Cystic drift (Mola hydatidosa)

Cystic drift is a kind of disease chorion, characterized by the transformation of the villi in botryoidal education, consisting of a transparent bubbles (Fig. 41, a, b, C).


Fig. 41.
while examining the introduction (General view); b, C - type of fibers in norm and molar.

The size of each bubble varies on the value of millet grain to large berries of grapes, and sometimes comes to a considerable size. The bubbles are connected by tree trunks with a grayish color. They contain a clear liquid, which can be defined albumin and mucin. Gallbladder, drift occurs in 0,05-0,06% of pregnancies.
There are two forms of a molar: one of them is characterized by degeneration of only the part of the villi, the other - all villi. Full gallbladder introduction develops in the first months of pregnancy, when the chorion in the entire periphery of the eggs is equipped with a lint; partial gallbladder drift occurs only after the division will happen hairy sheath on chorion frondosum a. chorion laeve, i.e., after 3 months of pregnancy. In view of this, the clinical picture is different: with full bubble entry fruit is always dies when partial - can sometimes be born alive and viable.
Histological structure. Histologically this kind of change hairy sheath is characterized by the growth of syncytium and laganovska layer (hypertrophy of the villi); stroma is exposed mainly edema. Wall of each bubble is composed of the remnants of the connective tissue stroma former hairs, covered with growths of cells of laganovska layer and syncytium, randomly shuffled each other. Often these growths of cells undergo necrosis and degeneration. Stalks are connecting separate bubbles, just as well come from the chorion and are nothing like reborn his NAP. Along with this, there are changes in the relevant areas decidua: germinating bubbles decidua atrophies, thin, threaded hemorrhages, and sometimes destroyed by the impact of proteolytic enzymes, emitted during the decay of the modified cells of chorion villus.
Histological pattern molar not the same everywhere. In some cases, the wall of the bubble is covered with a single layer of epithelium, in others there is a multilayer epithelium and complex stroma where there are large round or polygonal cells with eccentrically positioned one or two cores and large vacuoles. These features gave the prognostic value in the sense of malignancy, however, this assumption was not confirmed.
In most cases, the bubbles avascular or poorly supplied with blood vessels; vessels are observed mostly in the legs bubbles. However, there can be the bubbles with well-developed vascular network.
The degree of development of the vessels depends on the period of development of a molar: if there are early avascular education, for late - significant development vascular network (borschevskaya).
Etiology. The reasons for the degeneration of the chorionic villi and education of a molar still not completely understood. The development of a molar previously associated only with syphilis, jade, chlorosis, anemia etc., recently dominated by two views. Some see the reason of occurrence of a molar in inflammatory changes of the uterine wall (endometritis decidualis), and the rebirth of fibers is considered a phenomenon of secondary origin. In favour of the specified view the facts speak recurrence of the disease in one and the same woman (4-11 times) even during fertilization from different men. I believe that the mucous membrane of the uterus is not always amazed all over that next to the affected remain healthy areas where the egg can grow normally. As evidence of past assumptions are cases deizisau of pregnancy in which one egg was reborn, and the second one was healthy.
Proponents of the second theory see the reason of development of a molar in primary disease eggs or secondary changes that occur when you stop the development of the eggs. Some authors consider that the egg gets sick in the ovary and then going wrong, the expansion of the villi, accompanied by the change of the epithelium and the destruction of their stroma. Advocates of this view point to the fact that molar often observed bilateral small cystic degeneration of the ovaries; especially abundant growth in recent luteal tissue can cause excessive activity of chorionic epithelium. In such cases, the ovaries are defined in the form of spherical or kovacovich tumors with rough surface.
Most modern midwives consider changes in the ovary phenomenon of secondary origin; they tend to explain their property changes chorionic epithelium. Anyway currently not possible to finally resolve, where lies the root cause of the disease - in the egg or in the inflammatory changes in the uterine wall. Undoubtedly, the role of not only local, but also the General conditions, leading to a weakening of the safety devices in pregnant (C. S. Gruzdev). This may be explained by the emergence of large crowds luteal cells in the ovaries associated with abnormal activity placental elements - CVS. The expansion of the luteal cells enhances the products of lipids. While in a normal pregnancy is exaggerated only luteal education from the past ovulation, molar exaggerated also not had time to disappear luteal cells, which consists in scars from yellow bodies and arising out of previous ovulation.
Upon removal of a molar often increases the growth of cysts yellow body, which many obstetricians mistakenly removed; meanwhile established that luteum cysts disappear on their own within a few weeks and are classified as benign. It should be noted that in some cases NAP grow even muscles and serous cover of the uterus, spreading mainly through the veins (mola hydatidosa destruens, Fig. 42); the development of this "destructive", malignant form, appears to be worth the loss of the endometrium physiological ability to delay and limit the growth of the villus.


Fig. 42. Destruida form of a molar.

Excessive development of the luteal tissue in the ovaries and significantly increased secretion of the latter, on the one hand, and the activities of syncytium - on the other, lead to the fact that women molar there are a number of symptoms (edema, albuminuria), characteristic of toxicosis of pregnancy, which gives the right to some authors include cystic drift to the disorders of toxic origin.
In conclusion, we have to say is that, although the true reason of occurrence of a molar not installed but still, of course, the main value in the etiopathogenesis of it have neuro-endocrine disorders.
An indirect indication of the ongoing qualitative and quantitative changes in hormonal balance is that in the urine molar dramatically increases the number of chorionic gonadotropin (in one liter of more than 500 000 ME), while in physiological pregnancy quantity varies 5000-10 000 ME.
More disposed to cystic skid older pregnant, although some authors, on the contrary, believe receptive age of 20-30 years. Often gallbladder drift observed in nulliparous.
It should be borne in mind that there may be cases of a molar and for ectopic pregnancy, which are extremely rare. Such a case was observed by us in 1952 in Sverdlovsk. In the gynecological Department of the Institute MME was adopted 15/11 1952 sick S., 26 years old, with diagnosis right tubal pregnancy and underwent surgery. Remote fallopian tube externally hold their shape, being somewhat advanced in its middle part. The ovaries from both sides were slightly increased in the growths.
In the context of remote pipes were in the lumen it discovered reborn hairs in the form of bubbles. In the future, the diagnosis was confirmed by histological examination.
From an anamnesis it is estimated that up to ectopic pregnancy at this woman had two childbirth and one unsafe abortion.


The diagnosis. When available bubble entry bright clinical symptoms are the increase of the uterus, exceeding the expected duration of pregnancy, and often heavy bleeding with discharge of bubbles. Bleeding usually begin from the second month of pregnancy, and achieve the highest degree by the time of the expulsion of skidding, occurring more often on the third or fourth month. Sometimes puzarnyi shipping is delayed in the uterus for a longer time, even in excess of a normal pregnancy. Often, however, the bleeding does not exist or are dirty, brownish color selection.
In addition to external bleeding, when mola hydatidosa can be and internal bleeding (usually when mola hydatidosa destruens); as corrosive effects CVS lead to perforation of the uterine wall and causes bleeding in the abdomen. Furthermore, there is a kind of tugolessky consistency of the uterus (in a normal pregnancy, the consistency testovaty). If the gallbladder introduction develops in the second half of pregnancy, it is not possible to feel part of the fruit and listen to his heartbeat, which at this stage of the pregnancy must already exist. Pregnant and the doctor does not feel the movement of the fetus.
Molar sometimes there are other symptoms of toxicosis of pregnancy: a protein in the urine, vomiting, swelling in the legs, sudden loss of weight. Molar in 30%, there is nephropathia hyperemesis. Sometimes a pregnant pain in the lower back, which by the time of the expulsion of a molar increase. More precise symptoms for diagnosis is not available.
Differential diagnosis. In the absence of bright symptoms of a molar possible diagnostic errors. The reason for the errors can give miscarriages with bleeding in the uterus, causing her stretching, multiple pregnancy, tumors of the pregnant uterus, acute polyhydramnios, incorrect detection of pregnancy. Against miscarriage with bleeding in the uterus will speak rapidly growing molar uterus and a number of other clinical symptoms. When multiple births (births of twins) the growth of the uterus occurs slower than molar usually there is no bleeding, as in the second half of pregnancy are able to hear the heartbeat and feel part of the fruit; pregnant at this time celebrating the movement of the child. Substantial assistance in such cases, providing x-ray.
In favor of the tumor in most cases, they say the anamnesis, clinical course (resistance and duration of bleeding) and objective data of the research.
In acute polyhydramnios, which develops in the second half of pregnancy, there is a clear fluctuation, the woman feels the movement of the fetus, bleeding usually not observed, sometimes you can hear the heartbeat of the fetus. Diagnostic errors in the determination of pregnancy are eliminated when you study of pregnant; this reveals the absence of the characteristic features of a molar.
When flowed normally childbirth released on the last sometimes it is possible to note the partial rebirth of the villi in the bubbles.
The forecast. Cystic drift is a very serious complication. Prediction at it the worse, the longer it remains in the uterus, as is often the gallbladder skids can be a source of development horionepitelioma. The danger increases when corrosive form of a molar.
Mortality molar is estimated at approximately 10%. Death from bleeding molar noted in exceptional cases, often occur septic diseases as a result of decomposition lingering remnants of tissue, blood and fibrinous clots. In the literature there are indications about the possibility of thrombosis and sometimes panicucci diseases.
The task of the doctor is to deliver pregnant by draining its bleeding and remove the modified egg. In the future, the woman who had cystic skid, must be at least six months under the supervision of a doctor to immediately with the appearance of the characteristic features of horionepitelioma get radical assistance.
Chorionepithelioma most often appears on the b-8 weeks - after the removal or spontaneous birth eggs, struck a molar, much less commonly, through a year or more. Therefore, many authors recommend to watch the woman who had cystic skid, not less than one and a half to two years. These women need to examine periodically the urine by biological method Asheim-Condeca or produce here reaction to the frogs.
If there is a positive biological reactions Asheim - Condeca (or here) shows prophylactic purpose of androgens (methyltestosterone, testosterone propionate). Dose for a course of treatment is 2.5 to 3 g daily dose of 30 mg (1 tablet of methyltestosterone contains b mg), shall be made under the tongue three times a day 2 tablets. The testosterone propionate is appointed by intramuscular injection oil 2,5% (or 5%) solution 1 ml (25-30 mg) a day; in the course of six injections.
Treatment. Spontaneous birth of a molar occurs in 50-70% of all cases. To accelerate the expulsion reborn ovum it is necessary to strengthen often available, but not efficient enough of contractile activity of the uterus. With this purpose apply quinine, pituitrin and other similar tools.
Active intervention is appropriate only when the fever and bleeding. Because we often meet with corrosive form of a molar, all manipulations should be made with caution. Best of separating and highlighting of a molar to produce the finger method. If the bleeding is very strong and the cervical canal is quite open, and some eggs is in him, that, besides finger method, valid removal of the rests of the ovum tool method with a blunt curettes large and abortion-Tsang.
It is also possible expulsion eggs through careful squeezing his outer techniques.
Delete parts of the ovum through curettes may use only a doctor, fluent in operative technique.
In urgent cases (significant and heavy bleeding) when intractable neck apply the expansion of the cervical canal or dissection of the neck walls, and in exceptional cases - vaginal or brunetoochka caesarean section. If the uterus after the surgery well have been a cavity it is completely free from parts of skidding, the swab should not be entered; however, where this is uncertain and there is bleeding, valid introduction of a tampon on 2-4 h, as it will contribute to the reduction of the uterus and vyhodnou remnants of a molar. In cases of major bleeding appropriate introduction for a few minutes essential swab.
Inside or subcutaneously prescribed drugs LPV, injections of adrenaline and penicillin; recommended the introduction pituitrin.
When the gallbladder skid reached enormous proportions and the bubbles expand to the abdominal cover, produce a hysterectomy.
Ovarian cysts, developing molar, no need to remove; usually with the liquidation of a molar they disappear, although in the literature there are cases (K. N. Rabinovich, S. P. Vinogradov), when and after removal of a molar was observed the growth of cysts. With increasing cachexia and the growth of tumors should be deleted along with the uterus to avoid the development of horionepitelioma.