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Gestational → pregnancy
Tropho → nutrition
Blast → bud/early developmental cell
GTD → begins in the layer of cell called trophoblast
that normally surrounds an embryo.
The term gestational trophoblastic disease refers to
pregnancy-related trophoblastic proliferative
• Abnormal growth of cells inside a women’s
• Dont develop from cells of uterus.
• Starts in the cells that would normally develop
• Most GTD’s are benign, some are cancerous.
Relationship of HM. IM. CH
hydatidiform therapeutic or
mole spontaneous abortion
invasion mole choriocarcinoma.
It is a neoplastic proliferation of the trophoblast in which
the terminal villi are transformed into vesicles filled with
clear viscid material.
fertilizes by paternal X’s only
46 XX (diploidy)
20% → malignancy
No chemo,serum beta hCG
(-ve) f/u 1 year on OCPs.
Maternal & paternal X’s
Fetus non viable
10% → malignancy
No chemo,serum beta hCG(-ve)
f/u 1 year on OCPs.
• The entire uterus
no signs of fetus
evidence of a
NON METASTASIS GOOD PROGNOSIS POORPROGNOSIS
↓ ↓ ↓
Uterus only pelvis/lungs brain/liver
100% cure > 95% cure 65% cure
SINGLE AGENT CHEMOTHERAPY MULTIPLE AGENT
1Y,F/U ON OCS AFER β hCG(-ve) CHEMOTHERAPY
5 Y F/U ON OCS AFTER
Though it is not known a number of associated factors
have been noted:
the absence of fetal circulation;
dietary protein deficiency
age:>45 years women are 10 times more likely to
develop HM than those younger
abnormal fertilization process:
the fertilization of a normal ovum with a
duplicated haploid sperm:46XX
the fertilization of an empty egg by two
• The antecedent pregnancy is :
Hydatidiform mole in about 57% of
Normal pregnancy in about 26% of
Abortion and ectopic pregnancy in
about 17% of cases.
Site: In the uterus 90% of
cases; 10 % of cases in the
ovaries ,vagina, vulva, lung,
liver, and brain.
Uterus: It may be localized in the form of
hemorrhagic polyp or multiple hemorrhagic
,necrotic masses in the cavity.
Some times it is present in the uterine
wall (intramural) and the cavity is empty.
Ovaries : May show stormal
lutein hyperplasia, and theca-
lutein cysts. And may be site of
Malignant hyperplasia of both
Absence of villi.
Destruction of the surrounding myomatrum.
• Blood : The main method of spread ,and occurs
Genital : Vagina, vulva, and ovary.
Extra genital : Lung, liver, brain, and bones
especially skull and spine.
The lung is the commonest site for secondaries
and haemoptysis may be the presenting
Causes of death
• Vaginal bleeding.
• Intraperitoneal hemorrhage.
• Metastasis to the vaital organs e.g,brain.
• Pulmonary complications.
i) Women age being under 20 years ,above 35
years of age.
ii) Previous GRD
iii) Being asia/ asian ethinicity
iv) Abo blood groups of parents appear to be a
v) Women with blood group A is higher risk
• Persistent GTD should be
considered in any woman
acute respiratory or neurological
symptoms after any pregnancy.
The clinical classification of gestational
A. Low risk: All patient of documented
metastatic disease who do not have “high-
1. B-hCG level higher than
2. Associated pregnancy episode
more than 4 months before the
• Gtd that is not cured by initial surgery.
• Mole grown from the surface layer of uterus
into the muscular layer below(myometrium)
• Can spread withi n the body like a malignant
• Treatment → chemotherapy
• Prophylaxis: After care of vesicular
D&C after one week of the
Monitored for the signs and symptoms of
trophoblastic neoplassmic by:.
I. serial hCG.
II. Diagnostic D&C is done if :
The hCG levels remains high.
The hCG levels rises after gets negative.
Uterine sub involution.
Persistence of theca lutein cysts in the
Every case of secondary postpartum
Every case of post abortive bleeding.
I. Non metastatic GTD:
o Methotrexate (antimetabolite) +folinic
o The cytotoxic therapy is controlled by
doing CBC,platelet count and LFT.
o After the the hCG level gets normal
;stop the therapy and follow-up by
weekly estimation of hCG levels.
• Women scoring: Non metastatic
GTD,and(low risk) GTD receive
intramuscular methotrexate on
alternate days, followed by six rest
days, with each course consisting of
o Physical examination, chest x-ray,
o Total abdominal hysterectomy ,if the
patient does not desire to maintain
child-bearing, in the middle of the
first treatment course .
II.Low metastatic GTD:
o Methotraxate , or Actinomycin D
,if there is resistance ,change to
III.High risk metastatic GTD :
o Triple chemotherapy :
Actinomycin D, and
• After successful therapy ,the hCG levels
are obtained :
every 2weeks for 3 months,
every month for 3months,
every 2months for 6 months then every
sixes months indefinitely.
• If at any time hCG levels rises, repeat
the evaluation , staging ,and
• Physical examination, and chest x-ray
follow-up at 6 weeks, then every
3months for one year, then every 6
months for one year.
• If a further molar pregnancy does occur,
in 68–80% of cases it will be of the
same histological type
• Women who undergo chemotherapy
are advised not to conceive for one
year after completion of treatment
• Hydatidiform mole : grown into →muscular layer
of uterus .
• Develop from both complete (common)& partialmoles.
• Develop in a little less than 1 out of 5 women who had a
complete mole removed.
• Risk:Women> 40 years ,has had GTD in the past.
• Sometimes go away on their own,bt most often more treatment
• A tumor/mole that grows completely through the wall of uterus
may result in bleeding into abdominal/pelvic cavity;this can be
• Malignant form of GTD.
• Develops from: complete(common)&partial moles,
normal pregnancy, miscarriage.
• Rarely can develop that are not related to
pregnancy(areas other than uterus)
• Develop in ovaries ,testicles, chest or abdomen.
• These cases :it is mixed with other types of cancer
→mixed germ cell tumor.
• Very rare form of GTD
• Develops: placenta attaches the lining of uterus.
• Develops after:normal pregnancy/abortion but may
develop after a complete/partial mole.
• Most of them don’t spread to other parts of body.
• Tendency to grow(invade) the muscular layer of uterus.
• Insensitive to chemo drugs,surgery is aimed at completely
removing the disease.
i)Evacuation of pregnancy : relief of symptoms
Suction curettage is prefered method of evacuation.
ii) Hysterectomy : if no other pregnancy is wished
by the patient.
iii)Chemotherapy drugs : methotrexate (IV) systemic.
iv) Advised not to get pregnant for 1 year after
completion of treatment.
• Pre-operative working
• Histology benign
• Histology malignancy
• Bleeding ,nausea& vomiting
• Fundus> before date
→no Fetal heart tone
• Snowstorm fetus absent
→honey coomb,fetus present
• hCG tilter serum,chest x ray
→suction empty the uterus
• Complete &incomplete H.moles
• Good&poor prognosis
PROGNOSIS & STAGING
• Women with a hydatidiform mole have an
• Choriocarcinoma →→ highly malignant tumor life
Patient compliants ????
Vaginal bleeding…passage of
grapes(villi ie vesicles)
• No fetal sounds(tone)
• Uterus extends to her