SlideShare a Scribd company logo
Abraham T.
Gestational
Trophoblastic Disease
2
Introduction
• Gestational trophoblastic disease (GTD) refers to a spectrum
of interrelated but histologically distinct tumors originating
from the placenta.
• These diseases are characterized by a reliable tumor marker,
which is the β-subunit of human chorionic gonadotropin (β-
HCG), and have varied tendencies or local invasion and spread.
3
Introduction …
• Gestational trophoblastic disease (GTD) is the term used
to encompass a group of tumors with abnormal
trophoblast proliferation.
• Trophoblast produce human chorionic gonadotropin (HCG),
thus the measurement of this peptide hormone in serum is
essential for GTD diagnosis, management, and
surveillance.
4
WHO classification of GTD
5
Classification ….
• Hydatidiform moles are excessively edematous immature
placentas.
• These include the benign complete hydatidiform mole and
partial hydatidiform mole and the malignant invasive mole.
• Invasive mole is deemed malignant due to its marked
penetration into and destruction of the myometrium as well as
its ability to metastasize.
6
Classification ….
• Nonmolar trophoblastic neoplasms include choriocarcinoma,
placental site trophoblastic tumor, and epithelioid
trophoblastic tumor.
• These three are differentiated by the type of trophoblast
they contain.
7
Classification ….
• The malignant forms of GTD are termed gestational
trophoblastic neoplasia (GTN).
• These include invasive mole, choriocarcinoma, placental site
trophoblastic tumor, and epithelioid trophoblastic tumor.
• These malignancies develop weeks or years following any type
of pregnancy, but frequently occur after a hydatidiform mole.
8
Incidence
• The incidence of gestational trophoblastic disease has
remained fairly constant at approximately 1 to 2 per
1,000 deliveries in the United States and Europe. (Drake,
2006; Loukovaara, 2005; Lybol, 2011)
• Can follow any gestational event – abortion, miscarriage,
ectopic, normal pregnancy
9
Risk factors
• Maternal age at the upper and lower extremes
• A history of prior unsuccessful pregnancies
• personal history of GTD
• Combination oral contraceptive (COC)
• vitamin A deficiency and low dietary intake of carotene
• Smoking
• Irregular menstrual cycles
10
Types of Gestational Trophoblastic
Disease
• Hydatidiform mole (complete or partial)
• Invasive mole
• Choriocarcinoma
• Placental-site trophoblastic tumor
• Epithelioid trophoblastic tumor
11
Hydatidiform mole
• The most common form of gestational trophoblastic
disease (GTD).
• Also known as a molar pregnancy.
• Hydatidiform moles are not cancerous, but they can
develop into cancerous GTDs.
• There are 2 types of hydatidiform moles: complete and
partial.
12
13
Hydatidiform mole…
• The degree of histological changes, karyotypic differences, and
the absence or presence of embryonic elements are used to
classify them as either complete or partial moles.
• These two also vary in associated risks for developing medical
comorbidities and post evacuation GTN.
• Of the two, GTN more frequently follows complete
hydatidiform mole.
14
Hydatidiform mole…
• Complete moles have a potential for local invasion and
dissemination.
• After molar evacuation, local uterine invasion occurs in 15% of
patients, and metastasis occurs in 4%.
• High risk for developing postmolar tumor:
 HCG level >.100,000 mIU /mL
 Excessive uterine enlargement
 Theca lutein cysts 6 cm in diameter
15
Invasive mole
• This common manifestation of GTN is characterized by whole
chorionic villi that accompany excessive trophoblastic overgrowth
and invasion.
• These tissues penetrate deep into the myometrium, sometimes to
involve the peritoneum, adjacent parametrium, or vaginal vault.
• Invasive moles can develop mostly from complete hydatid moles.
16
Invasive mole …
• The risk of developing an invasive mole increases in women who had
gestational trophoblastic disease in the past.
• A tumor or mole that grows completely through the wall of the
uterus may result in bleeding into the abdominal or pelvic cavity. This
bleeding can be life threatening.
17
Choriocarcinoma
• Choriocarcinoma is a malignant form of gestational
trophoblastic disease (GTD).
• This extremely malignant tumor contains sheets of
anaplastic trophoblast and prominent hemorrhage,
necrosis, and vascular invasion.
• Gestational choriocarcinoma initially invades the
endometrium and myometrium but tends to develop early
blood-borne systemic metastases.
18
Placental-site trophoblastic tumor
• Placental-site trophoblastic tumor (PSTT) is a very rare form of
gestational trophoblastic disease (GTD) that develops where the
placenta attaches to the lining of the uterus.
• Most commonly develops following a term gestation.
• Typically, patients have irregular bleeding months or years after the
antecedent pregnancy, and diagnosis is confirmed with endometrial
sampling.
19
Cont …
• Hysterectomy is the primary treatment or nonmetastatic
Placental site trophoblastic tumor due to its relative
insensitivity to chemotherapy.
• Metastatic PSTT has a much poorer prognosis than its
postmolar GTN counterparts. As a result, aggressive
combination chemotherapy is indicated.
20
Epithelioid Trophoblastic Tumor
• It is rare trophoblastic tumor is distinct from
gestational choriocarcinoma and PSTT .
• Epithelioid trophoblastic tumor develops from neoplastic
transformation of chorionic-type intermediate
trophoblast.
• The diagnosis is usually confirmed in advance by
endometrial biopsy.
21
Cont …
• Microscopically, this tumor resembles PSTT , but the
cells are smaller and display less nuclear pleomorphism.
• Grossly, epithelioid trophoblastic tumor grows in a
nodular fashion rather than the infiltrative pattern of
PSTT.
• Hysterectomy is the primary treatment due to presumed
chemoresistance.
22
Staging
• A staging system based on the anatomical spread has been
developed by FIGO (the International Federation of Gynecology and
Obstetrics).
23
Clinical presentations and complications
• Vaginal bleeding: The abnormal and rapid growth of trophoblastic
tissue causes separation of blood vessels from the decidual bed
which results in painless vaginal bleeding. This blood loss may occur
gradually and cause severe anemia which may need blood transfusion.
•
• Excessive uterine size: Because of abnormal proliferation of
trophoblastic tissue and Retained blood clots and trophoblastic
tissue
24
Cont ….
• Hyperemesis gravidarum: excessive nausea and vomiting with
unkown mechanism which may cause electrolyte and metabolic
disturbances. It may be related to BHCG.
• Ovarian theca lutein cysts: in patients with high levels of HCG,
usually more than 100,000 miu/ml.
25
Cont …
• Pre-eclampsia: GTD should be suspected in pregnant patients with
signs and symptoms of pre-eclampsia in early pregnancy-especially
during the first and early second trimester.
• Hyperthyroidism: A normal HCG will have weak thyrotropic activity
on TSH receptors. However, because of increase thyroxin binding
globulin levels in pregnancy, this will cause a small change in thyroid
hormone activity.
26
Cont…
• Acute cardiopulmonary distress: incidence of 27%.
• It occurs in patients with a uterine of size greater than 16
weeks and with very high HCG levels.
• Signs/symptoms include tachycardia, chest pain, hypoxia,
tachypnea, diffuse rales and chest radiographic features of
bilateral pulmonary infiltration.
27
Cont …
• DIC: Consumption coagulopathy can occur as a result of activation of
the coagulation cascade by factors released from abnormal
trophoblastic tissue.
• This may be due to placental tissue release of substances that have
some thromboplastin properties.
28
Diagnosis OF GTD
• History
 Amenorrhoea
 Hyperemesis gravidarum
 Vaginal bleeding
• Examination
 Uterine size – bigger for dates
 Adnexal mass
 Evidence of metastatic disease eg vaginal metastases
29
Diagnosis OF GTD ….
• Investigations:
 Urine and serum HCG, Full blood count, Renal and liver function tests
 Thyroid function test, Clotting profile
 Chest x-ray: to check for any lung metastasis.
 Ultrasound of pelvis and liver
 CT abdomen and thorax
 CT or MRI brain: indicated if there are any neurological symptoms or any pulmonary
metastasis.
 Positron emission tomography (PET) - CT: to find the source of a rising HCG which could
not be detected by other imaging tools. This type of scan detects tumor tissue which has
high glucose uptake and metabolic rate.
30
Treatment modalities
• Suction Curettage
• Hysterectomy
• Prophylactic Chemotherapy
31
Hyperthyroidism in GTD
• Plasma thyroxine levels are often elevated in women with
complete moles, but clinical hyperthyroidism is unusual and is
identified in only approximately 5% of patients.
• If hyperthyroidism is suspected before the induction of
anesthesia for molar evacuation, β- adrenergic blocking agents
should be administered.
• After molar evacuation, thyroid function test results return
rapidly to normal.
32
Hyperthyroidism….
• Hyperthyroidism develops almost exclusively in patients with very
high HCG levels.
• Some investigators have suggested that HCG is the thyroid
stimulator in women with GTD, because positive correlations
between serum HCG levels and total T4 or T3 concentrations have
been observed.
33
Anesthesia Management
• The preoperative management of these patients present multitude of challenges
for the anesthesiologists.
• Thus anesthetist should be prepared to deal with such complications.
 Cardiac failure (secondary to thyrotoxicosis)
 Thyroid storm
 Hypertension
 Embolization of pulmonary arteries by trophoblastic materials
 Hypovolemia
 DIC, and
 Pulmonary edema are some of them.
34
Cont …
• In d/t literature TIVA, SA and GA have been described
for the management of molar evacuation.
• Crucial to anesthesia management is the perioperative
prevention of thyrotoxic crisis and control of
sympathetic stimulation secondary to hyperthyroidism.
35
Cont …
• In actively bleeding or hypotensive patients; general
anesthesia has to be used to facilitate evacuation.
• However, uterine relaxation may increase blood loss and
inhaled anesthetics with known tocolytic effect such as
halothane, enflurane and isoflurane should therefore only
be used in low concentrations.
36
Cont …
• In hemodynamically stable patients, thiopentone is the induction
agent of choice because of its anti thyroid action.
• In hemodynamically unstable patients, etomidate is the induction
agent of choice.
• A non depolarizing muscle relaxant which does not cause histamine
release should be used.
• Depending on the size of the uterus a rapid sequence induction may
need to be done.
37
Cont …
• If the patient is hemodynamically stable in the
preoperative period, regional anesthesia is appropriate
• Has no tocolytic effect
• Offered minimal interference with the patients
cardiovascular status and
• Provided excellent post-operative pain relief after
surgery.
38
Cont …
• Intraoperative events like hypotension and tachycardia
can be treated with antiarrhythmic agents and
transfusion with a plasma expander and crystalloid fluid.
39
Cont …
• Antiarrhythmic agents like esmolol and digoxin can be
used effectively in treating tachycardia and atrial
fibrillation.
• In case of refractory atrial fibrillation and cardiac
failure cardioversion can be considered.
40
Cont …
• Stable patients with clinical hyperthyroidism should be treated with
antithyroid medications until a euthyroid state is achieved.
• Emergency patients with bleeding and severe hyperthyroidism
should get a dose of a beta blocker and steroid to prevent
thyrotoxic crisis.
• Another option in these patients is plasmapheresis which is used for
rapid hormonal control by removing excess hormones.
41
Summary
• Gestational trophoblastic disease is proliferation of
trophoblastic tissue in pregnant or recently pregnant
women.
• Manifestations may include excessive uterine
enlargement, vomiting, vaginal bleeding, and
preeclampsia, particularly during early pregnancy.
42
Summary …
• Diagnosis includes measurement of the β-subunit of
human chorionic gonadotropin, pelvic ultrasonography,
and confirmation by biopsy.
• Tumors are removed by suction curettage/hyterectomy.
• If disease persists after removal, chemotherapy is
indicated.
43
Thank You!!!
44

More Related Content

What's hot

Anaethetic management of obstetric haemorrhage
Anaethetic management of obstetric haemorrhageAnaethetic management of obstetric haemorrhage
Anaethetic management of obstetric haemorrhage
Sasidhar Puvvula
 
Hellp syndrome and anesthesia
Hellp syndrome and anesthesiaHellp syndrome and anesthesia
Hellp syndrome and anesthesia
prateek gupta
 
Meningomyelocele and Anesthesia
Meningomyelocele and AnesthesiaMeningomyelocele and Anesthesia
Meningomyelocele and Anesthesia
Dr.S.N.Bhagirath ..
 
Anesthesia For Congenital Diaphragmatic Hernia
Anesthesia For Congenital Diaphragmatic HerniaAnesthesia For Congenital Diaphragmatic Hernia
Anesthesia For Congenital Diaphragmatic Hernia
krishna dhakal
 
Post Operative Nausea & Vomiting
Post Operative Nausea & VomitingPost Operative Nausea & Vomiting
Post Operative Nausea & Vomiting
Kiran Rajagopal
 
NON OPERATING ROOM ANAESTHESIA
NON OPERATING ROOM ANAESTHESIA NON OPERATING ROOM ANAESTHESIA
NON OPERATING ROOM ANAESTHESIA
Kundan Ghimire
 
Combined Spinal Epidural Anesthesia
Combined Spinal Epidural AnesthesiaCombined Spinal Epidural Anesthesia
Combined Spinal Epidural Anesthesia
Bilal Baig
 
Intraoperative awareness
Intraoperative awarenessIntraoperative awareness
Intraoperative awareness
Himanshu Jangid
 
Hypothermia and anaesthesia implication
Hypothermia and anaesthesia implicationHypothermia and anaesthesia implication
Hypothermia and anaesthesia implication
drriyas03
 
Epidural analgesia for labour
Epidural analgesia for labourEpidural analgesia for labour
Epidural analgesia for labour
HIRANGER
 
anaesthetic consideration for thyroid surgery
anaesthetic consideration for thyroid surgeryanaesthetic consideration for thyroid surgery
anaesthetic consideration for thyroid surgery
aljamhori teaching hospital
 
Anesthesia for non Obstetric Surgery in Pregnancy
Anesthesia for non Obstetric Surgery in PregnancyAnesthesia for non Obstetric Surgery in Pregnancy
Anesthesia for non Obstetric Surgery in Pregnancy
isakakinada
 
Obstetric anaesthesia
Obstetric anaesthesiaObstetric anaesthesia
Obstetric anaesthesia
Ismail Abdelgawad
 
Anesthesia awareness
Anesthesia awarenessAnesthesia awareness
Anesthesia awareness
RamanGhimire3
 
Anaesthesia for congenital heart disease
Anaesthesia for congenital heart diseaseAnaesthesia for congenital heart disease
Anaesthesia for congenital heart disease
Dhritiman Chakrabarti
 
Hypertension and Anesthesia
Hypertension and AnesthesiaHypertension and Anesthesia
Hypertension and Anesthesia
anujkarki
 
NON OPERATING ROOM ANAESTHESIA
NON OPERATING ROOM ANAESTHESIANON OPERATING ROOM ANAESTHESIA
NON OPERATING ROOM ANAESTHESIA
Unnikrishnan Prathapadas
 
Physics In Anaesthesia
Physics In AnaesthesiaPhysics In Anaesthesia
Physics In Anaesthesia
NARENDRA PATIL
 
Anaesthesia for LSCS
Anaesthesia for LSCSAnaesthesia for LSCS
Anaesthesia for LSCS
Himanshu Jangid
 
thyroid diseases and anesthesia management
thyroid diseases and anesthesia managementthyroid diseases and anesthesia management
thyroid diseases and anesthesia management
maryammahmood123
 

What's hot (20)

Anaethetic management of obstetric haemorrhage
Anaethetic management of obstetric haemorrhageAnaethetic management of obstetric haemorrhage
Anaethetic management of obstetric haemorrhage
 
Hellp syndrome and anesthesia
Hellp syndrome and anesthesiaHellp syndrome and anesthesia
Hellp syndrome and anesthesia
 
Meningomyelocele and Anesthesia
Meningomyelocele and AnesthesiaMeningomyelocele and Anesthesia
Meningomyelocele and Anesthesia
 
Anesthesia For Congenital Diaphragmatic Hernia
Anesthesia For Congenital Diaphragmatic HerniaAnesthesia For Congenital Diaphragmatic Hernia
Anesthesia For Congenital Diaphragmatic Hernia
 
Post Operative Nausea & Vomiting
Post Operative Nausea & VomitingPost Operative Nausea & Vomiting
Post Operative Nausea & Vomiting
 
NON OPERATING ROOM ANAESTHESIA
NON OPERATING ROOM ANAESTHESIA NON OPERATING ROOM ANAESTHESIA
NON OPERATING ROOM ANAESTHESIA
 
Combined Spinal Epidural Anesthesia
Combined Spinal Epidural AnesthesiaCombined Spinal Epidural Anesthesia
Combined Spinal Epidural Anesthesia
 
Intraoperative awareness
Intraoperative awarenessIntraoperative awareness
Intraoperative awareness
 
Hypothermia and anaesthesia implication
Hypothermia and anaesthesia implicationHypothermia and anaesthesia implication
Hypothermia and anaesthesia implication
 
Epidural analgesia for labour
Epidural analgesia for labourEpidural analgesia for labour
Epidural analgesia for labour
 
anaesthetic consideration for thyroid surgery
anaesthetic consideration for thyroid surgeryanaesthetic consideration for thyroid surgery
anaesthetic consideration for thyroid surgery
 
Anesthesia for non Obstetric Surgery in Pregnancy
Anesthesia for non Obstetric Surgery in PregnancyAnesthesia for non Obstetric Surgery in Pregnancy
Anesthesia for non Obstetric Surgery in Pregnancy
 
Obstetric anaesthesia
Obstetric anaesthesiaObstetric anaesthesia
Obstetric anaesthesia
 
Anesthesia awareness
Anesthesia awarenessAnesthesia awareness
Anesthesia awareness
 
Anaesthesia for congenital heart disease
Anaesthesia for congenital heart diseaseAnaesthesia for congenital heart disease
Anaesthesia for congenital heart disease
 
Hypertension and Anesthesia
Hypertension and AnesthesiaHypertension and Anesthesia
Hypertension and Anesthesia
 
NON OPERATING ROOM ANAESTHESIA
NON OPERATING ROOM ANAESTHESIANON OPERATING ROOM ANAESTHESIA
NON OPERATING ROOM ANAESTHESIA
 
Physics In Anaesthesia
Physics In AnaesthesiaPhysics In Anaesthesia
Physics In Anaesthesia
 
Anaesthesia for LSCS
Anaesthesia for LSCSAnaesthesia for LSCS
Anaesthesia for LSCS
 
thyroid diseases and anesthesia management
thyroid diseases and anesthesia managementthyroid diseases and anesthesia management
thyroid diseases and anesthesia management
 

Similar to Gestational trophoblastic disease and Anesthesia

Gestational Trophoblastic Disease Detailed
Gestational Trophoblastic Disease DetailedGestational Trophoblastic Disease Detailed
Gestational Trophoblastic Disease Detailed
CalebMucho
 
GTDS presentation.pptx gynecology lecture
GTDS presentation.pptx gynecology lectureGTDS presentation.pptx gynecology lecture
GTDS presentation.pptx gynecology lecture
Awais irshad
 
GTN (1).ppt
GTN (1).pptGTN (1).ppt
GTN (1).ppt
ParulSinha25
 
Gestational trophoblastic neoplasia management
Gestational trophoblastic neoplasia management Gestational trophoblastic neoplasia management
Gestational trophoblastic neoplasia management
Amit Sehrawat
 
Gestational Trophoblastic Disease -MBChB 6th Year 2018.pptx
Gestational Trophoblastic Disease -MBChB 6th Year 2018.pptxGestational Trophoblastic Disease -MBChB 6th Year 2018.pptx
Gestational Trophoblastic Disease -MBChB 6th Year 2018.pptx
RobertoMaina2
 
Gestational trophoblastic disease
Gestational trophoblastic diseaseGestational trophoblastic disease
Gestational trophoblastic disease
Tanya Das
 
Gestational trophoblastic disease by sittichoke
Gestational trophoblastic disease by sittichokeGestational trophoblastic disease by sittichoke
Gestational trophoblastic disease by sittichoke
Ck-chonburi Chonburi
 
Gestational trophoblastic disease natangwe
Gestational trophoblastic disease natangweGestational trophoblastic disease natangwe
Gestational trophoblastic disease natangwe
Natangwe Tangi
 
Gestational_Trophoblastic_Tumours_UG_LECT..ppt
Gestational_Trophoblastic_Tumours_UG_LECT..pptGestational_Trophoblastic_Tumours_UG_LECT..ppt
Gestational_Trophoblastic_Tumours_UG_LECT..ppt
PuiteaChhangte
 
Gestational trophoblastic diseases
Gestational trophoblastic diseasesGestational trophoblastic diseases
Gestational trophoblastic diseases
drmcbansal
 
Gestational trophoblastic disease
Gestational trophoblastic diseaseGestational trophoblastic disease
Gestational trophoblastic disease
Muni Venkatesh
 
Gestational trophoblastic diseases
Gestational trophoblastic diseasesGestational trophoblastic diseases
Gestational trophoblastic diseases
Ayub Medical College
 
Gt ds
Gt dsGt ds
3 (part 2) Gestational Trophoblastic Disease .ppt
3 (part 2) Gestational Trophoblastic Disease .ppt3 (part 2) Gestational Trophoblastic Disease .ppt
3 (part 2) Gestational Trophoblastic Disease .ppt
Ahad412190
 
Radiology night 10/2015
Radiology night 10/2015Radiology night 10/2015
Radiology night 10/2015
Naglaa Mahmoud
 
Gestational Trophoblastic Disease.ppt
Gestational Trophoblastic Disease.pptGestational Trophoblastic Disease.ppt
Gestational Trophoblastic Disease.ppt
MohammadTalha294621
 
GTN
GTNGTN
GESTATIONAL TROPHOBLASTIC DISEASE...pptx
GESTATIONAL TROPHOBLASTIC DISEASE...pptxGESTATIONAL TROPHOBLASTIC DISEASE...pptx
GESTATIONAL TROPHOBLASTIC DISEASE...pptx
Iram Chaudhry
 
management of gestational trophoblastic disease .pptx
management of gestational trophoblastic disease .pptxmanagement of gestational trophoblastic disease .pptx
management of gestational trophoblastic disease .pptx
banchygelan2
 
1. GTD.ppt
1. GTD.ppt1. GTD.ppt
1. GTD.ppt
HansarKemal1
 

Similar to Gestational trophoblastic disease and Anesthesia (20)

Gestational Trophoblastic Disease Detailed
Gestational Trophoblastic Disease DetailedGestational Trophoblastic Disease Detailed
Gestational Trophoblastic Disease Detailed
 
GTDS presentation.pptx gynecology lecture
GTDS presentation.pptx gynecology lectureGTDS presentation.pptx gynecology lecture
GTDS presentation.pptx gynecology lecture
 
GTN (1).ppt
GTN (1).pptGTN (1).ppt
GTN (1).ppt
 
Gestational trophoblastic neoplasia management
Gestational trophoblastic neoplasia management Gestational trophoblastic neoplasia management
Gestational trophoblastic neoplasia management
 
Gestational Trophoblastic Disease -MBChB 6th Year 2018.pptx
Gestational Trophoblastic Disease -MBChB 6th Year 2018.pptxGestational Trophoblastic Disease -MBChB 6th Year 2018.pptx
Gestational Trophoblastic Disease -MBChB 6th Year 2018.pptx
 
Gestational trophoblastic disease
Gestational trophoblastic diseaseGestational trophoblastic disease
Gestational trophoblastic disease
 
Gestational trophoblastic disease by sittichoke
Gestational trophoblastic disease by sittichokeGestational trophoblastic disease by sittichoke
Gestational trophoblastic disease by sittichoke
 
Gestational trophoblastic disease natangwe
Gestational trophoblastic disease natangweGestational trophoblastic disease natangwe
Gestational trophoblastic disease natangwe
 
Gestational_Trophoblastic_Tumours_UG_LECT..ppt
Gestational_Trophoblastic_Tumours_UG_LECT..pptGestational_Trophoblastic_Tumours_UG_LECT..ppt
Gestational_Trophoblastic_Tumours_UG_LECT..ppt
 
Gestational trophoblastic diseases
Gestational trophoblastic diseasesGestational trophoblastic diseases
Gestational trophoblastic diseases
 
Gestational trophoblastic disease
Gestational trophoblastic diseaseGestational trophoblastic disease
Gestational trophoblastic disease
 
Gestational trophoblastic diseases
Gestational trophoblastic diseasesGestational trophoblastic diseases
Gestational trophoblastic diseases
 
Gt ds
Gt dsGt ds
Gt ds
 
3 (part 2) Gestational Trophoblastic Disease .ppt
3 (part 2) Gestational Trophoblastic Disease .ppt3 (part 2) Gestational Trophoblastic Disease .ppt
3 (part 2) Gestational Trophoblastic Disease .ppt
 
Radiology night 10/2015
Radiology night 10/2015Radiology night 10/2015
Radiology night 10/2015
 
Gestational Trophoblastic Disease.ppt
Gestational Trophoblastic Disease.pptGestational Trophoblastic Disease.ppt
Gestational Trophoblastic Disease.ppt
 
GTN
GTNGTN
GTN
 
GESTATIONAL TROPHOBLASTIC DISEASE...pptx
GESTATIONAL TROPHOBLASTIC DISEASE...pptxGESTATIONAL TROPHOBLASTIC DISEASE...pptx
GESTATIONAL TROPHOBLASTIC DISEASE...pptx
 
management of gestational trophoblastic disease .pptx
management of gestational trophoblastic disease .pptxmanagement of gestational trophoblastic disease .pptx
management of gestational trophoblastic disease .pptx
 
1. GTD.ppt
1. GTD.ppt1. GTD.ppt
1. GTD.ppt
 

Recently uploaded

10 Benefits an EPCR Software should Bring to EMS Organizations
10 Benefits an EPCR Software should Bring to EMS Organizations   10 Benefits an EPCR Software should Bring to EMS Organizations
10 Benefits an EPCR Software should Bring to EMS Organizations
Traumasoft LLC
 
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa CentralClinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central
19various
 
Ketone bodies and metabolism-biochemistry
Ketone bodies and metabolism-biochemistryKetone bodies and metabolism-biochemistry
Ketone bodies and metabolism-biochemistry
Dhayanithi C
 
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdfCHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
rishi2789
 
Complementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLSComplementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLS
chiranthgowda16
 
Outbreak management including quarantine, isolation, contact.pptx
Outbreak management including quarantine, isolation, contact.pptxOutbreak management including quarantine, isolation, contact.pptx
Outbreak management including quarantine, isolation, contact.pptx
Pratik328635
 
Cervical Disc Arthroplasty ORSI 2024.pptx
Cervical Disc Arthroplasty ORSI 2024.pptxCervical Disc Arthroplasty ORSI 2024.pptx
Cervical Disc Arthroplasty ORSI 2024.pptx
LEFLOT Jean-Louis
 
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptxREGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
LaniyaNasrink
 
share - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptxshare - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptx
Tina Purnat
 
Medical Quiz ( Online Quiz for API Meet 2024 ).pdf
Medical Quiz ( Online Quiz for API Meet 2024 ).pdfMedical Quiz ( Online Quiz for API Meet 2024 ).pdf
Medical Quiz ( Online Quiz for API Meet 2024 ).pdf
Jim Jacob Roy
 
Cell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune DiseaseCell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune Disease
Health Advances
 
Cosmetology and Trichology Courses at Kosmoderma Academy PRP (Hair), DR Growt...
Cosmetology and Trichology Courses at Kosmoderma Academy PRP (Hair), DR Growt...Cosmetology and Trichology Courses at Kosmoderma Academy PRP (Hair), DR Growt...
Cosmetology and Trichology Courses at Kosmoderma Academy PRP (Hair), DR Growt...
Kosmoderma Academy Of Aesthetic Medicine
 
Acute Gout Care & Urate Lowering Therapy .pdf
Acute Gout Care & Urate Lowering Therapy .pdfAcute Gout Care & Urate Lowering Therapy .pdf
Acute Gout Care & Urate Lowering Therapy .pdf
Jim Jacob Roy
 
Chapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptxChapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptx
Earlene McNair
 
Physical demands in sports - WCSPT Oslo 2024
Physical demands in sports - WCSPT Oslo 2024Physical demands in sports - WCSPT Oslo 2024
Physical demands in sports - WCSPT Oslo 2024
Torstein Dalen-Lorentsen
 
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấuK CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
HongBiThi1
 
Top Travel Vaccinations in Manchester
Top Travel Vaccinations in ManchesterTop Travel Vaccinations in Manchester
Top Travel Vaccinations in Manchester
NX Healthcare
 
The Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of RespirationThe Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of Respiration
MedicoseAcademics
 
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptxEar and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Dr. Rabia Inam Gandapore
 
CLEAR ALIGNER THERAPY IN ORTHODONTICS .pptx
CLEAR ALIGNER THERAPY IN ORTHODONTICS .pptxCLEAR ALIGNER THERAPY IN ORTHODONTICS .pptx
CLEAR ALIGNER THERAPY IN ORTHODONTICS .pptx
Government Dental College & Hospital Srinagar
 

Recently uploaded (20)

10 Benefits an EPCR Software should Bring to EMS Organizations
10 Benefits an EPCR Software should Bring to EMS Organizations   10 Benefits an EPCR Software should Bring to EMS Organizations
10 Benefits an EPCR Software should Bring to EMS Organizations
 
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa CentralClinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central
 
Ketone bodies and metabolism-biochemistry
Ketone bodies and metabolism-biochemistryKetone bodies and metabolism-biochemistry
Ketone bodies and metabolism-biochemistry
 
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdfCHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
CHEMOTHERAPY_RDP_CHAPTER 1_ANTI TB DRUGS.pdf
 
Complementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLSComplementary feeding in infant IAP PROTOCOLS
Complementary feeding in infant IAP PROTOCOLS
 
Outbreak management including quarantine, isolation, contact.pptx
Outbreak management including quarantine, isolation, contact.pptxOutbreak management including quarantine, isolation, contact.pptx
Outbreak management including quarantine, isolation, contact.pptx
 
Cervical Disc Arthroplasty ORSI 2024.pptx
Cervical Disc Arthroplasty ORSI 2024.pptxCervical Disc Arthroplasty ORSI 2024.pptx
Cervical Disc Arthroplasty ORSI 2024.pptx
 
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptxREGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
REGULATION FOR COMBINATION PRODUCTS AND MEDICAL DEVICES.pptx
 
share - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptxshare - Lions, tigers, AI and health misinformation, oh my!.pptx
share - Lions, tigers, AI and health misinformation, oh my!.pptx
 
Medical Quiz ( Online Quiz for API Meet 2024 ).pdf
Medical Quiz ( Online Quiz for API Meet 2024 ).pdfMedical Quiz ( Online Quiz for API Meet 2024 ).pdf
Medical Quiz ( Online Quiz for API Meet 2024 ).pdf
 
Cell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune DiseaseCell Therapy Expansion and Challenges in Autoimmune Disease
Cell Therapy Expansion and Challenges in Autoimmune Disease
 
Cosmetology and Trichology Courses at Kosmoderma Academy PRP (Hair), DR Growt...
Cosmetology and Trichology Courses at Kosmoderma Academy PRP (Hair), DR Growt...Cosmetology and Trichology Courses at Kosmoderma Academy PRP (Hair), DR Growt...
Cosmetology and Trichology Courses at Kosmoderma Academy PRP (Hair), DR Growt...
 
Acute Gout Care & Urate Lowering Therapy .pdf
Acute Gout Care & Urate Lowering Therapy .pdfAcute Gout Care & Urate Lowering Therapy .pdf
Acute Gout Care & Urate Lowering Therapy .pdf
 
Chapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptxChapter 11 Nutrition and Chronic Diseases.pptx
Chapter 11 Nutrition and Chronic Diseases.pptx
 
Physical demands in sports - WCSPT Oslo 2024
Physical demands in sports - WCSPT Oslo 2024Physical demands in sports - WCSPT Oslo 2024
Physical demands in sports - WCSPT Oslo 2024
 
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấuK CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
K CỔ TỬ CUNG.pdf tự ghi chép, chữ hơi xấu
 
Top Travel Vaccinations in Manchester
Top Travel Vaccinations in ManchesterTop Travel Vaccinations in Manchester
Top Travel Vaccinations in Manchester
 
The Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of RespirationThe Nervous and Chemical Regulation of Respiration
The Nervous and Chemical Regulation of Respiration
 
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptxEar and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
Ear and its clinical correlations By Dr. Rabia Inam Gandapore.pptx
 
CLEAR ALIGNER THERAPY IN ORTHODONTICS .pptx
CLEAR ALIGNER THERAPY IN ORTHODONTICS .pptxCLEAR ALIGNER THERAPY IN ORTHODONTICS .pptx
CLEAR ALIGNER THERAPY IN ORTHODONTICS .pptx
 

Gestational trophoblastic disease and Anesthesia

  • 1.
  • 3. Introduction • Gestational trophoblastic disease (GTD) refers to a spectrum of interrelated but histologically distinct tumors originating from the placenta. • These diseases are characterized by a reliable tumor marker, which is the β-subunit of human chorionic gonadotropin (β- HCG), and have varied tendencies or local invasion and spread. 3
  • 4. Introduction … • Gestational trophoblastic disease (GTD) is the term used to encompass a group of tumors with abnormal trophoblast proliferation. • Trophoblast produce human chorionic gonadotropin (HCG), thus the measurement of this peptide hormone in serum is essential for GTD diagnosis, management, and surveillance. 4
  • 6. Classification …. • Hydatidiform moles are excessively edematous immature placentas. • These include the benign complete hydatidiform mole and partial hydatidiform mole and the malignant invasive mole. • Invasive mole is deemed malignant due to its marked penetration into and destruction of the myometrium as well as its ability to metastasize. 6
  • 7. Classification …. • Nonmolar trophoblastic neoplasms include choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. • These three are differentiated by the type of trophoblast they contain. 7
  • 8. Classification …. • The malignant forms of GTD are termed gestational trophoblastic neoplasia (GTN). • These include invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. • These malignancies develop weeks or years following any type of pregnancy, but frequently occur after a hydatidiform mole. 8
  • 9. Incidence • The incidence of gestational trophoblastic disease has remained fairly constant at approximately 1 to 2 per 1,000 deliveries in the United States and Europe. (Drake, 2006; Loukovaara, 2005; Lybol, 2011) • Can follow any gestational event – abortion, miscarriage, ectopic, normal pregnancy 9
  • 10. Risk factors • Maternal age at the upper and lower extremes • A history of prior unsuccessful pregnancies • personal history of GTD • Combination oral contraceptive (COC) • vitamin A deficiency and low dietary intake of carotene • Smoking • Irregular menstrual cycles 10
  • 11. Types of Gestational Trophoblastic Disease • Hydatidiform mole (complete or partial) • Invasive mole • Choriocarcinoma • Placental-site trophoblastic tumor • Epithelioid trophoblastic tumor 11
  • 12. Hydatidiform mole • The most common form of gestational trophoblastic disease (GTD). • Also known as a molar pregnancy. • Hydatidiform moles are not cancerous, but they can develop into cancerous GTDs. • There are 2 types of hydatidiform moles: complete and partial. 12
  • 13. 13
  • 14. Hydatidiform mole… • The degree of histological changes, karyotypic differences, and the absence or presence of embryonic elements are used to classify them as either complete or partial moles. • These two also vary in associated risks for developing medical comorbidities and post evacuation GTN. • Of the two, GTN more frequently follows complete hydatidiform mole. 14
  • 15. Hydatidiform mole… • Complete moles have a potential for local invasion and dissemination. • After molar evacuation, local uterine invasion occurs in 15% of patients, and metastasis occurs in 4%. • High risk for developing postmolar tumor:  HCG level >.100,000 mIU /mL  Excessive uterine enlargement  Theca lutein cysts 6 cm in diameter 15
  • 16. Invasive mole • This common manifestation of GTN is characterized by whole chorionic villi that accompany excessive trophoblastic overgrowth and invasion. • These tissues penetrate deep into the myometrium, sometimes to involve the peritoneum, adjacent parametrium, or vaginal vault. • Invasive moles can develop mostly from complete hydatid moles. 16
  • 17. Invasive mole … • The risk of developing an invasive mole increases in women who had gestational trophoblastic disease in the past. • A tumor or mole that grows completely through the wall of the uterus may result in bleeding into the abdominal or pelvic cavity. This bleeding can be life threatening. 17
  • 18. Choriocarcinoma • Choriocarcinoma is a malignant form of gestational trophoblastic disease (GTD). • This extremely malignant tumor contains sheets of anaplastic trophoblast and prominent hemorrhage, necrosis, and vascular invasion. • Gestational choriocarcinoma initially invades the endometrium and myometrium but tends to develop early blood-borne systemic metastases. 18
  • 19. Placental-site trophoblastic tumor • Placental-site trophoblastic tumor (PSTT) is a very rare form of gestational trophoblastic disease (GTD) that develops where the placenta attaches to the lining of the uterus. • Most commonly develops following a term gestation. • Typically, patients have irregular bleeding months or years after the antecedent pregnancy, and diagnosis is confirmed with endometrial sampling. 19
  • 20. Cont … • Hysterectomy is the primary treatment or nonmetastatic Placental site trophoblastic tumor due to its relative insensitivity to chemotherapy. • Metastatic PSTT has a much poorer prognosis than its postmolar GTN counterparts. As a result, aggressive combination chemotherapy is indicated. 20
  • 21. Epithelioid Trophoblastic Tumor • It is rare trophoblastic tumor is distinct from gestational choriocarcinoma and PSTT . • Epithelioid trophoblastic tumor develops from neoplastic transformation of chorionic-type intermediate trophoblast. • The diagnosis is usually confirmed in advance by endometrial biopsy. 21
  • 22. Cont … • Microscopically, this tumor resembles PSTT , but the cells are smaller and display less nuclear pleomorphism. • Grossly, epithelioid trophoblastic tumor grows in a nodular fashion rather than the infiltrative pattern of PSTT. • Hysterectomy is the primary treatment due to presumed chemoresistance. 22
  • 23. Staging • A staging system based on the anatomical spread has been developed by FIGO (the International Federation of Gynecology and Obstetrics). 23
  • 24. Clinical presentations and complications • Vaginal bleeding: The abnormal and rapid growth of trophoblastic tissue causes separation of blood vessels from the decidual bed which results in painless vaginal bleeding. This blood loss may occur gradually and cause severe anemia which may need blood transfusion. • • Excessive uterine size: Because of abnormal proliferation of trophoblastic tissue and Retained blood clots and trophoblastic tissue 24
  • 25. Cont …. • Hyperemesis gravidarum: excessive nausea and vomiting with unkown mechanism which may cause electrolyte and metabolic disturbances. It may be related to BHCG. • Ovarian theca lutein cysts: in patients with high levels of HCG, usually more than 100,000 miu/ml. 25
  • 26. Cont … • Pre-eclampsia: GTD should be suspected in pregnant patients with signs and symptoms of pre-eclampsia in early pregnancy-especially during the first and early second trimester. • Hyperthyroidism: A normal HCG will have weak thyrotropic activity on TSH receptors. However, because of increase thyroxin binding globulin levels in pregnancy, this will cause a small change in thyroid hormone activity. 26
  • 27. Cont… • Acute cardiopulmonary distress: incidence of 27%. • It occurs in patients with a uterine of size greater than 16 weeks and with very high HCG levels. • Signs/symptoms include tachycardia, chest pain, hypoxia, tachypnea, diffuse rales and chest radiographic features of bilateral pulmonary infiltration. 27
  • 28. Cont … • DIC: Consumption coagulopathy can occur as a result of activation of the coagulation cascade by factors released from abnormal trophoblastic tissue. • This may be due to placental tissue release of substances that have some thromboplastin properties. 28
  • 29. Diagnosis OF GTD • History  Amenorrhoea  Hyperemesis gravidarum  Vaginal bleeding • Examination  Uterine size – bigger for dates  Adnexal mass  Evidence of metastatic disease eg vaginal metastases 29
  • 30. Diagnosis OF GTD …. • Investigations:  Urine and serum HCG, Full blood count, Renal and liver function tests  Thyroid function test, Clotting profile  Chest x-ray: to check for any lung metastasis.  Ultrasound of pelvis and liver  CT abdomen and thorax  CT or MRI brain: indicated if there are any neurological symptoms or any pulmonary metastasis.  Positron emission tomography (PET) - CT: to find the source of a rising HCG which could not be detected by other imaging tools. This type of scan detects tumor tissue which has high glucose uptake and metabolic rate. 30
  • 31. Treatment modalities • Suction Curettage • Hysterectomy • Prophylactic Chemotherapy 31
  • 32. Hyperthyroidism in GTD • Plasma thyroxine levels are often elevated in women with complete moles, but clinical hyperthyroidism is unusual and is identified in only approximately 5% of patients. • If hyperthyroidism is suspected before the induction of anesthesia for molar evacuation, β- adrenergic blocking agents should be administered. • After molar evacuation, thyroid function test results return rapidly to normal. 32
  • 33. Hyperthyroidism…. • Hyperthyroidism develops almost exclusively in patients with very high HCG levels. • Some investigators have suggested that HCG is the thyroid stimulator in women with GTD, because positive correlations between serum HCG levels and total T4 or T3 concentrations have been observed. 33
  • 34. Anesthesia Management • The preoperative management of these patients present multitude of challenges for the anesthesiologists. • Thus anesthetist should be prepared to deal with such complications.  Cardiac failure (secondary to thyrotoxicosis)  Thyroid storm  Hypertension  Embolization of pulmonary arteries by trophoblastic materials  Hypovolemia  DIC, and  Pulmonary edema are some of them. 34
  • 35. Cont … • In d/t literature TIVA, SA and GA have been described for the management of molar evacuation. • Crucial to anesthesia management is the perioperative prevention of thyrotoxic crisis and control of sympathetic stimulation secondary to hyperthyroidism. 35
  • 36. Cont … • In actively bleeding or hypotensive patients; general anesthesia has to be used to facilitate evacuation. • However, uterine relaxation may increase blood loss and inhaled anesthetics with known tocolytic effect such as halothane, enflurane and isoflurane should therefore only be used in low concentrations. 36
  • 37. Cont … • In hemodynamically stable patients, thiopentone is the induction agent of choice because of its anti thyroid action. • In hemodynamically unstable patients, etomidate is the induction agent of choice. • A non depolarizing muscle relaxant which does not cause histamine release should be used. • Depending on the size of the uterus a rapid sequence induction may need to be done. 37
  • 38. Cont … • If the patient is hemodynamically stable in the preoperative period, regional anesthesia is appropriate • Has no tocolytic effect • Offered minimal interference with the patients cardiovascular status and • Provided excellent post-operative pain relief after surgery. 38
  • 39. Cont … • Intraoperative events like hypotension and tachycardia can be treated with antiarrhythmic agents and transfusion with a plasma expander and crystalloid fluid. 39
  • 40. Cont … • Antiarrhythmic agents like esmolol and digoxin can be used effectively in treating tachycardia and atrial fibrillation. • In case of refractory atrial fibrillation and cardiac failure cardioversion can be considered. 40
  • 41. Cont … • Stable patients with clinical hyperthyroidism should be treated with antithyroid medications until a euthyroid state is achieved. • Emergency patients with bleeding and severe hyperthyroidism should get a dose of a beta blocker and steroid to prevent thyrotoxic crisis. • Another option in these patients is plasmapheresis which is used for rapid hormonal control by removing excess hormones. 41
  • 42. Summary • Gestational trophoblastic disease is proliferation of trophoblastic tissue in pregnant or recently pregnant women. • Manifestations may include excessive uterine enlargement, vomiting, vaginal bleeding, and preeclampsia, particularly during early pregnancy. 42
  • 43. Summary … • Diagnosis includes measurement of the β-subunit of human chorionic gonadotropin, pelvic ultrasonography, and confirmation by biopsy. • Tumors are removed by suction curettage/hyterectomy. • If disease persists after removal, chemotherapy is indicated. 43

Editor's Notes

  1. GTD histologically is divided into hydatidiform moles ( molar lesions), which are characterized by the presence of villi, and nonmolar trophoblastic neoplasms, which lack villi.
  2. A complete mole has abnormal chorionic villi that grossly appear as a mass of clear vesicles. These vary in size and often hang in clusters from thin pedicles. In contrast, a partial molar pregnancy has focal and less advanced hydatidiform changes and contains some fetal tissue. Although both forms of moles usually fill the uterine cavity, they rarely may be tubal or other forms of ectopic pregnancy
  3. complete moles typically have a diploid karyotype, and 85 to 90 percent o cases are 46,XX. Partial moles are most commonly triploid in karyotype. They are usually 69, XXXY, which arise from fertilization of an apparently normal ovum by 2 sperms.
  4. Theca lutein cysts is a type of bilateral functional ovarian cyst filled with water, straw color filled. To be a functional cyst the mass must reach a diameter of at least three centimeters. Human chorionic gonadotropin HCG is disease specific tumor marker which is released by both hydatidiform moles and gestational trophoblastic neoplasms. It is a glycoprotein that consists of an α-subunit which resembles pituitary hormones like TSH, FSH, and LH and hormone specific β- subunit which is unique for placental production.
  5. invasive mole- This is a benign tumor. It arises from myometrial invasion of a hydatidiform mole by direct migration through tissue or venous extension. About 10-17% of hydatidiform moles will lead to an invasive mole, and about 15% of these will metastasize to the vagina or lung.
  6. The risk of developing an invasive mole increases in women who had gestational trophoblastic disease in the past. Because these moles have grown into the uterine muscle layer, they aren't completely removed during a D&C.
  7. Trophoblastic embolization (the main cause in more than 50% of the patients of GTD).  High-output cardiac failure (which is from thyrotoxicosis).  Pulmonary congestion (which is from severe anemia).  Pregnancy induced hypertension.  Aspiration pneumonitis.  Sepsis.  Blood transfusion and acute lung injury which usually manifest 6 hours after transfusion.  Iatrogenic fluid overload.
  8. Tocolytes….terbtaline. Nefidepine, magnesium sulphate….>>>used to suppress premature labor contraction>>>>it stops or delay labor to give time for the child lung to be mature. The volatile anaesthetics include Sevoflurane, Desflurane, Isoflurane, and Halothane inhibited the spontaneous contractility of isolated pregnant human uterine muscle in a dose-related manner.
  9. Digoxin…decrease HR due to increased intracellular ca lengethens phase 4 and 0 of action potential and due to increased storage of calcium in SR increase myocardial contractility because of increased release of ca during each action potential.
  10. Management of the thyroid storm: This may occur at any time during the perioperative period. 1. Admission to ICU with supportive therapy include fluid and electrolyte control, oxygen, acetaminophen for hyperpyrexia (avoid aspirin because it increase free thyroid hormones). 2. Treat congestive heart failure. 3. B-blocker as Propanolol or Esmolol. 4. Methimazol or PTU. 5. Lugol's solution or potassium iodide should be used 1 hour after PTU because iodide may cause reflex release of thyroid hormone. 6. Glucocorticoid.