OutlineDEFINITIONCLASSIFICATION INCIDENCERISK FACTORS AND EITIOLGYCLINICAL PRESENTATIONLABORATORY FINDINGS IMAGINGTREATMENTFOLLOW UPPROGNOSISREVIEW

Definition:, Neoplastic proliferation of placental tissue.

GTN is an abnormal proliferation of placental tissue involving both cytotrophoblasts and syncytiotrophoblasts,

it can be either benign or malignan .It is a disease of early pregnancy occuring

mostly before the 16 weeks of gestation like ectopic pregnancy and miscarriage.

Classification of GTN

1. Benign GTN Complete mole Incomplete mole

2. Malignant GTN Invasive mole Choriocarcinoma

Benign (Hydatidiform mole)It is characterized histologically by cystic

swelling of choronic villi accompanied by variable amount of trophoblastic proliferation.

Have increased risk of invasive mole and choriocarinoma

Currently diagnosed at early age b/c of USG and close monitoring of early pregnancy.

Occurs at extremes of reproductive ages.More common in eastern world (Asia)

2 types of hydatidiform mole

Genetically either two sperms fertilize an empty ovum or one sperm duplicates / 46xx

Complete mole GTNComplete mole is the most common benign GTN

which result from fertilization of an empty egg with a sigle x sperm resulting paternaly derived 46,xx karyotype.

No fetus,umblical cord and amniotic fluid is seen.The uterus is filled with grape like vesicles composed

of edematous avascular villi.Progression to malignancy is 20%.Beta HCg very high.

Excessive vomiting AND nausea Pregnancy with bleeding

Large for dates uterusU/S – no fetus fetal heart sound absent

Increased B – HCG levelsSnow strom appearance on USG

CLINICAL PRESENTION WITH LAB AND USG

Incomplete or partial mole

Triploid – 2 sets of paternal and one set of maternal chromosomes

PRESENATION

Patient presents with pregnancy and irregular vaginal bleeding

U/S – Embryo with molar changes in placenta

Early fetal death

Comparison b/w complete &partial mole

CHORIOCARCINOMAIt is malignant neoplasm of trophoblastic cells derived from a previously normal or abnormal pregnancy.Rapidly invasive and metastasizes widely.Good response to chemotherapy in comparison to choriocarcioma arising in ovary from germ cell.

CHORIOCARCINOMA

1/20,000 t0 30,000 preg in US in AF 1/250050 % follow CM25 % Non molar abortion25 % term pregnancy1/40 hydatidiform mole

>>choriocarcinoma.1/150,000 normal pregnancies.

Patients present with irregular or heavy vaginal bleeding or symptoms due to Metastasis to brain, lung , liver.

Malignant GTN and prognosis This is the gestational trophoblastic

tumor which can develop into three categories,

1. Non metastatic disease is localized to uterus.cure rate is 100%.

2. Good prognosis metastatic disease has distant metastasis with the most common location being the pelvis or lung.cure rate is >95%.

3. Poor prognosis metastatic disease with most common metastasis to brain or liver.cure rate is 65%.

r

Case presentation of a molar pregnancy

Management

Gestational amenorrhea Bleeding prior to 16wks of GAPassage of grape like vesicles per

vaginum Excessive nausea and vomitingDistension of abdomen at a higher

rate.Previous history of molar , ectopic

pregnancy or History of any abortion or miscarriageHistory of oedema feet , headache ,

pain epigestrum.

HISTORY

Examination

Abdominal examinationFundus larger then datesAbsence of fetal heart toneBilateral cystic enlagrgement of the overyNo fetal movmentsAnemia in case of heavy bleedigVaginal examinationSpotting on vaginal examination Vesicles may also be seen

Clinical presentation

InvestigationsBaseline investigaion: Cbc RBS Blood group Rh incompatability Screening for hep B nd C Urine analaysis,…..SPECIFIC investigationsb-hcg titer-------baseline for future comprisonChest x-ray-----to ruled out lung mestatasisUSG……. On USG if there is complete mole,fetus will be absent and snowstorm appearance of uterus will be seen.If fetus is preset and thickened uterus with honeycomb appearance is seen then it will be incomplete mole

USG findingsComplete mole no fetal tissue snow storm appeara

Partial mole with some fetal tissue honey comb appearance

TREATMENTTreatment is based on the histoloy&location of metastasis;;After SUCTION & EVACUATIO to empty the uterusWill send the sample to histopathology lab to confirm either it is benign or malignant..Hysterectomy at who have completed.

3 things to notice here.1.no fetus,2.uterus full of avascular cysts,3.rouund uterus inspite of ovoid shape.

COMPLETE MOLE

If it is a benign GTN?????Give the pt ocp for the durion of thr follow up.

Follow up weekly with serum beta HCG titer untill negative for 3 weeks,then monthly titer untill reamain it negative for 12 months.

Follow up is for 1 year-ve means hCG <5mU/ml)

Its diagnosed as GTD and the patient should be evaluated for a metastatic workup

( CTscans of the brain,thorax,abdomin

and the pelvis)D&C before initiation of chemotherapy.

If serial b hCG titers plateau or rises then

For non metastatic or good prognosis metastatic disease

1. Administer single chemotherapeutic agent like methotrexate or actinomycin D untill weekly beta HCG level become negative for three weeks,then monthly titer untill negative for twelve months.

2. Follow up is for 1 year.

For poor prognosis metastatic diseaseAdminister multiple agent chemotheray (like

methotrexate,actinomycin D and cytoxan)

Chemotherapy will be continued untill weekly beta HCG level become negative for three weeks,then monthly titer for 2 years,then every 3 months for another 3 years.

Follow up is for 5 years

PrognosisVery goodFive years survival after a course of

chemotherapy even when metastasis have been demonstrated can even be expected in 85% of cases of choriocarcinoma.

THANK YOU