Introduction
Vesicular mole is the premalignant form of GTN. Division into complete and partial mole is according to the degree of tissue changes and to presence or absence of a fetus/embryonic tissue elements. Complete hydatidiform moles have more clinical importance due to high chance of persistence or its progression to choriocarcinoma. Fifteen to twenty percent of complete moles while less than five percent of partial mole will develop into gestational trophoblastic neoplasia.1, 2, 3
There is a geographic variation in the incidence of molar pregnancy with a higher incidence indeveloping countries and in women at extremes of age i. e. women who are younger than 20 years or women who are older than 40 years of age. It is also a higher in nulliparous women, and in women of low economic status. The incidence is greater in those women whose diets are deficient in various nutrients such as protein, folic acid, as well as carotene. 1, 4, 5, 6, 7, 8
The prior failed pregnancy also increases incidence of GTD along with maternal age. The elective abortion and miscarriage is associated with the rise in VM pregnancy.
GTD is group of disorders which could convert to Gestational Trophoblastic Neoplasia (GTN). Most common (>50%) cause of GTN is Vesicular mole. 2, 3, 4, 5, 6, 7, 8, 9 The prevention of VM, early diagnosis and also follow up is of utmost importance to save the life of mother. 2, 5
According to the RCOG guidelines the mode of treatment in suspected complete vesicular mole should be suction and evacuation while that in partial molar pregnancy should be medical termination. This is because the fetal parts usually present as an obstacle to suction and evacuation. VM is of clinical as well as an epidemiological interest because of its significant impact on women's health. It was found that 15% of VM can complicate into invasive mole leading to persistent bleeding per vagina, rupture of the uterus and choriocarcinoma. 1, 4
The aim of the study is to determine incidence, outcomes and complications of VM at SKNMC hospital.
Materials and Methods
The present study is an observational, retrospective study carried out at our tertiary care centre over a period of 5yrs from August 2015 to August 2020. It was started after the approval from our institutional committee.
The study population included all confirmed cases of vesicular mole who presented at our tertiary care centre. 34 cases that had fulfilled the inclusion criteria were chosen as the study population.
Data was collected over a period of 5yrs. For retrospective cases, indoor papers were retrieved from the medical record department; data was recorded and entered in the case record forms for analysis. Waiver of consent was applied for retrospective cases. For prospective cases, indoor patients were enrolled and their records were analyzed until discharge from tertiary care centre.
Exclusion criteria
Confirmed cases of vesicular mole operated outside and referred to our tertiary care centre.
Patient not consenting to being a part of the study.
This was a retro-prospective observational study and collected data was compiled in a master chart, analysed and outcomes of different variables under study have been expressed in the form of mean, frequencies, percentages and charts.
Results
There were total 34 cases of VM pregnancies during the study period that were diagnosed with a histological confirmation and treated in the hospital. The number of deliveries during the period of study was 19098. We found the incidence of 0.17% or 1 in 561of the total delivered patients.
The patient’s age ranged from 18 to 40 years with a mean of 25.4±5 years. VM occurred more in the age group 16-25 years, was lowest in age group 31-35yrs i.e zero cases.Figure 1
The parity distribution of the patient ranges from 0 to 4. V mole is most common in nulliparous women constituted 65%.
The mean gestational age of the patients at presentation was 9.4 week, with a range of 7 to 17 weeks. 30 out of 34 (88%) patients were diagnosed during 1st trimester.(Table 2 )
Table 1
Clinical manifestation of the patient
Vaginal bleeding occurred in 19 (56%) cases, hyperemesis gravidarum in 10 (29%) cases and anemia in 13 (38%) cases. The disparity between uterine size and period of gestation was seen in 10 (29%) cases and ovarian enlargement in 10 (29%) cases. 4 (12%) patients developed preeclampsia.(Table 1)
Hemorrhage after suction and evacuation was seen in 26% cases needing intra and post operative blood transfusion. 6% patients developed thyrotoxicosis. During follow up invasive mole was diagnosed in 2 (6%) cases based on persistently high β hCG levels after suction evacuation and pelvic ultrasound. 1 patient (3%) developed choriocarcinoma and died within 6 months after hysterectomy.(Figure 3)
Table 2
Chemotherapy (According to FIGO 2000 GTN Scoring system)
|
Single drug therapy |
3 (9%) |
|
Multiple drugs |
2(5%) |
3 Women with score ≤ 6 were treated with single drug methotrexate and folinic acid on alternate day. 2 women with score ≥ 7 were treated with methotrexate and actinomycin. The incidence of patient needing chemotherapy is 14%.(Table 2)
Discussion
In our study the incidence of VM is 0.17% or 1 in 561 deliveries. It varies according to geographical region1, 2, 3, 7, 8, 10 and is more in developing countries. The incidence is higher than UK 1/714 and non-Asian countries 1/752 but lower than other Asian countries 1/387.
VM was most common among nulliparous women almost 65% in our study. This finding is similar with the study of Aghajanian P. 3 The mean age at the time of presentation was 25.4±5 years which is similar to the study of Anyanwu M, Bah K. 5
In the study more than 88% of the VM patients were diagnosed during 1st trimester. The mean gestation age was 9.4 weeks. This finding is similar to the studies of Olivier M1 and Aghajanian P. 3 More number of patients were identified due to routine first trimester ultrasonography, even though they were asymptomatic at the time of diagnosis. 1, 3 This signifies the role of an early ultrasound.
The most common clinical manifestation of VM is abnormal vaginal bleeding besides amenorrhea which occurred in 56% of cases. This agrees with the studies of Oliver M 1 and A. Igwebe. 11 Abnormal vaginal bleeding is most common sign of molar pregnancies. 5, 12 In 29% of case the uterine size was larger than gestational age.
The commonest complication in the study was haemorrhage seen in 26% of patients, needing blood transfusion.
The incidence of pre-eclmpsia is variable with rates as high as 20% in some studies. In our study it was 12% which correspondence with the studies of Aghajanian 3 and Igwegbe A. 11 Aghajanian observed that pre-eclampsia in the first trimester or early second trimester – an unusual finding in normal pregnancy – is pathognomonic for hydatidiform mole 3
Hyperthyroidism was detected in 6% of cases which was similar to the study of Igwegbe A. 11 This is due to the stimulation of thyrotropin receptors by hCG. 2 Hyperthyroidism in the molar pregnancies is asymptomatic as it is usually sub-clinical.
Suction and evacuation was done in all the cases. 5 patients (14%) needed post-evacuation chemotherapy. There was rise in hCG after evacuation leading to invasive mole in 2 patients and choriocarcinoma 1 patient. Prophylactic chemotherapy following complete molar pregnancy in all patients is still controversial. According to Green top guidelines no 38 and New Zealand GTD guidelines 2018 prophylactic chemotherapy is not recommended. 12 According to some studies3, 13, 12, 10, 14, 15, 16, 17 the risk of GTD in patients with molar pregnancy was decreased if treated with prophylactic chemotherapy after surgery. However, serial hCG monitoring is still needed as prophylactic chemotherapy does not drop the risk to zero. The patients who received prophylaxis chemotherapy need more chemotherapy if their disease recurs. 12
Most of the patients 88% accepted contraception. A barrier contraceptive was used by most of the patients. 11 Following evacuation, contraceptive is recommended to avoid pregnancy for 12 months. It minimizes any deleterious effects on the developing oocytes. It also avoids the confusion of disease relapse from hCG produced in pregnancy. 11, 12, 10, 18, 19
The post treatment follow up should be for 6 months from the date of evacuation or from normalistion of the hCG level. 12 Unfortunately, the follow up in most 63.4% of the patients was for less than 5 months 11 and only 30.2% cases had follow up up for 7 months.
The case fatality rate in our study is 2.9%. The death occurred in a patient who developed choriocarcinoma 6 months after suction and evacuation. The patient did not have regular follow up and came with vaginal bleeding. The patient died within 2 months after hysterectomy and chemotherapy.
A major limitation of the study is that the incidence of outcome of subsequent pregnancies after complete treatment in patient with prior molar pregnancies was not studied.
