Bleeding in Early Pregnancy

Question 1

What disorders are included in gestational trophoblastic disease (GTD)?

Answer 1

1. Complete molar pregnancy
2. Partial molar pregnancy
3. Invasive mole
4. Choriocarcinoma
5. Placental site trophoblastic tumor (PSTT).

Question 2

What is gestational trophoblastic neoplasia (GTN)?

Answer 2

A condition characterized by a persistent elevation of βhCG after GTD.

Question 3

How are molar pregnancies classified?

Answer 3

Based on genetic and histopathological features.

1. Complete moles (CM)
2. Partial moles (PM)

Question 4

What is the genetic origin of complete moles?

Answer 4

Diploid and androgenic, with no fetal tissue evidence.

Question 5

What is the most common cause of complete moles?

Answer 5

Duplication of a single sperm after fertilization of an empty ovum.

Question 6

What is the genetic origin of partial moles?

Answer 6

Triploid, with two paternal haploid and one maternal haploid gene sets.

Question 7

List some clinical presentations of GTD.

Answer 7

1. Irregular vaginal bleeding
2. Hyperemesis
3. Excessive uterine enlargement
4. Early failed pregnancy.

Question 8

What systemic symptoms can GTD cause?

Answer 8

1. Hyperthyroidism
2. Early pre-eclampsia
3. Abdominal distension due to theca lutein cysts.

Question 9

How is GTD diagnosed using ultrasound?

Answer 9

1. Characteristic “honeycomb” or “snowstorm” appearance
2. Presence of theca lutein cysts.

Question 10

What βhCG level is suggestive of GTD?

Answer 10

Levels greater than two multiples of the median.

Question 11

How is the definitive diagnosis of molar pregnancy made?

Answer 11

Through histological examination of the products of conception.

Question 12

What is the method of choice for evacuating a complete molar pregnancy?

Answer 12

Suction curettage.

Question 13

Is medical evacuation recommended for complete molar pregnancies?

Answer 13

No, it is avoided if possible.

Question 14

What precautions are taken during evacuation of molar pregnancies?

Answer 14

1. Senior supervision
2. Avoiding oxytocic infusion prior to completion of evacuation.

Question 15

Why is Anti-D prophylaxis required after molar pregnancy evacuation?

Answer 15

To prevent isoimmunization.

Question 16

When is a second uterine evacuation recommended in GTD?

Answer 16

Only if symptoms persist, and after consultation with a trophoblastic screening center.

Question 17

What should be done for women with persistent bleeding post-pregnancy event?

Answer 17

A urine pregnancy test to rule out GTN.

Question 18

How long is the follow-up after GTD if βhCG normalizes within 56 days?

Answer 18

6 months from uterine evacuation.

Question 19

How long should women with GTD avoid pregnancy after follow-up?

Answer 19

Until follow-up is complete or chemotherapy is concluded.
Around 1 year

Question 20

What chemotherapy regimen is used for low-risk GTN (FIGO score ≤ 6)?

Answer 20

Single-agent methotrexate with folinic acid.

Question 21

What chemotherapy is used for high-risk GTN (FIGO score ≥ 7)?

Answer 21

Multi-agent chemotherapy including:

• methotrexate
• cyclophosphamide
• vincristine.

Question 22

What is the treatment approach for PSTT?

Answer 22

Surgery, as it is less sensitive to chemotherapy.

Question 23

What long-term risk is associated with multi-agent chemotherapy in GTN?

Answer 23

Increased risk of secondary cancers like AML, colon cancer, and melanoma.

Question 24

What contraceptive methods are recommended post-GTD treatment?

Answer 24

Barrier methods until βhCG normalizes, then oral contraceptive pills.

Question 25

What is the effect of chemotherapy on menopause in GTN patients?

Answer 25

Accelerated menopause, earlier by 1–3 years depending on the regimen.

Question 26

When should hCG levels be measured after future pregnancies in GTD patients?

Answer 26

6–8 weeks postpartum to exclude recurrence.

Question 27

Why should intrauterine devices be avoided in GTD patients until βhCG normalizes?

Answer 27

To reduce the risk of uterine perforation.

Question 28

What imaging feature differentiates partial from complete molar pregnancies?

Answer 28

Evidence of fetal tissue or red blood cells in partial moles.

Question 29

What histological features are seen in complete moles?

Answer 29

- Trophoblastic hyperplasia without fetal tissue - Edematous villi - Swollen chorionic villi.

Question 30

What histological features are seen in partial moles?

Answer 30

- Some fetal tissue present - Trophoblastic proliferation - Edema - Mix of normal and abnormal villi.