Gestational Trophoblastic Diseases Hydatiform Mole

8/3/2019 Gestational Trophoblastic Diseases Hydatiform Mole

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Gestational TrophoblasticDisease (GTD)


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Types of GTD

Benign

Hydatidiform mole/molar pregnancy

(complete or incomplete)

malignant

Invasive mole

Choriocarcinoma (chorioepithelioma)

Placental site trophoblastic tumor


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The term Gestational TrophoblasticTumors has been applied the latter

three conditionsArise from the trophoblastic elements

Retain the invasive tendencies of the

normal placenta or metastasis Keep secretion of the human chorionic

gonadotropin (hCG)

Types of GTD


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PATHOLOGICCLASSIFICATION

CLINICALCLASSIFICATION

Hydatidiform mole

*complete

*incomplete

Benign gestationaltrophoblastic disease

Invasive moleMalignant

trophoblastic diseaseNonmetastatic

Placental sitetrophoblastictumor

Metastatic

Choriocarcinoma High risk Low risk

Pathologic and clinical classificationsfor gestational trophoblastic disease


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Hydatidiform Mole(molar pregnancy)


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Definition and Etiology Hydatidiform mole is a pregnancy

characterized by vesicular swelling of

placental villi and usually the absence ofan intact fetus.

The etiology of hydatidiform mole

remains unclear, but it appears to be dueto abnormal gametogenesis andfertilization


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In a complete mole the mass oftissue is completely made up of

abnormal cells There is no fetus and nothing can

be found at the time of the firstscan.

Definition and Etiology


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In a partial mole, the mass maycontain both these abnormal cells

and often a fetus that has severedefects.

In this case the fetus will beconsumed ( destroyed) by the

growing abnormal mass veryquickly. (shrink)

Definition and Etiology


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Incidence 1 out of 1500-2000 pregnancies in the

U.S. and Europe 1 out of 500-600 (another report 1%)

pregnancies in some Asian countries.

Complete > incomplete


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Repeat hydatidiform moles occure in0.5-2.6% of patients, and these

patiens have a subsequent greater riskof developing invasive mole orchoriocarcinoma

There is an increased risk of molarpregnancy for women over the age 40

Incidence


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Approximately 10-17% of hydatidiformmoles will result in invasive mole

Approximately 2-3% of hydatidiformmoles progress to choriocarcinoma( most of them are curable)

Incidence

Not definitely benign disease ,has a tight relationship with GTT


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Clinical risk factors for molar pregnancy

Age (extremes of reproductive years)

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Reproductive history

prior hydatidiform mole

prior spontaneous abortion

DietVitamin A deficiency

Birthplace

Outside North America( occasionally has

this disease)


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Cytogenetics

Complete molar pregnancyChromosomes are paternal , diploid

46,XX in 90% cases46,XY in a small part

Partial molar pregnancy

Chromosomes are paternal and maternal, triploid.69,XXY 80%

69,XXX or 69,XYY 10-20%

Wrong life message , so can not develop normally


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Comparative Pathologic Features ofComplete and Partial Hydatidiform Mole

Feature Complete Mole Partial Mole

Karyotype Usually diploid 46XX Usually triploidy 69XXX mostcommon.

Villi All villi hydropin; no

normal adjacent villi

Normal adjacent villi may be

present

vessels present they contain nofetal blood cells

blood cells

Fetal tissue None present Usually present

Trophoblast Hyperplasia usuallypresent to variabledegrees

Hyperplasia mild and focal


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Complete hydatidiform mole demonstrating

enlarged villi of various size


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Hydatidiform mole: specimen from suctioncurettage


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A large amount of villi in the uterus.


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The microscopic appearance of hydatidiform mole:

Hyperplasia of trophobasitc cells

Hydropic swelling of all villi

Vessles are usually absent


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A sonographic findings of a molar pregnancy. Thecharacteristic snowstorm pattern is evident.


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Transvaginal sonogram demonstrating the snow storm appearance.


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Color Dopplor facilitates visualization of the enlarged spiralarteriesclose proximity to the snow storm appearance


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Color Doppler image of a hydatidiform mole and surroundingvessels. The uterine artery is easily identified from its anatomicallocation.


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Dopplor waveform analysis demonstrates low vascular resistance(RI=0.29) in

the spiral arteries, much lower than that obtained in normal early pregnancy


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Partial hydartidiform mole


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Microscopic image of partial molar pregnancy.


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Here is a partial mole in a case of triploidy. Notethe scattered grape-like masses with interveningnormal-appearing placental tissue.


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Large bilateral theca lutein cysts resembling ovarian germ celltumors. With resolution of the human chorionic gonadotropin(HCG)stimulation, they return to normal-appearing ovaries.


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Signs and Symptoms of Complete

Hydatidiform MoleVaginal bleeding

Hyperemesis ( severe vomit)

Size inconsistent with gestationalage( with no fetal heart beating andfetal movement)

Preeclampsia

Theca lutein ovarian cysts


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Signs and Symptoms of Partial

Hydatidiform MoleVaginal bleeding

Absence of fetal heart tones

Uterine enlargement andpreeclampsia is reported in only 3%of patients.

Theca lutein cysts, hyperemesis israre.


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Diagnosis of hydatidiform moleQuantitative beta-HCG

Ultrasound is the criterion standard for

identifying both complete and partialmolar pregnancies. The classic imageis of a snowstorm pattern


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The most common symptom of a mole isvaginal bleeding during the first trimester

however very often no signs of a problemappear and the mole can only be diagnosed byuse of ultrasound scanning. (rutting check)

Occasionally, a uterus that is too large for thestage of the pregnancy can be an indication.

NOTE: Vaginal bleeding does not alwaysindicate a problem!

Diagnosis


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Differential diagnosis

Abortion

Multiple pregnancy

Polyhydramnios


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Treatment

Suction dilation and curettage :to removebenign hydatidiform moles

When the diagnosis of hydatidiform mole isestablished, the molar pregnancy should beevacuated.

An oxytocic agent should be infused

intravenously after the start of evacuationand continued for several hours to enhanceuterine contractility


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Removal of the uterus (hysterectomy) :used rarely to treat hydatidiform moles if

future pregnancy is no longer desired.

Treatment


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Chemotherapy with asingle-agent drug

Prophylactic (for prevention)chemotherapy at the time ofor immediately followingmolar evacuation may be

considered for the high-riskpatients( to prevent spreadof disease )

Treatment


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High-risk postmolar

trophoblastic tumor1. Pre-evacuation uterine size larger than expected

for gestational duration

2. Bilateral ovarian enlargement (> 9 cm thecalutein cysts)

3. Age greater than 40 years

4. Very high hCG levels(>100,000 m IU/ml)

5. Medical complications of molar pregnancy such astoxemia, hyperthyrodism and trophoblasticembolization (villi come out of placenta )

6. repeat hydatidiform mole


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Patients with hudatidiform mole arecurative over 80% by treatment of

evacuation. The follow-up after evacuation is key

necessary

uterine involution, ovarian cystregression and cessation of bleeding

Follow-up


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Quantitative serum hCG levels shouldbe obtained every 1-2 weeks until

negative for three consecutivedeterminations,

Followed by every 3 months for 1years.

Contraception should be practicedduring this follow-up period

Follow-up

Documents

Gestational Trophoblastic Diseases Hydatiform Mole