Gestational trophoblastic disease, GTD, incidence,risk factors, Etiology,complete mole,partial mole,clinical features, diagnosis,differential diagnosis,complications, management,follow up

2. GTD
 Heterogenous group of inter-related lesions that arise from
abnormal proliferation of placental trophoblasts
 Histologically distinct and can be benign or malignant
 BENIGN lesions- Hydatidiform moles ,
Complete mole ,
Partial mole
 MALIGNANT lesions(GTN)- Invasive mole,
Placental site trophoblastic tumor(PSTT),
Epitheloid trophoblastic tumors(ETT),
Choriocarcinoma.

3.  Malignant lesions are locally invasive and metastatic in
nature
 GTNs are among the rare human tumors that can be
cured even in the presence of widespread
dissemination
 Although GTNs commonly follow a molar pregnancy,
they can occur after any gestational event, including
induced or spontaneous abortion/ ectopic
pregnancy/term pregnancy.

4. HYDATIDIFORM MOLES
 INCIDENCE- higher in Eastern countries than in the
West.
 India and Middle East- 1:160 and 1:500
 Malignant potential is higher in South East Asia(10-
15%) compared to western countries(2-4%).
 Geographical and environmental factors plays a major
role.

5. Risk factors
 Age –adolescents (7%)and women over 40 years (2-
10%)
 Ova from adolescents and older women may be more
susceptible to abnormal fertilization
 Diet deficiency- vitamin A, b- carotene, folic acid
 Maternal age and nutrition influences the incidence of
complete mole than partial mole

6. Risk factors
 Blood group A or AB are at slightly higher risk than
those with type B or O
 Smoking
 Previous h/o GTD-
-If one previous mole, 1% chance of
recurrence(vs. 0.1% in general population)
-if 2 previous moles, risk of recurrence increases
to 16-28%
 Oral contraceptive use & h/o irregular menstruation
increases the risk for partial mole

7. Pathology
 Based on morphology, histopathology and karyotype,
Hydatidiform mole
Complete mole Partial mole

8. Complete mole
 Arise from an ovum fertilised by an haploid sperm,
which duplicates its own chromosomes.
 Ovum nucleus may be absent or inactivated.
sperm empty egg 46,XX
23x 23X 23X

9. .
sperm empty egg 46,XY
 They usually have 46,XX karyotype, but about 10% have
46,XY karyotype.
 Molar chromosomes are entirely of paternal origin, with
mitochondrial DNA of maternal origin
23Y 23 X 23 X 23Y

10. Partial mole
 They usually have triploid karyotype (69
chromosomes),the extra haploid set of chromosome is
derived from the father.
sperm normal egg 69,XXY
(69,XXX)
23Y 23 X 23X 23Y 23X
23 X 23X 23X 23X 23X

11. Recurrent molar pregnancy
 Due to dysregulation of normal parental imprinting of
genes, with loss of maternally transcribed genes.
 Recurrent complete molar pregnancy is due to
biparental origin, rather than the more usual
androgenetic origin.
 Mutations in NLRP7 gene is responsible for abnormal
development of embryonic and extra embryonic
tissue.

12. Complete vs. partial mole
Complete mole Partial mole
Based on clinical findings
1. Fetus
2. Fetal vessels
ABSENT PRESENT( malformed/
IUGR)
Histologically
1) hydropic changes
2) trophoblastic
hyperplasia
Diffuse & placenta not
present
Marked
Focal
Mild to moderate
b- HCG VERY HIGH Comparatively low
Karyotype 46 XX ( paternally
derived)
69 XXY
MALIGNANT
POTENTIAL
15-20% rare

13. Clinical features
 Vaginal bleeding – most common
-H/o passage of vesicles
- due to separation of molar tissues from decidua and
disruption of maternal vessels, and large volumes of
retained blood may distend the endometrial cavity
 Uterine enlargement-
-doughy in consistency
-trophoblastic overgrowth and usually associated
with high levels of HCG
- External & internal ballotment cannot be elicited
and FHR cannot be heard in Doppler.

14. Clinical features
 Theca lutein cysts ( 50%)- due to high level HCG
which cause ovarian hyperstimulation.
 It regresses spontaneously after molar evacuation
usually within 2-4 months.
 Partial mole have the signs & symptoms of missed/
incomplete abortion.
 Asymptomatic (<1%)

15. Complications
 Anaemia (5%) – due to prolonged bleeding
 Pre eclampsia (27%)- before 24 weeks
 Hyperemesis (8%)- may lead to electrolyte disturbances
 Hyperthyroidism (7%)
 Trophoblastic embolization-
-occurs after molar evacuation and they may
present with chest pain, dyspnea, tachycardia but within 72
hrs it can be resolved with cardiopulmonary support .

16. Differential diagnosis
 Mistaken date
 Multiple pregnancy
 Acute hydraminos
 Fibroid in pregnancy
 Threatened abortion

17. Diagnosis
 Ultrasonography – most sensitive, quick & safe
1) Complete mole :
- characteristic vesicular pattern( SNOW STORM
) is seen as early as the first trimester.
-absence of fetal shadow
2) Partial mole :
-focal cystic spaces in placental tissues and there is
an increase in the transverse diameter of gestational sac.
-Malformed fetus / IUGR fetus and placenta are
visualised

18. Diagnosis
 HORMONAL assays-
are mainly confined to post molar & post
chemotherapy follow up
 Serum b- HCG level is very high in complete mole
than partial mole.
 Human placental lactogen- low in C. Mole but raised
in P.mole, Pulmonary metastasis, PSTT.
 Chest X- ray – to rule out pulmonary metastasis
 CT scan- for liver / brain metastasis
 Histopathology – for partial mole

19. Treatment
 Evaluate for co existing conditions:
- history & physical
- CBC, coagulation profile, serum chemistry
- thyroid function
-blood type and cross match( trophoblast cells
express RhD factor, for RH-ve patients should receive
Rh immune globulin)
- pelvic USG and
- Chest X ray

20. Treatment
 Suction & curettage : preferred method, regardless
of uterine size
 Indications-
i)who desire to preserve fertility
ii)haemodynamically stable Procedure –
Oxytocin infusion>>>>> dilatation & curettage

21. Treatment
 Hysterectomy – may be performed with the mole in
situ and for those who are willing for surgical
sterilization.
 Ovaries may be preserved at the time of surgery, even
in presence of theca lutein cysts.
 It does not prevent metastasis ; patients still require
follow up with assessment of HCG levels.

22. Follow up
After evacuation
weekly monitoring of HCG until normal for 3 consecutive
weeks
Monthly monitoring until normal for 6 consecutive months
& 3 monthly in first year / 6 monthly in second year.
 Average time to achieve the first normal HCG after
evacuation is about 9 weeks.

23. Follow up
 After achieving non detectable levels, the risk of
developing GTN approaches to be 0.
 Encourage patients to use effective contraception
during HCG follow up and preferably pregnancy
should be avoided for 1 year.
 Oral contraceptives are safe during follow up.
 Incomplete evacuation will cause HCG levels to
remain elevated and interfere with proper follow up.

24. Follow up
 Follow up for 2 years remains the only option for
detecting early choriocarcinoma .
 Pelvic examination – to r/o vulval / vaginal metastasis.
 USG abdomen – for theca lutein cysts
 Chest X ray

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