Gestational Trophoblastic Disease Flashcards
Definition?
Presence of abnormal tissue derived from fetal cells in the uterus
Hydropic chorionic villi
What are the types?
BENIGN 75%
90% complete molar
10% incomplete molar
MALIGNANT 25%
Persistent/ invasive mole 75%
Choriocarcinima 25%
Placental site trophoblastic tumor PSTT <1%
What are the risk factors for GTD?
- Previous gtd
- Extremes of age
- Nulliparity
How does a complete mole form?
Fertilization of an empty egg. Thus may be by one sperm which replicates after fertilization to give 46xx
OR 2 speed which fertilizd one egg to give 46xx or 46xy
How does partial molar pregnancy form?
Fertilization of egg that HAS genetic material by 2 sperm to give 69xxy
Triploidic
What hormones do HCG mimic?
TSH, LH, FSH as they share a subunits with hcg
What is the presentation in complete GTD?
Think about the hormone that is involved HCG and the ones it mimics (TSH, FSH, LH)
HISTORY
- **passing grape like /cherry like tissue
- **Nausea, Vomiting -hcg
- **Irritability
- **Photophobia, Dizziness - pre-eclampsia symptoms due to placental compromise (trophoblastic invasion)
- ** pre-eclampsia symptoms - Htn, edema
- **Nervousness, Anorexia , Tremor - tsh simulation
Pre-eclampsia before 20 weeks is pathognomonic for molar pregnancy
EXAMINATION
- **Masses felt in ovaries -theca lutein cysts - LH stimulation
- **uterus maybe large for gestational age
What is the workup for complete GTD?
- Serum HCG quantitative
2. Pelvic U/S
What’s seen on U/S in complete GTD?
Grape like formations in the uterus as well as tou mat
What’s seen on complete U/S in GTD?
Grape like formations in the uterus as well as tou mat
Treatment of benign GTD (complete and incomplete) ?
Dilatiation and Curretage under General anesthesia
Preoperative tests - CBC, PT/PTT, U&E, TFT, GXM because she may be rhesus negative and If she is she must be given ANTI D
MUST have blood available as she may bleed profusely
What do we do at follow up for complete and partial GTD after treatment?
- Quantitative HCG 48 hours post D and C
- Serial HCGs weekly until levels are normal for 3 consecutive weeks
- After normal Serial HCGs monthly for 6 months 4. If continuously abnormal or platued consider malignant disease
BARRIER CONTRACEPTION SHOULD BE USED for first 6 months as we don’t want her to get pregnant and affect hcg reading as well as hormonal contraception may affect readings as well
How long does it take for HCG levels to normalize in each type of molar pregnancy?
NORMAL PREGNANCY LOSS - 4 WEEKS
PARTIAL MOLAR POST D&C - 8 WEEKS
COMPLETE MOLAR POST D&C - 14 WEEKS
If after D&C the HCG is decreasing then plateaus and then begins to rise again what does this mean?
Means she has a persistent mole and we consider that malignant GTD
Define partial molar pregnancy.
From a normal egg and two sperm fertilizing it. So it is triploidic.
Characterized by focal hydropoc villi and proliferation of cytotrophoblasts (do not produce HCG)
not characterized by high HCG
There is often a fetus with many abnormalities
Less malignant potential compared to complete
What is presentation of partial molar pregnancy
Usually spontaneous abortion around late first to early second trimester
Examination is typically unremarkable (may find SGA)
What is the workup for partial molar pregnancy?
Quantitative HCG - Will be normal for pregnancy due to no excess syncitiotrophoblasts
PELVIC U/S -may reveal empty gestational sac or fetus with abnormalities or enlarged placenta with Swiss cheese appearance or low amniotic fluid
After what events does malignant GTD normally occur?
25% occur after these events
- Molar pregnancy (usually persistent/invasive GTD)
- Miscarriage
- Ectopic pregnancy
- Normal pregnancy (usually choriocarcinoma)
- Elective abortion
Outline the staging of malignant molar pregnancy.
Stage 1 confined to the uterus
Stage 2 metastasis to the pelvis or vagina
Stage 3 metastases to the lungs (common)
Stage 4 distant metastases e.g. brain
Discuss a persistent invasive mole.
Almost always occurs after evacuation of a molar pregnancy within months to a year
Complete moles are more likely to become malignant
Clinically presents as woman with hx of molar pregnancy with HCG rise or plateua on follow up
Diagnosed based on pelvic sonogram and HCG levels
MUST GET BASELINE CHEST X RAY TO CHECK FOR METASTATIC DISEASE
What is the treatment for persistent invasive mole?
The risk is assessed based on the FIGO score (French international federation of gynecology and obstetrics) <6 low risk >6 high risk
Low risk - methotrexate only
High risk - methotrexate actinomycin D, etoposide ( some persons use a 5 drug regimen)
What is the follow up for persistent invasive mole?
Serial HCG every week until normal for 3 consecutive weeks then monthly HCGs for a year.
Barrier contraception must be used until HCGs have normalized
Pt should avoid pregnancy for at least one year after treatment as methotrexate can cause congenital abnormalities
What is a choriocarcinoma?
It is a malignancy of placental tissue. It’s a necrotizing tumor consisting of both cytotrophoblasts and syncitiotrophoblasts which are not organized into villi (aplastic)
It can occur in ovaries and testes but is rare in these areas. Most common is gestational related
It is a very bloody tumor- lots of vasculature
His does choriocarcinoma present?
Often presents in metastatic stage with lung or cns symptoms
Late postpartum bleeding (>6-8 weeks pp)
ON EXAMINATION
- ** uterine enlargement
- **vaginal mass metastatic
- **bilateral theca lutein cysts due to extra hcg being produced
- **
How is choriocarcinoma diagnosed?
SONOGRAPHY - vascular tumor
HCG levels - elevated as syncitiotrophoblasts are present producing excess HCG
MRI OR CT- if metastatic disease is suspected
How is choriocarcinoma treated?
Stage 1 methotrexate
All other stages 3 medicine regimen and all other treatment tenets the same as invasive mole
What is PSTT? Placental site trophoblastic tumor
Very rare malignant tumor derived from cytotrophoblasts at the placental implantation site.
Does not metastasize normally if they do there is poor prognosis
Rare
No HCG as there are no syncitiotrophoblasts
What is the clinical presentation of PSTT
Chronic persistent irregular bleeding weeks to years after pregnancy
May note an enlarged uterus in examination
How is PSTT diagnosed and treated?
DIAGNOSIS
Pelvic U/S
HCG may be drawn to rule out choriocarinoma
HCG usually less than 100mIU/ml
TREATMENT
hysterectomy is the treatment of choice followed by chemotherapy using EMA/CO (etoposide methotrexate actonimycin D cyclophosphamide and vincristine aka onco….)
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