GESTATIONAL

TROPHOBLASTIC DISEASE
(GTD)
 DEFINITIONS

It is a spectrum of trophoblastic diseases that

includes:
• Complete molar pregnancy
• Partial molar pregnancies
• Invasive mole
• Choriocarcinoma
• Placental site trophoblastic tumor
The last 2 may follow abortion, ectopic or
normal pregnancy.
HYDATIDIFORM MOLE
(VESICULAR MOLE)
Joel Federico, RN, MAN
 DEFINITION
• Hydatidiform mole is a rare mass or growth that forms
inside the uterus at the beginning of pregnancy. It is a
type of gestational trophoblastic disease (GTD)
• The placental trophoblastic cells proliferate abnormally
• It is neoplastic proliferstion of the trophoblast in which
the terminal villi are transformed into vesicles filled
with clear viscid material
• Forms vesicular which is grape like on its appearances
 DEFINITION
• Hydatidiform moles are abnormal pregnancies
characterized histologically by
• Trophoblastic proliferation (Both syncitiotrophoblast &
cytotrophoblast)
• Edema of the villous stroma (Hydropic) .
• Based on the degree and extent of these tissue
changes, hydatidiform moles are categorized as either
• Complete hydatidiform mole.
• Partial hydatidiform mole.
 9

TYPES
There are two types:
1. Partial (incomplete) molar
pregnancy: there is an abnormal
growth of placenta and some fetal
development.
2. Complete molar pregnancy: there
is an abnormal placenta but no
fetus.
 10

TYPES
There are two types:
1. Partial (incomplete) molar
pregnancy: there is an abnormal
growth of placenta and some fetal
development.
2. Complete molar pregnancy: there
is an abnormal placenta but no
fetus.
 11

COMPLETE MOLE
• Most hydatidiform moles are complete
• Have a 46 xx karyotype
• Both of the x chromosomes are paternally derived
• It results from the fertilization of an „empty egg”
by haploid sperm 23x which then duplicates to
restore the diploid chromosomal complement
• Only a small percentage are 46 XY
• Complete molar pregnancy is only rarely
associated with a fetus, and this may represent a
form of twinning
 12

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COMPLETE MOLE
13

• Histopathologic findings associated

with a complete molar pregnancy
• Hydropic villi
• Absence of fetal blood vessels
• Hyperplasia of trophoblastic
tissue
• Invasive mole differs from
hydadtidiform mole only in its
propensity to invade locally and to
metastasize
 14

COMPLETE MOLE
COMPLETE MOLE
DIAGNOSTICS

• Serum β-human chorionic

gonadotropin (β-hcg) higher than
normal pregnancy values
• Ultrasonography
• Reveals a „snowstorm” pattern
• Chest film
 COMPLETE MOLE
PROGNOSIS
• Complete mole has the latent risk of local invasion or telemetastasis
• The high-risk factors includes
• β-HCG > IU/L
• Uterine size is obviously larger than that with the same gestational
time.
• The luteinizing cyst is > 6cm
• If > 40 years old, the risk of invasion and metastasis may be 37%, If >
50 years old, the risk of invasion and metastasis may be 56%.
• Repeated mole: the morbidity of invasion and metastasis increase 3~4
times
 17

PARTIAL MOLE

• Ultrasonography performed for other indications may

indicate possible molar degeneration of the placenta
associated with the developing fetus
• An amniocentesis should be performed to determine
whether karyotype of the coexisting fetus is normal
• Uterine size is usually normal or small for dates
• Preeclampsia usually occurs between 17 and 22
weeks (about 1 month later than with complete mole)
• Partial moles rarely metastasize, and only rarely is
there a need for chemotherapy
18
 19

PATHOGENESIS OF PARTIAL MOLE

HYDATIDIFORM MOLE
RISK FACTORS
• Hydatidiform mole results from overproduction of the tissue in that is supposed to
develop into the placenta
• Extremes of maternal age:
• Greater than 35 years old carries a five to ten-fold increased risk risk
• Early teenage years, usually less than 20 years old
• Previous molar pregnancy increases the risk 1% to 2% for future pregnancies
• Women with previous spontaneous abortions or infertilities
• Dietary factors including patients that have diets deficient in carotene (vitamin A
precursor) and animal fats
• Smoking
 21

HYDATIDIFORM MOLE
SYMPTOMS SYMPTOMS

• Bleeding in the first half • Preeclampsia

of pregnancy • Irritability
• Irregular bleeding • Dizziness
• Heavy vaginal • Photophobia
bleeding • Hyperthyroidism
• Lower abdominal pain • Nervousness
• Excessive nausea/ • Anorexia
hyperemesis • Tremors
gravidarum
 22

HYDATIDIFORM MOLE
SIGNS SIGNS
• Tachycardia • Enlarged uterus
• Tachypnea • 50% patients with molar
• Hypertension pregnancies
• Absent fetal heart • 25% have size compatible
tones (and fetal parts) and 25% have size smaller
• Grape-like vesicles of than gestational age
the mole may be • Ovarian enlargement by theca-
detected in the vagina lutein cyst
• Occurs in about 1/3of women
with molar pregnancies
HYDATIDIFORM MOLE
DIFFERENTIAL
DIAGNOSIS

• Multiple pregnancy.
• Hydatidiform mole
• .Threatened abortion.
• Ectopic pregnancy.
HYDATIDIFORM MOLE
TREATMENT
• Evacuation
• Suction evacuation followed by sharp curettage of the uterine cavity
• Regardless of the duration of pregnancy
• Intravenous oxytocin
• To help stimulate uterine contractions and reduce blood loss
• Most patient have an uncomplicated course in the postoperative
period
• Some require blood, fresh frozen plasma or platelet transfusion
• Rarely a patient can experience acute respiratory distress from
trophoblastic embolization or fluid overload
HYDATIDIFORM MOLE
FOLLOW UP

• For 6 months from the date of uterine evacuation.

• For 6 months from normalization of the β hCG level. B
• For 12 months from the date of uterine evacuation.
HYDATIDIFORM MOLE
CHEMOTHERAPY

• Prophylactic chemotherapy is not indicated, because

90% have spontaneus remissions.
• If the β-hcg levels plateau or rise at any time,
chemotherapy should be initiated
 HYDATIDIFORM MOLE
Post-evacuation Surveillance

• Why?
• To determine when pregnancy can be allowed
• To detect persistent trophoblastic disease (i.e.
GTN)
 HYDATIDIFORM MOLE
Post-evacuation Surveillance
• How?
A baseline serum β -hCG level is obtained within 48 hours after
evacuation.
• Levels are monitored every 1 to 2 weekswhile still elevated to detect
persistent trophoblastic disease (GTN).
• These levels should progressively fall to an undetectable level (<5
mu/ml).If symptoms are persistent, more frequent β hCG estimation
and U/S examination ± D&C are advised
HYDATIDIFORM MOLE
What Is Safe Contraception Following
GTD?
• Barrier methods until normal β hCG level.
• Once βhCG level have normalized:Combined oral
contraceptive (COC ) pill may be used.
• If oral COC was started before the diagnosis of GTD ,COC
can be continue as its potential to increase risk of GTN is
very low
• IUCD should not be used until β hCG levels are normal to
reduce uterine perforation.
 30

CHORIOCARCINOMA
CHORIOCARCINOMA
• The frankly malignant form of gestational trophoblastic disease
• Genetic analysis of choriocarcinomas usually reveals aneuploidy or
polyploidy
• Typical for anaplastic carcinomas
• Appears grossly as a vascular-appearing, irregular and „beefy” tumor
• Often growing through the uterine wall
• Metastatic lesions appear hemorrhagic and have consistency of
currant jelly
• Histological consist of sheets of malignant cytotrophoblast and
syncytiotrophoblast with no identifiable villi
CHORIOCARCINOMA
• 50%gestational choriocarcinoma result from
hydatidiform mole
• Trophoblastic disease following a normal pregnancy
is always choriocarcinoma
• The tumor has a tendency to disseminate
hematogenously, particularly to the lungs, vagina,
brain, liver, kidneys and gastrointestinal tract
• FIGO staging of gestational trophoblastic neoplasia
CHORIOCARCINOMA
SYMPTOMS
• Symptoms of metastatic disease
• Vaginal bleeding
• Uterine choriocarcinoma
• Vaginal metastasis
• Hemoptysis, cough, dyspnea
• Result of lung metastasis
• Headache, dizzy spells
• Central nervous system metastases
• Rectal bleeding, dark stools
• Metastasis to gastrointestinal tract
CHORIOCARCINOMA
SIGNS
• Uterine enlargement
• Blood seen on examination with a speculum
• Mass in vagina (metastatic tumor)
• Acute abdomen
• Rupture of uterus
• Abdominal pain
• Theca-lutein cyst
• Neurologic signs
• Partial weakness, paralysis, aphasia etc
CHORIOCARCINOMA
DIAGNOSTIC
• Great imitator of the other diseases !!!!
• May not be suspected
• Unless it follows molar pregnancy
• Screen for choriocarcinoma: β-hcg
• Computer tomography (CT)
• Pelvis Abdomen head
• Cerebrospinal fluid β-hcg level
• Ratio of serum to cerebrospinal fluid hcg levels of less than 40:1
suggest central nervous system involvement
• β subunit does not cross the blood-brain barrier readily
 CHORIOCARCINOMA
TREATMENT
• Chemotherapy
• Methotrexate
• Actinomycin D
• Cyclophosphamide
• Modified Bagshave regimen (EMA-CO)
• Surgery
• Hysterectomy
• Pulmonary resection
• Radiotherapy (in conjunction with chemotherapy)
• Brain
• liver
CHORIOCARCINOMA
PROGNOSIS
• 95-100% of patients with GTN with good prognosis are cured
• 50 – 70 % patients with poor diagnosis are cured
• Most patient who die have brain or liver metastases
• Causes of death:
• Vaginal bleeding.
• Haemoptysis.
• Intraperitoneal hemorrhage.
• Peritonitis.
• Metastasis to the vital organs e.g, brain.
• Pulmonary complications