Gestational trophoblastic disease (GTD) is a group of rare diseases in which abnormal trophoblast cells grow inside the uterus after conception. It encompasses a spectrum of proliferative abnormalities of trophoblast associated with pregnancy. In GTD, a tumor develops inside the uterus from tissue that forms after conception. This tissue is made of trophoblast cells and normally surrounds the fertilized egg in the uterus. Trophoblast cells help connect fertilized egg to the wall of the uterus and form part of the placenta. Sometimes there is problem with the fertilized egg and trophoblast cells. Instead of a healthy fetus developing, a tumor forms. Until there are signs or symptoms of the tumor, the pregnancy will seem like a normal pregnancy. Most GTD is benign and does not spread, but some types become malignant and spread to nearby tissues or distant parts of the body. It is a general term and includes different types of disease: • Hyaditiform Moles (HM) o Complete HM o Partial HM • Gestational Trophoblastic Neoplasia (GTN) o Invasive moles o Choriocarcinomas o Placental site trophoblastic tumors (very rare) o Epithelioid trophoblastic tumor (even more rare) Hyatid is the greek term which means “watery”. Hyaditiform mole is a rare mass or growth that forms inside the womb (uterus) at the beginning of the pregnancy. It is type of gestational trophoblastic disease (GTD). Vesicular mole is defined as the abnormal condition of the placenta where partly degenerative and partly proliferative changes occur in the young chorionic villi. • These changes results in the formation of clusters of small cysts of varying sizes. It is best regarded as a benign Neoplasia of the chorion with malignant potential. Approximately 1 in every 1000 pregnancies is diagnosed as a molar pregnancy. In India the incidence is 1 in 400.The highest incidence is in Philippines being 1 in 80 pregnancies.

1. Presented by:
ITISHA ROSE PRASAD
Nursing tutor
Gov CON, Kanpur

2. Trophoblast cells help connect fertilized egg
to the wall of the uterus and form part of the
placenta. Sometimes there is problem with
the fertilized egg and trophoblast cells.
Instead of a healthy fetus developing, a
tumor forms. Until there are signs or
symptoms of the tumor, the pregnancy will
seem like a normal pregnancy.

3. It is a general term and includes different types of
disease:
•Hyaditiform mole/Vesicular mole
COMPLETE
HYADTIFORM
MOLE
PARTIAL
HYADTIFORM
MOLE

4. •Gestational Trophoblastic Neoplasia (GTN)
INVASIVE
MOLE
CHORIO-
CARCINOMA
PLACENTAL SITE
TROPHOBLASTIC
TUMOR

5. Hyatid is the greek term which means “watery”.
Hyaditiform mole is a rare mass or growth that forms
inside the womb (uterus) at the beginning of the
pregnancy. It is type of gestational trophoblastic
disease (GTD).

6. DEFINITION-
 Vesicular mole is defined as
the abnormal condition of the
placenta where partly
degenerative and partly
proliferative changes occur in
the young chorionic villi.
 INCIDENCE-
 Approximately 1 in every
1000 pregnancies is diagnosed
as a molar pregnancy. In India
the incidence is 1 in 400
NORMAL PLACENTA
VESICULAR MOLE

7. Risk
Factors
Cytogenic
Abnormality
Increased
Chromosome
ratio
Disturbed
Immune
Mechanism
Faulty
Nutrition
Previous
Molar
Pregnancy
Maternal
Age

8. COMPLETE MOLE PARTIAL MOLE
•Whole conceptus formed
into mass of vesicles
•Only a part of trophoblast
shows molar changes
•No fetus is present (Sac is
empty)
•There is fetus or at least
an amniotic sac
•It is the result of the
fertilization of annucleated
ovum with a sperm which
will duplicate giving rise to
chromosomes of paternal
origin only.
•It is the result of the
fertilisation of an ovum by
2 sperms so the
chromosomal number is 69
chromosomes

9. Partial Hyaditiform Mole
Complete Hyaditiform Mole

10.  TYPES-
 Complete Mole-
◦ The whole conceptus is
transformed into a mass of
vesicles.
◦ No embryo is present.
◦ It is the result of the fertilization
of annucleated ovum (which has
no chromosomes) with a sperm
which will duplicate giving rise
to chromosomes of paternal
origin only.

11.  Partial Mole-
◦ A part of the trophoblastic
tissue only shows molar
changes
◦ There is a fetus or at least an
amniotic sac.
◦ It is the result of the
fertilisation of an ovum by 2
sperms so the chromosomal
number is 69 chromosomes.

12.  CLINICAL
MANIFESTATION-
Symptoms-
 Vaginal Bleeding (“White
currant in red currant juice”)
 Lower abdominal pain
 Hyper emesis
 Breathlessness
 Thyrotoxic features- tremors,
tachycardia
 Symptoms of hyperthyroidism
 Expulsion of grape like vesicles
per vaginum.
 History of quickening absent GRAPE LIKE
VESICLES

13.  Per abdomen-
 Size of the uterus is more than expected for the
period of amenorrhea.
 Feel of the uterus is firm elastic due to absence of
amniotic sac.
 Fetal parts are not felt, nor any fetal movements.
 Absence of fetal heart sound which cannot be
detected even by Doppler.

14. Per Vaginal-
 Internal ballottement cannot
be elicited.
 Presence of vesicles in the
vaginal discharge.
 If the cervical os is open,
instead of the membranes,
blood clot or the vesicles
may be felt.

15. DIAGNOSTIC EVALUATION-
 History taking
 Pelvic examination
 Tests done may include-
Complete blood count, ABO and Rh grouping.
Hepatic, Renal and thyroid function tests.
hCG (quantitative levels) blood test
X-ray – abdomen and chest

16.  USG- characteristic feature is
“Snowstorm Appearance”

17. Suction Evacuation
Supportive Therapy
Counselling for Regular
Follow Up
MANAGEMENT

18. SUPPORTIVE THERAPY-
 IV infusion with ringers solution is started.
 Blood transfusion is given with the patient is
anaemic
 Parenteral antibiotic is given if there is associated
infection.
.

19. DEFINITIVE THERAPY-
Suction evacuation (SE)-
It can even be done if uterus is of 28 weeks of
gestation.

20. The patients can be grouped into-
 Group A- the mole is in the process of expulsion
(less common)
 Group B- the uterus remains inert (early diagnosis)

21. Group A- cervix is favourable-
 Suction evacuation under diazepam sedation or
general anaesthesia.
 Conventional dilatation of the cervix followed by
evacuation.
◦ Continuous monitoring of the patient.
◦ 500 ml Ringers solution IV infusion is set up
◦ Use of oxytocin for the expulsion of the moles.

22.  Digital exploration and removal of the moles by
ovum forceps under general anaesthesia may also be
an alternative.
 Once the evacuation procedure is complete,
methergin 0.2 mg is given IM.
OVUM FORCEP
REMOVAL OF MOLES BY
OVUM FORCEP

23.  Group B- cervix is tubular and closed
 Prior slow dilatation of the cervix is done by
introducing laminaria tent followed by suction and
evacuation.
 Alternatively, vaginal misoprostol (PGE1) 400 ug, 3
hours before surgery may be used.
LAMINARIA TENT
FOR CERVICAL
DILATATION

24.  Following evacuation, Anti- D immunoglobulin
should be given to the Rh- negative non immunized
patient.
 The other options are- hysterectomy and hysterotomy

25. FOLLOW UP-
 Routine follow ups is mandatory for all cases for at
least 1 year.
 The hCG levels following evacuation should regress
to normal within 4-8 weeks time.
 Initially the check up should be done at an interval of
one week till the serum hCG level becomes negative.

26.  Once negative, the patient is followed every 1 month
for 6 months
 Women who undergo chemotherapy should be
followed for 1 year after hCG has been normal.
 The patient should not get pregnant during the period
of follow- up.

27. CONTRACEPTIVE ADVICE-
 The patient is traditionally advised not to be pregnant
for at least one year.
 But, if the patient so desires, she can get pregnant
after 6 months following the negative hCG titre.
 IUD is contraindicated.
 Combined oral pills can be used after the hCG value
has become normal.
 Injection DMPA can be used safely.
 Barrier method and surgical method of contraception.

28. Acute
pulmonary
insufficiency
Coagulation
failure.
Pre-
Eclampsia
Perforation
of the
uterus.
Sepsis
Haemorrhage
and
shock

29. Late-
 The development of Choriocarcinomas following
Hyaditiform mole ranges between 2 and 10 %