Mrs. Soz Ali, a 34-year-old woman, presented with vaginal bleeding and nausea. Examination found a bulky uterus consistent with a 10 week gestation. Laboratory tests showed an elevated beta-hCG level of 7981 U/l and ultrasound revealed an increased uterine echogenicity with a "snowstorm" appearance. This is consistent with a diagnosis of complete hydatidiform mole based on the clinical presentation, lab tests, and imaging findings. Complete molar pregnancies carry risks of persistent trophoblastic disease, chemotherapy may be required for treatment.

1. Muhammed Hama-Ali Barznji
6th year medical student – university of slemani college
of medicine
Gestational Trophoblastic Disease

2. Gestational Trophoblastic Disease
Muhammed Hama-Ali Barznji
6th year medical student – university of
slemani college of medicine

3. ”for his discoveries of mechanisms for autophagy”

4. Mrs Soz Ali 34-year-old woman from Slemani-
sarchnar, she is vegetarian, married for 7
years 3rd Gravida ,Para 0 at 14 Ws GA.
The previous abortions were at 7&8 weeks.
She complains of:
1-Mild vaginal bleeding for 4 days
2-Nausea, and moderate vomiting
Case Scenario

5. • . bright Red spots commenced & days
before which she thought was normal in
pregnancy.
• However since then the bleeding is almost
as heavy as period. there are no clots. mild
abdominal pain.
• systemically she has nausea for 3 weeks
and vommit periodically.
• there is no other significant
gynaecologically history.
Case Scenario

6. Examination:
 the patient had a blood pressure of 100/70 and a pulse of
100 bpm.
 She was well orientated, afebrile and had a slight pallor.
 She had some lower abdominal discomfort with more
tenderness at the right iliac fossa, but there was no
rebound or guarding.
 On speculum examination: reveals closed cervix with some
blood coming from cervical canal.
 Bimanual examination: uterus feels bulky and soft,
approximately 10 week in gestation.
 There is no adnexal tenderness or cervical excitation
Case Scenario

7. Investigation
 Serology
 ↑ β-hCG: B-HCG was 7981 U/l
 Cross match and grouping: A+ , Hb was 8.0 g/l
 Ultrasound : increase uterine echoginicity classically have
"snowstorm" appearance with no fetus
 Gross pathology : "honeycombed uterus" or "cluster of
grapes" gross appearance
Case Scenario

8. Google image
US scanning revealed

9. Gestational trophoblastic disease
(GTD)
 rare tumors  abnormal growth of cells inside a
woman's uterus.
 these tumors start in the cells that would normally
develop into the placenta during pregnancy.
 The term gestational ==> pregnancy.
 GTD begins in the layer of cells called the
trophoblast that normally surrounds an embryo.
(Tropho- means nutrition, and -blast means bud or
early developmental cell.)

10. Classification of gestational Trophoblastic
disease
WHO Classification
Malignant
neoplasms of
various types of
trophoblats
Malformations of
the chorionic villi
that are
predisposed to
develop
trophoblastic
malignacies
Benign entities
that can be
confused with
with these other
lesions
Choriocarcinoma
Complete
Hydatidiform moles
Placental site nodule
Exaggerated placental site
Epithilioid
trophoblastic tumors
Placental site
trophoblastic tumor Partial
Invasive

12. Risk factors
 Age: childbearing age  (J curve) with extremes of reproductive
life associated with an increased incidence.
 Prior molar pregnancy: an increased risk of further molar
pregnancies.
one mole  < 2%,
two molar  one in six;
following three moles the risk may be as high as one in two
 Family history: underlying genetic disorder in such cases.
 Nutrional and socioeconomic factors: low dietary intake of
carotene and animal fat

13. Hydatidiform Mole
 The most commonGTD.
 Hydatidiform moles are not cancerous, but they can develop into
cancerous GTDs.
Histologically characterized by :
Trophoblastic proliferation &
Edema of the villous stroma (Hydropic) .
Based on the degree and extent of these tissue changes,
hydatidiform moles are categorized as either
Complete hydatidiform mole.
Partial hydatidiform mole.

14.  A partial hydatidiform mole develops when 2 sperm
fertilize a normal egg. These tumors contain some fetal
tissue, but this is often mixed in with the trophoblastic
tissue. It is important to know that a viable (able to
live) fetus is not being formed.
 A complete hydatidiform mole most often develops
when either 1 or 2 sperm cells fertilize an egg cell that
contains no nucleus or DNA (an “empty” egg cell). All
the genetic material comes from the father's sperm
cell. Therefore, there is no fetal tissue.

16. Hydatidiform Mole
 Clinical Presentation:
 Complete mole:
Vaginal
bleeding
Severe
anemia
Passage of
hydropic
villi

17. Hydatidiform Mole
Usually, in
association
with,
Excessive uterine enlargement
Hyperemesis gravidarum
Preeclampsia
Markedly elevated hCG 100,000
mIU/mL
Hyperthyroidism
Theca lutein cysts
Clinical Presentation:
Complete mole:

18. Hydatidiform Mole
 Clinical Presentation:
 Partial mole:
 History:
 Vaginal bleeding
 Usually diagnosed as missed or incomplete
abortion
 Physical:
 A uterus small or equal to gestational age

20. Feature Partial mole Complete mole
Karyotype
Most commonly
69, XXX or - XXY
Most commonly
46, XX or -,XY
Pathology
Fetus Often present Absent
Amnion, fetal RBC Usually present Absent
Villous edema Variable, focal Diffuse
Trophoblastic proliferation Focal, slight-moderate Diffuse, slight-severe
Clinical presentation
Diagnosis Missed abortion Molar gestation
Uterine size Small for dates 50% large for dates
Theca lutein cysts Rare 25-30%
Medical complications Rare 10-25%
Postmolar CTN 2.5-7.5% 6.8-20%
Features Of Partial And Complete Hydatidiform Moles
Clinical Gynecological Oncology 2007 Cunningham et al Williams Obsterics 23rd ,

21. Hydatidiform Mole
 Diagnosis:
 History
 Clinical examination
 Ultrasound examination
 Serum hCG levels
 Histopathological examination
 Cytogenetic and molecular biological
examination

22. Hydatidiform Mole
Diagnosis:
 Ultrasonography:
* The diagnosis of molar pregnancy is
nearly always made by ultrasonography
Complete mole
•The classical finding is a “snow storm"
pattern
•Theca lutein cysts are frequent
findings on ultrasound

23. The snow storm appearance of complete hydatidiform mole

24. Theca lutein cysts, a frequent finding on ultrasound

25. Hydatidiform Mole
Diagnosis:
 Ultrasonography:
Partial mole
Abnormal gestational sac
The classic vesicular sonographic
findings of a complete mole are
usually not seen
Focal sonographic cystic changes
and/or hydropic changes in the
placenta are significantly associated
with the diagnosis of a partial molar
pregnancy

26. Hydatidiform Mole
Diagnosis:
 Ultrasonography:
 However, based on ultrasound, correct diagnosis can be suspected
in only:
• 84% of patients with complete mole and
• 30% of patients with partial mole
(Lindholm and Flam, 1999)
 The accuracy of ultrasonogrophy is gestational age dependent
In comlete mole:
• 100% of cases cane be diagnosed at a gestational age of 13 eeks
or more
• 50% of cases cane be diagnosed in earlier pregnancies
(Lazarus et al, 1999)

27. Hydatidiform Mole
 Diagnosis:
 Serum hCG levels:
 Serum hCG levels of greater than 92 000 IU/l
associated with absent fetal heart beat indicate a
diagnosis of complete hydatidiform moles (Romero
et al, 1985)
 Serum hCG level decreases quickly if the patient has
an abortion, but it does not in molar pregnancy

28. Hydatidiform Mole
 Diagnosis:
 Histopathological examination:
 It should always be done as far as possible and
samples should be kept for DNA analysis for a
final diagnosis when histology can not
differentiate molar pregnancy from abortion

29. Hydatidiform Mole
 Management:
Complete history and physical examination
Investigations
Medical and surgical care
1
3
2

30. Hydatidiform Mole
 Management:
 History and physcal examination:
 Should aim to rule out the classic symptoms
and signs that would lead to a diagnosis of:
 severe anemia
 dehydration
 preeclampsia
 thyrotoxicosis
The patient should be stabilized
hemodynamically 

31. Hydatidiform Mole
 Management:
 Investigations:
 Laboratory:
 Pre-evacuation hCG
 Complete blood count
 Electrolytes, BUN, creatinine
 Liver function tests
 Thyroid function tests
 Imaging:
 Pelvic ultrasound
 Chest x-ray

32. Hydatidiform Mole
 Management:
 Medical care:
 Correction of:
 Anemia
 Dehydration
 Hyperthyroidism
 hypertension

33. Hydatidiform Mole
 Management:
 Surgical care:
Suction curettage (with
oxytocin or prostaglandin
infusion)
Hysterectomy
•The method of choice
•Increased risk of medical
complications
•Associated with a markedly
decreased rate of malignant
sequelae (3.5%) when compared
with suction evacuation.

35. Persistent trophoblastic disease(GTN)
 In a proportion of patients (10%), trophoblastic disease persists,
as evidenced by continuing clinical symptoms particularly
vaginal bleeding and/or elevation of hCG levels, excessive uterine
size and prominent theca lutein cysts.
 Because of routine registration and good follow-up , the great
majority of patients requiring chemotherapy for persistent
disease are recognized early.
Unversity of slemani college of medicine lectures – department of gynecology

36.  Defining persistent trophoblastic disease
and Indications for initiating chemotherapy:
 1-high, plateau or rising hCG level after evacuation.
 2-persistent vaginal bleeding with raised hCG.
 3-hCG > 20000IU/L more than 4 weeks after evacuation.
 4- Histological evidence of choriocarcinoma.
 5-pulmonary, vulval or vaginal metastases unless the hCG
level is falling.
 6-brain, liver, gastrointestinal metastases or lung metastases
>2cm on chest radiography
Unversity of slemani college of medicine lectures – department of gynecology

37. Hydatidiform Mole
 Complications associated with molar pregnacy:
 Those related to the increased trophoblastic
tissue volume:
 Theca-lutein cysts
 Pregnancy-induced hypertension,
 hyperthyroidism,
 Respiratory distress
 Hyperemesis
 Those related to its management:
 Uterine perforation

38. Post-evacuation Surveillance
Why?
To determine when pregnancy can be allowed
To detect persistent trophoblastic disease (i.e. GTN)

39.  A baseline serum β -hCG level is obtained within 48 hours after
evacuation.
 Levels are monitored every 1 to 2 weeks while still elevated to
detect persistent trophoblastic disease (GTN).
 These levels should progressively fall to an undetectable level (<5
mu/ml).
If symptoms are persistent, more frequent β hCG
estimation and U/S examination ± D&C are
advised
RCOG Guideline No. 38 ; 2010
The Post-evacuation Surveillance. How?

40. Hydatidiform Mole
 Prognosis:
 Post-molar gestational trophoblastic disease:
 Risk:
 Following complete mole: 20%
 Following partial mole: 5%
 Type:
 70% to 90% are persistent or invasive moles
 10% to 30% are choriocarcinomas
 Subsequent fertility:
 Following chemotherapy, fertility is usually maintained and regular
cycle restart 2-6 months after completion of treatment. Further
pregnancy should be deferred for 12 month after treatment to avoid
any teratogenic effect.

42. A malignant form of GTD which can
develop from a hydatidiform mole or from
placental trophoblast cells associated with a
healthy fetus ,an abortion or an ectopic
pregnancy.

43. Symptoms and signs
 Bleeding
 Infection
 Abdominal swelling
 Vaginal mass
 Lung symptoms
 Symptoms from other metastases

44. Doppler image of choriocarcinoma

45. FIGO staging:
 Stage I disease confined to uterus.
 Stage II outside uterus but limited to genital structures.
 Stage III extends to lung with or without genital tract
involvement.
 Stage IV all other metastases.
 This disease ids highly chemo sensitive and surgery is indicated
in small groups.

47. 1- International Journal of Gynecological Cancer, 14, 366- 369. ((
http://dx.doi.org/10.1111/j.1048-891X.2004.014223.x ))
2- American Congress of Obstetricians and Gynecologists
3- American Cancer Society
4- Williams Gynecology, 2e
Barbara L. Hoffman, John O. Schorge, Joseph I. Schaffer, Lisa M. Halvorson,
Karen D. Bradshaw, F. Gary Cunningham, Lewis E. Calver
5- royal college of obstetricians and gynaecologists : Green–top
Guideline No. 38 February 2010
6- Slideshare presentations plus medscape and some other websites
7- Case Scenario by XOM based on the above references
8- Kaplans vedio tutorial for USMLE
9- Unversity of slemani college of medicine lectures – department of
gynecology
References

49. If you Have questions
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