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Gestational Trophoblastic Diseases (GTD) - 090205

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26 views19 pages

Gestational Trophoblastic Diseases (GTD) - 090205

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g60635165
Copyright
© © All Rights Reserved
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GESTATIONAL

TROPHOBLASTI
C DISEASES
(GTD)
By: Hon Dr. Joe Akabuike
OUTLINE
 Introduction
 Epidemiology / risk factors
 Clinical features
 Hydatidiform mole
 Invasive mole
 Choriocarcinoma
INTRODUCTION
 GTD is defined as abnormal trophoblastic
proliferation originating from placenta
trophoblast
 Runs a spectrum from a benign hydatidiform
mole to highly malignant choriocarcinoma
 In-between is invasive mole
 Unique and normally developed from aberrant
fertilization
 The first solid tumour that has proven to be
highly curative
 They elaborate a unique and characteristic
tumour marker - human chronic
gonadotropin G(hcg)
EPIDEMIOLOGY
 Incidence of GTD varies due to challenges
in diagnosis (most are missed as
abortion)
 Incidence of complete mole 1:1000-2000
pregnancies
 Partial mole 1:700 pregnancies
 Majority of complete and partial mole
abort spontaneously during the first
trimester of pregnancy (2% of all
miscarriages)
 Incidence of choriocarcinoma 1:10,000-
1:50,000
RISK FACTORS
 Increased maternal age
 Previous Hx of molar pregnancy
 Women with blood group A has greater
risk than blood group O
CLINICAL FEATURES
• Abnormal vagina bleeding
• Uterine enlargement greater than gestational
age
• Abnormal high level of hcg
• Associated medical complications (pregnancy
induced hypertension, hyperthyroidism,
hyperemesis gravidarium , anaemia, ovarian
theca lutein cysts)
• Accidents to ovarian cysts (rupture, torsion and
bleeding)
• Women with choriocarcinoma can present with
dyspnoea, neurological symptoms, abdominal
pain a few weeks to several years after their
last pregnancy
HYDATIDIFORM MOLE
 Most common form of GTD
 Usually benign in nature
 Incidence is higher in woman younger than
20 and older than 40 years
 More in nullipara and in women of low social
economic status
 Poor diet (decrease in protein, folic acid,
carotene)
 More in women of blood group A
 Blood group AB tend to have worse prognosis
 Two distinct forms exist (complete and partial
mole)
COMPLETE MOLE (GROSS
ANATOMY)
 Resembles bunches of grape like
vesicles, pearly white in colour
 Vesicles vary in size from a few
millimeters to up to 2cm to 3cm in
diameter and attached to the main stalk
by a thin pedicles
 The fetus, amniotic sac and placenta are
conspicuously absent
COMPLETE MOLE
(HISTOLOGY)
 Hydropic degeneration and swelling of
villous stroma
 Absence of villous blood vessels
 Proliferation of the trophoblastic
epithelium
 The villous structure is preserved and
identifiable (Benign nature)
PARTIAL MOLE
 May resemble a normal placenta but
contains a few vesicle
 A fetus or fetal part is identifiable
 In a set of twins, one may be mole and
the other normal fetus
 Most often the fetus are malformed and
dies en-uteri
 A case of live birth following partial mole
has been reported
DIFFERENCE BETWEEN
COMPLETE AND PARTIAL MOLE
Complete Partial

Karyotype Diploid (46xx or 46 xy) Triploid (69xxx or


69xxy )
Placenta villi Diffusely hydrophic Focally hydrophic

Trophoblasts Diffuses hyperplasia Mild focal

Fetal parts Nil present

Fetal RBC Nil present

Frequency of classical common rare


symptoms
Risk of persistent II (b) 20-30 % < 5%
 Diagrams
a) Normal placenta
b) Complete mole
c) Partial mole
MANAGEMENT OF
HYDATIDIFORM MOLE
 History, physical examination,
investigation, treatment
 History of amenorrhea, vaginal bleeding,
symphysio-fundal
height >> than gestational age
 Hyperemesis gravidarium, PIH
 Astronomical high level of hcg
 Ultrasound showing snow storm
appearance in the uterine cavity or
classical vesicles using high resolution
scan
TREATMENT
 Stabilize patient (IV fluid, blood transfusion)
 Surgical evacuation using suction machine (no
10-12 Karman canula)
 Medical induction : not advocated due to fear
of haemorrhage
 Hysterectomy especially in women that have
completed pregnancy
 Medical termination can be used in partial mole
 Follow up with hcg assay to rule out persistent
mole and choriocarcinoma
 Barrier contraception for at least one year
 Risk of malignant transformation is 3%
INVASIVE MOLE
 Also called persistent mole
 Presents with signs and symptoms
between hydatidiform mole and
choriocarcinoma
 Shows high level of hCg
 Can manifest with metastasis in the
brain or liver
TREATMENT

Chemotherapy
CHORIOCARCINOMA
 50% follows evacuation of hydatidiform
mole
 25% follows abortion
 20% follow full term pregnancy
 5% extra-uterine pregnancy
 Can occur many years after normal
pregnancy
SYMPTOMS OF
CHORIOCARCINOMA
 Persistent or irregular uterine
haemorrhage following abortion, molar
pregnancy or normal delivery
 Offensive vaginal discharge
 Anaemia
 Uterine rupture
TREATMENT
 Chemotherapy
(100% cure)
 Methotrexate is
the drug of
choice

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