undergraduate course lectures in Obstetrics&Gynecology Prepared by Dr Manal Behery,PROFESSOR OF OB&GYNE.Faculty of medicine,Zagazig University

1. GestationalGestational
Trophoblastic DiseaseTrophoblastic Disease

2. ClassificationClassification
1.1. Hydatidiform (vesicular )moleHydatidiform (vesicular )mole
Complete and PartialComplete and Partial
2.2. Invasive moleInvasive mole
3.3. ChoriocarcinomaChoriocarcinoma
4.4. Placental-site trophoblastic tumorPlacental-site trophoblastic tumor

3. Vesicular moleVesicular moleVesicular moleVesicular mole
Vesicular moleVesicular moleVesicular moleVesicular mole

4. It is a benign neoplasm of the chorionic villiIt is a benign neoplasm of the chorionic villi
characterized bycharacterized by
1.1. Marked proliferation of the trophoplast,bothMarked proliferation of the trophoplast,both
the syncytium & cytotrophoplast are affected.the syncytium & cytotrophoplast are affected.
2.2. Oedema or hydropic degeneration of theOedema or hydropic degeneration of the
connective tissue stroma of the villi which leadsconnective tissue stroma of the villi which leads
to their distension and formation of vesicles.to their distension and formation of vesicles.
3.3. Avascularity of the villi: the blood vesselsAvascularity of the villi: the blood vessels
disappear from villi explaining early death ofdisappear from villi explaining early death of
the embryothe embryo
• Hyperplasia of trophobasitc cells
• Hydropic swelling of all villi
• Vessels are usually absent
Normal
villaVM

5. IncidenceIncidence
 1:2000 pregnancies in United States and Europe,1:2000 pregnancies in United States and Europe,
10 times more in Asia.10 times more in Asia.
 Predisposing factors includePredisposing factors include ::
Race, deficiency of protein or caroteneRace, deficiency of protein or carotene
 The incidence is higher toward the beginning andThe incidence is higher toward the beginning and
more toward the end of the childbearing period.more toward the end of the childbearing period.
 It is 10 times more in women over 45 years old.It is 10 times more in women over 45 years old.

6. PathologyPathology
The uterus is distended byThe uterus is distended by
thin walled, translucent,thin walled, translucent,
grape-likegrape-like vesiclesvesicles ofof
different sizes.different sizes.
 These areThese are degenerated chorionic villidegenerated chorionic villi filled withfilled with
fluid.fluid.
 There isThere is no vasculature in the chorionic villino vasculature in the chorionic villi
leads to early death of the embryo.leads to early death of the embryo.

7.  High hCG causesHigh hCG causes multiple theca lutein cystsmultiple theca lutein cysts
in the ovaries in about 50% of cases.in the ovaries in about 50% of cases.
 Cysts may reach a large size (10 cm or more.Cysts may reach a large size (10 cm or more.
 Cysts disappearCysts disappear
 within few months(2-3),within few months(2-3),
 after evacuation of the mole.after evacuation of the mole.
PathologyPathology

8. (i) Complete mole(i) Complete mole
 The whole conceptus is transformed into aThe whole conceptus is transformed into a
mass of vesicles.mass of vesicles.
 No embryoNo embryo is present.is present.
 It is the result of fertilization of enucleatedIt is the result of fertilization of enucleated
ovum ( has no chromosomes) with a spermovum ( has no chromosomes) with a sperm
which will duplicate giving rise towhich will duplicate giving rise to 4646
chromosomeschromosomes ofof paternal originpaternal origin only.only.

9. (i) Complete mole:(i) Complete mole:

10. Complete moleComplete mole

11. (ii) Partial mole(ii) Partial mole
- A part of trophoblastic tissue only showsA part of trophoblastic tissue only shows
molar changes.molar changes.
- There is a fetus or at least an amniotic sac.There is a fetus or at least an amniotic sac.
- It is the result of fertilization of an ovum by- It is the result of fertilization of an ovum by
2 sperms so the chromosomal number is 692 sperms so the chromosomal number is 69
chromosomeschromosomes

12. Partial molePartial mole

13. ((ii) Partial moleii) Partial mole

14. Differentiation between complete and partial moleDifferentiation between complete and partial mole
FeatureFeature Complete MoleComplete Mole Partial MolePartial Mole
Embryonic orEmbryonic or
foetal tissuefoetal tissue
Absent Present
Swelling of theSwelling of the
villivilli
Diffuse Focal
TrophoblasticTrophoblastic
hyperplasiahyperplasia
Diffuse Focal
KaryotypeKaryotype Paternal 46 XX
(96%) or 46 XY (4%)
Paternal and
maternal 69 XXY
or 69 XYY
MalignantMalignant 5-10% Rare

15. Diagnosis

16. (A)(A) SymptomsSymptoms
1.1. AmenorrhoeaAmenorrhoea:: usually of short period (2-3usually of short period (2-3
months).months).
2.2. Exaggerated symptomsExaggerated symptoms of pregnancyof pregnancy
especially vomiting.especially vomiting.
3.Symptoms of preeclampsia may be present as3.Symptoms of preeclampsia may be present as
headache, and oedemaheadache, and oedema

17. 4.4. Vaginal bleedingVaginal bleeding ::
 The main complaint, due to separation of vesiclesThe main complaint, due to separation of vesicles
from uterine wall, there may be a blood stainedfrom uterine wall, there may be a blood stained
watery discharge, the watery part is from rupturedwatery discharge, the watery part is from ruptured
vesicles.vesicles.
 Prune juicePrune juice discharg may occur.discharg may occur.
 passage of vesiclespassage of vesicles is diagnosticis diagnostic..
 The blood may be concealed causing enlargementThe blood may be concealed causing enlargement
& tenderness of the uterus.& tenderness of the uterus.
(A) Symptoms(A) Symptoms

18. 5.5. Abdominal painAbdominal pain ::- dull-aching- dull-aching ,-,- ColickyColicky oror
Sudden And SevereSudden And Severe due to perforating moledue to perforating mole
- Ovarian painOvarian pain due to stretching of the ovariandue to stretching of the ovarian
capsule or complication in the cystic ovary ascapsule or complication in the cystic ovary as
torsiontorsion
(A) Symptoms(A) Symptoms

19. Signs

20. General examinationGeneral examination
1.1. Pre-eclampsiaPre-eclampsia in 20-30% of cases, usuallyin 20-30% of cases, usually
before 20 weeks’ gestation.before 20 weeks’ gestation.
2.2. PallorPallor indicating anemia may be presentindicating anemia may be present..
3.3. HyperthyroidismHyperthyroidism in 3-10% of casesin 3-10% of cases
4.4. ..
5.5. Breast signsBreast signs of pregnancy.of pregnancy.

21. Abdominal examinationAbdominal examination
1.1. The uterus is >the period ofThe uterus is >the period of
amenorrhoea in 50% of cases,amenorrhoea in 50% of cases,
corresponds to it in 25% andcorresponds to it in 25% and
smaller in 25% with inactive or dead mole.smaller in 25% with inactive or dead mole.
1.1. The uterus is doughy in consistency due toThe uterus is doughy in consistency due to
absence of amniotic fluid and its distensionabsence of amniotic fluid and its distension
with vesicles.with vesicles.
2.2. Fetal parts and heart sound cannot be detectedFetal parts and heart sound cannot be detected
except in partial mole.except in partial mole.

22. Local examinationLocal examination
1.1. Passage of vesicles (sure sign).Passage of vesicles (sure sign).
2.2. Bilateral ovarian cysts in 50% of cases.Bilateral ovarian cysts in 50% of cases.
3.3. No internal ballottement.No internal ballottement.

23. (C) Investigations(C) Investigations
Serum b -hCG levelSerum b -hCG level
is highly elevated ( > 100.000 mIU/m1is highly elevated ( > 100.000 mIU/m1))
"" snow stormsnow storm" appearance,on US" appearance,on US
no identifiable fetus,no identifiable fetus,
 X-rayX-ray of the chest: should be performed inof the chest: should be performed in
every case of trophoplastic tumouevery case of trophoplastic tumour.r.

24. Partial Mole: Complex mass with manyPartial Mole: Complex mass with many
cystic areas (between arrowheads) and ancystic areas (between arrowheads) and an
embryo (arrow) in a patient with aembryo (arrow) in a patient with a ββ-HCG-HCG
of 280,000 mIU/mlof 280,000 mIU/ml

25. Complete MoleComplete Mole
Complete mole:Complete mole:
“snowstorm” appearance“snowstorm” appearance
with multiple cystic areas, nowith multiple cystic areas, no
fetal tissue presentfetal tissue present
Corresponding T1 weightedCorresponding T1 weighted
MRI (MRI can be helpful inMRI (MRI can be helpful in
determining extent ofdetermining extent of
trophoblastic disease)trophoblastic disease)

26. A real-time ultrasound of a hydatidiform mole.
The dark circles of varying sizes at the top
center are the edematous villi.

27. ComplicationsComplications
1.1. Haemorrhage.Haemorrhage.
2.2. InfectionInfection
3.3. Perforation.Perforation.
4.4. Pregnancy induced hypertensionPregnancy induced hypertension
5.5. Hyperthyroidism.Hyperthyroidism.
6.6. choriocarcinoma in about 5% of cases andchoriocarcinoma in about 5% of cases and
7.7. invasive mole in about 10% of cases.invasive mole in about 10% of cases.
8.8. Recurrent mole may occur(1-2%).Recurrent mole may occur(1-2%).

28. TreatmentTreatment
 molar pregnancy should be evacuated.molar pregnancy should be evacuated.
 Suction dilation and curttageSuction dilation and curttage
 20 units oxytocin in 500 m1 of 5% glucose20 units oxytocin in 500 m1 of 5% glucose
should be infused IV after the start ofshould be infused IV after the start of
evacuation and continued for several hours toevacuation and continued for several hours to
enhance uterine contractilityenhance uterine contractility

29. Dilatation of the cervixDilatation of the cervix is done up to a Hegar'sis done up to a Hegar's
number equal to the period of amenorrhoea in weeksnumber equal to the period of amenorrhoea in weeks
e.g. Ne.g. Noo. 10 Hegar for 10 weeks’ amenorrhoea. 10 Hegar for 10 weeks’ amenorrhoea
- The suction canula used will beThe suction canula used will be
- of the same size also.of the same size also.
(I) Suction evacuation(I) Suction evacuation

30. (I) Suction evacuation(I) Suction evacuation
- A suction canula which may be metal or aA suction canula which may be metal or a
disposable plastic (preferred) is introduceddisposable plastic (preferred) is introduced
into the uterine cavity.into the uterine cavity.
- The canula is connected to a suction pumpThe canula is connected to a suction pump
adjusted at negative pressure of 300-500adjusted at negative pressure of 300-500
mmHg according to the duration of pregnancymmHg according to the duration of pregnancy

31. The material removed is sent forThe material removed is sent for
histological examination to excludehistological examination to exclude
malignancymalignancy ..

32. CurettageCurettage
 After evacuation ,After evacuation ,
 the uterus is gently curetted with a sharpthe uterus is gently curetted with a sharp
curette.curette.
 Some advise curettage one week afterSome advise curettage one week after
evacuation to ensure complete removal,evacuation to ensure complete removal,
but the is not the routine practice.but the is not the routine practice.

33. Theca lutein cystsTheca lutein cysts
 They are hormone dependent.They are hormone dependent.
 Disappear spontaneously after evacuation ofDisappear spontaneously after evacuation of
the mole.the mole.
 So, they are not removed surgically unlessSo, they are not removed surgically unless
complication occur as torsion or rupture.complication occur as torsion or rupture.

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

35. (II)Hysterotomy(II)Hysterotomy
may be needed for evacuation of a largemay be needed for evacuation of a large
mole to minimize and facilitate control ofmole to minimize and facilitate control of
bleeding.bleeding.
should be considered in women >40 yearsshould be considered in women >40 years
who have completed their family for fearwho have completed their family for fear
of developingof developing
choriocarcinoma.choriocarcinoma.
(III) Hysterectomy

36. (IV) Medical induction(IV) Medical induction
Oxytocins and / or prostaglandins may beOxytocins and / or prostaglandins may be
used to encourage expulsion of the moleused to encourage expulsion of the mole
but must always be followed by surgicalbut must always be followed by surgical
evacuation.evacuation.

37. Follow upFollow up
 detection of serum ß-hCG bydetection of serum ß-hCG by
radioimmunoassay is essentialradioimmunoassay is essential
 Normally B –subunit reach normalNormally B –subunit reach normal
level 8-12 wks after evacuationlevel 8-12 wks after evacuation

38.  ß-hCG is measured byß-hCG is measured by
 radioimmunoassay every week till the testradioimmunoassay every week till the test
becomes negative for 3 successive weeks, thenbecomes negative for 3 successive weeks, then
the test is repeated every month for one year.the test is repeated every month for one year.
 Pregnancy is allowed if the test remainsPregnancy is allowed if the test remains
negative for one year.negative for one year.
Follow upFollow up

39. Follow upFollow up
- Persistent high level or Rising hCG level afterPersistent high level or Rising hCG level after
disappearance means developing ofdisappearance means developing of
choriocarcinoma or a new pregnancy.choriocarcinoma or a new pregnancy.
- Serum B-hCG is undetectable 4 months afterSerum B-hCG is undetectable 4 months after
evacuation.evacuation.
-

40. Contraception during follow upContraception during follow up
 The combined pill is started when the beta-The combined pill is started when the beta-
HCG becomes negative. Till this happens,HCG becomes negative. Till this happens,
the condom can be used.the condom can be used.
 If the pill is used early the beta-HCG willIf the pill is used early the beta-HCG will
take a longer time to become negative astake a longer time to become negative as
oestrogen stimulates the growth ofoestrogen stimulates the growth of
trophoplast.trophoplast.

41. The intrauterine device is not used becauseThe intrauterine device is not used because
it may lead to irregular uterine bleedingit may lead to irregular uterine bleeding
which confuses the follow upwhich confuses the follow up
IUD during follow upIUD during follow up

42. Invasive moleInvasive mole oror
ChorioadenomaChorioadenoma
DestruensDestruens

43. DefinitionDefinition
 It is a trphoplastic tumour with penetrationIt is a trphoplastic tumour with penetration
of the myometrium by the chorionic villi.of the myometrium by the chorionic villi.
 It is locally malignantIt is locally malignant
and rarely metastasizesand rarely metastasizes..
It may lead to perforationIt may lead to perforation
of uterusof uterus

44. A case of invasive mole: inside the uterine cavity the typicalA case of invasive mole: inside the uterine cavity the typical
““snow storm” appearance can be detected, The location ofsnow storm” appearance can be detected, The location of
blood flow suggest an invasive mole.blood flow suggest an invasive mole.

45. The same patient owing to the myometrial invasion.The same patient owing to the myometrial invasion.
Reduced vascular resistance is detected in the uterine artery.Reduced vascular resistance is detected in the uterine artery.

46. Early features suggesting persistant GTN orEarly features suggesting persistant GTN or
post molar syndrome includepost molar syndrome include
1.1. Recurrent Or Persistent Vaginal BleedigRecurrent Or Persistent Vaginal Bleedig
2.2. SubinvoluationSubinvoluation
3.3. AmenorrhoeaAmenorrhoea
4.4. Persistence of ovarian enlargement.Persistence of ovarian enlargement.
5.5. No malignancy in endometrial biopsyNo malignancy in endometrial biopsy

47. ChemotherapyChemotherapy
 Started if persistant or malignant disease developStarted if persistant or malignant disease develop
 The level of serum HCG doubles in 2 weeks), afterThe level of serum HCG doubles in 2 weeks), after
exclusion of a new pregnancyexclusion of a new pregnancy
 plateaus failure HCG to decrease over 3 weeks)plateaus failure HCG to decrease over 3 weeks)
oror
 the test for the hormone becomes positive afterthe test for the hormone becomes positive after
being negative orbeing negative or
 If metastases appear.If metastases appear.

49. DefinitionDefinition
A malignant form of GTD which canA malignant form of GTD which can
develop from a hydatidiform mole or fromdevelop from a hydatidiform mole or from
placental trophoblast cells associated with aplacental trophoblast cells associated with a
healthy fetus ,an abortion or an ectopichealthy fetus ,an abortion or an ectopic
pregnancy.pregnancy.

50. Symptoms and signsSymptoms and signs
 BleedingBleeding
 InfectionInfection
 Abdominal swellingAbdominal swelling
 Vaginal massVaginal mass
 Lung symptomsLung symptoms
 Symptoms from other metastasesSymptoms from other metastases

51. Doppler image of choriocarcinoma