GTD.pptx

Gynecology -Final MBBS
Gestational Trophoblastic Disease

1. MOLAR PREGNANCIES Gaya 

2. Group of diseases caused by over growth of placenta Types Benign Hydatidiform mole - complete - Incomplete Malignant Gestational Choriocarcinoma Invasive mole ( chorioadenomadestruens ) Placental site trophoblastic tumor

3. Hydatidiform Mole Hydatidiform mole is a pregnancy characterized by vesicular swelling of placental villi (simple vesicular) Complete mole - only molar change Partial mole - part of the embryo is formed

4. In this condition the trophoblast shows marked proliferation and embryo dies at an early stage. The chorionic villi undergo hydropic degeneration and shows gross oedema.

5. C omplete mole Mass of tissue is completely made up of abnormal cells There is no fetus Arise from an empty ovum fertilized by a sperm, which then duplicates its own chromosomes Molar chromosomes- entirely paternal in origin Karyotype : 46XX (90% cases); 46XY(10%) mitochondrial DNA is maternal

6. Partial mole Mass may contain both abnormal cells and often a fetus that has severe defects . Chorionic villi of varying size with focal hydatidiform swelling Ovum fertilize with 2 sperms or 1 sperm which dupilcates Chromosomes are paternal and maternal, triploid 69,XXY 69,XXX or 69,XYY Identifiable fetal or embryonic tissues may present exhibits stigmata of triploidy : growth retardation, multiple congenital malformations

7. Symptoms and Signs Vaginal Bleeding: most common symptom in early pregnancy, they may even passed vesicles Hyperemesis gravidarum and : associated with elevated hCG levels Preeclampsia is observed in about 25% patient

8. Hyperthyroidism Develops almost exclusively in patient with very high hCG levels as hCG is thyroid stimulator Respiratory distress due to trophoblastic embolization (rarely) Theca luteal ovarian cyst Result from ovarian hyper stimulation by high serum hCG levels ,and undergo spontaneous regression after evacuation of the mole.

9. On Examination, When palpating uterine fundus Uterine size larger than the gestational age

10. Diagnosis Markedly elevated hCG levels- (these cyst developed due to high hCG levels and undergo spontaneous regression after evacuation of the mole)

11. USS USS shoes the typical “snow storm” appearance B/L theca –luteal cysts are usually presnent in majority of patient

12. Treatment When the diagnosis of hydatidiform mole is established , the molar pregnancy should be evacuated. Suction evacuation No medical termination due to risk of embolisation

13. Suction evacuation Oxytocin drip (20 units in 500ml of saline) should be started and once the uterine contraction are established patient is taken to OT Suction evacuation performed After that patient should be follow up with regular serum beta hCG levels

14. Patient should be seen weekly until serum beta hCG level normal and Also should be examined for vaginal nodules , regression of size of uterus , and disapear of theca luteal cyst. Thereafter patient is seen 2 weekly for another 3 month and monthly for another 9 month

15. During evacuation anticipate heavy bleeding DT * 5-6 units IV access with wide bore cannulise Perform by an experienced surgeon

16. Patient advice to Use barrier method OCP should be avoid until serum beta hCG levels become normal Progesterone preparation should be avoided as they cause irregular bleeding IUD also is best avoid

17. More than 80% moles are benign and outcome after treatment is very good /pregnancy should be avoid until 12 month 10-15% moles develop inti invasive moles. This condition is also known as persistence trophoblastic disease

18. Invasive mole Definition This term is applied to a molar pregnancy in which molar villi grow into the myometrium or its blood vessels, and may extend into the broad ligament and metastasize to the lungs, the vagina or the vulva. May cause to uterine perforation and gestational bleeding

19. Placental site tumours Very rare and can follow any type of pregnancy Composed only trophoblast cells They are syncytial cells- hCG are absent (level very low) Diagnosis – curettage Histological examination

20. Gestational Choriocarcinoma Characterized by abnormal trophoblastic hyperplasia and anaplasia , absence of chorionic villi (2-3%) A malignant form of GTD which can develop from hydatidiform mole Normal pregnancy following an miscarriage ectopic pregnancy . Tissue invade the wall and other organ

21. Following evacuation patient presenting with Continued irregular bleeding (ex-following miscarriage ) Both ovaries enlarge with theca lutein cyst formed as result of high level of chorionic gonadotrophins from tumor cells.

22. Theca lutein cyst is a type of bilateral functional ovarian cyst filled with clear, straw-colored fluid. To be classified a functional cyst, the mass must reach a diameter of at least three centimeters .

23. Metastatic Vagina is common site- it appears as purplish nodules that resemble haematomas Secondary spread to- lungs, liver, brain , and bone Lungs are common ( cannon ball lesions ) typically in choriocarcinoma

24. Treatment After evacuation of vesicular mole patient has to be followed up with serum beta hCG levels. If the level rising ,curettage of cavity is done for histological confirmation Chemotherapy done with METHOTREXATE and combination with ACTINOMYCIN D and other agents

25. Hysterectomy is not recommended routinely but should be considered in resistant disease and if there is sever hemorrhage