Gestational Trophoblastic Disease

Question 1

Give the 2 types of non-cancerous forms of GTD

Answer 1

1. Complete hydatidiform mole
   -Pregnancy formed form an empty ovum (no chromosomes) which gets fertilized by 2 sperms (dispermy). No maternal DNA, no fetal parts.
   -common in older women
   Risk of persistence and invasion higher than in partial hydatidiform
   -Bunch of grapes
2. Partial hydatidiform mole
   -Pregnancy that forms from two sperms fertilizing one egg. Triplody
   -fetus is abnormal (growth restriction, mental retardation, limb anomalies)

Question 2

give the 3 types of cancerous forms of GDT

Answer 2

1. Invasive hyadatidiform moles
   -Previously benign hyatidiform moles become malignant and move to other sites of the body
2. Choriocarcinoma
   -Very aggressive tumour occurring up to 15 years after the last pregnancy
3. Placenta site tumours
   - Tumours occurring many years after last pregnancy

Question 3

what is the main diagnostic feature of Persistent GTD

Answer 3

in a post molar pregnancy patient, the beta hCG does not regress but either rises or plateau

Question 4

outline the clinical presentation of hydatidiform molar pregnancy (5)

Answer 4

Hyperemesis gravidum
Uterus larger than dates
Vaginal bleeding
Lower abdominal pain
passing grape-like material
Preeclampsia
Thyrotoxicosis

Question 5

How is the diagnosis of a molar pregnancy made

Answer 5

Pelvic US:
-Snow storm in complete moles (grape-like material)
-Focally abnormal placenta in partial moles, fetal anomalies may be seen week13-20

Special investigations
-FBC, UEC,
-beta hCG
-Thyroid function
-Metastasis screen: CXR
-HIV counselling and testing
Cross match

NB beta HCG not helpful for diagnostic but is useful in evaluating regression or progression of disease

Question 6

Discuss management of a hydatidiform molar pregnancy

Answer 6

-Rescuscitation if necessary (correction of fluids and blood transfusion)
-Suction and curettage
-Products to be sent for histology for diagnosis
-F/U : Two weekly visits until beta hCG is negative, then monthly for 6 months.
Effective contraception mandatory, any pregnancy during f/u alters beta hCG results

NB to crossmatch and Rh, obtain consent for procedure and transfusion if needed. If pt Rh negative may need rhogam for future pregnancy

Question 7

What factors worsen the prognosis of Gestational Trophoblastic Neoplasia
(factors likely to make the tumour chemo-resistant) 6/8

Answer 7

-Age >40
-If prior pregnancy was a term delivery, worst prognosis than if it were a mole or miscarriage
-The longer the time between the last pregnancy and the now diagnosis, the worse the prognosis
-The higher the beta hCG the worser
-The size of the largest tumour
-The number of metastasis
-The site of metastasis -liver&brain worse than lung, spleen, kidney or GIT
-Previously failed chemo

Question 8

ouline thee clinical presentation of persistent GTD (3)

Answer 8

Mostly asymptomatic
Vaginal bleeding
Metastatic symptoms

Question 9

outline the clinical presentation of choriocarcinoma in GTD

Answer 9

75% present with non-gynae specialties with sx of metastasis

-Cerebral  convulsions or cerebrovascular accidents
-Pulmonary  haemoptysis + dyspnoea
-Vaginal  bleeding or a vaginal lesion (violet/blue in colour)
-Gastrointestinal  rectal bleeding
-Renal  haematuria
-Liver  abdominal distension, hepatomegaly
-Liver metastases carry a poor prognosis as they can rupture and the patient can die due to exsanguination

Question 10

is choriocarcinoma common in older or younger patients

Answer 10

younger

Question 11

what type of chemotherapy do you use for GTD Neoplasia

Answer 11

Single agent -Methotrexate or Actinomycin D
Multi-agent Chemo -EMA-CO (Etoposide, Actinomycin D, Methotrexate, Vincristine and Cyclophosphamide)

Low risk patients (Score 0-6) are treated with single agent
High Risk Patients (Score 6 and above) are treated with multi agent chemo

Question 12

how would you manage choriocarcinoma

Answer 12

Low-risk GTD receive single agent methotrexate or actinomycin-D

High-risk disease receive multiple agent chemotherapy which includes the following drugs: Etoposide, Actinomycin D, Methotrexate, Vincristine and Cyclophosphamide ( EMA-CO).

Chemotherapy is administered until B-HCG levels are less than 10 i.u and thereafter an additional 2-6 cycles are administered as “insurance”. Women must be given adequate contraception during treatment and advised not to fall pregnant for one year after treatment.

Question 13

discuss the management of GTD

Answer 13

Management of GTD:
* Suction curettage for a non-invasive molar pregnancy ( fertility preserved)
* Hysterectomy for disease confined to the uterus in women who have completed child-bearing
* Placental Site Trophoblastic Tumour
* Resection of isolated chemotherapy-resistant nodules, for example thoracotomy, craniotomy

Emergency surgery
* Hysterectomy for uncontrolled bleeding after evacuation or sepsis
* Oophorectomy for torsion of ovarian cysts.
* Craniotomy if intracerebral metastases bleed
* Laparotomy for bowel or urinary tract obstruction etc.