Molar Pregnancy (GTD)

.# Gestational Trophoblastic Disease By Dr Mona Ahmed

Gestational Trophoblastic Disease (GTD)

• Gestational Trophoblastic Diseases
• Proliferative disorder of trophoblastic cells
• It could begin premalignant or malignant
• Unique tumours that developed from abnormality at fertilization and are entirely fetal in origin.
• They consist of syncytiotrophoblast and cytotrophoblast and express bHCG as a tumour marker
• They are highly sensitive to chemotherapy
• More common in Asian women and in those from the Far East

Classification of GTD (WHO)

Premalignant:

• Partial hydatidiform mole.
• Complete hydatidiform mole.

Malignant:

• Invasive mole.
• Choriocarcinoma.
• Placenta site trophoblastic diseases.

Molar Pregnancy (Hydatidiform Mole)

Definition Hydatid means… drop of water; mole… spot

• Abnormal form of pregnancy where a non-viable fertilized egg implants in the uterus and converts the pregnancy process to a pathological one

Risk Factors

1. Extreme of reproductive age (20 folds <15 years and 10 folds >40 years).
2. Previous molar pregnancy.
3. Women of blood group A with partner with group O (increases 10 folds).
4. High parity.
5. Diet deficiency of protein or vit A deficiency.
6. Smoking.
7. Increase paternal age.

Types of Molar Pregnancy

• Complete Mole

  • Fertilization of an empty egg by one sperm.
  • All placental villi swollen.
  • Fetus, cord, amniotic membrane are absent.
  • Paternal chromosomes only. 46 XX.
  • Diploidy

• Incomplete Mole

  • Fertilization of an egg by two sperms
  • Some placental villi swollen
  • Fetus, cord, amniotic membrane are present
  • Paternal and maternal 69XXY
  • Triploid

#RR empty egg trace genetic

Symptoms and Signs

• Amenorrhoea
• Irregular vaginal bleeding
• Abdominal pain
• Hyperemesis gravidarum.
• Breathlessness
• Expulsion of grape-like vesicles
• Large for date uterus.
• Firm elastic uterus (doughy)
• Lutein cyst
• Features of hyperthyroidism
• Early preeclampsia (1st trimester or early 2nd trimester)

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Investigations

1. US

   • Complete mole Hyperechoic multiple cysts filled the uterus (snowstorm appearance).

   • Partial mole Appear as missed miscarriage with cystic lesions in the placenta (sometimes), but definitive diagnosis when sending POC to chromosomal analysis.

Choriocarcinoma

• Enlarged uterus.
• With highly vascular mass that invades the endometrium.
• And sometimes with areas of necrosis & cystic lesions.

2. Blood Tests

• Quantitative bHCG.
• FBC.
• RFT & electrolytes.
• LFT.
• TFT.

2. CXR.

3. Group & Saving.

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ManagementZ

• Surgical evacuation
• Suction evacuation by expert hands
• Do serial bHCG until it becomes -ve
• Avoid pregnancy at least 6 months after the last -ve bHCG.
• Give her contraceptives; avoid COCP & IUCD.

Complications

Excessive intraoperative bleeding. Perforation or atony (possible hysterectomy). Persistent trophoblastic disease.

Pulmonary oedema 2ry to heart failure due to:

• ✓ Preeclampsia.
• ✓ Hyperthyroidism.
• ✓ Anaemia.
• ✓ Or excessive fluid overload.
• Trophoblastic embolus DIC *ARDS.

Follow-up

• Serial bHCG for at least 6 months after evacuation.
• Pregnancy at least 6 months after last unpredictable bHCG.
• Contraceptive; avoid COCP.
• After any pregnancy, follow up with bHCG.