Gestational trophoblastic disease, obstetric and gynecology

1. GESTATIONAL
TROPHOBLASTIC
DISEASE
Maryam Majid AL-Ezairej
Obstetrics and gynecology
Collage of medicine, RAKMHSU

2. objectives
 Introduction
 pathophysiology
 Clinical features
 Work up
 Management
 Follow up

3. Introduction
 Gestational trophoblastic disease (GTD) forms a group of disorders spanning
the conditions of complete and partial molar pregnancies through to the
malignant conditions of invasive mole, choriocarcinoma and the very rare
placental site trophoblastic tumour (PSTT).
 Molar pregnancies can be subdivided into complete (CM) and partial moles
(PM) based on genetic and histopathological features.

4. Background
 Complete moles are diploid and androgenic in origin, with no evidence of
fetal tissue.
 Complete moles usually (75–80%) arise as a consequence of duplication of a
single sperm following fertilisation of an ‘empty’ ovum.
 complete moles (20–25%) can arise after dispermic fertilisation of an ‘empty’
ovum.
 Partial moles are usually (90%) triploid in origin, with two sets of paternal
haploid genes and one set of maternal haploid genes.
 Partial moles occur, in almost all cases, following dispermic fertilisation of an
ovum. 10%of partial moles represent tetraploid or mosaic conceptions.
 In a partial mole, there is usually evidence of a fetus or fetal red blood cells.
 GTD (hydatidiform mole, invasive mole, choriocarcinoma, placental-site
trophoblastic tumour) is a rare event

7. CLINICAL FEATURES
 The classic features of molar pregnancy are irregular vaginal bleeding,
hyperemesis, excessive uterine enlargement and early failed pregnancy.
 Absence of Fetal parts & FHR
 Vaginal passage of hydropic vesicles (White Currant in red currant jelly-
passage of moles per vagina)
 Rarer presentations include hyperthyroidism, early onset pre-eclampsia or
abdominal distension due to theca lutein cysts.
 Clinicians should check a urine pregnancy test in women presenting with such
symptoms.

8. WORK UP
 URINE PREGNANCY TEST
 Base line HCG
 Baseline chest x-ray
 Complete blood count , Blood for ABO & Rh
 Clotting function studies
 Tests for associated medical complications
 IMAGING
 ultrasound
 Contrast CT scan of the abdomen and pelvis
 Chest CT
 MRI of the head (preferable to CT) – Only if lung metastasis or persistent mole

9. Diagnosis of molar pregnancy
 HCG levels
 Much Elevated compared to a normal pregnancy of
similar gestational age
 Ultrasound examination is helpful in making a pre-evacuation
diagnosis but the definitive diagnosis is made by histological
examination of the products of conception.

10. Ultrasound
 Complete mole:
 Ultrasound shows central
heterogeneous mass with
numerous anechoic spaces
(swelling of hydropic chorionic villi);
“snowstorm pattern”
 Partial mole:
 Fetus, often growth restricted,
reduced amniotic fluid, “swiss
cheese pattern” of chorionic villi .

11. Management
Principles-Immediate Evacuation
-Follow up
Termination methods
 Suction Evacuation (Treatment of choice)
• In combination with oxytocin
• Curettage is done at the end
• Intraoperative USG helps
 Hysterectomy:
 Age of the patient (>40 years)
 No desire to preserve fertility
 Malignant potential

12. Follow up
 Serum βHCG* tested
 Within 48 hours after evacuation
 Every 2 weeks till normal
 Then monthly for 6 months
*any rise/persistent plateau in levels should prompts evaluation &
treatment
 Contraception
 Abstinence or barrier before hCG normalization
 OCP is started after hCG normalizes
 Must be used during the entire follow-up period
 At least 6 months / preferred 1 year

13. FOLLOW UP

14. GTD
Benign
(Hydatidiform
mole)
Complete
Partial
Persistent (Invasive
mole)
Malignant
Non-metastatic
(PSTT)
Metastatic
(Choriocarcinoma)

15. INVASIVE MOLE
 Histologically identical to complete mole
 Invades myometrium without intervening stroma
 Diagnosis
 Persistence of HCG
 By MRI
 Best diagnosis: histology
 Treatment
 Chemotherapy
 Surgery

16. Choriocarcinoma
 Malignant form
 May follow
 Histologically: no villi structure
 Rapid myometrium invasion , uterine vessel invasion & systemic metastasis by
embolization
 Abnormal bleeding for >6 weeks after any pregnancy should be evaluated
 LOOK FOR SYSTEMIC METS (CT scan/PET scan)
 Most common sites of metastasis are lungs & genital tract
 If metastases are present, signs and symptoms associated with the metastatic
disease, such as hemoptysis, abdominal pain, hematuria, and neurologic
symptoms, may be present.

17. Investigation
 Serum quantitative hCG
 CBC
 Liver enzymes
 Pelvic ultrasonography
 Chest radiograph(staging)
 CT scan of the chest (optional): Micro-metastases detected
 CT scan of the abdomen and pelvis
 Contrast CT and MRI of the head

18. Staging and scoring
International Federation of Gynecology and Obstetrics staging
 Stage I – Confined to the uterus
 Stage II –Limited to the genital structures
 Stage III-Lung metastases
 Stage IV –Other metastases

19. FIGO SCORE

20. Management of choriocarcinoma
 Decided by revised FIGO scoring system
 Non-metastatic - by Methotrexate or Actinomycin D
 Score ≥7 needs multi agent chemotherapy
 Radiotherapy is added for brain or liver metastasis
 PROGNOSIS
 Cure rates for non metastatic & good prognosis choriocarcinoma ≈ 100%
 Poor prognosis is 80-90%
 Indications for surgery
 Control of hemorrhage
 Remove chemo resistant disease