Definition | Gestational trophoblastic disease (GTD) comprises a group of disorders spanning the premalignant conditions of complete and partial molar pregnancies (also known as hydatidiform moles) through to the malignant conditions of invasive mole, choriocarcinoma and the very rare placental site trophoblastic tumour (PSTT) and epithelioid trophoblastic tumour (ETT). The malignant potential of atypical placental site nodules (PSNs) remains unclear.
The diagnosis of GTN does not require histological confirmation. The diagnosis of complete mole, partial mole, atypical PSN and PSTT/ETT does require histological confirmation. |
How do molar pregnancies present to the clinician? | The most common presentation is irregular vaginal bleeding, a positive pregnancy test and supporting ultrasonographic evidence. Less common presentations of molar pregnancies include hyperemesis, excessive uterine enlargement, hyperthyroidism, early‐onset pre‐eclampsia and abdominal distension due to theca lutein cysts. [New 2020] Very rarely women can present with haemoptysis or seizures due to metastatic disease affecting the lungs or brain. [New 2020] |
What is the best method for removal of a molar pregnancy? | Suction curettage is the method of choice for removal of complete molar pregnancies,except when the size of fetal parts deters the use of suction curettage and then medical removal can be used. |
Is it safe to prepare the cervix prior to surgical removal? | Preparation of the cervix immediately prior to uterine removal is safe. Anti‐D prophylaxis is recommended following removal of a molar pregnancy. |
Can oxytocic infusions be used during surgical removal? | Excessive vaginal bleeding can be associated with surgical management of molar pregnancy and the involvement of an experienced clinician is advised. The use of oxytocic infusion prior to completion of the removal is not recommended. If the woman is experiencing significant haemorrhage prior to or during removal, surgical removal should be expedited and the need for oxytocin infusion weighed up against the risk of tissue embolisation. |
In what circumstances should a repeat surgical removal be indicated and what is the timing? | There is almost always a role for urgent surgical management for the woman who is experiencing heavy or persistent vaginal bleeding causing acute haemodynamic compromise, particularly in the presence of retained pregnancy tissue on ultrasound. [New 2020] |
Should pregnancy tissue from all miscarriages be examined histologically? | The histological assessment of material obtained from the medical or surgical management of all miscarriages is recommended to exclude trophoblastic neoplasia if no fetal parts are identified at any stage of the pregnancy. |
Should pregnancy tissue be sent for examination after abortion? | There is no need to routinely send pregnancy tissue for histological examination following therapeutic abortion, provided that fetal parts have been identified at the time of surgical abortion or on prior ultrasound examination. |
UPT indication ? | Women who receive care for a miscarriage should be recommended to do a urinary pregnancy test 3 weeks after miscarriage. If it is medical TOP ,or H/P specimen not sent (H/P should be sent in pregnancy with no fetal parts) Repeat UPT at 8 week if pt bleeding irrespective of method of TOP,and mode of delivery [New 2020] |
How should women with an elevated human chorionic gonadotrophin after a possible pregnancy event be managed? | Referral to a GTD centre should be considered for all women with persistently elevated human chorionic gonadotrophin (hCG) l either after an ectopic pregnancy has been excluded, l or after two consecutive treatments with methotrexate for a pregnancy of unknown location. [New 2020] |
Biopsy of secondary deposits in the vagina | Biopsy of secondary deposits in the vagina can cause major haemorrhage and is not recommended. |
How is twin pregnancy of a viable fetus and presumptive coexistent molar pregnancy managed? | should be referred to a regional fetal medicine centre and GTD centre. In the situation of a twin pregnancy where there is one viable fetus and the other pregnancy is molar, the woman should be counselled about the potential increased risk of perinatal morbidity and the outcome for GTN. Prenatal invasive testing for fetal karyotype should be considered in cases where it is unclear if the pregnancy is a complete mole with a coexisting normal twin or a possible singleton partial molar pregnancy. Prenatal invasive testing for fetal karyotype should also be considered in cases of abnormal placenta, such as suspected mesenchymal hyperplasia of the placenta. |
How should a placental site nodule or atypical placental site nodule be managed? | Women with an atypical placental site nodule (PSN) or where the local pathology is uncertain should have their histology reviewed centrally. All women with atypical PSN will then be called up for central review to discuss the existing data, perform staging investigations and to determine further management. Women with typical PSN do not currently require further investigation or review. [New 2020] |
Women with the following diagnoses should be registered and require follow‐up as determined by the screening centre: | l complete molar pregnancy/partial molar pregnancy l twin pregnancy with complete or partial molar pregnancy l limited macroscopic or microscopic molar change suggesting possible early complete or partial molar pregnancy/choriocarcinoma l PSTT or ETT l atypical PSN. [New 2020] |
What is the optimum follow‐up following a diagnosis of GTD? | For complete molar pregnancy, if hCG has reverted to normal within 56 days of the pregnancy event then follow‐up will be for 6 months from the date of uterine removal. If hCG has not reverted to normal within 56 days of the pregnancy event then follow‐up will be for 6 months from normalisation of the hCG level. Follow‐up for partial molar pregnancy is concluded once the hCG has returned to normal on two samples, at least 4 weeks apart. [New 2020] Women who have not received chemotherapy no longer need to have hCG measured after any subsequent pregnancy event. [New 2020] PSTT and ETT are now recognised as variants of GTN. They may be treated with surgery because they are less sensitive to chemotherapy |
What is the recommended interval between a complete or partial molar pregnancy and trying to conceive in the future, what is the monitoring of women following a successful pregnancy after a previous molar pregnancy and what is the outcome of subsequent pregnancies? | Women are advised not to conceive until their follow‐up is complete in molar pregnancy Women who undergo chemotherapy are advised not to conceive for 1 year after completion of treatment, as a precautionary measure. Women who have a pregnancy following a previous molar pregnancy, which has not required treatment for GTN, do not need to send a post‐pregnancy hCG sample. Histological examination of placental tissue from any normal pregnancy, after a molar pregnancy, is not indicated. [New 2020] Further pregnancies are achieved in approximately 80% of women following |
Is hormone replacement therapy safe for women to use after GTD? | Hormone replacement therapy and any contraceptive method may be used once hCG levels have returned to normal. |
Twin pregnancy with molar pregnancy | 51 % live birth rate 40 % fetal loss 20% PET Need for chemotherapy is 15 % if PTD < 26 week |
Investigation | Choriocarcinoma CT chest and abdomen /or MRI head and pelvis Doppler pelvis HCG |
Cure rate | l Cure rate 100 % if score 6 or below l 94% if score>6 l Score 13 having high risk of death in 4 weeks of chemotherapy du eto haemorrhage,chemo resistant. l PSTT,ETT are not managed as per FIGO,if diagnosis after 48 months then 100 % death rate l Diagnosis after 48 months |
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