This document discusses gestational trophoblastic disease (GTD), which includes a spectrum of tumors arising from abnormal trophoblast proliferation. GTD encompasses benign conditions like hydatidiform moles as well as malignant tumors known as gestational trophoblastic neoplasia (GTN). Complete and partial hydatidiform moles are distinguished based on histological features and presence of fetal tissue. Risk factors for molar pregnancies include younger and older maternal age as well as prior molar pregnancies. Molar pregnancies are diagnosed using beta-hCG levels, ultrasound findings, and pathology. Treatment involves surgical evacuation followed by beta-hCG monitoring to detect GTN, which may require chemotherapy. Prognosis

1. Moderator : Dr Winta
:Dr Girmachew
Presenter: Yosef
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2.  is a group of tumor characterized by abnormal
trophoblast proliferation.
histologically......presence or absence of villi
hydatidiform mole
 complete hydatidiform mole
partial hydatidiform mole
invasive mole
non molar trophoblastic neoplasia
choriocarcinoma,
placentalsite trophoblastic tumor, and
epithelioidtrophoblastic tumor
these four are
malignant (GTN)
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3. Benign hydatidiform mole
• A complete mole has abnormal chorionic villi that
grossly appear as a mass of clear vesicles,no fetal
tissue
• Where as a partial molar pregnancy has focal and
less advanced hydatidiform changes and contains
some fetal tissue
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4. Epidmiology and risk factors for molar pregnancy
• High prevalence in Asians, Hispanics, and American Indians
• The incidence in USA and Europe is 1-2 per 1000 deliveries
• The strongest risk factors are age and previous molar
pregnancy
• Age common in both extremes of reproductive age
• prior one complete mole 1.5% risk
• prior one partial mole 2% risk
prior two molar px has 23%risk of 3rd molar px
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5. Pathogenesis
• Molar pregnancies arise from chromosomally
abnormal fertilizations
1. ? complete moles...dipolid
2. ? partial moles.......triploid
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6. Clinical findings in molar px
• 1 to 2 months amenorrhea
• Vaginal bleeding, passage of vesicles,
exaggerated Sx of preg
• Absence of fetal heart tones
• Hyperemesis gravidarum
• Size inconsistent with gestational
age( with no fetal heart beating and fetal
movement)....soft consistency
• Preeclampsia, Thyrotoxicosis
• Theca lutein ovarian cysts
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7. Diagnosis of Hydatidiform mole
•History and physical examination
• Quantitative beta-HCG( elaborates unique tumor
marker for diagnosis & follow-up)
• Ultrasound is the criterion standard for identifying
both complete and partial molar pregnancies.
• complete mole appears as an echogenic uterine mass
with numerous anechoic cystic spaces. The classic image
is of a “snowstorm” pattern
• partial mole has features that include a thickened,
multicystic placenta along with a fetus or at least
fetaltissue
? pathologic diagnosis
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8. Differential diagnosis
•Abortion, ectopic px
•Multiple pregnancy
•Polyhydramnios
•Pelvic tumors
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9. Investigation
 CBC, BG& RH, U/A, Serum beta hCG, TFT,
workup for PE, serum electrolyte,PT, aPTT,
OFT, HIV test
 Imaging:- U/S(ABD/VAG), Doppler U/S,
CXR(if indicated)
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10. Management
 General:
- ABC(shock,CHF)
- HTN, Thyrotoxicosis
- Blood transfusion, Anemia
- Anti-D(Rh alloimmunization)
- Infection
 Specific
Termination of molar px
 Suction(MVA,EVA), dilation
and curettage
 Hysterectomy : -used rarely,
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11.  Base line β-hCG level is obtainedwithin 48 hours after evacuation
 Quantitative serum hCG levels should be obtained every 1-2
weeks until negative for three consecutive determinations,
 The median time for β-hCG become negative is 7 weeks for partial
moles and 9 weeks for complete moles.
 Followed by every 1 month for 6 months and every 2 months for
1 year.
 Contraception using OCP should be practiced during this follow-
up period...should be combined with other methods
Follow-up
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12. • complete moles have a 15 to 20 %, partial mole 1-5%
• older age,
• β-hCG levels >100,000 mIU/mL,
• uterine size that is large-for-gestational age,
• theca-lutein cysts>6 cm,and
• slow decline inβ-hCGlevels
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13. • This group includes invasive mole, choriocarcinoma, placentalsite
trophoblastic tumor, andepithelioidtrophoblastic tumor.
• These tumors almost always develop following some formof
recognized pregnancy.
Half follow hydatidiform mole,
 fourth follow miscarriage or tubalpregnancy, and another
fourth develop after a preterm or term pregnancy
they are usually diagnosed by persistently elevated serum β-hCG
levels
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14. • GTNs are characterized clinically by their aggressive
invasion into the myometrium and ability to metastasize
• The most common finding with GTN is irregular bleeding
associated with uterine subinvolution
• Myometrial perforation from trophoblastic growth may
cause intraperitoneal hemorrhage
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15. • if a woman experiance unusually persistent bleeding
after any type of pregnancy
• measurement of serum β-hCG levels
• diagnostic curettage.
• Uterine size is assessed along with careful examination for
lower genital tract metastases,
• work up for metastasis organ function taste,
sonography, chest CT scan or radiograph, and brain and
abdominopelvic CT scan or MR imaging
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16. • 1. Plateau of serum β-hCG level (±10 percent)for four
measurements during a period of 3 weeks or longer—days 1, 7, 14,
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• 2. Rise of serum β-hCG level >10 percent during three weekly
consecutive measurements or longer, during a period of 2 weeks or
more—days 1, 7, 14
• 3. Serumβ-hCG level remains detectable for 6 months or more
• 4. Histological criteria for choriocarcinoma
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17. FIGO Staging System for Gestational Trophoblastic Tumors
Stage Description
Ⅰ Limited to uterine corpus
Ⅱ
Extends to the adnexae, outside the uterus, but
limited to the genital structures
Ⅲ Extends to the lungs with or without genital tract
Ⅳ All other metastatic sites
 Sub-stages assigned for each stage as follows:
A: No risk factors present
B: One risk factor
C: Both risk factors
 Risk factors used to assign sub-stages:
1. Pretherapy serum hCG > 100,000 mlU/ml
2. Duration of disease >6 months 17

18. Mod WHO Prognostic Scoring System
Score
Prognostic factor 0 1 2 4
Age(years) <40 ≥40 — —
Pregnancy history
Hydatidiform
mole
Abortion,
ectopic
Term
pregnancy
—
Interval (months) of
treatment
<4 4-6 7-12 >12
Initial hCG(mIU/ml) <103 103-104 104-105 >105
Largest tumor(cm) <3 3-5 >5 —
Sites of metastasis Lung
Spleen,
kidney
GI tract, liver Brain
No. of metastasis — 1-4 4-8 8
Previous (treatment) — — Single drug 2 or more
<7 low risk, 7 high risk for death
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19. • Invasive Mole
• most common GTN that follow hydatidiform moles
• locally aggressive, but less prone to metastasize
• Gestational Choriocarcinoma
• the most common type of GTN to follow a term pregnancy or a
miscarriage
• Metastases often develop early and are generally blood-borne
• common sites are the lungs and vagina
• Placental Site Trophoblastic Tumor (PSST)
• uncommon tumor arises from implantation site-intermediate trophoblast
• high proportion of free β-hCG (>30 percent) is diagnostic
• usually resistant to chemotherapy
• Epithelioid Trophoblastic Tumor
• rare tumor develops from chorionic-type
intermediatetrophoblast
• Grossly, the tumor grows in a nodular fashion.
• Primary treatment is hysterectomy because this tumor is
relatively resistant to chemotherapy.
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20. Treatment
 Principles:
- Chemotherapy
- Surgery(resistant & persistent metastasis)- Liver,
Brain, Lung, other
- Radiotherapy
Low risk or high risk?
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21. Treatment.....
Low risk
 Single-agent chemotherapy is the
treatment of choice for patients
wishing to preserve their fertility.
 Methotrexate(MTX) or
Actinomycin-D
 Treatment is continued until three
consecutive normal hCG levels
have been obtained and two
courses have been given after the
first normal hCG level.
 If resistance to sequential single-
agent chemotherapy develops,
combination chemotherapy would
be taken
High risk
 Multiagent chemotherapy
with or without adjuvant
radiotherapy or surgery
should be the initial
treatment for patients with
high-risk metastatic GTN
 EMA-CO regimen formula is
good choice for high-risk
metastatic GTN
 Etoposide, methotrexate, and
dactinomycin (actinomycin D) ,
cyclophosphamide and
vincristine (Oncovin)
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22. Prognosis
 Cure rates approach 100% in nonmetastatic and low-risk
metastatic GTD
 Intensive multimodality therapy has resulted in cure rates
of 80-90% in patients with high-risk metastatic GTD
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23. Follow-up After Successful Treatment
 Quantitative serum hCG levels should be obtained monthly
for 6 months, every two months for remainder of the first
year, every 3 months during the second year
 Contraception should be maintained for at least 1 year
after the completion of chemotherapy.
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24. • williams obstetrics 24th edition
• williams gynecogy 3rd edition
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