GESTATIONAL TROPHOBLASTIC DISEASE

DEFINITION Gestational Trophoblastic Disease(GTD) encompasses a spectrum of proliferative abnormalities of Trophoblastic associated with pregnancy Persistent GTD is referred as Gestational Trophoblastic Neoplasia(GTN)

Conventional Histological Classification Hydatidiform Mole(Complete and partial) Invasive Mole Choriocarcinoma Placental site trophoblastic tumor(PSTT)

HYDATIDIFORM MOLE

DEFINITION It is an abnormal condition of the placenta where there are partly degenerative and partly proliferative changes in the young chorionic villi Cluster of small cyst Benign with malignant potential

INCIDENCE Philippines 1 in 80 India 1 in 400 USA 1 in 2000

TYPES COMPLETE INCOMPLETE

ETIOLOGY Exact cause is unknown Highest in teenage pregnancies and women over 35 years of age Prevalence vary with race and ethnic origin Faulty nutrition

ETIOLOGY……Contd Disturbed maternal immune mechanism Chromosomes are derived from the father H/O hydatidiform mole increase the chance of recurrence

PATHOLOGY Disease of the CHORION Death of the ovum or Failure of the embryo to grow Hydatidiform mole (Cyst begin to form from 3rd to 5th week, when feto-maternal circulation has become established)

PATHOLOGY….Contd HYDATIDIFORM MOLE Secretions from hyperplastic cells and Transferred substances from the maternal blood Accumilation of these substances in the stroma of the villi(which are devoid of blood vessels) Distension of the villi to form small cyst

NAKED EYE APPEARANCE Mass filling in the uterus Mass is made up of clusters of cyst of varying size No trace of embryo or amniotic sac

MICROSCOPIC APPEARANCE Marked proliferation of syncitial and cyto- trophoblastic epithelium Thinning of stromal tissue due to accumulation of fluid Absence of blood vessels Villus pattern is distinctly maintained

OVARIAN CHANGES Increased HCG Bilateral leuteal cyst (Increased HCG,P,E) Regress 2 months after expulsion of mole

CLINICAL FEATURES AGE AND PARITY Prevalent amongst teenaged and elderly H/O amenorrhoea 8-12 weeks

CLINICAL FEATURES…..Contd SYMPTOMS Vaginal bleeding Varying degree of lower abdominal pain Over distension of the uterus Concealed haemorrhage Perforation of the uterus Infection Uterine contraction to expel the content

CLINICAL FEATURES…..Contd Constitutional symptoms Patient becomes sick Excessive vomiting Breathlessness Thyrotoxic feature Expulsion of grape like vesicles per vaginum is diagnostic H/O quickening absent

CLINICAL FEATURES…..Contd SIGNS Feature of early pregnancy Patient looks more ill Pallor out of proportion to visible blood loss Features of pre eclampsia

CLINICAL FEATURES….Contd PER ABDOMEN Size of the uterus is more than the period of amenorrhoea Feel the uterus doughy Fetal parts are not felt No fetal movement Absence of FHS

CLINICAL FEATURES….Contd VAGINAL EXAMINATION Internal ballottement cannot be elicited Unilateral or bilateral enlargement of the ovary Finding vesicles in the vaginal discharge Cervical os open

INVESTIGATIONS Full blood count, ABO and Rh Hepatic, renal and thyroid function test Sonography – Snow storm appearance HCG – 1 in 200 to 1 in 500 X-Ray abdomen- No fetal shadow X-Ray chest – Pulmonary embolism

COMPLICATIONS Haemorrhage and shock Seperation Perforation Evacuation Infection No membranes Degenerated vesicles Lowered resistance Increased operative interference

COMPLICATIONS…..Contd Perforation of the uterus Dilatation and evacuation Perforating mole Pre –eclampsia with convulsion Coagulation failure Acute pulmonary insufficiency 4-6 hours following evacuation LATE Choriocarcinoma

MANAGEMENT PRINCIPLE To restore the blood loss To evacuate the uterus To minimise infection

MANAGEMENT……Contd PATIENT CLASSIFICATION GROUP A Mole is in the process of expulsion GROUP B Uterus remain inert

MANAGEMENT……Contd SUPPORTIVE THERAPY GROUP A Morphine 15mg IM 5% Dextrose Blood transfusion GROUP B Blood should be kept ready prior to elective evacuation

MANAGEMENT……Contd DEFINITIVE MANAGEMENT GROUP A S/E or D/E Oxytocin 10-20 units in 500 ml 5% dextrose 40-60 drops/minute Digital exploration and removal of ovum under GA using ovum forceps Methergin 0.2mg IM GROUP B Blood should be kept ready prior to elective evacuation Slow dialatation of the cervix followed by suction and evacuation

COMPLICATIONS OF VAGINAL EVACUATION Injury to the uterus Haemorrhage Shock Acute pulmonary insufficiency Thyroid storm

COMPLICATIONS OF VAGINAL EVACUATION Injury to the uterus Haemorrhage Shock Acute pulmonary insufficiency Thyroid storm

INDICATIONS FOR HYSTERECTOMY Patient with age over 35yrs Completed family irrespective of age Uncontrolled haemorrhage or during surgical evacuation Reduces the risk of GTN

INDICATIONS FOR HYSTEROTOMY Profuse vaginal bleeding Cervix unfavourable Accidental perforation of the uterus following surgical evacuation