Molar Pregnancy 葡萄胎妊娠
After a sperm fertilizes an egg, new tissues develop that normally form the fetus and placenta. A molar pregnancy, also known as gestational trophoblastic disease, occurs when the tissue that was supposed to form the placenta grows abnormally and can form a tumor that can spread beyond the womb or uterus.
卵子受精后，通常会有新的组织生成以形成胚胎和胎盘。葡萄胎妊娠，又称为妊娠滋养细胞疾病，是由这些本应发育成为胎盘的组织异常增生导致的，且这些组织可能形成肿瘤扩散到子宫外。
Molar pregnancy occurs in approximately one in a thousand pregnancies in the United States. The rate is higher in women of advanced maternal age and of Asian descent (1).
在美国，葡萄胎妊娠在所有妊娠中的发生率大约为1/1000，高龄产妇和亚裔人群的病发率更高。
The classic presentation of a molar pregnancy includes vaginal bleeding, passage of vesicles per vagina, uterine enlargement greater than expected for gestational age, and abnormally high levels of β-hCG. However, in one study 40% of molar pregnancies were asymptomatic, 60% presented with vaginal bleeding and 2% with hyperemesis symptoms (2).
葡萄胎妊娠的典型症状包括阴道流血，阴道排出物见到水泡状组织，子宫异常增大和异常高的HCG水平。不过，一项研究发现40%的葡萄胎妊娠无症状，60%有阴道流血的表现，2%出现呕吐症状。
Due to availability of present day ultrasound technology, many molar pregnancies are identified early in gestation as abnormal intrauterine pregnancies, and the diagnosis is confirmed later by pathology. On ultrasound, the typical “snowstorm” appearance is less likely to be seen in the first trimester. More commonly, an anembryonic pregnancy is detected. Only 40% of women with confirmed hydatidiform mole had a preevacuation ultrasound diagnosis suggesting molar pregnancy. The sensitivity, specificity, and positive and negative predictive values for routine pre-evacuation ultrasound examination for hydatidiform mole are 44%, 74%, 88%, and 23%, respectively (3). Molar pregnancy is often diagnosed after treatment of a failed pregnancy. However, if it is suspected preoperatively, suction dilation and curettage is the preferred route of uterine evacuation to ensure complete removal and to allow pathologic evaluation of the tissue (4). A quantitative β-hCG level, complete blood count, and chest x-ray should be obtained preoperatively. Additional laboratory tests may be indicated if there are signs of hyperthyroidism and preeclampsia.
通过现代超声波检查技术，许多葡萄胎妊娠可以在早期被确定为子宫内异常妊娠，并通过后期病理检查证实诊断。孕早期的超声波检查不太可能能看到葡萄胎妊娠典型的“暴风雪”外观，更常见的是检测到无胚胎妊娠。确诊为葡萄胎妊娠的女性中，在手术前通过超声波检查提提示有葡萄胎妊娠的占比仅为40%。常规葡萄胎妊娠的术前超声波检查的敏感性，特异性以及阳性和阴性预测值分别为44%，74%，88%和23%。葡萄胎妊娠通常在治疗妊娠失败后才被诊断出来。但是，如果在手术前怀疑为葡萄胎妊娠，则最好采用抽吸术和刮宫术处理，以确保完全清除子宫内病变组织并进行组织病理评估(4)。手术前应当检测HCG水平，血常规和照胸部X光。如果患者有甲亢和先兆子痫的症状，则可能需要进行其他检查。
Surgical evacuation in the operating room is recommended for uterine size greater than 16 weeks, due to the increased risk of hemorrhage. Hysterectomy can be considered for women who have completed childbearing. Following uterine evacuation, the quantitative β-hCG level should be followed every one to two weeks until negative and then monthly for an additional six months. A plateau or rise in the β-hCG should trigger evaluation for a new conception, and if excluded, prompt referral for treatment of gestational trophoblastic disease. Women diagnosed with molar pregnancy should use an effective method of contraception during the six-month follow-up period.
由于子宫出血风险增加，因此建议对子宫大小超过孕16周的患者进行清宫手术。对于已经完成生育计划的女性，可以考虑行子宫切除术。在做完清宫手术后，应每1-2周随访检测HCG水平直至降到阴性范围，之后半年内每月做一次HCG水平复查。HCG水平保持稳定或者有所增加时，需要检查是否有新妊娠，如果排除新妊娠，则判断为妊娠滋养细胞疾病，应当立即转诊接受治疗。被诊断患有葡萄胎妊娠的妇女应在其后六个月的随访期内使用有效的避孕方式。
References
参考文献
1. Di Cintio E, Parazzini F, Rosa C, et al. The epidemiology of gestational trophoblastic disease. Gen Diagn Patho 1997;143:103-8.
2. Germer O, Segal S, Kpomar A, Sassoon E. The current clinical presentation of complete molar pregnancy. Arch Gynecol Obset 2000;264:33-4.
3. Sebire NJ, Markrydimas G, Agnatis NJ, et al. Updated diagnosis criteria for partial and complete hydatidiform moles in early pregnancy. Anticancer Res 2003;23:1723-8.
4. Doll KM, Soper JT. The role of surgery in the management of gestational trophoblastic neoplasia. Obstet Gynecol Surv 2013;68:533-42. Doi: 10.1097/OGX. 0b13e31829a82df.
