Hshsusnns

1. GESTATIONAL TROPHOBLASTIC
DISEASES
Prof.Dr. Mehnaz Khakwani
Chairperson & Head of Department
Obs& Gynae Unit I
Nishtar Hospital Multan

2. LEARNING OUTCOMES:
By the end of presentation, the participants should
be able to:
 Diagnose a case of gestational trophoblastic
disease.
 Plan treatment for a case of hydatidiform mole.

3. INTRODUCTION
 Abnormal proliferation of gestational
trophoblastic tissue that forms a spectrum of
diseases from the benign partial hydatidiform
mole to the malignant choriocarcinoma and
placental site trophoblastic tumours.

4. CLASSIFICATION(WHO):
 Pre-malignant :
 Partial hydatidiform mole
 Complete hydatidiform mole
 Malignant:
 Invasive mole
 Chorio-carcinoma
 Placental site tumours

5. INCIDENCE
 Geographical and racial variation
 Higher in Africa and Asia
 In Europe and North America 0.2-1.5 / 1000 LB.
 Extremes of reproductive age. Higher in
teenage pregnancies (1.3 fold) & above 40yrs
(10 fold)
 Complete mole – 1:1000
 Partial mole – 3:1000.

6. PARTIAL MOLE
 In this form of hydatidiform mole, embryo or
fetus co-exist with placental abnormality.
 Though it tends to die at earlier gestation i.e at
8-9 wks.
 Less hydropic swelling of chorionic villi & focal
changes.

7. PARTIAL MOLE
Genetics:
 Partial moles are triploid with two sets of
paternal and one set of maternal
chromosomes i.e. 2 sperms fertilize an egg.
 This results in triploid. i.e. 69 Chromosomes.

8. PARTIAL MOLE
Clinical presentation :
 Irregular bleeding
 Large for dates uterus
 Detection on routine USG
 Hyperemesis gravidarum
 Pre-eclampsia
 Hyperthyroidism
 DIC

9. COMPLETE MOLE:
 Abnormal pregnancy which consists of placental
tissue only and there is no embyo in it.
 There is cytotrophoblastic and syncytiotrophoblastic
hyperplasia. Placental villi are swollen resulting in
cistern formation.

10. COMPLETE MOLE:
Genetics:
 In complete mole all of the genetic material is
paternal in origin and results from fertilization of
an empty egg lacking maternal DNA.
 Chromosomes count is 46XX, 46XY.

11. COMPLETE MOLE:

12. COMPLETE MOLE
Macroscopically:
No fetal pole visible. Bunch of grapes.
Microscopically:
Some embryonic cells present.
Histologically :
It shows oedematous villous stroma .
USG: Snow-storm appearance .
Clinical presentation: Same as partial mole

13. INVESTIGATIONS:
 All base line investigations
 Serum β HCG
 USG
 CXR
 T3,T4,TSH

14. INVESTIGATIONS: Serum β hCG
 Ideal tumour marker --- useful in diagnosis and follow up.
 Produced by synchtiotrophoblastic cells of placenta. Two
subunits alpha & βeta.
 β hCG level are higher in hydatidiform mole than in singleton
pregnancy.
 hCG can be measured in serum and urine.

15. PELVIC ULTRASOUND

16. Differential Diagnosis
 Threatened abortion
 Ectopic pregnancy
 Local causes of bleeding
 Twin pregnancy
 Fibroid uterus

17. TREATMENT
Suction evacuation in majority of the
cases.
 Hysterectomy if life threatning
hemorrhage during suction evacuation.
 Chemotherapy if indicated.

18. FOLLOW UP
 Once suction evacuation done, 90% of patient
require no treatment.
 Among 10% patients, 3% develop choriocarcinoma
& 7% invasive mole.
 Follow up done by measurement of hCG level at
regular intervals.

19. FOLLOW UP
 In full term normal delivery, hCG level became
undetectable with in 10-20 days.
 Takes longer time after non-molar abortion.
 Takes longer time after evacuation of hydatidiform
mole i.e. 8wks up to 6 months.

20. FOLLOW UP
 Measure hCG level every 2wks till it becomes undetectable.
 If hCG reverted to normal within 56 days then follow up will
be for 6 months from the date of uterine evacuation.
 If hCG has not reverted to normal within 56 days then
folllow up for 6 months from normalization of hCG level.

21. FOLLOW UP
 Monthly during 1st yr.
 Three monthly during 2nd yr.
 Measure hCG after every pregnancy.

22. PREGNANCY / CONTRACEPTION
 Avoid pregnancy until follow-up is complete.
Women undergoing chemotherapy should not
conceive for one year after completion of
treatment.

23. CONTRACEPTION
 Contraception by barrier methods until hCG levels
are normal
 COCs may be used once hCG levels are normal
IUCDs should not be used until hCG levels are normal
to reduce risk of uterine perforation.

24. INDICATIONS FOR CHEMOTHERAPY
Raised hCG level 6 months after evacuation
 hCG plateau in 3 consecutive serum samples
 hCG >20,000iu/l > 4 weeks after evacuation
Rising hCG in 2 consecutive serum samples

25. INDICATIONS FOR CHEMOTHERAPY
Pulmonary, vulval or vaginal mets unless hCG
level is falling
Heavy PV bleeding or GI/ intraperitoneal
bleeding
Histological evidence of choriocarcinoma
Brain, liver, GI mets or lung metastasis >2 cm
on CXR.

26. CHORIOCARCINOMA
 Common in Asia
 Incidence: 1:250 to 1:6000
 Epidemiology : 50% : after complete mole
25% : term pregnency
25% : non molar abortion

27. PRESENTATION
 Irregular vaginal bleeding
 Abdominal / vaginal mass
 Features related to metastasis eg. in CNS,
lungs, liver.

28. INVESTIGATIONS
 Beta hCG levels.
 Biopsy (it can cause haemorrhage )
 CXR
 USG
 CT/ MRI
 CSF HCG level (in case of metastasis in CNS)

29. PROGNOSIS
 The prognosis and treatment
depends on scoring system.

30. Classification (scoring)
 Age of pt
 Antecedent pregnancy
 Months from index pregnancy
 Pre-treatment hcg
 Largest tumour size
 Size of mets
 Number of mets
 Previous chemotherapy.

32. Low Risk…≤ 6
Treatment:
 Single agent chemotherapy
 METHOTREXATE 50 mg IM
+
FOLINIC ACID after 30 hours 6 mg IM.

33. High risk: ≥ 7
 Combination of multiple drugs.
 EMA/CO regimen.
 Continue treatment until hCG are normal and
for a further 6 cosecutive weeks.
 Follow up by serial beta hCG levels.

34. SURGICAL TREATMENT
 Hysterectomy
Indications:
 Persistent heavy p/v bleeding.
 Uterine perforation.
 Drug resistant disease.

35. SUMMARY:
Suction evacuation is the mainstay of treatment for
hydatiform mole.
Follow up with beta hCG is very essential.
Indications for chemotherapy should be followed.
Avoid pregnancy until the follow up is complete.