gestational trophoblastic diseases, management and follow up. GTN- classification. molar pregnancy, compete mole partial mole, invasive mole

1. MANAGEMENT &
FOLLOW UP OF GTD
By RAVALI 2ND YEAR PG

2. 1. EVALUATE PATIENT
2. EVACUATE THE MOLE
3. MANAGEMENT Of THECA LEUTIN CYST
4. ROLE OF HYSTERECTOMY
5. FOLLOW UP
6. NATURAL HISTORY OF MOLAR
PREGNANCY
7. ROLE OF PROPHYLACTIC CHEMOTHERAPY
8. MANAGEMENT OF PREGNANCY AFTER
MOLE

3. ◦ associated medical complications
including preeclampsia
hyperthyroidism,
electrolyte imbalance
anemia.
◦ After the patient’s condition is stabilized-
Suction evacuation-(S/E), irrespective of period
of pregnancy.
Management of GTD-Mole
1. Evaluate patient-

4. 2. EVACUATION OF MOLE
Suction curettage-
1.Oxytocin infusion
2.Cervical dailatation
3.Suction curettage
4.Sharp curettage

5. Oxytocin infusion—started after cervical dilatation
Cervical dilation—As the cervix is being dilated, uterine
bleeding often increases (Retained blood in the endometrial cavity may be expelled during
cervical dilation) Active uterine bleeding should not deter the
prompt completion of cervical dilation.
Suction curettage—Within a few minutes of suction
curettage, uterine size may decrease & bleeding will be
controlled.
uterus - >14weeks of gestation, one hand should be
placed on top of the fundus, & massaged to stimulate
uterine contraction and reduce the risk of perforation.

6. Sharp curettage—When suction evacuation is completed, gentle sharp
sharp curettage is performed to remove any residual molar tissue.
◦ Rh–VE – GIVE ANTI-D
Because trophoblast cells express RhD factor, patients who are Rh negative should
receive Rh immune globulin at the time of evacuation
Informed consent
Hydration
Wide bore I.V canula
Blood should be cross matched
Stabilize pt- (htn, hyperthyroid, anemia)
Passage of uterine sound- avoided
Usually cervical dilatation not required
12 mm canula, tip should be just above int
os
Cannula not to be advance till fundus
Intraoperative usg guidenence may be
useful

7. 3.MANAGEMENT Of THECA LEUTIN
CYST
◦ Usually resolved spontaneously
◦ Pressure symptoms +
USG guided cyst aspiration may be done
◦ Torsion-
laparotomy and ovariotomy ( older days)
laproscopic manipulation treatment of choice

8. 4.HYSTERECTOMY
◦ If the patient desires surgical sterilization (age
>40yrs), a hysterectomy may be performed with the
mole in situ.
◦ The ovaries preserved- even in the presence of
prominent theca lutein cysts.
◦ Large ovarian cysts may be decompressed by
aspiration. Hysterectomy does not prevent
metastasis; patients still require follow-up with
assessment of hCG levels

9. 5. FOLLOW UP
◦ No marker to decide which molar pregnancy will proceed
to choriocarcinoma.
◦ Histological features no clue to the future behaviour of the
mole and its progression to carcinoma
◦ decision in the follow-up should not be influenced by
histology
◦ Follow-up for 2 years remains the only option for detecting
early choriocarcinoma (if it occurs, develops within this period of evacuation
of the mole)

10. ◦ A method of detecting persistent moles and development of
choriocarcinoma – estimation of the hCG level in the serum
and urine.
Human Chorionic Gonadotropin
◦ After evacuation, patients should be monitored with hCG
levels ( an hCG assay that can detect all forms of hCG including beta-hCG, core hCG, C-terminal hCG, nicked-free beta,
beta core, and preferably the hyperglycosylated forms, should be used. ) until these levels are
normal for 3 consecutive weeks, followed by monthly until the
levels are normal for 6 consecutive months.
◦ usually first normal hCG level after evacuation is about 8
weeks
◦ nondetectable serum hCG levels- risk of relapse is low

11. Post molar surveillance-by βhCG
levels
serum βhCG - within 48hrs after evacuation.
Serum βhCG once in 1 week, till 3 consecutive -ves (<5
mIU/L)
If βhCG becomes normal ≤8Wks after evacuation,
βhCG once in a month for 6 months from the time of evacuation
one month for partial mole.
If βhCG doesn’t become negative>8wks,
weekly βhCG until negative followed by monthly once until 6 months
from the time of first negative, then allowed pregnancy.

12. ◦ At Charing Cross Hospital, the hormone is measured in serum
and urine then in urine only for several months once values are
normal. If patients follow this protocol, the risk of missing
treatable disease is about 1:2000
◦ Other centres in the world have advocated using shorter follow-
up protocols, particularly for partial mole, where the risk of
malignancy is lower.
◦ This increases the risk of undetected malignant disease- do not
advocate shortening follow-up.

14. ◦ Pelvic examination -any vulval and vaginal metastasis, and the
uterine size is recorded.
◦ ovarian cyst -reduction in size noted
◦ CXR – to detect lung metastasis.
◦ Persistent uterine bleeding calls for a curettage-sent for HPE
{detect choriocarcinoma}
◦ Pelvic ultrasound scan can detect residual or locally invasive
tumour as well as an ovarian cyst.
◦ Pregnancy should be avoided preferably by barrier methods
for at least 1 year (preferably 2 years) as a fresh pregnancy
would interfere with the hCG levels .
Follow up cont.

15. ◦ Complete mole -15-20% to develop GTN
◦ Partial mole -0.1-5%
◦ Patient education –is crucial to understand and
comply with surveillance protocols
Why follow up is very imp?
(Post molar surveillance)

16. FOLLOW UP (contraception)
◦ During entire period of follow up - reliable
contraception
◦ Barrier methods- until Monthly βhCG reverts to
normal
◦ IUCD -after βhCG –ve (Because of the potential risk of uterine perforation, bleeding, and infection, IUCD
should not be inserted until the patient achieves a normal hCG level.)
◦ oral combined contraceptives pills may be used safely
after molar evacuation during the entire interval of
hormonal follow-up.(Oral combined pills lower the luteinizing hormone (LH) level
and thereby, the hCG level and can cause misinterpretation of results. )
◦ progestogen-only pills cause irregular bleeding

17. 6.NATURAL HISTORY OF MOLAR
PREGNANCY
• Resolution occurs in 80% of complete moles and 96% of
partial moles
• Molar pregnancies @high risk for development of persistent
GTN
- hcg > 1lakh mlIU/ml
-fundal height greater than POG
-bilateral thecal cysts
- respiratory distress after evacuation , eclampsia,
hyperthyroidism
- subinvolution of uterus, irregular bleeding p/v after
evacuation

18. 7.Prophylactic Chemotherapy
◦ Prophylactic chemotherapy -controversial.
◦ As exposing all patients to potentially toxic treatment
when only about 20% are at risk of developing
persistent tumor.
◦ Prophylaxis may be particularly useful -high-risk
complete molar pregnancy, especially when hCG
assessments for follow-up are unavailable or
unreliable.

19. 8.Management of pregnancy after mole
◦ Avoid conception -6 months after hCG normalize (molar
pregnancy)
◦ Persistent GTD- post chemotherapy -12 months in low risk
and 24 months in high risk
◦ Risk of subsequent molar pregnancy
>one molar --- 1-1.9%
>two molar --- 15-19%
◦ Next pregnancy -1st trimester USG
◦ H/P/E of Placenta or products- after each pregnancy
◦ β- hCG 6& 10 weeks after each subsequent pregnancy

20. Algorithm for diagnosis & management
of Hydatidform mole
(Complete or partial)
Physical and pelvic examination, Pelvic ultrasound
-Blood count, transfusion if needed
-Blood investigations(renal, hepatic, thyroid)
Baseline serum βhcg, Chest X-ray
Evacuation by suction
(Hysterectomy only if needed)
Monitor serum βhCG once in 1 week
EFFECTIVE contraception & follow up

21. Recurrence
◦ Consecutive mole cases tested for germline
mutations
◦ Mutations in germlines- NLRP7 ,KHDC3L
,PADI6 genes
◦ Mutant cases- assisted reproductive technique
with use of donor eggs recommended foe
future pregnancy

22. Criteria for Diagnosis of GTN (FIGO)
◦ β hCG –plateau across 4 measurements over a three week period
(days1,7,14,21) ( with in≤10% rise of the previous result)
◦ β hCG –rise >10% in 3 measurements over a two week
period (days1,7,14)
◦ βhCG remain elevated for >6 months
◦ Histological diagnosis of Chorio carcinoma

23. Staging of Gestational Trophoblastic Neoplasia
Stage I Disease confined to uterus
Stage II GTN extending outside uterus but limited to
genital structures (adnexa, vagina, broad
ligament)
Stage III GTN extending to lungs with or without
genital tract involvement
Stage IV All other metastatic sites

24. FIGO/WHO Risk Scoring System
0 1 2 4
Age (years) <40 >40
Antecedent pregnancy Mole Abortion Term
Interval between
pregnancy and start of
chemotherapy (months)
≤4 4 - 6 7 - 12 ≥12
Pre-treatment hCG
(mIU/mL)
≤ 103 103 - 104 104 - 105 ≥ 105
Largest tumour,
including uterine (cm)
- 3 -4 ≥ 5 -
Site of metastases
including uterus
lung Spleen,
kidney
Gastrointestinal
tract,
Brain
liver
Number of metastases 1 - 4 5 - 8 >8
Prior -failed
chemotherapy
--- --- single
drug
2or >
drugs
Total score: ≤ 6-low risk ≥7-high risk >12 Ultra high risk

25. REFERENCES
◦ International Society for the Study of Trophoblastic Disease, European
Organisation for the Treatment of Trophoblastic Disease, and the Gynecologic
Cancer InterGroup. Mangili G, Lorusso D, Brown J, Pfisterer J, Massuger L, Vaughan
M, Ngan HY, Golfier F, Sekharan PK, Charry RC, Poveda A, Kim JW, Xiang Y,
Berkowtiz R, Seckl MJ.Int J Gynecol Cancer. 2014 Nov;24(9 Suppl 3):S109-16. doi:
10.1097/IGC.0000000000000294. Review.PMID: 25341573
◦ Berek and novaks gynecology 16th edition
◦ Essentials of obstetrics – Poonam Sachdeva
◦ Shaw-16th edition
◦ https://www.bmj.com/bmj/section-
pdf/186556?path=/bmj/337/7667/Clinical_Review.full.pdf

26. CHEMOTHERAPY
ROLE OF SURGERY
FOLLOW UP IN
PERSISTANT TROPHOBLASTIC
DISEASES and WILL BE DISCUSSED
BY
DR.MEGHANA