GTD Case Study

1. GTD Case Study Diagnosis and management of hydatidiform mole Diagnosis and evaluation of postmolar GTN

2. Case Scenario • A 21 year old nulligravida presents with bleeding during early pregnancy. Last normal menses was 9 weeks ago, home urine pregnancy test was positive 2 weeks ago, and she has been spotting for two days with heavier bleeding the last 6 hours. • Examination: afebrile, BP 130/84, P 112, T 37.4. the patient is anxious and tremulous, oriented X 3. The uterine fundus is not tender and palpable mid-way between symphysis and umbilicus. FHTs not present. Pelvic: Cervical cyanosis, uterus enlarged to 14 weeks’ size, bilateral 6 cm cystic adnexal masses.

3. Questions • What is your differential diagnosis? • What initial diagnostic tests would you obtain? • What ancillary tests would be helpful for managing this patient?

4. Laboratory Results • Serum beta hCG 510,000 mIU/ml • Ultrasound: mixed echogenic intrauterine mass with no fetus identified. Bilateral septated ovarian cysts. • CBC: WBC 8,900; hct 27%; plates 252k • Electrolytes, Cr, LFTs normal • T4 elevated 2 X normal, TSH normal • CXR: No effusions, infiltrates, nodules or edema

5. Ultrasound Images

6. Questions • What is your primary diagnosis? • What are secondary diagnoses? • What is your management plan?

7. Initial Management • Beta blockers are begun to stabilize the secondary hyperthyroidism caused by stimulation from hCG • Blood is cross-matched in the event that transfusion is required • Large-bore IV is started • The patient is taken to the operating room for an emergent suction D & E to evacuate the hydatidiform mole • Theca lutein cysts will be monitored after evacuation, but do not require operative intervention

8. Initial Management • During suction D&E a large amount of grape-like tissue clusters are evacuated. EBL is 500 mL. Pitocin is started by IV infusion after cervical dilatation; there is prompt uterine involution and scant bleeding. • In the recovery room, the patient becomes tacchypneic and tacchycardic, with generalized rales. SaO2 is 88% on 2 liters oxygen via nasal prongs.

9. Questions • What is your differential diagnosis for this patient’s acute respiratory decompensation? • What diagnostic tests could be obtained to aid in management?

10. Post-evacuation CXR

11. Management of ARDS • CXR now demonstrates diffuse pulmonary edema with no evidence of trophoblasticembolization. • Electrolytes are normal, Cr normal. • Hct has fallen to 22%, WBC 11,000, and plates 300k • The patient is transferred to the ICU for monitoring in the event that intubation is required. • She is transfused, treated with furosemide, and improves with resolution of ARDS over 36 hours

12. Hospital Course • On POD #3 the patient is transferred out of the ICU with SaO2 98% on room air and ambulatory. • Uterine involution to 4-5 weeks’ size, persistent 6 cm cystic adnexal masses. No vaginal bleeding. • Pathology: Complete hydatidiform mole • hCG 80,000 mIu/mL • Hct 28% • Electrolytes, LFTs normal • T4 1.5 X normal

13. Questions • How should this patient be monitored after evacuation of hydatidiform mole? • Why is she being monitored? • How soon can she attempt pregnancy? • How should she prevent pregnancy during monitoring? • Are there any risks during subsequent pregnancy after a hydatidiform mole?

14. Monitoring after Hydatidiform Mole • The patient is scheduled for weekly serum quantitative beta hCG testing until normal values (<5 mIu/ml), and then monthly hCG values for at least 6 months. • Follow-up pelvic examination in 2-3 weeks to monitor her ovarian theca lutein cysts. Thyroid function tests will be repeated during that visit. • The patient is offered, and accepts, oral contraceptives to prevent pregnancy during monitoring with hCG values. • She is counseled that she has an increased (1-2%) risk of a second mole in subsequent pregnancies. • She is counseled that her risk of malignant GTN is increased (>50%) because of the very high hCG, theca lutein cysts and medical complications of her molar pregnancy

15. Monitoring after Hydatidiform Mole • The patient’s hCG rapidly drops to 8,000 mIU/mL by week 4 and examination reveals regressing ovarian cysts. Subsequent monitoring as follows: • Week 5: 7,800 mIU/mL • Week 6: 8,500 mIU/mL • Week 7: 10,050 mIU/ml – the patient reports increased vaginal spotting

16. Questions • What is your provisional diagnosis? • What additional diagnostic tests should be obtained? • What tests will be obtained to aid in management? • What general category of treatment will be given (eg: surgery, radiation therapy, chemotherapy)?

17. Evaluation of GTN • An ultrasound reveals persistent tissue in the uterus and bilateral 4 cm theca lutein cysts. • CXR reveals 3 new lesions, each 1-2 cm • Brain MRI is negative for metastases. • CT of chest/abdomen/pelvis reveals approximately 15 bilateral pulmonary subcentimeter metastases, in addition to the lesions noted above. No other metastases are noted. • hCG is confirmed to be 11,000 mIU/mL • CBC, electrolytes, Cr, and LFTs are essentially normal

18. Management • This patient has low-risk postmolar GTN. • FIGO Stage II by staging studies • FIGO risk score < 8 • She is offered single-agent chemotherapy with intramuscular methotrexate • She is counseled that her chance of cure without requiring multiagent chemotherapy or hysterectomy is > 90% and overall cure rates approach 100% • If hysterectomy can be avoided, future fertility is not affected by methotrexate • 1-2% risk of second mole