Gestational Trophoblastic Disease Flashcards
What is Gestational trophoblastic disease (GTD)?
Abnormal proliferation of trophoblastic (placental) tissue
What are the categories of GTD?
Molar pregnancies (80%)
Persistent/invasive moles
Choriocarcinoma
Placental site trophoblastic tumors (arises from fetal tissue)
What do GTD tumors produce?
hCG
What is the treatment for GTD?
Chemotherapy (extremely sensitive)
What are the risk factors for GTD?
Extremes in age and prior history of GTD
Nulliparity
diet low in beta-carotene, folic acid, animal fat
OCP use
How do complete moles arise?
Fertilization of an enucleate ovum (empty egg) by one normal sperm which replicates itself
Chromosomal pattern of 46XX (all sperm derived)
What are the signs of complete mole?
Syncytiotrophoblastic proliferation leading to hydropic degeneration = grape-like vesicles in uterus without fetus
Very high hCG levels (>100,000) which has the same alpha subunit as FSH, LH, and TSH = large theca lutein cysts, hyperthyroidism, hyperemesis gravidarum, early preeclampsia (photophobia)
What is the most common presenting sign of molar pregnancy?
Irregular or heavy vaginal bleeding during early pregnancy
How is molar pregnancy diagnosed?
hCG > 100,000
pelvic ultrasound showing snowstorm pattern
pathologic exam of intrauterine tissue
What is the treatment for molar pregnancy?
Immediate removal of uterine contents (D&C)
baseline hCG
RhoGAM for all RH- patients
beta blockers and anti-hypertensives
type/screen for blood in case of heavy uterine bleeding
What is the average time to normalization of hCG levels post-evacuation?
14 weeks for complete
8 weeks for partial
What are you concerned with if hCG levels plateau or rise?
Persistent/invasive disease
What is a partial molar pregnancy?
Normal ovum fertilized by 2 sperm simultaneously = 69XXY
Presence of fetus
Why are hCG levels in partial molar pregnancy not elevated?
Proliferation of cytotrophoblastic tissue which does not produce hCG
What pattern can be seen on pelvic ultrasound with partial molar pregnancy?
Swiss-cheese appearance
What is important for patients to be on during follow-up of molar pregnancy?
Contraception because resolution is based on serial hCG monitoring
What is the staging for malignant GTD?
Stage I: confined to uterus
II: mets to pelvis or vagina
III: mets to lung
IV: distant mets
How is malignant GTD treated?
Extremely sensitive to chemotherapy
no surgery
What can be seen on pelvic ultrasound with persistent/invasive mole?
High vascular flow on doppler
What is choriocarcinoma?
Malignant necrotizing tumor, typically with preceding complete molar pregnancy (50%)
Pure epithelial tumor
What is the histologic pattern of choriocarcinoma?
Sheets of anaplastic cytotrophoblasts and syncytiotrophoblasts in the absence of chorionic villi
How does choriocarcinoma spread?
Hematogenously to lungs, vagina, pelvis, brain, liver, intestines, kidneys
What are the signs and symptoms of choriocarcinoma?
Late post-partum bleeding (>6-8 weeks), or irregular uterine bleeding years afterwards
Often presents with metastatic disease = resp distress, cough, dyspnea, hemoptysis, CNS symptoms, vaginal bleeding, etc
What is the nickname for choriocarcinoma?
The great imitator (because of mets)
