This document discusses gestational trophoblastic disease (GTD), including classifications, genetics, risk factors, clinical features, investigations, management, and follow up. GTD includes benign, non-neoplastic lesions like molar pregnancies as well as gestational trophoblastic neoplasms. Molar pregnancies are classified as complete or partial moles. Complete moles usually arise from abnormal fertilization, while partial moles are usually triploid. Follow up of molar pregnancies involves monitoring beta-hCG levels to detect persistent trophoblastic disease.
16-Aug-2021-"Gestational trophoblastic disease (GTD) is a spectrum of abnormal growth and proliferation of the trophoblasts of the placenta that continue even beyond the end of pregnancy of the placenta".
Ectopic pregnancy refers to the pregnancy occurring outside the uterine cavity, predominantly i.e. 90% of them in the fallopian tube. Ectopic pregnancy affects 11 in 1000 pregnancies and is a significant cause of morbidity and at times mortality in the first trimester of pregnancy. In a 20-year longitudinal study on ectopic pregnancy in a defined
population of women aged 15e39 years the rate of ectopic pregnancy per 1000 diagnosed conceptions increased
from 5.8 during 1960e4 to 11.1 during 1975e9. The mean annual incidence of ectopic pregnancy per 1000 women
increased from 0.6 to 1.2 during the same period. The numbers of ectopic pregnancies per 1000 diagnosed
conceptions increased with increasing age of the women and were 4.1 in the teenage group, 6.9 in women aged
20e29 years, and 12.9 in women aged 30e39.
16-Aug-2021-"Gestational trophoblastic disease (GTD) is a spectrum of abnormal growth and proliferation of the trophoblasts of the placenta that continue even beyond the end of pregnancy of the placenta".
Ectopic pregnancy refers to the pregnancy occurring outside the uterine cavity, predominantly i.e. 90% of them in the fallopian tube. Ectopic pregnancy affects 11 in 1000 pregnancies and is a significant cause of morbidity and at times mortality in the first trimester of pregnancy. In a 20-year longitudinal study on ectopic pregnancy in a defined
population of women aged 15e39 years the rate of ectopic pregnancy per 1000 diagnosed conceptions increased
from 5.8 during 1960e4 to 11.1 during 1975e9. The mean annual incidence of ectopic pregnancy per 1000 women
increased from 0.6 to 1.2 during the same period. The numbers of ectopic pregnancies per 1000 diagnosed
conceptions increased with increasing age of the women and were 4.1 in the teenage group, 6.9 in women aged
20e29 years, and 12.9 in women aged 30e39.
Pathology of Ectopic pregnancy, spontaneous abortion and gestational trophobl...Sufia Husain
DISORDERS OF PREGNANCY AND PLACENTA.
Pathology of ECTOPIC PREGNANCY, SPONTANEOUS ABORTION AND GESTATIONAL TROPHOBLASTIC DISEASE for medical and health care students
Abortion Including Recurrent Abortion And Septic Abortion.pptxDeepekaTS
Abortion is defined as the spontaneous or induced termination of pregnancy
before fetal viability. Many prefer miscarriage for spontaneous loss.
abortion as
loss or termination of a pregnancy with a fetus aged younger than 20 weeks’
gestation or weighing <500 g.
Of all miscarriages, approximately half are euploid abortions, that is, carrying a normal chromosomal complement.
Most common abnormalities are
trisomy, found in 50 to 60 percent;
monosomy X, in 9 to 13 percent; and
triploidy, in 11 to 12 percent
A prominent miscarriage risk is associated with poorly
controlled diabetes mellitus, obesity, thyroid disease, and systemic lupus
erythematosus. In these, inflammatory mediators may be an underlying theme
to pregnancy loss.
For women undergoing cancer treatment, direct therapeutic radiation can
cause miscarriage.
Recurrent miscarriages need to be investigated actually. You had live births but now had four consecutive miscarriages. It is better to have a thrombophilia screen and products of conception needed to be send out for histopathology to check any chromosomal, congenital, structural anomaly.
Read More:https://www.icliniq.com/qa/miscarriage/why-am-i-having-frequent-miscarriages
Introduction
Natural conception
Epidemiologic figures
Factors affect the natural conception rate
Causes of subfertility
Female causes of subfertility
ovulation
Ovarian problems
Marker of ovarian reserve
Tubal blockage
Endometrial factors
Uterine factors
Cervical factors
History and PE
Investigations
Treatment
Male subfertility
Hypothalamic-pituitary disease
Obesity
Primary hypogonadism
Sperm transport disorders
Defective ejaculation
History and PE
Investigations
Surgical sperm retrieval
Cryopreservation of gametes
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
4. Partial Mole Complete Mole(46XX or XY
Normal Fetus with
the Placenta
Triploidy 69XXY
11/26/2019 Reproductive Health Module AL2013
5. 46xx
23x
Proliferation of
monospermic
androgenetic
complete HM
Duplication
of haploid
sperm
Maternal DNA
lost from
ovum
46xy
23x
Proliferation of
dispermic
androgenetic
complete HM
Two paternal
genetic
contributions
Maternal DNA
lost from
ovum
69xxx
23x
Proliferation of
triploid
partial HM
Maternal and two
paternal genetic
contribution
69xxy
11/26/2019 Reproductive Health Module AL2013
Complete moles usually (75–80%) arise as a consequence
of duplication of a single sperm following fertilization of
an ‘empty’ ovum. Some complete moles (20–25%) can
arise after dispermic fertilization 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 fertilization of an ovum.
7. TERMINOLOGY- Gestational
trophoblastic disease (GTD)
Benign, non-neoplastic trophoblastic
lesions
Lesions characterized by abnormal proliferation of
trophoblast of the placenta.
This category is comprised of benign, non-neoplastic
lesions,
Placental site nodule,
Exaggerated placental site,
Hydatidiform mole.
Complete hydatidiform mole
Partial hydatidiform mole
Invasive mole (chorioadenoma destruens)11/26/2019 Reproductive Health Module AL2013
8. Gestational trophoblastic neoplasia (GTN)
Gestational neoplasms include:
invasive mole
epithelioid trophoblastic tumor
choriocarcinoma
placental site trophoblastic tumor,
In the absence of tissue for a definitive
histopathologic diagnosis, disease diagnosed
as a result of persistent elevation of human
chorionic gonadotropin (hCG) after
evacuation of a molar pregnancy is termed11/26/2019 Reproductive Health Module AL2013
9. Types of GTD — There are various
histologically distinct subtypes of GTD
Benign, non-neoplastic trophoblastic lesions —
These lesions are frequently diagnosed only as an
incidental finding on an endometrial curettage or
hysterectomy specimen.
●Exaggerated placental site
●Placental site nodule
Hydatidiform mole — Hydatidiform moles result from
abnormalities in fertilization. They are essentially
benign, but carry an increased risk of persistent or
malignant gestational trophoblastic neoplasia (GTN).
●Complete hydatidiform mole
●Partial hydatidiform mole
●Invasive mole (chorioadenoma destruens)
11/26/2019 Reproductive Health Module AL2013
11. Hydatidiform Mole
Complete Hydatidiform Mole(46XX or 46XY)
Partial Hydatidiform Mole(69XXY)
11/26/2019 Reproductive Health Module AL2013
12. Incidence
The incidence of molar pregnancy in
Southeast Asia is 7 to 10 times higher
than in Europe or North America.
In Taiwan, for example, the reported
incidence of molar pregnancy is 1 in
125, as compared with an incidence of
1 in 1500 live births in the United
States.
11/26/2019 Reproductive Health Module AL2013
13. Incidence
Complete mole – 1: 1000 pregnancies
Partial Mole - 1: 3000 Pregnancies
Choriocarcinoma - 1: 50000 following normal
deliveries
(29% - 83% following complete mole)
Placental site Trophoblastic Tumour – Rare
11/26/2019 Reproductive Health Module AL2013
14. Risk Factors
Age
Increasing age is the best-established risk factor for
complete molar pregnancy, women over 40 years of
age having a 5 to 10-fold higher risk than younger
women.
Because of the higher number of pregnancies in
younger women, however, most complete moles
occur in women under 35.
Lowest risk – Age 25 – 29 years
6 times higher – Age less than 15 yrs.
4 times higher - Age 40- 45 yrs.
400 times higher – over 50 yrs.
Maternal age has not been associated with risk of
partial molar pregnancy.
11/26/2019 Reproductive Health Module AL2013
15. Risk Factors
History of previous GTD
Increases the risk
1 previous – 1:76
Women with a prior molar gestation have a
1% risk of repeat mole, approximately 10
times the risk of molar pregnancy in the
general population.
2 previous - 1: 6.5
Histories of prior spontaneous abortion or
infertility are risk factors for both complete
and partial molar pregnancy.
11/26/2019 Reproductive Health Module AL2013
16. CLINICAL FEATURES
Hydatidiform Mole
Vaginal Bleeding
Hyperemesis Gravidarum
Passing grape like structures
Hyperthyroidism - Signs and symptoms of
hyperthyroidism can be present due to stimulation of
the thyroid gland by the high levels of circulating hCG
or by a thyroid stimulating substance (ie, thyrotropin)
produced by the trophoblasts. Clinical
hyperthyroidism has been reported in 3.7% of women
with a hydatidiform mole diagnosed after the
10th week of gestation
11/26/2019 Reproductive Health Module AL2013
17. CLINICAL FEATURES
Features of metastasis/embolization - Lung
metastases are found in 4-5% of patients with a complete
hydatidiform mole and rarely in cases of partial hydatidiform
moles.
PARTIAL MOLE EXIBITS LESS INTENSE
FEATURES –
Uterine enlargement and preeclampsia is reported in
only 5% of patients. Theca lutein cysts, hyperemesis,
and hyperthyroidism are extremely rare.
11/26/2019 Reproductive Health Module AL2013
18. Examination
Uterus more than dates
Preeclampsia
Theca lutein cysts: These are ovarian cysts
greater than 6 cm in diameter and
accompanying ovarian enlargement.
11/26/2019 Reproductive Health Module AL2013
21. Complete Hydatidiform Mole
microscopy
Complete hydatidiform moles
have edematous placental villi,
hyperplasia of the
trophoblasts, and lack or
scarcity of fetal blood vessels.
11/26/2019 Reproductive Health Module AL2013
In the partial hydatidiform mole
fetal tissue is often present, as
well as amnion and fetal
vessels with fetal red blood
cells within the mesenchyme of
the villi. Like in complete
hydatidiform moles, hydropic
(oedematous) villi and
26. Management
Stabilize the patient.
Transfuse for anemia, and correct any coagulopathy.
Treat hypertension.
Watch for and be prepared to treat thyroid storm, a
rare complication.
Administer Rh immune globulin to nonsensitized
RhD-negative women because of the possibility of a
partial mole with fetal erythrocytes that express the
RhD antigen. (RhD is not expressed in human
trophoblast cells.)
11/26/2019 Reproductive Health Module AL2013
27. Management
Evacuation – Suction evacuation is best
oxytocins, Prostaglandins -.
Prostaglandin or oxytocin induction is not
recommended because of the increased risk of
bleeding and malignant sequelae.
11/26/2019 Reproductive Health Module AL2013
28. Follow- up
How
How often
How long
AVOID PREGNANCY – Need
Contraception
(Barrier Method Recommended)
11/26/2019 Reproductive Health Module AL2013
29. Follow up
• Serum hCG levels are obtained weekly until the
levels are within reference range for 3-4 weeks.
• Levels should consistently drop and should never
increase.
• Normal levels are usually reached within 8-12 weeks
after evacuation of the hydatidiform mole. As long as
the hCG levels are falling intervention is not needed.
• Once levels have reached the reference range for 3-4
weeks, check them monthly for 6 months. Once in 2
months for another 6 months
• If the serum hCG levels plateau or rise, the patient is
considered to have malignant disease (ie, gestational
trophoblastic neoplasia) and metastatic disease11/26/2019 Reproductive Health Module AL2013
30. Use of the monitoring serum hCG
following evacuation of Hydatidiform
moleMole evacuation
Days1000 50
10
100
1000
1000000
100000
10000
1 150
Start
treatment
Stop
treatment
11/26/2019 Reproductive Health Module AL2013
31. The risk of gestational trophoblastic neoplasia
(GTN), malignant disease, is higher for
complete than partial mole. GTN, usually
invasive mole (IM) or Choriocarcinoma,
develops in 15 to 20 percent of women with
complete mole and 1 to 5 percent of women
following partial mole.
11/26/2019 Reproductive Health Module AL2013
32. Gestational Trophobalstic Neoplasia
Invasive Mole
Choriocarcinoma – Following
Complete Mole
Partial Mole
Abortion
Normal Pregnancy
Placental site trophoblastic tumour
11/26/2019 Reproductive Health Module AL2013
33. Gestational Trophoblastic Neoplasia(GTN)
Hydatidiform mole (60%)
Previous spontaneous abortion/abortion
(30%)
Normal pregnancy or ectopic gestation (10%)
GTN most commonly follows hydatidiform mole
as a persistently elevated hCG titer. There may
also be continuing and recurring bleeding after
a mole.
11/26/2019 Reproductive Health Module AL2013
37. CLINICAL FEATURES
Choriocarcinoma
30% presents with symptoms due to
metastasis
Pulmonary – Parenchymal, Pleural or
embolization
Cerebral - Focal signs, Haemorrhage
Hepatic - Pain, hepatomegaly
11/26/2019 Reproductive Health Module AL2013
38. Gestational Trophobalstic Neoplasia
Placental Site Trophoblastic Tumour
Following
Complete Mole
Abortion
Normal Delivery
This is a rare slow growing malignant tumour
which produces little HCG
11/26/2019 Reproductive Health Module AL2013
39. CLINICAL FEATURES
Placental site trophoblastic tumour
Slow growing
Late metastasis
Produces HPL – Amenorrhoea
Galactorrhoea
hcg – usually low
11/26/2019 Reproductive Health Module AL2013
40. Epithelioid trophoblastic tumor(Rare)
Clinical Features
Epithelioid trophoblastic tumor (ETT) is derived from the
chorionictype intermediate trophoblast. Rarely, ETT can
coexist with choriocarcinoma or PSTT. The majority of
ETT occurs in the reproductive age group. Patients often
have symptoms resembling those in PSTT and about 70%
of patients have abnormal vaginal bleeding. The serum
hCG level is usually mildly elevated. Similar to PSTT,
ETT is not chemosensitive and it is mainly treated by
surgery.
11/26/2019 Reproductive Health Module AL2013
41. Clinical Features
Hydatidiform Mole
Bleeding
Passing grape like
structures
Uterus more than dates
Hyperemesis
PIH
Theca lutein cysts
Hyperthyroidism
Invasive Mole
Persistent vaginal
bleeding
Haematuria
Rectal bleeding
Respiratory symptoms
Rising HCG
Choriocarcinoma
30% presents with
symptoms
due to metastasis
Pulmonary
Parenchymal,
Pleural
or embolization
Cerebral –
Focal signs,
Haemorrhage
Hepatic -
Pain, hepatomegaly
Placental site
trophoblastic tumour
Slow growing
Late metastasis
Produces HPL –
Amenorrhoea
Galactorrhoea
11/26/2019 Reproductive Health Module AL2013
43. Management of GTN
1. Clinical examination (watch for vaginal metastasis).
2. Serial weekly hCG measurements on serum.
3. Complete blood count and platelets. PT, PTT,
fibrinogen, BUN, creatinine, liver function tests.
4. Chest X-ray.
5. Brain, MR (or CT) scan when there is any suspicion of
cerebral metastases.
6. Liver CT scans when indicated. A whole body CT scan
is normally performed in patients who have lung
metastases.
11/26/2019 Reproductive Health Module AL2013
44. 7. Curettage should be performed if there is uterine
bleeding Biopsies may be obtained from accessible sites.
There is severe risk of hemorrhage at the biopsy site.
8. MRI when indicated.
9. T4, thyroid studies when indicated.
10. Selective scanning using anti-hCG antibody linked to
radioactive iodine or indium may be done if there is
persistent disease resistant to chemotherapy
11/26/2019 Reproductive Health Module AL2013
45. A score of 6 or less is low-risk disease treatable by single agent
chemotherapy. A score of 7 or greater is high-risk disease that requires
combination chemotherapy
11/26/2019 Reproductive Health Module AL2013
47. Chemotherapy regimen for low-
risk patients
Methotrexate (MTX) -50 mg by IM injection
repeated every 48h x 4 doses
Leucovorin(folinic acid) -15mg orally 30h after
each injection of MTX
Courses repeated every 2 weeks, i.e. days 1,
15, 29, etc.
Actinomycin D - Appears more effective
11/26/2019 Reproductive Health Module AL2013
48. Chemotherapy regimen for high
risk patients - EMA/CO
Day 1 Etoposide
Actinomycin D
Methotrexate
100mg/m2 by IV infusion over 30 min
0.5 mg IV bolus
300mg/m2 by IV infusion over 12 h
Day 2 Etoposide
Actinomycin D
Folinic acid rescue
starting 24 h after
commencing the MTX
infusion
100mg/m2 by IV infusion over 30 min
0.5mg IV bolus
15mg IM or orally every 12h x 4 doses
Day 8 Vincristine
Cyclophosphamide
1mg/m2 IV bolus
600mg/m2 IV infusion over 30 min
11/26/2019 Reproductive Health Module AL2013
49. EP/EMA if Resistant to EMA/CO
EP
Etoposide 150 mg/m2 IV
Cisplatin 75 mg/m2 IV
Etoposide 100 mg/m2 IV
Methotrexate 300 mg/m2 IV
Actinomycin D 0.5 mg IV
EMA
Day 1
Day 1
Day 2 Folinic acid 15 mg orally/IM bd x 4
24 h post MTX
11/26/2019 Reproductive Health Module AL2013
50. Follow up of patients with gestational
trophoblastic tumours who have been
treated with chemotherapy
Weekly for the first 6 weeks
Then every week until 6 months
Then fortnightly until one year
Then monthly x 12
Then 2 monthly x 6
Then 3 monthly x 4
Then 4 monthly x 3
Then 6monthly for life
11/26/2019 Reproductive Health Module AL2013
51. Three doses of chemotherapy should be given beyond
the first undetectable hcg value
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52. Complications of GTD
a) Haemorrhage
b)Infection
c)Respiratory Complications –metastasis
Pleural effusion
Respiratory failure
d)Cerebral metastasis
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53. Post treatment issues
Pregnancy after treatment – wait for 12
months after completing chemotherapy
Contraception
Prognosis - Low risk – 100%
High risk - 86%
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56. A 30 year old woman in her first pregnancy presents with a history of
10 weeks amenorrhea and mild vaginal bleeding. On clinical
examination the uterine size was compatible with a 16 week
pregnancy. An ultrasound scan revealed a complete hydatidiform
mole.
3.1 Describe the management of this patient until discharge from the
ward (30 marks)
3.2 Give five (5) complications of this condition (10 marks)
3.3 Outline her long term management with justification (60 marks)
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59. Definitions
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).
If there is any evidence of persistence of GTD, most
commonly defined as a persistent elevation of beta human
chorionic gonadotrophin (βhCG), the condition is referred
to as Gestational trophoblastic neoplasia (GTN).
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60. Gestational Trophobalstic
Neoplasia(GTN)
Persistent Gestational Trophoblastic Disease indicated
by persistent elevation of beta human chorionic
gonadotrophin(βhCG)
Invasive Mole
Choriocarcinoma
Placental site trophoblastic tumour
Epithelioid Trophoblasic Tumour
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