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GTD

GTD

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Published by: Mohd Helmy on Jan 01, 2013
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01/08/2014

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Clinical Features

1. Bleeding (may vary from spotting to profuse hemorrhage, women may bleed intermittently for weeks and even months, At times there may be considerable hemorrhage concealed within the uterus. Iron-deficiency anemia is common) 2. Uterine Size (The growing uterus often enlarges more rapidly than usual, exceeding in about half of cases that expected from the gestational age) 3. Fetal Activity (uterus is enlarged sufficiently to extend well above the symphysis, typically no fetal heart motion is detected) 4. Gestational Hypertension (Because hypertension caused by pregnancy is rarely seen before 24 weeks, preeclampsia that develops before this gestational age may be from hydatidiform mole or extensive molar degeneration)

5. Hyperemesis (nausea and vomiting may develop) 6. Thyrotoxicosis (Plasma thyroxine often elevated, but clinically apparent hyperthyroidism is unusual) 7. Embolization (Variable amounts of trophoblastic cells with or without villous stroma escape from the uterus into the venous outflow at the time of molar evacuation. The volume may be such as to produce signs and symptoms of acute pulmonary embolism or edema.)

Diagnosis
1. 2. 3. 4. 5. History Clinical examination Ultrasound examination Serum hCG levels Histopathological examination

• Diagnosis: – Ultrasonography: * The diagnosis of molar pregnancy is nearly always made by ultrasonography
Complete mole
•The classical finding is a “snow storm" pattern •Theca lutein cysts are frequent findings on ultrasound

The snow storm appearance of complete hydatidiform mole

Theca lutein cysts, a frequent finding on ultrasound

• Diagnosis: – Ultrasonography:
Abnormal gestational sac The classic vesicular sonographic findings of a complete mole are usually not seen Focal sonographic cystic changes and/or hydropic changes in the placenta are significantly associated with the diagnosis of a partial molar pregnancy

Partial mole

• Diagnosis: – Serum hCG levels: • Serum hCG levels of greater than 100000 mIU/ml associated with absent fetal heart beat indicate a diagnosis of complete hydatidiform moles

• Serum hCG level decreases quickly if the patient has an abortion, but it does not in molar pregnancy

• Diagnosis: – Histopathological examination: • It should always be done as far as possible and samples should be kept for DNA analysis for a final diagnosis when histology can not differentiate molar pregnancy from abortion

Table3: Pathological features of complete and partial hydatidiform mole
Complete Mole
Macroscopically
A mass of large, edematous villi that are diffusely distributed, typically described as resembling a cluster of grapes

Partial Mole
The placental tissue is less bulky A few enlarged villi with a focal distribution A fetus may be identified grossly that often has multiple congenital anomalies including syndactyly of the fingers & toes

The grape like vesicles in gross appearance

Management:

1

Complete history and physical examination

2

Investigations

3

Medical and surgical care

• Management: – History and physical examination: • Should aim to rule out the classic symptoms and signs that would lead to a diagnosis of: –severe anemia –dehydration –preeclampsia –thyrotoxicosis The patient should be stabilized hemodynamically

• Management:
– Investigations:
• Laboratory:
     Pre-evacuation hCG Complete blood count Electrolytes, BUN, creatinine Liver function tests Thyroid function tests

• Imaging:
 Pelvic ultrasound  Chest x-ray

• Management: – Medical care: • Correction of:  Anemia  Dehydration  Hyperthyroidism  hypertension

Plan of Management
There are 2 important basic lines : 1. Evacuation of the mole 2. Regular follow-up to detect persistent trophoblastic disease If both basic lines are done appropriately, mortality rates can be reduced to zero

For Complete mole is:
Suction curettage

For Partial mole: It depends on the fetal parts
1. Small fetal parts :Suction curettage 2. Large fetal parts: Medical (oxytocics) In partial mole the oxytocics is safe ,as the hazard to embolise and disseminate trophoblastic tissue is very low

Suction curettage

10mm

Canula up to a maximum of 12 mm, is usually sufficient to evacuate all complete molar pregnancies

Other seats of suction curettage

Suction curettage has been performed using 10mm canula under U/S guidance :
El SHERBINY HOSP

Canula

The Molar Content For Histopathological Examination

Prophylactic Chemotherapy
• Prophylactic Chemotherapy: The long-term prognosis for women with a H. mole is not improved with prophylactic chemotherapy. Because toxicity including death may be significant, it is not recommended routinely * • It may be useful in the high-risk cases when follow-up are unavailable or unreliable.

Hysterectomy
Hysterectomy may be preferred to suction
curettage at age ≥ 40 with no desire for further pregnancies especially with other risk factors for GTN as :  Large theca lutein cysts( >6 cm)  Significant uterine enlargement  Pretreatment βhCG ≥ 105. • Although hysterectomy does not eliminate possibility of GTN this, it markedly reduces its likelihood

The current FIGO criteria for diagnosis of post-molar GTD a) Four values or more of hCG documenting a plateau (±10% of hCG value) over at least 3 weeks: days 1, 7, 14, and 21. b) A rise of hCG of 10% or greater for 3 values or longer over at least 2 weeks; days 1,7 and 14. c) The presence of histologic choriocarcinoma.

d) Persistence of hCG 6 months after mole evacuation.

Follow-up evaluation of molar pregnancy
1. Prevent pregnancy for a minimum of 6 months using hormonal contraception. 2. Monitor serum hCG levels every 2 weeks. Serial measurement of serum hCG is important to detect trophoblastic neoplasia. 3. Chemotherapy is not indicated as long as these serum levels continue to regress. 4. Once the hCG level falls to a normal level, test the patient monthly for 6 months; then follow-up is discontinued and pregnancy allowed. 5. Estrogen-progestin contraceptives or depotmedroxyprogesterone usually are used to prevent a subsequent pregnancy during the period of surveillance.

References
1. Williams Obstetric 22nd Edition (2005) 2. RCOG (2010)

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