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My MRCOG Part 2 > Module 13 - Gestational Trophoblasic Disease > Flashcards

Module 13 - Gestational Trophoblasic Disease Flashcards

GTG 38

1
Q

What is the overall incidence of GTD?

A

1:714 pregnancies
(But <1:500 if <15 years
and 1:8 if >50 years).

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2
Q

GTD is pre-malignant. What conditions does this group include?

A

Complete molar
Incomplete molar

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3
Q

What is the pathophysiology of complete molar pregnancies?

A

DIPLOID
75% - sperm duplication in empty egg. 25% - 2 sperm in one egg.

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4
Q

What is the pathophysiology of partial molar pregnancies?

A

TRIPLOID
90% 2 sperm in 1 egg.

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5
Q

What differentiates complete from partial molar?

A

Complete - no foetal parts.

Partial has Foetal RBCs or feotal parts.

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6
Q

What are the clinical signs of GTD?

A

Irregular PVB
+UPT
very raised bHCG
US evidence
Enlarged uterus

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7
Q

What proportion of GTN present with irregular PVB?

A

60%

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8
Q

What is the sensitivity and PPV of US in complete molar pregnancies?

A

95% sensitivity
40% PPV

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9
Q

What are the US features are complete molar pregnancy?

A

5-7/40: polypoid mass
>8/40: thickened cystic appearance of villous tissue and no gestational sac (BUNCH OF GRAPES).

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10
Q

What is the sensitivity and PPV of US for partial molar?

A

Sensitivity 20%
PPV 20%

(but 40% if soft markers are also used).

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11
Q

What are the US features consistent with a partial molar pregnnacy?

A

Enlarged placenta.
Cystic changes in decidual reaction.
Empty sac.
Foetal RBCs or foetal parts.
>1:1.5 transverse to AP ratio of cystic spaces in placenta.

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12
Q

Do GTD patients need anti D after removal of pregnancy tissue?

A

Complete - no as there is no trophoblasic tissue.

Patial - yes. Give if suspected if hysto will take >72 hours.

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13
Q

Is cervical preparation safe pre SMM in GTD?

A

Yes.

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14
Q

What is the risk of retained POC after D&C vs MMM for GTD?

A

1% D&C
16% MMM

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15
Q

Are oxytotics safe after treatment for GTD?

A

NO!
Risk of systemic GTD spread via vascular system.

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16
Q

When should D&C be repeated after GTD treatment?

A

Represent with PVB and instability.
HCG<5000 (as 40% then avoid chemo).

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17
Q

What proportion of GTN is NOT recognised pre removal?

A

3%

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18
Q

When is histology required?

A

After all medical or surgical procedures if no foetal parts seen on USS (inc pole).
(except TOP).

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19
Q

Some women have fmailial high bHCG. What range would this expected to be in?

A

10 - 200
(regular cycles and can conceive)

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20
Q

What are the differentials for persistently mildly raised bHCG?

A
  1. Germ cell tumours
  2. Epithelial tumours (inc breast, bladder, lung, liver and colorectal)
  3. Pituitary hCG
  4. human anti-mouse antibodies.
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21
Q

HCG tests detect what types of HCG?

A
  1. Intact bHCG subunit
  2. Free bHCG subunit
  3. Nicked HCG
  4. hCG (b core) fragment.
22
Q

Why is there a worse prognosis if women are found to have GTN after a non molar pregnancy?

A

Present later
More advanced and more likely mets.

23
Q

What is the risk of GTN if bHCG normal at 8/52?

A

<1%

24
Q

Should vaginal lesions be biopsied if women present with irregular bleeding after non-molar pregnancy?

A

NO
Risk of major haemorrhage
leave them alone, could be GTN deposits.

25
Q

What FU is recommended for complete molar?

A

If bHCG normalised in >56 days, then FU for 6 months after tissue removal.

If bHCG normalised >56 days then FU for 6 months after bHCG normalised.

26
Q

What FU is recommended for partial molar?

A

Can stop follow up once 2 normal bHCGs 4 weeks apart.

27
Q

Ectopic molar tissue can be confused what?
How should this be managed?

A

Choriocarcinoma

Manage as per ectopics.

28
Q

What are the risks of:
1. fetal demise
2. PTL
3. PET
if there is a viable twin with co- existing molar?

A
  1. 40% fetal demise
  2. 36% PTL
  3. 4 - 20% PET
29
Q

In co-existing GTD/viable twins, what is the likely placental histology?

A

Mesenchymal hyperplasia.

30
Q

What is the risk of needing chemotherapy after GTN vs co-existing twin?

A

GTD 15%
Co-existing twin 1%

31
Q

What is the treatment for PSTT and ETT?

A

HYSTERECTOMY for local disease.
but intense chemo if mets or long time between pregnancy and diagnosis.

32
Q

What are the types of GTN?

A
  1. Invasive mole
  2. Choriocarcinoma
  3. PSTT (placental site trophoblastic tumour)
  4. ETT (epithelioid trophoblastic tumour).
33
Q

What is a PSN?
What are the 2 types?

A

Placental Site Nodule
Atypical and Typical types.

34
Q

Is typical PSN concerning?

A

No, this is benign and relatively common. No FU needed.

35
Q

Is atypical PSN concerning?

A

Yes. refer to GTD centre.
10-15% turn into PSTT or ETT.
Therefore need staging lap and hysterectomy.

36
Q

How is atypical PSN often identified?

A

endometrial biopsy for irregular PVB.

37
Q

What single dose chemotherapy agent is used to treat GTN?

A

Methotrexate.

38
Q

What chemotherapies might be used in multi-agent chemotherapy?

A

(Platanum based).
Methotrexate.
Dactinomycin
Etopiside
Cyclophosphamide
Vincristine

39
Q

What staging system is used for GTN?

A

FIGO 2000

40
Q

What is a low risk score for GTN?
What is the cure rate?
What chemotherapy regime us used?

A

6 or less
100% cure rate
Single dose chemotherapy

41
Q

What % of GTD is PSTT or ETT?

A

0.2%
but poor chemo response and likely lymph spread.

42
Q

What is the best prognostic factor for PSTT and ETT?

A

Stage 4 - 100% death

Also : Time since ante-descent pregnancy
<48 months - nearly all survive
>48 months - 100% death.

43
Q

How long after chemo treatment for GTN should a woman avoid conceiving?

A

1 year
(2% risk of teratogencity in that time and increased rate miscarriage)

44
Q

After next pregnancy, do women need a post natal bHCG?

A

Yes if had chemotherapy for GTN.

No if did not have chemotherapy for GTN.

45
Q

What is the risk of PTL in next pregnancy after GTD?
What is unusual about this risk?

A

25% risk
but ONLY in next pregnancy.

46
Q

What is the risk of stillbirth of conceive <12 months after GTD treatment?

A

0-2%

47
Q

What is the rate of successful future pregnancy after GTD treatment?

A

80% (for single and multi agent chemo)

48
Q

Should post chemo AMH be used to evaluate ovarian reserve?

A

No, because this doesn’t reflect the woman’s ability to conceive.

49
Q

Is it common for periods to stop during chemotherapy treatment?

A

Yes.

But generally return, unless intense high dose chemo then unlikely to regain ovarian function post treatment.

50
Q

FIGO Scoring Table for GTN

A

TABLE

My MRCOG Part 2 (37 decks)

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