2. GTD
Heterogenous group of inter-related lesions that arise from
abnormal proliferation of placental trophoblasts
Histologically distinct and can be benign or malignant
BENIGN lesions- Hydatidiform moles ,
Complete mole ,
Partial mole
MALIGNANT lesions(GTN)- Invasive mole,
Placental site trophoblastic tumor(PSTT),
Epitheloid trophoblastic tumors(ETT),
Choriocarcinoma.
3. Malignant lesions are locally invasive and metastatic in
nature
GTNs are among the rare human tumors that can be
cured even in the presence of widespread
dissemination
Although GTNs commonly follow a molar pregnancy,
they can occur after any gestational event, including
induced or spontaneous abortion/ ectopic
pregnancy/term pregnancy.
4. HYDATIDIFORM MOLES
INCIDENCE- higher in Eastern countries than in the
West.
India and Middle East- 1:160 and 1:500
Malignant potential is higher in South East Asia(10-
15%) compared to western countries(2-4%).
Geographical and environmental factors plays a major
role.
5. Risk factors
Age –adolescents (7%)and women over 40 years (2-
10%)
Ova from adolescents and older women may be more
susceptible to abnormal fertilization
Diet deficiency- vitamin A, b- carotene, folic acid
Maternal age and nutrition influences the incidence of
complete mole than partial mole
6. Risk factors
Blood group A or AB are at slightly higher risk than
those with type B or O
Smoking
Previous h/o GTD-
-If one previous mole, 1% chance of
recurrence(vs. 0.1% in general population)
-if 2 previous moles, risk of recurrence increases
to 16-28%
Oral contraceptive use & h/o irregular menstruation
increases the risk for partial mole
7. Pathology
Based on morphology, histopathology and karyotype,
Hydatidiform mole
Complete mole Partial mole
8. Complete mole
Arise from an ovum fertilised by an haploid sperm,
which duplicates its own chromosomes.
Ovum nucleus may be absent or inactivated.
sperm empty egg 46,XX
23x 23X 23X
9. .
sperm empty egg 46,XY
They usually have 46,XX karyotype, but about 10% have
46,XY karyotype.
Molar chromosomes are entirely of paternal origin, with
mitochondrial DNA of maternal origin
23Y 23 X 23 X 23Y
10. Partial mole
They usually have triploid karyotype (69
chromosomes),the extra haploid set of chromosome is
derived from the father.
sperm normal egg 69,XXY
(69,XXX)
23Y 23 X 23X 23Y 23X
23 X 23X 23X 23X 23X
11. Recurrent molar pregnancy
Due to dysregulation of normal parental imprinting of
genes, with loss of maternally transcribed genes.
Recurrent complete molar pregnancy is due to
biparental origin, rather than the more usual
androgenetic origin.
Mutations in NLRP7 gene is responsible for abnormal
development of embryonic and extra embryonic
tissue.
12. Complete vs. partial mole
Complete mole Partial mole
Based on clinical findings
1. Fetus
2. Fetal vessels
ABSENT PRESENT( malformed/
IUGR)
Histologically
1) hydropic changes
2) trophoblastic
hyperplasia
Diffuse & placenta not
present
Marked
Focal
Mild to moderate
b- HCG VERY HIGH Comparatively low
Karyotype 46 XX ( paternally
derived)
69 XXY
MALIGNANT
POTENTIAL
15-20% rare
13. Clinical features
Vaginal bleeding – most common
-H/o passage of vesicles
- due to separation of molar tissues from decidua and
disruption of maternal vessels, and large volumes of
retained blood may distend the endometrial cavity
Uterine enlargement-
-doughy in consistency
-trophoblastic overgrowth and usually associated
with high levels of HCG
- External & internal ballotment cannot be elicited
and FHR cannot be heard in Doppler.
14. Clinical features
Theca lutein cysts ( 50%)- due to high level HCG
which cause ovarian hyperstimulation.
It regresses spontaneously after molar evacuation
usually within 2-4 months.
Partial mole have the signs & symptoms of missed/
incomplete abortion.
Asymptomatic (<1%)
15. Complications
Anaemia (5%) – due to prolonged bleeding
Pre eclampsia (27%)- before 24 weeks
Hyperemesis (8%)- may lead to electrolyte disturbances
Hyperthyroidism (7%)
Trophoblastic embolization-
-occurs after molar evacuation and they may
present with chest pain, dyspnea, tachycardia but within 72
hrs it can be resolved with cardiopulmonary support .
17. Diagnosis
Ultrasonography – most sensitive, quick & safe
1) Complete mole :
- characteristic vesicular pattern( SNOW STORM
) is seen as early as the first trimester.
-absence of fetal shadow
2) Partial mole :
-focal cystic spaces in placental tissues and there is
an increase in the transverse diameter of gestational sac.
-Malformed fetus / IUGR fetus and placenta are
visualised
18. Diagnosis
HORMONAL assays-
are mainly confined to post molar & post
chemotherapy follow up
Serum b- HCG level is very high in complete mole
than partial mole.
Human placental lactogen- low in C. Mole but raised
in P.mole, Pulmonary metastasis, PSTT.
Chest X- ray – to rule out pulmonary metastasis
CT scan- for liver / brain metastasis
Histopathology – for partial mole
19. Treatment
Evaluate for co existing conditions:
- history & physical
- CBC, coagulation profile, serum chemistry
- thyroid function
-blood type and cross match( trophoblast cells
express RhD factor, for RH-ve patients should receive
Rh immune globulin)
- pelvic USG and
- Chest X ray
21. Treatment
Hysterectomy – may be performed with the mole in
situ and for those who are willing for surgical
sterilization.
Ovaries may be preserved at the time of surgery, even
in presence of theca lutein cysts.
It does not prevent metastasis ; patients still require
follow up with assessment of HCG levels.
22. Follow up
After evacuation
weekly monitoring of HCG until normal for 3 consecutive
weeks
Monthly monitoring until normal for 6 consecutive months
& 3 monthly in first year / 6 monthly in second year.
Average time to achieve the first normal HCG after
evacuation is about 9 weeks.
23. Follow up
After achieving non detectable levels, the risk of
developing GTN approaches to be 0.
Encourage patients to use effective contraception
during HCG follow up and preferably pregnancy
should be avoided for 1 year.
Oral contraceptives are safe during follow up.
Incomplete evacuation will cause HCG levels to
remain elevated and interfere with proper follow up.
24. Follow up
Follow up for 2 years remains the only option for
detecting early choriocarcinoma .
Pelvic examination – to r/o vulval / vaginal metastasis.
USG abdomen – for theca lutein cysts
Chest X ray