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Gestational Trophoblastic Disease (GTD) Part I: Molar Pregnancy
Gestational Trophoblastic Disease (GTD) Part I: Molar Pregnancy
Classifications
Gestational Trophoblastic Disease (GTD)
Invasive I-Pathologic Partial mole Chorio mole Complete mole Classification carcinoma
Placental site trophoblastic tumour
II-Clinical Classification
hCG based: WHO, FIGO, ACOG 2004 & RCOG 2010
Benign G.T.D.
Non metastatic
Metastatic
Low risk
High risk
1- It is now possible to diagnose a mole by ultrasonography in minutes . 2-It became the most curable gynec. malignancy.
3-hCG has very important role in the diagnosis, evaluation and follow up of GTN
4- The cytogenetic profile has thrown light on the etiology of the disease .
Hydatidiform Mole
(H. MOLE) = Vesicular Mole
Partial mole
Most commonly 69, XXX or - XXY
Complete mole
Most commonly 46, XX or -,XY
Clinical presentation
Diagnosis Uterine size Theca lutein cysts Medical complications Missed abortion Small for dates Rare Rare Molar gestation 50% large for dates 25-30% 10-25%
Postmolar CTN 2.5-7.5% 6.8-20% Disaia &Creasman Clinical Gynecological Oncology 2007
rd
Karyotype
Homozygous 90%
Heterozygous 10%
Complete H. Mole
Microscopically Enlarged, edematous villi and abnormal trophoblastic proliferation that diffusely involve the entire villi No fetal tissue, RBCs or amnion are produced
Macroscopically, these microscopic changes transform the chorionic villi into clusters of vesicles with variable dimensions like bunch of grapes" No fetal or embryonic tissue are produced Uterine enlargement in excess of gestational age . Theca-lutein cyst associated in 30%
1-Trophoblastic proliferation
2-Hydropic Degeneration
Uterine wall
Pathogenesis of Choriocarcinoma
Aneuploidy
(Not a multiplication of 23 chromosome )
Partial H. Mole
Microscopically: The enlarged, edematous villi and abnormal trophoblastic proliferation are slight and focal and did not involve the entire villi. There is a scalloping of chorionic villi Fetal or embryonic or fetal RBCs Macroscopically: The molar pattern did not involve the entire placenta. Uterine enlargement in excess of gestational age is uncommon. Theca-lutein cysts are rare Fetal or embryonic tissue or amnion
Vesicles
Maternal side
Partial Hydatiform Mole
Fetal hand demonstrating syndactyly. The fetus had a triploid karyotype, and the chorionic tissues were a partial mole
Partial H. mole.
Very rarely
Acute respiratory failure Neurological symptoms such as seizures (?metastatic disease).
A. Hyperemesis B. Bilateral enlarged theca lutein cysts C. Vaginal bleeding D. Uterine enlargement> than expected for GA
E. Pregnancy-induced hypertension
U/S& hCG
Definite diagnosis on first U/S examination U/S alone: 68% U/S + hCG > threshold of 82,350 mIU/mL: 89%
Disaia &Creasman Clinical Gynecological Oncologym 7th edd. 2007
TVS Milestones Versus hCG hCG mIU/mL Weeks Detection Level >5 3-4
Choriodecidual thickening
100 7000
4-5
5- 6
Yolk sac
Heart motion
Maximum level
10,000
50,000to 100,000
6
6- 7
8-10
Complete hydatidiform mole. The classic "snowstorm" appearance is created by the multiple placental vesicles.
Complete H.Mole (High-resolution) U/S Complex intrauterine mass containing many small cysts.
Case Scenario 1
A 24-year-old 2nd Gravida ,Para 1 woman at 8 Ws GA (Blood group: O, negative) complains of: 1-Worsening nausea, and vomiting over the last 2 weeks which is unlike her prior pregnancy . 2-Irregular vaginal bleeding over the last 7 days She denies any abdominal or back cramps. What does the differential diagnosis include for this patient?
What Does The Differential Diagnosis Include For This Patient? The differential diagnosis of bleeding with early pregnancy and progressive vomiting are: Multiple pregnancy. Hydatidiform mole. Threatened abortion. Ectopic pregnancy.
Which Diagnostic Test Would Be Most Useful? The most useful diagnostic test is :
U/S
U/S DD :
1-Missed abortion 2-Degenerated fibroid
Differential Diagnosis:
Long standing missed abortion with cystic degeneration of the placenta
subunit hCG
The B subunit hCG assay: 195,000 mlU/mL Then 1-What is the most likely diagnosis? 2-How can the patient be managed?
Most
Vesicular Mole
evacuation
B. Suction evacuation to be repeated 1-2 weeks later
10mm
Canula up to a maximum of 12 mm, is usually sufficient to evacuate all complete molar pregnancies.
Suction curettage has been performed using 10mm canula under U/S guidance :
El SHERBINY HOSP
Canula
U/S Guided Suction Curettage Suction curettage can be performed under U/S guidance to: Facilitate the procedure
The Case is Now Confirmed Histopathological As A Complete H. Mole What Is The Most Appropriate Management?
A- Surveillance :Weekly then monthly hCG B-Hysterectomy C-Transvaginal U/S examination D-Repeated curettage &Biopsy E-Prompt chemotherapy
A.
Complete H. Mole with large for date uterus& Theca-lutein cyst Patient was 42 years 5th G P5 initial BhCG:195,000mIU/mL
Second Uterine Evacuation :There is no clinical indication for the routine use of second uterine evacuation
RCOG Guideline No. 38 ; 2010
Prophylactic Chemotherapy: The long-term prognosis for women with a H. mole is not improved with prophylactic chemotherapy. Because toxicityincluding deathmay be significant, it is not recommended routinely *
It may be useful in the high-risk cases when followup are unavailable or unreliable. * *
American College of Obstetricians and Gynecologists, 2004*
No
When Anti-D Is Required?
Post-evacuation Surveillance
Why?
To determine when pregnancy
can be allowed
To detect persistent trophoblastic disease (i.e. GTN)
At the 9 week follow up the hCG level : 2u/L Is this level sufficient to stop follow up ?
No
4-
level.
C. For 12 months from the date of uterine
evacuation.
At this period levels of hCG are monitored every month Practically once hCG has normalized after molar evacuation, the possibility of GTN developing is very low.
Case Scenario 2
A 34-year-old woman, married for 7 years
3rd Gravida ,Para 0 at 14 Ws GA.
US scanning revealed
Degenerating myoma
Free T4
Protein in urine
Thank You
Egypt