GESTATIONAL TROPHOBLASTIC

NEOPLASIA
Wilson Julian Dalimarta
2016-061-001
Supervised by : dr. Hesty, Sp. OG
 Introduction
• Gestational trophoblastic disease (GTD) = a
group of tumors typified by abnormal
trophoblast proliferation
• The malignant forms of gestational
trophoblastic disease are termed gestational
trophoblastic neoplasia (GTN)
• GTN usually occurs after a hydatiform mole
CASE REPORT
 Patient’s Identity
• Name : Mrs. A
• Date of birth / Age : April 21th 1987/ 31 year-old
• Nationality : Indonesian
• Address : Kp. Selabintana Kulon RT 003/002, Kec.
Sukabumi
• Marital status : Married
• Occupation : Housewife
• Religion : Moslem
• Date of admission : June 7th, 2018
• Date of examination : June 7th, 2018
 History Taking
• Chief Complaint
Bleeding since 2 months before admission
• History of Present Illness
- Patient, 31 years old, G4P1A2, with 21 weeks gestational age, came with complaint
of vaginal bleeding since 2 months before admission.
- The bleeding was started just as spot bleeding, but it was gradually increasing so
that now, the patient need to change her pad three to four times a day. The color of
the blood is bright red.
- The patient also felt significant weight loss recently.
- The patient had come to a clinic one day before admission and had been examined
by an obstetrician. The result of USG examination which had been done by the
obstetrician had shown that the patient had hydatiform mole.
- The patient denied any fetal tissue-like material from the blood. The patient also
denied feeling any abdominal pain. The patient admitted that she had felt nausea
and vomiting 3 months ago, but the complaints weren’t felt anymore..
 History of Past Ilnesses
• History of molar pregnancy : twice (G1 in 2012 and G3
in 2015)
• Histroy of ectopic pregnancy : denied
• History of diabetes mellitus : denied
• History of hypertension : denied
 Familial History
• History of hypertension : denied
• History of kidney disease : denied
• History of diabetes mellitus : denied
• History of auto immune disease : denied
• History of cancer : denied
 Menstruation Histroy
• Menarche : 12 years old
• Menstrual cycle : regularly every 28-30 days, 5 days
duration and without history of pain during menstruation
• Amount of menstrual blood : 2-3 normal pads / day ( ± 60 cc )
• LMP : January 23rd 2018
 Contraception History
• History of using contraception pills for 6 years
since 2012.
 Marital Histroy
• Married once for 6 years
 Obstetrical History
Gestational Birth
No Date Labor History Sex
Age Weight
1. 2012 Hydatiform
mole

2. 2013 37 weeks Spontaneous M 3,200 gr

per vaginam

3. 2015 Hydatiform
mole
 Physical Examination
• General condition : moderately ill appearance
• Consciousness : compos mentis
• Blood pressure : 100/60 mmHg
• Heart rate : 120 bpm
• Respiratory rate : 21x/minute
• Temperature : 36°C
• Weight : 38 kg
• Height : 152 cm
• BMI : 16,44 kg/m2 (underweight)
• General Examination
• Eyes : anemic conjunctiva +/+, icteric sclera -/-
• Mouth : wet oral mucosa membrane
• Heart : regular 1st and 2nd heart sounds, murmur -, gallop -
• Lung
– Inspection : symmetric chest expansion in breathing
– Percussion : resonant on both lungs
– Auscultation : vesicular breath sounds +/+, rhonchi -/-, wheezing
-/-
• Abdomen
– Inspection : rounded shape
– Palpation : soft, tenderness (-)
– Auscultation : bowel sound +
• Extremities : warm, edema -/-/-/-, CRT < 2 seconds
 Gynecologic Examination
• LMP : January 23rd 2018
• Fundal height : on umbilical
 Laboratory
Types Results Types Results
Hematology Hemostasis
Hemoglobin 8.0 BT 2.30
Hematocrit 26 CT 8.00
Leucocytes 5900 Chemical clinics
Platelets 174.000 GDS 105
Eritrocyte 3.0 AST 64
MCV 86 ALT 18
MCH 27 Ureum 17
MCHC 31 Creatinine 0,22
Types Results
Immunoserology
Qualitative antiHIV Non reactive
Types Results
Qualitative HBs-Ag Non reactive
Microscopic
Urine
Chemical Urine Urine
Color Yellow Leukosit 2-4
Purity Slightly cloudy
Eritrosit 12-15
Ph 6.0
Epithel +
Density 1.015
Leukosit Negative Cylinder Negative
Nitrite Negative Crystal Negative
Protein Negative
Bacteria Negative
Glucose Negative
Keton Negative
Urobilinogen Negative
Bilirubin Negative
Eritrosit Positive (+++/50)
 Working Diagnosis
• Mrs. A, 31 years old, G4P1A2, with molar
pregnancy suspect gestational trophoblastic
neoplasia
 Management
• CT-scan thorax
• Rontgen thorax
CT-scan thorax tanpa dan dengan kontras potongan axial sagittal dan koronal
didapatkan kesimpulan : Gambaran massa metastasis intrapulmonal berbentuk coin
lesion ukuran sekitar 1 sd 3 cm ditandai adanya lesi hipoden relative bulat berbatas
tegas tepi regular, berbagai ukuran di paru bilateral.
 Prognosis
• Quo ad vitam : dubia ad malam
• Quo ad functionam : malam
• Quo ad sanationam : malam
CASE ANALYSIS
 Theory Case
Risk factors - There is an ethnic - The patient was Asian.
predisposition to hydatidiform - The patient had history of
mole, which has increased molar pregnancy.
prevalence in Asians, - The patient was 31 years old.
Hispanics, and American
Indians.
- The strongest risk factors are
age and a history of prior
hydatidiform mole. Women at
both extremes of reproductive
age are most vulnerable.
Specifically, adolescents and
women aged 36 to 40 years
have a twofold risk, but those
older than 40 have an almost
tenfold risk.
Clinical - Typically, there are - The patient’s last menstrual period were
Findings usually 1 to 2 months of January 23rd 2018.
amenorrhea before - The patient had anemia and history of
discovery. hyperemesis 2 months before admission.
- Only 2 percent had - The patient’s chief complaint were
anemia or hyperemesis
vaginal bleeding.
- Untreated molar
- There was no fetal heart sound found.
pregnancies will almost
- The patient felt tired more easily and
always cause uterine
bleeding that varies palpitation.
from spotting to profuse - The patient’s fundal height was larger
hemorrhage. higher for dates.
- The enlarged uterus
has a soft consistency,
but typically no fetal
heart motion is detected
Clinical - The thyrotropin-like - The patient felt tired more easily and
Findings effects of hCG palpitation.
frequently cause serum - The patient got no preeclampsia nor
free thyroxine (fT4)
eclampsia symptoms.
levels to be elevated and
thyroidstimulating - The patient’s fundal height was larger
hormone (TSH) levels to higher for dates.
be decreased. Despite
this, clinically apparent
thyrotoxicosis is unusual
and, in our experience,
can be mimicked by
bleeding and sepsis
from infected products.
- Severe preeclampsia
and eclampsia are
relatively common with
large molar pregnancies.
However, these are
seldom seen today
because of early
diagnosis and
evacuation.
- The uterine size can be
large or small for dates.
Diagnosis - With a complete molar - The quantitative β-Hcg for
(Physical pregnancy, serum β-hCG this patient was not
examination, levels are commonly examined.
Laboratory elevated above those - The USG was performed in
studies and expected for gestational the previous healthcare.
USG) age.
- Sonographically, a
complete mole appears as
an echogenic uterine mass
with numerous anechoic
cystic spaces but without a
fetus or amnionic sac. The
appearance is often
described as a “snowstorm”
LITERATURE REVIEW
 Definition
• Gestational trophoblastic disease (GTD) = a
group of tumors typified by abnormal
trophoblast proliferation.
• GTD histologically is divided into :
– Hydatidiform moles, which are characterized by
the presence of villi
– Nonmolar trophoblastic neoplasms, which lack
villi.
• Hydatidiform moles are excessively edematous
immature placentas. These include :
– the benign complete hydatidiform mole and
partial hydatidiform mole
– the malignant invasive mole due to its marked
penetration into and destruction of the
myometrium as well as its ability to metastasize
 Epidemiology and Risk Factors
• Ethnic predisposition :
– Asians
– Hispanics
– American Indians
• Age :
– 36 to 40 years old  twofold risk
– >40  tenfold risk
• Prior hydatidiform mole :
– Prior complete mole : 1,5%
– Previous partial mole : 2,7%
– 2 prior molar pregnancies : 23%
 Pathogenesis
• Molar pregnancies arise from chromosomally
abnormal fertilizations