This document defines gestational trophoblastic disease and describes the pathological classification and genetic features of complete and partial hydatidiform moles. It also discusses the clinical presentation, diagnosis, treatment, and follow up of molar pregnancies. The main treatment is surgical evacuation, followed by careful monitoring of hCG levels to detect persistent trophoblastic tissue which may develop into invasive mole or choriocarcinoma in about 10% of cases. Close follow up for years after evacuation is important to identify and treat malignant cases early through chemotherapy.

1. Dr. Muhabat Salih Saeid
MRCOG-London-UK

2. Definition : It is a clinical term used to
indicate three closely related
conditions characterized by active
abnormal proliferation of
trophoblastic cells : :
hydatidiform mole ,
invasive hydatidiform mole and
Choriocarcinoma

3.  These neoplasm's retain
certain characteristic of the
normal placenta such as
invasive tendencies and the
ability to make hCG
hormone

4.  Pathological classification :
 Hydatidiform mole = 80 % of cases.
 Invasive mole =12-15% of cases.
 Choriocarcenoma=5-8% of cases.
 Clinical classification : The course, and prognosis
of the disease accurately reflected by hCG
hormone
 Benign = 80%
 Malignant=20%

5.  The hydatidiform mole incidence ranges from 1
in 522 pregnancies in Japan
 To 1 in 1500 pregnancies in USA,and Sweden, this
variation is not understood, but ethnic factors
have been suggested .
 The incidence is higher in the poorest
socioeconomic classes than the semiprivate(4
times), and (8 times) than the privet , and these
mostly related to diet especially protein deficiency
.

6.  The maternal age over 40 years
found to have a 5.2-fold increased
risk of trophoblastic disease in
compression to the mothers below
the age of 35 years.

7.  Hydatidiform mole can be
subdivided into:
complete and
partial mole

8.  Based on:
1.Genetic and
2.Histopathological
features

9.  Genetic features: One of the most remarkable
discoveries about hydatidiform mole has been the
demonstration that complete moles have
chromosomes exclusively from the paternal side
,and the karyotype is nearly always 46,xx and
only rarely is 46,XY observed.
 The normal mechanism is for a haploid
sperm,23X,to fertilize an empty egg, and to
duplicate itself to form a 46,XX complement.
Much less commonly ,two spermatozoa, one being
23,X, and the other,23,Y, can fertilize an empty
egg, to give karyotype a 46,XY.

10. •10

11. Aretriploid in origin
with two sets of
paternal haploid genes
and one set of maternal
haploid genes

12. •12

13.  They occur, in almost all
cases, following dispermic
fertilization of an ovum.
 There is usually evidence of
a fetus or fetal red blood cells

14.  In the partial moles ,the normal
finding is a triploid karyotype ,69
chromosomes instead of normal 46.
The most common mechanism appears
to be fertilization of normal egg by two
sperm, giving a complement of
69,XXY.

15. Complete mole :
 there are numerous edematous
vesicles, which looks like a bunch
of small clear grapes,
 usually no fetus, or membranes.,

16.  microscopically: there are:
 large oedematous enlarged villi ,
 a vascular ,
 with variable degree of trophoblastic hyperplasia.
 carries greater risk of malignancy and requires
longer follow up than the partial mole.

17. •Partial mole
•Complete mole
•17

18. •Partial mole
•Complete mole
•18

19.  Partial mole:
 Shows a less clear -cut picture ,with
the formation of vesicles usually focal ,
 fetus and membranes may present,
 the vesicles have degree of vascularity.

20.  In general ,the more active
trophoblastic appearance the
greater the risk of malignancy.
 So the subsequent management
depends more on the hCG results
than the histological reports.

21. Bleeding : Bleeding in early
pregnancy after variable period of
amenorrhea is the most common
clinical sign of the mole (occurs in
90% of cases), with the passage of
the vesicles.

22. Hyperemesis gravidarum :
Occurs into 25% of cases of
moles ,and appears more
common when the uterus is
much enlarged and hCG levels
are very high.

23.  Uterine enlargement: The uterus is
commonly “large for date”in 50% of case of
moles ,
 although, in a small proportion of cases the
uterus corresponding to the gestational age
or smaller than date.
 The uterus having a doughy consistency.
 The fetal parts are not palpable, and fetal
heart is absent.

24. Large theca lutein cysts of the
ovary are present in “20%”of
moles , these may be
exaggerated the clinical picture
of large for date uterus. These
cysts are manifestation of
excessive hCG.

25. •25

26.  Pre-eclampsia :Occur in association
with the moles with range widely from
12-54%,these due to differing times of
diagnosis, the longer pregnancy
progresses ,the greater chance to
developing pre-eclampsia. If the signs
of pre-eclampsia appears early in
pregnancy , the possibility of
hydatidiform mole should be looked
for with out delay.

27.  Hyperthyrodism: Develop in small
proportion of women ,and this may be due
to thyrotrophic effects of the human
chorionic thyrotrophin , which may lead to
goitre,fine tremor ,supra-ventricular
tachycardia, and weight loss.
 DIC can develop in long-standing hydatidiform
moles , when there is embolization of
trophoblastic tissue to the lung, leads to
thromboplastic substances which stimulate
fibrin,and platelet deposition.

28. History and examination :
From the history of
amenorrhea ,passage of vesicles
vaginally with bleeding ;the size
and consistency of the uterus.

29. The increasing use of
ultrasound in early
pregnancy has probably
led to the earlier
diagnosis of molar
pregnancy

30. By the U/S examination can
be diagnosed from very early
pregnancy ,characterized by
“Snow-storm" appearance.

31. •31

32. By very high levels of serum
hCG than the normal singleton
pregnancy ,which is diagnostic
and prognostic to the course of
the disease ,with very short
dappling time.

33. The risks of hydatidiform mole are:
 Immediate hemorrhage ,sepsis, or pre-
eclampsia; the treatment of these
conditions has vastly improved
recently.
 Molar metastases :
Of a non proliferative ”benign” type
can occur.

34.  Choriocarcinoma: The most important
danger association with the
hydatidiform mole is the development
of malignant GTD(Invasive mole or
choriocarcinoma) in about 10% of
cases,

35. The aim of treatment is to eliminate
all trophoblastic tissue from the
maternal systems ;
If the hydatidiform mole diagnosed
,steps should be taken to evacuate
the uterus, and this achieved by:

36. Suction & curettage
(S&C): The method of
choice even when
evacuation large mole

37.  Under GA.
 Cervix dilation till 12mm.and S&C induced
to the uterine cavity.
 I.V oxytocin infusion is started .
 S&C started by negative pressure of about
60 to 70cmHg.
 The curette is genteelly rotated to ovoid
perforation of the soft uterus, and the
majority of the molar tissue is evacuated
rapidly ,and the uterine size decreases

38. Uterine stimulation.

39. Medical termination of complete
molar pregnancies including
cervical preparation prior to
suction evacuation, should be
avoided where possible.

40.  The contraction of the myometrium
may force tissue into the venous spaces
at the site of the placental bed.
 The dissemination of this tissue may
lead to the profound deterioration in
the woman, with embolic and
metastases disease occurring in the
lung

41. Surgical evacuation:

42.  Surgical evacuation: Hysterectomy has been
recommended as a suitable method of
treating hydatidiform mole in older women
who completed their family ,to reduce the
risk of post-molar trophoblastic disease .
.The hysterectomy should be carried out
with little monopolization to ovoid
precipitating mobilization of trophoblastic
tissue.

43.  Inpartial molar pregnancies
where the size of the fetal
parts deters the use of
suction curettage, medical
termination can be used.

44.  After the uterus has been evacuated :
 About 90% of cases ,the trophoblastic tissue
die out completely.
 About 10% of cases the trophoblastic tissue
does not die out completely and may persist
or recur as : invasive mole or
choriocarcinoma.

45. So it is important that women who
have had a hydatidiform mole:
 should have close follow-up by serum
hCG levels after the evacuation of the
uterus,
To ensure early recognition of persistent
trophoblastic tissue .

46.  After a molar pregnancy ,the hCG
levels will usually have returned to non
pregnant levels by 4 to 6 weeks after
evacuation.
 The follow-up is recommended for 2
years in cases of complete moles, and 6
months of cases of partial moles after
the evacuation of uterus.

47.  Serial quantitative measurement of
serum hCG level at weekly
intervals, after evacuation of moles
till 4 to 5 weeks when the hCG
become normal. Then every other
week .When the titer gets negative
the measurements are done every
month fore 1 year.

48.  Indicationof chemotherapy after
the evacuation of the hydatidiform
mole in:
Serum hCG >20000 i.u/L , at any
time after evacuation of mole.
 Raised hCG at 4 to 6 weeks after
evacuation of mole.

49. Evidence of metastases
,hepatic,brain,and pulmonary.
Persistent uterine hemorrhage
after evacuation of mole with
raised hCG levels.

50.  To achieve effective follow-up ,the
pregnancy is better to be avoided ,and also
the use of oral contraceptive pills until the
hCG levels returns to normal after the
evacuation of the mole.
 Early diagnosis of persistent trophoblastic
disease ensures a good prognosis and an
effective system of follow-up.

51. Malignant trophoblastic disease can
exist in two forms:
Invasive mole = non-metastatic form.
Choriocarcinoma = metastatic form .

52.  Both treated with the chemotherapy
and monitored by hCG tumor marker.
 Choriocarcinoma subdivide into :
 good-prognosis (Low-risk) ,and
 poor- prognosis (High-risk).

53.  The diagnosis of invasive moles or
“chorioadenoma destruens” is applied to
the moles characterized by :
 Abnormal peneterativeness and,
 Extensive local invasion, along with
 Excessive trophoblastic proliferation ,
 With preserved villous pattern.

54.  The proliferative villi may invade the
myomatrum ,paramatrum or the vaginal
wall, although there is rarely evidence of
metastasis.
 The morbidity and mortality of this disease
results from the penetration of the tumar
through the myomatrum and to the pelvic
vessels with the resultant hemorrhage “the
morbidity and mortality rate 10 %” .

55.  Choriocarcinoma subdivide
into:
good-prognosis (low risk).
Poor- Prognosis (High risk).

56. •56

57.  The incidence of choriocarcinoma
in the West: 1 :10000 and 1:70000
pregnancies; and
 In Asia between 1:250 and 1:6000
pregnancies..

58.  The antecedent pregnancy is :
Hydatidiform mole in about 57%
of cases.
Normal pregnancy in about 26%
of cases.
Abortion and ectopic pregnancy in
about 17% of cases.

59.  The risk of Choriocarcinoma
after a hydatidiform mole is
about 2-4% which is 1000 times
greater than after a normal
pregnancy.

60.  Choriocarcinoma is more
likely to occur after complete
mole .
 The incidence is in excess in
maternal blood group A, and
deficit in group O.

61.  Site: In the uterus 90% of
cases; 10 % of cases in the
ovaries ,vagina, vulva, lung,
liver, and brain.

62.  Macroscopically:
 Uterus: It may be localized in the form
of hemorrhagic polyp or multiple
hemorrhagic ,necrotic masses in the
cavity.
 Some times it is present in the uterine
wall (intramural) and the cavity is
empty.

63. Ovaries : May show stormal lutein
hyperplasia, and theca-lutein cysts.
And may be site of secondaries.

64.  Microscopically:
 Malignant hyperplasia of both
cytotrophoblasts,and syncytiotrophoblasts.
 Extensive hemorrhage.
 Absence of villi.
 Destruction of the surrounding
myomatrum.

65.  Direct : Through the myomatrum and
may end in uterine perforation
,internal hemorrhage, and peritonitis
.Through the fallopian tubes to the
ovaries.

66. •66

67.  Blood : The main method of spread ,and
occurs to;
 Genital : Vagina, vulva, and ovary.
 Extra genital : Lung, liver, brain, and
bones especially skull and spine.
 The lung is the commonest site for
secondaries and haemoptysis may be the
presenting symptom.

68.  Lung
 Vagina
 Brain
 Liver
•68

69.  Vaginal bleeding.
 Haemoptysis.
 Intraperitoneal hemorrhage.
 Peritonitis.
 Metastasis to the vital organs
e.g,brain.
 Pulmonary complications.

70.  Symptoms :
 Recent history of expulsion of vesicular
mole ,or abortion, or full term pregnancy.
 Persistent vaginal bleeding is the
commonest presentation.
 Haemoptysis.
 Abdominal swelling (uterus or ovaries).

71.  PersistentGTD should be
considered in any woman
developing:
acute respiratory or
neurological symptoms
after any pregnancy.

72.  Signs:
 Marked deterioration of the
general condition.
 An abdominal swelling may be
felt.

73.  Vaginally :
The uterus symmetrically enlarged
(less than 12 weeks).
The ovaries may be enlarged.
Hemorrhagic secondaries may be
seen in the vagina or vulva

74.  Investigation:
 Serum hCG.
 Chest X-ray for pulmonary metastasis.
 L.F.T .
 Liver scan.
 CAT scan for the secondaries.
 EEG .
 U/S for abdomen and pelvis.
 Diagnostic D&C.

75. The clinical classification of gestational
trophoblastic disease:
I. Non-metastatic.
II. Metastatic:
A. Low risk: All patient of documented
metastatic disease who do not have “high-
risk factors”.

76. B. High risk:
1. B-hCG level higher than
100.000miu/ml.
2. Associated pregnancy episode
more than 4 months before the
diagnosis.

77. 3. Following full-term pregnancy.
4. Liver or brain metastasis.
5. Failure of previous chemotherapy.
6. Symptoms of malignancy more than 4
months

78.  Prophylaxis: After care of vesicular
mole;
 D&C after one week of the
evacuation.
 Monitored for the signs and symptoms of
trophoblastic neoplassmic by:.
I. serial hCG.

79. II. Diagnostic D&C is done if :
 The hCG levels remains high.
 The hCG levels rises after gets negative.
 Uterine sub involution.
 Persistence of theca lutein cysts in the ovaries.
 Every case of secondary postpartum
haemorrhage.
 Every case of post abortive bleeding.

80. I. Non metastatic GTD:
o Methotrexate (antimetabolite) +folinic
acid.
o The cytotoxic therapy is controlled by
doing CBC,platelet count and LFT.
o After the the hCG level gets normal ;stop
the therapy and follow-up by weekly
estimation of hCG levels.

81.  Women scoring: Non metastatic
GTD,and(low risk) GTD receive
intramuscular methotrexate on alternate
days, followed by six rest days, with each
course consisting of four injections

82. o Physical examination, chest x-
ray, and LFT.
o Total abdominal hysterectomy ,if the
patient does not desire to maintain
child-bearing, in the middle of the
first treatment course .

83. II. Low metastatic GTD:
o Methotraxate , or Actinomycin D
,if there is resistance ,change to
triple chemotherapy.

84. o The criteria for initiation, and
continuation of each methotraxate
treatment ;
 Platelet count more than 100.000.
 WBC more than 3000.
 Absolute neutrophil count between 1000-
1500.
 Normal LFT, renal function.

85. III. High risk metastatic GTD :
o Triple chemotherapy :
Methotraxate, Actinomycin D,
and Cytoxan.

86. o Surgery:
 TAH may be done in patients not
desirous of further reproduction.
 Surgical extirpation of isolated
metastasis e.g. pulmonary if
resistant to chemotherapy.

87. o Irradiation: Whole brain
irradiation for cerebral
metastases , The whole organ
irradiation for hepatic
metastases

88.  After successful therapy ,the hCG
levels are obtained :
 every 2weeks for 3 months,
 every month for 3months,
 every 2months for 6 months then every
sixes months indefinitely.

89.  If at any time hCG levels rises, repeat
the evaluation , staging ,and
chemotherapy.
 Physical examination, and chest x-ray
follow-up at 6 weeks, then every
3months for one year, then every 6
months for one year.

90.  Pregnancy is not allowed except after
one year of negative follow up but with
danger of :
 Molar pregnancy (4-5 times greater
risk).
 Spontaneous abortion.
 Premature delivery.

91. If a further molar
pregnancy does occur,
in 68–80% of cases
it will be of the
same histological type

92.  Women who undergo
chemotherapy are advised
not to concieve for one year
after completion of
treatment

93. THIS IS THE END OF THE
LECTURE .
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