The document outlines the classification, pathology, symptoms, investigations, and treatment of gestational trophoblastic disease, including hydatidiform moles, invasive moles, and choriocarcinoma. It details both complete and partial moles, their clinical presentations, diagnostic criteria, associated complications, and therapeutic approaches. Follow-up care and monitoring for potential malignancy are also emphasized, alongside recommendations for future pregnancies.

1. Gestational
Trophoblastic Disease

2. Classification
1. Hydatidiform (vesicular )mole
Complete and Partial
2. Invasive mole
3. Choriocarcinoma
4. Placental-site trophoblastic tumor

3. VVeesicsicularular
m
m
o
l
e
o
l
e
Vesicular mole
VVeesisiccuularlar
m
o
l
m
o
l
e
e
Vesicular mole

4. It is a benign neoplasm of the chorionic villi
characterized by
1. of
ro .
2.
s
M
a
M
a
r
r
k
k
e
e
d
d
p
r
p
r
o
o
l
i
f
l
i
f
e
r
e
r
a
a
t
i
o
n
t
i
o
n
ththeessynynccyytiutiumm&
&
c
c
y
y
t
o
t
o
t
O
O
e
d
e
d
e
e
m
m
a
a o
o
r
r
h
h
y
d
r
y
d
r
o
o
p
p
i
c
i
c
ccononnneecctitivvee tistisssuuee
sstrtroo toto thetheirir
ddisistentenssionionaan
de
m
d fo
t
t
h
h
e
e
trtroop
p
h
h
opop
la
lasst,t
,b
b
ot
hot
h
phhooplaplasstta
a
r
r
e
ea
a
f
f
f
f
e
c
e
c
t
e
t
e
d
d
geennereraationtionofof
thethe
a ooffththeevviillilliw
w
h
h
i
c
i
c
h
hl
e
l
e
a
a
d
orrmmaationtionooff
vvesesiciclesles..
3.
disappear from villi explaining early death of
disappear from villi explaining early death of
• Hyperplasia of trophobasitc cells
• Hydropic swelling of all villi
•
thV
ee
s
es
ee
ml
sbarreyuosuallyabsent
Avascularity of the villi: the blooNdovremssaels
villa
VM

5. Incidence
1:2000 pregnancies in United States and Europe,
10 times more in Asia.
Predisposing factors include :
Race, deficiency of protein or carotene
The incidence is higher toward the beginning and
more toward the end of the childbearing period.
It is 10 times more in women over 45 years old.

6. Pathology
The uterus is distended by
thin walled, translucent,
grape-like vesicles of
different sizes.
These are degenerated chorionic villi filled with
fluid.
There is no vasculature in the chorionic villi
leads to early death of the embryo.

7. High hCG causes multiple theca lutein cysts
in the ovaries in about 50% of cases.
Cysts may reach a large size (10 cm or more.
Cysts disappear
within few months(2-3),
after evacuation of the mole.
Pathology

8. (i) Complete mole
The whole conceptus is transformed into a
mass of vesicles.
No embryo is present.
It is the result of fertilization of enucleated
ovum ( has no chromosomes) with a sperm
which will duplicate giving rise to 46
chromosomes of paternal origin only.

9. (i) Complete mole:

10. Complete mole

11. (ii) Partial mole
- A part of trophoblastic tissue only shows
molar changes.
- There is a fetus or at least an amniotic sac.
- It is the result of fertilization of an ovum by
2 sperms so the chromosomal number is 69
chromosomes

12. Partial mole

13. (ii) Partial mole

14. Differentiation between complete and partial mole
Feature
Embryonic or
foetal tissue
Complete Mole Partial Mole
Absent Present
Diffuse Focal
Swelling of the
villi
Trophoblastic
hyperplasia
Diffuse Focal
Karyotype Paternal 46 XX Paternal and
(96%) or 46 XY (4%) maternal 69 XXY
or 69 XYY
Malignant 5-10% Rare

15. Diagnosis

16. (A) Symptoms
1. Amenorrhoea: usually of short period (2-3
months).
2. Exaggerated symptoms of pregnancy
especially vomiting.
3.Symptoms of preeclampsia may be present as
headache, and oedema

17. 4. Vaginal bleeding :
The main complaint, due to separation of vesicles
from uterine wall, there may be a blood stained
watery discharge, the watery part is from ruptured
vesicles.
Prune juice discharg may occur.
passage of vesicles is diagnostic.
The blood may be concealed causing enlargement
& tenderness of the uterus.
(A) Symptoms

18. 5. Abdominal pain :- dull-aching ,- Colicky or
Sudden And Severe due to perforating mole
- Ovarian pain due to stretching of the ovarian
capsule or complication in the cystic ovary as
torsion
(A) Symptoms

19. Signs

20. General examination
1. Pre-eclampsia in 20-30% of cases, usually
before 20 weeks’ gestation.
2. Pallor indicating anemia may be present.
3. Hyperthyroidism in 3-10% of cases
4. .
5. Breast signs of pregnancy.

21. Abdominal examination
1. The uterus is >the period of
amenorrhoea in 50% of cases,
corresponds to it in 25% and
smaller in 25% with inactive or dead mole.
1. The uterus is doughy in consistency due to
absence of amniotic fluid and its distension
with vesicles.
2. Fetal parts and heart sound cannot be detected
except in partial mole.

22. Local examination
1. Passage of vesicles (sure sign).
2. Bilateral ovarian cysts in 50% of cases.
3. No internal ballottement.

23. (C) Investigations
Serum b -hCG level
is highly elevated ( > 100.000 mIU/m1)
" snow storm" appearance,on US
no identifiable fetus,
X-ray of the chest: should be performed in
every case of trophoplastic tumour.

24. Partial Mole: Complex mass with many
cystic areas (between arrowheads) and an
embryo (arrow) in a patient with a β-HCG
of 280,000 mIU/ml

25. Complete Mole
Complete mole:
“snowstorm” appearance
with multiple cystic areas, no
fetal tissue present
Corresponding T1 weighted
MRI (MRI can be helpful in
determining extent of
trophoblastic disease)

26. real-time ultrasound of a hydatidiform mole.
The dark circles of varying sizes at the top
center are the edematous villi.

27. Complications
1. Haemorrhage.
2. Infection
3. Perforation.
4. Pregnancy induced hypertension
5. Hyperthyroidism.
6. choriocarcinoma in about 5% of cases and
7. invasive mole in about 10% of cases.
8. Recurrent mole may occur(1-2%).

28. Treatment
molar pregnancy should be evacuated.
Suction dilation and curttage
20 units oxytocin in 500 m1 of 5% glucose
should be infused IV after the start of
evacuation and continued for several hours to
enhance uterine contractility

29. Dilatation of the cervix is done up to a Hegar's
number equal to the period of amenorrhoea in weeks
e.g. No. 10 Hegar for 10 weeks’ amenorrhoea
-
-
The suction canula used will be
of the same size also.
(I) Suction evacuation

30. (I) Suction evacuation
- A suction canula which may be metal or a
disposable plastic (preferred) is introduced
into the uterine cavity.
- The canula is connected to a suction pump
adjusted at negative pressure of 300-500
mmHg according to the duration of pregnancy

31. The material removed is sent for
histological examination to exclude
malignancy .

32. Curettage
After evacuation ,
the uterus is gently curetted with a sharp
curette.
Some advise curettage one week after
evacuation to ensure complete removal,
but the is not the routine practice.

33. Theca lutein cysts
They are hormone dependent.
Disappear spontaneously after evacuation of
the mole.
So, they are not removed surgically unless
complication occur as torsion or rupture.

34. Large bilateral theca lutein cysts resembling ovarian germ cell tumors. With
Larrgeseolbuitiloanteorfat
h
le
th
hu
em
ca
an
lc
uh
to
er
i
io
nn
i
cc
yg
so
tn
sa
d
ro
et
sr
o
ep
mi
n
(
bH
lC
inG
g)
s
ot
i
vm
au
rl
ia
at
i
no
n
g,
t
e
h
r
e
m
yrectuerlnlto
tumonorrsm.a
Wl
-
a
ip
tp
he
a
rr
ei
n
sg
oo
lv
ua
tr
ii
oe
s
n.of the human chorionic gonadotropin(HCG)
stimulation, they return to normal-appearing ovaries.

35. (II)Hysterotomy
may be needed for evacuation of a large
mole to minimize and facilitate control of
bleeding.
(III) Hysterectomy
should be considered in women >40 years
who have completed their family for fear
of developing
choriocarcinoma.

36. (IV) Medical induction
Oxytocins and / or prostaglandins may be
used to encourage expulsion of the mole
but must always be followed by surgical
evacuation.

37. Follow up
detection of serum ß-hCG by
radioimmunoassay is essential
Normally B –subunit reach normal
level 8-12 wks after evacuation

38. ß-hCG is measured by
radioimmunoassay every week till the test
becomes negative for 3 successive weeks, then
the test is repeated every month for one year.
Pregnancy is allowed if the test remains
negative for one year.
Follow up

39. Follow up
- Persistent high level or Rising hCG level after
disappearance means developing of
choriocarcinoma or a new pregnancy.
- Serum B-hCG is undetectable 4 months after
evacuation.
-

40. Contraception during follow up
The combined pill is started when the beta-
HCG becomes negative. Till this happens,
the condom can be used.
If the pill is used early the beta-HCG will
take a longer time to become negative as
oestrogen stimulates the growth of
trophoplast.

41. The intrauterine device is not used because
it may lead to irregular uterine bleeding
which confuses the follow up
IUD during follow up

42. Invasive mole or
Chorioadenoma
Destruens

43. Definition
It is a trphoplastic tumour with penetration
of the myometrium by the chorionic villi.
It is locally malignant
and rarely metastasizes.
It may lead to perforation
of uterus

44. A case of invasive mole: inside the uterine cavity the typical
“snow storm” appearance can be detected, The location of
blood flow suggest an invasive mole.

45. The same patient owing to the myometrial invasion.
Reduced vascular resistance is detected in the uterine artery.

46. Early features suggesting persistant GTN or
post molar syndrome include
1. Recurrent Or Persistent Vaginal Bleedig
2. Subinvoluation
3. Amenorrhoea
4. Persistence of ovarian enlargement.
5. No malignancy in endometrial biopsy

47. Chemotherapy
Started if persistant or malignant disease develop
The level of serum HCG doubles in 2 weeks), after
exclusion of a new pregnancy
plateaus failure HCG to decrease over 3 weeks)
or
the test for the hormone becomes positive after
being negative or
If metastases appear.

49. Definition
A malignant form of GTD which can
develop from a hydatidiform mole or from
placental trophoblast cells associated with a
healthy fetus ,an abortion or an ectopic
pregnancy.

50. Symptoms and signs
Bleeding
Infection
Abdominal swelling
Vaginal mass
Lung symptoms
Symptoms from other metastases

51. Doppler image of choriocarcinoma