Sonographic Criteria for Earlier Detection of Molar Pregnancies

Such advancement in disease detection has made the once hallmarked “typical mixed echogenic pattern” no longer seen [5]. This pattern replaces the placenta. It is produced by the villi and intrauterine blood clots. Since most cases of molar pregnancies are evacuated in the fi rst trimester, these typical sonographic presentations are now rarely encountered [2,6]. For reasons unknown, the incidence of moles varies by race and age. Hydatiform mole occurs at present in approximately 1 in 2000 pregnancies in Europe and the United States, but the rate approaches 1 in 500 in Japan, Singapore and Malaysia. A signifi cant increase in the incidence of moles has been observed in women after age 40 and in women 20 years and younger.


Introduction
For years, it has been the accepted standard for hydatiform molar pregnancies to be recognized by ultrasound examination during the second trimester [1]. Medical literature depicts, in late pregnancy, these moles as a uterine cavity fi lled with heterogenous mass as well as anechoic spaces of varying size and shape, no fetal development and large ovarian cysts [2][3][4].
Such advancement in disease detection has made the once hallmarked "typical mixed echogenic pattern" no longer seen [5]. This pattern replaces the placenta. It is produced by the villi and intrauterine blood clots. Since most cases of molar pregnancies are evacuated in the fi rst trimester, these typical sonographic presentations are now rarely encountered [2,6]. For reasons unknown, the incidence of moles varies by race and age. Hydatiform mole occurs at present in approximately 1 in 2000 pregnancies in Europe and the United States, but the rate approaches 1 in 500 in Japan, Singapore and Malaysia. A signifi cant increase in the incidence of moles has been observed in women after age 40 and in women 20 years and younger.
Gestational Trophoblastic Disease (GTD) is a spectrum of interrelated disease processes that originate from the placenta. Hydatiform mole and invasive moles are 2 subgroups comprising GTD. Invasive moles can be further broken down into: choricarcinoma and the rare Placental Site Trophoblastic Tumor (PSTT).
The hydatiform mole is represented by villi, composed of trophoblastic tissue, that become edematous and proliferate. When a hydatiform mole locally invades the myometrium, it is called chorioadenoma destruens. This is one of the invasive groups of moles. Choriocarcinoma, the other type of invasive https://www.peertechz.com/journals/journal-of-gynecological-research-and-obstetrics Citation: Gupta  mole, is noted for its widely metastatic invasion [7,8]. These are composed of malignant trophoblastic cells but lack hydropic villi. The malignant tumors develop following formation of a hydatiform mole. Placental Site trophoblastic tumors are rare and consist of intermediate trophoblastic cells that persist after a term pregnancy. These tumors may invade adjacent tissues or even metastasize [8].
95% of hydatiform moles are complete moles, which result from the fertilization of an empty ovum by a normal sperm. Patients defi cient in carotene or animal fat in the diet, increased maternal age, history of spontaneous abortions, infertility and previous molar pregnancies are particularly susceptible to these moles. Molar pregnancies typically present with painless vaginal bleeding in the fourth-fi fth month of pregnancy. The uterine size typically surpasses the correlating gestational age and ovarian enlargement may be observed as well [9]. Excessive vomiting more exaggerated than hyperemesis gravidarum may be noted in these patients.
The clinical diagnosis is based on assessing beta-hcg levels that may reach measurements greater than 100,000 mIU/ ml. Clinical features consist of excessive vomiting, transient hyperthyroidism, palpitations and elevated BPs. However, USG and histopathological examinations are used for the defi nitive diagnosis [9].

Methods
We performed a retrospective analysis of 69 cases. These Of the 69 consecutive cases that were examined, the average maternal age was 28 years. The average gestational age was 9 weeks and, if present, the typical presenting complaints were painless vaginal bleeding. Of the ultrasonographic fi ndings that were compared in all patients with histological material from endometrial curettage and or hysterectomy, the fi ndings seen included, but not limited to: miscarriages, complete moles, and partial moles.

Results
Of the 69 pregnant patients that were pathologically confi rmed to have had molar pregnancies, 48 cases were found This fi nding was the most consistent among the various ultrasounds, as the incidence of this fi nding was signifi cant (89%). The gestational sac was visualized in 74% of these cases as well, making this an important identifying marker in suspected cases of molar pregnancy. Fetal poles were noted on ultrasound in 41% cases, and uterine enlargement was seen in 33% cases. As seen in these results, the characteristic: snowstorm" appearance is represented the smallest percentage (19%) cases.
Of the 69 cases, 21 were directly sent to the operating room, with no ultrasounds performed, for an immediate dilatation and curettage. This data helps to identify specifi c diagnostic criteria that can be used in the future to determine molar pregnancies earlier than the current methods allow.

Discussion
With the advent of early molar pregnancy detection, the purpose of our study was to demonstrate the existence of unique highly sensitive sonographic criteria for the diagnosis of these molar pregnancies in the fi rst and early second trimester. This retrospective case study was carried out to identify patients with the primary diagnosis of possible molar pregnancies, that  [11]. During the fi rst trimester of molar pregnancies, the expected hydatiform ultrasound characteristics are less readily apparent. Subsequently, two larger, more recent studies have reported that correct preevacuation identifi cation of molar pregnancies by USG is achieved in 40-60% cases in the fi rst and early second trimester.
In these, more recent studies, the main sonographic fi ndings in early molar pregnancy appeared to be cystic changes of the endometrium, increased placental heterogeneity and hyperechogenic masses fi lling the uterine cavity [4,12].
Based on the evidence identifi ed by previous research, our study sought to exhibit the sensitivity of ultrasound and the most sensitive sonographic criteria for the diagnosis of molar pregnancies in the fi rst and early trimester. Our study reporting 56% sensitivity, is consistent with recent studies that reported 40-60% sensitivity of ultrasound in diagnosing fi rst trimester molar pregnancies with new sonographic criteria.
Our results confi rmed that cystic changes of the endometrium and increased placental heterogeneity, seen on ultrasound are the key diagnostic features in evaluating molar pregnancies in the fi rst trimester.
Due to the progression of medical advancement, ultrasound has replaced all other means for early screening and has helped in establishing the differential diagnosis of molar pregnancies in-utero. Traditionally, the sonographic fi nding of the "snowstorm" appearance has been the hallmark of diagnosis.
Our study shows this hallmark is apparent in only 19% of molar pregnancies. Thus, this feature should not be relied on as diagnostic when evaluating molar pregnancies in fi rst trimester pregnancies. However, thanks to the advancement of medicine, this late pathognomonic fi nding is becoming obsolete based upon our evolving ability to diagnose GTD early on during the fi rst trimester of pregnancy rather than the second trimester.

Conclusion
Our study evaluated the sonographic features of molar pregnancy in early pregnancy among patients that presented between 2014 to 2016. This time period was chosen as the sonographic fi ndings were reliably available for this duration.
The typical second trimester sonographic features of molar pregnancies cannot be used for diagnosis of this condition in fi rst trimester, instead cystic changes in endometrium and increased placental heterogeneity should be more commonly utilized.