Hydatidiform mole etiology diagnosis treatment principles of clinical examination. Is a hydatidiform mole a death sentence for a woman? Which doctors should you contact if you have a hydatidiform mole?

What is hydatidiform mole and what is the danger of this disease? Today the website for mothers will tell you.

Any pregnancy, whether it is long-awaited or in the form of a surprise, should bring only joy. But sometimes the presence of a serious pathology can deprive a pregnant woman of the opportunity to count on a happy outcome of childbirth.

Some diseases require termination of pregnancy, and the sooner the better.

Hydatidiform mole is a serious disease of the ovum, which is characterized by degeneration of chorionic villi(outer embryonic membrane) into blisters with liquid, very similar in appearance to grapes. The pathology causes the proliferation of epithelial villi and inevitable death of the fetus.

Fortunately, it is rare - in about one out of two thousand pregnant women.

Types of disease

• With a simple hydatidiform mole, manifestations of the disease are observed in the first trimester of pregnancy. This form is characterized by the presence of two sets of paternal chromosomes in the fertilized egg. The maternal genotype is completely absent. The embryo does not form, the fertilized egg and placenta do not form.
• With a partial hydatidiform mole, the egg contains two sets of paternal chromosomes and one maternal genotype. This situation can occur if the egg is fertilized by two sperm at the same time. This form of pathology is observed in. Placental tissue manages to form, but is cystic in nature.
• The invasive form of the disease is characterized by extensive growth of chorionic villi into the myometrium. Tissue destruction can lead to severe bleeding.

Causes of hydatidiform mole

Experts still do not have accurate information about why this disease develops.

Some argue that the primary cause of hydatidiform mole lies in initial pathology of the uterine walls, as a result of which the transformation of chorionic villi occurs.

Proponents of another theory believe that the egg itself is initially unhealthy, being in. Leaving the ovary diseased egg after conception, it gives rise to the development of hydatidiform mole throughout the entire uterine cavity.

The third reason is incorrect set of chromosomes during fertilization: the presence of a duplicate of the paternal chromosomes with a partial or complete absence of the maternal genotype.

Signs and symptoms of hydatidiform mole

A pregnant woman may experience characteristic signs of the disease:

• severe form of toxicosis with persistent salivation and frequent vomiting;
• exhaustion;
• manifestation of gestosis not typical for early stages;
• liver failure;
• presence of protein in urine tests;
• pain in the abdominal area;
• iron deficiency in the body.

And yet, pregnancy after suffering a hydatidiform mole is possible in most cases. But not earlier than two years after finishing chemotherapy and taking anti-cancer drugs.

Hydatidiform mole refers to diseases associated with the pathology of the trophoblast, a temporary organ necessary for attachment of the embryo to the wall of the uterus. Subsequently, the placenta is formed from it. The trophoblast itself is a tissue that begins to differentiate in the early stages of embryonic development and which, with the appearance of the placenta, turns into extraembryonic tissue that forms the fetal part of the septum, separating the organisms of the embryo and mother and providing nutrition to the fetus.

Trophoblastic diseases are either tumors or conditions that predispose to the development of tumors. These tumors are rare and unique in that they arise from products of conception and grow into the tissue of the mother's uterus. Since these diseases are associated with pregnancy, they mainly affect young women (the average age of patients is 25 years).

During hydatidiform mole, the trophoblast degenerates into a huge number of small bubbles. These bubbles occupy the entire uterine cavity and tend to grow rapidly and spread to the lungs, i.e. metastasis. Hydatidiform mole cells produce human chorionic gonadotropin. Normally, human chorionic gonadotropin, the pregnancy hormone, is produced during pregnancy, but in much smaller quantities. During a hydatidiform mole, the embryo dies in the early stages of development.

Causes

Hydatidiform mole occurs when, for unknown reasons, maternal genes are lost and paternal chromosomes are duplicated. Sometimes (in 5% of cases) a hydatidiform mole is caused by the fertilization of an empty (nuclear-free) or regular egg by two sperm.

The incidence of hydatidiform mole (MH) is relatively low and amounts to 1 case per 1000 births. However, the incidence of the disease varies in different regions. Thus, in the USA, the disease occurs from 0.6-1.1 per 1000 pregnancies, and in some areas of Asia and South America - 10 times more often (1 case in 120 pregnancies).

Symptoms of the disease

The clinical picture of PZ is extremely diverse and unusual. However, the main symptom of this disease is bleeding from the genital tract after a long delay in menstruation. In addition, severe nausea, vomiting, weakness, increased blood pressure, headaches, swelling, and the appearance of protein in the urine in the early stages of pregnancy may cause concern.

All of the above symptoms should force a woman to immediately contact an obstetrician-gynecologist.

When examined by a specialist, the most characteristic symptom is a discrepancy between the size of the uterus and the delay in menstruation. In most cases, the size of the uterus is 3-4 weeks larger than expected. For example, if, judging by the last menstruation, the gestational age is 8 weeks, then if a hydatidiform mole is suspected, the size of the uterus will correspond to 12 weeks of pregnancy.

However, the size of the uterus may correspond to the expected duration of pregnancy, and in early stages of pregnancy it may even be smaller than the obstetrician-gynecologist suggests.

In addition, characteristic, but not necessary for PZ is the presence of ovarian cysts (cavitary formations with liquid contents), which can reach up to 15 cm in diameter.

Diagnosis and treatment

In connection with the development of ultrasound diagnostics, making a diagnosis of “hydatidiform mole” does not cause great difficulties, since the ultrasound picture typical for this disease is well known to specialists.

Treatment of the benign form of trophoblastic disease of hydatidiform mole mainly comes down to its removal using vacuum aspiration - suction of the contents of the uterus using metal cylindrical tips and an electric vacuum pump.

After histological confirmation of the diagnosis (examination under a microscope of material obtained from the uterus), the patient should be sent to a specialized oncology institution.

Observation for 8 weeks after surgery includes serum human chorionic gonadotropin (HCG) testing once a week and pelvic ultrasound (US) once every two weeks.

In the absence of signs of the disease (normal hCG level up to 15 MME/ml, absence of tumor formations according to pelvic ultrasound and X-ray examination of the lungs, as well as restoration of the normal menstrual cycle), chemotherapy is not administered.

Further testing of hCG in blood serum is carried out once every two weeks for 3 months, and then once a month for six months. The optimal time for the desired pregnancy to occur is one year after the evacuation of a hydatidiform mole.

If 8 weeks after evacuation of the hydatidiform mole there is no normalization of CG levels or there is a tendency to increase CG, the patient is prescribed an in-depth examination, since these test results indicate that hydatidiform mole cells remain in the uterus or other organs, which produce HG.

According to a pelvic ultrasound, foci of hydatidiform mole in the uterus can be detected, and an X-ray examination of the lungs can reveal metastatic lesions. Such patients are prescribed chemotherapy. Chemotherapy is the most commonly used drug to treat this disease. METHOTREXATE And DACTINOMYCIN or a combination thereof in combination with LEUCOVORIN. Treatment is carried out until hCG levels normalize, the menstrual cycle is restored, and pathological foci in the uterus and lungs disappear. However, we must remember that fibrotic changes - foci of connective tissue at the site of pathological foci in the uterus and lungs - can persist for quite a long time, despite complete recovery.

After achieving clinical and laboratory remission (a period when there are no symptoms of the disease and all tests are normal), another 2 to 3 courses of preventive chemotherapy with the same drugs are carried out.

After treatment, the patient remains under the supervision of an oncologist for 1-1.5 years (during this time, hCG in the blood serum is determined every month). At this time, it is recommended to abstain from pregnancy, while the optimal option for preventing unwanted pregnancy is hormonal contraception, which, along with the contraceptive effect, regulates ovarian function, impaired as a result of the disease and chemotherapy.

Timely diagnosis and correct treatment tactics make it possible to preserve a woman’s reproductive function and guarantee the onset of a normal pregnancy and subsequent childbirth.

According to the Russian Cancer Research Center named after. N.N. Blokhin, thanks to the success of chemotherapy, it was possible to cure almost 100% of patients suffering from PZ. In 90% of patients receiving chemotherapy, menstrual function was completely restored, and in 70% pregnancy occurred, which ended in normal birth.

It should be noted that pathological changes in children born to women after a hydatidiform mole are somewhat more common than in children of healthy women. At the same time, pathology during childbirth (bleeding, weak labor duration, etc.) in patients who had trophoblastic disease was slightly higher compared to healthy women. This fact indicates that after this disease a woman needs especially careful monitoring by doctors.

Hydatidiform mole (molar pregnancy) is a rare complication of pregnancy that occurs in approximately one woman in a thousand. It occurs when the chorionic villi - the membrane that surrounds the fetus and attaches it to the wall of the uterus - degenerates into vesicular structures that resemble bunches of grapes. Their size varies greatly: from half a match head to a large grape. These neoplasms are considered benign.

In pregnant women with twins, in rare cases, one fetus may develop normally, but the second embryo does not form or dies as a result of a hydatidiform mole. In such cases, many women can carry and give birth to a healthy child.

What happens during a hydatidiform mole?

During a normal pregnancy, the fertilized egg (zygote) begins to divide, and upon reaching a certain number of cells, they are divided into two groups: from one the embryo is formed, from the other - the fetal membranes, including the chorion. Hydatidiform mole develops in two cases:

1. The sperm fertilizes the egg, which does not have its own nucleus. Subsequently, the paternal chromosomes are doubled, thus replacing the missing maternal ones. But such a zygote is not viable, an embryo does not form from it, and the chorionic villi turn into abnormal vesicles. This type of hydatidiform mole is called complete.
2. Two sperm penetrate a normal egg at the same time. Zygote cells contain 3 sets of chromosomes, which leads to the death of the embryo in the early stages of development. The chorionic villi also develop abnormally and form vesicles. This pathology is called incomplete hydatidiform mole.

Causes of hydatidiform mole

The causes of hydatidiform mole have not been established at this time. But there are known factors that increase the risk of its development:

• age: complete hydatidiform mole occurs in adolescence and in those over 45 years of age. In this case, the number of previous pregnancies does not matter. There was no significant relationship between incomplete pregnancy and age;
• molar pregnancy in history - if a woman has had such a pathology previously, the chances of re-development are assessed as 1-2% (without such experience 0.6%). Two or more hydatidiform moles increase this figure to 15-20%;
• ethnicity: this complication of pregnancy is most often found in representatives of Asian countries (Philippines, Japan, Taiwan);
• previous miscarriages.

Symptoms

Molar pregnancy is often perfectly disguised as a normal pregnancy and the diagnosis is usually made during the first planned ultrasound (at 10-14 weeks of pregnancy).

If there are signs of disturbances, they usually occur between the 4th and 12th weeks. The most common symptom is uterine bleeding, brownish-reddish vaginal discharge, in which altered chorionic villi resembling a bunch of grapes are sometimes visible. These are serious symptoms that require immediate evaluation by a doctor. Standard diagnosis of the causes of bleeding includes ultrasound, during which a picture characteristic of a hydatidiform mole is detected.

Many women who are subsequently diagnosed with a molar pregnancy report weakness and nausea in the first semester, usually more intense than during normal pregnancy.

If a miscarriage occurs, the fetal tissue must be sent for examination to rule out hydatidiform mole.

A medical examination may reveal other signs of hydatidiform mole:

• the uterus is larger than is typical for the current period;
• high blood pressure;
• preeclampsia;
• ovarian cysts;
• anemia;
• hyperthyroidism;
• lack of fetal movement and heartbeat.

Diagnostics

Diagnosis begins with a conversation with a doctor. It is very good to prepare answers to some questions in advance:

• date of last menstruation?
• When were the symptoms first noticed?
• Are the unpleasant sensations constant or appear from time to time?
• is there any pain? if so, what is the nature and intensity of the pain?
• Compared to the most intense day of normal menstruation, is the discharge stronger, weaker, the same?
• Are you worried about dizziness?
• Have you previously been diagnosed with hydatidiform mole?
• what chronic diseases do you have?
• Are you planning to get pregnant in the future?

The next steps to confirm the diagnosis are a gynecological examination and laboratory diagnostics. A woman's blood is taken for general and biochemical analysis, the level of human chorionic gonadotropin is determined, and she is sent for an ultrasound of the abdominal cavity. If a molar pregnancy has already been diagnosed, then in a number of other cases, visual diagnostic methods (X-ray, CT, MRI) are used to check for the presence of metastases in the lungs, brain, and liver.

Treatment of hydatidiform mole

Hydatidiform mole cannot result in the birth of a child (with the exception of twins). Therefore, if such a pathology is detected, the pregnancy is terminated. Sometimes the body independently cleanses the uterine cavity of cysts that come out along with the discharge. If this does not happen, they are removed surgically. As a rule, under general anesthesia. The standard procedure is called uterine dilation and curettage. During it, the doctor uses a gynecological speculum to gain access to the cervix, opens it and uses a vacuum device to remove the contents of the organ cavity.

It is difficult to get rid of absolutely all pathological cells. Fortunately, after surgery, in 90% of women they die off on their own.

To ensure the success of treatment, women donate blood regularly for 6 months or more to monitor the level of human chorionic gonadotropin (hCG). If at the end of this period the hormone is still present in the blood, this may indicate a relapse of the disease or the degeneration of benign growths into malignant ones. Normally, the hCG hormone is released during pregnancy. Therefore, women are asked to refrain from conceiving for six months to a year in order to avoid incorrect interpretation of the results, and in the case of incomplete removal of abnormal chorion tissue, the development of a repeat molar pregnancy.

For women who no longer plan to have children, removal of the uterus (hysterectomy) may be recommended.

Alternative treatment for hydatidiform mole

There are quite a few “grandmother’s” recipes on the Internet that supposedly help cure molar pregnancy. But none of them have proven effectiveness. The time spent on ineffective procedures may be enough to transform a benign tumor into a malignant one, which is much more difficult to treat.

Complications

In some cases, the unremoved cells do not die, but continue to multiply, forming more and more cysts (recurrent hydatidiform mole). The worst option is the transformation of the tumor into malignant choriocarcinoma. Cancer cells penetrate the tissue of the uterus, sometimes growing through it and causing internal bleeding. When tumor cells grow into blood vessels, they spread through the blood to organs and form metastases, most often in the lungs, brain or liver.

Chemotherapy is highly effective if choriocarcinoma and recurrent hydatidiform mole are detected in time. Relapse after treatment occurs in approximately 1-3% of women. It is imperative to monitor the level of hCG, since this indicator helps to notice the re-development of the disease in time and begin a course of chemotherapy in a timely manner.

Forecast

Complete cure is possible in most cases. Only 1% of women may experience a recurrence of the disease in the future. After a second molar pregnancy, the risk of developing a third is much higher - up to 15-20%.

In rare cases, benign neoplasms become malignant. But even with this option, chemotherapy leads to complete recovery in 90% of women.

Emotional complications

Subsequent pregnancies

Repeated pregnancy should be planned only after the entire period of monitoring hCG levels has been completed. In the future, a woman has a good chance of conceiving, bearing and giving birth to a healthy child. The doctor leading the pregnancy must know about previous hydatidiform moles, as well as other features of previous pregnancies. Since women who have already been diagnosed once are at a slightly higher risk of developing it, they may be recommended to have their first ultrasound scan earlier than with the standard examination regimen.

Hydatidiform mole is a benign tumor that develops in the uterine cavity as a result of fertilization of the egg, when instead of a normal embryo and placenta, numerous cysts appear in the uterus. Cysts in medicine are called blisters with fluid, and it is with the growth of such blisters in the uterine cavity that the name of this disease is associated - hydatidiform mole.

How common is hydatidiform mole?

Hydatidiform mole is detected in approximately 1 in 1000-1500 women with signs of early pregnancy.

Why does hydatidiform mole develop?

There are several known reasons for the development of hydatidiform mole, and all of them are associated with “failures” in the fertilization process. Thus, a hydatidiform mole can develop if an egg was mistakenly fertilized by two sperm at once, or if a sperm fertilized a defective egg that does not contain genetic information.

Who is at increased risk of hydatidiform mole?

• In women under 20 years of age and over 35 years of age
• In women who have already had a hydatidiform mole once
• In women who have already had an early miscarriage
• In women whose diet is poor in vitamin A

Partial and complete hydatidiform mole

There are two types of hydatidiform mole:

• Partial hydatidiform mole occurs as a result of erroneous fertilization of an egg by two sperm at once. In this case, areas of normal placenta and embryonic tissue may be found in the uterus, which, however, is deformed and non-viable.
• Complete hydatidiform mole develops when genetic information on the maternal side is missing for some reason. In this case, neither an embryo nor areas of normal placenta are found in the uterus.

Symptoms and signs of hydatidiform mole

The insidiousness of a hydatidiform mole is that at first it manifests itself as a normal early pregnancy: positive, nausea and vomiting in the morning, etc.

However, soon the woman begins to notice alarming symptoms:

• Bloody vaginal discharge similar to menstruation
• Vaginal discharge containing blood clots and areas of tissue that look like blisters
• Severe nausea and vomiting (which is often mistaken for severe toxicosis)
• Pain and discomfort in the abdominal area
• Increased sweating, cold hands and feet, rapid heartbeat, irritability

If the symptoms listed above appear, a woman should consult a gynecologist as soon as possible.

Why is hydatidiform mole dangerous?

In rare cases, a hydatidiform mole begins to behave like a malignant tumor: it grows into body tissue and can metastasize. This condition is called invasive hydatidiform mole.

It has been noted that complete hydatidiform mole more often leads to this complication: in approximately 20% of cases. With partial hydatidiform mole, this complication develops in 5% of cases.

An invasive mole may contain cancer cells. In this case, they speak of chorionepithelioma or chorionic carcinoma.

Fortunately, chorionepithelioma can be successfully treated and almost always goes away after a course of chemotherapy.

Diagnosis of hydatidiform mole

Since the first symptoms of a hydatidiform mole are very similar to the symptoms of pregnancy, a woman is often unaware of the presence of problems and consults a doctor to register her pregnancy. And already during the first gynecological examination, the gynecologist may suspect this disease.

What will the gynecologist find?

The size of the uterus during a hydatidiform mole usually does not correspond to the period of missed menstruation and exceeds the norm by several weeks. For example, a woman thinks she is pregnant and is 5 weeks pregnant, but her uterus is 8-9 weeks pregnant. Another common finding by a gynecologist during hydatidiform mole is an increase in the size of the ovaries due to the appearance of a large number of cysts in them.

What will the ultrasound show?

Ultrasound is the most reliable method for diagnosing hydatidiform mole. Using ultrasound, you can not only clarify the diagnosis, but also find out the type of disease (complete or partial hydatidiform mole). With a complete hydatidiform mole, an ultrasound will not detect either an embryo or placenta in the uterus. With partial hydatidiform mole, ultrasound reveals areas of normal placenta and embryo. The typical ultrasound appearance of a hydatidiform mole is that of many small cysts (blisters), which some doctors describe as a “blizzard.” In addition, ultrasound reveals enlarged ovaries with a large number of cysts.

Transvaginal ultrasound (through the vagina) is often used to detect hydatidiform mole in the early stages.

What will a blood test for hCG show?

A blood test for hCG during hydatidiform mole allows not only to clarify the diagnosis of hydatidiform mole, but is also used to diagnose malignant complications and to monitor the effectiveness of treatment. HCG levels during hydatidiform mole often exceed 100,000 mIU/ml (mIU/ml). A too rapid increase in hCG levels may indicate a dangerous complication of hydatidiform mole - the development of chorionepithelioma.

What other tests and examinations may be needed?

When the diagnosis of hydatidiform mole is confirmed, the woman may be prescribed additional tests: thyroid hormone test, general blood test, lung X-ray, computed tomography (CT) scan and others. All these tests are aimed at identifying possible complications of hydatidiform mole.

Treatment of hydatidiform mole

Treatment of hydatidiform mole involves removing the tumor from the uterine cavity. Most often, this procedure is called cleansing, although vacuum aspiration (“sucking out” the contents of the uterine cavity with a special instrument) is often used to remove a hydatidiform mole. Regardless of the method of removing a hydatidiform mole, this procedure is performed under general anesthesia.

The material obtained as a result of curettage of the uterus is then sent for histological examination. Histology allows you to confirm the diagnosis of hydatidiform mole and clarify its type (complete or partial).

In some cases, the doctor is unable to eliminate the tumor entirely, and then another cleaning may be necessary. This is very important, since otherwise the tumor can grow into neighboring organs and even metastasize (in this case they talk about invasive hydatidiform mole). Invasive hydatidiform mole may be indicated by spotting or bleeding during the first weeks and months after curettage.

If malignant complications of a hydatidiform mole develop, treatment with anticancer drugs (chemotherapy) may be required.

How does the hCG level change after curettage of a hydatidiform mole?

The level of hCG in the blood is an important indicator to make sure that the treatment for hydatidiform mole was effective and your health is no longer in danger.

Normally, after treatment for a hydatidiform mole, the hCG level begins to decrease, reaching normal values ​​(typical for non-pregnant women) within 8-12 weeks.

If after curettage the hCG level remains the same or continues to increase, the woman requires further diagnosis and treatment.

What happens after treatment for hydatidiform mole?

Over the next few months after curettage, you will need close supervision by your doctor. You will have to regularly take blood tests for hCG (initially once a week, then a little less frequently), undergo an ultrasound of the pelvic organs and visit a gynecologist for preventive examinations.

Planning pregnancy after hydatidiform mole

Fortunately, having experienced a hydatidiform mole does not reduce the chances of a successful pregnancy and the birth of a healthy child in the future. However, after treatment for hydatidiform mole, gynecologists recommend waiting a little while planning a pregnancy.

You can resume trying to conceive no earlier than 6 months after your hCG levels have returned to normal. If chemotherapy was used to treat a hydatidiform mole, it is recommended to postpone pregnancy planning for 12 months.

In order to avoid getting pregnant during the period of recovery of the body, it is recommended to use. Birth control pills also increase the risk of complications from hydatidiform moles and are therefore not recommended.

Hydatidiform mole, 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 pregnancy, although it is quite rare. On average, based on statistical data, such a pathology is recorded in 1 case per 1000 pregnancies.

Epidemiology

The prevalence of this disease varies by 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 Russian Federation, the pathology is diagnosed in one case in every 820-3000 pregnancies.

Separately, we should highlight chorionepitonlioma, which is diagnosed in 2 cases per 100,000 births.

Types of hydatidiform mole

Hydatidiform mole should be understood as a pathology of the fertilized egg (chorion), which during development should transform into the placenta. The villous membrane of the embryo or chorion undergoes a transformation, during which the villi degenerate into cysts (grape-shaped formations), which in size range from lentils to grapes and resemble grape bunches in 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, and therefore can develop during pregnancy, after childbirth, miscarriage or medical abortion. It is also possible to develop a hydatidiform mole due to the presence of a tubal (ectopic) pregnancy.

It is customary to distinguish several types of hydatidiform mole:

Depending on the area of ​​damage to the ovum:

partial, or incomplete, hydatidiform mole;

complete hydatidiform mole.

Depending on the histological structure of the pathology:

chorionic carcinoma;

invasive or destructive;

a simple form of hydatidiform mole.

Based on the international classification of 1992 (Singapore), if the disease has a malignant course, here we are talking about invasive hydatidiform mole; it is customary to determine its stage:

stage zero – hydatidiform mole with high or low risk (0B or 0A);

first stage – the tumor is located within the uterus;

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 hydatidiform mole

With the development of the disease in the first 12 weeks of gestation, degeneration of all primary villi of the fetal egg occurs, and pronounced hyperplasia is present in the trophoblast layers, so it is worth talking about the presence of a full form of pathology. Some patients call this form of pathology early hydatidiform mole (this is explained by the timing of its occurrence). Morphologically, this type of disease is characterized by:

proliferation of trophoblasts that line the villi from the inside;

the villi are enlarged (widened) and swollen;

the epithelium of chorionic villi has either undergone dystrophic changes or is not determined;

there are no blood vessels in the villi;

the embryo is absent (dissolves).

The occurrence of the disease at later stages of gestation (from 3 months to 34 weeks inclusive) and the degeneration of only part of the chorionic villi is known as incomplete hydatidiform mole. In this case, intact villi have a normal appearance, vascularization and blood supply are preserved. 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 pathology develops in one of the placentas, the second can remain in normal appearance and functionality.

Invasive hydatidiform mole can occur both in the presence of complete (most often) and in the presence of partial. Distinctive features are:

villi, growing through the serous cover of the uterus and myometrium, penetrate the blood vessels and lymphatic network, thus spreading throughout the body and affecting internal organs;

the trophoblast hyperplasias, but retains the placental structure of the villi;

the 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 development of the disease is the presence of a pathological set of chromosomes in 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 the maternal chromosomes and the paternal haploid genome is doubled. However, it is possible for an initially empty egg to be fertilized by two sperm at the same time; this leads to the appearance of a 46XX or 46 XY karyotype. As a result, the embryo dies in the early stages of development, before the formation of placental blood circulation begins, while the chorionic villi continue to grow and develop.

The incomplete form of the pathology is caused by triplody - 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 69ХУУ, 69ХХХ, 69ХХУ chromosomes. In such cases, the embryo dies at the 10th week of pregnancy due to multiple developmental anomalies, but in very rare cases the development of a viable fetus is possible.

The reasons that lead to hydatidiform mole have not been determined to this day, however, there are a number of theories that can explain the occurrence of chromosomal abnormalities after the egg is fertilized:

lack of protein - when there is a deficiency, there is a shortage of genes in the chromosome of the fertilized egg;

enzymatic theory - based on an increase in the level of the enzyme hyaluronidase, which is capable of dissolving vascular walls;

immunological theory - the embryo and subsequently the fetus are antigens to the female body, therefore, in the presence of an insufficiently expressed immune response, degeneration of the chorionic villi occurs, when normally a miscarriage should occur;

decidual theory - the development of endometritis in the decidua, which subsequently leads to the degeneration of chorionic villi;

damage to the egg located in the ovary - maturation of an inferior egg in the follicle;

viral theory (viruses, including toxoplasmosis, damage sets of chromosomes of both the father and mother).

Factors that increase the likelihood of disease:

consanguineous marriages;

thyrotoxicosis;

malnutrition (vitamin A deficiency, animal protein deficiency);

weakened immune system;

repeated miscarriages and abortions;

numerous births;

age (pregnant women under 18 or over 40 years old).

Clinical picture of the pathology

Symptoms of the disease are not always clearly expressed in the early stages. A woman feels that she is pregnant because signs of early toxicosis appear, the pregnancy test is positive and there is a delay in menstruation. Quite often, pathology is discovered accidentally during a medical abortion.

A characteristic feature is early toxicosis, which is very severe 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 gestosis. Swelling occurs, blood pressure rises, and when examining urine, the presence of a large amount of protein of fetal origin is noted. Eclampsia can develop as early as 3-4 months of gestation. Preeclampsia is more typical for the full form of the pathology and develops in the presence of a significant size of the uterus and a high level of beta-subunits of hCG 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.

Hydatidiform mole is indicated by such signs as periodic bleeding from the vagina, which is present in 90-100% of cases, as well as the size of the uterus, which exceeds the expected gestational age. Uterine bleeding most often occurs early and is disguised as spontaneous abortion. In some cases, the appearance of spotting coincides 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 bubbles characteristic of the disease in the discharge.

If germination of the villi of the serous membrane (destroying hydatidiform mole) and the myometrium of the uterus develops, intra-abdominal bleeding may occur with symptoms of an acute abdomen. Invasive forms of pathology are dangerous due to the risk of developing profuse bleeding, which requires emergency hospitalization.

Prolonged and massive bleeding leads to the development of anemia in the patient with a risk of death.

In 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 mole. Most often, the disappearance of metastases occurs spontaneously, after removal of the pathological focus, but 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 region and lower abdomen. The nature and intensity of pain varies, and the manifestation of pain is often a precursor to bleeding. Pressing, dull or aching pain occurs due to the growth of the uterine walls into the serous layer 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 thecallutein cysts or the occurrence of intra-abdominal bleeding.

In 7% of patients with the full form of the pathology, thyrotoxicosis develops, 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 thyroid-stimulating receptors.

In the presence of a complete hydatidiform mole, embolism (blockage) of the branches of the pulmonary artery and respiratory failure may occur (about 2% of cases). This complication is characterized by chest pain, shortness of breath, tachypnea and tachycardia, cough and cyanosis. Scattered wheezing is heard, and X-ray examination of the lungs reveals the presence of bilateral focal darkening.

Diagnostics

This disease requires differential diagnosis with multiple pregnancy, acute polyhydramnios, pregnancy in the presence of fibroids, ectopic pregnancy and spontaneous abortion.

After collecting complaints and medical history, 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 palpable (in case of ovarian enlargement over 6 cm), which arise during the first two weeks and are considered unfavorable signs for the prognosis of pathology;

heterogeneous structure of the uterus: with general softening, nodular compactions are determined;

the size of the uterus does not correspond to the size of the expected period of pregnancy (exceeds).

In the presence of a large abdomen, the most reliable signs of pregnancy (palpation of large parts of the baby, heartbeat) are not determined.

Additional research methods include:

histological method - allows you to determine the morphological type of the disease (the material is obtained by scraping from the uterine cavity);

immunochemical method - consists of determining trophoblast β-globulin in the blood. In the presence of pathology, the level is 76-93%;

test for the level of hCG in the blood - in the absence of pregnancy, there is no hCG in the woman’s blood. During pregnancy, it appears in the blood on the eighth day from the moment of conception, and a peak of 5000-10000 units occurs on the 60th day. If hCG levels are high after week 12, hydatidiform mole should be suspected;

diagnostic hysteroscopy, laparoscopy – performed if necessary;

hysterosalpingography – used to clarify the diagnosis and monitor the effect of chemotherapy. In the invasive form, the hysterogram determines the contour penetration of the contrast agent in the zone of penetration into the myometrium of the villi;

X-ray examination of the chest - to detect metastases in the lungs;

ultrasound examination - the significant size of the uterus is determined against the background of the absence of a fetus or embryo; a characteristic sign is the presence of homogeneous fine-grained tissue, luteal cysts. The diagnostic value of ultrasound is 100%.

Treatment

In the presence of a hydatidiform mole, therapy consists of removing the pathology, which is performed using the following methods:

extription 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 main pathology);

induction 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 minor cesarean section with further curettage of the uterine cavity is required);

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, uterine contractions, cold applied to the lower abdomen and antibiotics are indicated. After the pathology has been eliminated, the patient is discharged with mandatory follow-up at the antenatal clinic.

The second stage of therapy consists of treatment with chemotherapy drugs. Indications for its use are:

prolonged level or increase in hCG titer;

detection of metastases during removal of a hydatidiform 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 source 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 treatment of the pathology, doctors recommend protecting against pregnancy for one year after hCG disappears in the urine and blood. It is best to use oral combined contraceptives, but protection using barrier agents is also possible. Insertion of an intrauterine device is not recommended due to the high risk of uterine perforation.

What does clinical observation consist of and how long does it last?

After the removal of the hydatidiform mole, it takes about 73 days for hCG to completely disappear. The observation is:

MRI of the brain for 2 years with a frequency of 6 months, in case of detection of cerebral metastases;

annual chest x-ray;

Ultrasound of the pelvic organs every two weeks until remission occurs, and then quarterly;

weekly determination of hCG levels in the blood until 2 negative results are obtained;

monthly determination of hCG levels for six months, then every 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, pregnancy is allowed a year after treatment and normalization of hCG; if there was an invasive form with chemotherapy, you can plan a pregnancy after 2 years.

Why is this pathology dangerous?

In 29% of patients after treatment, infertility occurs, in 14% of cases amenorrhea develops, and in 4% of women the process becomes malignant. Pregnancy that occurs earlier than 2 years after chemotherapy is dangerous due to the high risk of chromosomal mutations and fetal development abnormalities. Complications may also develop during childbirth: abnormalities in labor, bleeding.

What is the prognosis after treatment?

Modern methods of therapy can achieve 100% cure, in 90% of cases it is possible to restore the menstrual cycle. 70-80% of patients manage to become pregnant and carry a healthy baby.