GTD

Question 1

abnormal conceptions with excessive placental and little/no fetal development

Answer 1

hydatidiform moles

Question 2

most common karyotype for h mole

Answer 2

46xx (androgenic diploidy, one sperm or 2 sperms)

Question 3

most common pathogenesis for h mole

Answer 3

endoreduplication: empty ovum is fertilized by haploid sperm that endoreduplicates to make a homozygous complete mole

Question 4

alternate pathogenesis for complete h mole

Answer 4

dispermy: empty ovum is fertilized by two haploid sperms giving to a heterozygous complete mole

Question 5

h mole pattern on uts

Answer 5

snowstorm pattern

Question 6

histopathologic appearance of h mole

Answer 6

severe trophoblastic proliferation cauing elevated bhcg

Question 7

physiologic effects of elevated bhcg titer

Answer 7

• corpus size is larger than aog
• vaginal bleeding
• presence of theca lutein cysts
• presence of medical problems (preeclampsia, anemia, hyperthyroid, pulmo embolism causing rds)

Question 8

most common pathogenesis in partial hm

Answer 8

dispermy on non-empty ovum = triploid partial mole (69xxy, 69xxx, 69xyy)

Question 9

tvuts appearance

Answer 9

baby with many abnormalities or no baby (misdiagnosed as missed abortion)

Question 10

histopath of phm

Answer 10

markedly cystic villi and normal sized villi
fetal components and rbc are present
less elevated bhcg

Question 11

effects of elevated bhcg in phm

Answer 11

vaginal bleeding
corpus similar/smaller than aog
theca lutein cysts and associated medical problems

Question 12

t/f management is different for the two h moles

Answer 12

false, management is similar

Question 13

principles of h mole management

Answer 13

recognize and manage associated medical conditions
evacuate promptly and appropriately
identify patients at high risk for gtn
regular post-evan bhcg surveillance

Question 14

medical complications that must be treated first

Answer 14

anemia
hyperemesis gravidarum
respiratory insufficiency
dic
preeclampsia
hyperthyroidism

Question 15

t/f in patients with molar pregnancy, even if they present with elevated bp and proteinuria in the first trimester, then diagnose with pre-eclampsia

Answer 15

true

Question 16

common presenting symptoms of hyperthyroidism in h mole

Answer 16

thyroid enlargement and tachycardia

Question 17

possible evacuation methods for molar products

Answer 17

hysterectomy if family is completed

suction curettage

Question 18

t/f medical induction can be done to evacuate molar products

Answer 18

FALSE, causes more bleeding and higher risk for gtns

Question 19

management procedures for closed cervix, pre-evacuation

Answer 19

mechanical dilators and hegar dilators prior to curretage

Question 20

t/f using prostaglanding and pre-evacuation oxytocin is NOT RECOMMENDED prior to evacuation

Answer 20

true

Question 21

t/f theca lutein cysts indicate oophorectomy

Answer 21

false, don’t do anything they will regress in 8 weeks

only indication: with torsion, rupture, or necrosis

Question 22

confirmatory tests for h mole classification

Answer 22

immunostain p57kip2
cytogenetic studies (flow cytometry or karyotyping)

Question 23

risk of malignant degeneration of h mole

Answer 23

complete: 15-25%

partial 0.5-4%

Question 24

how to decrease risk for gtn

Answer 24

chemoprophylaxis with methotrexate

hcg surveillance

Question 25

indications for chemoprophylaxis

Answer 25

- >40 yo - uterine size 6+ weeks larger than aog - theca lutein cyst of 6+ cm - medical complications - bhcg 100,000+ mlu/ml - recurrent h mole - h mole with normal twin fetus - poor follow up

Question 26

contraindications for chemoprophylaxis

Answer 26

``` hgb <100 mg/dl or hct <0.3 wbc <3,000 or >10,000 platelet <100,000 neutrophils (ANC) <1.5 active infection abnormal renal/liver function ```

Question 27

process of bhcg monitoring

Answer 27

1 week after evacuation every 2 weeks until 3 normal titers every month for 6 months no pregnancy

Question 28

preferred contraceptive after h mole

Answer 28

barrier: not really progestins: very, irregular bleeding combined ocp!!

Question 29

t/f iuds can cause heavy menstrual bleeding which can confuse the monitoring after h mole

Answer 29

true

Question 30

t/f ocps suppress endogenous FSH

Answer 30

false, LH which has similar structure to bchg

Question 31

when to allow pregnancy after h mole

Answer 31

after 6 mos of normal serum bhcg level

Question 32

work-ups during pregnancy after h mole

Answer 32

perform early uts submit placenta for histopath monitor bhcg 6 weeks postpartum

Question 33

when to refer for post molar gtn

Answer 33

rise in bhcg of 10%+ plateauing for bhcg values after evacuation presence of metastasis at any site

Question 34

risk factors for gtn

Answer 34

major risk factor is antecedent pregnancy (h mole is associated with 50% of gtns) asians

Question 35

history of gtn patient

Answer 35

previous h mole vaginal bleeding and anemia s/sx of metastasis

Question 36

t/f you can do biopsy if you find a vaginal mass in px suspected with gtn

Answer 36

FALSE, DO NOT PERFORM BIOPSY IT WILL CAUSE BLEEDING

Question 37

supporting evidence of gtn with clinical diagnosis

Answer 37

sonographic picture and elevated bhcg titer

Question 38

t/f chest ct scan can detect occult metastases in the presence of normal cxr

Answer 38

true

Question 39

t/f chest ct is used for monitoring and staging, not for risk score assessment

Answer 39

true

Question 40

indications for brain ct

Answer 40

neuro s/sx | all px with pulmonary metastases having aggregate diameter of 3+ cm

Question 41

FIGO anatomic staging

Answer 41

``` I = uterus II = outside uterus but in pelvis III = pulmonary metastasis IV = metastases to the other sites ```

Question 42

t/f histopath is needed to start gtn treatment

Answer 42

false

Question 43

t/f it's possible to treat gtn with chemo alone

Answer 43

true

Question 44

treatments for gtn

Answer 44

nonmetastatic or metastatic low-risk: single agent methotrexate or actinomycin metastatic high risk: emaco regimen

Question 45

when is consolidation therapy done

Answer 45

when patient reaches normal hcg titers <5

Question 46

patient is cured of gtn when

Answer 46

3 consecutive normal serum bhcg levels

Question 47

hcg monthly monitoring

Answer 47

``` monthly for first 6 mos every 2 mos for next 6 mos every 3 mos for 1 year evey 6 mos after lifetime monitoring ``` no pregnancy for first 2 years

Question 48

complications for gtn

Answer 48

early menopause secondary malignancies (etoposide) av malformation in uterus

Question 49

clinical presentation of pstt/ett

Answer 49

irregular uterine bleeding distant from preceding non-molar gestation

Question 50

diagnosis for pstt/ett

Answer 50

histopath pstt: implantation type intermediate trophoblasts ett: chorionic type intermediate trophoblasts

Question 51

management of pstt/ett

Answer 51

hysterectomy, resistant to chemo