Gestational trophoblastic diseases -OBG Nursing Rakhimol M R

Gestational trophoblastic diseases

1. GESTATIONAL TROPHOBLASTIC DISEASE

2. I t is defined as spectrum of disorder resulting from an abnormal placental growth and invasion.It is ranged from benign condition to the malignant . DEFENITION 2

3. the incidence of gestational trophoblastic disease varies dramatically in different regions of the world more common in south east Asia( Philippines, China, Indonesia). India- 1 in 400 pregnancies .Calculated Incidence of complete mole- 1 in 1945 pregnancies ,partial mole- 1 in 695 pregnancies. Age -CM most common at the extremes of reproductive age  epidemology 3

4. EXTREMES OF AGE(COMPLETE MOLE) H/O MOLAR PREGNANCY LOW SOCIOECONOMIC STATUS DIETARY DEFICIENCY OCP USE H/O OF SPONTANEOUS ABORTION OR INFERTILITY EXCESS IN MATERNAL BLOOD GROUP A /AB Risk factors 4

5. GTT BENIGN COMPLETE INCOMPLETE INVASIVE PSTT MALIGNANT Nbeame Job Title Name Job Title Name CLASSIFICATION 5 ETT CHORIO CARCINOMA

6. 6

7. PATHOPHYSIOLOGY 7

8. Trophoblastic proliferation Cystic swelling of chorionic villi ( HYDROPIC DEGENERATION) MARKED PROLIFERATION OF TROPHOBLAST ACCUMULATION OF FLUID & MATERNAL BLOOD IN THE STOMA DISTENTION OF VILLI SMALL VESICLES ABSENCE OF BLOOD VESSEL IN THE VILLI ABSORPTION AND EARLY DEATH OF EMBRYO 8

9. 9

10. BENIGN OR HYDTIDIFORM MOLE OR MOLAR PREGNANCY 10 DEFINITION It is a abnormal condition of placenta where there are partly degenerative and proliferative changes in the chorionic villi result in the formation of cluster of small cyst of varying size ( like bunch of grapes) aetiology of Hydatidiform mole is remains unclear, but it appears to be due to abnormal gametogenesis and fertilization.

11. 11

12. Complete mole 12 In a complete mole the mass of the tissue is completely made up of abnormal cells There is no foetus and nothing can find at the time of the first scan The fertilized egg has no maternal dna &instead has 2 sets of paternal dna

13. pathogenesis 13

14. PARTIAL mole 14 The fertilized egg contains the normal set of maternal dna but double the number of paternal dna, because of this embryo partially develops and doesn’t become a viable fetes.

15. PARTIAL mole 15

16. Add an Agenda Page Write an agenda here. Write an agenda here. Write an agenda here. 16

17. 17

18. Clinical features 18 Complete mole Most common in 1 st & 2 nd trimester Vaginal bleeding (White currant in red currant juice) Uterus is larger than pog f/o threatened abortion Hyper emesis Hypothyroidism Beta – hcg > 100000 miu /ml No foetal movements/ fhr

19. Clinical features 19 Features of pre- eclampsia Theca lutein ovarian cyst o/e Passage of grape like vesicle or spontaneous expulsion of entire mole Microscopic examination Bunch of grape due to villous swelling

20. Clinical features 20 Partial mole Late 1 st or 2 nd trimester Uterus is not enlarged more than pog Present as missed or incomplete abortion Hcg not more than 100000miu/l Microscopic examination Trophoblastic hyperplasia and nucleated rbcs of embryo in the villi

21. Add a Section Header And a subtitle

22. DIAGNOSIS 22

23. 23 History collection and physical examination CBC , ABO , Rh group Sonography X- Ray Histological examination Urine test ( HCG value increase more then 100,000 mIu / ml ) CT scan and MRI

24. 24

25. Write Your Topic or Idea Add a main point Elaborate on what you want to discuss. Add a main point Elaborate on what you want to discuss. 25

26. Write Your Topic or Idea Add a main point Elaborate on what you want to discuss. Add a main point Elaborate on what you want to discuss. Add a main point Elaborate on what you want to discuss. 26

27. MANAGEMENT 27

28. 28 TWO IMPORTANT BASE LINE EVACUATION OF THE MOLE REGULAR FOLLOW UP EVACUATION OF THE MOLE SUTION AND CURETTAGE MANAGEMENT OF ASSOCIAED FEATURES FOLLOW UP FOLLOW UP HCG :  weekly determination of B-HCG until these levels are normal for 3 consecutive weeks,foll0WEd by monthly values until normal for 6 consecutive months  Average time for first normal HCG post evacuation is 9 weeks,  non detectable HCG levels-risk of GTN is 0

29. 29 Contraception Should NOT conceive until follow up is complete. Use Barrier method until hCG revert to normal (OCPs may act as growth factor for trophoblastic tissue). Once hCG has normalized, the combined oral contraceptive pill may be used. IUCD should not be used until hCG levels are normal to reduce the risk of uterine perforation.

30. 30 Role of prophylactic chemotherapy It may be useful in the high-risk cases when follow up are unavailable or unreliable. HIGH RISK FACTORS:  hCG level >100,000 mIU /ml  Excessive uterine enlargement  Theca lutien cysts 6 cm in diameter

31. 31 Role of hysterectomy If the patient desires surgical sterilization, a hysterectomy may be performed with the mole in situ. Hysterectomy does not prevent metastasis; therefore, patients will require follow up with assessment of hCG levels. The ovaries may be preserved at the time of surgery, even in the presence of prominent theca luiten cysts.

32. . GESTATIONAL TROPHOPLASTIC NEOPLASIA  

33. GTN defines a heterogeneous group of lesions that represent an aberrant fertilization event. The pathogenesis is unique because the maternal tumor arises from fetal tissue. It is the most curable gynecologic malignancy. Malignant trophoblastic disease can exist in: Invasive mole ( = non – metastatic form). Choriocarcinoma .  Placental site trophoblastic tumor (PSTT). EpITHELOD TROPHOBLASTIC TUMOR

34. INVASIVE MOLE

35. Chorioadenoma destruens Most common Extensive local invasion- uterine perforation-intra abdominal bleeding -shock Excessive trophoblastic proliferation With preserved villous pattern The proliferative villi may invade the myomEtrIum , perimEtrIum ,broad ligament , or the vaginal wall. although there is rarely evidence of metastasis DIAGNOSIS –PERSISTENT VAGINAL BLEEDING & PAIN FOLLOWING EVACUATION OF HYDTIDIFORM MOLE. FOLLOW UP WITH SERIAL BETA HCG MANAGEMENT– AS PER SCORING AND SX

36. CHORIOCARCINOMA

37. 37

38. 38

39. 39

40. Gtn - figo staging 40

41. Prognostic scoring system 41

42. Prognostic scoring system 42

43. METHOTREXATE(1-1.5MG/KG)—1 ST LINE IM/IV DAY 1,3,5 &7 FOLIC ACID(.1-.15MG/KG)-----DAY 2,4,6,8 ACTINOMYCIN( 10-12MCG/KG) FOLLOW UP LOW RISK GTN 43

44. MULTI AGENT CT E-ECTOPOSIDE A-ACTINOMYCIN D M-METHOTREXATE C-CYCLOPHOSPHAMIDE O-ONCOVIN/VINCRYSTIN HIGH RISK GTN 44

45. MULTI AGENT CT E-ECTOPOSIDE A-ACTINOMYCIN D M-METHOTREXATE C-CYCLOPHOSPHAMIDE O-ONCOVIN/VINCRYSTIN HIGH RISK GTN 45

46. MANAGEMENT 46 1 ST CHEMOTHERAPY ASSESS FOR OTHER RESIDUAL DISEASE LUNGS MULTIPLE ORGAN ONE ORGAN UTERUS BRAIN CT

47. BETA HCG ASSAY EVERY 2WK NORMAL 2-3 CYCLE MONITOR HCG BETA HCG ASSAY EVERY MONTH FOR 24HRS FOLLOW UP 47

48. PTT 48

49. EXTREMELY RARE MIMICS PTT ETT 49

50. ROLE OF HYSTRECOMY

51. FUTURE CHILD BEARING

52. NURSING MANAGEMENT

53. THANK YOU

54. Name Title or Position Name Title or Position Name Title or Position Name Title or Position Add a Team Members Page Elaborate on what you want to discuss. 54