Partial vesicular. What is a hydatidiform mole during pregnancy? Surgical removal

07.05.2019

A cystic drift is understood as the pathology of the ovum, which is characterized by the transformation of chorionic villi (outer embryonic membrane) into cysts - vesicles containing fluid, proliferation of villous epithelium and, as a result, fetal death.

This pathological condition is manifested by early toxicosis, an increase in the size of the uterus in comparison with gestational age, and bleeding.

Bubble drift is detected by ultrasound, vaginal examination, determination of the content of β-hCG, FKG of the fetus.

Treatment consists in removing the skid by curettage of the uterine cavity, vacuum aspiration, in rare cases - carrying out a hysterectomy.

This pathological condition develops in 0.02 - 0.8% of all pregnancies. With this disease, there is an edema of the stroma (shell) and the proliferation of chorionic villi with the formation of specific bubble-like extensions that resemble bunches of grapes.

Cysts (vesicles) reach a size of twenty-five millimeters, contain a yellowish or opalescent liquid, which includes globulins, amino acids, chorionic gonadotropin, and albumin. Cysts, as a rule, do not have vessels; it is rarely possible to identify single capillaries in them.

Classification of cystic drift

There are several classifications of cystic drift. They are based on histological and morphological features. According to the degree of degeneration of the chorionic villi, a partial and complete drift is distinguished. In the full form, all chorionic villi are transformed, in the partial form, only a certain part of them.

In all cases, the fetus dies, however, the development of pathological formations continues, which is accompanied by a rather rapid increase in the size of the uterus. In addition to all this, there is an invasive (destructive) form of cystic drift, which is characterized by the germination of villi into the thickness of the muscular membrane of the uterus and subsequent destruction of tissues.

This condition can be worsened by the development of severe intraperitoneal (intra-abdominal) bleeding. By histological type, depending on the ratio of trophoblast structures, syncytial, mixed, cytotrophoblastic vesicular drift is isolated.

Causes and risk factors for the disease

Vesiculate mole develops as a result of chromosomal abnormalities during gestation. The full version of this pathology occurs when the maternal genes are lost and the set (haploid) of the paternal genes is duplicated or when a non-nucleated egg is fertilized simultaneously by two spermatozoa.

Partial cystic motility also develops as a result of genetic disorders: fertilization of an egg by a sperm cell that has a diploid set of chromosomes. This condition is often accompanied by the development of multiple malformations (syndactyly, hydrocephalus, etc.).

Bladder drift develops three times more often with repeated pregnancies, in young patients, as well as in pregnant women over thirty-five to forty years old. This pathology can be a complication of an ectopic pregnancy and therefore be localized in the fallopian tube.

Multiple childbirth, termination of pregnancy, immunodeficiency, thyrotoxicosis, lack of vitamin A and animal fats in food, closely related marriages are factors that several times increase the likelihood of developing cystic drift.

Symptoms that accompany the pathology

One of the most characteristic signs for this pathological condition is the release of dark liquid blood from the genital tract, which contains rejected drift bubbles.

Such bleeding can lead to significant anemization and, in some cases, become life-threatening.

The germination of elements of the cystic drift into the thickness of the muscular membrane of the uterus may be accompanied by its perforation and massive intra-abdominal bleeding.

The rapid enlargement of the uterus is the result of rapid proliferation of vesicles. Moreover, its size does not correspond in any way to the estimated gestational age.

Bubble drift is often accompanied by the development of toxicosis. At the same time, nausea, repeated vomiting, salivation, exhaustion, increasing liver failure, symptoms of preeclampsia, eclampsia and preeclampsia are observed already in the first trimester of pregnancy.

Since with cystic drift the fetus dies in the early stages, there are no reliable signs of pregnancy - parts of the fetus are not detected by palpation and ultrasound, the heartbeat is not heard and is not recorded by various hardware methods, there are no fetal movements.

At the same time, carrying out immunological and biological tests for pregnancy gives positive results. In thirty to forty percent of patients' observations, bilateral cysts (tecalutein) are detected, which regress on their own after removal of the cystic drift.

This pathological condition poses the greatest danger due to the possibility the appearance of dangerous malignant tumors, which later metastasize to the walls of the vagina, vulva, brain, lungs, abdominal organs.

Complete (simple) bladder skid

This pathological condition is the most common form of trophoblastic disease. It occurs with a frequency of 1/1000 - 1/1500 pregnancies (in Western countries). The greatest risk of developing complete hydatidiform mole is in women younger than fifteen and over forty.

Other risk factors are a history of miscarriages, abortion, and dietary errors (lack of vitamin A and animal fats). This pathological condition is characterized by the presence of a huge number of bubbles with transparent contents.

In this case, fetal tissue is completely absent. Clinically, this disease is manifested by a delay in menstruation. Pregnancy symptoms such as vomiting and nausea are more than normal, due to the high content of HCT, which is synthesized by abnormal trophoblast. Some patients may develop hyperthyroidism due to the fact that HCT has a weak stimulating effect on the thyroid tissue.

Partial bladder skid

This pathological condition is diagnosed when a fetus is found together with proliferating villi with hydropic degeneration.

The fetus usually dies at the end of the first or at the beginning of the second trimester, while the analysis of the placenta is needed to make a diagnosis, since the hydropic villi are not expressed to the same extent as with complete cystic drift.

The age of the patients is somewhat older than with a complete cystic drift. This condition is associated to a lesser extent with the risk of subsequent malignancy.

How to get pregnant without consequences

After removal of the cystic drift, the woman should be registered with the gynecologist for another year and a half.

During this control period, it is necessary to carefully make sure that pregnancy does not occur, since there is a risk of re-development of this pathological condition.

The most optimal method for planning pregnancy is hormonal contraceptives, which should be taken after consulting a gynecologist.

Due to the specific hormonal effect, the work of the ovaries will be regulated for the better, since during the operation and in the presence of complications it could be disturbed.

The next pregnancy should be under strict control, both by the medical staff and by the woman. This is important, since the likelihood of pathology and difficult childbirth after this condition increases several times. It is also important to know that after surgery or chemotherapy conception must be planned on time, no earlier than a year later.

Modern methods for the diagnosis of cystic drift

When diagnosed, this disease is differentiated with polyhydramnios, multiple pregnancies, spontaneous miscarriage, pregnancy against the background of uterine fibroids. Distinctive features of this pathology is the presence of bubbles in the bloody discharge, which is usually observed before the expulsion of the cystic drift.

Conducting a gynecological examination allows you to determine the change in the consistency of the uterus to a densely elastic form with the presence of areas of excessive softening, as well as an increase in the size of the uterus relative to the gestational period.

Ultrasound examination allows to confirm the enlargement of the uterus and the absence of the fetus, while the symptom of a "snow storm" (the presence of homogeneous fine-grained tissue), tecalutein ovarian cysts, having a diameter of more than six centimeters, is detected.

When conducting phonocardiography, fetal heartbeat is not recorded. According to indications, hysteroscopy, diagnostic laparoscopy, laparoscopic echography, ultrasound hysterosalpingoscopy can be performed.

If there is a suspicion of the development of a cystic drift, the content of chorionic gonadotropin (CG) is necessarily examined, if necessary, biochemical liver tests are performed, the level of creatinine and a coagulogram are determined.

In order to exclude metastatic screenings of cystic drift, a survey radiography of the abdominal cavity organs, chest, MRI or CT of the brain is performed. After removal of the pathological tissue, a special histological examination is performed, as well as the determination of the karyotype.

Methods for treating cystic drift

The main method of treating cystic drift is the removal of this formation. For this, methods of vacuum aspiration with control curettage are used after preliminary dilatation (expansion) of the cervix. To improve the contraction of this organ, pituitrin or oxytocin is prescribed. In rare cases, spontaneous expulsion from the uterine cavity of the cystic drift can be observed.

When the reproductive function is fulfilled or the development of threatening bleeding, the removal (extirpation) of the uterus without appendages is performed. The removed tissue must be subject to special histological examination.

After removal of the cystic drift for the next two months, the patient undergoes a weekly determination of the level of hCG in the blood serum, once every two weeks - ultrasound of the pelvis, as well as radiography of the lungs. If there are no signs of developing chorionepithelioma, then subsequent chemotherapy is not indicated.

Chemotherapy and radiation therapy

For chemotherapy, they are used drugs that act on cancer cells. It can be administered intramuscularly, intravenously, or in pill form.

Chemotherapy is a systemic method of treatment, since all drugs enter the bloodstream and are carried to all organs and tissues, killing all malignant cells in their path.

In radiation therapy, X-rays or other types of radiation are used to destroy tumor cells, as well as to reduce the size of a neoplasm.

The process of fertilization of an egg (conception) is the fusion of two germ cells, female and male. The formed chorion within a few days must reach the uterus and attach to its wall with the help of special villi. They also subsequently form the placenta and umbilical cord, which are vital for the ovum.

With an abnormal flow, the necessary villi are not formed, but turn into another substance. This growth is called a hydatidiform mole. It is in the process of continuous growth and has a grape-like shape. Pathology requires surgical treatment, as it poses a danger to a woman's life.

Etiology and clinical picture of pathology

Obviously, invasive cystic drift has a tumor etiology. In advanced situations, the structure can penetrate into the deep layers of the uterine wall and transform into chorionicarcinoma (malignant neoplasm). It is believed that the disease appears due to chromosomal abnormalities in the process of conception.

In this case, an uncharacteristic tissue is formed with numerous vesicles filled with chorionic gonadotropin - a yellowish liquid. This is a pregnancy hormone (hCG), but due to the lightning-fast proliferation of modified tissue, its indicators increase sharply. Also present in the bubble content:

albumin;
amino acids;
globulins.

There are two types of neoplasms: partial and complete cystic drifts. Their symptoms vary somewhat. In the first case, the embryo initially receives a doubled set of male chromosomes (46) and a normal set of female chromosomes (23). In this case, the fetus develops with multiple anomalies, which further leads to its inevitable death.

With a complete cystic drift, the embryo is completely absent. An intensified growth of villi occurs on the entire surface of the chorion. In the photo you can see the modified tissues inherent in the neoplasm. In any case, the situation is critical and requires an immediate termination of the pregnancy.

Destructive cystic drift penetrates deep into the uterine wall or grows through. In this case, metastases in the vagina, liver and lungs are rarely diagnosed. Pathological anatomy is a common cause of extensive intra-abdominal blood loss.

Proliferative is a medical emergency. Such an invasive structure grows into the myometrium of the genital organ and provokes severe blood loss. The only way to save the woman is to remove the uterus with all the structures of the cystic mole.

There are no justified reasons for the occurrence of pathological education. Experts name factors that increase the risk of its occurrence:

previous abortions and miscarriages;
age (the age most susceptible to the development of pathology is up to 18 and after 45 years);
a history of cystic drift (complete or incomplete);
ethnicity (statistics indicate that girls of Asian descent are more likely to have the disease).

Cystic Skid Symptoms

Many women are interested in at what period of pregnancy the initial stage of cystic drift is diagnosed. At the beginning of gestation, ultrasound examination of the uterine cavity does not always reveal the pathological anatomy of the formation. In this case, there are symptoms inherent in cystic drift:

slight brown discharge, sometimes blood loss;
severe toxicosis that appears in the first weeks of gestation;
the rapid increase in the uterus, which is characteristic not for a normal pregnancy, but for a complete skid;
pain in the lower abdomen;
increased hCG rates;
severe gestosis (after 20 weeks).

Consequences and complications

The most serious complication is considered to be the degeneration of invasive cystic drift into oncology. As a result, abnormal cells invade the uterus, causing extensive internal bleeding. Loss of blood causes anemia.

If the modified villi grow into capillaries and blood vessels, then pathological cells of the cystic drift can spread to all systems and organs. In this case, metastases are formed in the internal organs (liver, lungs) and the brain.

There are several stages of the neoplasm, which differ in etiology and localization. Experts point out:

cystic drift within the uterus (has a good prognosis);
partial proliferation of vesicular tissue in the area of junction of the placenta (placenta bed);
metastatic tumor (spread of metastases to neighboring organs).

It happens that the disease recurs. Then you will need repeated curettage or chemotherapy. Pathology does not pass without leaving a trace for the woman's body. Negative consequences often appear:

infertility (in almost 30% of women);
amenorrhea (absence of menstruation, occurs in 12% of patients);
thrombosis;
septic diseases.

Diagnostic measures

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If a partial cystic drift develops and an embryo is present, it is difficult to recognize the pathology. On palpation, the uterus of natural size is palpated.

Ultrasound for cystic drift quite often does not detect the disease in the early stages, especially when a small part of the placenta is affected. As a result, such a fruit is still doomed to death, since it develops inadequately. Usually, a partial cystic drift is detected at a later date, and it is the analysis for the hCG hormone that is considered important.

A diagnosis of complete bladder drift is more likely. On examination, the gynecologist can determine the inappropriate size of the uterus (usually it is larger than it should be). Ultrasound examination reveals the absence of the embryo in the uterine cavity, and instead of it - a vesicular structure.

With this pathology, cysts are diagnosed on both ovaries about 6 cm in size.For an accurate diagnosis of the disease, it is important:

the content of chorionic gonadotropin;
coagulogram;
chest x-ray;
liver biochemical tests;
laparoscopic echography;
MRI of the brain;
determination of creatinine.

With insufficient diagnostic studies, cystic drift is mistakenly confused with polyhydramnios, uterine fibroids during pregnancy, miscarriage. It is important to identify pathology in time in order to reduce the likelihood of malignant transformation.

Sometimes a woman may develop symptoms of a neoplasm, and instead doctors find a dead ovum - a non-bubbly drift. This abnormality is called a missed pregnancy.

Treatment of bladder skid

The treatment for cystic motility, regardless of the degree of difficulty, is always to remove it. If the pregnancy is less than a month, use the vacuum aspiration method. This therapy helps to preserve the reproductive organs.

At a later date, the most effective method is the surgical curettage of the contents of the uterus. The operation is always performed under general anesthesia.

Surgical removal

Preparation for the operation includes the introduction of the patient with general anesthesia (Oxytocin). After that, the surgeon makes the expansion of the cervix. This procedure is usually accompanied by heavy bleeding. Next, the doctor removes the contents of the uterus with a vacuum apparatus or by scraping. At the same time, a procedure called curettage (removal of the modified tissue through a curette) is also performed.

Sometimes the cystic mole passes into the walls of the uterus so deeply that the surgeon cannot completely separate the invasive neoplasm from the woman's reproductive organ. In view of the possible extensive bleeding, in this case, a decision is made to completely amputate the uterus.

In addition to the above methods of treating the disease, other therapy options are used in medicine. They are selected individually for each patient. The way the operation is performed depends on the type of bladder drift:

vacuum excohleation;
extrusion of the uterus (while the cysts on the ovaries are not removed, they regress a few months after the eradication of the underlying disease);
excitement of labor (the patient is injected with prostaglandins, which provokes artificial childbirth, sometimes a woman is given a small cesarean section).

Post-removal therapy

After the operation has been performed, the woman is prescribed a course of antibiotics. Over the next two years, she should be observed by a gynecologist. In the first 2 months after the removal of incomplete cystic skid, it is necessary to do:

weekly tests for the content of the hormone hCG;
Ultrasound of the abdominal cavity (once every 2 weeks);
X-rays of light.

A month after therapy, the woman should resume her menstrual cycle. If there are no menstruation for more than 7 weeks, or, conversely, they are too abundant, accompanied by an unpleasant odor and at the same time severe abdominal pain, dizziness and general weakness are observed, you need to consult a gynecologist. Perhaps an infection has entered the body or hormonal levels have been disturbed. A relapse is sometimes diagnosed.

Treatment for malignant transformation

If the examinations after the operation reveal signs of a destructive cystic drift or chorionepithelioma in the body, chemotherapy is indicated intramuscularly, in the form of tablets or droppers. Usually, experts prescribe a course of Methotrexate or Dactinomycin. In addition, under the close scrutiny of doctors are:

the level of HKC in the blood;
pelvic organs (do ultrasound every 14 days);
lungs (control of the spread of metastases).

Along with chemotherapy, radiation therapy is an effective method of combating pathology. X-rays are often used. During the treatment period, a new pregnancy is contraindicated. For safety reasons, oral contraceptives are prescribed.

If the level of beta-hCG is low and there are no metastases to the internal organs, the prognosis is considered good. Otherwise, the prognosis is unfavorable.

According to statistics, almost 90% of women who have undergone cystic drift, menstruation resumes within 4-5 weeks after treatment. Pregnancy after cystic drift, proceeding without pathologies, is possible in almost 70% of women.

Doctors recommend planning conception no earlier than six months after therapy, and if the treatment was carried out with the use of chemotherapy, it should take about 2 years. In this case, a woman needs to be carefully examined, to normalize her hormonal background. If sexually transmitted diseases are diagnosed, they should be treated before pregnancy to reduce the risk of signs of recurrent cystic drift.

Forecast and prevention

In 20% of patients, the diagnosed complete cystic mole is reborn into a malignant formation with the appearance of metastasis. Pathology detected in time (up to 4 weeks) gives a chance to recover without complications. 1% of women with a history of this disease are at risk of a return of the insidious ailment.

As such, there is no prevention of this disease, since the reliable causes of its occurrence are unknown. Before conceiving a child, it is recommended to perform a number of activities.

Bubble drift, although it does not belong to true neoplasms, is included in the group of trophoblast diseases and is inextricably linked with pregnancy. In fact, this disease is considered, although quite rare, but a complication of pregnancy (including ectopic). On average, according to statistics, the disease occurs in 1 case per 1000 pregnancies.

Epidemiology

The prevalence of the disease depends on geographic location and race. For example, in North America, this pathology is diagnosed in 1 case per 1200 pregnancies, in the Far East (Japan, China) and South America, cystic drift is diagnosed more often, about 1 episode per 120 pregnant women, and in the Russian Federation, the disease is detected in one case per 820 - 3000 gestations.

Separately, it should be said about chorionepithelioma, there are 2 cases of the disease per 100,000 births.

Bubble drift and its types

By cystic drift, they mean the pathology of the ovum, specifically the chorion, which in the future should be transformed into the placenta. The chorion or villous membrane of the embryo undergoes a certain transformation, during which the villi degenerate into grape-like formations (cysts), ranging in size from lentils to grapes and outwardly resembling bunches of grapes. The diameter of the bubbles reaches 25 mm, and they are filled with an opalescent transparent liquid, which, in addition to hCG, contains albumins and globulins, and various amino acids.

The disease, as already indicated, has a connection with pregnancy, and its development can occur against the background of a gestation pregnancy, after an abortion (see) or miscarriage, after delivery. Possible development of cystic drift after ectopic pregnancy (in the tube).

There are several types of cystic drift:

Depending on the histological structure:
- simple form of cystic skid;
- destructive or invasive;
- chorionic carcinoma;
Depending on the area of the chorionic lesion:
- complete blistering skid;
- incomplete or partial blistering skid.

According to the international classification from 1992 (Singapore), if the disease has a malignant course, in this case we are talking about invasive cystic drift, then its stage is determined:

Stage 0 - low or high risk hydatidiform mole (like 0A or 0B);
Stage I - the tumor is within the uterus;
Stage II - there are foci of metastasis in the pelvic organs and the vagina;
Stage III - metastases are found in the lungs;
Stage IV - distant metastases (brain, liver) were diagnosed.

Characteristics of the types of cystic drift

If the disease develops in the first 12 weeks of gestation, and all the primary chorionic villi are reborn and there is pronounced hyperplasia of both layers of the trophoblast, then they speak of the full form of the disease. Some patients call it early bladder drift (apparently due to the timing of its onset). Morphologically, this type of pathology is characterized by:

absence of an embryo (it is absorbed);
there are no blood vessels in the villi;
the epithelium of the chorionic villi is not determined or has undergone dystrophic changes;
the villi are swollen and enlarged (enlarged);
proliferation of trophoblasts covering the villi from the inside.

The onset of pathology at a later stage of gestation (after 3 months, up to 34 weeks) and the degeneration of part of the chorionic villi is called incomplete cystic drift. Intact villi of normal appearance, blood supply and vascularization are preserved. In this case, there is a fetus, but its death occurs when the pathological process spreads to more than a third of the placenta.

In the case of multiple pregnancies, with the development of a disease in one of the placentas, it is possible to preserve a normal second placenta.

Invasive cystic drift can develop against the background of complete (more often) and partial. Distinctive morphological features are:

bubbles grow into the muscle layer of the uterus;
the trophoblast is hyperplastic, but retains the placental structure of the villi;
villi, germinating the myometrium and the serous cover of the uterus, enter the blood and lymph vessels and spread throughout the body, affecting the internal organs.

The destructive form of the disease occurs in 5 - 6% of cases and is the most severe.

Causes and mechanism of development

The mechanism of development of the disease lies in the pathological set of chromosomes of the embryo, when it has a double paternal set of chromosomes in the case of loss or initially complete absence of maternal chromosomes in the egg.

In the full form of the disease, the karyotype of the embryo is represented by a set of 46XX, if the egg has "lost" the maternal chromosomes and the paternal haploid genome has doubled. But it is possible to fertilize an initially empty egg with 2 sperm at the same time, in which case the karyotype of the embryo looks like 46XX or 46XY. As a result, the embryo dies in the early stages of development, even before the formation of placental circulation, but later the chorionic villi develop and grow.

The incomplete form of the disease is caused by triploidy - the result of fertilization of the egg by 2 sperm with a delay in the haploid set of the mother's chromosomes. The embryo karyotype can contain 69XXY, 69XXX or 69XYY chromosomes. In this case, the death of the embryo occurs at 10 weeks of gestation (due to numerous developmental abnormalities), but it is possible (in rare cases) to develop a viable fetus.

The causes of cystic drift have not yet been identified, but there are a number of theories explaining the occurrence of chromosomal abnormalities after fertilization of the egg:

viral theory (viruses, including Toxoplasma, have a damaging effect on the set of chromosomes of the mother and father);
oocyte damage in the ovary - a defective oocyte matures in the follicle;
decidual theory - endometritis develops in the decidual membrane, which leads to changes in the chorionic villi);
immunological theory - the embryo and fetus are considered as antigens to the woman's body and against the background of an insufficiently expressed immune response, the chorionic villi are degenerated instead of a miscarriage;
enzymatic theory - based on an increased level of an enzyme - hyaluronidase, which dissolves the vascular wall;
lack of protein - its deficiency leads to a shortage of genes in the chromosomes of a fertilized egg.

Factors that increase the likelihood of the disease:

age (young pregnant women - up to 18 years old, or over 40);
numerous childbirth;
repeated abortions and miscarriages;
weakened immunity;
insufficient nutrition (deficiency of animal proteins and vitamin A);
thyrotoxicosis;
closely related marriages.

Clinical picture

Symptoms of the disease in the early stages are not always pronounced. The woman feels pregnant, as evidenced by the absence of menstruation, a positive pregnancy test and signs of early toxicosis. Often, pathology is discovered by chance, during an abortion.

It is characteristic that early toxicosis in patients is difficult, vomiting, sometimes indomitable and salivation, lead to dehydration (see) of the body and electrolyte disturbances, significant weakness and lethargy. Early severe toxicosis is diagnosed in 20 - 35% of patients. In 27% of cases, signs of early toxicosis are combined with symptoms of late toxicosis or preeclampsia. They appear, blood pressure rises, and a large amount of protein is found in the urine, which is of fetal origin. Eclampsia may develop as early as 3-4 months of gestation. Gestosis is characteristic of the full form of the disease and develops with a significant size of the uterus and an excessively high level of the β-subunit of hCG in the blood. Therefore, the development of preeclampsia in the early stages of gestation should alert the doctor in relation to cystic drift.

Cystic drift is indicated by symptoms such as repeated bleeding from the genital tract, which occurs in 90 - 100% of cases, and the size of the uterus exceeding the duration of pregnancy. Uterine bleeding is disguised as spontaneous abortion and usually occurs early. In some cases, spotting coincides with the onset of menstruation (see). In more than half of patients (up to 68%), the asymptomatic period lasts less than 2 months. An undoubted symptom of the disease is the detection of bubbles in the blood secretions characteristic of the disease.

In the case of germination of myometrial villi and serous membrane of the uterus (destroying cystic drift), intra-abdominal bleeding with symptoms of an acute abdomen is possible. The invasive form of the disease is also dangerous with the occurrence of profuse bleeding, requiring urgent measures. Massive and prolonged bleeding contributes to the patient's anemization and can be fatal.

With a destructive form of pathology, metastases to the vaginal walls, vulva and lungs, to the brain are often observed. In some cases, metastatic foci are found after removal of the cystic drift. Metastases often disappear spontaneously, after the elimination of the main pathological focus, but in some cases they cause severe complications and death.

About 15% of patients complain of pain in the lower abdomen and / or in the lumbar region. The intensity and nature of the pain are different, the appearance of the pain syndrome often precedes the bleeding. Aching, dull or pressing pains occur when the uterine walls grow to the serous cover or when neighboring organs are compressed by large tecalutein cysts, and the appearance of acute, paroxysmal pains is associated with torsion or rupture of thecalutein cysts or with intra-abdominal bleeding.

In 7% of patients with the full form of the disease, it develops, which is characterized by an increase in the size of the thyroid gland and an increase in the level of thyroid hormones, moist and warm skin. The development of thyrotoxicosis is due to an increase in the level of trophoblastic beta-globulin, which has a weak stimulating effect on thyroid-stimulating hormone receptors.

With the full form of the disease, embolism of the branches of the pulmonary artery and the development of respiratory failure (in 2% of patients) is possible. The complication is characterized by the appearance of chest pain and, tachycardia and tachypnea, cyanosis and cough. On auscultation, scattered rales are heard, and bilateral focal darkening is determined on radiography of the lungs.

Diagnostics

The disease requires differential diagnosis with, pregnancy with more than one fetus or against the background of myomatous nodes, with spontaneous abortion, etc.
After collecting anamnesis and complaints, an examination is carried out on a gynecological cress, during which it is revealed:

the size of the uterus exceeds the size of the expected gestational age;
heterogeneous structure of the uterus: against the background of a softened uterus, nodular seals are revealed;
in 50% of cases, bilateral luteal (with an increase in the size of the ovaries more than 6 cm) are palpable, which appear within the first 2 weeks and are considered an unfavorable prognostic sign;
the presence of tumor-like formations in the vagina and vulva.

With a large abdomen, reliable signs of pregnancy are not determined (fetal heartbeat, palpation of large parts of the fetus).

Additional diagnostic methods are used:

Ultrasound procedure... Reveals the significant size of the uterus, the absence of an embryo or fetus, a characteristic feature - the presence of tissue of a homogeneous fine-grained structure (symptom of "snow storm"), luteal cysts. The diagnostic value of ultrasound is 100%.
Chest x-ray... Allows you to detect metastases in the lungs.
Hysterosalpingography... GHA allows you to clarify the diagnosis and control the effect of chemotherapy. On the hysterogram with an invasive form, the contour penetration of contrast is visualized at the site of the insertion of the villi into the myometrium.
Diagnostic laparoscopy,... Carried out if necessary.
Study of the level of hCG in blood. In non-pregnant women, hCG is normally absent in the serum. During gestation, hCG appears on the 8th day after conception, and its peak falls on the 60th day and is 5,000 - 10,000 U. If hCG levels remain high after 12 weeks, blistering is expected.
Immunochemical method... Consists in the determination of trophoblastic beta-globulin in the blood. With the development of this disease, its level is 76 - 93%.
Histological method... Helps to determine the morphological variant of the disease (material - scraping from the uterine cavity).

Treatment

With the development of cystic drift, treatment consists in its removal, which is carried out by the following methods:

curettage of the uterine cavity with preliminary expansion of the cervical canal;
vacuum-excohleation (preferable, as it is less traumatic);
finger removal, which also requires vacuum aspiration or scraping;
excitement of labor with prostaglandins, if the size of the uterus exceeds 20 weeks of pregnancy and an invasive form of pathology is excluded (with ineffectiveness or profuse bleeding - a small cesarean followed by curettage of the uterus);
extirpation of the uterus with preservation of the appendages (luteal cysts are not removed, their regression is observed within 3 months after elimination of the cystic drift).

After surgery, cold on the lower abdomen, uterine contractors and antibiotics are shown. After the elimination of the pathology, the patient is discharged under the dispensary supervision of the antenatal clinic.

The second stage of treatment is chemotherapy. Indications for its appointment:

an increase in the titer of hCG or remains at the same level for a long time;
invasive form of the disease after surgical treatment;
detection of metastases during or after removal of the cystic drift.

The drug of choice is dactinomycin, which is administered intravenously, the number of courses is determined individually. Metatrexate can be used, but it is more nephrotoxic. Metastases after removal of the cystic drift either disappear on their own, or after chemotherapy.

Question answer

What methods of contraception can be used after recovery?

After treatment of the disease, it is recommended to prevent pregnancy for a year after the disappearance of hCG in the blood and urine. It is desirable to use combined oral contraceptives, but contraception by barrier methods is also possible. IUD insertion is not recommended as there is a risk of uterine perforation.

How long does dispensary observation last and what is it?

After elimination of the cystic drift, hCG completely disappears on average after 73 days. Observation consists of:

weekly determination of hCG until 2 negative results are obtained;
then monthly determination of hCG for 6 months, then every 2 months up to a year, in the second year - every quarter, and in the third - once every six months;
ultrasound scanning of the pelvic organs every 2 weeks until remission, then every quarter for a year;
X-ray of the lungs annually;
MRI of the brain for 2 years every six months in case of detection of cerebral metastases.

When can a pregnancy be planned?

With a simple form of the disease, pregnancy is allowed 12 months after treatment and normalization of hCG, in the case of an invasive form and chemotherapy, pregnancy planning is possible after 2 years.

Why is cystic drift dangerous?

In 29% of patients after the disease, amenorrhea is observed in 14% of cases, and malignancy occurs in 4% of women (the development of chorionepithelioma). Pregnancy that occurs earlier than 2 years after chemotherapy is fraught with a high risk of developing fetal abnormalities and chromosomal mutations. Complications in childbirth are also possible: bleeding and abnormalities of labor forces.

What is the prognosis after a previous illness?

The current methods of treatment allow to achieve 100% recovery of patients, and in 90% of cases, the restoration of the menstrual cycle. 70 - 80% of women manage to get pregnant and endure pregnancy.

Bubble drift, 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 the ectopic, 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 depends on 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 territory of the Russian Federation the pathology is diagnosed in one case for every 820-3000 pregnancies.

Chorionepithelialoma should be separately identified, which is diagnosed in 2 cases per 100,000 births.

Types of cystic drift

By cystic drift, one should mean the pathology of the ovum (chorion), which, in the course of development, must transform into the placenta. The villous membrane of the embryo or chorion undergoes transformation, during which the villi are reborn into cysts (aciniform formations), which range in size 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, albumin, and of course hCG.

The disease is directly related to pregnancy, therefore, it can develop against the background of gestation, after delivery, miscarriage or medical abortion. It is also possible to develop cystic drift against the background of the presence of a tubal (ectopic) pregnancy.

It is customary to distinguish several types of cystic drift:

Depending on the area of destruction of the ovum:

partial, or incomplete, gallbladder drift;

full bladder skid.

Depending on the histological structure of the pathology:

chorionic carcinoma;

invasive or destructive;

a simple form of cystic skid.

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

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

the first stage - the tumor is located within the uterus;

the second stage - there are foci of metastasis in the vagina and pelvic organs;

the third stage is the presence of metastases in the lungs;

fourth stage - distant metastases (liver, brain) are diagnosed.

Characteristics of the main types of cystic drift

With the development of the disease in the first 12 weeks of gestation, all primary villi of the ovum degenerate, and there is pronounced hyperplasia 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 an early cystic drift (this is due to the timing of the onset). Morphologically, this type of disease is characterized by:

proliferation of trophoblasts that line the villi from the inside;

the villi are enlarged (dilated) and edematous;

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

there are no blood vessels in the villi;

the embryo is absent (resorbed).

The onset of the disease at a later gestational age (from 3 months to 34 weeks inclusive) and the degeneration of only part of the chorionic villi is known as incomplete cystic drift. At the same time, intact villi have a normal appearance, vascularization and blood supply in them are preserved. In this case, there is a fetus, but its death occurs due to the spread of pathology to a third or more of the placenta.

If the pregnancy is multiple and the pathology develops in one of the placentas, the second can remain in its normal form and functionality.

Invasive cystic drift 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 the lymphatic network, thus spreading throughout the body and affecting the internal organs;

the trophoblast is hyperplastic, but retains the placental structure of the villi;

bubbles begin to grow into the muscle 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 consists in the presence of a pathological set of chromosomes of the embryo, when only a double set of the father's chromosomes is present as a result of the initial complete absence or with the loss of the 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 duplicates. However, it is possible to fertilize an initially empty egg with two sperm at the same time, this leads to the appearance of a 46XX or 46XY karyotype. As a result, the embryo dies at the early stages of development, before the formation of placental blood circulation, while the chorionic villi continue to grow and develop.

An incomplete form of pathology is caused by triplodia - the fertilization of an egg with two sperm with a delay in the maternal haploid set of chromosomes. The karyotype of the embryo in such cases may contain 69XYY, 69XXX, 69XXY chromosomes. In such cases, the embryo dies at 10 weeks of gestation due to multiple developmental anomalies, however, in very rare cases, the development of a viable fetus is also possible.

The reasons that lead to gallbladder drift have not yet been determined, but there are a number of theories that can explain the occurrence of chromosomal abnormalities after the egg is fertilized:

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

enzymatic theory - based on an increase in the level of the enzyme hyaluronidase, which is able to dissolve the vascular walls;

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

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

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

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

Factors in which the likelihood of the disease increases:

closely related marriages;

thyrotoxicosis;

insufficient nutrition (deficiency of vitamin A, animal proteins);

weakened immunity;

repeated miscarriages and abortions;

numerous childbirth;

age (pregnant women under 18 or over 40).

The clinical picture of pathology

Symptoms of the disease are not always clear in the early stages. The woman feels that she is pregnant, because there are signs of early toxicosis, the pregnancy test is positive and there is a delay in menstruation. Quite often, the detection of pathology occurs by chance during a medical abortion.

A characteristic feature is early toxicosis, which is very difficult 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, symptoms of early toxicosis are combined with signs of late toxicosis and preeclampsia. Edema occurs, blood pressure rises, and when urine is examined, a large amount of protein of fetal origin is noted. Eclampsia may develop as early as 3-4 months of gestation. Gestosis is more typical for the full form of pathology and develops in the presence of a significant size of the uterus and a high level of β-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 cystic drift.

Cystic drift is indicated by such signs as intermittent bleeding from the vagina, which are present in 90-100% of cases, as well as the size of the uterus, which exceeds the expected gestational age. Uterine bleeding occurs most often early and is disguised as a spontaneous abortion. In some cases, the appearance of spotting coincides in time 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 in the secretions characteristic of the disease.

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

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

With 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 skid. Most often, the disappearance of metastases occurs spontaneously, after removal of the pathological focus, however, there is a possibility of the development of severe complications that lead to the death of the patient.

About 15% of all patients complain of pain in the lumbar and lower abdomen. The nature and intensity of pain are different, and the manifestation of pain syndrome is quite often a precursor of bleeding. Pressing, dull or aching pains occur as a result of the germination of the walls of the uterus to the serous cover or as a result of compression of adjacent organs by large tecalutein cysts. The manifestation of paroxysmal, acute pain is the result of rupture or torsion of thecalutein cysts or the occurrence of intra-abdominal bleeding.

In 7% of patients with the full form of pathology, thyrotoxicosis develops, which is characterized by tremor, tachycardia, an increase in the level of thyroid hormones and an increase in the thyroid gland, warm and moist integuments. The development of thyrotoxicosis is explained by an increase in the content of peat β-globulin, which has a stimulating effect on thyrotropic receptors.

In the presence of a complete cystic drift, embolism (blockage) of the branches of the pulmonary artery may occur and the occurrence of respiratory failure (about 2% of cases). This complication is characterized by the occurrence of chest pain, shortness of breath, tachypnea and tachycardia, cough and cyanosis. Scattered rales are heard, an X-ray examination of the lungs makes it possible to establish the presence of bilateral focal darkening.

Diagnostics

This disease requires differential diagnosis with multiple pregnancies, acute polyhydramnios, pregnancy with fibroids, ectopic pregnancy and spontaneous abortion.

After collecting complaints and anamnesis, the doctor performs a gynecological examination, during which it is diagnosed:

the presence of tumor-like formations in the vulva and in the vagina;

in 50% of cases, bilateral luteal ovarian cysts are palpated (in the case of ovarian enlargement over 6 cm), which occur during the first two weeks and are considered unfavorable signs for the prognosis of pathology;

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

the size of the uterus does not correspond to the size of the expected gestational age (exceed).

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

Additional research methods are used:

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 in the determination of trophoblastic β-globulin in the blood. In the presence of pathology, the level is 76-93%;

a study 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 the peak of 5000-10,000 units falls on the 60th day. If hCG levels are high after 12 weeks, blister drift should be suspected;

diagnostic hysteroscopy, laparoscopy - performed if necessary;

hysterosalpingography - used to clarify the diagnosis and control the effect of chemotherapy. With an invasive form, the hysterogram determines the contour penetration of the contrast agent in the zone of penetration into the myometrium of the villi;

chest x-ray - to detect lung metastases;

ultrasound - significant sizes of the uterus are 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 cystic drift, therapy consists in removing the pathology, which is performed by the following methods:

extrusion of the uterus and preservation of the appendages (lutenin cysts are not excised, since their regression is observed within 3 months after the removal of the underlying pathology);

excitement 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, it is required to perform a small cesarean section with further curettage of the uterine cavity);

finger removal, requiring scraping and vacuum aspiration;

vacuum-excohleation (more preferable due to low trauma);

curettage of the uterus by penetration through the dilated cervical canal.

After surgery, means for contraction of the uterus, cold on the lower abdomen and antibiotics are shown. After the pathology has been eliminated, the patient is discharged with compulsory dispensary observation in the antenatal clinic.

The second stage of therapy consists in performing treatment with chemotherapy drugs. The indications for its appointment are:

long-term steel indicator or increase in hCG titer;

detection of metastases during removal of the vesicular drift;

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 it is more nephrotoxic. Metastases, after the lesion of the pathology is removed, either disappear on their own, or are destroyed by chemotherapy.

Most popular questions on the topic

What methods of contraception are acceptable for use after healing?

After treatment of the pathology, doctors recommend protection from pregnancy for one year after the disappearance of hCG in the urine and blood. It is best to use combined oral contraceptives, but barrier protection is also acceptable. The insertion of an intrauterine device is not recommended as there is a high risk of uterine perforation.

What is dispensary observation and how long does it last?

After elimination of the cystic drift, it takes about 73 days for hCG to completely disappear. The observation is:

MRI of the brain for 2 years at intervals of 6 months, in case of detection of cerebral metastases;

annual chest x-ray;

Ultrasound of the pelvic organs every two weeks before the onset of remission, and then quarterly;

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

monthly determination of the level of hCG for six months, then after 2 months during the year, quarterly for 2 years and once every 6 months for the third.

When is pregnancy planning allowed?

In the presence of a simple form of pathology, it is allowed to become pregnant a year after treatment and normalization of hCG, if there was an invasive form with chemotherapy, pregnancy can be planned after 2 years.

Why is such a pathology dangerous?

In 29% of patients, after cure, infertility occurs, in 14% of cases, amenorrhea develops, in 4% of women, malignancy of the process occurs. Pregnancy that occurs earlier than 2 years after chemotherapy is dangerous with a high risk of chromosomal mutations and fetal malformations. Complications during childbirth may also develop: abnormalities of labor forces, bleeding.

What is the prognosis after recovery?

Modern methods of therapy allow achieving 100% cure, in 90% of cases it is possible to restore the menstrual cycle. 70-80% of patients manage to get pregnant and bear a healthy baby.

What is cystic drift and what is the danger of this disease - today the site for mothers will tell the site.

Any pregnancy, be it long-awaited or in the form of a surprise, should only bring 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.

Bubble drift is a formidable disease of the ovum, which is characterized by regeneration of chorionic villi(outer embryo membrane) into bubbles of liquid, outwardly very reminiscent of grapes. Pathology causes the proliferation of villi of the epithelium and the inevitable death of the fetus.

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

Varieties of the disease

With a simple cystic drift, 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 a fertilized egg. The maternal genotype is completely absent. The embryo is not formed, the formation of the ovum and placenta does not occur.
With a partial vesicular 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 has time to form, but is cystic in nature.
The invasive form of the disease is characterized by an extensive proliferation of chorionic villi inside the myometrium. The destruction of tissues can lead to severe bleeding.

Causes of the blistering skid

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

Some argue that the primary cause of cystic drift lies in initial pathology of the walls of the uterus, as a result of which the transformation of the chorionic villi occurs.

Proponents of another theory believe that the egg itself is initially unhealthy, being in. Leaving the ovary ovum affected by pathology after conception, it starts the development of cystic drift in the entire uterine cavity.

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

Signs and symptoms of cystic skid

A pregnant woman can record the characteristic signs of the disease:

severe toxicosis with persistent saliva and frequent vomiting;
exhaustion;
the manifestation of gestosis, which is not characteristic of early terms;
liver failure;
the presence of protein in urine tests;
pain in the abdomen;
iron deficiency in the body.

And yet, pregnancy after suffering a cystic drift is possible in most cases. But not earlier than two years after the end of chemotherapy and taking anticancer drugs.