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Gestational Trophoblastic Diseases Hydatiform Mole
Gestational Trophoblastic Diseases Hydatiform Mole
Types of GTD
Benign
Hydatidiform mole/molar pregnancy (complete or incomplete)
malignant
Invasive mole Choriocarcinoma (chorioepithelioma) Placental site trophoblastic tumor
Types of GTD
The term Gestational Trophoblastic Tumors has been applied the latter three conditions Arise from the trophoblastic elements Retain the invasive tendencies of the normal placenta or metastasis Keep secretion of the human chorionic gonadotropin (hCG)
CLINICAL CLASSIFICATION
Benign gestational trophoblastic disease
Invasive mole
Placental site trophoblastic tumor Choriocarcinoma
Nonmetastatic
High risk
Low risk
In a complete mole the mass of tissue is completely made up of abnormal cells There is no fetus and nothing can be found at the time of the first scan.
In a partial mole, the mass may contain both these abnormal cells and often a fetus that has severe defects. In this case the fetus will be consumed ( destroyed) by the growing abnormal mass very quickly. (shrink)
Incidence
1 out of 1500-2000 pregnancies in the U.S. and Europe 1 out of 500-600 (another report 1%) pregnancies in some Asian countries. Complete > incomplete
Incidence
Repeat hydatidiform moles occure in 0.5-2.6% of patients, and these patiens have a subsequent greater risk of developing invasive mole or choriocarcinoma There is an increased risk of molar pregnancy for women over the age 40
Incidence
Approximately 10-17% of hydatidiform moles will result in invasive mole Approximately 2-3% of hydatidiform moles progress to choriocarcinoma ( most of them are curable)
Not definitely benign disease , has a tight relationship with GTT
Cytogenetics
Complete molar pregnancy
Chromosomes are paternal , diploid 46,XX in 90% cases 46,XY in a small part
Chromosomes are paternal and maternal, triploid. 69,XXY 80% 69,XXX or 69,XYY 10-20%
Wrong life message , so can not develop normally
Complete Mole
Usually diploid 46XX All villi hydropin; no normal adjacent villi
Partial Mole
Usually triploidy 69XXX most common. Normal adjacent villi may be present
present they contain no blood cells fetal blood cells None present Hyperplasia usually present to variable degrees Usually present Hyperplasia mild and focal
Color Dopplor facilitates visualization of the enlarged spiral arteriesclose proximity to the snow storm appearance
Color Doppler image of a hydatidiform mole and surrounding vessels. The uterine artery is easily identified from its anatomical location.
Dopplor waveform analysis demonstrates low vascular resistance(RI=0.29) in the spiral arteries, much lower than that obtained in normal early pregnancy
Here is a partial mole in a case of triploidy. Note the scattered grape-like masses with intervening normal-appearing placental tissue.
Large bilateral theca lutein cysts resembling ovarian germ cell tumors. With resolution of the human chorionic gonadotropin(HCG) stimulation, they return to normal-appearing ovaries.
Vaginal bleeding Hyperemesis ( severe vomit) Size inconsistent with gestational age( with no fetal heart beating and fetal movement) Preeclampsia Theca lutein ovarian cysts
Vaginal bleeding Absence of fetal heart tones Uterine enlargement and preeclampsia is reported in only 3% of patients. Theca lutein cysts, hyperemesis is rare.
Diagnosis
The most common symptom of a mole is vaginal bleeding during the first trimester however very often no signs of a problem appear and the mole can only be diagnosed by use of ultrasound scanning. (rutting check) Occasionally, a uterus that is too large for the stage of the pregnancy can be an indication. NOTE: Vaginal bleeding does not always indicate a problem!
Differential diagnosis
Abortion Multiple pregnancy Polyhydramnios
Treatment
Suction dilation and curettage :to remove benign hydatidiform moles When the diagnosis of hydatidiform mole is established, the molar pregnancy should be evacuated. An oxytocic agent should be infused intravenously after the start of evacuation and continued for several hours to enhance uterine contractility
Treatment
Removal of the uterus (hysterectomy) : used rarely to treat hydatidiform moles if future pregnancy is no longer desired.
Treatment
Chemotherapy with a single-agent drug Prophylactic (for prevention) chemotherapy at the time of or immediately following molar evacuation may be considered for the high-risk patients( to prevent spread of disease )
6.
Pre-evacuation uterine size larger than expected for gestational duration Bilateral ovarian enlargement (> 9 cm theca lutein cysts) Age greater than 40 years Very high hCG levels(>100,000 m IU/ml) Medical complications of molar pregnancy such as toxemia, hyperthyrodism and trophoblastic embolization (villi come out of placenta ) repeat hydatidiform mole
Follow-up
Patients with hudatidiform mole are curative over 80% by treatment of evacuation. The follow-up after evacuation is key necessary uterine involution, ovarian cyst regression and cessation of bleeding
Follow-up
Quantitative serum hCG levels should be obtained every 1-2 weeks until negative for three consecutive determinations, Followed by every 3 months for 1 years. Contraception should be practiced during this follow-up period