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INVESTIGATIONS
ULTRASOUND
Diagnostic.
""SNOW STORM""appearance
Theca lutein cysts in ovaries
if partial mole ? FETAL SHADOW
focal cystic spaces in the placenta
placenta with scattered cysts
Absence of fetal shadow helps confirm a complete mole
Thecalutein cyst.
Snowstorm appearance
Partial mole
PARTIAL MOLE
Doppler ? Absence of Fetal heart sound
Serum B-hCG
High >40,000 mIU/ml
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
LIMITATIONS
Early gestations- beta HCG not highly elevated.
False negative usg where chorionic villi have not attained
characteristic vescicular pattern - early gestations
Only 20-30% of partial moles have sonographic evidence
Diagnosis made from the histological view of abortal specimen
In unclear cases with live fetus & desired pregnancy,
fetal karyotyping is done for the triploidy.
Histopathology
Need to differentiate from hydropic abortuses
Failed pregnancies from union of haploid egg & halpoid
sperm.
Show hydropic degeneration.
? Complete moles-
? a)Trophoblastic proliferation
? b) hydropic villi
Partial moles
1. Two populations of villi
2. Enlarged dysmorphic villi with trophoblastic inclusions.
3. Enlarged cavitated villi
4. Syncitiotrophoblastic hyperplasia
ANCILLARY TECHNIQUES
Immunostaining of p57KIP2
expressed only in tissues containing maternal allele.
So absent in complete moles
Molecular genotyping determines whether
? Diploid diandric
? Triploid diandric monogynic
? Biparental diploidy
MANAGEMENT
2 PHASES
IMMEDIATE EVACUATION.
SUBSEQUENT FOLLOW UP.
EVACUATION
SUCTION EVACUATION is the treatment of choice
irrespective of size of the uterus
Cervical ripening agents like misoprostol- to dilate the cervix to
facilitate evacuation,if needed
Not given in nulliparous, as it increases uterine contractions &
risk of embolisation to pulmonary vasculature
PRE-OPERATIVE
History and clinical evaluation.
Laboratory tests:
Hemogram
Serum beta ?Hcg
Creatinine
Hepatic amino transferase
TSH, free T4 levels
Blood grouping, screening and crossmatch
?
Chest radiograph
?
Ultrasound pelvis to exclude pregnancy
?
Adequate cross matched blood has to be
arranged
?
Iv infusion started (chance of heavy bleeding)
?
CT or MRI of head for brain metastasis.
INTRAOPERATIVE
Large bore IV catheters
Done in local anaesthsia. Regional and general used if needed.
Karman cannula ?size 6 or 8
Consider sonography machine.
If significant haemorrhage prior to evacuation, surgical evacuation
should be done, The need for oxytocin infusion weighed up
against the risk of tumour embolisation.
Symptomatic Theca leutin cysts usually regress after
evacuation.
In extreme cases, aspiration is done.
If torsion lead to extensive infarct, oophrectomy is
suggested.
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
? 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
Complications during evacuation
lHaemorrhage
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
ROLE OF HYSTERECTOMY
NOT indicated except as prophylaxis for preventing
choriocarcinoma in patients in perimenopausal age & who
have completed family ;
But even with hysterectomy,chance of metastasis is always
present
FOLLOW UP
CRUCIAL part of management
Helps in early detection of any malignant change and prompt
institution of chemotherapy
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
becomes normal.
Contraceptive measures are adopted to prevent pregnancy.
Advised not to conceive til fol ow up is complete.
Each visit : relevant symptoms ? irregular bleeding,persistent cough
,hemoptysis , dyspnea
Clinical examination ? uterine size
ovarian cysts
vulval & vaginal metastasis
distant metastasis
? Ultrasound if necessary ? residual/local y invasive tumor, subinvolution
of uterus ,ovarian cysts
Risk of GTN
Complete moles - 20% progress to GTN
Risk factors for postmolar GTN:
Advanced maternal age
High preevacuation BhCG levels >1lakh mIU/mL
Uterus large for dates
Bilateral theca lutein cysts
Respiratory distress after evacuation
Eclampsia or Hyperthyroidism
Uterine subinvolution with post-evacuation bleeding
This post was last modified on 12 August 2021