About gestational trophoblast disease's

1. Gestational Trophoblastic
Disease (GTD).
By group 2
ultrasound abnormalities of the first
trimester gestational trophoblastic
diseases.

2. GROUP MEMBERS.
1. KABAKWA HERBERT.
2. KATO THADIUOS.
3. ZIKUSOKA JOHN.
4. NAKAMYA BRIDGET.
5. YASIN KIDIRI.
6. KISEMBO WILBERT.
7. ATUKWATSE CAROLINE.
8. EDOLU JAMES.
9. BAZEKETA ALI.
• 10. WANYANA LESTETUTA.
• 11. AHEBWA CHRISTINE.
• 12. MUZUNGU EDWARD.
• 13. SEMUJU CEDRIC JUNIOR.
• 14. SANYU JOHNSON.
• 15. MUSOMBOLI BWAMBALE
EDWIN.
• 16. MOSESE ISAMAT.
• 17. SSEBANAKITA LAWRENCE.
• 18. KITUMBA STEPHEN.

3. • Indications for this scan.
Vaginal bleeding.
Abdominal swelling.
Palpable mass.
Lung symptoms (to rule out possible metastasis).
A rapidly growing pregnancy (faster than expected).

4. INTRODUCTION .. Embryology.
Gestational trophoblastic disease (GTD) encompasses a spectrum of
conditions arising from abnormal proliferation of trophoblastic tissue
during pregnancy.
The first trimester begins on the first day of your last period and
lasts until the end of week 12.
In the first week of intrauterine development, the zygote undergoes
various mitotic divisions giving rise to numerous cell stages i.e. 2,4,8,16 &
32 cell-stage.
At the 8 cell-stage, there’s compaction of cells to form a tight ball which
shortly divides into a morula (16 cell-stage) and further into a blastocyst
(32 cell-stage) with fluid-filled cavities.
Continued …. Next slide.

5. Continuation....
It is therefore this blastocyst which will give rise to 2 distinct cell
populations i.e. embryoblast (inner) and trophoblast (outer) which
subsequently develop into the embryo and placenta + gestation
sac respectively.
Unfortunately, in most cases, this latter stage always when
interrupted results into the abnormal proliferation and hence the
development of a disorganized mass of tissue HENCE THE
CONDITION TERMED GTD.

6. Types of GTD.
Benign.
• Hydatidiform mole/molar pregnancy
(complete and incomplete).
Malignant.
• Invasive mole.
• Choriocarcinoma (chorioepithelioma).
• Placental site trophoblastic tumor.

8. Types of GTD.
The term Gestational Trophoblastic
Tumors has been applied in the latter
three conditions.
1. Arise from the trophoblastic elements.
2. Retain the invasive tendencies of the
normal placenta or metastasis.
3. Keep secretion of the human chorionic
gonadotropin (hCG).

9. PATHOLOGIC
CLASSIFICATION
Hydatidiform mole
*complete
*incomplete
CLINICAL
CLASSIFICATION
Benign gestational
trophoblastic disease
Pathologic and clinical classifications
for Gestational Trophoblastic
Disease.
Invasive mole
Malignant
trophoblastic disease
Nonmetastatic
Placental site
trophoblastic tumor
Metastatic
Choriocarcinoma High risk Low risk

10. A. HydatidiformMole..
(=vesicular Mole) (=molarpregnancy)

11. A hydatidiform mole also known as a molar pregnancy
or vesicular mole, is a neoplastic proliferation of the
trophoblast in which the terminal villi are
transformed into fluid filled vesicles.
It is characterized by vesicular swelling of the
placental villi and usually absence of an intact feus.

12. MOLAR PREGNANCY occurs as a result of abnormal
gametogenesis and fertilization. It can be divided into;
1) complete mole.
2) partial mole.
COMPLETE MOLAR PREGNANCY.
A complete mole occurs as a result of fertilization of an
empty or inactivated ovum with a haploid sperm(s) which
would duplicate to give rise to 46 chromosomes of paternal
origin only.
NB. Partial mole discussed in the following slides.

13. Definition and Etiology.
 Hydatidiform mole is a pregnancy
characterized by vesicular swelling of
placental villi and usually the absence of
an intact fetus.
 The etiology of hydatidiform mole
remains unclear, but it appears to be due
to abnormal gametogenesis and
fertilization.

14. Continuation..
 In a ‘complete mole’ the mass of
tissue is completely made up of
abnormal cells.
 There is no fetus and nothing can be
found at the time of the first scan.

15. Continuation..
 In a ‘partial mole’, the mass may
contain both these abnormal cells
and often a fetus that has severe
defects.
 In this case the fetus will be
consumed ( destroyed) by the
growing abnormal mass very
quickly..(The fetus shrinks).

16. Incidence.
• 1 out of 1500-2000 pregnancies in the
U.S. and Europe.
• 1 out of 500-600 (another report 1%)
pregnancies in some Asian countries.
• Complete > incomplete.

17. Incidence.
 Repeat hydatidiform moles occure in
0.5-2.6% of patients, and these
patiens have a subsequent greater risk
of developing invasive mole or
choriocarcinoma.
 There is an increased risk of molar
pregnancies for women over the age
40.

18. Incidence.
Approximately 10-17% of hydatidiform
moles will result in invasive mole.
 Approximately 2-3% of hydatidiform
moles progress to choriocarcinoma
( most of them are curable).
Not definitely benign disease ,
has a tight relationship with
GTT.

19. Clinical risk factors for molar
pregnancy.
Age(extremes of reproductiveyears);
<15.
>40.
Reproductivehistory;
Prior hydatidiform mole.
Priorspontaneousabortion.
Diet;
Vitamin A deficiency.

20. Cytogenetics.
Compl ete mol ar pregnancy.
Chromosomes are paternal , diploid
46, XX in 90% cases.
46, XY in a small part.
Part I al mol ar pregnancy.
Chromosomes are paternal and maternal, triploid.
69, XXY 80%.
69, XXX or 69, XYY 10-20%.
Wrong life message , so cannot develop normally

22. Comparative Pathologic Features of
Complete and Partial Hydatidiform Mole.
Feature Complete Mole Partial Mole
Karyotype Usually diploid 46XX
Villi
vessels
Usually triploid 69XXX most common.
Normal adjacent villi may be present.
Blood cells.
Fetal tissue
All villi hydropin;
No normal adjacent villi.
Present they contain.
No fetal blood cells.
None present. Usually present.
Trophoblast Hyperplasia usually
present to variable
degrees.
Hyperplasia mild and focal.

23. Signs and Symptoms of Complete
Hydatidiform Mole.
• Vaginal bleeding.
• Hyperemesis ( severe vomiting).
• Size inconsistent with gestational
age (with no fetal heart beat and
fetal movement).
• Preeclampsia.
• Theca lutein ovarian cysts.

24. Signs and Symptoms of Partial
Hydatidiform Mole.
• Vaginal bleeding.
• Absence of fetal heart tones.
• Uterine enlargement and
preeclampsia is reported in only 3%
of patients.
• Theca lutein cysts, hyperemesis is
rare.

25. .
Appearance of partial mole on ultrasound scan.
Greatly enlarged placenta relative to the size of the
uterine cavity.
Cystic spaces within the placenta (sometimes
absent).
Amniotic cavity ( gestational sac ) containing amorphous
inappropriately small fetal echoes which may be
surrounded by a relatively thick rim of placental echoes
with intermingling cystic spaces.
 Presence of a well – formed but growth – retarded fetus
either dead or alive with hydropic degeneration of fetal
parts frequently present.
 Color Doppler may show high velocity and low
impedance flow.

26. .
Appearance of partial mole on ultrasound scan .. Images.

27. Differences between partial and complete mole.
Complete moles Partial moles
Occurs due to fertilization of an
enumerated oocyte by one or two
haploid spermatozoa.
Occurs due to the fertilization of a
normal oocyte by two spermatozoa or
one abnormal spermatozoon causing
some fetal development.
More common. Less common.
Occurs with fusion of two sperms with
an egg that lost its DNA.
Occurs with the reduplication of a
fertilized egg with one or two sperms.
Results in diploid fertilized egg. Results in a triploid fertilized egg.
Possible genotypes 46, XX and 46 XY. Possible genotypes 69XXY and 69XXX.
Does not have and doesn’t express.
maternal DNA.
Has and expresses maternal DNA.
Does not develop a fetus. May develop a deformed nonviable fetus.

28. Diagnosis of hydatidiform mole.
 Quantitative beta-hCG.
 Ultrasound is the criterion standard for
identifying both complete and partial molar
pregnancies.
 The classic image is of a “snowstorm”
pattern.

29. Diagnosis.
 The most common symptom of a mole is
vaginal bleeding during the first
trimester.
 However very often no signs of a problem
appear and the mole can only be diagnosed by
use of ultrasound scanning. (rutting check).
 Occasionally, a uterus that is too large for the
stage of the pregnancy can be an indicator.
 NOTE: Vaginal bleeding does not always
indicate a problem!

30. Hydatidiform mole: specimen from suction
curettage.

31. A sonographic findings of a molar pregnancy. The
characteristic “snowstorm” pattern is evident.

32. Transvaginal sonogram demonstrating the “
snow storm” appearance.

33. arteriesclose proximity to the “ snow storm” appearance.
Color Dopler facilitates visualization of the enlarged spiral

34. Color Doppler image of a hydatidiform mole and surrounding
vessels. The uterine artery is easily identified.

35. 19-Sep-12 o warda

36. Doppler waveform analysis demonstrates low vascular resistance(RI=0.29) in the
spiral arteries, much lower than that obtained in normal early pregnancy.

37. 19-Sep-12

38. Partial hydartidiform mole

39. A partial mole in a case of triploidy. Note the
scattered grape-like masses with intervening
normal-appearing placenta tissue.

40. Large bilateral theca lutein cysts resembling ovarian germ cell
tumors. With resolution of the human chorionic gonadotropin hCG)
stimulation, they return to normal-appearing ovaries.

41. Differential diagnosis.
• Abortion.
• Multiple pregnancy.
• Polyhydramnios.

42. Follow-up.
 Patients with hydatidiform mole are
curative over 80% by treatment of
evacuation.
 The follow-up scans after evacuation is
key necessary.
 uterine involution, ovarian cyst
regression and cessation of bleeding.

43. B. Invasivemole.

44. Definition.
This term is applied to a molar
pregnancy in which molar villi grow into
the myometrium or its blood vessels, and
may extend into the broad ligament and
metastasize to the lungs, the vagina or the
vulva.

45. Invasive mole: the tissue invades into the myometrial layer.
No obvious borderline, with obvious bleeding.

46. Invasive hydatidiform mole infiltrating the myometrium.

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

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

49. Transvaginal color Doppler scan of a patient with invasive mole.
uterine curettage, Persistent color signals within the myometrium.

50. Doppler image of invasive mole.

51. Power Doppler easily detects a vascular echogenic
nodule within the myometrium, suggesting
Invasive mole.

52. Doppler image of invasive mole. Doppler waveform
analysis depicts low vascular resistance (RI= 0.35).

53. Common Sites for Metastatic Gestational
Trophoblastic Tumors.
Site Per cent
Lung 60-95
Vagina 40-50
Vulva/cervix 10-15
Brain 5-15
Liver 5-15
Kidney 0-5
Spleen 0-5
Gastrointestinal 0-5

54. C. Choriocarcinoma

55. 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.

56.  Characterized by abnormal
trophoblastic hyperplasia and anaplasia
(absence of chorionic villi).
Definition….

57. Doppler image of choriocarcinoma.

58. Doppler image of choriocarcinoma.

59. Signs and symptoms.
• Bleeding.
• Infection.
• Abdominal swelling.
• Palpable mass.
• Lung symptoms.
• Symptoms from other metastases.

60. FIGO Staging System for Gestational Trophoblastic
Tumors
Stage Description
Ⅰ
Ⅱ
Ⅲ
Ⅳ
Limited to uterine corpus
Extends to the adnexae, outside the uterus,
but limited to the genital structures
Extends to the lungs with or without genital
tract
All other metastatic sites

61. o warda
19-Sep-12

62. IIa
IIb
o warda
19-Sep-12

63. IIIa<3cm or locate in half lung
IIIb disease beyond IIIa
o warda
19-Sep-12

64. o warda
19-Sep-12

65. Diagnosis and evaluation
 Gestational trophoblastic tumor is
diagnosed by rising hCG following
evacuation of a molar pregnancy or
any pregnancy event.
 Once the diagnosis established the
further examinations should be done
to determine the extent of disease
( X- ray, CT, MRI, ultrasound.)

66. D. Placenta Site Trophoblastic Tumor (PSTT).

67. Definition.
 Placenta Site Trophoblastic Tumor is an
extremely rare tumor that arised from the
placental implantation site.
 Tumor cells infiltrate the myometrium and
grow between smooth-muscle cells.

72. Dignosis and treatment.
 Surum hCG levels are relatively low
compared to those seen with
choriocarcinoma.
 Several reports have noted a benign behavior of
this disease. They are relatively chemotherapy-
resistant, and deaths from metastasis have
occurred.
 Surgery has been the mainstay of treatment.

73. Epithelioid Trophoblastic Tumors.
These are rare group of malignant gestational Trophoblastic
neoplasms arising from chorionic type intermediate trophoblastic.
They account for less than 2% of all the gestational trophoblastic
diseases.
Signs and symptoms
per vaginal bleeding with mild elevation of serum beta HCG.

74. Morphology:
Gross appearance
Necrosis
Ulceration
Fistula formation
Microscopic appearance
Nodular well circumscribed infiltration at the periphery
Uniform mononucleated tumors cells are arranged in nests
and cords.
There is extensive Neurosis with irregular contours
There is also calcification.

75. Sonographic features
Solitary nodules with sharp margins .
Heterogeneous, hypo/hyperechoic masses.
Highly vesicular periphery.
Hy

76. Location.
Commonly 40% occurs in upper uterine segment and 31% cases in the
cervix.
Rarely occur in the vagina , broad ligaments and fallopian tubes
management is normally by chemotherapy and hysterectomy.

77. THANK YOU FOR BEARING
WITH US.
MAY THE ALMIGHTY GOD
BLESS YOU ABUNDANTLY.