{"id":382,"date":"2020-08-13T20:20:17","date_gmt":"2020-08-13T20:20:17","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=382"},"modified":"2020-10-20T17:02:22","modified_gmt":"2020-10-20T17:02:22","slug":"gestational-trophoblastic-disease","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/basic_obgyn\/advanced-training\/gestational-trophoblastic-disease\/","title":{"rendered":"GTD"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/leRP_ldzy8Q\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><span data-mce-type=\"bookmark\" style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" class=\"mce_SELRES_start\">\ufeff<\/span><\/iframe><\/p>\n<p>Duration 10:02<\/p>\n<hr \/>\n<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/y7zKvtSmvlQ\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration 11:19<\/p>\n<input type='hidden' bg_collapse_expand='69e9c84729bd99003321113' value='69e9c84729bd99003321113'><input type='hidden' id='bg-show-more-text-69e9c84729bd99003321113' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9c84729bd99003321113' value='Hide Transcript'><button id='bg-showmore-action-69e9c84729bd99003321113' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#fcfcfc;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9c84729bd99003321113' ><\/p>\n<p>00:00<br \/>\nThe topic of this presentation<br \/>\n00:02<br \/>\nis on hydatidiform moles.<br \/>\n00:04<br \/>\nA hydatidiform mole, also known<br \/>\n00:06<br \/>\nas a molar pregnancy,<br \/>\n00:08<br \/>\nis a relatively rare condition<br \/>\n00:10<br \/>\nwhereby there is<br \/>\n00:10<br \/>\nabnormal proliferation<br \/>\n00:12<br \/>\nof the placenta in a pregnancy,<br \/>\n00:14<br \/>\nresulting in a massive cyst<br \/>\n00:16<br \/>\nin the uterus rather than<br \/>\n00:17<br \/>\na viable pregnancy.<br \/>\n00:19<br \/>\nToday we&#8217;ll be talking about two<br \/>\n00:20<br \/>\ntypes of moles, complete moles<br \/>\n00:22<br \/>\nand pasture moles,<br \/>\n00:23<br \/>\nas well as their complications.<br \/>\n00:25<\/p>\n<p>00:28<br \/>\nSome of the risk factors<br \/>\n00:29<br \/>\nfor molar pregnancies<br \/>\n00:31<br \/>\ninclude extremes of age.<br \/>\n00:33<br \/>\nThat is below 20 or above 35.<br \/>\n00:36<br \/>\nA prior history<br \/>\n00:37<br \/>\nof gestational trophoblastic<br \/>\n00:39<br \/>\ndisease, nulliparity, a diet<br \/>\n00:42<br \/>\nlow in beta carotene,<br \/>\n00:44<br \/>\nfolic acid, and animal<br \/>\n00:45<br \/>\nfat, smoking, and usage of OCPs.<br \/>\n00:49<\/p>\n<p>00:52<br \/>\nThere are two types of molar<br \/>\n00:54<br \/>\npregnancies,<br \/>\n00:54<br \/>\ncomplete and incomplete.<br \/>\n00:56<br \/>\nA complete mole is a result<br \/>\n00:58<br \/>\nof the fertilization<br \/>\n00:59<br \/>\nof an enucleate ovum.<br \/>\n01:00<br \/>\nThat is an ovum with a missing<br \/>\n01:02<br \/>\nor nonfunctional nucleus<br \/>\n01:04<br \/>\nwith a normal sperm which then<br \/>\n01:06<br \/>\nreplicates itself.<br \/>\n01:07<br \/>\nMore rarely a complete mole<br \/>\n01:09<br \/>\ncan be formed<br \/>\n01:10<br \/>\nby the fertilization<br \/>\n01:11<br \/>\nof an enucleate egg<br \/>\n01:12<br \/>\nwith two normal sperms.<br \/>\n01:14<br \/>\nIn both cases the chromosomes<br \/>\n01:16<br \/>\nin a complete mole<br \/>\n01:17<br \/>\nare all paternally derived.<br \/>\n01:19<br \/>\nComplete moles are the more<br \/>\n01:21<br \/>\ncommon molar pregnancy,<br \/>\n01:23<br \/>\naccounting for 90% of molar<br \/>\n01:25<br \/>\npregnancies.<br \/>\n01:26<br \/>\nAmong them the most<br \/>\n01:27<br \/>\ncommon karyotype is 46XX.<br \/>\n01:29<\/p>\n<p>01:33<br \/>\nIn a complete mole<br \/>\n01:34<br \/>\nthere<br \/>\n01:34<br \/>\nis<br \/>\n01:35<br \/>\nnoninvasive trophoblastic<br \/>\n01:36<br \/>\nproliferation, which leads<br \/>\n01:38<br \/>\nto diffused swelling<br \/>\n01:39<br \/>\nof the chorionic villi and<br \/>\n01:40<br \/>\nhydropic degeneration.<br \/>\n01:42<br \/>\nThis gives the mole<br \/>\n01:43<br \/>\nits characteristic appearance<br \/>\n01:45<br \/>\nof grape-like vesicles<br \/>\n01:46<br \/>\nfilling the uterus.<br \/>\n01:47<br \/>\nNotably, in a complete mole<br \/>\n01:49<br \/>\nthere&#8217;s an absence of fetus,<br \/>\n01:51<br \/>\nfetal villi, or fetal red blood<br \/>\n01:53<br \/>\ncells.<br \/>\n01:54<br \/>\nIn addition, there&#8217;s<br \/>\n01:55<br \/>\nabnormal proliferation<br \/>\n01:57<br \/>\nof syncytial trophoblasts<br \/>\n01:59<br \/>\nwhich produces high levels<br \/>\n02:00<br \/>\nof hCG.<br \/>\n02:02<br \/>\nhCG has both alpha and beta<br \/>\n02:04<br \/>\nlevels, and the alpha sub unit<br \/>\n02:07<br \/>\ncan be found in LH, FSH,<br \/>\n02:09<br \/>\nand TSH.<br \/>\n02:10<br \/>\nBecause of this, they can act<br \/>\n02:12<br \/>\nas homologues to LH and FSH<br \/>\n02:15<br \/>\nand stimulate development<br \/>\n02:16<br \/>\nof large theca lutein cysts.<br \/>\n02:18<br \/>\nLikewise, they can also act<br \/>\n02:20<br \/>\nas homologues to TSH to cause<br \/>\n02:22<br \/>\nhypothyroidism.<br \/>\n02:24<br \/>\nThe high hCG levels can also<br \/>\n02:26<br \/>\ncause hyperemesis gravidarum<br \/>\n02:29<br \/>\nand early pre-eclampsia.<br \/>\n02:31<br \/>\n15% to 20% of complete<br \/>\n02:33<br \/>\nmoles progress to malignancy.<br \/>\n02:34<\/p>\n<p>02:38<br \/>\nOn the other hand,<br \/>\n02:39<br \/>\na partial or incomplete mole<br \/>\n02:41<br \/>\nis formed when a normal ovum is<br \/>\n02:43<br \/>\nfertilized by two sperms<br \/>\n02:45<br \/>\nsimultaneously.<br \/>\n02:46<br \/>\nThe most common karyotype<br \/>\n02:47<br \/>\nassociated with it is 69XXY.<br \/>\n02:51<br \/>\nAn incomplete mole results<br \/>\n02:53<br \/>\nin placenta abnormality<br \/>\n02:54<br \/>\ncharacterized<br \/>\n02:55<br \/>\nby focal hydropic villi,<br \/>\n02:58<br \/>\nand trophoblastic hyperplasia,<br \/>\n03:00<br \/>\nprimarily<br \/>\n03:01<br \/>\nof the cytotrophoblasts.<br \/>\n03:03<br \/>\nIn contrast to a complete mole,<br \/>\n03:05<br \/>\nthere&#8217;s normal or only slightly<br \/>\n03:08<br \/>\nelevated hCG<br \/>\n03:09<br \/>\nsince cytotrophoblasts do not<br \/>\n03:11<br \/>\nproduce hCG.<br \/>\n03:13<br \/>\nUniquely incomplete moles are<br \/>\n03:15<br \/>\nassociated with the presence<br \/>\n03:17<br \/>\nof a fetus.<br \/>\n03:18<br \/>\nIn fact, amniotic fluid<br \/>\n03:19<br \/>\nand fetal heart rate<br \/>\n03:20<br \/>\nmay also be present.<br \/>\n03:23<br \/>\nHowever, the fetus often has<br \/>\n03:25<br \/>\nmultiple structural<br \/>\n03:26<br \/>\nabnormalities,<br \/>\n03:27<br \/>\nand it&#8217;s likely to be growth<br \/>\n03:29<br \/>\nrestricted.<br \/>\n03:30<br \/>\nFurthermore, most fetuses<br \/>\n03:31<br \/>\nsurvive only several weeks<br \/>\n03:33<br \/>\nin vitro<br \/>\n03:34<br \/>\nbefore being spontaneously<br \/>\n03:36<br \/>\naborted<br \/>\n03:36<br \/>\nin the late first or early<br \/>\n03:38<br \/>\nsecond trimester.<br \/>\n03:40<br \/>\nIt is worthy to note<br \/>\n03:41<br \/>\nthat partial moles are almost<br \/>\n03:42<br \/>\nalways benign<br \/>\n03:44<br \/>\nand have a much lower malignancy<br \/>\n03:46<br \/>\npotential than a complete mole.<br \/>\n03:48<br \/>\nCompared to the 15% to 20%<br \/>\n03:50<br \/>\nwho progress<br \/>\n03:51<br \/>\nto a persistent mole,<br \/>\n03:52<br \/>\nless than 5%<br \/>\n03:53<br \/>\nof patients with partial moles<br \/>\n03:55<br \/>\nwill develop<br \/>\n03:55<br \/>\npersistent malignant disease.<br \/>\n03:56<\/p>\n<p>04:00<br \/>\nA molar pregnancy usually<br \/>\n04:02<br \/>\npresents with the following<br \/>\n04:03<br \/>\nsymptoms.<br \/>\n04:04<br \/>\nFirst vaginal bleeding, which<br \/>\n04:06<br \/>\nis caused by the separation<br \/>\n04:07<br \/>\nof the tumor<br \/>\n04:08<br \/>\nfrom underlying desidual,<br \/>\n04:10<br \/>\nleading to disruption<br \/>\n04:11<br \/>\nof maternal vessels.<br \/>\n04:13<br \/>\nIn cases of prolonged bleeding,<br \/>\n04:14<br \/>\nsigns and symptoms of anemia<br \/>\n04:16<br \/>\nmay be observed.<br \/>\n04:17<br \/>\nOne may also observe passage<br \/>\n04:18<br \/>\nof molar vesicles, nausea<br \/>\n04:20<br \/>\nand vomiting caused<br \/>\n04:22<br \/>\nby hyperemesis gravidarum.<br \/>\n04:25<br \/>\nOn physical examination<br \/>\n04:26<br \/>\none may observe hypertension<br \/>\n04:28<br \/>\ndue to pre-eclampsia,<br \/>\n04:30<br \/>\nand a uterine size which is more<br \/>\n04:31<br \/>\nthan gestational age, which may<br \/>\n04:33<br \/>\nbe caused by tumors, blood<br \/>\n04:35<br \/>\nclots, or hemorrhage.<br \/>\n04:38<br \/>\nPartial or incomplete moles<br \/>\n04:39<br \/>\npresent in the same way.<br \/>\n04:41<br \/>\nHowever the symptoms are less<br \/>\n04:42<br \/>\nsevere from that<br \/>\n04:43<br \/>\nof complete moles,<br \/>\n04:45<br \/>\nas the hCG levels are only<br \/>\n04:47<br \/>\nslightly elevated.<br \/>\n04:49<br \/>\nAs such, they are diagnosed<br \/>\n04:50<br \/>\nlater than complete moles.<br \/>\n04:52<br \/>\n90% of them will present<br \/>\n04:54<br \/>\nwith vaginal bleeding<br \/>\n04:55<br \/>\nfrom miscarriage or incomplete<br \/>\n04:57<br \/>\nabortion in late first<br \/>\n04:59<br \/>\nor early second trimester.<br \/>\n05:01<br \/>\nAs such incomplete moles are<br \/>\n05:03<br \/>\noften diagnosed later<br \/>\n05:04<br \/>\nthan complete moles.<br \/>\n05:05<br \/>\nUnlike complete moles,<br \/>\n05:07<br \/>\nthe abdomen is smaller<br \/>\n05:08<br \/>\nfor its gestational age,<br \/>\n05:10<br \/>\ndue to the presence<br \/>\n05:11<br \/>\nof complications<br \/>\n05:12<br \/>\nsuch as intrauterine growth<br \/>\n05:13<br \/>\nrestriction.<br \/>\n05:14<\/p>\n<p>05:17<br \/>\nBecause hCG levels are extremely<br \/>\n05:20<br \/>\nhigh in complete moles<br \/>\n05:21<br \/>\nrelative to values<br \/>\n05:22<br \/>\nfor normal pregnancy<br \/>\n05:24<br \/>\nand correlate with tumor size,<br \/>\n05:26<br \/>\nthey can be used to diagnose<br \/>\n05:28<br \/>\nand assess treatment<br \/>\n05:29<br \/>\neffectiveness.<br \/>\n05:30<br \/>\nA serum hCG level above 100,000<br \/>\n05:33<br \/>\nis indicative of a molar<br \/>\n05:35<br \/>\npregnancy.<br \/>\n05:37<br \/>\nUnder pelvic ultrasound<br \/>\n05:38<br \/>\nno fetus or amniotic fluid<br \/>\n05:40<br \/>\nis seen.<br \/>\n05:41<br \/>\nInstead the intrauterine tissue<br \/>\n05:43<br \/>\nhas a snowstorm appearance<br \/>\n05:44<br \/>\ndue to the swelling<br \/>\n05:45<br \/>\nof chorionic villi.<br \/>\n05:48<br \/>\nIn the figure on the left we see<br \/>\n05:49<br \/>\nthe classically described<br \/>\n05:51<br \/>\nsnowstorm appearance<br \/>\n05:52<br \/>\nof a complete mole<br \/>\n05:53<br \/>\nin the region label M.<br \/>\n05:55<br \/>\nIn addition the skin may also<br \/>\n05:57<br \/>\nreveal [INAUDIBLE]<br \/>\n05:58<br \/>\nbilateral theca lutein cysts.<br \/>\n06:01<br \/>\nHowever,<br \/>\n06:01<br \/>\nthe definitive diagnosis<br \/>\n06:03<br \/>\nof molar pregnancy<br \/>\n06:04<br \/>\nis made<br \/>\n06:05<br \/>\non pathological examination<br \/>\n06:07<br \/>\nof intrauterine tissue<br \/>\n06:09<br \/>\nafter the uterus has been<br \/>\n06:10<br \/>\nevacuated.<br \/>\n06:10<\/p>\n<p>06:14<br \/>\nIn diagnosing<br \/>\n06:15<br \/>\nan incomplete molar pregnancy<br \/>\n06:18<br \/>\nserum hCG levels<br \/>\n06:19<br \/>\nare likely to be relatively<br \/>\n06:20<br \/>\nnormal.<br \/>\n06:21<br \/>\nPelvic ultrasound may reveal<br \/>\n06:23<br \/>\na fetus with a heartbeat.<br \/>\n06:25<br \/>\nIn addition, intrauterine tissue<br \/>\n06:26<br \/>\nhas a Swiss cheese appearance.<br \/>\n06:29<br \/>\nSimilar to complete moles,<br \/>\n06:30<br \/>\na definite diagnosis can only<br \/>\n06:32<br \/>\nbe made<br \/>\n06:33<br \/>\non pathological examination<br \/>\n06:34<br \/>\nof the intrauterine tissue<br \/>\n06:36<br \/>\nafter evacuation.<br \/>\n06:36<\/p>\n<p>06:40<br \/>\nThe management<br \/>\n06:41<br \/>\nof complete and partial moles<br \/>\n06:42<br \/>\nare similar.<br \/>\n06:44<br \/>\nThe definitive treatment<br \/>\n06:45<br \/>\ninvolves the immediate removal<br \/>\n06:47<br \/>\nof uterine contents<br \/>\n06:48<br \/>\nby suction curettage.<br \/>\n06:50<br \/>\nIn older women who have<br \/>\n06:51<br \/>\ncompleted their family<br \/>\n06:53<br \/>\na hysterectomy may be performed<br \/>\n06:55<br \/>\ninstead.<br \/>\n06:56<br \/>\nFollowing evacuation<br \/>\n06:57<br \/>\nor hysterectomy patients<br \/>\n06:58<br \/>\nhave to be followed up closely<br \/>\n07:00<br \/>\nfor persistent disease, which<br \/>\n07:02<br \/>\noccurs in 15% to 25%<br \/>\n07:05<br \/>\nof patients<br \/>\n07:05<br \/>\nwith a complete mole.<br \/>\n07:07<br \/>\nSerial hCG titers are measured<br \/>\n07:09<br \/>\nwithin 48 hours of evacuation.<br \/>\n07:12<br \/>\nAnd then weekly until negative<br \/>\n07:14<br \/>\nfor three consecutive weeks.<br \/>\n07:16<br \/>\nhCG levels are then followed<br \/>\n07:18<br \/>\nmonthly for six months.<br \/>\n07:20<br \/>\nAny plateau or rise in hCG<br \/>\n07:22<br \/>\nlevels during this period<br \/>\n07:23<br \/>\nis<br \/>\n07:24<br \/>\nindicative<br \/>\n07:24<br \/>\nof a persistent or invasive<br \/>\n07:26<br \/>\nmole.<br \/>\n07:27<br \/>\nBecause it is<br \/>\n07:28<br \/>\ncritical to monitor hCG levels,<br \/>\n07:30<br \/>\npregnancy must be avoided<br \/>\n07:32<br \/>\nin the follow up period<br \/>\n07:33<br \/>\nwith reliable contraception<br \/>\n07:35<br \/>\nsuch as oral contraceptive<br \/>\n07:37<br \/>\npills.<br \/>\n07:38<br \/>\nSubsequent pregnancies should be<br \/>\n07:39<br \/>\nclosely monitored<br \/>\n07:40<br \/>\nwith early ultrasound and hCG<br \/>\n07:43<br \/>\nmonitoring<br \/>\n07:44<br \/>\nto exclude recurrent disease.<br \/>\n07:46<\/p>\n<p>07:50<br \/>\nIn 20% of patients with a molar<br \/>\n07:52<br \/>\npregnancy, the hydatitiform mole<br \/>\n07:54<br \/>\nundergoes<br \/>\n07:55<br \/>\nmalignant transformation<br \/>\n07:57<br \/>\nto cause persistent or invasive<br \/>\n07:58<br \/>\ndisease.<br \/>\n07:59<\/p>\n<p>08:02<br \/>\nSome of the risk factors<br \/>\n08:04<br \/>\nfor malignant transformation<br \/>\n08:06<br \/>\ninclude a maternal age above 40<br \/>\n08:08<br \/>\nyears old, extremely high<br \/>\n08:11<br \/>\nbeta hCG levels,<br \/>\n08:12<br \/>\nand the presence of theca lutein<br \/>\n08:15<br \/>\ncysts larger than 6 cm<br \/>\n08:16<br \/>\nin diameter.<br \/>\n08:18<br \/>\nInvasive moles are therefore<br \/>\n08:20<br \/>\nmore commonly associated<br \/>\n08:21<br \/>\nwith complete molar pregnancies.<br \/>\n08:23<\/p>\n<p>08:26<br \/>\nInvasive moles occur when there<br \/>\n08:28<br \/>\nis local uterine invasion<br \/>\n08:30<br \/>\nof a complete or incomplete<br \/>\n08:31<br \/>\nmole, and make up 75%<br \/>\n08:33<br \/>\nof gestational trophoblastic<br \/>\n08:35<br \/>\nneoplasia.<br \/>\n08:36<br \/>\nThey are characterized<br \/>\n08:38<br \/>\nby penetration<br \/>\n08:39<br \/>\nof large swollen villi<br \/>\n08:40<br \/>\nand trophoblasts<br \/>\n08:41<br \/>\ninto the myometrium<br \/>\n08:43<br \/>\nvia direct extension<br \/>\n08:44<br \/>\nthrough tissue or venous<br \/>\n08:46<br \/>\nchannels.<br \/>\n08:47<br \/>\nMost of the invasive moles<br \/>\n08:49<br \/>\nare nonmetastatic, with about<br \/>\n08:51<br \/>\n15% metastasizing to the lungs<br \/>\n08:53<br \/>\nor vagina.<br \/>\n08:54<br \/>\nPatients with invasive moles<br \/>\n08:56<br \/>\nare usually<br \/>\n08:57<br \/>\nasymptomatic at the time<br \/>\n08:58<br \/>\nof diagnosis.<br \/>\n08:59<br \/>\nHowever, they may sometimes<br \/>\n09:01<br \/>\npresent with abnormal uterine<br \/>\n09:02<br \/>\nbleeding.<br \/>\n09:03<\/p>\n<p>09:06<br \/>\nAnother form<br \/>\n09:07<br \/>\nof malignant trophoblastic<br \/>\n09:08<br \/>\ndisease is choriocarcinoma.<br \/>\n09:11<br \/>\nIt is a highly malignant tumor,<br \/>\n09:13<br \/>\nwhere the trophoblastic tumors<br \/>\n09:14<br \/>\ntravel via the blood stream<br \/>\n09:16<br \/>\nto achieve extra uterine spread<br \/>\n09:18<br \/>\nto distant organs.<br \/>\n09:19<br \/>\n50% of choriocarcinoma<br \/>\n09:21<br \/>\nis preceded by hydatitiform<br \/>\n09:23<br \/>\nmoles,<br \/>\n09:24<br \/>\nand 25% from normal pregnancy,<br \/>\n09:27<br \/>\nand 25% from miscarriage,<br \/>\n09:29<br \/>\nabortion,<br \/>\n09:30<br \/>\nor ectopic pregnancies.<br \/>\n09:32<br \/>\nHistologically choriocarcinomas<br \/>\n09:35<br \/>\nare characterized by sheets<br \/>\n09:37<br \/>\nof trophoblastic cells formed<br \/>\n09:39<br \/>\nfrom both the inner cyto<br \/>\n09:41<br \/>\nand outer syncytial layers<br \/>\n09:44<br \/>\nof the trophoblastic cells<br \/>\n09:46<br \/>\nwithout apparent villi<br \/>\n09:47<br \/>\nformation.<br \/>\n09:48<br \/>\nNecrosis and severe hemorrhage<br \/>\n09:50<br \/>\nmay be seen as the cancer cells<br \/>\n09:52<br \/>\ndestroy the uterine wall<br \/>\n09:53<br \/>\nand vasculature.<br \/>\n09:55<br \/>\nMetastatic disease is also<br \/>\n09:56<br \/>\ncommon with potential metastasis<br \/>\n09:59<br \/>\nto organs such as the lungs,<br \/>\n10:01<br \/>\nvagina, pelvis, brain, liver,<br \/>\n10:04<br \/>\nintestines, and kidneys.<br \/>\n10:05<\/p>\n<p>10:09<br \/>\nPatients with choriocarcinoma<br \/>\n10:11<br \/>\ncommonly present with post<br \/>\n10:12<br \/>\npartum bleeding or irregular<br \/>\n10:14<br \/>\nuterine bleeding years<br \/>\n10:16<br \/>\nafter pregnancy.<br \/>\n10:17<br \/>\nIt is also known<br \/>\n10:18<br \/>\nas the great imitator,<br \/>\n10:20<br \/>\nbecause patients can present<br \/>\n10:21<br \/>\nwith signs and symptoms<br \/>\n10:22<br \/>\nof many disease entities.<br \/>\n10:25<br \/>\nThe diagnosis of choriocarcinoma<br \/>\n10:26<br \/>\nof the placenta<br \/>\n10:27<br \/>\nis similar to invasive moles.<br \/>\n10:30<br \/>\nAnd metastasis should be<br \/>\n10:31<br \/>\nassessed with a full blood<br \/>\n10:33<br \/>\ncount, coagulation profiles,<br \/>\n10:35<br \/>\nrenal panel, and liver function<br \/>\n10:37<br \/>\ntests.<br \/>\n10:38<br \/>\nImaging studies are also<br \/>\n10:39<br \/>\nhelpful in determining<br \/>\n10:41<br \/>\nthe metastatic sites.<br \/>\n10:43<br \/>\nIf vagina or lung metastasis are<br \/>\n10:45<br \/>\npresent, a CT or MRI brain<br \/>\n10:48<br \/>\nshould be obtained.<br \/>\n10:49<br \/>\nThe treatment mortalities<br \/>\n10:50<br \/>\nfor choriocarcinoma<br \/>\n10:53<br \/>\nof the placenta<br \/>\n10:53<br \/>\nis similar to that<br \/>\n10:54<br \/>\nof invasive moles,<br \/>\n10:56<br \/>\nwith low risk patients treated<br \/>\n10:57<br \/>\nwith single agent chemotherapy,<br \/>\n11:00<br \/>\nand high risk patients treated<br \/>\n11:01<br \/>\nwith multi agent chemotherapy.<br \/>\n11:03<\/p>\n<p>11:06<br \/>\nWith that we have come<br \/>\n11:07<br \/>\nto the end of our presentation.<br \/>\n11:09<br \/>\nBelow are the references used<br \/>\n11:10<br \/>\nfor this topic.<br \/>\n11:11<br \/>\nAnd we hope this has been<br \/>\n11:13<br \/>\ninformative.<br \/>\n11:13<\/p>\n<p>11:16<br \/>\nThank you.<\/p>\n<p><\/div>\n<hr \/>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>\ufeff Duration 10:02 Duration 11:19 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