Gestational Trophoblastic Disease

GESTATIONAL TROPHOBLASTIC DISEASE
DEFINITION Also known as Hydatidiform Mole; H-mole; Molar pregnancy It is abnormal proliferation and then degeneration of the trophoblastic villi As the cells degenerate, they become filled with fluid and appear as clear fluid-filled, grape-sized vesicles. The embryo fails to develop beyond a primitive start. Microscopically, moles may be identified by three classic findings: edema of the villous stroma, avascular villi, and nests of proliferating syncytiotrophoblastic or cytotrophoblastic elements surrounding villi. Abnormal trophoblast cells must be identified because they are associated with choriocarcinoma, a rapidly metastasizing malignancy. The incidence of gestational trophoblastic disease is approximately 1 in every 1500 pregnancies. RISK FACTORS Women who have a low protein intake In women older than age 35 years In women of Asian heritage In blood group A women who marry blood group O men.
TYPES OF MOLAR GROWTH Two types of molar growth can be identified by chromosome analysis. 1. Complete mole all trophoblastic villi swell and become cystic; if an embryo forms it dies early at only 1-2mm in size with no fetal blood present in the villi. On chromosomal analysis, although the karyotype is a normal 46XX or 46 XY, this chromosome component was contributed only by the father an empty ovum was fertilized and the chromosome material was duplicated. 2. Partial mole some of the villi form normally. The syncytiotrophoblastic layer of villi, however is swollen and misshapen. A macerated embryo of approximately 9 weeks, gestation may be present and fetal blood may be present in the villi. A partial mole has 69 chromosomes (a triploid formation in which there are three chromosomes instead of two for every pair, one set supplied by an ovum that apparently was fertilized by two sperm or an ovum fertilized by one sperm in which meiosis or reduction division did not occur).this could also occur if one set of 23 chromosomes was supplied by one sperm and an ovum that did not undergo reduction division supplied. Rarely lead to choriocarcinoma. hCG titers are lower in partial than in complete moles; titers also return to normal faster after mole evacuation.
FEATURES Embryonic/fetal tissue COMPLETE Absent (whole conceptus is transformed into a mass of vesicles) Swelling of villi Diffuse Focal PARTIAL Present (with fetus or at least an amniotic sac)
Trophoblastic hyperplasia
Diffuse
Focal
Karyotype
Paternal 46XX (97%) or 46XY (47%)
Paternal and maternal 69XXY or 69XYY Rare
Malignant changes
5-10%
Table 1.Various features of a complete and a partial mole.
CLINICAL MANIFESTATIONS Amenorrhea Marked nausea and vomiting in early pregnancy Strongly positive serum/urine test of hCG (1 2 million IU) Abnormal uterine bleeding usually during the 1st trimester (most common symptom) may be bright red or dark brown in color and may be slight, profuse or intermittent. Rapid enlargement of the uterus; uterine size greater than anticipated by dates
Blood may be concealed in the uterus, thereby causing enlargement. Abdominal pain: may be dull-aching due to rapid distension of uterine by mole or by concealed hemorrhage; colicky due to start of expulsion
Symptoms of PIH at week 20 onwards (hypertension, edema and proteinuria) UTZ shows dense growth (similar to a snowflake pattern) but no fetal growth in the uterus No fetal heart sounds heard Passage of clear fluid-filled vesicles Theca lutein cysts Ovarian pain due to stretching of ovarian capsule or complication in the cystic ovary as torsion. Pallor indicating anemia may be present Hyperthyroidism develops in 3-10% of cases manifested by enlarged thyroid gland and tachycardia (due to chorionic thyrotropin secreted by the trophoblast and hCG also has a thyroid-stimulating effect) DIAGNOSTIC FINDINGS HCG blood test Chest x-ray CT or MRI of the abdomen Complete blood count Blood clotting tests Kidney and liver function tests
SURGICAL MANAGEMENT Hysterectomy Suction curettage method of choice THERAPEUTIC MANAGEMENT Prepare the mother for uterine evacuation (before evacuation, diagnostic tests are done to determine metastatic disease). Baseline pelvic examination Chest radiograph Evacuation of the mole is done by vacuum aspiration; oxytocin is administered after evacuation to contract uterus. Monitor for postprocedure hemorrhage and infection. Tissue is sent to the laboratory for evaluation, and follow-up is important to detect changes suggestive of malignancy. Human Chorionic Gonadotropin levels are monitored every 1 to 2 weeks until normal prepregnancy levels are attained; then the levels are checked every 1 to 2 months for 1 year. Instruct the client and significant other about birth control (oral contraceptives) measures so that pregnancy can be prevented during the 1 year follow-up. Prophylactic course: methotrexate (DOC for choriocarcinoma) with dactinomycin if metastasis occurs

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GESTATIONAL TROPHOBLASTIC DISEASE

Paternal 46XX (97%) or 46XY (47%)

Paternal and maternal 69XXY or 69XYY Rare

Table 1.Various features of a complete and a partial mole.

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