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Gaby’s Green Top Guidelines > 2020 38 Gestational Trophoblastic Disease > Flashcards

2020 38 Gestational Trophoblastic Disease Flashcards

1
Q

** What are the common signs & symptoms of molar pregnancies? **

A
  1. Irregular PV bleeding
  2. Positive pregnancy test
  3. Ultrasonographic evidence
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2
Q

** What are the less common presentations of molar pregnancies? **

A
  1. Hyperemesis
  2. Excessive uterine enlargement
  3. Hyperthyroidism
  4. Early-onset pre-eclampsia
  5. Abdominal distensión by theca lutein cysts
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3
Q

** What are the very rare presentations of molar pregnancy? **

A
  1. Haemoptysis due to lung mets
  2. Seizures due to brain mets
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4
Q

** How is molar pregnancy definitively diagnosed? **

A

Histology

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5
Q

** What method should be used for removal of a molar pregnancy? **

A
  1. Complete molar: suction curettage
  2. Consider US guidance to minimise chance of perforation or RPOC
  3. Partial molar: suction curettage unless fetal parts too big, then medical
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6
Q

** What surgical considerations are there for molar pregnancy removal? **

A
  1. Anti-D prophylaxis after
  2. Cervical preparation is safe
  3. Oxytocin infusion not recommended due to risk of tissue embolisation
  4. Senior consideration of oxytocin if significant haemorrhage
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7
Q

** When should repeat surgical removal be done for molar pregnancy? **

A
  1. Urgent if heavy or persistent PVB causing acute haemodynamic instability
  2. RPOC on USS
  3. If not acutely compromised, involve GTD referral centre
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8
Q

** How should GTD be excluded following miscarriage? **

A
  1. Histological assessment of all, if no fetal parts identified at any stage of pregnancy
  2. UPT at 3 weeks
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9
Q

** How should GTD be excluded following abortion? **

A
  1. No need to routinely send if fetal parts identified in prior USS
  2. UPT at 3 weeks
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10
Q

** How should elevated hCG after a possible pregnancy be managed? **

A

Referral to GTD centre, provided
1. Ectopic pregnancy excluded, or
2. 2 consecutive treatments with methotrexate

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11
Q

** Who should be investigated for GTN after a non-molar pregnancy? **

A
  1. Persistent PVB: urine hCG in all lasting more than 8 weeks
  2. Symptoms of mets including dyspnoea, haemoptysis, new onset seizures or paralysis
    NB Do not biopsy secondary deposits in vagina as can cause major haemorrhage
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12
Q

** How should suspected ectopic molar pregnancy be managed? **

A
  1. As other ectopic pregnancy
  2. Send pregnancy tissue to a centre with appropriate expertise
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13
Q

** How is twin pregnancy of a viable fetus & coexistente molar managed? **

A
  1. If diagnosed or suspected, refer to FMU & GTD centre
  2. Counselling about increased risk of perinatal mortality
  3. Consider prenatal invasive testing: complete mole with coexisting normal vs singleton partial molar
  4. Also for suspected mesenchymal hyperplasia of placenta
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14
Q

** Which women should be registered at GTD centres? **

A
  1. Complete or partial molar
  2. Twin with complete or partial molar
  3. Limited macro or microscopic change suggesting early complete or partial molar or choriocarcinoma
  4. PSTT: placental site trophiblastic tumour
  5. ETT: epithelial trophoblastic tumour
  6. Atypical PSN: placental site nodule
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15
Q

** What is the optimum follow-up following a diagnosis of GTD? **

A
  1. Complete, hCG normal after 56 days ➡️ 6 months from uterine removal
  2. Complete, not normal after 56 days ➡️ 6 months from hCG normalisation
  3. Partial: after 2 normal hCG samples, > 4 weeks apart
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16
Q

** What is the optimum treatment for GTN? **

A
  1. Single-agent or multi-agent chemo
  2. Base Tx on FIGO 2000 scoring system
  3. PSTT & ETT less sensitive to chemo so treated surgically
17
Q

** What are the recommendations for future pregnancy after GTD? **

A
  1. Do not TTC until follow-up complete
  2. > 1 year following chemotherapy
  3. Do not need histology or post-preg hCG from subsequent normal pregnancy if not treated for GTN
18
Q

** What is the long-term outcome of women treated for GTN? **

A
  1. Overall cure rate close to 100%
  2. Further pregnancies in approx 80% following either methotrexate or multi-agent chemo
  3. Increased risk of premature menopause if combination agent chemo
19
Q

** What are the implications of GTD for subsequent a) contraception, b) fertility drugs, c) HRT

A

a) most contraception OK, wait until hCG normalised before coil
b) fertility drugs safe once hCG normalised
c) HRT safe once hCG normalised

Gaby’s Green Top Guidelines (16 decks)

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