Gestational trophoblastic disease€¦ · Hydatidiform mole • Abnormal proliferation of placental trophoblastic cells tends to invade myometrium( villi) more than placenta 1. Complete

Gestational trophoblastic

disease

General Consideration

• Definition

proliferation abnormalities originating from trophoblast tissue of the placenta

• Classification :

benign (hydatidiform mole)

Malignant ( invasive mole, choriocarcinoma)

Hydatidiform mole

• Abnormal proliferation of placental trophoblastic cells tends to invade myometrium( villi) more than placenta

1. Complete mole 46 xx ( problem at time of conception)

2. Partial mole triploidy 69xxy (70%)or 69xyy(30%)

Morphology of complete mole

• Numerous odematous vesicle appear as bunch of small clear grape

no fetal tissue

• Risk of progress to persistant GTT 20%

Morphology of partial mole

• There is fetal & placental tissue ( pregnancy

is complicated by hypertension & IUGR)

Epidermiology of molar preg

• Geographical: asian

• Diet ( low protein, folic acid , carotane ),

low socioeconomic:

• Maternal age: (14-16years) , ( 40years )

• Blood group A married group O man

• Previous molar pregnancy ( 0.5-2%)

Manifestation

• 1. Clinical presentation

• Because of more proliferative activity so more

exaggeration of signs &symptoms

• . Vaginal bleeding &anaemia : 90%

• Anemia is due to bleeding ( IDA), folic acid

deficiency from( poor intake ,increase requirement

to folic acid )

• Hyperemsis gravidrum :25%, related to high

level of HCG

• Pre-eclampsia : before 24 weeks

• Thyroid dysfunction:2% ,molar preg.

Associated with high thyroxine

• Embolism: trophoblast tiss. Escape from

uterus through venous outflow lead to emboli

• DIC: emboli of troph. Tissue release

thromboplastin to circulation &stimulate

fibrin & PLT deposition ( coagulation

failure)

• 2. Abdominal examination

• A. uterine enlargement (large for date

uterus),doughy in consistancy ( no amniotic

fluid), no palpable fetal part or FH.

• B. Bilateral ovarian cyst( theca lutein cyst):

25-60% , prolong high level of HCG

stimulate ovaries. they regress after

evacuation of mole

• Diagnosis.

• U/S : echo of vesicle ( snow storm )

• Quantative measurement of HCG

treatment

• Aim: Elimination of all trophoblastic tissue

1. Proper preparation of patient prior evacuation by full investigation & chest x- ray

• Evacuation:

1. Suction curettage ( vacuum -60 mm) & send mat. For histopathology

2. uterine stimulate ( pGE2, oxytocin)

3. Hysterectomy , if patient 40 years& complete her family.

• Follow up:

• 1. serial quanatative HCG: ( 48 hr. &then

every 1 wk ) complete elimination 8-10 wk ,

until 3 consecutive weeks are normal then do

monthly for 6 month ( partial) & for 1 year to

complete mole.

• 2. pelvic examination: monthly

• To rule out any vaginal or vulval metastasis

• Size of uterus ,presence ovarian cysts &size

• 3. contraception: for at least 1 year ,barrier

method is the best, medroxy progesterone

inj. , low dose estrogen occp ( E = 30 micro

g).

• 4- chemotherapy: indication

• Raised HCG level 6 months after

evacuation

• HCG plateau in 3 consecutive serum

sample

o HCG more than 20.000 IU after 4 weeks

after evacuation

o Rising HCG in 2 consecutive serum sample

o Heavy vaginal bleeding or GI, intraperitonal

bleeding

o Pulmonary, vulval or vaginal metastasis

unless HCG level is falling

• Brain, liver, GI metastasis or lung

metastasis more than 2 cm on cxR

• Histological evidence of choriocarcinoma

• Complication of molar pregnancy

• Immediate

• Massive bleeding

• Sepsis

• Severe PE

• Remote ( metastasis & malignant 20% of

complete mole develop to persistant GTT

&4% partial)

• Persistant gestational trophoblastic

disease

• Non metastatic (invasive mole) 15% after

molar preg.

• Metastatic (distant) 5%

• Incidence& epidemiology :

• geographical:asia

• Age : in old is more

• Parity: in high parity

• Socioeconomic : in low

• Antecedent preg,: molar 50%, abortion

25%,normal term preg 25%.

• Maternal blood gr: gr.A high

• Clinical features:

• Vaginal bleeding

• Amenorrhea: producing HCG from distant

tumour metastasis

• Vaginal nodule or abdominal swelling

• Pulmonary metastasis;( dyspnea,

hemoptysis)

Staging: no. of factors influence

prognosis of persistant GTT

• Level of HCG: if it is high 100.000IU before Rx

means worse prognosis

• Metastasis: site (brain, liver) , number, size of

largest mass

• Antecedent preg: term preg is worse

• Preg/ Rx interval : prolong interval (4 months)

bad prognosis

• Previous unsuccessful chemo therapy : bad

( drug resistant , accumlating drug toxicity

Age : more than 40 yr ( bad)

Parity : high parity ( bad)

Each of the following prognostic factor is given

score ranging from ( 0-4 )

4 2 1 0 score - - more than

40

Less

than40

age

- Term abortion mole Antec

edent

preg Brain

liver

GIT Spleen

kidney

lung Site of

metastasi

s

More than

8

5-8 1-4 number

According to this score we

divide patients to

• Low risk patient :score less than or equal 6

• High risk patient : score more than or

equal 7

• Treatment:

• Chemotherapy

• Surgical

• Follow up

Low risk patients_ survival rate

100% • Methotrexate( drug of choice) bec.

Simplicity& low toxicity ( available

antidote)

• Before give chemotherapy : we should send

pat .to full Ix CBC ( WBC,PLT,Hb) LFT,

RFT ,CXR.

• It is given parentally IM/ IV

• Excreted in urine , contraindication renal

failure

methotrexate

• Methotrexate is given in alternative day

with folinic acid

• During period of therapy ,we should

montering HCG ( 2t/wk) ,WBC/ daily, ( less

than 1000 stop it), PLT/ daily ( less than

50.000 stop it)

Toxicity of methotrexate

• Mylo suppression( thrombo- cytopnea,

granulocytopnea)

• Mucus membrane inflammation( stomatitis,

conjuctivitis, vaginitis)

• Skin rash

• Nephrotoxicity

• heptotoxicity

methotrexate • After 8 days coarse of chemtherapy , 1

week rest & then 2nd coarse of Rx

• We need 2-4 courses to reach undetected

level of HCG

• 2-3 extra courses of treatment is needed (

bec. Approx. 100.000 of trophoblastic cell

may escape & undetected by HCG).

• Actinomycin (I.m for 5 days)

High risk patient/ EMA/CO chem

• D1( etoposide, methotrexate, actinomycin)

• D2( etoposide , folinic acid, actinomycin)

• 2nd wk ( D8) vincristine / cyclophosphamide

Surgical treatment

• Uterine perforation by invasive mole

• Uncontrol uterine bleeding

• Drug resistance focus ( HCG is high un

stead of chemotherapy or focal lesion

increase or plateau in size)

• Age is more than 40 years & complete her

family

Follow up

• Aim: to detect remission or relapse

• Monthly HCG in first year. Then yearly in

the next 5 years.

Thank you