Gestational trophoblastic disease

1. GTD
By: Semarya Berhe (Asst. Professor)

2. Gestational trophoblastic disease (GTD)
 Refers to a spectrum of interrelated but histologically
distinct tumors originating from the placenta.
 These diseases are characterized by a reliable
tumor marker (beta -subunit of human chorionic
gonadotropin [beta-hCG]) and have varying
tendencies toward local invasion and spread.
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3. Modified World Health Organization Classification
of Gestational Trophoblastic Disease
Hydatidiform mole
Molar lesions
Complete
Partial
Invasive mole
Non molar lesions
Choriocarcinoma
Placental site trophoblastic tumor
Epithelioid trophoblastic tumor
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4. Incidence
 The incidence of gestational trophoblastic disease
has remained fairly constant at approximately 1 to 2
per 1,000 deliveries in the United States and Europe
(Drake, 2006; Loukovaara, 2005; Smith, 2003).
 A similar frequency has been observed in South
Africa and Turkey (Moodley, 2003; Ozalp, 2003).
 Although higher incidence rates have been reported
in parts of Asia, this may have largely reflected
discrepancies between population-based and
hospital-based data collection.
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5. Magnitude of gestational Trophoblastic diseases and
associated factors in Hawassa University
Comprehensive Specialized Hospital
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 A retrospective review was conducted in Hawassa University
Comprehensive Specialized Hospital, Southern Ethiopia from
September 11, 2005 to September 11, 2010.E.C.
 Total of 16,957 deliveries and 194 Gestational trophoblastic cases.
 The magnitude of GTD was 11.4%.
 GTD deliveries were diagnosed in the first pregnancy 15.5% of
cases and 40.2% between para one and four.
 Vaginal bleeding was the most common presenting symptom 87.1%
and 46.4% patients had anemia at admission and 26.3% of patients
were transfused with blood.
 Hydatidiform mole was the commonest disease accounting for
90.2%.
 Suction curettage was the commonest treatment modality 70.8%.
 Having history of GTD, hyperemesis gravidarum, respiratory
symptoms and not referred cases had a statistically significant
association with hydatidiform mole.
 (Mandefro Yilma, et.al; The Ethiopian Journal of Reproductive Health; 2020; 12;2: 21-
27)

6. Risk Factors
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Maternal Age
 Maternal age at the upper and lower extremes has been
found to carry a higher risk of gestational trophoblastic
disease (Loukovaara, 2005; Tham, 2003).
 More specifically, teenage women and those aged 36 to
40 years have approximately double the risk. Patients
older than 40 years of age have a 7.5-fold higher risk,
and the association is most pronounced among women
at least 45 years of age (Parazzini, 1991; Sebire, 2002a).
 One explanation may relate to ova from older women
having higher rates of abnormal fertilization (Schorge,
2000).
 Similarly, older paternal age also has been associated
with increased risk (La Vecchia, 1984; Parazzini, 1986).

7. Obstetric History
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 History of prior unsuccessful pregnancies increases the
risk of gestational trophoblastic disease.
 Previous spontaneous abortion at least doubles the risk
of molar pregnancy (Parazzini, 1991).
 Personal history of gestational trophoblastic disease
increases the risk of developing a molar gestation in a
subsequent pregnancy by at least 10-fold (Parazzini,
1991; Sebire, 2003).
 The frequency in a subsequent conception is
approximately 1 to 2 percent, and most cases mirror the
same type of mole as the preceding pregnancy
(Berkowitz, 1994).
 Furthermore, following two episodes of molar pregnancy,
23 percent of later conceptions result in another molar
gestation (Berkowitz, 1998).

8. Other Factors
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 In several case-control studies, combination oral
contraceptive (COC) pill use has been associated with an
increased risk of GTD.
 Specifically, prior COC pill use approximately doubles the
risk, and a longer duration of use also seems to correlate
positively with risk (Palmer, 1999; Parazzini, 2002).
 Moreover, women who used combination oral
contraceptive pills during the cycle in which they became
pregnant appear to have a fourfold higher risk (Palmer,
1999).
 Many of these associations, however, are weak and
could be explained by confounding factors other than
causality (Parazzini, 2002).

9. Cont.….
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 Certain epidemiologic characteristics appear to differ
markedly between complete and partial moles.
 For example, vitamin A deficiency and low dietary
intake of carotene are associated with an increased
risk of only complete moles (Berkowitz, 1985, 1995;
Parazzini, 1988a).
 Partial moles have been linked to higher educational
levels, smoking, irregular menstrual cycles, and
obstetric histories in which only male infants are
among the prior live births (Berkowitz, 1995;
Parazzini, 1986).

10. Hydatidiform Mole (Molar Pregnancy)
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 Abnormal pregnancies characterized histologically
by aberrant changes within the placenta.
 Specifically, the chorionic villi in these placentas
show varying degrees of trophoblastic proliferation
and edema of the villous stroma.
 Based on the degree and extent of these tissue
changes, hydatidiform moles are categorized as
either complete hydatidiform moles or partial
hydatidiform moles .
 Cytogenetic studies have shown that chromosomal
abnormalities play an integral role in the
development of hydatidiform moles (Lage, 1992).

11. Features of Complete and Partial
Hydatidiform Moles
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12. Cont.….
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 Microscopically, complete moles display enlarged,
edematous villi and abnormal trophoblastic
proliferation that diffusely involve the entire placenta.
 Macroscopically, these changes transform the
chorionic villi into clusters of vesicles with variable
dimensions. Indeed, the name hydatidiform mole
stems from this "bunch of grapes" appearance.
 In these pregnancies, no fetal tissue or amnion is
produced.
 As a result, this mass of placental tissue completely
fills the endometrial cavity

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14. Clinical Findings
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 anemia and uterine sizes in excess of that predicted for
their gestational age.
 hyperemesis gravidarum,
 preeclampsia, and
 theca-lutein cysts
 Vaginal bleeding
 Plasma thyroxine levels are often elevated in women with
complete moles, but clinical hyperthyroidism is unusual
and is identified in only approximately 5 percent of
patients (Amir, 1984; Berkowitz, 1987).
 In these circumstances, serum free thryoxine levels are
elevated as a consequence of the thyrotropin-like effect
of -hCG (Hershman, 2004).

15. Partial Hydatidiform Mole
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 These moles vary from complete hydatidiform moles
clinically, genetically, and histologically.
 The degree and extent of trophoblastic proliferation
and villous edema are decreased compared with that
in complete moles.
 Moreover, most partial moles contain fetal tissue and
amnion in addition to placental tissues.
 As a result, patients with partial moles typically
present with signs and symptoms of an incomplete
or missed abortion.

16. Cont.….
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 Most women will have vaginal bleeding,
 but because trophoblastic proliferation is slight and
only focal, uterine enlargement in excess of
gestational age is uncommon.
 Similarly, preeclampsia, theca-lutein cysts,
hyperthyroidism, and other dramatic clinical features
are rare (Stefos, 2002).
 Pre-evacuation beta -hCG levels are lower than
those for complete moles and often do not exceed
100,000 mIU/mL.

17. Diagnosis of Hydatidiform Mole
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 First-trimester diagnosis of hydatidiform mole is now
common because of the routine use of serum beta-
hCG measurements and transvaginal sonography.
 An important characteristic of molar pregnancy is its
tendency to produce excess beta-hCG due to
trophoblastic proliferation.
 As a result, serum beta-hCG levels commonly are
greater than that expected for the gestational age
(Sasaki, 2003).

18. Cont.…
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 Diagnosis of molar pregnancy more frequently is
found sonographically because of the identifiable
diffuse swelling and enlargement of the chorionic
villi.
 Most first-trimester complete moles demonstrate a
typical sonographic appearance:
 a complex, echogenic intrauterine mass containing many
small cystic spaces.
 Fetal tissues and amnionic sac are absent (Benson,
2000).
 In contrast, sonographic features of a partial molar
pregnancy include a
 thickened, hydropic placenta with a concomitant fetus
(Zhou, 2005

19. Treatment
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 Suction curettage is the preferred method of evacuation
regardless of uterine size in patients who wish to remain
fertile (Tidy, 2000).
 Other surgical procedures, however, may be employed for
specific indications.
 For example, hysterectomy may be performed with
preservation of the ovaries if a woman wishes surgical
sterilization.
 Additionally, theca-lutein ovarian cysts regress after
delivery but may be aspirated if symptomatic (Berkowitz,
1996).
 Oophorectomy, however, should not be performed except
for rare circumstances when torsion of an ovary enlarged
by theca-lutein cysts leads to extensive ovarian infarction
(Mungan, 1996).

20. cont.…
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 Because of the tremendous vascularity of these
placentas, blood products should be available prior
to the evacuation of larger moles, and adequate
infusion lines should be established.

21. Cont.….
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 At the beginning of the evacuation, the cervix is dilated to
admit a 10- to 12-mm plastic Karmen suction cannula.
 As aspiration of molar tissues ensues, intravenous
oxytocin is given; 20 units of synthetic oxytocin is mixed
with 1 L of crystalloid and infused at rates to achieve
uterine contraction.
 Finally, a thorough, gentle curettage is performed
 Intraoperative sonography may assist in documenting
complete evacuation.
 Following curettage, because of the possibility of partial
mole and its attendant fetal tissue, Rh immune globulin
should be given to nonsensitized RhD-negative women.
 Rh immune globulin, however, may be withheld if the
diagnosis of complete mole is certain (Fung Kee, 2003).

22. Invasive Mole
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 This is a common manifestation of GTN
characterized by the presence of whole chorionic villi
that accompany excessive trophoblastic overgrowth
and invasion.
 These tissues penetrate deep into the myometrium,
sometimes involving the peritoneum, adjacent
parametrium, or vaginal vault.
 Such moles are locally invasive but generally lack
the pronounced tendency to develop widespread
metastases typical of choriocarcinoma.
 Invasive moles originate almost exclusively from
complete or partial molar gestations (Sebire, 2005a).

23. Gestational Choriocarcinoma
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 This extremely malignant tumor
 Comprised of sheets of anaplastic cytotrophoblast
and syncytiotrophoblast cells with prominent
hemorrhage, necrosis, and vascular invasion.
 Unlike molar disease, however, chorionic villi are
characteristically absent.
 Initially invade the endometrium and myometrium but
tend to develop early blood-borne systemic
metastases

24. Placental Site Trophoblastic Tumor
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 This tumor consists predominantly of intermediate
trophoblasts at the placental site and is a rare variant
of GTN with unique disease behavior (Scully, 1981).
 Follow any type of pregnancy but develop more
commonly following a normal pregnancy.
 They tend to infiltrate only within the uterus,
disseminate late in their course, and produce low
levels of beta-hCG relative to their mass (Twiggs,
1998).
 When this tumor does spread, however, the pattern
mirrors that of gestational choriocarcinoma.
 Fifteen percent of all reported cases were fatal
(Baergen, 2006).

25. Epithelioid Trophoblastic Tumor
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 This rare trophoblastic tumor is distinct from
gestational choriocarcinoma and placental site
trophoblastic tumor.
 Epithelioid trophoblastic tumor develops from
neoplastic transformation of chorionic-type
intermediate trophoblast.
 Microscopically, this tumor resembles placental site
trophoblastic tumor, but the cells are smaller and
display less nuclear pleomorphism.

26. Cont.
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 Grossly, epithelioid trophoblastic tumor grows in
a nodular fashion rather than the infiltrative
pattern of placental site trophoblastic tumor.
 Hysterectomy is the primary method of
treatment, but approximately 20 to 25 percent of
patients will present with metastatic disease.
 Currently, there are too few reported cases to
evaluate the efficacy of chemotherapy (Shih,
1998).

27. Nursing Assessment
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 Assess the abdominal girth of the pregnant woman
to check if it is within the usual landmark of
pregnancy.
 Assess for signs and symptoms of pregnancy
induced hypertension, because for a woman with H-
mole, they occur earlier than the 20th week of
pregnancy.
 Instruct the woman to save all perineal pads
containing any clots or tissue that has passed out of
her during bleeding.

28. Nursing Interventions
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 Measure abdominal girth and fundal height to
establish baseline data regarding the growth of the
uterus.
 Assist patient in obtaining a urine specimen for urine
test of hCg.
 Save all pads used by the woman during bleeding to
check for clots and tissues she may have
discharged.

29. Cont.
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 Provide your patient with an open environment and a
trusting relationship so she would be encouraged to
express her feelings.
 Honestly answer the patient’s questions to foster a
trusting relationship between nurse and client.
 Provide an assurance that it is not her own fault that this
happened to her to lessen her sense of guilt and self-
blame.

30. Cont.
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 The pain a mother experiences at the loss of a
pregnancy is never comparable to any pain in the
world.
 Expecting for an addition in the family and losing it
before it is even born is a difficult situation, but
somehow we, as nurses, have the ability to give
them comfort and reduce the pain they are feeling
through the knowledge that we have.

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END