Bleeding In Early Preg ( GTD) Flashcards
Def
Incidence
Class
- placental trophoblastic cells disease
-0 .15% - bengin
• complete
• partial - malignant
• non metastatic : invasive mole
• metastatic: choriocarcinoma, placental site , epitheloid tumour
Talk about vesicular mole
- incidence
- risk factors
- recurrence
- the commenst
- 1- extremties of age >20 , <35
2- low intake of vitA, animal fat
3- race : asia - second ~> doubled ,third~> 33%
Patho of vesicular mole
- incidence
- fert
- gross
- micro
1- complete
• the commenst
• empty ovum , 1 sperm ~> 46xx after duplication( paternal thus no embryo)
• gross
- grape like vesicles vary from milli to centimetres
- hydatiform changes are generlized with no amniotic fluid, fetal tissues
• micro
- diffuse proliferation of trophoblastic cells
- marked edema, enlargement of villous stroma ( hydropoc villi)
- disappearance of villius fetal blood vessels
Partial
- less common as it is diagnosed as spontaneous ( missed)
- n ovum , 2sperm ~> 69xxx,xxy,xyy
- gross
• placenta with molar change , fetus with anomalies
• hydatiform changes are focal wtih amniotic fluid, fetus
• micro
- focal proliferation of trophoblastic tissue
- focal edema , enlargement of villius stroma
- there are umbilical cord , amniotic membrane, fetus
Changes of ovary in vm
(4)
1- enlarged due to theca lutein cysts ( hyperstimulation by bhcg)
2- more common in complete due generlized trophoblastic proliferation ( ++++ bhcg)
3- bilateral , vary in size , yellowish , smooth surface
4- regress after molar evacution
Cp of molar preg
1- recurrent bleeding
2- pallor if recurrent , hypovemic shock if severe sudden ~> expulsion
3- less pain unless separation or expulsion
4- PRUNE JUICE ( water, blood )
5- PASSAGE OF VESICLES WITH VAGINAL BLEEDING
6- UT IS SOFT, DOUGHY due to abscence of amniotic fluid , fetus
7- fl is above calculated ga due to rapidly proliferating tropho
8- enlarged ovary with theca letin cysts
9- +bhcg~> nausea vomiting
10- + bhcg ~> preeclampsia but rare
Malignant
- incidence
- class
- less common
50% after molar preg , may be after abortion or even full term preg - non metastatic : invasive
Metastatic: choriocarcinoma , placental site , epitheliod tumour
They classified into
Low risk
• < 4 month from preg event
• < 40 y
• < 100,000 b hcg
• < 6cm theca lutein
• no brain or liver metastasis
• no chemo
• good prognosis
High risk
• >4 month from preg event
• >40 y
• >100,000 b hcg
• >6cm theca lutein
• brain or liver metastasis
• chemo
• bad prognosis
Talk about
Invasive mole
Malignant
- gross
- micro
Invasive
- gross : local invasion of myometrium with hemorrhage, necrosis
- micro : local invasion of myometrium by trophoblastic cells and DIFFERENTIATED villi
Malignant
- its malignant tumour with early blood borne metastasis to lungs, vagina
- gross : red friable mass invading muometrium, blood vessels with necrosis, hemorrhage
- micro : columns and sheets of trophoblastic and UNDIFFERENTIATED villi invading myometrium, blood vessels
Grading
Staging
In malignant
• G1 ~> < 5% malignant undiff
G2 ~> 5:50 % malignant undiff
G3~»50% malignant undiff
• figo staging
Stage 1 : uterus
Stage 2: local spred to genital tract
Stage 3: LUNGS
Stage 4: distant metastasis
Talk about
- inv
- ttt
In malignant
- (5)
• persistent bleeding following the event
• bhcg : fail to decrease ( plateau) or rise
• tvs/tas : ut lesion , theca letuin cysts
• pelvic MRI : myometrial invasion
• metastic work up - Low risk ~> mtx
High risk ~> mac ( mtx , actinomycin d , cyclophosphamide)
Hysterectomy if
• old
• no desire for fertility
• severe bleeding
• chemoresistent as placental site , endothelial tumour
- inv
- comp
Of vm
1- us : gold standard
- complete :
• SNOWSTORM appearance
• no fetal echoes
• ovarian theca lutein cysts
- partial
• fetus in first tri with anomaly
• placenta with molar hyrdopic changes
2- Bhcg : magnoon > 100,000 in first 8 w
3- metastatic work up : to exclude
- comp
3 ~> hcg
3~> metast
2~> ملهمش علاقة - ++ bhcg
• hyperemesis gravidarum
• pih , preeclampsia
• hypothyroidism: 9% due to thyrois stimulating effect of hcg
• trophoblastic embolism in lungs causing RDS
• complete ~> invasive (20%)
Partial ~>invasive ( 4%)
• choriocarcinoma (5%)
• ovarian cysts comp ( torsion, hge, rupture)
• hypovolemic shock
Management of vm
Ttt + follow up
Medical
1- misoprostol ( pge1) for dilation
2- ecbolics : enchance contraction of ut
3- suction
4- gentle currettge to ensure complete evacuation
Surgical ( hysterectomy )
If
• old patient
• large size
• no desire for fertility
Follow up
-Bhcg : must decrease
48h ~> week~> 3week ~> month for 1 year
- contraception for 1 year with ocp ( iud msh hymna elvesicles)
- if plateau or ptd ~> mtx
Can i do d, c in malignant gtd
No d, c
Due to friablity , spread , no need to confirm
