Gestational Trophoblastic Diseases - Clinicals, Diagnosis, and Management

Gynecological Oncology

Clinicals - History

Fact Explanation
Period of amenorrhoea Usually this disease variety arises from pregnancy so the patient may complain of period of amenorrhoea. Period of amenorrhoea
Usually this disease variety arises from pregnancy so the patient may complain of period of amenorrhoea.
Abdominal distension incompatible with period of amenorrhea The uterine distension by the tumour results in an enlargement of the abdomen to a greater extent than which would be expected for the period of amenorrhoea. Abdominal distension incompatible with period of amenorrhea
The uterine distension by the tumour results in an enlargement of the abdomen to a greater extent than which would be expected for the period of amenorrhoea.
Per vaginal bleeding either scanty bleeding or passage of grape like vesicles Patient might complain passage of grape like vesicles which are tumour products or slight altered blood discharge. Per vaginal bleeding either scanty bleeding or passage of grape like vesicles
Patient might complain passage of grape like vesicles which are tumour products or slight altered blood discharge.
Severe nausea and vomiting Because of the high hCG level in the blood, there will be clinical features of Hyperemesis gravidarum with severe nausea and vomiting. Severe nausea and vomiting
Because of the high hCG level in the blood, there will be clinical features of Hyperemesis gravidarum with severe nausea and vomiting.
Ankle swelling, facial swelling and headache GTD is associated with pregnancy induced hypertension (PIH) and features of PIH such as ankle swelling, facial swelling and headache can occur Ankle swelling, facial swelling and headache
GTD is associated with pregnancy induced hypertension (PIH) and features of PIH such as ankle swelling, facial swelling and headache can occur
heat intolerance, insomnia, anxiety, enlargement of the neck Hyperthyroidism is associated with GTD. This is thought to occur due to molecular mimicry between human chorionic gonadotrophin (HCG) and thyroid-stimulating hormone (TSH), and hence cross-reactivity with the TSH receptor. heat intolerance, insomnia, anxiety, enlargement of the neck
Hyperthyroidism is associated with GTD. This is thought to occur due to molecular mimicry between human chorionic gonadotrophin (HCG) and thyroid-stimulating hormone (TSH), and hence cross-reactivity with the TSH receptor.
Dyspnoea, Cough, Hemoptysis Pulmonary metastasis can occur and features of lung involvement with dyspnoea, cough, hemoptysis are seen Dyspnoea, Cough, Hemoptysis
Pulmonary metastasis can occur and features of lung involvement with dyspnoea, cough, hemoptysis are seen
Altered level of consciousness, headache, personality changes, seizures Metastasis to brain cause these Altered level of consciousness, headache, personality changes, seizures
Metastasis to brain cause these
Abdominal pain Abdominal metastasis can cause bleeding in to the peritoneal cavity and pain Abdominal pain
Abdominal metastasis can cause bleeding in to the peritoneal cavity and pain
Haematuria Renal metastasis can cause macroscopic hematuria Haematuria
Renal metastasis can cause macroscopic hematuria

Clinicals - Examination

Fact Explanation
Symphysio-fundal height larger than dates Usually the disease follows a normal pregnancy and the patient may present with a period of amenorrhoea and with enlarged uterus which is larger than the period of amenorrhoea. Symphysio-fundal height larger than dates
Usually the disease follows a normal pregnancy and the patient may present with a period of amenorrhoea and with enlarged uterus which is larger than the period of amenorrhoea.
Nodules in the vulva and vagina Metastasis to vulva and vagina may cause these highly vascular blue-black nodules Nodules in the vulva and vagina
Metastasis to vulva and vagina may cause these highly vascular blue-black nodules
Abdominal tenderness Metastases to liver or gastrointestinal tract may produce abdominal pain. Abdominal tenderness
Metastases to liver or gastrointestinal tract may produce abdominal pain.
Abdominal guarding, rigidity Hemoperitneum can occur due to rupture of abdominal metastasis. Abdominal guarding, rigidity
Hemoperitneum can occur due to rupture of abdominal metastasis.
Jaundice May be present if liver metastasis causes biliary obstruction. Jaundice
May be present if liver metastasis causes biliary obstruction.
Altered level of consciousness and focal neurological deficits Brain metastasis cause focal neurologocal deficits depending on the location of brain metastasis and altered level of consciousness Altered level of consciousness and focal neurological deficits
Brain metastasis cause focal neurologocal deficits depending on the location of brain metastasis and altered level of consciousness
Dullness on percussion, reduced breath sounds on respiratory system examination Pulmonary metastasis may cause canon ball metastasis and these lung signs can occur. Dullness on percussion, reduced breath sounds on respiratory system examination
Pulmonary metastasis may cause canon ball metastasis and these lung signs can occur.
High blood pressure Pregnancy induced hypertension is associated with GTD and elevated blood pressure in the first trimester may be seen High blood pressure
Pregnancy induced hypertension is associated with GTD and elevated blood pressure in the first trimester may be seen
Pallor Profuse bleeding may be sever enough to cause anemia hence pallor. Pallor
Profuse bleeding may be sever enough to cause anemia hence pallor.
Goitre, tremor, lid lag and retraction and signs of hyperthyroidism Hyperthyroidism is associated with GTD. This is thought to occur due to molecular mimicry between human chorionic gonadotrophin (HCG) and thyroid-stimulating hormone (TSH), and hence cross-reactivity with the TSH receptor. Goitre, tremor, lid lag and retraction and signs of hyperthyroidism
Hyperthyroidism is associated with GTD. This is thought to occur due to molecular mimicry between human chorionic gonadotrophin (HCG) and thyroid-stimulating hormone (TSH), and hence cross-reactivity with the TSH receptor.

Investigations - Diagnosis

Fact Explanation
Serum Beta hCG The levels are very high than in normal pregnancy. Serum Beta hCG
The levels are very high than in normal pregnancy.
Full blood count This helps to detect anemia secondary to bleeding. Full blood count
This helps to detect anemia secondary to bleeding.
Pelvic ultrasonography This may show persistent molar tissue in the uterus which gives "Snow storm" appearance. Pelvic ultrasonography
This may show persistent molar tissue in the uterus which gives "Snow storm" appearance.
A uterine dilatation and curettage (D&C) and histopathology This may help to determine the histological diagnosis of H-mole whether it's partial, complete, invasive or a choriocarcinoma A uterine dilatation and curettage (D&C) and histopathology
This may help to determine the histological diagnosis of H-mole whether it's partial, complete, invasive or a choriocarcinoma

Investigations - Management

Fact Explanation
Serum Beta hCG The levels are done in the follow up to assess the response to therapy and to see the recurrence. Serum Beta hCG
The levels are done in the follow up to assess the response to therapy and to see the recurrence.
Full blood count This is done to assess blood counts while patients are on Methotrexate Full blood count
This is done to assess blood counts while patients are on Methotrexate
High resolution CT scan of the chest High resolution tomography (HRCT) is helpful to diagnose interstitial lung disease secondary to methotrexate. High resolution CT scan of the chest
High resolution tomography (HRCT) is helpful to diagnose interstitial lung disease secondary to methotrexate.
Prothrombin time and international normalization ratio This is done to exclude any coagulopathy Prothrombin time and international normalization ratio
This is done to exclude any coagulopathy
Full blood count To exclude anaemia and also counts are done when patient is on chemotherapeutic agents. Full blood count
To exclude anaemia and also counts are done when patient is on chemotherapeutic agents.
Renal function tests including estimated glomerular filteration rate, serum creatinine, blood urea nitrogen To assess fitness for anesthesia Renal function tests including estimated glomerular filteration rate, serum creatinine, blood urea nitrogen
To assess fitness for anesthesia
Chest radiograph Lung is the most frequent site of metastasis therefore to stage the disease this is done. FIGO Staging is done as following. Stage I – Confined to the uterus, Stage II – Limited to the genital structures, Stage III – Lung metastases and Stage IV – Other metastases Chest radiograph
Lung is the most frequent site of metastasis therefore to stage the disease this is done. FIGO Staging is done as following. Stage I – Confined to the uterus, Stage II – Limited to the genital structures, Stage III – Lung metastases and Stage IV – Other metastases
CT scan of the chest This is done to detect small metastasis missed in chest x -ray CT scan of the chest
This is done to detect small metastasis missed in chest x -ray
CT scan of the abdomen and pelvis This is done to stage the disease. Other common sites of metastasis are lower genital tract, brain, liver, kidney, and gastrointestinal tract. CT scan of the abdomen and pelvis
This is done to stage the disease. Other common sites of metastasis are lower genital tract, brain, liver, kidney, and gastrointestinal tract.
MRI abdomen, pelvis, brain This is done to stage the disease and to detect metastasis at other sites such as lower genital tract, brain, liver, kidney, and gastrointestinal tract. MRI brain helps in detecting cerebral metastasis MRI abdomen, pelvis, brain
This is done to stage the disease and to detect metastasis at other sites such as lower genital tract, brain, liver, kidney, and gastrointestinal tract. MRI brain helps in detecting cerebral metastasis
Cerebral spinal fluid/plasma hCG ratio Cerebral involvement can elevate this ratio. Cerebral spinal fluid/plasma hCG ratio
Cerebral involvement can elevate this ratio.
18-fluorodeoxyglucose positron emission tomography (FDG-PET) Tumor sites are highly metabolically active and this principle is the basis for this test to detect tumor deposits. 18-fluorodeoxyglucose positron emission tomography (FDG-PET)
Tumor sites are highly metabolically active and this principle is the basis for this test to detect tumor deposits.
Histopathology and immunohistochemical staining Histology helps to differentiate partial, complete mole, invasive mole and choriocarcinoma. Imunohistochemical staining for p57 may be helpful as well. Histopathology and immunohistochemical staining
Histology helps to differentiate partial, complete mole, invasive mole and choriocarcinoma. Imunohistochemical staining for p57 may be helpful as well.
Liver enzymes (AST, ALT) May be elevated in the presence of liver metastasis. Liver enzymes (AST, ALT)
May be elevated in the presence of liver metastasis.

Management - Supportive

Fact Explanation
Patient education and counseling Patient should be properly educated regarding the disease, the nature, the available treatment options, importance of follow up and the prognosis. Counseling plays such an important role, especially regarding next pregnancy and the possibility of recurrence. A partial mole should be followed up up to 6 months and a complete mole up to 1 year. Patient education and counseling
Patient should be properly educated regarding the disease, the nature, the available treatment options, importance of follow up and the prognosis. Counseling plays such an important role, especially regarding next pregnancy and the possibility of recurrence. A partial mole should be followed up up to 6 months and a complete mole up to 1 year.
Contraception Patient should be educated to avoid pregnancy because this may cause diagnostic confusion with high hCG. Barrier method is the preferred method of contraception. Combined oral contraceptive pills cause proliferation of trophoblastic tissue. intrauterine contraceptive devices, DMPA should be better avoided as these can also cause irregular bleeding hence diagnostic confusion. Contraception
Patient should be educated to avoid pregnancy because this may cause diagnostic confusion with high hCG. Barrier method is the preferred method of contraception. Combined oral contraceptive pills cause proliferation of trophoblastic tissue. intrauterine contraceptive devices, DMPA should be better avoided as these can also cause irregular bleeding hence diagnostic confusion.
Careful followup Patient should be carefully followed up with hCG levels. A partial mole should be followed up up to 6 months and a complete mole up to 1 year. Careful followup
Patient should be carefully followed up with hCG levels. A partial mole should be followed up up to 6 months and a complete mole up to 1 year.

Management - Specific

Fact Explanation
Chemotherapy Treatment decisions may be determined by FIGO prognostic score. Patients FIGO prognostic score of ≤6 respond well to single-agent chemotherapy with either methotrexate or actinomycin-D. 7 or higher are treated with a combination of chemotherapy known as EMA-CO regimen consisting etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine. Chemotherapy
Treatment decisions may be determined by FIGO prognostic score. Patients FIGO prognostic score of ≤6 respond well to single-agent chemotherapy with either methotrexate or actinomycin-D. 7 or higher are treated with a combination of chemotherapy known as EMA-CO regimen consisting etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine.
Suction curettage When patients have fertility wishes, suction curettage is the preferred method. Oxytocic agents and prostaglandin analogues are used only when there is massive hemorrhage after evacuation. 250 IU anti-D immunoglobulin is given for Rh negative women after surgical evacuation Suction curettage
When patients have fertility wishes, suction curettage is the preferred method. Oxytocic agents and prostaglandin analogues are used only when there is massive hemorrhage after evacuation. 250 IU anti-D immunoglobulin is given for Rh negative women after surgical evacuation
Surgical management Uncontrolled vaginal bleeding and no fertility wishes direct towards a hysterectomy. A hemorrhage is also controlled by ligation of uterine or hypogastric artery or embolization. Hepatic artery embolization to control hemorrhage from hepatic metastases is also done. Surgical management
Uncontrolled vaginal bleeding and no fertility wishes direct towards a hysterectomy. A hemorrhage is also controlled by ligation of uterine or hypogastric artery or embolization. Hepatic artery embolization to control hemorrhage from hepatic metastases is also done.
Radiotherapy for metastatic disease Cerebral metastasis and liver metastasis may benefit from radiotherapy Radiotherapy for metastatic disease
Cerebral metastasis and liver metastasis may benefit from radiotherapy

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