Gestational

Trophoblastic Disease
 Classification

1. Hydatidiform (vesicular )mole

Complete and Partial
2. Invasive mole
3. Choriocarcinoma
4. Placental-site trophoblastic tumor
Vesicular
Vesicular mole
mole
Vesicular
Vesicular mole
mole
 It is a benign neoplasm of the chorionic villi
characterized by
1. Marked proliferation of the trophoplast,both
the syncytium & cytotrophoplast are affected.

2. Oedema or hydropic degeneration of the

connective tissue stroma of the villi which leads
to their distension and formation of vesicles.

• Hyperplasia of trophobasitc cells

3. Avascularity of the villi: the blood vessels
Normal
VM• Hydropic swelling of all villi
disappear from villi explaining early death of
villa
• Vessels are usually absent
the embryo
 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.
 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.

 Pathology
 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.
 (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.
(i) Complete mole:
Complete mole
 (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
Partial mole
(ii) Partial mole
Differentiation between complete and partial mole

Feature Complete Mole Partial Mole

Embryonic or Absent Present
foetal tissue
Swelling of the Diffuse Focal
villi
Trophoblastic Diffuse Focal
hyperplasia
Karyotype Paternal 46 XX Paternal and
(96%) or 46 XY (4%) maternal 69 XXY
or 69 XYY
Malignant 5-10% Rare
Diagnosis
 (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
 (A) Symptoms
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
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
Signs
 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.

 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.
 Local examination

1. Passage of vesicles (sure sign).

2. Bilateral ovarian cysts in 50% of cases.

3. No internal ballottement.
 (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.
 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
 Complete Mole

Complete mole: Corresponding T1 weighted

“snowstorm” appearance MRI (MRI can be helpful in
with multiple cystic areas, no determining extent of
fetal tissue present trophoblastic disease)
A real-time ultrasound of a hydatidiform mole.
The dark circles of varying sizes at the top
center are the edematous villi.
 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%).

 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
 (I) Suction evacuation
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
- 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
 The material removed is sent for
histological examination to exclude
malignancy .
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.
 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.
 Large bilateral theca lutein cysts resembling ovarian germ cell tumors. With
Large bilateral
resolution of thetheca
human lutein
chorioniccysts resembling stimulation,
gonadotropin(HCG) ovarian germ cell to
they return
tumors. With resolution
normal-appearing ovaries. of the human chorionic gonadotropin(HCG)
stimulation, they return to normal-appearing ovaries.
 (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.
 (IV) Medical induction

Oxytocins and / or prostaglandins may be

used to encourage expulsion of the mole
but must always be followed by surgical
evacuation.
 Follow up
 detection of serum ß-hCG by
radioimmunoassay is essential

 Normally B –subunit reach normal

level 8-12 wks after evacuation
 Follow up
 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
- 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.
-
 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.
 IUD during follow up

The intrauterine device is not used because

it may lead to irregular uterine bleeding
which confuses the follow up
Invasive mole or
Chorioadenoma
Destruens
 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
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.
 The same patient owing to the myometrial invasion.
Reduced vascular resistance is detected in the uterine artery.
 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
 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.
 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.
 Symptoms and signs
 Bleeding
 Infection
 Abdominal swelling
 Vaginal mass
 Lung symptoms
 Symptoms from other metastases
Doppler image of choriocarcinoma