Download MBBS Gestational Trophoblastic Disease Lecture PPT

GESTATIONAL TROPHOBLASTIC
. DISEASE
? Group of tumors typified by abnormal trophoblast
proliferation
?

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Histologically :
1. hydatidiform mole
a) benign complete and partial mole
b) malignant invasive mole
2. non-molar trophoblastic malignant neoplasms

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a) choriocarcinoma
b) placental site trophoblastic tumor
c) epithelioid trophoblastic tumor

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GESTATIONAL TROPHOBLASTIC
. DISEASE

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PREMALIGNANT
GTN/MALIGNANT GT
CONDITIONS
DISEASE/PERSISTENT GT
DISEASE

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Complete hydatidiform
Invasive mole
mole
Choriocarcinoma
Partial hydatidiform

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Placental site trophoblastic
mole
tumor
Epithelioid trophoblastic
tumor

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HYDATIDIFORM MOLE
Classical histological findings of molar pregnancy

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include trophoblastic proliferation and villi with
stromal edema
Hydropic degeneration and avascularity of chorionic
villi..
Degree of histological changes,karyotypic

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differences,absence or presence of embryonic
elements ... a) complete mole
b) partial mole
GTN frequently follows complete hydatidiform mole

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PATHOGENESIS ....
COMPLETE MOLE:
duplication of chromosome of haploid sperm after
meiosis ,following fertilization of inactivated or empty
ovum; 46XX.

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androgenesis.
Less commonly chromosomal pattern 46XX and 46XY
may occur due to dispermic fertilization of empty
ovum dispermy.
paternal origin.

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Abnormal chorionic villi grossly appear as mass of
clear vesicles.

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COMPLETE MOLE
PARTIAL MOLE

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PARTIAL MOLE:

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triploid( 69XXX or 69XXY);less commonly 69XYY.
2 sets of paternal haploid genes and 1 set of maternal
haploid genes (dispermic fertilization) .This paternal
contribution is called diandry .
Less frequently a similar haploid egg may be fertilzed by an

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unreduced diploid 46XY sperm.
Show some fetal tissue,at least an amniotic
sac.
Fetus with features of triploidy or tetraploidy (also seen) ...
IUGR,multiple malformation,dies earier.

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FEATURES OF COMPLETE AND PARTIAL HYDATIDIFORM MOLE
FEATURE
COMPLETE MOLE
PARTIAL MOLE

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? KARYOTYPE
? 46,XX or -XY
? 69XXX or XXY
? CLINICAL
PRESENTATION

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? preliminary diagnosis
? MOLAR GESTATION
? MISSED ABORTION
? uterine size
? 50% LARGE for dates

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? SMALL for dates
? theca lutein cysts
? 25-30%
? RARE
? medical

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? 10-25%
? RARE
complications
? initial hcg levels
? >100,000 mIU/mL

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? <100,000mIU/mL
? rate of subsequent
? 15-20% of cases
? 1-5% of cases
GTN

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FEATURES OF COMPLETE AND PARTIAL HYDATIDIFORM MOLE
PATHOLOGY
COMPLETE
PARTIAL MOLE
MOLE

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EMBRYO-FETUS
ABSENT
OFTEN PRESENT
AMNION,FETAL
ABSENT

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OFTEN PRESENT
RBCs
VILLOUS EDEMA
WIDESPREAD
FOCAL

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TROPHOBLASTIC SLIGHT TO
FOCAL,SLIGHT
PROLIFERATION
SEVERE
TO MODERATE

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Trophoblast
MARKED
MILD
ATYPIA
P57KIP2

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NEGATIVE
POSITIVE
immunostaining
Scalloping of
ABSENT

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PRESENT
chorionic villi
Stromal inclusions ABSENT
PRESENT

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HISTOLOGY :

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Complete mole .....

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INCIDENCE AND AETIOLOGY :

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Varies with ethnic differences : Asians > Caucasions. (3)
Maximum in orientals like chineese and japaneese
Extremes of age : adolescents and 36-40 years (2)
:>40yrs (10)
Previous mole. : complete mole - .9% risk

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-2 prior complete mole -20% have 3rd
: partial mole - .3% risk
? Sporadic ( vast majority)
? Familial syndrome of recurrent hydatidiform mole-rare.
Role of other factors ?less clear.

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SYMPTOMS...
Amenorrhea of varying duration
Passage of vesicles per vaginum
Bleeding per vaginum

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Nausea and vomiting ...
more pronounced with complete than partial mole
as gestation advances

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SIGNS...
Uterus : 50% cases-enlarged; larger than period of

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. amenorrhea; softer
:35% corresponds to gestational period
:15% it may be smaller
Fetal heart sounds wont be heard with complete
mole.

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Hyperemesis

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? Theca lutein cysts felt in ovaries(50%cases) most common
with complete mole
- Larger moles are more likely to develop cysts:
overstimulation of luteal elements by hCG.

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- Theca lutein cysts-PT Disease
- regress following evacuation(expectant
management preferred)
.
-rarely undergo torsion, infarction and .

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hemorrhage
.
-oophrectomy -extensive infarction after
untwisting .
.

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Thyrotoxicosis--thyrotrophic like effect of hCG .
- free T 4 THYROXINE- inc;TSH-decrease
- mimicked by bleeding and sepsis from infected products.
Respiratory distress ?due to embolisation

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PARTIAL MOLE may not present with classic features
of a complete mole.
Vaginal bleeding is a usual symptom.
Many a times- incomplete or missed abortion

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? Uterine bleeding-

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-spotting or profuse hemorrhage
-almost always with untreated molar pregnancy
-may preceed spontaneous molar abortion or
follows an intermittent course for weeks to months
? Fe deficiency anemia ?advanced moles with

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concealed uterine hemorrhage

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Pre-eclampsia/eclampsia:
- Early onset pre-eclampsia (HTN <20wks ?important to
rule out hydatidiform mole)
- Severe pre-eclampsia/eclampsia-common with

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advanced molar pregnancy.....seldom seen today...early
diagnosis evacuation
( exception- normal fetus+complete mole
in continuing twin gestations severe pre-
eclampsia mandates preterm delivery... )

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TWIN PREGNANCIES...
Chromosomally normal fetus + complete diploid
molar pregnancy
Single partial molar pregnancy + abnormal fetus

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Amniocentesis and fetal karyotyping-
confirmation
Survival of normal fetus depends on associated
comorbidity from molar component...pre-
eclampsia and hemorrhage necessitates preterm

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delivery...

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