Gestational trophoblastic disease for undergraduate
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undergraduate course lectures in Obstetrics&Gynecology Prepared by Dr Manal Behery,PROFESSOR OF OB&GYNE.Faculty of medicine,Zagazig University

undergraduate course lectures in Obstetrics&Gynecology Prepared by Dr Manal Behery,PROFESSOR OF OB&GYNE.Faculty of medicine,Zagazig University

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Gestational trophoblastic disease for undergraduate Presentation Transcript

  • 1. GestationalGestational Trophoblastic DiseaseTrophoblastic Disease
  • 2. ClassificationClassification 1.1. Hydatidiform (vesicular )moleHydatidiform (vesicular )mole Complete and PartialComplete and Partial 2.2. Invasive moleInvasive mole 3.3. ChoriocarcinomaChoriocarcinoma 4.4. Placental-site trophoblastic tumorPlacental-site trophoblastic tumor
  • 3. Vesicular moleVesicular moleVesicular moleVesicular mole Vesicular moleVesicular moleVesicular moleVesicular mole
  • 4. It is a benign neoplasm of the chorionic villiIt is a benign neoplasm of the chorionic villi characterized bycharacterized by 1.1. Marked proliferation of the trophoplast,bothMarked proliferation of the trophoplast,both the syncytium & cytotrophoplast are affected.the syncytium & cytotrophoplast are affected. 2.2. Oedema or hydropic degeneration of theOedema or hydropic degeneration of the connective tissue stroma of the villi which leadsconnective tissue stroma of the villi which leads to their distension and formation of vesicles.to their distension and formation of vesicles. 3.3. Avascularity of the villi: the blood vesselsAvascularity of the villi: the blood vessels disappear from villi explaining early death ofdisappear from villi explaining early death of the embryothe embryo • Hyperplasia of trophobasitc cells • Hydropic swelling of all villi • Vessels are usually absent Normal villaVM
  • 5. IncidenceIncidence  1:2000 pregnancies in United States and Europe,1:2000 pregnancies in United States and Europe, 10 times more in Asia.10 times more in Asia.  Predisposing factors includePredisposing factors include :: Race, deficiency of protein or caroteneRace, deficiency of protein or carotene  The incidence is higher toward the beginning andThe incidence is higher toward the beginning and more toward the end of the childbearing period.more toward the end of the childbearing period.  It is 10 times more in women over 45 years old.It is 10 times more in women over 45 years old.
  • 6. PathologyPathology The uterus is distended byThe uterus is distended by thin walled, translucent,thin walled, translucent, grape-likegrape-like vesiclesvesicles ofof different sizes.different sizes.  These areThese are degenerated chorionic villidegenerated chorionic villi filled withfilled with fluid.fluid.  There isThere is no vasculature in the chorionic villino vasculature in the chorionic villi leads to early death of the embryo.leads to early death of the embryo.
  • 7.  High hCG causesHigh hCG causes multiple theca lutein cystsmultiple theca lutein cysts in the ovaries in about 50% of cases.in the ovaries in about 50% of cases.  Cysts may reach a large size (10 cm or more.Cysts may reach a large size (10 cm or more.  Cysts disappearCysts disappear  within few months(2-3),within few months(2-3),  after evacuation of the mole.after evacuation of the mole. PathologyPathology
  • 8. (i) Complete mole(i) Complete mole  The whole conceptus is transformed into aThe whole conceptus is transformed into a mass of vesicles.mass of vesicles.  No embryoNo embryo is present.is present.  It is the result of fertilization of enucleatedIt is the result of fertilization of enucleated ovum ( has no chromosomes) with a spermovum ( has no chromosomes) with a sperm which will duplicate giving rise towhich will duplicate giving rise to 4646 chromosomeschromosomes ofof paternal originpaternal origin only.only.
  • 9. (i) Complete mole:(i) Complete mole:
  • 10. Complete moleComplete mole
  • 11. (ii) Partial mole(ii) Partial mole - A part of trophoblastic tissue only showsA part of trophoblastic tissue only shows molar changes.molar changes. - There is a fetus or at least an amniotic sac.There is a fetus or at least an amniotic sac. - It is the result of fertilization of an ovum by- It is the result of fertilization of an ovum by 2 sperms so the chromosomal number is 692 sperms so the chromosomal number is 69 chromosomeschromosomes
  • 12. Partial molePartial mole
  • 13. ((ii) Partial moleii) Partial mole
  • 14. Differentiation between complete and partial moleDifferentiation between complete and partial mole FeatureFeature Complete MoleComplete Mole Partial MolePartial Mole Embryonic orEmbryonic or foetal tissuefoetal tissue Absent Present Swelling of theSwelling of the villivilli Diffuse Focal TrophoblasticTrophoblastic hyperplasiahyperplasia Diffuse Focal KaryotypeKaryotype Paternal 46 XX (96%) or 46 XY (4%) Paternal and maternal 69 XXY or 69 XYY MalignantMalignant 5-10% Rare
  • 15. Diagnosis
  • 16. (A)(A) SymptomsSymptoms 1.1. AmenorrhoeaAmenorrhoea:: usually of short period (2-3usually of short period (2-3 months).months). 2.2. Exaggerated symptomsExaggerated symptoms of pregnancyof pregnancy especially vomiting.especially vomiting. 3.Symptoms of preeclampsia may be present as3.Symptoms of preeclampsia may be present as headache, and oedemaheadache, and oedema
  • 17. 4.4. Vaginal bleedingVaginal bleeding ::  The main complaint, due to separation of vesiclesThe main complaint, due to separation of vesicles from uterine wall, there may be a blood stainedfrom uterine wall, there may be a blood stained watery discharge, the watery part is from rupturedwatery discharge, the watery part is from ruptured vesicles.vesicles.  Prune juicePrune juice discharg may occur.discharg may occur.  passage of vesiclespassage of vesicles is diagnosticis diagnostic..  The blood may be concealed causing enlargementThe blood may be concealed causing enlargement & tenderness of the uterus.& tenderness of the uterus. (A) Symptoms(A) Symptoms
  • 18. 5.5. Abdominal painAbdominal pain ::- dull-aching- dull-aching ,-,- ColickyColicky oror Sudden And SevereSudden And Severe due to perforating moledue to perforating mole - Ovarian painOvarian pain due to stretching of the ovariandue to stretching of the ovarian capsule or complication in the cystic ovary ascapsule or complication in the cystic ovary as torsiontorsion (A) Symptoms(A) Symptoms
  • 19. Signs
  • 20. General examinationGeneral examination 1.1. Pre-eclampsiaPre-eclampsia in 20-30% of cases, usuallyin 20-30% of cases, usually before 20 weeks’ gestation.before 20 weeks’ gestation. 2.2. PallorPallor indicating anemia may be presentindicating anemia may be present.. 3.3. HyperthyroidismHyperthyroidism in 3-10% of casesin 3-10% of cases 4.4. .. 5.5. Breast signsBreast signs of pregnancy.of pregnancy.
  • 21. Abdominal examinationAbdominal examination 1.1. The uterus is >the period ofThe uterus is >the period of amenorrhoea in 50% of cases,amenorrhoea in 50% of cases, corresponds to it in 25% andcorresponds to it in 25% and smaller in 25% with inactive or dead mole.smaller in 25% with inactive or dead mole. 1.1. The uterus is doughy in consistency due toThe uterus is doughy in consistency due to absence of amniotic fluid and its distensionabsence of amniotic fluid and its distension with vesicles.with vesicles. 2.2. Fetal parts and heart sound cannot be detectedFetal parts and heart sound cannot be detected except in partial mole.except in partial mole.
  • 22. Local examinationLocal examination 1.1. Passage of vesicles (sure sign).Passage of vesicles (sure sign). 2.2. Bilateral ovarian cysts in 50% of cases.Bilateral ovarian cysts in 50% of cases. 3.3. No internal ballottement.No internal ballottement.
  • 23. (C) Investigations(C) Investigations Serum b -hCG levelSerum b -hCG level is highly elevated ( > 100.000 mIU/m1is highly elevated ( > 100.000 mIU/m1)) "" snow stormsnow storm" appearance,on US" appearance,on US no identifiable fetus,no identifiable fetus,  X-rayX-ray of the chest: should be performed inof the chest: should be performed in every case of trophoplastic tumouevery case of trophoplastic tumour.r.
  • 24. Partial Mole: Complex mass with manyPartial Mole: Complex mass with many cystic areas (between arrowheads) and ancystic areas (between arrowheads) and an embryo (arrow) in a patient with aembryo (arrow) in a patient with a ββ-HCG-HCG of 280,000 mIU/mlof 280,000 mIU/ml
  • 25. Complete MoleComplete Mole Complete mole:Complete mole: “snowstorm” appearance“snowstorm” appearance with multiple cystic areas, nowith multiple cystic areas, no fetal tissue presentfetal tissue present Corresponding T1 weightedCorresponding T1 weighted MRI (MRI can be helpful inMRI (MRI can be helpful in determining extent ofdetermining extent of trophoblastic disease)trophoblastic disease)
  • 26. A real-time ultrasound of a hydatidiform mole. The dark circles of varying sizes at the top center are the edematous villi.
  • 27. ComplicationsComplications 1.1. Haemorrhage.Haemorrhage. 2.2. InfectionInfection 3.3. Perforation.Perforation. 4.4. Pregnancy induced hypertensionPregnancy induced hypertension 5.5. Hyperthyroidism.Hyperthyroidism. 6.6. choriocarcinoma in about 5% of cases andchoriocarcinoma in about 5% of cases and 7.7. invasive mole in about 10% of cases.invasive mole in about 10% of cases. 8.8. Recurrent mole may occur(1-2%).Recurrent mole may occur(1-2%).
  • 28. TreatmentTreatment  molar pregnancy should be evacuated.molar pregnancy should be evacuated.  Suction dilation and curttageSuction dilation and curttage  20 units oxytocin in 500 m1 of 5% glucose20 units oxytocin in 500 m1 of 5% glucose should be infused IV after the start ofshould be infused IV after the start of evacuation and continued for several hours toevacuation and continued for several hours to enhance uterine contractilityenhance uterine contractility
  • 29. Dilatation of the cervixDilatation of the cervix is done up to a Hegar'sis done up to a Hegar's number equal to the period of amenorrhoea in weeksnumber equal to the period of amenorrhoea in weeks e.g. Ne.g. Noo. 10 Hegar for 10 weeks’ amenorrhoea. 10 Hegar for 10 weeks’ amenorrhoea - The suction canula used will beThe suction canula used will be - of the same size also.of the same size also. (I) Suction evacuation(I) Suction evacuation
  • 30. (I) Suction evacuation(I) Suction evacuation - A suction canula which may be metal or aA suction canula which may be metal or a disposable plastic (preferred) is introduceddisposable plastic (preferred) is introduced into the uterine cavity.into the uterine cavity. - The canula is connected to a suction pumpThe canula is connected to a suction pump adjusted at negative pressure of 300-500adjusted at negative pressure of 300-500 mmHg according to the duration of pregnancymmHg according to the duration of pregnancy
  • 31. The material removed is sent forThe material removed is sent for histological examination to excludehistological examination to exclude malignancymalignancy ..
  • 32. CurettageCurettage  After evacuation ,After evacuation ,  the uterus is gently curetted with a sharpthe uterus is gently curetted with a sharp curette.curette.  Some advise curettage one week afterSome advise curettage one week after evacuation to ensure complete removal,evacuation to ensure complete removal, but the is not the routine practice.but the is not the routine practice.
  • 33. Theca lutein cystsTheca lutein cysts  They are hormone dependent.They are hormone dependent.  Disappear spontaneously after evacuation ofDisappear spontaneously after evacuation of the mole.the mole.  So, they are not removed surgically unlessSo, they are not removed surgically unless complication occur as torsion or rupture.complication occur as torsion or rupture.
  • 34. Large bilateral theca lutein cysts resembling ovarian germ cell tumors. With resolution of the human chorionic gonadotropin(HCG) stimulation, they return to normal-appearing ovaries. Large bilateral theca lutein cysts resembling ovarian germ cell tumors. With resolution of the human chorionic gonadotropin(HCG) stimulation, they return to normal-appearing ovaries.
  • 35. (II)Hysterotomy(II)Hysterotomy may be needed for evacuation of a largemay be needed for evacuation of a large mole to minimize and facilitate control ofmole to minimize and facilitate control of bleeding.bleeding. should be considered in women >40 yearsshould be considered in women >40 years who have completed their family for fearwho have completed their family for fear of developingof developing choriocarcinoma.choriocarcinoma. (III) Hysterectomy
  • 36. (IV) Medical induction(IV) Medical induction Oxytocins and / or prostaglandins may beOxytocins and / or prostaglandins may be used to encourage expulsion of the moleused to encourage expulsion of the mole but must always be followed by surgicalbut must always be followed by surgical evacuation.evacuation.
  • 37. Follow upFollow up  detection of serum ß-hCG bydetection of serum ß-hCG by radioimmunoassay is essentialradioimmunoassay is essential  Normally B –subunit reach normalNormally B –subunit reach normal level 8-12 wks after evacuationlevel 8-12 wks after evacuation
  • 38.  ß-hCG is measured byß-hCG is measured by  radioimmunoassay every week till the testradioimmunoassay every week till the test becomes negative for 3 successive weeks, thenbecomes negative for 3 successive weeks, then the test is repeated every month for one year.the test is repeated every month for one year.  Pregnancy is allowed if the test remainsPregnancy is allowed if the test remains negative for one year.negative for one year. Follow upFollow up
  • 39. Follow upFollow up - Persistent high level or Rising hCG level afterPersistent high level or Rising hCG level after disappearance means developing ofdisappearance means developing of choriocarcinoma or a new pregnancy.choriocarcinoma or a new pregnancy. - Serum B-hCG is undetectable 4 months afterSerum B-hCG is undetectable 4 months after evacuation.evacuation. -
  • 40. Contraception during follow upContraception during follow up  The combined pill is started when the beta-The combined pill is started when the beta- HCG becomes negative. Till this happens,HCG becomes negative. Till this happens, the condom can be used.the condom can be used.  If the pill is used early the beta-HCG willIf the pill is used early the beta-HCG will take a longer time to become negative astake a longer time to become negative as oestrogen stimulates the growth ofoestrogen stimulates the growth of trophoplast.trophoplast.
  • 41. The intrauterine device is not used becauseThe intrauterine device is not used because it may lead to irregular uterine bleedingit may lead to irregular uterine bleeding which confuses the follow upwhich confuses the follow up IUD during follow upIUD during follow up
  • 42. Invasive moleInvasive mole oror ChorioadenomaChorioadenoma DestruensDestruens
  • 43. DefinitionDefinition  It is a trphoplastic tumour with penetrationIt is a trphoplastic tumour with penetration of the myometrium by the chorionic villi.of the myometrium by the chorionic villi.  It is locally malignantIt is locally malignant and rarely metastasizesand rarely metastasizes.. It may lead to perforationIt may lead to perforation of uterusof uterus
  • 44. A case of invasive mole: inside the uterine cavity the typicalA case of invasive mole: inside the uterine cavity the typical ““snow storm” appearance can be detected, The location ofsnow storm” appearance can be detected, The location of blood flow suggest an invasive mole.blood flow suggest an invasive mole.
  • 45. The same patient owing to the myometrial invasion.The same patient owing to the myometrial invasion. Reduced vascular resistance is detected in the uterine artery.Reduced vascular resistance is detected in the uterine artery.
  • 46. Early features suggesting persistant GTN orEarly features suggesting persistant GTN or post molar syndrome includepost molar syndrome include 1.1. Recurrent Or Persistent Vaginal BleedigRecurrent Or Persistent Vaginal Bleedig 2.2. SubinvoluationSubinvoluation 3.3. AmenorrhoeaAmenorrhoea 4.4. Persistence of ovarian enlargement.Persistence of ovarian enlargement. 5.5. No malignancy in endometrial biopsyNo malignancy in endometrial biopsy
  • 47. ChemotherapyChemotherapy  Started if persistant or malignant disease developStarted if persistant or malignant disease develop  The level of serum HCG doubles in 2 weeks), afterThe level of serum HCG doubles in 2 weeks), after exclusion of a new pregnancyexclusion of a new pregnancy  plateaus failure HCG to decrease over 3 weeks)plateaus failure HCG to decrease over 3 weeks) oror  the test for the hormone becomes positive afterthe test for the hormone becomes positive after being negative orbeing negative or  If metastases appear.If metastases appear.
  • 48. DefinitionDefinition A malignant form of GTD which canA malignant form of GTD which can develop from a hydatidiform mole or fromdevelop from a hydatidiform mole or from placental trophoblast cells associated with aplacental trophoblast cells associated with a healthy fetus ,an abortion or an ectopichealthy fetus ,an abortion or an ectopic pregnancy.pregnancy.
  • 49. Symptoms and signsSymptoms and signs  BleedingBleeding  InfectionInfection  Abdominal swellingAbdominal swelling  Vaginal massVaginal mass  Lung symptomsLung symptoms  Symptoms from other metastasesSymptoms from other metastases
  • 50. Doppler image of choriocarcinoma