GESTATIONAL

TROPHOBLASTIC
DISEASE

PRESENTED BY –
ASHA S MARIHAL
2ND YEAR M.Sc NURSING
20NPG003
DEPT. OF OBG
SDMIONS
 DEFINITION

Gestational Trophoblastic Diseases(GTD) encompasses a

spectrum of proliferative abnormalities of trophoblasts

associated with pregnancy. Persistent GTD is referred as

Gestational Trophoblastic Neoplasia(GTN).

 CLASSIFICATION

1. Hydatidiform mole
Benign = 80%
a. Partial Hydatidiform mole
b. Complete Hydatidiform mole.
Malignant=20% (GTN)
2. Persistent or invasive mole =12-15% of cases.
3. Placental site trophoblastic tumour (rare).
4. Choriocarcinoma = 5-8% of cases .
 HYDATIDIFORM MOLE

• It is an abnormal condition of the placenta where there are

partly degenerative and partly proliferative changes in then
young chorionic villi.

CLASSIFICATION

COMPLETE PARTIAL
MOLE MOLE
 COMPLETE MOLE

• The whole conceptus is transformed into a mass of vesicles.

• No embryo is present.

• It is the result of fertilization of a nucleated ovum (has no

chromosomes) with a sperm which will duplicate giving rise

to 46 chromosomes of paternal origin only

 PARTIAL MOLE

• A part of trophoblastic tissue only shows molar changes.

• There is a fetus or at least an amniotic sac present .

• It is the result of fertilization of an ovum by 2 sperms so the

chromosomal number is 69 chromosomes.

 ETIOLOGY

• The cause is not definitely known. However, the following factor and

hypothesis have been forwarded:

• Its prevalence is the highest in teenage pregnancies and in those

women over 35 years of age.

• The prevalence appears to vary with race and ethnic origin

• Nutritional deficiency (inadequate intake of protein, animal fat and

carotene.)
• Disturbed maternal immune mechanism suggested by-

A. Rise in gamma globulin level in absence of

hepatic disease.

B. Increased association with AB blood group which

possesses no ABO antibody.

• Cytogenetic abnormality- in general, complete moles have a 46, XX

karyotype (85%), the molar chromosome are derived entirely from the
father.

• History of prior hydatidiform mole increases the chance of recurrence (1

to 4%)
 CLINICAL SYMPTOM
Complete Mole
1. Vaginal bleeding
2. Uterus is larger than POG
3. Hyperemesis Gravidarum
4. PET 10-15%
5. hyperthyroidism 7%
6. Theca leutin cysts
7. Beta HCG levels
8. Passage of grapes like vesicle
PARTIAL MOLE
• Uterus is often not enlarged more than POG

• More often presents as Missed or incomplete abortion

• Pre evacuation h CG levels are not more than 100,000IU/ L

• Macroscopic : villous swelling is less intense

• Embryo is present
Symptoms
• Amenorrhea: usually of short period (2-3 months).

• Exaggerated symptoms of pregnancy especially vomiting.

• Vaginal bleeding which is usually dark brown and may be

associated with passage of vesicles.

• Abdominal pain: may be dull-aching due to rapid distension

of the uterus,

• colicky due to starting expulsion,

• sudden and severe due to perforating mole.

Signs
General examination:

• Pre-eclampsia develops in 20% of cases, usually before 20

weeks’ gestation.

• Hyperthyroidism develops in 10% of cases manifested by

enlarged thyroid gland, tachycardia and elevated plasma
thyroxin level.

• Breast signs of pregnancy.

 INVESTIGATION
• Urine pregnancy test: it is positive in high dilution. 1/200 is
highly suggestive, 1/500 is surely diagnostic. In normal
pregnancy it is positive in dilutions up to 1/100.

• Serum β-hCG level: is highly elevated (>100000 mIU/ml).

• Ultrasonography reveals: The characteristic intrauterine

"snow storm" appearance, no identifiable foetus, bilateral
ovarian cysts may be detected.

• X-ray: shows no fetal skeleton.

 COMPLICATION

1. Haemorrhage.

2. Infection due to absence of the amniotic sac.

3. Perforation of the uterus.

4. Pregnancy induced hypertension

5. Hyperthyroidism.

6. Subsequent development of choriocarcinoma

 TREATMENT

• As soon as the diagnosis of vesicular mole is established the

uterus should be evacuated.

• The selected method depends on the size of the uterus,

whether partial expulsion has already occur or not, the

patient's age and fertility desire.

• Cross- matched blood should be available before starting.

SUCTION EVACUATION :

• It is carried out under general anaesthesia, but not that which

relax the uterus as halothane as it may induce severe
bleeding.

• An infusion of 20 units oxytocin in 500 m1 of 5% glucose

should be maintained throughout the procedure.

• Dilatation of the cervix is done up to a Hegar's number equal

to the period of amenorrhea in weeks e.g. No. 10 Hegar for
10 weeks’ amenorrhea. The suction canula used will be of
the same size also.
• 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.

• Although some recommended a gentle sharp curettage to the

uterus after evacuation, it is preferable to wait one week for
fear of uterine perforation.
Hysterotomy

• It may be needed for evacuation of a large mole to minimize

and facilitate control of bleeding.

• Hysterotomy: It should be considered in women over 40 years

who have completed their family for fear of developing
choriocarcinoma.

Medical induction

• Oxytocin and / or prostaglandins may be used to encourage

expulsion of the mole but must always be followed by surgical
evacuation.
 FOLLOW UP CARE

• As choriocarcinoma may complicate the vesicular mole after its

evacuation, detection of serum ß-hCG by radioimmunoassay for
2 years is essential.

Detection is done every:

• 2 weeks after evacuation to ensure regression of ß-hCG level

then,

• every month for one year then,

• every 3 months for another year.

• Persistent high level indicates remnants of molar tissues which

necessitate chemotherapy (methotrexate) with or without

curettage. Hysterectomy is indicated if women had enough

children

• Rising hCG, level after disappearance means developing of

choriocarcinoma or a new pregnancy. So combined contraceptive

pills should be used for prevention of pregnancy which can be

misleading.
• It is expected that urine pregnancy test is negative 4 weeks
after evacuation and serum β-hCG is undetectable 4 months
after evacuation.

Early features suggesting residual molar tissue include:

• recurrent or persistent vaginal bleeding,

• amenorrhoea,

• failure of uterine involution,

• persistence of ovarian enlargement.