Contents: Introduction Classification Complete and partial mole: Choriocarcinoma Residual/ Invasive mole.

1. Gestational Trophoblastic Diseases:
A Review for PG Preparation
Dr. Prithwiraj Maiti
Intern, R.G.Kar Medical College, Kolkata
Founder of Pgblaster India
Author of the following titles (Both published by Jaypee Brothers):
A Practical Handbook of Pathology Specimens and Slides &
An Ultimate Guide to Community Medicine

2. Table of contents
• Introduction
• Classification
• Complete and partial mole:
1. Differences
2. Associated conditions
3. Clinical features
4. Diagnosis
Management
5. Follow-up
6. Role of prophylactic chemotherapy
• Choriocarcinoma
• Residual/ Invasive mole.

3. Introduction
• GTDs are a spectrum of diseases arising from trophoblastic cells in
placenta.

4. Classification of GTDs
• Hydatidiform mole: Complete and partial
• Invasive mole
• Choriocarcinoma.

5. Complete and Partial mole
Differences
Features Complete mole Partial mole
Fetus/ embryo Absent Present
Trophoblastic
proliferation
Marked Minimal
Villous edema Marked Focal
Karyotyping Diploid:
46 XX
46 XY
Triploid:
69 XXX
69 XXY
69 XYY
p57 immunostaining Negative Positive

6. Associated Conditions
• Pre-eclampsia (present in 50% of cases)
• Theca-lutein cyst: Causing unilateral/ bilateral enlargement of ovary
• Thyrotoxicosis like features (due to ↑chorionic thyrotropin production)
• Hyperemesis (due to ↑hCG production).

7. Clinical features of molar pregnancy
• Period of amenorrhea
• Vaginal bleeding
• Lower abdominal pain
• Expulsion of grape like vesicles per vagina (diagnostic)
• Size of uterus is usually more than the period of amenorrhea
• Feel of uterus is firm and elastic (due to absence of amniotic sac)
• Fetal heart sound (FHS) not audible
• Features of associated conditions, if present [Ex: Hypertension and
proteinuria (pre-eclampsia), uni/bi-lateral enlargement of ovary (theca-
lutein cyst), tachycardia/ tremor (thyrotoxicosis), excessive vomiting
(hyperemesis)].

8. Diagnosis
• USG: Classical snow-storm appearance
(created by multiple placental vesicles filling
the uterine cavity)
• Serial estimation of serum β-hCG levels (high
levels are seen in molar pregnancy due to
excessive production by trophoblastic cells)
• Definitive diagnosis is made only by
histopathological examination of the
products of conception.

9. Management
• If mole is in the process of expulsion: Suction-evacuation
• If uterus is inert and os closed: Slow dilatation of cervix followed by
suction-evacuation
• Most common immediate complication after evacuation is bleeding
• Special management:
Indications
Hysterectomy Hysterotomy
Age > 35 years Profuse vaginal bleeding
Family completed Unfavorable cervix
Uncontrollable hemorrhage/
perforation during suction-evacuation
Perforation during suction-evacuation

10. Follow up after definitive management
• Must for all patients
• Done for at least 1 year as the occurrence of choriocarcinoma from a
complete mole is highest during this period
• Usually serum β-hCG becomes negative after 6-8 weeks of molar
evacuation
• OCPs are the preferred mode of contraception during this period
• IUDs are not to be inserted until the β-hCG level is undetectable
because of the risk of uterine perforation if an invasive mole is present.

11. Role of prophylactic chemotherapy
• Drug of choice: Methotrexate.
• Indications:
1. If the hCG level fails to become normal by 10-12 weeks
2. Rising hCG levels after reaching normal levels
3. Post evacuation hemorrhage (reflecting residual trophoblastic
activity)
4. When follow up visits are not adequate
5. Evidences of metastasis.

12. Choriocarcinoma
• Extremely malignant, commonest cause of systemic metastasis
among gynecological malignancies
• Most common complication of choriocarcinoma is vaginal bleeding
• Most common site of metastasis is lung
• Those choriocarcinoma arising after full term pregnancy has the worst
prognosis
• Management is by chemotherapy.

13. Residual/ Invasive mole
• Invasive moles originate almost exclusively from complete/ partial
molar gestations
• These are characterized by presence of whole chorionic villi that
accompany excessive trophoblastic overgrowth and invasion
• These tissues penetrate deep into the myometrium; sometimes
involving the peritoneum, adjacent parametrium or vaginal vault
• There is no evidence of muscle necrosis
• Clinical features are: persistent hemorrhage and uterine perforation
• Management: Chemotherapy.

14. Chemotherapeutic regimen for GTDs
• Single agent: Methotrexate
• Multiple agents (EMACO Regimen):
E. Etoposide
M. Methotrexate
AC. Actinomycin-D
O. Oncovin (Vincristine).

15. Thank you