Gestational Trophoblastic Disease

HYDATIDIFORM MOLE(h.mole)

Eva U. Corpuz
BSN-II
(reporter)
 Gestational trophoblastic disease
 A group of diseases
originated from placental trophoblastic cells

 Gestational trophoblasitc disease (GTD)

 Hydatidiform mole (complete and partial)
 Invasive mole
 Choriocarcinoma
 Placental-site trophoblastic tumor (PSTT)
clinically
histologically
 Gestational trophoblastic neoplasia (GTN)

 Non-gestational trophoblastic tumor

 Uncommon, derived from germ cells in ovarian or testicular
 Development and differentiation of
gestational trophoblastic cells
 gestational trophoblastic cells evolved from extra-embryonic
cells
 At the time of implantation
cytotrophoblast outermost layer of the blastocyst
 7-8 days after implantation
syncytiotrophoblast implantation site
 Before villi formation previllous trophoblast
 2 weeks after pregnancy, primary villi formation
Villous surface villous trophoblast
Other parts extravillous trophoblast
 Development and Differentiation of
gestational trophoblastic cells
 Cytotrophoblast
trophoblast stem cells
proliferability and differentiability
 Syncytiotrophoblast
differentiated mature cells
synthesize pregnancy-related hormones
material exchange between the fetus and the mother
 Two differentiated forms of Cytotrophoblast
villous surface area Syncytiotrophoblast
extravillous Intermediate trophoblast
Hydatidiform mole
 Hydatidiform mole

 Complete moles
Hydropic degeneration of all villi
Villous edema, trophoblastic hyperplasia, fetal-derived
blood vessels disappear in stroma
 Partial moles
combine embryo or fetus
Villous edema partially, trophoblastic proliferation
lighterly, fetal-derived blood vessels present stroma
Complete moles Partial moles
 Hydatidiform mole
Related Factors
 Complete moles
 Area common in Latin America, Asia
uncommon in North America and Europe
 Race differences of the same race in different regions
 Nutrition and Economy lack of Vit A
 Age < 20 or >35 years
 The fertilization of an empty egg
the fertilization of an empty egg by a haploid sperm
Diploid genome 90% of the time (usually 46,XX)
 Genomic imprinting disorder
 Hydatidiform mole
 Partial moles
 high-risk factors are still unknown
 "Haploid egg" fertilization
usually two sperm fertilize a normal egg
a triploid karyotype (69 chromosomes ), with the extra
haploid set of chromosomes derived from father
 Comparison of complete and partial
hydatidiform moles
Complete Partial
46, XX(90%) Triploid
Karyotype
46, XY(10%) (69XXY, 69XXX)
Embryo Absent Present
Villi Hydropic Few hydropic
Mild focal
Trophoblasts Diffuse hyperplasia
hyperplasia
Villus outline regular irregular
Blood vessel absence presence
 Hydatidiform mole
Clinical Presentation
 Complete moles
 Abnormal vaginal bleeding during early pregnancy( 8-12week)
most common symptom
 Uterine enlargement exceeding normal pregnant uterus
 Others
Abdominal pain
Pregnancy-induced hypertension
Theca lutein ovarian cyst
Hyperthyroidism (CHM)
 Partial moles
 Mild symptoms, Confused with abortion easily
Clinical Manifestations
 Vaginal bleeding (97%) /anemia
 Enlarged uterus (size > dates)
 Pelvic pain
 Theca lutein cysts
 Hyperemesis gravidarum
 Hyperthyroidism
 Preeclampsia <20 weeks gestation
 Vaginal passage of hydropic vesicles
 Partial mole usually presented as incomplete
or missed abortion
 Hydatidiform mole
hCG regression pattern after hydatidiform
Mean time of the hCG regressed to normal
— 9 weeks no more than 14 weeks
Abnormal hCG regression pattern after hydatidiform
signifies the presence of GTN
 Complete mole
 15% local invasion and 4% distant metastasis
 High –risk :
①HCG>100,000U/L
② Enlargement of Uterine
③ Theca lutein ovarian cyst >6cm
 Partial mole
 4%local invasion and almost no distant metastasis
 High –risk :unclear
 Risk Factors:

 History of previous GTD

 If one previous mole, 1% chance of recurrence
(vs. 0.1% in general population)
 If 2 previous moles, risk of recurrence increases
to 16-28%
 Smoking
 Vitamin A deficiency
 Blood type:
 A or AB are at slightly higher risk than those with
type B or O
 Hydatidiform mole
 Diagnosis
 Abnormal bleeding after amenorrhea
 Inappropriately enlarged uterus

 Absence of fetal heart sounds

not palpate fetus between 16-20th week

 Vaginal discharge hydatidiform-like tissue

Hydatidiform mole should be considered

 Hydatidiform mole
 Diagnosis
 Ultrasound
Complete moles produce a characteristic vesicular sonographic
pattern, usually referred to as a “snowstorm” pattern

 HCG
 Elevated above expected for gestational age
 Dynamic observation for 8-10 weeks, continued to rise
 HCG-related molecules
Hyperglycosylated HCG
free β-HCG subunit

 DNA karyotype
Complete moles — usually diploid
Partial moles — usually triploid
Diagnosis and Management of
Molar Pregnancy
 Workup : The pathologic diagnosis of a hydatidiform mole is made from
dilation and curettage (D&C) performed for an incomplete abortion or
because of suspicion of hydatidiform mole based on clinical findings
(physical examination, hCG levels, ultrasonography).
 The following tests should be performed preoperatively:
 Quantitative serum hCG level
 Complete blood count (CBC)
 Prothrombin time, partial thromboplastin time
 Comprehensive metabolic panel with renal and liver function tests
 Blood type and screen [Rh-negative patients must be given RhO
 (D) immune globulin (RhoGAM)]
 Chest radiograph
Diagnosis and Management of
Molar Pregnancy….
 Follow-Up.
 After the surgical evacuation of a hydatidiform mole, all
 patients should be monitored as follows

 hCG level should be measured 48 hours after evacuation.

 hCG level should be determined weekly until results are

normal for 3 consecutive weeks, then monthly until results are normal
for 6 to 12 consecutive months
a “snowstorm” pattern
 Hydatidiform mole
 Treatment
Suction curettage
 Molar pregnancy should be terminated as soon as
possible when diagnosis has been confirmed
 Suction curettage is a first choice, must be fully
done in operating room
 tissue from curettage should
be submitted to pathology
 Hydatidiform mole
Treatment
 Theca lutein cysts of the ovary
do not need special treatment

 Prophylactic chemotherapy:
HM don’t need usually chemotherapy because HM is
benign disease.
A controversial topic
only be offered to patients with high-risk factor or
impossible follow-up
 Evaluate for coexisting conditions:
- History and physical
- CBC, coagulation profile, serum chemistry
- thyroid function
- blood type and cross match
- chest radiography
- pelvic ultrasonography
 Evacuation of mole
- Suction curettage
-Hysterectomy Only remove local invasion,
but not distant metastasis; Only for old
women without childbearing desire
 Hydatidiform mole
Follow-up
 necessary for diagnosis of early GTN
 Methods:
 HCG
 Symptom: Abnormal uterine bleeding
 Pelvic examination
 Ultrasound, chest X-ray and CT
 Contraception:
 Condom and oral contraceptives, not IUD
 Duration for contraceptiom — 1 year
 Medical Complications of
Hydatidiform Mole
 Common complications include anemia, infection,
hyperthyroidism, pregnancy-induced hypertension or
pre-eclampsia, and theca lutein cysts.
 Anemia : A hemoglobin of less than 10 g/dL, seen in
50% of patients with
 complete moles and results from excessive vaginal
bleeding
 Pre-eclampsia: occurs in approximately 25% of cases
and presents with the signs and symptoms of pre-
eclampsia seen in nonmolar pregnancies [hypertension
(HTN), proteinuria, edema].
 Medical Complications of
Hydatidiform Mole
 Hyperthyroidism : Seven percent of patients with complete moles present
with hyperthyroidism, with clinical findings of tachycardia, HTN, and
tachypnea.
 These patients should receive beta-sympathetic blockade before
induction of anesthesia to prevent thyroid storm, which can be
precipitated by surgery itself.
 Both hyperthyroidism and pregnancy-induced hypertension usually abate
promptly after evacuation of the molar pregnancy and may not always
require specific therapy.
 Theca lutein cysts (cysts >6 cm) are observed in 50% of patients and
result from hCG stimulation. These cysts may require 2 to 4 months to
resolve completely.
 Medical Complications of
Hydatidiform Mole
 Pulmonary distress : is observed in 2% of patients. Frequently, it
occurs at the time of evacuation of a mole in patients with marked
uterine enlargement.

 Patients present with chest pain, shortness of breath, tachypnea,

tachycardia, and hypoxemia. These signs and symptoms usually
resolve within 72 hours of institution of supportive measures.

 In general, pulmonary complications should be treated

aggressively. Interventions, including pulmonary artery catheter
monitoring and assisted ventilatory support, may be required.
 Gynecology and Obstetrics (FIGO)
Staging of Gestational Trophoblastic
Disease
Stage 1
 Strictly confined
to uterus
Stage 2
 Extension
outside uterus
but limited to
pelvic structures
Stage 3
 Extension to
lungs
Stage 4
 All other
metastatic sites
Thank you !