Gestational Trophoblastic disease

Question 1

Definition of gestational trophoblastic disease

Answer 1

A group of placental related trophoblastic disorders derived from a pregnancy

Question 2

Definition of gestational trophoblastic neoplasia

Answer 2

A term used to describe gestational trophoblastic disease requiring chemotherapy or excisional treatment because of persistence of HCG or presence of metastases

Question 3

Types of gestational trophoblastic disease

Answer 3

Hydatidiform mole (complete or partial)
Invasive mole
Gestational choriocarcinoma
Placental site trophoblastic tumour
Epitheloid trophoblast tumour

Question 4

Definition of hydatidiform mole

Answer 4

A premalignant disease originating in villous trophoblast characterised by abnormal chorionic villi with trophoblast hyperplasia as a consequence of over expression of paternal genes, occurring due to aberrant fertilisation of an oocyte

Question 5

Karyotype of complete v partial hydatidiform mole

Answer 5

Complete = diploid
Partial = triploid (or tetra or mosaic)

Question 6

Risk factors for hydatidiform mole

Answer 6

Prior molar pregnancy
Extremes of maternal age
Asian woman

History of spontaneous termination and infertility

Question 7

Cause of hydatidiform mole pregnancies

Answer 7

Complete: occurs when ovum containing no genetic material is fertilised by 1 sperm (haploid) that duplicates genome OR by dispermy

Partial: occurs when oocyte with genetic material is fertilised with two separate haploid sperm (failure of zona pellucida)

Question 8

What is the only gestational trophoblastic disease in which there is a presence of a foetus (incl. +/- foetal cardiac activity)

Answer 8

Partial hydatidiform mole

Question 9

Clinical presentation of hydatidiform mole

Answer 9

Symptoms of early pregnancy (missed period, positive pregnancy test, morning sickness, increased urination etc.)
Signs/symptoms of early pregnancy complications (PV bleeding, pelvic discomfort, hyperemesis gravidarum)
Significantly raised hCG ( hyperthyroidism, theca lutein cysts, early preeclampsia, anaemia)
Uterine size greater than GA
Unusually high bhCG

Question 10

Difference between complete and partial hydatidiform mole presentations

Answer 10

high bhCG more likely in complete (hyperemesis gravidarum, theca lutein cysts, hyperthyroidism)
Uterine size more likely to be larger than expected in complete mole

Question 11

Findings on TVUS of hydatidiform mole

Answer 11

Foetus only present in partial mole (+ placental abnormality - enlarged, swiss cheese, echogenic chorionic villi)
OR absence of foetus/embryo and amniotic fluid in complete
“swiss cheese” pattern - numerous discrete hypoechoic spaces
Ovarian theca lutein cysts (complete)

Question 12

Management of hydatidiform mole

Answer 12

Investigate for metastasis if indicated by symptoms
Suction curettage evacuation of uterus + histopathology of contents
Rh immunoglobulin if Rh -ve
Serial measurements of hCG (weekly until non-detectable for 3 weeks, if complete mole, continue monthly for 6 months post evacuation to ensure remains normal)

Question 13

Factors further increasing risk of development of GTN from GTD

Answer 13

Uterine size larger than dates pre-evacuation
hCG higher than 100,000
Bilateral theca lutein cysts

Question 14

Definition of an invasive mole

Answer 14

A type of gestational trophoblastic neoplasia that develops after a molar pregnancy and is characterised by oedematous chorionic villi with trophoblastic proliferation invading the myometrium

Question 15

Aetiology of gestational trophoblastic neoplasia

Answer 15

50% arise from molar pregnancies
25% arise from miscarriages or tubal pregnancies
25% arise from term or preterm pregnancies

Question 16

Most common sites of metastasis of invasive mole

Answer 16

lungs and vagina

Question 17

Presentation of gestational trophoblastic neoplasia

Answer 17

Raised hCG (sx of hyperthyroidism, ovarian theca lutein cysts, hyperemesis, preeclampsia)
Abnormal uterine bleeding
Pelvic discomfort
Symptoms of mets
- Pulm (SOB, CP, cough, haemoptysis)
- Vag (bleeding, d/c)
- CNS (headache, neuropathy, dizziness, speech, hemiparesis, nausea, visual)
- Hep (jaundice, pain)

Question 18

Management of gestational trophoblastic disease

Answer 18

Hysterectomy if confined to uterus and completed child bearing
Low risk (WHO risk less than 7) - MTX OR actinomycin
High risk 7+ or choriocarcinoma- EMACO (actinomycin, etoposide, MTX)
Advise not to conceive for 12 months after completing chemotherapy