Gestational Trophoblastic disease

1. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Hydatidiform mole
Chorioadenoma destruens
Choriocarcinoma
• 1 in 2000 pregnancies (UK) – 1 in 700 (Asiatic countries)
• 16% are invasive mole,
• 2.5% choriocarcinoma

2. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Features are large-for-dates uterus,
PV bleeding and high hCG
Curettage should be repeated after one month if bleeding don't
stopped or hCG remains elevated
Follow-up is by hCG and advise not to get pregnant for 12
months
Choriocarcinoma blood-borne metastases, treatment with
methotrexate

3. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Abnormality of early trophoblast may arise as a
develepment anomaly of placental tissue and results in the
formation of a mass of oedematous and avascular villi. There is
usually no fetus but the condition can be found in the presence
of a fetus. The placenta is replaced by a mass of grapelike
vesicles known as a hydatidiform mole.
Invasion of the myometrium without systemic spread occurs in
about 16% of cases of benign mole and is known as invasive mole
or chorioadenoma destruens.
Malignant change occurs in 2.5% and is known as
choriocarcinoma.

4. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Pathology
Benign mole remains confined to the uterine cavity and decidua.
The histopathology exhibits a villous pattern, which is also
found in the invasive mole, the tissue penetrates the
myometrium deeply and may result in serious haemorrhage.
Choriocarcinoma comprises plexiform columns of trophoblastic
cells without villous patterns. Widespread blood-borne
metastases are a feature of this disease which, until recent years,
carried a very high mortality rate.
Metastases may occur locally in the vagina but most commonly
appear in the lungs.
Theca lutein cysts occur in about one-third of all cases as a
result of high circulating levels of hCG. These regress
spontaneously with removal of the molar tissue.

5. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Clinical presentation
Molar pregnancy most commonly presents as bleeding in the
first half of pregnancy and spontaneous abortion often occurs at
about 20 weeks' gestation.
Occasionally, the passage of a grape-like villus heralds the
presence of a mole.
The uterus is larger than dates in about half the cases but this is
not a reliable sign as it may sometimes be small for dates.
Severe hyperemesis, pre-eclampsia and unexplained anaemia are
all factors suggestive of this disorder. The diagnosis can be
confirmed by ultrasound scan and by the presence of very high
levels of hCG in the blood or urine.

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7. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Management
Once the diagnosis is established, the pregnancy is terminated
by suction curettage.
Adequate replacement of blood loss is essential and the
procedure is accompanied by the infusion of oxytocin to ensure
that the uterus remains well contracted.
All cases of molar pregnancy should be followed for 1 year and
further pregnancy during this time is con-traindicated.
Serial estimations of subunit hCG are followed; where these
remain elevated for more than 1 month after uterine
evacuation, or where per­sistent haemorrhage occurs, repeat
curettage should be performed.

8. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
If the histological evidence shows malignant change,
chemotherapy with methotrexate and actinomycin D is employed
and produces good results. Management of these cases is
concentrated in specialised centres.
It may occasionally be necessary to remove the uterus where
haemorrhage becomes life-threatening. It must be remembered
that chorio­carcinoma sometimes can occur following an
abortion or a normal term intra-uterine pregnancy.

9. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Hydatidiform moles
Risk factors include:
maternal age >35 years (>2 x increase),
prior molar pregnancy (10 x increase),
long-term use of oral contraceptives (2 x increase),
dietary deficiency ((3-carotene, vitamin A).
Clinical presentation. Partial moles usually present as a missed
abortion during the 1 st or early 2nd trimester.
Normal or marginally elevated þ-hCG levels are
common.
Complete moles typically have abnormal vaginal
bleeding (85%).
10% of women will have anaemia, hyperemesis
gravidarum or pre­eclampsia.

10. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Sonographic findings.
Partial moles may be suspected by visualizing a fetus with focal
cystic spaces in the placenta and an increase in the
transverse diameter of the gestational sac.
Complete moles classically have a 'snowstorm' appearance of
diffuse hydropic swelling without a fetus. Diagnosis of
hydatidiform moles is made by histopathological analysis.
Partial moles have a non-viable fetus with malformations
(syndactyly, hydrocephalus, growth restriction), variably
hydropic (swollen) villi and minimal trophoblastic
hyperplasia.
Complete moles have no fetal tissue and consist of diffusely
hydropic villi (grape-like vesicles) with widespread
trophoblastic hyperplasia.

11. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Treatment. Dilatation and evacuation is the most common initial
treatment for molar pregnancy.
Hysterectomy is an alternative in selected patients who desire
surgical sterilization.
Prophylaxis. Anti-D immunoglobulin should be administered to
appropriate Rh-negative patients.
Surveillance. þ-hCG levels should be monitored until they are
undetectable.
Hormonal contraception should be encouraged to prevent
pregnancy and reduce the potential for complicating þ-hCG
interpretation.
·Future pregnancies. Patients may expect normal reproductive
out­come of subsequent conceptions. The risk of developing
another hyda­tidiform mole

12. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Gestational trophoblastic neoplasia (GTN)
• Antecedent gestation: most commonly occurs following
a molar pregnancy, but may occur after any gestational
event (termination or spontaneous miscarriage ,
ectopic pregnancy , term pregnancy).
• Diagnosis is not uniform worldwide, but includes one of
these criteria:
 þ-hCG plateau of 4 measurements over a period of at last 3 weeks
 þ-hCG rise of 3 measurements over a period of at last 2 weeks
 þ-hCG level remains elevated for more than 6 months
• Histological diagnosis of choriocarcinoma.

13. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Choriocarcinoma consists of sheets of anaplastic
cytotrophoblast and syncytiotrophoblast cells
without chorionic villi.
Invasive moles may have the histological features
of either choriocarcinoma or hydatidiform mole,
but metastases are always choriocarcinoma.

14. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
GTN is anatomically staged.
The combination of a chest X-ray, abdominal-pelvic CT scan and
pelvic examination is an effective strategy to determine the
extent of disease. Chest and head CT are indicated if the chest
X-ray is abnormal.
Biopsy of suspected metastatic lesions is not recommended and
may cause haemorrhage.
The World Health Organization (WHO) prognostic scoring
system (opposite) is used to categorize patients with GTN into
low-risk (score: 0-6) or high-risk (score: 7 or higher) groups.

15. GESTATIONAL TROPHOBLASTIC DISEASE (GTD)
Treatment
Low-risk GTN is most frequently treated by methotrexate.
If the tumour is resistant, the patient may be switched
to dactinomycin.
High-risk GTN is usually best managed by combination
chemo­therapy (etoposide, methotrexate, dactinomycin,
Cytoxan, vincristine) due to the increased risk of
tumour resistance to a single agent.
Surveillance. þ-hCG levels are measured until therapy is
completed. Follow-up should continue for 12 (stage I—
III) to 24 months (stage IV).
Prognosis. 98-100% of stage I—III patients and 75-80% of
stage IV patients will be cured.