Gestational trophoblastic disease
Gestational trophoblastic disease: neoplasms of trophoblastic cells, forming the placenta.
Benign hydatidiform mole (majority of cases)
Malignant and metastatic choriocarcinoma
Local invasive disease also occurs. Excessive placental tissue develops and levels of beta-HCG increase, usually to levels higher than expected for a normal pregnancy.
Benign hydatidiform mole
These are benign growths of trophoblastic tissue; however, the occasionally develop into cancer known as choriocarcinoma. Complete moles have a 46,XX karyotype, whereas partial moles have are 69,XXY karyotype and are usually associated with an abnormal fetus.
Signs and symptoms: Heavy or irregular painless uterine bleeding during the first half of pregnancy. The uterus as large for dates and hyperemesis gravidarium is common. Expulsion of vesicles resembling a “bunch of grapes” may be seen. No fetal movement or heart tones. Preeclampsia in the first half of pregnancy is pathognomonic of hydatiform mole.
Diagnosis: Higher than normal beta-HCG titers are a suspicious finding. Ultrasound provides definite of diagnoses, showing a “snowstorm” pattern with no sac or fetus. Chest x-ray is important to rule out metastases to the lung.
Treatment: Suction evacuation and curettage. Serum beta-HCG is assayed weekly after evacuation and generally declines within 3 to 4 months to undetectable levels. Levels are forward for 6 to 12 months, and pregnancy should be avoided during this time. Patients with persistent beta-HCG titers in the absence of pregnancy may have gestational choriocarcinoma and should be worked up and treated.
Gestational Choriocarcinoma
Half of the gestational choriocarcinoma develop from hydatidiform moles. The rest arise for your normal, ectopic, or aborted pregnancy. Choriocarcinomais may be locally invasive or may metastasize through the circulation of the lungs, vagina, brain, GI tract, liver, and kidneys.
Signs and symptoms: Choriocarcinoma generally presents after metastases has occurred, and the diagnoses may be missed unless onset follows a molar pregnancy. Vaginal bleeding, dyspnea, cough, hemoptysis, CNS findings, and rectal bleeding are possible signs of metastases ensure prompt an evaluation of beta-HCG levels and in any woman who has recently been pregnant.
Diagnosis: High beta-HCG levels in a snowstorm one of the sound indicate gestational trophoblastic disease. To evaluate for metastasis, CT scans of abdomen, pelvis, and head is necessary. CSF fluid for beta-HCG titer is required.
Treatment: Chemotherapy with methotrexate, but multiagent chemotherapy and radiation may be needed for persistent disease. Frequent follow-up beta-HCG titers confirm remission in the majority of patients. If beta-HCG levels do not form to a normal level, a hysterectomy is indicated. Cure rates are greater than 90%.
I. F/u of hydatidiform mole p suction evacuation with curettage.
A. Hydatidiform moles are benign growths of trophoblastic tissue, which may potentially become malignant – gestational choriocarcinoma. Suction evacuation and curettage is the method of choice, especially if the patient is interested in maintaining reproductive function. It is done under GA, blood should be readily available, oxytocin 10 to 20 units in 1 L of IV fluids, should run during the procedure. RhoGAM is given to Rh-negative woman.
B. After removal of hydatidiform mole by suction evacuation and sharp curettage, serum ß-hCG is assayed weekly until three consecutive negative values have been obtained, then every 1 to 2 months for an additional 6 – 12 months, during which time pregnancy must be avoided, because the serum ß-hCG from pregnancy will confound assessment. Effective contraception must be used.
1) In pregnancy ß-hCG levels peak at 12 to 14 weeks of gestation and rarely exceed 100,000 mIU/ml. ß-hCG titers in excess of 100,000 mIU/ml are consistent with hydatidiform mole.
2) Three consecutive negative ß-hCG values are considered to be evidence of remission.
C. If suction evacuation and curettage of hydatidiform moles is successful, the ß-hCG usually declines within 3 – 4 months. If on the other hand ß-hCG, persists after the procedure, and pregnancy is ruled out, a Dx of gestational choriocarcinoma must be considered and patient evaluated.
D. Ultrasound provides definitive Dx for hydatidiform mole, showing absence of fetus, or gestational sac, and “snowstorm” pattern of multiple intrauterine echoes.
E. CXR is obtained during the time of suction evacuation and curettage of the hydatidiform mole at 4 and 8 weeks postoperatively.
F. Pelvic exam at 2 – 4 weeks post suction evacuation and curettage, and monthly thereafter to detect clinical evidence of recurrence.
II. Clinical findings in Hydatidiform mole:
A. Spotting or H’ge
B. Absence of FHTs
C. Absence gestation sac or fetus on US and presence of “snowstorm” pattern.
D. Uterus is enlarged beyond its appropriate size
E. PIH <20 weeks
F. Hyperthyroidism
G. Expulsion of vesicles resembling a “bunch of grapes”
H. Higher than normal beta-hCG titers
I. Acute respiratory distress syndrome 2° to trophoblastic embolization.