Download MBBS GTD Management Lecture PPT

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INVESTIGATIONS

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ULTRASOUND

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Diagnostic.
""SNOW STORM""appearance
Theca lutein cysts in ovaries
if partial mole ? FETAL SHADOW
focal cystic spaces in the placenta

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placenta with scattered cysts
Absence of fetal shadow helps confirm a complete mole

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Thecalutein cyst.

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Snowstorm appearance

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Partial mole

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PARTIAL MOLE

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Doppler ? Absence of Fetal heart sound
Serum B-hCG
High >40,000 mIU/ml

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Role now limited to Post molar and post chemo
followup
X ray chest ? to rule out embolization and
pulmonary metastasis
CT chest,abdomen and brain

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LIMITATIONS
Early gestations- beta HCG not highly elevated.
False negative usg where chorionic villi have not attained
characteristic vescicular pattern - early gestations

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Only 20-30% of partial moles have sonographic evidence
Diagnosis made from the histological view of abortal specimen

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In unclear cases with live fetus & desired pregnancy,
fetal karyotyping is done for the triploidy.

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Histopathology
Need to differentiate from hydropic abortuses
Failed pregnancies from union of haploid egg & halpoid
sperm.

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Show hydropic degeneration.
? Complete moles-
? a)Trophoblastic proliferation
? b) hydropic villi

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Partial moles
1. Two populations of villi

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2. Enlarged dysmorphic villi with trophoblastic inclusions.
3. Enlarged cavitated villi
4. Syncitiotrophoblastic hyperplasia

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ANCILLARY TECHNIQUES
Immunostaining of p57KIP2
expressed only in tissues containing maternal allele.

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So absent in complete moles
Molecular genotyping determines whether
? Diploid diandric
? Triploid diandric monogynic
? Biparental diploidy

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MANAGEMENT

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2 PHASES

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IMMEDIATE EVACUATION.
SUBSEQUENT FOLLOW UP.

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EVACUATION
SUCTION EVACUATION is the treatment of choice
irrespective of size of the uterus
Cervical ripening agents like misoprostol- to dilate the cervix to

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facilitate evacuation,if needed
Not given in nulliparous, as it increases uterine contractions &
risk of embolisation to pulmonary vasculature

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PRE-OPERATIVE
History and clinical evaluation.

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Laboratory tests:
Hemogram
Serum beta ?Hcg
Creatinine
Hepatic amino transferase

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TSH, free T4 levels
Blood grouping, screening and crossmatch

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Chest radiograph
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Ultrasound pelvis to exclude pregnancy
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Adequate cross matched blood has to be
arranged
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Iv infusion started (chance of heavy bleeding)
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CT or MRI of head for brain metastasis.

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INTRAOPERATIVE
Large bore IV catheters
Done in local anaesthsia. Regional and general used if needed.
Karman cannula ?size 6 or 8
Consider sonography machine.

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If significant haemorrhage prior to evacuation, surgical evacuation
should be done, The need for oxytocin infusion weighed up
against the risk of tumour embolisation.

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Symptomatic Theca leutin cysts usually regress after
evacuation.
In extreme cases, aspiration is done.
If torsion lead to extensive infarct, oophrectomy is

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suggested.

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POST EVALUATION.
? Once evacuation is complete a gentle but thorough curettage is
done to remove any remnants
? Intra or post evacuation ultrasound is done to ascertain the
completeness of evacuation

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? If necessary, a check curettage can be done.
? All products of conception must be sent for HPE ? to
confirm,to rule out neoplasia, presence of fetal parts
? Anti-D prophylaxis to mother if Rh-ve

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Complications during evacuation
lHaemorrhage

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lPerforation ( as uterus is very soft) ? emergency laparotomy needed
lmassive DIC / massive pulmonary embolization by molar tissue.
Sudden unexplained col apse during evacuation from acute
pulmonary HTN and cardiac failure

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ROLE OF HYSTERECTOMY
NOT indicated except as prophylaxis for preventing

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choriocarcinoma in patients in perimenopausal age & who
have completed family ;
But even with hysterectomy,chance of metastasis is always
present

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FOLLOW UP
CRUCIAL part of management

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Helps in early detection of any malignant change and prompt
institution of chemotherapy

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Weekly fol ow up with BhCG til levels become normal (usual y within
8 weeks)
Thereafter monthly testing for 6 months (risk of developing GTN is
greatest in the first 6 months)
If not normal within 8 weeks, fol ow up til 6 months after the B hcg

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becomes normal.
Contraceptive measures are adopted to prevent pregnancy.
Advised not to conceive til fol ow up is complete.

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Each visit : relevant symptoms ? irregular bleeding,persistent cough
,hemoptysis , dyspnea
Clinical examination ? uterine size
ovarian cysts

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vulval & vaginal metastasis
distant metastasis
? Ultrasound if necessary ? residual/local y invasive tumor, subinvolution
of uterus ,ovarian cysts

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Risk of GTN
Complete moles - 20% progress to GTN

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Risk factors for postmolar GTN:
Advanced maternal age
High preevacuation BhCG levels >1lakh mIU/mL
Uterus large for dates
Bilateral theca lutein cysts

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Respiratory distress after evacuation
Eclampsia or Hyperthyroidism
Uterine subinvolution with post-evacuation bleeding

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