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Molar pregnancy
- 1. CASE SUMMARY • 18years , primi presented in ER with complain of amenorrhoea for 3 months followed by PV bleeding for 2 days with passage of grape like vesicles ,on examination uterus 24 weeks size and vitals stable and hemoglobin 8gm /dl %. • WHAT COULD BE THE DIAGNOSIS?
- 2. Molar Pregnancy Dr HemNath Subedi IInd year Resident OBGYN COMSTH
- 4. CONTENTS • DEFINITION • INCIDENCE •TYPES • CLINICAL FEATURES • INVESTIGATIONS • DIAGNOSIS • MANAGEMENT • COMPLICATIONS
- 5. DEFINITION • Gestational TrophoblasticDisease (GTD) is a spectrum of abnormal growth and proliferation of the trophoblasts that continue even beyond the end of pregnancy
- 6. INCIDENCE • The reportedincidence of GTD varies widely worldwide, from a low of 23 per 100,000 pregnancies (Paraguay) to a high of 1,299 per 100,000 pregnancies (Indonesia). • The malignant potential of GTD is also higher in South Asia (10-15%) compared to western countries (2-4%)
- 7. Types • Gestational trophoblasticdisease – Molar pregnancy (hydatidiform mole) or premalignant • Complete mole • Incomplete or partial mole – Gestational trophoblastic neoplasia or malignant • Invasive mole • Choriocarcinoma • Placental site trophoblastic tumor • Epitheloid trophoblastic tumor
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- 9. Spectrum of GestationalTrophoblastic Disease • Premalignant Malignant COMPLETE MOLE INVASIVE MOLE PARTIAL MOLE CHORIOCARCINOMA PLACENTAL SITE TROPHOBLASTIC TUMOR ABORTION OR NORMAL PREGNANCY 15%* 0.5%* Seckl mj, fisher RA. Choriocarcinoma and partial partial hydatidiform mole . Lancet 2000;356:688
- 10. Genetic basis ofdeveloping Gestatinal Trophoblastic Disease • Defective locus at 19q13.4 in five families and this abnormalities excitingly, been localized to a single gene NALP7. • Choriocarcinoma has been found to be developed after delation of 7p12- q11.2,amplification of 7q21-q31, and loss of 8p12-p21. Murdoch S,djuric U et al . Mutation I NALP7 cause hydatidiform moles and reproductive wastage in human. Mustada T ,sasaki M et al .human Chromosome 7 carries a putative tumor suppressor gene(s) involved in choriocarcinoma . Oncogene 1997;15: 2773-2781
- 11. Clinical features • Vaginalbleeding • Excessive uterine growth • Hyperemesis gravidarum • Hyperthyroidism • Preeclampsia • Embolization of trophoblastic tissue • Theca lutein cyst • Metastatic features – pulmonary- cough, chest pain, hemoptysis, dyspnoea, chest x ray finding -80% – Vaginal – growth in vagina irregular bleeding per vagina - 30% – Hepatic- Epigastric pain -10% – CNS – acute focal neurologic deficit. - 10% -Gestational Trophoblastic Disease,in Bereks And Novaks Gynecology ,15th Edition, Walter Wilkinson, Newyork 2012, Pp ,
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- 14. Diagnosis • Clinical features •History • Physical examination • Investigation – Lab investigation – Beta-hCG, LFT, RFT, CBC, urine R/E – USG abdomen and pelvis – Chest x ray – CT scan – Histopathological examination
- 15. USG Showing snowstrom patttern
- 16. Staging of GestationalTrophoblastic Neoplasia • Stage I - Disease confined to uterus • Stage II -GTN extending outside uterus but limited to genital structures (adnexa, vagina, broad ligament) • Stage III -GTN extending to lungs with or without known genital tract involvement • Stage IV -All other metastatic sites Goldstein DP, Vzanten-Przybysz I, Bernstein MR, et al. Revised FIGO staging system for gestational trophoblastic tumors: recommendations regarding therapy. J Reprod Med 1998;43:37–43.
- 17. WHO PROGNOSTIC SCORING SCORES0 1 2 4 AGE IN YRS <40 >40 - - ANTECEDENT PREGNANCY H.MOLE ABORTION TERM - INTERVAL SINCE LAST PREGNANCY <4 MONTHS 4-6 7-12 >12 BHCG <1000 10^3-10^4 10^4-10^5 >10^5 LARGE SIZE TUMOR 3-4 5 - - SITE OF METATSTASIS SPLEEN,KIDNE Y GI LIVER, BRAIN NUMBER OF METASTASIS 1-4 5-8 >8 PREVIOUS FAILED CHEMO SINGLE DRUG TWO OR MORE DRUG Adapted from FIGO Low risk score <6 ,High risk score >7
- 18. Management of gestationaltrophoblastic disease Hydatidiform mole Evacuation Serial hCG levels FIGO scoring GTN LOW RISK SINGLE AGENT CHEMO HIGH RISK COMBINATION OF CHEMO SERAIL HCG MONITORING RELAPLSED AND RESISTANT DIEASE SECOND LINE CHEO THARAPY Resolution 6 months HCG follow up RESOLUTION LIFE LONG Hcg follow up Adapted from , management of trophoblastic disease ,in resent advances in obstetrics and gynecology, 24th edition,jeypee brothers , india pp 135-151
- 20. Indications for chemotherapyin GTD • Histological evidence of choriocarcinoma • Evidence of metastases in brain, liver or gastrointestinal tract or radiological opacities >2 cm on chest x ray. • Pulmonary , vulval or vaginal metastates unless hcg falling • Heavy Vaginal Bleeding Or Evidence Of Gasrointestinal Or Intraperitoneal Hemorrhage • Rising Hcg After Evacuation • Serum Hcg >20,000 Iu/L More Than 4weeks After Evacuation, Because Of Risk Of Uterine Perforation. • Elevated hcg 6months after evacuation even if still falling. Adapted from , management of trophoblastic disease ,in resent advances in obstetrics and gynecology, 24th edition,jeypee brothers , india pp 135-151
- 21. Low risk treatmentregimen • Methotrexate 1mg/kg /day for 1st , 3rd ,5th,7th day. • Folinic acid rescue 0.1mg/kg/day for 2nd ,4th ,6th,8th day • Typical side effects – Stomatitis – Conjunctivitis – Abdominal pain – Chest pain Alazzam M, Tidy J, Hancock BW, et al.: First line chemotherapy in low risk gestational trophoblastic neoplasia. Cochrane Database Syst Rev (1): CD007102, 2009
- 24. High risk treatmentregimen • EMA/CO – Etoposide – Methotrexate – Actinomycin d – Cyclcophosphamide – Oncovin/vincristine • Week 1, Days 1-2: EMA With Folinic Acid Rescue. • Week 2, Day 8: CO • Typical Side Effects – Myelosuprpression-granulocyte Colony Stimulatin Factor Used To Prevent Neutropenia And Maintain Dose Intensity – Nausea/Vomiting – Mucositis – Reversible Alopecia – Neuropathy Bagshawe KD, Harland S. Immunodiagnosis and monitoring of gonadotropin-producing metastases in the centraL nervous system . Cancer 1976;38:112–118.
- 25. Follow up ofpatient Year 1 2-weekly serum and urine hCG for 1-6 months 2 weekly urine hCG for 7-12 months Year 2 4 weekly urine hCG Year 3 8 weekly urine hCG Year 4 3-monthly urine hCG Year 5 4-monthly urine hCG Year 6-life 6-monthly urine hCG Available at: http://www.hmole-chorio.org.uk/clinicians_info_post_chemo_followup.html
- 26. Pregnancy after GTN •Live births (66.9%), • Preterm deliveries (6.7%), • Ectopic pregnancies (1.1%), • Stillbirths (1.4%) • Repeat molar pregnancies (1.7%) Garrett LA, Garner EO, Feltmate CM, et al. Subsequent pregnancy outcomes in patients with molar pregnancy and persistent gestational trophoblastic neoplasia. J Reprod Med 2008;53:481–486.
- 27. Recurrence rate ofGTN • 1.5 % of patient with prior complete mole . • 2.7 % of patient with prior partial mole. • 23% of patient with two prior molar pregnancies. • 2.5% of patients with no metastatic disease. • 3.7% of patients with good-prognosis metastatic disease. • 13% of patients with poor-prognosis metastatic disease. Mutch DG, Soper JT, Babcock CJ, et al.: Recurrent gestational trophoblastic disease. Experience of the Southeastern Regional Trophoblastic Disease Center. Cancer 66 (5): 978-82, 1990 Gestational trophoblastic disease in: Williams obstetrics, 24th edition, newyork, magraw hill.
- 28. COMPLICATIONS • IMMEDIATE – Massivehemorrhage – Early onset preeclampsia and Eclampsia – Hyperemesis Gravidarum – Pulmonary embolism – Uterine perforation – IUGR of viable pregnancy – Still birth – Preterm birth • REMOTE – Choriocarcinoma
- 29. Questions • Define typesof molar pregnancy and write difference between complete hydatidiform mole and partial mole? • What are the clinical features of molar pregnancy how will you manage a case of molar pregnancy? • Write complications of molar pregnancy.