Gestational Trophoblastic Disease

Question 1

What comes under gestational trophoblastic disease

Answer 1

Covers spectrum caused by Placental Overgrowth; Includes Hydatidiform Mole,
Choriocarcinoma, Invasive Mole and Placental Site Trophoblastic Tumour
o 0.6 – 2.3 per 1000; 50% follow Hydatidiform Mole, 25% Normal Pregnancy and 25%
Ectopic or Miscarriage

Question 2

Risk Factors for Molar Pregnancy

Answer 2

Extremes of Reproductive Age (Complete Moles only), Ethnicity (Double risk in East Asia, particularly Korea and Japan), Previous Molar (10-fold)

Question 3

Complete Mole

Answer 3

Diffuse Hydropic Villi
with Trophoblastic Hyperplasia; Diploid,
Derived from Sperm cells duplicating own chromosome following fertilisation of empty ovum
o Mostly 46XX with no evidence of foetal tissue

Question 4

Partial Mole

Answer 4

Consists of Hydropic and Normal Villi; Triploid (69 XXX, XXY, XYY) with one
maternal and two paternal haploid sets
Most occur after two sperms fertilising an ovum; Foetus may be present

Question 5

How do molar pregnancies present?

Answer 5

90% present with Irregular First-Trimester bleeding; 25% Uterus large-for-dates; Pain can occur from Ovarian Hyperstimulation Cysts due to high hCG levels, Exaggerated Pregnancy
Symptoms – Hyperemesis (10%), Hyperthyroid (5%), Early Pre-Eclampsia (5%)

Question 6

How to investigate molar pregnancy?

Answer 6

Ultrasound – ‘Snowstorm’ appearance of Mixed
Echogenicity, representing Hydropic Villi and
Intrauterine Haemorrhage; Large Luteal Cysts can
be seen due to high hCG levels
o In Partial Mole, Signs of Early Growth Restriction or Structural Abnormalities in
a possibly viable foetus may be seen

Question 7

Management of Hydatidiform Mole

Answer 7

Histological examination of POC to confirm diagnosis
Complete Mole: Surgical evacuation, oxytocin may be required after evacuation
Partial Mole: Surgical evacuation preferable

Question 8

Managing Persistent GTD

Answer 8

Some require chemotherapy
Indications include hCG > 20000 4 weeks post evacuation or rising hcg after evacuation in absence of new pregnancy, persistent symptoms

Question 9

Advice for Women

Answer 9

Women should be advised not to conceive until hCG normal for 6/12
o Little evidence for avoiding Hormonal Contraception or HRT while waiting for hCG to
return to normal
o hCG should be checked after 6 and 10 weeks of subsequent pregnancies ?Recurrence
• Specialist Follow up – Monitors hCG post-Evacuation and monitors for Persistence/Neoplasia

Question 10

Choriocarcinoma

Answer 10

Highly Malignant Tumour comprising Syncytio- and Cytotrophoblast with Myometrial Invasion; Local spread and Vascular Metastasis to lungs common
o 50% Preceded by Hydatidiform Mole, 40% by Normal Pregnancy, 5% by Miscarriage
or Ectopic, 5% Non-Gestational Origin

Question 11

Signs of choriocarcinoma

Answer 11

Vaginal Bleeding, Abdominal/Vaginal Swelling, Amenorrhoea, Intra-Abdominal Haemorrhage
(Due to Uterine Perforation by Tumour tissue)
o Metastatic Disease – Dyspnoea, Haemoptysis; Can also spread to Brain, Kidney, Liver or Spleen with site-specific symptoms

Question 12

Investigating choriocarcinoma

Answer 12

Serum hCG, Ultrasound, CXR, CT CAP

Question 13

How to treat choriocarcinoma

Answer 13

Treatment with Chemo based on FIGO Prognostic score based on Age, Tumour Burden, Interval and Type from Preceding Pregnancy (Longer interval and Term = Poorer prognosis) and Response to Previous Chemo
o Chemo continued until hCG normal for 6/52
o Low Risk – Methotrexate and Folinic Acid; near 100% cure
o High risk – Etoposide, Methotrexate, Dactinomycin; Alternate with Cyclophosphamide and Vincristine; Might require Salvage Surgery; 95% cure
▪ Risk of secondary cancers, Small increased risk of Miscarriage and Stillbirth
but no increase in Foetal Abnormalities