1. GESTATIONAL TROPHOBLASTIC DISEASE

2. 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)

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

4. HYDATIDIFORM MOLE

6. 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

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

8. TYPES
COMPLETE
INCOMPLETE

9. 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

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

11. 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)

12. 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

13. 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

14. 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

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

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

18. 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

19. 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

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

21. 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

22. 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

23. 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

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

25. 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

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

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

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

29. MANAGEMENT……Contd DEFINITIVE MANAGEMENT GROUP A S/E or D/E
Oxytocin units in 500 ml 5% dextrose 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

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

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

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

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