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Senior Obstetrics and Gynaecology > Gestational Trophoblastic Disease > Flashcards

Gestational Trophoblastic Disease Flashcards

1
Q

Definition?

A

Presence of abnormal tissue derived from fetal cells in the uterus

Hydropic chorionic villi

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2
Q

What are the types?

A

BENIGN 75%
90% complete molar
10% incomplete molar

MALIGNANT 25%
Persistent/ invasive mole 75%
Choriocarcinima 25%
Placental site trophoblastic tumor PSTT <1%

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3
Q

What are the risk factors for GTD?

A
  1. Previous gtd
  2. Extremes of age
  3. Nulliparity
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4
Q

How does a complete mole form?

A

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

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5
Q

How does partial molar pregnancy form?

A

Fertilization of egg that HAS genetic material by 2 sperm to give 69xxy

Triploidic

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6
Q

What hormones do HCG mimic?

A

TSH, LH, FSH as they share a subunits with hcg

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7
Q

What is the presentation in complete GTD?

A

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
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8
Q

What is the workup for complete GTD?

A
  1. Serum HCG quantitative

2. Pelvic U/S

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9
Q

What’s seen on U/S in complete GTD?

A

Grape like formations in the uterus as well as tou mat

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10
Q

What’s seen on complete U/S in GTD?

A

Grape like formations in the uterus as well as tou mat

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11
Q

Treatment of benign GTD (complete and incomplete) ?

A

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

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12
Q

What do we do at follow up for complete and partial GTD after treatment?

A
  1. Quantitative HCG 48 hours post D and C
  2. Serial HCGs weekly until levels are normal for 3 consecutive weeks
  3. 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

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13
Q

How long does it take for HCG levels to normalize in each type of molar pregnancy?

A

NORMAL PREGNANCY LOSS - 4 WEEKS
PARTIAL MOLAR POST D&C - 8 WEEKS
COMPLETE MOLAR POST D&C - 14 WEEKS

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14
Q

If after D&C the HCG is decreasing then plateaus and then begins to rise again what does this mean?

A

Means she has a persistent mole and we consider that malignant GTD

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15
Q

Define partial molar pregnancy.

A

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

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16
Q

What is presentation of partial molar pregnancy

A

Usually spontaneous abortion around late first to early second trimester

Examination is typically unremarkable (may find SGA)

17
Q

What is the workup for partial molar pregnancy?

A

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

18
Q

After what events does malignant GTD normally occur?

A

25% occur after these events

  1. Molar pregnancy (usually persistent/invasive GTD)
  2. Miscarriage
  3. Ectopic pregnancy
  4. Normal pregnancy (usually choriocarcinoma)
  5. Elective abortion
19
Q

Outline the staging of malignant molar pregnancy.

A

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

20
Q

Discuss a persistent invasive mole.

A

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

21
Q

What is the treatment for persistent invasive mole?

A

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)

22
Q

What is the follow up for persistent invasive mole?

A

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

23
Q

What is a choriocarcinoma?

A

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

24
Q

His does choriocarcinoma present?

A

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
  • **
25
Q

How is choriocarcinoma diagnosed?

A

SONOGRAPHY - vascular tumor
HCG levels - elevated as syncitiotrophoblasts are present producing excess HCG
MRI OR CT- if metastatic disease is suspected

26
Q

How is choriocarcinoma treated?

A

Stage 1 methotrexate

All other stages 3 medicine regimen and all other treatment tenets the same as invasive mole

27
Q

What is PSTT? Placental site trophoblastic tumor

A

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

28
Q

What is the clinical presentation of PSTT

A

Chronic persistent irregular bleeding weeks to years after pregnancy

May note an enlarged uterus in examination

29
Q

How is PSTT diagnosed and treated?

A

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….)

30
Q

Hg

A

Jhv

31
Q

Tf

A

Hg

Senior Obstetrics and Gynaecology (11 decks)

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