GTD

Question 1

Types of GTD

Answer 1

Choriocarcioma
Molar pregnancy
Partial mole
Placental site strophoblastic tumour (PSTT)

Question 2

Complete mole pathophysiology

Answer 2

Usually arise following duplication of a single sperm following fertilization of an empty ovum (75-80%)
20-25% dispermic fertilization of an empty ovum

Question 3

Partial mole

Answer 3

90% triploid
Two sets of paternal haploid genes and one set of maternal haploid genes
Usually dispermic fertilization of an ovum
Usually evidence of a fetus or fetal blood cells

Question 4

Incidence GTD

Answer 4

1/714
Complete mole 1:1000
Partial 3:1000

Question 5

Presentation of mole

Answer 5

Irregular vaginal bleeding
HG
Excessive uterine enlargement
Early failed pregnancy

Rarer:
Hypothyroidism
Early onset PET
ARFailure - usually due to Mets

Question 6

Treatment of mole

Answer 6

Suction curettage
Urinary preg test should be performed 3 weeks after medical management of failed pregnancy if products of conception are not sent for histology
Don’t use oxytocic infusions

Question 7

Which women should be investigated for persistent GTN after a non-molar pregnancy

Answer 7

Any woman who develops persistent vaginal leading after a pregnancy event is at risk of having GTN
Need urine preg test

Question 8

Follow up of GTD

Answer 8

Hcg normal within 56 days -> 6 months
Hcg not normal by 56 days, then 6 months after this has normalised
Need follow up after any future pregnancy (test hcg 6-8 weeks PP)

Question 9

Treatment for GTN

Answer 9

Chemo for complete mole 15%, 0.5% partial mole
Low risk - methotrexate and folinic acid
High risk multi agent
Cure rate LR 100%, HR 95%

Question 10

Long term outcomes

Answer 10

Earlier menopause

If have multi-agent chemo, may have increased risk of secondary cancers

Question 11

Contraception following dx of GTD

Answer 11

Barrier only until hcg normal
Hcg normal - COC can be used
NO intrauterine devices until hcg normal - increased risk of perforation

Question 12

Recurrent complete molar pregnancy genetic mutation

Answer 12

Autosomal recessively inherited NLRP7 on chromosome 19q

Question 13

Origin of mole

Answer 13

Varying degrees of trophoblastic proliferation (cytotrophoblast and syncytiotrophoblast)
Vesicular swelling of placental villi (villous hydrops)

Question 14

Risk factors molar pregnancy

Answer 14

Asian
Advanced or very young maternal age
Previous molar pregnancy
Increased risk malignant transformation if using OCP while hcg levels elevated
Familial -chromosome 19q-NLRP7

Question 15

Histopathology

Answer 15

Complete: diffuse villous hydrops, diffuse trophoblast hyperplasia; macroscopic:cystic villi=clusters of grapes

Partial: focal villous hydrops with scattered abnormally sized/scalloped villi, focal trophoblastic hyperplasia, trophoblastic pseudoinclinations, identifiable fetal tissues

Question 16

Risk of recurrence

Answer 16

1 mole 2%

2 20%

Question 17

USS appearance of CHM

Answer 17

Placental mass containing multiple echoes (snowstorm appearance) without an associated embryo and bilateral ovarian thecal luteal cysts

40-60%accuracy USS dx

Question 18

Work up required before chemotherapy

Answer 18

Clinical assessment
CNS assessment
Baseline hcg
TFTs
U/Es
LFTs
FBC
CXR
Pelvic US
Review of histopathology

Question 19

Choriocarcinoma

Answer 19

Hcg-secreting tumour

3% of molar pregnancies

Question 20

Choriocarcinoma pathology

Answer 20

Large haemorrhagic mass
Abnormal trophoblastic hyperplasia and anaplasia with the absence of chorionic villi, haemorrhage and necrosis, and with direct invasion into the myometrium and venous sinuses
Mets spread via vessels

Question 21

Placental site trophoblastic tumour

Answer 21

Mostly mononuclear intermediate trophoblast and syncytial elements without chorionic villi, infiltrating in sheets between myometrial fibers
Usually from non-molar pregnancies
Produce small amounts of hcg and human placental lactogen
Usually lymphatic spread
Treatment is usually hysterectomy and pelvic lymphadenectomy

Question 22

Invasive mole

Answer 22

10% of moles
15% met to lung and vagina
Usually diagnosed clinically