gest-troph-neoplasia-1

gest-troph-neoplasia-1 - THE MANAGEMENT OF THE MANAGEMENT...

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Unformatted text preview: THE MANAGEMENT OF THE MANAGEMENT OF GESTATIONAL TROPHOBLASTIC NEOPLASIA Dr .Ashraf Fouda Damietta General Hospital Gestational trophoblastic neoplasia ((GTN 1. 2. 3. 3. 4. 4. 5. Complete vesicular mole Partial vesicular mole Partial Invasive mole Invasive Placental-site trophoblastic Placental-site tumor tumor Choriocarcinoma Choriocarcinoma Incidence: 1:2000 pregnancies in United States and Europe, but 10 times more in Asia. 10 Predisposing factors include : Predisposing Race,deficiency of protein or carotene Race,deficiency The incidence is higher toward the The beginning and more toward the end of the childbearing period. childbearing It is 10 times more in women over 45 It 10 over years old. years However, this may under represent the true incidence of the disease because of problems with reporting, particularly with regard to partial moles. Persistent GTN may develop after a : 1. Molar pregnancy, 2. Non-molar pregnancy or 3. Live birth. The incidence after a live birth is estimated at 1/50 000. Background Hydatidiform mole can be subdivided into complete and partial mole based on: Genetic and Histopathological features. 1. 2. Complete moles Complete moles are diploid and androgenetic in origin, with no evidence of fetal tissue. Complete moles Usually arise as a consequence of duplication of the haploid sperm following fertilization of an ‘empty’ ovum. Some complete moles arise after dispermic fertilization of an ‘empty’ ovum. :Complete mole Partial moles Are triploid in origin with two sets of paternal haploid genes and one set of maternal haploid genes. Partial mole Partial moles They occur, in almost all cases, following dispermic fertilization of an ovum. There is usually evidence of a fetus or fetal red blood cells. The widespread use of ultrasound has led to earlier diagnosis of pregnancy and has changed the pattern of molar pregnancy. The majority of women present with : symptoms of early pregnancy failure, while presentation with: 1. 2. 3. Hyperemesis, Early severe pre-eclampsia and Hyperthyroidism is very rare. Diagnosis of gestational trophoblastic neoplasia Early complete molar Early pregnancies are commonly associated with the ultrasound diagnosis of delayed miscarriage or anembryonic pregnancy. C Diagnosis of gestational trophoblastic neoplasia Complete moles may be Complete associated with suggestive ultrasonographic changes in the placenta. C Ultrasonography in Complete moles reveals: Complete reveals: 1. 2. 3. The characteristic intrauterine " The snow storm" appearance, snow No identifiable foetus, Bilateral ovarian cysts may be Bilateral detected. detected. A real-time ultrasound of a hydatidiform mole. The dark circles of varying sizes at the top center are the edematous villi. Ultrasonography Ultrasonography has limited value has in detecting partial molar pregnancies. Diagnosis of gestational trophoblastic neoplasia The increasing use of ultrasound in early pregnancy has probably led to the earlier diagnosis of molar pregnancy. C Diagnosis of gestational trophoblastic neoplasia However, the majority of histologically proven complete moles are associated with an ultrasound diagnosis of delayed miscarriage or anembryonic pregnancy. C Diagnosis of gestational Diagnosis trophoblastic neoplasia trophoblastic The ultrasound features of a The complete mole are reliable. But the ultrasound diagnosis But of a partial molar pregnancy is more complex. pregnancy C Diagnosis of gestational trophoblastic neoplasia The finding of multiple soft markers, The including both : including 1. cystic spaces in the placenta and cystic 2. a ratio of transverse to anterior2. posterior dimension of the gestation posterior sac of greater than 1.5 is required for the reliable diagnosis of a partial molar pregnancy. C partial Diagnosis of gestational trophoblastic neoplasia Estimation of human chorionic gonadotrophin (hCG) levels may be of value in diagnosing molar pregnancies. C Diagnosis of gestational trophoblastic neoplasia When there is diagnostic doubt about the possibility of a combined molar pregnancy with a viable fetus then ultrasound examination should be repeated before C Twins, when there is one viable fetus and the other pregnancy is molar The pregnancy should be allowed to proceed if the mother wishes, following appropriate counselling. C Twins, when there is one viable fetus and the other pregnancy is molar The probability of achieving a viable baby is 40% and there is a risk of complications such as pulmonary embolism and C pre-eclampsia. Evacuation of molar pregnancies Evacuation Surgical evacuation of molar Surgical pregnancies is advisable. pregnancies Routine repeat evacuation Routine after the diagnosis of a molar pregnancy is not warranted. pregnancy C Suction curettage Is the method of choice of evacuation for complete molar pregnancies. C Suction curettage Because of the lack of fetal parts a suction catheter, up to a maximum of 12 mm, is usually sufficient to evacuate all complete molar pregnancies. Medical termination of complete molar pregnancies Including cervical preparation prior to suction evacuation, should be avoided where possible. C Routine use of oxytocic agents There is theoretical concern, because of the potential to embolize and disseminate trophoblastic tissue through the venous system. C Routine use of oxytocic agents The contraction of the myometrium may force tissue into the venous spaces at the site of the placental bed. The dissemination of this tissue may lead to the profound deterioration in the woman, with embolic and metastatic disease occurring in the C lung. Evacuation of molar pregnancies Evacuation It is recognized that significant haemorrhage may occur as a consequence of evacuating a large uterine cavity, It is recommended, where possible, that oxytocic infusions are only commenced once evacuation has been C completed. Evacuation of molar pregnancies If the woman is experiencing significant haemorrhage prior to evacuation and some degree of control is required ,then use of oxytocic infusions will be necessary according to the clinical condition. C Evacuation of molar pregnancies Evacuation It is suggested that prostaglandin analogues should be reserved for cases where oxytocin is ineffective. Because evacuation of a large molar pregnancy is a rare event, advice and help from an experienced colleague should be sought where appropriate. C Evacuation of partial mole Evacuation mole In partial molar pregnancies where the size of the fetal parts deters the use of suction curettage, medical termination can be used. C Partial molar pregnancies These women may be at an increased risk of requiring treatment for persistent trophoblastic neoplasia, although the proportion of women with partial mole needing chemotherapy is low (0.5%). C Histological examination of products of conception of All products of conception All obtained after evacuation (medical or surgical) (medical should undergo histological examination. C Histological examination of products of conception products In view of the difficulty in making a diagnosis of a molar pregnancy before evacuation, the histological assessment of material obtained from the medical or surgical management of incomplete abortions is recommended in order to exclude trophoblastic neoplasia. C Histological examination Histological of products of conception Because persistent trophoblastic neoplasia may develop after any pregnancy it is recommended that all products of conception obtained after repeat evacuation should undergo histological C examination. Histological examination Histological of products of conception of Products of conception from Products therapeutic terminations of pregnancy should be examined if there is if no evidence of fetal tissue. no C The management of women with gynecological symptoms after evacuation of a molar pregnancy of In cases where there are In persisting symptoms, such as vaginal bleeding, after initial vaginal after evacuation, consultation with the screening centre should be sought before surgical intervention. C before The management of women with The gynecological symptoms after evacuation of a molar pregnancy evacuation There is no clinical indication for the routine use of a second uterine evacuation in the management of molar pregnancies. D The management of women with The gynecological symptoms after evacuation of a molar pregnancy evacuation Uterine evacuation may be recommended, in selected cases, by the screening centre as part of the management of persistent trophoblastic neoplasia. D Persistent GTN after a non molar pregnancy Women with persistent Women abnormal vaginal bleeding after a non molar pregnancy should undergo a pregnancy test to exclude persistent GTN. test C Persistent GTN after a non molar pregnancy Persistent GTN can occur after nonmolar pregnancies. Vaginal bleeding is a common presenting symptom but symptoms from metastatic disease, such as dyspnoea or abnormal neurology, can occur. C Persistent GTN after Persistent a non molar pregnancy Persistent GTN should be Persistent GTN considered in any woman developing acute respiratory or neurological symptoms neurological after any pregnancy. C Persistent GTN after Persistent a non molar pregnancy The prognosis for women with GTN after nonmolar pregnancies may be worse (21% mortality after a live birth, 6% after a nonmolar miscarriage) and in part due to the delay in diagnosis . C Registration of women with molar pregnancy molar Registration of any molar Registration pregnancy is essential. pregnancy C Women with the following molar pregnancies should be registered and require follow up for 6–24 months as determined by the screening centre: 1. Complete Hydatidiform mole 2. Partial Hydatidiform mole 3. Twin pregnancy with complete or partial hydatidiform mole 4. Choriocarcinoma C 5. Placental site trophoblastic tumour. Treatment of persistent GTN Treatment Women with persistent GTN Women should be treated at a specialist centre with appropriate chemotherapy. chemotherapy C Treatment of persistent GTN The need for chemotherapy following a complete mole is 15% and 0.5 % after a partial mole. C Treatment of persistent GTN Women with evidence of persistent GTN should undergo assessment of their disease followed by chemotherapy. Disease risk is scored according to the FIGO staging for GTN. C Treatment of persistent GTN Women scoring six or less (low risk) receive intramuscular methotrexate on alternate days, followed by six rest days, with each course consisting of four injections. C Treatment of persistent GTN Women who develop resistance to methotrexate are treated with a combination of intravenous dactinomycin and etoposide. Women scoring seven or more (high risk) receive combination C chemotherapy. Placental site trophoblastic tumour Placental site trophoblastic tumour is now recognized as a variant of gestational trophoblastic neoplasia. Surgery and multi-agent chemotherapy play major roles in the clinical management of this tumour. C Future pregnancy Future Women should be advised Women not to conceive not until the hCG level has been normal for six months. normal C Future pregnancy Future 1. 2. The risk of a further molar pregnancy is low (1/55) and More than 98% of women who become pregnant following a molar pregnancy will not : Have a further mole or Be at increased risk of obstetric C complications. Future pregnancy If a further molar pregnancy does occur, in 68–80% of cases it will be of the same histological type. C Future pregnancy After the conclusion of any further pregnancy (at any gestation) further urine or blood samples for hCG estimation are requested to exclude disease recurrence. C Future pregnancy Women who undergo chemotherapy are advised not to conceive for one year after completion of treatment. C Contraception and hormone replacement therapy replacement The combined oral The contraceptive pill and hormone replacement therapy are safe to use after hCG safe levels have reverted to normal. levels C Contraception and hormone replacement therapy replacement The combined pills, if taken while hCG levels are raised, may increase the need for treatment. However, it can be used safely after the hCG levels have returned to normal. D Contraception and hormone replacement therapy replacement The small potential risk of using emergency hormonal contraception, in women with raised hCG levels, is outweighed by the potential risk of pregnancy to the woman. D ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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