Gestational Trophoblastic Disease

2. 1. Define “Gestational Trophoblastic Disease”.
2. Classify Gestational Trophoblastic Disease.
3. Describe the clinicopathological features of complete and incomplete
molar pregnancy.
4. Recognize the diagnostic values of S.B.HCG.
5. Differentiate the benign from malignant disease.
6. Discuss the significance of Persistent trophoblastic disease
7. Describe how to follow-up and contraception

3. INTRODUCTION
The term (GTD) describes a group of inter-related
diseases including the pre-malignant disorders of
partial and complete hydatidiform mole and the
malignant diseases or persistent GTD of invasive
mole, choriocarcinoma and the rare placental site
trophoblastic tumor,epitheloid trophoblastic
tumor(PSTT/ETT)
. It occurs when trophoblastic tissue which part of
blastocyst and normally invades the endometriaum
to form the placenta, proliferates abnormally and
aggressively.

4. Persistent GTD most commonly follows a molar pregnancy, it
can be seen any type of gestation including term
pregnancy ,abortion and ectopic pregnancy.
GTD produce hCG which is important in the diagnosis
management and follow-up of patients

5. EPIDEMIOLOGY
the incidence in the UK is approximately 1 in 2 thousand
pregnancies, compared with 1 in 200 in Asia.
Maternal age appears to be the most consistent risk factor
associated with molar gestation.
Pregnancy below the age 15 and over the age of 45year are
associated with a increase risk.
Woman who have had a previous mole have an increased risk.
Following one mole the risk is 1 in 2% and after two molar
pregnancies the risk is 15 to 20 %.
Occasionally family clusters ,underlying genetic disorder and
nutritional factor also appear to be risk factors.
With a low dietary intake of carotene and animal fat.

7. Pathogenesis of Partial H. Mole

9. DEFINITIONS
a hydatitiform mole: is a benign tumor of the trophoblast and be either
partial or complete.
Partial mole: this is the commonest type fetus or fetal tissue is present,
cells are triploid. Dried from two sperms and one egg and rarely
become malignant.
Complete mole: no fetus is present. The cells are entirely paternal in
origin usually occur when a sperm fertilize an empty egg and then
undergo mitosis so that the cells are diploid 80% or dispermic
fertilization20% maternal chromosomes are lost. There is five to ten
percent risk of malignant changes.
Invasive mole: this is a tumor like process invading the myometrium with
metastatic potential. It usually follow a complete mole may resolve
spontaneously.
Choriocarcinoma: this is arising form the trophoblast after a mole, a
miscarriage or even following a normal pregnancy.

10. The Snow storm appearance

11. Complete hydatidiform mole
 A sperm has fertilized an “empty”
egg (contains no nucleus or DNA).
 All the genetic material comes from
the father’s sperm. Therefore, there
is no fetal
tissue.46xx(monospermic80%,46xyd
ispermic20%)
 Up to 20% of patients with complete
moles will need additional surgery or
chemotherapy after their initial
surgery.
 Characteristic grape like structures,
usually diagnosed from uterine
products
Partial hydatidiform
mole
 Two sperm fertilize a
normal egg.
 These contain some fetal
tissue mixed in with the
trophoblastic tissue.
 No viable fetus is being
formed.
 Only a small percentage
of patients with partial
moles need further
treatment after initial
surgery.
 Often misdiagnosed as
hydropic abortion.
COMPLETE VS PARTIAL HYDATIFORM
MOLE

12. CLINICAL FEATURES
• Moles usually present with bleeding in early pregnancy.
• The clinical presentation of CHM as excessive uterine size
anemia, hyper emesis, preeclampsia, hyperthyroidism.
• Theca lutein cysts, The uterus is large for dates and
ultrasound may show a snowstorm appearance in second
trimester.
• Serum beta HCG and chest x-ray should be performed to
exclude metastases
• Invasive mole can produce heavy bleeding lower
abdominal pain. Or intraperitonial hemorrhage.
• The clinical features of PHM are usually less severe then
those of CHM. And condition is usually diagnosed on
histological review of curetting.

13. INVESTIGATIONS
Blood Tests
Beta subunit hCG
Diagnostic
Prognostic
Higher than normal levels of hcg when>200,000iul are
suggestive of molar pregnancy but inPHM the levels
rarely above normal
Normally after emptying the mole, the β-HCG regression
curve is steadily decreased, and reach normal level
within 9~14 weeks
Persistent mole: if the HCG is still positive 3 months
after the mole is completely emptied, called persistent
mole
Liver and kidney function test

14. • Ultrasound can identify most cases of GTD.
-is used to help diagnose a mole and find out if it is
invading local tissues.
• X-ray chest
More imaging tests will be done if after the mole has been
removed and the blood levels of HCG haven’t
disappeared
• Computed tomography (CT)
• Magnetic resonance imaging


15. MANAGEMENT
• suction curettage is the method of choice for evacuation of
molar pregnancy. Following suction curettage of a PHM
patient should have anti RhD prophylaxis.
• urgent histological analysis of tissue must be carried out.
• the patient should be registered with the regional
registration center.

16. PERSISTENT TROPHOBLASTIC DISEASE
• after any molar pregnancy the onset of malignant change
or persistent GTD is always indicated by:
- persistently elevated HCG
- or continuing clinical symptoms.
- Vaginal bleeding
- excessive uterine size.
• This occur 15% percent of CHM. And 1% of PHM.
• Periodic assays of urine and serum performed for six
months or longer. because majority of patients requiring
chemotherapy for persistent disease.

17. ROLE OF SURGERY.
• At present there are 2 indication for
hysterectomy to control severe uterine hemorrhage
and to eliminate disease that is confined to the
uterus and resistant to chemotherapy
PSTT,ETT.

18. FOLLOW UP.
All patients with confirmed PHM and CM require detail follow up
serum beta HCG samples should be obtained at 2 weekly
intervals post evacuation. Until normal levels are reached.
Following these urinary beta HCG samples are requested at 4
weekly interval.
If patients BhCG value reach normal range within 8 weeks of
post evacuation follow-up limited to 6 months. for patients
who do not have normal BhCG within 8 wreaks of
evacuation,folloup extended for 2years.
Follow-up is currently for life, an hCG sample is requested six
and ten weeks at the end of each new pregnancy.

19. CONTRACEPTION.
A low dose contraceptive pill have failed to show any
evidence of increased risk of malignant sequel after
molar pregnancy .CCOP,HRT are safe to use after
hcg level normal.
There is a agreement that the intrauterine devices
should be avoided until HCG level are normal
because of risk of uterine perforation and bleeding.
Women should be advised not to conceive until the hcg
level has been normal for six months or follow up has
been completed