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Presented by: Dr. Mashael Shebaili Assistant Prof. Consultant Ob

Classification of gestational Trophoblastic disease. WHO Classification. Malignant neoplasms of various types of trophoblats. Malformations of the chorionic villi that are predisposed to develop trophoblastic malignacies. Benign entities that can be confused with with these other lesions. Choriocarc

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Presented by: Dr. Mashael Shebaili Assistant Prof. Consultant Ob

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    2. Classification of gestational Trophoblastic disease

    3. Hydatidiform Mole Definition: In latin "hydatid" means "drop of water "mole" means "spot Pathologically, Hydatidiform moles represents placentas with abnormally developed chorionic villi (enlarged, edematous and vesicular villi with variable amounts of proliferative trophoblast)

    5. Hydatidiform Mole Incidence: In the United States, 1in 600 therapeutic abortions 1 in 1,500 pregnancies Internationally: In Japan & China, 1-2 in 1,000 pregnancies In Indonesia & India, 12 in 1,000 pregnancies In the United Arab of Emirates, 2 in 1000 deliveries (population-based study; Graham IH, Fajardo AM; 1988) In Saudi Arabia; 1.48 in 1000 live births (hospital-based study; Felemban AA, et al; 1969)

    10. Pathogenesis and Cytogenetics of HM

    11. Complete Mole, Pathogenesis

    12. Complete Mole, Pathogenesis

    13. Partial Mole, Pathogenesis

    14. Hydatidiform Mole

    16. Hydatidiform Mole Clinical Presentation: Complete mole:

    17. Hydatidiform Mole

    18. Hydatidiform Mole

    19. Hydatidiform Mole

    20. Hydatidiform Mole

    21. Hydatidiform Mole Clinical Presentation: Partial mole: History: Vaginal bleeding Usually diagnosed as missed or incomplete abortion Physical: A uterus small or equal to gestational age

    22. Hydatidiform Mole Diagnosis: History Clinical examination Ultrasound examination Serum hCG levels Histopathological examination Cytogenetic and molecular biological examination

    23. Hydatidiform Mole Diagnosis: Ultrasonography: * The diagnosis of molar pregnancy is nearly always made by ultrasonography

    26. Hydatidiform Mole Diagnosis: Ultrasonography:

    27. Hydatidiform Mole Diagnosis: Ultrasonography: However, based on ultrasound, correct diagnosis can be suspected in only: 84% of patients with complete mole and 30% of patients with partial mole (Lindholm and Flam, 1999) The accuracy of ultrasonogrophy is gestational age dependent In comlete mole: 100% of cases cane be diagnosed at a gestational age of 13 eeks or more 50% of cases cane be diagnosed in earlier pregnancies (Lazarus et al, 1999)

    28. Hydatidiform Mole Diagnosis: Serum hCG levels: Serum hCG levels of greater than 92 000 IU/l associated with absent fetal heart beat indicate a diagnosis of complete hydatidiform moles (Romero et al, 1985) Serum hCG level decreases quickly if the patient has an abortion, but it does not in molar pregnancy

    29. Hydatidiform Mole Diagnosis: Histopathological examination: It should always be done as far as possible and samples should be kept for DNA analysis for a final diagnosis when histology can not differentiate molar pregnancy from abortion

    39. Hydatidiform Mole Management:

    40. Hydatidiform Mole Management: History and physcal examination: Should aim to rule out the classic symptoms and signs that would lead to a diagnosis of: severe anemia dehydration preeclampsia thyrotoxicosis ?The patient should be stabilized hemodynamically ?

    41. Hydatidiform Mole Management: Investigations: Laboratory: Pre-evacuation hCG Complete blood count Electrolytes, BUN, creatinine Liver function tests Thyroid function tests Imaging: Pelvic ultrasound Chest x-ray

    42. Hydatidiform Mole Management: Medical care: Correction of: Anemia Dehydration Hyperthyroidism hypertension

    43. Hydatidiform Mole Management: Surgical care:

    44. Hydatidiform Mole Complications associated with molar pregnacy: Those related to the increased trophoblastic tissue volume: Theca-lutein cysts Pregnancy-induced hypertension, hyperthyroidism, Respiratory distress Hyperemesis Those related to its management: Uterine perforation

    45. Hydatidiform Mole, complications Theca-lutein cysts: Prevalence: Clinically evident theca lutein cysts (usually >56 cm) are detected in about 25-35% of women with molar pregnancies Association: They usually correlate with marked elevation of serum hCG levels above 100,000 IU/l Complications: Pain or pressure that may require percutaneous aspirations. Torsion, rupture, or bleeding are rare complications that can require oophorectomy Bilateral theca letein cysts increase the risk of post-molar GTD Course: The mean time for theca luteal cysts to regress is approximately 8 weeks

    46. Hydatidiform Mole, complications Respiratory distress syndrome: Prevalence: Rare Pathophysiology: Embolization of trophoblastic tissue Transient impairment of left ventricular function during induction of anesthesia for suction D&C of molar pregnancy coexisting conditions such as anemia, hyperthyroidism, hypertension from preeclampsia Risk factors: Uterine size larger than 14 to 16 weeks High levels of hCG

    47. Hydatidiform Mole, complications Respiratory distress syndrome: Presentation: Tachypnia and tachycardia following evacuation Bilateral pulmonary infiltrates on chest x-ray Management: Central venous monitoring Ventilatory support Course: It should resolve within 24 to 48 hours after molar evacuation

    48. Hydatidiform Mole, complications Hyperthyroidism: Prevalence: Clinical hyperthyroidism is seen in less than 10% of patients with molar pregnancies A small number of patients may have elevated thyroid function tests without clinical evidence of disease Management: Beta-blockers should be administered prior to molar evacuation to prevent thyroid storm that may be induced by anesthesia and surgery.

    49. Hydatidiform Mole A hydatidiform mole and a co-existent fetus: Prevalence: Rare (1 in 22,000100,000) partial moles and twin gestations with co-existent fetuses and molar gestations Diagnosis: Usually, by ultrasound Few, after examination of the placenta following delivery Complications: Increased risk of medical complications Increased risk for postmolar gestational trophoblastic disease Management: No clear guidelines for management

    50. Hydatidiform Mole Risk Factors for post-molar gestational trophoblastic disease: Advanced maternal age Factors that reflect the volume of trophoblastic tissue:Clinical factors that are associated with high hCG levels (>100,000 mIU/mL) uterus large for date, bilateral theca lutein cysts, Respiratory distress syndrome after molar evacuation, eclampsia, hyperthyroidism, Uterine subinvolution with post evacuation hemorrhage. (With any one of these factors or a combination of many, the risk of post-molar GTD has ranges from 25% to 100%)

    51. Hydatidiform Mole Risk Factors for post-molar gestational trophoblastic disease: The presence of invasive trophoblast antigen (ITA) which has 100% sensitivity and specificity for invasive trophoblastic tumors (Cole et la, 2003) *There is no correlation between the degree of anaplasia and the risk of post-molar GTD

    52. Hydatidiform Mole Prophylactic Chemotherapy: In one randomized clinical trial, a single course of methotrexate and folinic acid reduced the incidence of postmolar trophoblastic disease from 47.4% to 14.3% (P <.05) in patients with high-risk moles: hCG levels greater than 100,000 mIU/mL, uterine size greater than gestational age, ovarian size greater than 6 cm), However, the incidence was not reduced in patients with low-risk moles On the other hand, the use or prophylactic chemotherapy increases the risk of drug resistance Because of the excellent primary cure rates among women with post-molar GTD, and mortality achieved by monitoring patients with serial hCG determinations and instituting chemotherapy only in patients with postmolar gestational trophoblastic disease outweighs the potential risk and small benefit of routine prophylactic chemotherapy.

    53. Hydatidiform Mole Surveillance after molar pregnancy evacuation: Rationale: Prompt identification of patients who develop malignant postmolar gestational trophoblastic disease Method: Serial quantitative serum hCG determinations using commercially availableassays capable of detecting -hCG to baseline values(<5 mIU/mL) Frequency: within 48 hours of evacuation, weekly while elevated and then monthly when undetectable for 6 months in the case of partial moles and 12 months in the case of complete moles Pelvic examination: Duration: while hCG is elevated to monitor the involution of pelvic structures and to aid in the identification of vaginal metastasis

    54. Hydatidiform Mole Surveillance after molar pregnancy evacuation: Contraception: Rationale: Pregnancy obscures the value of monitoring hCG levels during this interval and may result in a delayed diagnosis of postmolar malignant gestational trophoblastic disease Method: Oral contraceptive pills Advantages: They do not increase the incidence of postmolar gestational trophoblastic disease They do not alter the pattern of regression of hCG values In a randomizedstudy, by Berkowitz et al in 1998, patients treated with oral contraceptives had one half as many intercurrent pregnancies as those using barrier methods, and the incidence of postmolartrophoblastic disease was lower in patients using oral

    55. Hydatidiform Mole Surveillance after molar pregnancy evacuation: What are the characteristics of false-positive hCG values, also known as phantom hCG? False positive hCG assays have been identified recently Cause: the presence of non-specific heterophil antibodies in the patients sera directed against animal antibodies present in commercial kits Should be suspected if hCG values plateau at relatively low levels and do not respond to therapeutic maneuvers Evaluation of patients with suspected false positive hCG: Urinary hCG Serial dilutions of the serum

    56. Hydatidiform Mole Prognosis: Post-molar gestational trophoblastic disease: Risk: Following complete mole: 20% Following partial mole: 5% Type: 70% to 90% are persistent or invasive moles 10% to 30% are choriocarcinomas Diagnosis: A rising, plateauing, or persistent elevation of human chorionic gonadotropin after evacuation of a hydatidiform mole or an ectopic or term pregnancy

    57. Hydatidiform Mole

    58. Pregnancy after Hydatidiform Mole: Risk of another molar pregnancy: Increased by 10-fold (12% incidence) Current recommendations for management of subsequent pregnancies: an early ultrasound to confirm normal gestational development and dates A chest x-ray to screen for occult metastasis masked by the hCG rise of pregnancy Examination of the placenta or products of conception histologically at the time of delivery or evacuation for evidence of occult trophoblastic disease An hCG level should be obtained 6 weeks post evacuation or delivery to confirm normalization.

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