Gestational Trophoblastic Diseases Hydatiform Mole
Transcript of 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