History

Complete mole

The typical clinical presentation of complete molar pregnancies has changed with the advent of high-resolution ultrasonography. Most moles are now diagnosed in the first trimester before the onset of the classic signs and symptoms.^{[30, 31, 32]}

Vaginal bleeding

The most common classic symptom of a complete mole is vaginal bleeding. Molar tissue separates from the decidua, causing bleeding. The uterus may become distended by large amounts of blood, and dark fluid may leak into the vagina. This symptom occurs in 50% of cases.

Hyperemesis

Patients may also report severe nausea and vomiting. This is due to extremely high levels of human chorionic gonadotropin (hCG). This is reported to occur in 4% of patients diagnosed at 5-9 weeks of gestation, and in 23% when the diagnosis is made after 10 weeks' gestation.

Hyperthyroidism

Signs and symptoms of hyperthyroidism can be present due to stimulation of the thyroid gland by the high levels of circulating hCG or by a thyroid stimulating substance (ie, thyrotropin) produced by the trophoblasts.^[33] Clinical hyperthyroidism has been reported in 3.7% of women with a hydatidiform mole diagnosed after the 10th week of gestation.

Partial mole

Patients with partial mole do not have the same clinical features as those with complete mole. These patients usually present with signs and symptoms consistent with an incomplete or missed abortion, including vaginal bleeding and absence of fetal heart tones.

In a retrospective study (1994-2013) at a Brazilian trophoblastic disease center, investigators evaluated the clinical presentations and incidence of postmolar gestational trophoblastic neoplasia (GTN) among 355 women with complete mole (n =186) or partial mole (n = 169), with the following findings^[34]:

Risk of vaginal bleeding, biochemical hyperthyroidism, anemia, uterine size larger than dates, and hyperemesis: Reduced risk in women with partial mole
Preevacuation serum hCG levels: Lower in women with partial mole
Median gestational age at evacuation: complete mole, 9 weeks; partial mole, 12 weeks
Development of GTN: women with complete mole, 17.7%; women with partial mole, 4.1%

Those with complete mole were diagnosed more commonly before evacuation than women with partial mole because they presented more often with signs/symptoms of molar disease.^[34]

Complete mole

Note the following:

Size inconsistent with gestational age: A uterine enlargement greater than expected for gestational age is a classic sign of a complete mole. Unexpected enlargement is caused by excessive trophoblastic growth and retained blood. However, patients also present with size appropriate or smaller than expected for the gestational age.
Preeclampsia: Pelvic ultrasonography has resulted in the early diagnosis of most cases of hydatidiform mole and preeclampsia is seen in less than 2% of cases.^[31]
Theca lutein cysts: These are ovarian cysts greater than 6 cm in diameter and accompanying ovarian enlargement. These cysts are not usually palpated on bimanual examination but are identified by ultrasonography. Patients may report pressure or pelvic pain. Because of the increased ovarian size, torsion is a risk. These cysts develop in response to high levels of beta-hCG. They are reported in 11% of cases diagnosed at longer than10-weeks' gestational age. The cysts spontaneously regress after the mole is evacuated, but it may take up to 12 weeks for complete regression.

Theca lutein cysts.
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Complete mole.
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Complete mole with an area of clot near cervix consistent with bleeding.
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Partial mole

Uterine enlargement and preeclampsia is reported in only 5% of patients.^[35] Theca lutein cysts, hyperemesis, and hyperthyroidism are extremely rare.

Twinning

Twinning with a complete mole and a fetus with a normal placenta has been reported (see image below). Cases of healthy infants in these circumstances have been reported.^{[12, 36]}

Women with coexistent molar and normal gestations are at higher risk for developing persistent disease and metastasis.^[20] Termination of pregnancy is a recommended option.

The pregnancy may be continued as long as the maternal status is stable, without hemorrhage, thyrotoxicosis, or severe hypertension. The patient should be informed of the risk of severe maternal morbidity from these complications.^[37]

Prenatal genetic diagnosis by chorionic villus sampling or amniocentesis is recommended to evaluate the karyotype of the fetus.

Twin gestation. Complete mole and normal twin.

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Differential Diagnoses

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Amir SM, Osathanondh R, Berkowitz RS, Goldstein DP. Human chorionic gonadotropin and thyroid function in patients with hydatidiform mole. Am J Obstet Gynecol. 1984 Nov 15. 150(6):723-8. [QxMD MEDLINE Link].
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Fishman DA, Padilla LA, Keh P, Cohen L, Frederiksen M, Lurain JR. Management of twin pregnancies consisting of a complete hydatidiform mole and normal fetus. Obstet Gynecol. 1998 Apr. 91(4):546-50. [QxMD MEDLINE Link].
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Media Gallery

Theca lutein cysts.
Complete mole.
Complete mole with an area of clot near cervix consistent with bleeding.
Twin gestation. Complete mole and normal twin.

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Author

Lisa E Moore, MD, MS, FACOG, RDMS Professor, Department of Obstetrics and Gynecology, Chief, Division of Maternal-Fetal Medicine, Medical Director of Labor and Delivery, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Lisa E Moore, MD, MS, FACOG, RDMS is a member of the following medical societies: American Congress of Obstetricians and Gynecologists, Central Association of Obstetricians and Gynecologists, International Society of Ultrasound in Obstetrics and Gynecology, Society for Maternal-Fetal Medicine, Society of Diagnostic Medical Sonography

Disclosure: Nothing to disclose.

Coauthor(s)

Enrique Hernandez, MD, FACOG, FACS Chairman, Department of Obstetrics and Gynecology, J Robert Willson Professor of Obstetrics, Gynecology and Reproductive Science, Professor of Pathology, Temple University Hospital, Lewis Katz School of Medicine at Temple University

Enrique Hernandez, MD, FACOG, FACS is a member of the following medical societies: Alpha Omega Alpha, American Cancer Society, American College of Obstetricians and Gynecologists, American College of Surgeons, American Gynecological and Obstetrical Society, American Medical Association, American Society for Colposcopy and Cervical Pathology, Association of Professors of Gynecology and Obstetrics, Johns Hopkins Medical and Surgical Association, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of Gynecologic Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

A David Barnes, MD, MPH, PhD, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, CA), Pioneer Valley Hospital (Salt Lake City, UT), Warren General Hospital (Warren, PA), and Mountain West Hospital (Tooele, UT)

A David Barnes, MD, MPH, PhD, FACOG is a member of the following medical societies: American College of Forensic Examiners Institute, American College of Obstetricians and Gynecologists, Association of Military Surgeons of the US, American Medical Association, Utah Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Leslie M Randall, MD, MAS, FACS Professor and Director, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Diane Harris Wright Professor of Gynecologic Oncology Research, Massey Cancer Center, Virginia Commonwealth University School of Medicine

Leslie M Randall, MD, MAS, FACS is a member of the following medical societies: Academy for Innovation in Medical Education, American College of Surgeons, American Medical Association, American Society of Clinical Oncology, International Gynecologic Cancer Society, Society of Gynecologic Oncology

Disclosure: Nothing to disclose.

Additional Contributors

Jordan G Pritzker, MD, MBA, FACOG Adjunct Professor of Obstetrics/Gynecology, Hofstra North Shore-LIJ School of Medicine at Hofstra University; Attending Physician, Department of Obstetrics and Gynecology, Long Island Jewish Medical Center; Medical Director, Aetna, Inc; Private Practice in Gynecology

Disclosure: Nothing to disclose.