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APGO educational topic number 50
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gestational trophoblastic neoplasia
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gestational trophoblastic disease or GTD
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are abnormal proliferation of
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trophoblast from the placenta
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gestational trophoblastic neoplasia or
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GTN otherwise known as malignant GTD
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include choriocarcinoma placental side
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trophoblastic tumor and invasive moles
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these may follow a normal pregnancy or a
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hydatid afore mole in the past the
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majority of patients with GTN localized
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to the uterus were cured with
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hysterectomy but metastatic disease was
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associated with extremely high mortality
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rates now with the ability to measure
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beta HCG levels and highly effective
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chemotherapy most remove the GTN can be
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cured and their reproductive function
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preserved the objectives of this video
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are to describe the symptoms and
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physical exam findings of a patient with
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GTN including molar pregnancy to
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describe the diagnostic methods
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treatment options and follow-up for GTN
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including molar pregnancy and to
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recognize the difference between molar
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pregnancy and malignant GTN high data
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for moles otherwise known as molar
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pregnancies are non-invasive localized
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tumors that result from abnormal
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fertilization events that result in
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proliferation of trophoblastic tissues
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they are classified as partial or
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complete molar pregnancies partial and
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complete Hydra to deform moles are
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distinct disease processes although they
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are managed similarly in a partial molar
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pregnancy a haploid ovum is fertilized
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by two sperm this results in a triploid
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karyotype of 69 XXX or 69 x XY there is
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often a fetus present that a small for
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gestational age that usually dies in
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utero these rarely go on to become
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malignant complete molar pregnancies are
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a result of two sperm fertilizing an
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empty ovum the carrier type will be 46 x
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x or 46 XY the fetus will be absent and
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there is a 6 to 32 percent chance of a
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complete mole becoming malignant
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gestational trophoblastic neoplasia or
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malignant GTD can thus develop from an
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invasive HIDA to deform mole from a
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choriocarcinoma or a placental site
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trophoblastic tumor invasive moles are
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characterized by a demo disc chorionic
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villi with trophoblast proliferation
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that can invade
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to the myometrium choriocarcinoma z’ can
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come from normal pregnancies or molar
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pregnancies and they are composed of
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neoplastic since EO trophoblast and
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Saito trophoblast
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without chorionic villi placental side
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trophoblastic tumors are relatively rare
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and are characterized by an absence of
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the ly with proliferation of
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intermediate trophoblast cells the three
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major risk factors for gestational
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trophoblastic disease are one advanced
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maternal age two history of gestational
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trophoblastic disease and three Asian
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Native American or African ancestry
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let’s now move to signs and symptoms the
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most common symptom of a molar pregnancy
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is abnormal vaginal bleeding for a
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complete molar pregnancy
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signs and symptoms can include uterine
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enlargement greater than expected for
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gestational age absent fetal heart tones
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cystic enlargement of the ovaries
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hyperemesis gravidarum and an abnormally
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high level of HCG for gestational age
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for a partial molar pregnancy the signs
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and symptoms are often similar to
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miscarriage with vaginal bleeding and
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absent fetal heart tones women with
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malignant GTD may have subtle signs and
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symptoms of disease making the diagnosis
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more difficult abnormal bleeding for
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more than six weeks following any
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pregnancy normal or abnormal should be
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evaluated with beta HCG testing to
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exclude a new pregnancy or GTD let’s now
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discuss diagnosis a complete molar
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pregnancy can be identified an
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ultrasound with a diffuse heterogeneous
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echo genetic pattern that is referred to
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as a snowstorm pattern large cystic
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ovaries an ultrasound can also support
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the diagnosis of a complete molar
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pregnancy post molar G TN is most
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frequently diagnosed from increasing or
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plateau in beta HCG values after
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evacuation of a mole with g TN following
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a normal pregnancy and elevated beta HCG
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level and exclusion of pregnancy make
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the diagnosis let’s now move on to
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treatment the preferred method of
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evacuation for a molar pregnancy is
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suction dilation and curettage a
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hysterectomy can be performed for women
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who do not wish to preserve childbearing
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for follow-up patients should be
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monitored with serial beta HCG levels at
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48 hours post evacuation every 1 to 2
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weeks while elevated and then monthly
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for another 6 months during this time
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the patient should use a reliable
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conscious
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option if malignant GTD is diagnosed
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many patients will be referred to a
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cancer specialist and there should be an
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immediate evaluation for metastasis this
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includes a number of blood tests as well
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as imaging studies if there is no
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metastatic disease found the patient can
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be treated with weekly chemotherapy
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which will be intramuscular methotrexate
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with a cure rate close to 100%
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hysterectomy will shorten the duration
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and amount of chemotherapy required but
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it is not necessary for patients who
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wish to preserve childbearing if
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metastatic disease is found and the
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patient should be referred to a
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specialist for possible cancer staging
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and treatment with multi agent
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chemotherapy and possibly radiation
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patients should use reliable
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contraception during treatment and for
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the first year after remission this
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concludes the applicable on gestational
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trophoblastic disease we have discussed
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signs symptoms and therapeutic options
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for this condition and women