Gestational Trophoblastic

Disease (GTD)
USIM Yr 6- Gynae Posting
August 2015
 GTD

Placental Site
Complete/Partial
Invasive mole Choriocarcinoma Trophobalstic
Molar
Tumors (PSTT)

Gestational Trophoblastic Neoplasia (GTN)

 Molar Pregnancy
Complete Mole
Partial Mole
 Molar pregnancy
Characteristics/Type Complete Partial
Genetic Material Diploid Triplod
Origin Androgenic origin Two sets of paternal haploid
genes and one set of maternal
haploid genes
Duplication of a single sperm Dispermic fertilisation of an
following fertilisation of an ovum.
empty ovum or dispermic
fertilisation of an empty
ovum.
Fetal tissue Absent Present
 Incidence
In US 1 : 2000 pregnancies
In Far East 1 : 500
In Malaysia 1 : 400
How do molar pregnancies present to
the clinician?
Classic features
irregular vaginal bleeding, hyperemesis, excessive
uterine enlargement and early failed pregnancy.
Rarer presentations
Hyperthyroidism
early onset pre-eclampsia
abdominal distension due to theca lutein cysts.
acute respiratory failure
neurological symptoms such as seizures
 How are molar pregnancies
diagnosed?
Beta HCG
Ultrasound examination- snow-storm
appearance
Definitive diagnosis -histological examination
of the products of conception.
 Evacuation of a molar pregnancy
Suction curettage is the method of choice for
complete mole.
Partial Mole: medical evacuation when fetal
parts present.
Anti-D prophylaxis is required following
evacuation of a molar pregnancy.
 Which women should be investigated for
persistent GTN after a non-molar pregnancy?
Persistent vaginal bleeding after a pregnancy
at risk of having GTN.
A urine pregnancy test should be performed in
all cases of persistent vaginal bleeding.
Symptoms from metastatic disease, such as
dyspnoea or abnormal neurology, can occur
very rarely.
What is the optimum follow-up following a
diagnosis of GTD?
If hCG normalised by 56 days follow up will be
for 6 months from the date of uterine
evacuation.
If not reverted to normal within 56 days then
follow-up will be for 6 months from
normalisation of the hCG level.
Future pregnancy, hCG levels are measured 6-
8 weeks after the end of the pregnancy to
exclude disease recurrence.
 What is the optimum treatment for
GTN?
Single-agent or multi-agent chemotherapy
Treatment used is based on the FIGO 2000
scoring system for GTN
The need for chemotherapy following a
complete mole is 15% and 0.5 % after a partial
mole
Scores <6 >6
Chemotherapy Single-agent Multi-agent chemotherapy
Agent Methotrexate alternating daily Methotrexate, dactinomycin,
with folinic acid for 1 week etoposide, cyclophosphamide
followed by 6 rest days and vincristine.
Cure rate Almost 100% 95%
 When can women try to conceive in the
future?
Women should be advised not to conceive
until their follow-up is complete.
Women who undergo chemotherapy are
advised not to conceive for 1 year after
completion of treatment.
 What is the long-term outcome of
women treated for GTN?
Women who receive chemotherapy for GTN
are likely to have an earlier menopause.
Single agent- by 1 year
Multi-agent by 3 years
Women who require multi-agent
chemotherapy (etoposide) should be advised
that they may be at increased risk of
developing secondary cancers.
What is safe contraception following a diagnosis
of GTD and when should it be commenced?
Women with GTD should be advised to use
barrier methods of contraception until hCG
levels revert to normal.
Once hCG level have normalised, the
combined oral contraceptive pill may be used.
Intrauterine contraceptive devices should not
be used until hCG levels are normal to reduce
the risk of uterine perforation.
 Clinical Case
A 20-year-old woman presented to the emergency
department with a history of nausea, weight loss of about
10kg in 6 weeks, and intermittent vaginal bleeding.

On examination, she had tachycardia (108 BPM), a blood

pressure of 146/86 mm Hg, and a regular respiration rate of
18 breaths per minute.

You are the House officer in ED, how would you manage the
patient?
 Reference
The Management of Gestational Trophoblastic
Disease. RCOG Greentop Guideline No. 38
February 2010.