of methotrexate. After the end of chemotherapy, you can become pregnant no earlier than 12 to 24 months in order to exclude chromosomal mutations and fetal malformations.
By cystic drift is understood the pathology of the fetal egg, which is characterized by the transformation of the chorionic villi (the outer germinal membrane) into cysts - vesicles containing fluid, the growth of the epithelium of the villi and, as a result, the death of the fetus.
This pathological condition is manifested by early toxicosis, an increase in the size of the uterus in comparison with gestational age, and bleeding.
A mole is detected by ultrasound, vaginal examination, determination of the content of β-CHG, fetal PCG.
Treatment consists of removing the drift by curettage of the uterine cavity, vacuum aspiration, and in rare cases, a hysterectomy.
This pathological condition develops in 0.02 - 0.8% of all pregnancies. With this disease, there is edema of the stroma (shell) and growth of the chorion villi with the formation of specific bubble-like extensions that resemble bunches of grapes.
Cysts (vesicles) reach a size of twenty-five millimeters, contain a yellowish or opalescent liquid, which includes globulins, amino acids, human chorionic gonadotropin, albumins. Cysts, as a rule, do not have vessels, rarely single capillaries can be identified in them.
Classification of hydatidiform mole
There are several classifications of cystic drift. They are based on histological and morphological features. According to the degree of degeneration of the chorionic villi, partial and full skid. With a full form, all the villi of the chorion are transformed, with a partial one, only a certain part of them.
In all cases, the fetus dies, but the development of pathological formations continues, which is accompanied by a rather rapid increase in the size of the uterus. In addition to all this, there is an invasive (destructive) form of hydatidiform drift, which is characterized by the germination of villi into the thickness of the muscular membrane of the uterus and subsequent tissue destruction.
This condition may be worsened by the development of severe intraperitoneal (intra-abdominal) bleeding. According to the histological type, depending on the ratio of trophoblast structures, syncytial, mixed, cytotrophoblastic hydatidiform drift is distinguished.
Causes and risk factors of the disease
Molar mole develops as a result of chromosomal abnormalities during gestation. The full variant of this pathology occurs when the maternal genes are lost and the set of (haploid) paternal genes is duplicated, or when a non-nuclear egg is fertilized simultaneously by two spermatozoa.
Partial hydatidiform mole also develops as a result of genetic disorders: the fertilization of an egg by a spermatozoon that has a diploid set of chromosomes. This condition is often accompanied by the development of multiple malformations (syndactyly, hydrocephalus, etc.).
A mole develops three times more often in repeated pregnancies, in young patients, and also in pregnant women over thirty-five to forty years of age. This pathology can be a complication of an ectopic pregnancy and therefore be localized in the fallopian tube.
Multiple births, abortions, immunodeficiencies, thyrotoxicosis, dietary deficiency of vitamin A and animal fats, closely related marriages are factors that increase the likelihood of developing hydatidiform mole by several times.
Symptoms that accompany pathology
One of the most characteristic signs for this pathological condition is the discharge of dark liquid blood from the genital tract, which contains rejected mole vesicles.
Such bleeding can lead to significant anemization and, in some cases, become life-threatening.
Germination of elements of cystic drift into the thickness of the muscular membrane of the uterus may be accompanied by its perforation and massive intra-abdominal bleeding.
The rapid enlargement of the uterus is the result of the rapid growth of the vesicles. However, its size does not correspond to the expected gestational age.
Bubble drift is often accompanied by the development of toxicosis. At the same time, nausea, repeated vomiting, salivation, exhaustion, increasing liver failure, symptoms of preeclampsia, eclampsia and preeclampsia are observed already in the first trimester of pregnancy.
Since the fetus dies in the early stages with cystic drift, there are no reliable signs of pregnancy - parts of the fetus are not determined by palpation and with the help of ultrasound, the heartbeat is not heard and is not recorded by various hardware methods, there are no fetal movements.
At the same time, carrying out immunological and biological tests for pregnancy gives positive results. In thirty to forty percent of cases, bilateral cysts (thecalutein cysts) are detected in patients, which regress on their own after removal of the hydatidiform mole.
This pathological condition poses the greatest danger due to the possibility the emergence of dangerous malignant tumors, which later metastasize to the walls of the vagina, vulva, brain, lungs, and abdominal organs.
Complete (simple) mole
This pathological condition is the most common form of trophoblastic disease. It occurs with a frequency of 1/1000 - 1/1500 pregnancies (in Western countries). The greatest risk of developing a complete hydatidiform mole is in women younger than fifteen and older than forty.
Other risk factors are a history of miscarriage, termination of pregnancy, dietary errors (lack of vitamin A and animal fats). This pathological condition is characterized by huge amount bubbles with transparent content.
In this case, the tissues of the fetus are completely absent. Clinically, this disease is manifested by a delay in menstruation. Pregnancy symptoms such as vomiting and nausea are more than normal, due to the high content of HCG, which is synthesized by the abnormal trophoblast. Some patients may develop hyperthyroidism due to the fact that HCG has a weak stimulating effect on thyroid tissue.
Partial hydatidiform mole
This pathological condition is diagnosed when the fetus is found along with proliferating villi with hydropic degeneration.
The fetus usually dies at the end of the first or beginning of the second trimester, and analysis of the placenta is needed to make a diagnosis, since the hydropic villi are not as pronounced as with a complete hydatidiform mole.
The age of the patients is somewhat older than with a complete hydatidiform mole. This condition is associated to a lesser extent with the risk of subsequent malignancy.
How to get pregnant without consequences
After removal of the cystic drift, the woman should be registered with the gynecologist for another one to one and a half years.
During this control period, it is necessary to carefully make sure you don't get pregnant, since there is a risk of re-development of this pathological condition.
The most optimal method of pregnancy planning will be hormonal contraceptives which should be taken after consulting a gynecologist.
Due to the specific hormonal effects, the work of the ovaries will be regulated for the better, since during the operation and in the presence of complications, it could be disturbed.
The next pregnancy should be under strict control, both on the part of the medical staff and on the part of the woman. This is important, since the likelihood of pathology and difficult childbirth after given state increases several times. It is also important to know that after surgery or chemotherapy conception should be planned on time, not earlier than in a year.
Modern methods for diagnosing hydatidiform mole
When diagnosing, this disease is differentiated from polyhydramnios, multiple pregnancy, spontaneous miscarriage, pregnancy against the background of uterine fibroids. Distinctive features This pathology is the presence of bubbles in the spotting, which is usually observed before the expulsion of the mole.
Holding gynecological examination allows you to determine the change in the consistency of the uterus to a densely elastic form with the presence of areas of excessive softening, as well as an increase in the size of the uterus relative to the gestational age.
Ultrasound examination allows to confirm the enlargement of the uterus and the absence of the fetus, while a symptom of "blizzard" (presence of homogeneous fine-grained tissue), thecalutein ovarian cysts, having a diameter of more than six centimeters, is detected.
During phonocardiography, the fetal heartbeat is not recorded. According to indications, hysteroscopy, diagnostic laparoscopy, laparoscopic echography, ultrasonic hysterosalpingoscopy can be performed.
If you suspect the development of a cystic drift, the content of chorionic gonadotropin (CG) is mandatory, if necessary, biochemical liver tests are performed, the level of creatinine and a coagulogram are determined.
In order to exclude metastatic screenings of hydatidiform drift, a survey radiography of the abdominal cavity, chest, MRI or CT of the brain is performed. After removal of the pathological tissue, a special histological examination is performed, as well as the determination of the karyotype.
Ways to treat hydatidiform mole
The main treatment for cystic drift is the removal of this formation. For this, vacuum aspiration methods with control curettage are used after the implementation of preliminary dilatation (expansion) of the cervix. To improve the contraction of this organ, pituitrin or oxytocin is prescribed. In rare cases, there may be an independent expulsion from the uterine cavity of the cystic mole.
With the reproductive function performed or the development of threatening bleeding, the uterus is removed (extirpation) without appendages. The removed tissue is necessarily subject to special histological examination.
After removal of the hydatidiform mole, over the next two months, the patient undergoes a weekly determination of the level of hCG in the blood serum, every two weeks - ultrasound of the small pelvis, as well as x-ray of the lungs. If there are no signs of developing chorionepithelioma, then subsequent chemotherapy is not indicated.
Chemotherapy and Radiation Therapy
Used for chemotherapy 
drugs that act on cancer cells. It can be carried out intramuscularly, intravenously, and also in the form of tablets.
Chemotherapy is a systemic treatment since all medicines enter the bloodstream and spread to all organs and tissues, killing all malignant cells in their path.
In radiation therapy, X-rays or other types of radiation are used to destroy tumor cells, as well as reduce the size of the neoplasm.