Undergraduate course lectures in Obstetrics&Gynecology .Faculty of medicine,Zagazig University .Prepared by DR Manal BEHERY

1. Gestational
Trophoblastic Disease

2. Definition
A clinical spectrum including all
neoplasm derived from
abnormal trophoblastic
proliferation

3. Classification
1. Hydatidiform (vesicular )mole
Complete and Partial
2. Invasive mole
3. Choriocarcinoma
4. Placental-site trophoblastic
tumor

4. Vesicular mole
Vesicular mole
Vesicular mole
Vesicular mole

5. It is a benign neoplasm of the chorionic villi
characterized by
1. Marked proliferation of the trophoplast,both the
syncytium & cytotrophoplast are affected.
2. Oedema or hydropic degeneration of the
connective tissue stroma of the villi which leads
to their distension and formation of vesicles.
3. Avascularity of the villi: the blood vessels
disappear from villi explaining early death of
the embryo

6. The microscopic appearance of hydatidiform
: mole
Hyperplasia of trophobasitc cells •
Hydropic swelling of all villi •
Vessles are usually absent •

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

8. Pathology
The uterus is distended by
thin walled, translucent,
grape-like vesicles of
different sizes.
• These are degenerated chorionic villi
filled with fluid.
• There is no vasculature in the chorionic
villi leads to early death of the embryo.

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

10. :i) Complete mole(
• The whole conceptus is transformed
into a mass of vesicles.
• No embryo is present.
• It is the result of fertilization of
enucleated ovum ( has no
chromosomes) with a sperm which
will duplicate giving rise to 46
chromosomes of paternal origin only.

11. :i) Complete mole(

12. Complete mole

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

14. Partial mole

15. (ii) Partial mole

16. Differentiation between complete and partial
mole
Feature Complete Mole Partial Mole
Embryonic or Absent Present
foetal tissue
Swelling of the Diffuse Focal
villi
Trophoblastic Diffuse Focal
hyperplasia
Karyotype Paternal 46 XX Paternal and
(96%) or 46 XY (4%) maternal 69 XXY
or 69 XYY
Malignant 5-10% Rare

17. Diagnosis

18. (A) Symptoms
1.Amenorrhoea: usually of short period
(2-3 months).
2.Exaggerated symptoms of pregnancy
especially vomiting.
3.Symptoms of preeclampsia may be
present as headache, and oedema

19. (A) Symptoms
4. Vaginal bleeding :
• The main complaint, due to separation of
vesicles from uterine wall, there may be a
blood stained watery discharge, the watery
part is from ruptured vesicles.
• Prune juice disharge may occur.
• The blood is brown because it has retained
for sometime in the uterine cavity.
• passage of vesicles is diagnostic.
• The blood may be concealed causing
enlargment & tenderness of the uterus.

20. (A) Symptoms
5. Abdominal pain : may be
- dull-aching due to rapid distension of the
uterus by the mole or by cocealed
haemorrhage.
- Colicky due to starting expulsion,
- Sudden And Severe due to perforating mole
- Ovarian pain due to stretching of the ovarian
capsule or complication in the cystic ovary as
torsion

21. Signs

22. General examination
1.Pre-eclampsia in 20-30% of cases, usually
before 20 weeks’ gestation.
2.Pallor indicating anemia may be present.
3.Hyperthyroidism in 3-10% of cases
manifested by enlarged thyroid gland,
tachycardia (due to chorionic thyrotropin
secreted by trophoplast &HCG also has a
thyroid stimulating effect.
4.Breast signs of pregnancy.

23. Abdominal examination
1.The uterus is >the period of amenorrhoea in
50% of cases, corresponds to it in 25% and
smaller in 25% with inactive or dead mole.
2.The uterus is doughy in consistency due to
absence of amniotic fluid and its distension
with vesicles.
3.Fetal parts and heart sound cannot be detected
except in partial mole.

24. Local examination
1. Passage of vesicles (sure sign).
2. Bilateral ovarian cysts in 50%
of cases.
3. No internal ballottement.

25. (C) Investigations
1.Urine pregnancy test:
is positive in high dilution.
• 1/200 is highly suggestive,
• 1/500 is surely diagnostic.
• In normal pregnancy it is positive in
dilutions up to 1/100.
2. Serum b -hCG level
is highly elevated ( > 100.000 mIU/m1).

26. (C) Investigations
3. Ultrasonography reveals:
• The characteristic intrauterine " snow
storm" appearance,
• no identifiable foetus,
• bilateral ovarian cysts may be detected.
4. X-ray to the abdomen: shows no foetal
skeleton.
5. X-ray of the chest: should be performed in
every case of trophoplastic tumour.

27. Partial Mole: Complex mass with many
cystic areas (between arrowheads) and
an embryo (arrow) in a patient with a β-
HCG of 280,000 mIU/ml

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

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

30. Complications
1. Haemorrhage.
2. Infection due to absence of the amniotic sac and
due to the large surface area left after expulsion
or evacuation of the mole.
3. Perforation of the uterus. Spontaneous by a
perforating mole or during evacuation.
4. Pregnancy induced hypertension
5. Hyperthyroidism.
6. Subsequent development of choriocarcinoma in
about 5% of cases and invasive mole in about
10% of cases.
7. Recurrent mole may occur(1-2%).

31. Treatment
 When the diagnosis of hydatidiform mole is
established, the molar pregnancy should be
evacuated.
 Suction dilation and curttage to remove
benign hydatidiform mole
 An oxytocic agent 20 units oxytocin in 500 m1 of
5% glucose should be infused intravenously
after the start of evacuation and continued for
several hours to enhance uterine urettage
:contractility

32. (I) Suction evacuation
Dilatation of the cervix is done up to a Hegar's
number equal to the period of amenorrhoea in
weeks e.g. No. 10 Hegar for 10 weeks’
amenorrhoea
- The suction canula used will be of the same
size also.

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

34. The material removed is sent for histological
examination to exclude malignancy .

35. Curettage
• After evacuation ,
• the uterus is gently curetted with a
sharp curette.
• Some advise curettage one week after
evacuation to ensure complete
removal, but the is not the routine
practice.

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

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

38. (II)Hysterotomy
It may be needed for evacuation of
a large mole to minimize and
facilitate control of bleeding.

39. (III) Hysterectomy
It should be considered in women over
40 years who have completed their
family for fear of
developing
choriocarcinoma.

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

41. Follow up
 As choriocarcinoma may complicate
the vesicular mole after its
evacuation, detection of serum ß-
hCG by radioimmunoassay is
essential
 Normally B –subunit reach normal
level 8-12 wks after evacuation

42. Follow up
• ß-hCG is measured by
• radioimmunoassay every week till the
test becomes negative for 3 successive
weeks, then the test is repeated every
month for one year.
• Pregnancy is allowed if the test remains
negative for one year.

43. Follow up
- Persistent high level indicates remnants of
molar tissues which necessitate
chemotherapy ( methotrexate) with or
without curettage. Hysterectomy is
indicated if women had enough children.
- Rising hCG level after disappearance
means developing of choriocarcinoma or
a new pregnancy.

44. Follow up
It is expected that urine pregnancy
test is negative 4 weeks after
evacuation
* Serum B-hCG is undetectable 4
months after evacuation.

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

46. IUD during follow up
The intrauterine device is not used
because it may lead to irregular
uterine bleeding which confuses the
follow up

47. Invasive mole or
Chorioadenoma
Destruens

48. Definition
• It is a trphoplastic tumour with
penetration of the myometrium by the
chorionic villi.
• It is locally malignant
and rarely metastasizes.
It may lead to perforation
of uterus

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

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

51. Early features suggesting persistant GTN
or post molar syndrome include
1. Recurrent Or Persistent Vaginal
Bleedig
2. Subinvoluation
3. Amenorrhoea
4. Persistence of ovarian enlargement.
5. No malignancy in endometrial biopsy

52. Chemotherapy
Started if persistant or malignant disease •
develop
The level of serum HCG doubles in 2 weeks),
after exclusion of a new pregnancy
 plateaus failure HCG to decrease over 3
weeks) or
 the test for the hormone becomes positive
after being negative or
 If metastases appear.

54. Definition
A malignant form of GTD which can
develop from a hydatidiform mole or from
placental trophoblast cells associated with
a healthy fetus ,an abortion or an ectopic
.pregnancy

55. Symptoms and signs
• Bleeding
• Infection
• Abdominal swelling
• Vaginal mass
• Lung symptoms
• Symptoms from other metastases

56. Doppler image of choriocarcinoma