This document discusses gestational trophoblastic diseases, specifically hydatidiform moles. It covers the epidemiology, risk factors, types (complete vs. partial mole), clinical features, diagnosis, natural history, persistent gestational trophoblastic tumor, staging, and management of these conditions. The key points are that complete moles are paternal in origin and associated with higher risks, while partial moles are triploid and have lower risks. Diagnosis involves ultrasound and tissue biopsy. Follow up of hCG levels is important after treatment to monitor for persistent tumors. Staging and risk scoring help guide chemotherapy for metastatic or high risk cases.
Benign ovarian masses include functional cysts and tumors; most are asymptomatic.Most functional cysts and benign tumors are asymptomatic. Sometimes they cause menstrual abnormalities. Hemorrhagic corpus luteum cysts may cause pain or signs of peritonitis, particularly when they rupture. Occasionally, severe abdominal pain results from adnexal torsion of a cyst or mass, usually > 4 cm. Treatment varies depending on the patient's reproductive status.
Benign ovarian masses include functional cysts and tumors; most are asymptomatic.Most functional cysts and benign tumors are asymptomatic. Sometimes they cause menstrual abnormalities. Hemorrhagic corpus luteum cysts may cause pain or signs of peritonitis, particularly when they rupture. Occasionally, severe abdominal pain results from adnexal torsion of a cyst or mass, usually > 4 cm. Treatment varies depending on the patient's reproductive status.
A brief introduction regarding oxytocics & tocolytics which are the indispensable drugs in obstetrics. It consists of illustrative images, classification of drugs with their dosage, uses & side-effects along with contraindications
management of gestational trophoblastic disease .pptxbanchygelan2
Gestational trophoblastic disease (GTD) is the term used to describe the heterogeneous group of interrelated lesions that arise from abnormal proliferation of placental trophoblasts
Complete molar pregnancies are general ly diploid and all chromosomes are of paternal origin.
Partial molar pregnancies are triploid and the extra set of chromosomes i s paternal
Gestational trophoblastic disease (GTD) is a group of rare diseases in which abnormal trophoblast cells grow inside the uterus after conception. In gestational trophoblastic disease (GTD), a tumor develops inside the uterus from tissue that forms after conception (the joining of sperm and egg).
gestational trophoblastic disease is discussed in its basic knowledge update to enable undergraduate students help understand the disease, diagnose and treat GTD. also enables to follow and detect complications and malignant transformation of molar pregnancy. single drug and multiple dose chemotherapy depending on staging of the disease and related complications & side effects discussed.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
1. GESTATIONAL TROPHOBLASTIC
DISEASES
Prof. M.C.Bansal
MBBS,MS,MICOG,FICOG
Professor OBGY
Ex-Principal & Controller
Jhalawar Medical College & Hospital
Mahatma Gandhi Medical College, Jaipur.
2. HYDATIDIFORM MOLE
• Epidemiology:
▫ Incidence of GTD vary dramatically in different regions of the
world- incidence in Japan (2 per 1000 pregnancies) is about
3 times higher than in Europe or North America(0.6 to 1.1 per
1000 pregnancies)
▫ Incidence of partial mole (about 1 per 695 pregnancies) is 3
times higher than complete mole (about 1 per 1945
pregnancies)
• Risk factors of complete molar pregnancy:
▫ Low dietary intake of carotene
▫ Vitamin A deficiency
▫ Higher maternal age(35 yrs)
• Risk factor for partial mole:
▫ It has been associated with use of OCPs and history of
irregular menstruation.
▫ Not associated with dietary factors or maternal age
3. Types: (on the basis of gross morphology,
histopathology and karyotype)
• Complete mole
• Partial mole
Features Complete Mole Partial Mole
Fetal or embryonic tissue Absent Present
Hydatidiform swelling of Diffuse Focal
chorionic villi
Trophoblastic hyperplasia Diffuse Focal
Scalloping of chorionic villi Absent Present
Trophoblastic stromal inclusions Abse nt Present
Karyotype 46XX (90%); 46 XY Triploid
4. COMPLETE H. MOLE
• Complete H. Moles exhibit
characterstic swelling and
trophoblastic hyperplasia.
• Karyotype: 46XX (90% cases);
46XY(10%)
• Molar chromosomes- entirely
paternal in origin, although
mitochondrial DNA is maternal.
Complete moles arise from an
ovum that has been fertilized by a
haploid sperm, which then
duplicates its own chromosomes.
Ovum nucleus may be either
absent or inactivated.
5.
6. PARTIAL H. Mole
• Characterized by:
1. Chorionic villi of varying size with focal
hydatidiform swelling, cavitation and
trophoblastic hyperplasia.
2. Marked villous scalloping
3. Prominent stromal trophoblastic
inclusions
4. Identifiable fetal or embryonic tissues.
• Karyotype: triploid, the extra haploid set
is derived from father.
• When a fetus is present with partial
mole, it generally exhibits stigmata of
triploidy: growth retardation, multiple
congenital malformations- syndactyly,
hydrocephaly
7.
8.
9. Clinical features of complete mole:
A. Vaginal Bleeding: most common symptom (84%
patients)- may cause anaemia.
B. Excessive uterine size relative to gestational age: one
of the classic symptoms (28% patients). Endometrial
cavity may be expanded by both chorionic tissue and
retained blood. Is generally asociated with markedly
elevated hCG levels.
C. Preeclampsia: develops almost exclusively in
patients with excessive uterine size and markedly
elevated hCG levels.
D. Hyperemesis gravidarum: 8% patients, particularly
those with excessive uterine size and markedly
elevated hCG levels
10. E. Hyperthyroidism: rare these days. Anaesthesia or surgery may
precipitate thyroid storm.
• if hyperthyroidism is suspected, beta-adrenergic blocking
agents shud be given before induction of anaesthesia for molar
evacuation.
• Hyperthyroidism develops almost exclusively in patients with
very high hCG levels as hCG is thyroid stimulator in women
with GTD.
F. Respiratory distress due to trophoblastic embolization: occurs
rarely these days.
G. Theca leutin ovarian cysts: prominent cysts(>=6cm diameter)
develop in about half of patients with complete mole.
• Result from ovarian hyperstimulation by high serum hCG
levels.
• Regress spontaneously 2-4 mths after molar evacuation.
11. Clinical features of Partial H. Mole:
• Have signs and symptoms of incomplete of missed
abortion. Diagnosis is made after histological review of
tissue obtained by curettage.
• Vaginal bleeding is main symptom.
• Excessive uterine enlargement and pre eclampsia
occur rarely.
12. NATURAL HISTORY:
A. COMPLETE MOLE: after molar evacuation:
Local uterine invasion(15%)
Metastasis(4%)
High risk factors for postmolar tumor:
hCG levels> 100,000 mIU/ml
Excessive uterine enlargement
Theca leutin cysts 6cm in diameter
Older patients are also at increased risk.
B. PARTIAL H.MOLE: persistent tumor usually non-
metastatic develops in 2-4% cases. Chemotherapy is
required to achieve remission.
13. DIAGNOSIS:
USG-
• sensitive and reliable
method for complete
mole- characteristic
vesicular pattern even in
1st trimester.
• In partial molar
pregnancy-focal cystic
spaces in placental
tissues and increase in
transverse diameter of
gestational sac is seen.
14. Treatment:
• Pt should be evaluated carefully for presence of associated
medical complications.
• Most appropriate method of evacuation:
1. Hysterectomy: if patient desires surgical sterilization-
hysterectomy with mole in situ. Ovaries may be preserved
even in the presence of prominent theca leutin
cysts.hysterectomy doesn’t prevent metastasis, so patients
still require followup assessment of hCG levels.
2. Suction curettage: preferred method of evacuation regardless
of uterine size, for patients who desire fertility. Steps:
oxytocin infusion started before induction of anaesthesia.2.
cervical dilatation. 3. suction curettage. 4. blunt curettage.
• Trophoblastic cells express RhD factor, Rh neg patients
should receive Rh immunoglobulin at the time of evacuation.
15. Prophylactic chemotherapy:
• Prevents metastasis and local uterine invasion.
• It is particularly useful in management of high risk
complete molar pregnancy, esp. when hCG
assessments for follow-up are unavailable or
unreliable
16. Follow-up:
1. hCG: weekly -hCG levels until normal for 3
consecutive weeks, followed by monthly estimations
until normal for 6 consecutive months.
2. Contraception: patients are encouraged to use
effective contraception during entire hCG follow up
interval. IUCDs ar not used until patient achieves
normal hCG levels because of potential risk of
perforation. OCPs or barrier methods are used if
patient doesn’t desire surgical sterilization.
18. PERSISTENT GESTATIONAL
TROPHOBLASTIC TUMOR
A. NONMETASTATIC DISEASE: locally invasive GTT
develops in about 15% patients after evacuation of
complete mole and infrequently after other gestations.
Symptoms:
1. Irregular vaginal bleeding
2. Theca leutin cysts
3. Uterine subinvolution or assymetric enlargement
4. Persistently elevated serum hCG levels.
After molar evacuation, persistent GTT may exhibit the
histological features of either H. Mole or
choriocarcinoma.
After a non molar pregnancy, persistent GTT always has the
histological pattern of choriocarcinoma
19. B. PLACENTAL SITE TROPHOBLATIC
TUMOR:
• Placental-site trophoblastic tumor is an uncommon
but important variant of choriocarcinoma that consists
predominently of intermediate trophoblas. Relative to
their masses, these produce small amout of hCG and
hPL.
• They tend to remain confined to uterus, metastasizing
late in their course.
• These are relatively insensitive to chemotherapy.
20. C. METASTATIC DISEASE:
• Metastatic GTT occurs in 4% patients after evacuation
of complete mole, but it is seen more often when GTT
develops after nonmolar pregnancies.
• It has tendency towards early vascular invasion and
widespread dissemination.
• Most common sites are:
• PULMONARY(80%)- alveolar or snowstorm
appearence, discrete rounded opacities’canon-
appearence’, pleural effusion, embolic pattern.
respiratory symptoms and sonographic findings may
be dramatic, can be confused with primary pulmonary
disease.
21. Contn..
• VAGINAL(30%): suburethral, highly vascular
and may bleed vigorously when biopsied.
• HEPATIC(10%): painful enlargement,
intraperitoneal hemorrhage may occur.
• CNS(10%): may develop focal neurological
deficits.
22. Staging (FIGO)
• Staging 1-persistently elevated hCG&
tumorconfined to uterine carpus
• Stage2- metastesis to vagina,pelvis or both
• Stage3-Pulmonary metastesis with or without
uterine,vaginal,pelvic involment
• Stage4-advanced desease and Brain,kidneys
GIT, liver involment
23.
24. Prognostic Scoring system (WHO)
• Predicts potential for resistance to
chemotherapy.
• When score is >7- high risk case- requires
intensive chemotherapy for remission.
• Stage1 disease have low risk score while stage 4
disease have high risk score.
26. DIAGNOSTIC EVALUATION:
• Patients with persistent GTT should be carefully
evaluated before starting treatment:
1. Complete history and physical examination
2. Measurement of serum hCG value
3. Hepatic, renal and thyroid function tests
4. Determination of baseline TLC and platelet
counts.
27. Metastatic workup:
• Includes:
• Xray chest and CT scan
• USG and CT scan abdomen and pelvis
• CT or MRI scan of head
• hCG levels can be measured in CSF to exclude cerebral
involvement if CT brain is normal.
• Ratio of plasma to CSF hCG has to be lower than 60 in
presence of cerebral metastasis.
• Pelvic USG- useful in detecting extensive trophoblastic
uterine involvement and may also add in identifying
sites of resistent uterine tumors.
29. Management contn..
• Stage-1: If pt does not wish to preserve fertility ,
• Hysterectomy with Adjuvant single agent
chemotherapy------
• 1. To reduce dissamination of tumor cells
• 2.To mantain cytotoxic levelof drug inblood
circulation---to kill circulating cancer cells
• 3.To treat occult metastesis if any present.
Hysterectomy can also be done in all pts with stage1
placental site Trophpblastic tumor
Sngle drugChemotherapy alone is recomonded to stage1
pt who wants to presrve fertility.in resistant cases
,combination therapy should be administated.
30. Management of stageII and III
• Low risk patients with vaginal and pelvic metastasis
respond well(80%) to single agent therapy but high
risk cases are are treated with primary intensive
combination chemotherapy, bleeding from vaginal
metastasis may be controleed by packing or wide
local excision.
• Pt with pulmonary metastis—Primary intensive
combine chemotherapy.
• To control genital bleeding and sepsis----
Hysterectomymay be needed.
31. Follow up of stage1 2 3
• It should be done by:-
1. Weekly hCG measurement until they are
normal for 3 consecutive weeks
2. Monthly- for hCG measurement until they are
normal for 12 consecutive months
3. Effective contraception during the entire
interval of hrmonal follow up.
32. Management of stage 4
• Should be treated with intensive combination
chemotherapy and and surgery.
• Hepatic metastasis- hepatic artery infusion of
chemothapy may induce complte remission in
selected cases.
• Cerebral metastasis: whole brain
irradiation(3000cGy) in 10 fractions may be
instituated promptly. Crainotomy may be required
to provide acute decompression or to control
bleeding.
33. Follow up of stage 4
1. Weekly determination of hCG levels until they
are normal for 3 consecutive weeks
2. Monthly determination of hCG until they are
normal for 24 consecutive months.
3. These patients require gonadotropin follow up
because of high risk of recurrence.
34. CHEMOTHERAPY:
• Single-agent treatment: with either Actinomycin D or MTX have
achieved comparable and excellent remission rates in both non
metastatic and low risk metastatic GTT. Mtx 5mg with folinic acid x
3-5 days orally for 5-6 weeks is safe and effective.
▫ serum hCG level is measured weekly after each course of chemotherapy.
▫ After first treatment:
1. further chemotherapy is withheld as long as hCG level is falling
progressively.
2. Additional single agent chemotherapy is not administered at any
predetermined or fixed interval.
▫ Second course:
If hCG level plateaus for more than 3 consecutive weeks or begins to
raose again.
If hCG level doesn’t decline by 1 log within 18 days after completion of
first treatment.
▫ If response to first treatment is inadequate, dose of MTX is increased
from 1mg/kg per day to 1.5mg /kg per day for eack of the 4 treatment
days.
35. Combination Chemotherapy:
• Triple therapy: with MTX, Act-D and cyclophosphamide is in
• Duration of therapy: patients who require combination
chemotherapy must be treated intensively to attain remission.
It should be given as often as toxicity permits until patient
achieves 3 consecutive normal hCG levels. After normal hCG
levels are attained , atleast 2 additional courses of
chemotherapy
• adequate as an initial treatment in patients with metastasis and a high-risk prognostic score.
• are administered to reduce the risk of relapse.
37. Subsequent pregnancies:
A. Pregnancies after H. Mole:
increased risk of having a molar gestation in
subsequent conceptions. Risk: 1%
1. Pelvic USG during 1st trimester to confirm normal
gestational development
2. hCG measurement 6 weeks after completion of pregnancy
to exclude trophoblastic neoplasia.
B. Pregnancies after persistent GTT: patients who are
treated successfully with chemotherapy can expect
normal reproduction in future. The frequency of
congenital malformations is also not increased.