Molar Pregnancy vs. Hydropic Degeneration
Saturday, December 15, 2007
Kenneth F. Trofatter, Jr., MD, PhD
• At Wed Dec 05, 08:20:00 AM 2007, Daisy said…
On Nov 5th, I suffered a missed miscarriage at 11wks 5days which required an emergency D&C due to a suspected molar pregnancy. This is my 1st pregnancy. I am 36years old, have regular 28 day cycles, periods that last 4 days with medium flow, and nothing significant to note other than 5 sisters - all very very fertile.
Besides the obvious shock at facing what I was told at the early pregnancy clinic, I now want to ensure I understand what the histology report says. The histology report results presented "no atypical features", but there are things I do not understand.
The clinical details: "Missed abortion @ 10/40. No foetal pole on ultrasound scan. ??Hydropic changes seen on scan."
The macroscopic report reads: "a bulky amount of haemorrhagic products, 70x40x20mm's. No membranes seen. No foetal tissue seen."
The Microscopic report reads: Chorionic villi, inflamed and degenerate decidua, blood and fibrin, in keeping with retained products of conception. No atypical features seen"
Can you tell me in plain english what this means? We desperately want to have a baby and I'm concerned about maximising my success rates given the gynaecological challenges I could face at my age.
Thank you for any help.
•
At Thu Dec 13, 02:31:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…
Hi Daisy, sorry for your loss. From what you describe, you had a 'blighted pregnancy' that did not get past the very early stages of embryonic development, although the placental tissues continued to grow for awhile (which is not all unusual) and make pregnancy hormone (hCG) so that your body did not know the baby did not make it.
It is very unlikely that you actually had a 'molar pregnancy', although that is what your doctors were concerned about based on the ultrasound findings prior to your D&C. Hydropic degeneration (enlarged, fluid-filled, balloon-like) of the placental villi is characteristic of molar pregnancies, but also of pregnancies undergoing spontaneous abortion if it has been awhile from the time the baby was lost to the time of miscarriage or if the baby is chromosomally abnormal. First pregnancies have a high rate of miscarriage for reasons I have detailed in my posts, but at your age, there is also a greater chance that the baby had a chromosomal abnormality. These are not uncommon and most babies with aneuploidy are lost in the first trimester.
Your pathology report is not unusual under these circumstances - you had blood clot and the placental tissues were inflamed. The latter does NOT mean you lost this pregnancy as the result of an infection. It simply means that your immune system was reacting to the pregnancy tissues - that might be a good sign and increase your chance for success with a subsequent pregnancy.
True molar pregnancies occur in about 1 in 1000 to 1 in 1500 pregnancies. They are more common in very young women under the age of 15 and in women over the age of 40. Complete molar pregnancies usually result from a sperm fertilizing an egg in which the maternal chromosomes are either inactivated or lost. Occasionally, this results from two sperm fertizing the egg simultaneously. In most cases the maternal chromosomes do remain so the pregnancy tissues end up with three sets of chromosomes (a total of 69 chromosomes rather than the normal 46). No baby or fetal membranes develop in these situations, just the placental tissues. The placental villi may grow at a very fast rate and eventually become 'hydropic.' The uterus is usually enlarged for the gestational age expected for the pregnancy and the ultrasound appearance of the abnormal placental tissues is that of multiple small cysts, giving the classic 'grape-like appearance' of a molar pregnancy. Partial molar pregnancies in which there is an embryo, but also molar changes in the placental tissues can also occur, but these are less common.
Molar pregnancies can be accompanied by heavy bleeeding, very high levels of the pregnancy hormone (hCG), severe nausea and vomiting, hypertension (preeeclampsia-like, but prior to 20 weeks), abdominal pain/cramping and occaionally very large multicystic ovaries (theca lutein cysts) resulting from stimulation by the high levels of hCG. Women can have signs and symptoms of hyperthyroidism as well.
The primary concern of your doctors related to the possibility of a molar pregnancy is that as many as 20% can turn into choriocarcinoma (whereas simple hydropic degneration of placental tissues in a blighted pregnancy does not). Choriocarcinoma can be a very serious and rapidly progressing cancer, but today, almost all cases are entirely treatable if caught early enough. If a molar pregnancy is confirmed on the pregnancy tissues, we usually recommend serial measurements of hCG for at least six months (and in some cases a year) and also recommend that you do not get pregnant over that same time period. That will confuse the opportunity to make the diagnosis of choriocarcinoma and could delay early therapy. Women who have had a molar pregnancy are at increased risk (about 1%) for that to happen again.
Anyway, Daisy, I know you are sad over the loss of your pregnancy, but it appears you did not have a molar pregnancy - and that is good news. Once you have had a chance to recover, it should be safe to try again in a short period of time. Because of youir age, and this recent loss, I would recommend that when you do get to the latter part of the first trimester, you have 'combined first trimester risk assessment for aneuploidy' because you are at greater risk for having a baby with a chromosomal abnormality - but remember the odds are still in your favor that you will not!
Hope this helped. Thanks for reading and good luck to you!
Dr T
Labels: early miscarriage, hydropic placenta, molar pregnancy
17 Comments:
At Mon Dec 17, 01:58:00 PM 2007,
Anonymous said…
Dr. Trofatter,
I realize that that this comment has nothing to do with the original post. However, I thought it was the best way to reach you. I just received my First Trimester Screening Report and due to a free beta HCG level of 5.14 MoM (99.9 percentile), I have been given a risk of 1 in 135. I am 33. My PAAP-A was .89 MoM (50%). The internet is a dangerous place, but this HCG level seems ridiculously high and I am obviously concerned. I am scheduled for an amnio in your office. Are there any other causes for such a high HCG other than Down's? I have a subchorionic hemmorhage. Could this affect the results? You may remember me. I mentioned that I read your blog.
At Mon Dec 17, 02:00:00 PM 2007,
Anonymous said…
Dr. Trofatter,
I realize that that this comment has nothing to do with the original post. However, I thought it was the best way to reach you. I just received my First Trimester Screening Report and due to a free beta HCG level of 5.14 MoM (99.9 percentile), I have been given a risk of 1 in 135. I am 33. My PAAP-A was .89 MoM (50%). The internet is a dangerous place, but this HCG level seems ridiculously high and I am obviously concerned. I am scheduled for an amnio in your office. Are there any other causes for such a high HCG other than Down's? I have a subchorionic hemmorhage. Could this affect the results? You may remember me. I mentioned that I read your blog.
At Thu Dec 20, 03:57:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Dec 17: Just got your comment yesterday. Sorry for the delay. That is a high hCG and by itself does increase your risk for Down syndrome, but whenever there is bleeding early in pregnancy, I find it hard to trust the maternal serum screening results. The bleeding could be related to an abnormality of placentation that either increases the amount of hCG being produced or the amount that is getting into your blood stream (or both). Partial molar pregnancies can be associated with both bleeding and high levels of hCG as well. So, I think the best thing to do is to proceed with the amniocentesis to answer the question once and for all if the baby is chromosomally normal. I do remember you and thanks so much for reading! I will be pulling for you over the next several weeks! Dr T
At Tue Jan 15, 09:50:00 AM 2008,
Anonymous said…
After having 3 healthy pregnancies & deliveries, I too recently had a miscarriage (8 wks 3days) and had to have a D&C. Yesterday, at my 2 week check up, my dr tells me that the tissue sample showed signs of hydropic degeneration. I've read a lot about this occuring in molar pregnancies, but, due to having a Sonogram a few days prior, I know that the baby was implanted, normal size and had a healthy heart rate. What does this mean?
At Wed Jan 16, 08:54:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Jan 15: It is probably nothing to worry about. The pregnancy you lost was probably chromosomally abnormal and it is not unusual to see "hydropic degeneration" of the placental villi under those circumstances. It does not sound like a 'molar pregnancy'. Sorry for your loss and thank you for writing. Dr T
At Tue Apr 01, 06:34:00 PM 2008,
Anonymous said…
At 12 weeks pregnant, I went for my 1st trimester screening. It did not turn out well. They noted an abnormal amount of fluid behind the baby's neck and that the intestines and other organs were growing outside of the body. The heart rate was 85. I met with the doc. the day after and by then the heartbeat had stopped. He confirmed the abnormal amount of fluid behind the neck and the organs growing outside of the body. He mentioned it could possibly be Trisomy 13. However, I spoke to my regular ob today and he informed me that the pathology report came back "normal". Does this sound right?How could that be when there were the anomalies found at the 1st trimester screening? What does a normal pathology report mean?
At Thu Apr 03, 01:34:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Apr 1: Did the pathology report come back normal or did the fetal chromosome studies come back normal. The reason I am asking is that babies can have perfectly normal chromosomes and still have major malformations related to many different causes or syndromic problems. The latter are genetic defects often found in babies that have the correct number of chromosomes. It is important to sort this out for purposes of counseling you for future pregnancies. I suggest that you have your doctor get you in touch with a genetic counselor who can pull all the information and explain it to you in a straightforward manner. He/she will be in the best position to counsel you regarding future pregnancy risks based on that information. Incidentally, if the baby did have multiple organs outside the body, then the most common reason for that in early pregnancy is a condition called amniotic band syndrome. Ask your doctor to explain that to you or if you need more details, perhaps get back to me with your questions. Sorry for your loss and best wishes for the future. Dr T
At Fri Apr 04, 08:19:00 PM 2008,
Anonymous said…
Dear Dr. Trofatter,
My wife is scheduled for a D&C in 4 days for Molar Pregnancy. This will be her 7th week. Her Beta HCG has been increasing by 25,000 every 2 days, and is currently at 66,000. At this rate, her level will be well over 100,000 on the day of the procedure. What is her risk of developing choriocarcinoma? Is it still 20% as written in various articles? Is it critical for her to have the D&C earlier? She is 41 years old and has had 2 prior miscarriages within the past 2 years. Also, do you know any physicians in the Orange County, California area that have significant experience with Molar Pregnancy for her follow up care?
Thank you for your help.
At Mon Apr 07, 04:59:00 PM 2008,
Anonymous said…
Dr. Trofatter
My husband posted the question regarding my molar pregnancy. I am the patient, 41 y/o G4 P1, M/C x 2 in the last 2 years. My HCG was 44,000 on 4/2 and increased to 66,000 on 4/4. I have not had any HCG level checked since, but I assume it is above 100,000 by now, based on the constant nausea and other symptoms. The U/S showed classic snowstorm appearance with no identifiable fetal pole. Based on LMP, I am currently 7weeks. Do you usually recommend following HCG starting post op day 1 as a reference? Do you recommend using a lab that use immunoassay that detects hyperglycosylated hCG and nicked free beta-subunit? I understand that currently used immunoassays for HCG are not approved for use as a tumor marker (as in PGTD or choriocarcinoma). Based on the literature review, Siemens Immulite (formerly DPC Immulite) is considered the best assay with low to no false positive or negative results. However, the Labs which uses DPC Immulite both say that it is not indicated for use as a tumor marker.
I would greatly appreciate your input on 1) when to start checking HCG measurement post op. 2)HCG assay. Thank you very much. Shelly
At Mon Apr 07, 06:14:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 4: I am afraid the risk is about 20% and it doesn't much matter with regard to the timing of the D&C. Most OB/GYNs are quite comfortable following up a woman who has had a true molar pregnancy or they have a specialist in GYN Oncology to whom they regularly refer. Ask your wife's doctor about the plans for follow-up in detail andinclude your own questions about her/his comfort level under the circumstances. Good luck and I hope things turn out well. Thanks for reading! Dr T
At Tue Apr 08, 06:49:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Shelly: I must admit, I do not know the most recent information. But, I have never seen where the sensitive quantitative hCG assays used in most commercial laboratories couldn't be used for the routine follow-up of a molar pregnancy after evacuation. They may not be adequate for the follow-up of choriocarcinoma, but again, you will need to discuss that with a GYN Oncologist if and (hopefully not) when that need arises.
Although specific regimens vary, the most common ones involve immediate pre-and post-evacuation levels and then weekly until undetectable levels are reached. Follow-up after that is usually on a monthly basis to complete a year, although some current regimens shorten this period. The longer it takes for the hCG levels to be undetectable, the greater the likelihood of gestational trophoblastic neoplasia (GTN) or choriocarcinoma. In a study by Wolfberg and colleagues (Obstet Gynecol 2006;106:548-52), when levels fell below 50 mIU/mL anytime during follow-up, there is only a 1.1% chance of GTN, whereas if they were greater than 2000 mIU/mL at 4 weeks post-evacuation, that risk increased to more than 60%. The bottomline is that after levels become undetectable the risk of developing GTN is very low.
Anyway, we wish you luck with your evacuation procedure and especially during the follow-up period. If there are any real experts out there who are in a better position to address this issue, please feel free to write!
Dr T
At Tue Apr 08, 11:59:00 PM 2008,
Anonymous said…
Dr. Trofatter
Thank you very much for answering my questions. I had D&C. I am confused at a few things and want to clarify a couple of things.
My u/s at 5 weeks showed no fetal pole, just a clump of tissue. This was never reviewed by a radiologist. HCG was not checked at that time. At 6 weeks and 5 days, u/s showed a "cotton ball" shape, which had grown in size from the previous week, but no fetal pole. Again, this was never reviewed by a radiologist. The physician didn't know what it was but said that it didn't look normal and "could" be a molar pregnancy. My HCG on the same day was 44,000 which went up to 66,000 two days later. I continued to have constant nausea and extreme breast tenderness during this whole entire "pregnancy" but never had any bleeding. When I asked to have my HCG checked 48 hours post evacuation as a baseline, she said that there was no need to check until the pathology report came back and told me to follow up with her in 2 weeks. When I asked to treat my case as a molar pregnancy until proven otherwise, she told me not to worry about it because this could well be a missed abortion or "bad pregnancy where the fetus didn't grow." I simply don't understand how this could be a miscarriage when my HCG was very high (or at least high normal) and rising with no fetal pole. Even if it was a blighted ovum, you would not expect my HCG to be that high and continue to rise by 10,000/day. Based on my extensive literature review over the last few days, I learned that molar pregnancy can be diagnosed by u/s and HCGs. As your answer, I also found out that the HCG levels are checked 1-2 days post evacuation and weekly thereafter + baseline CXR. My follow up plan seems different from everything I've read so far. I understand that everyone has different styles of practices. I just want to know that if this is within the standard of practice so that I will be at peace and stop wondering. I'd greatly appreciate your input. Thank you very much for reading this long mail. Shelly
At Fri Apr 11, 06:28:00 PM 2008,
Anonymous said…
Dr. Trofatter -
I am 41 yrs old, and recently miscarried. I was 8 wks pregnant when I went in for the first U/S. They found no heartbeat at that time, and my HcG levels were 14,000. They performed a D & C several days later. I bled heavily after the D&C - about 2 weeks - with clots. I'm now being told that they found "abnormal tissue" with the fetal tissue, and I continue to show HcG levels in my blood work. My MD has asked me to return for the third week in a row for another HcG test. Should I be concerned this is a molar pregnancy?
At Tue Apr 15, 04:48:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Shelly Apr 8: Sorry I did not see you post before I left town for a few days. Sooner or later, you should ask your doctor for a second opinion with a Gynecologic Oncologist or make the phone call yourself. The pathology needs to be carefully reviewed and an action plan put into place if your hCG does not drop to negative in a timely fashion. Dr T
At Tue Apr 15, 04:52:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 11: Your doctors ARE concerned that this was a molar pregnancy, but the odds are that they are having a hard time differentiating 'hydropic degeneration' of an abnormal pregnancy from a true molar pregnancy. Regardless, the best thing to do is to follow the hCG levels until they are negative. Once they are, you are at very low risk for complications related to choriocarcinoma (gestational trophoblastic neoplasia). Good luck and thanks for reading! Dr T
At Tue May 27, 01:07:00 PM 2008,
Anonymous said…
I need some help i recently lost my brother on november 17 of last year,my sister in law has just found out shes pregnant the doctor told her the pregnancy lay dormant for six weeks and that shes now five and a half months gone and that the baby is my brothers she says shes due at the beginning of october,is this possible?please help if you can i am at my wits end with worry is this a miracle?
At Wed May 28, 04:42:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 27: Anything is possible....Dr T
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