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Bleeding in Early Pregnancy

   

3-Gestational Trophoblastic Disease

Originate from placental tissues

Rare human tumors curable even when metastatic

4 entities :

Pathology

· Complete mole

Karyotype :

· Partial mole

If presence of a fetus :

· Choriocarcinoma

Hydatidiform mole

45%

Normal term pregnancy

25%

Spontaneous abortion

25%

Ectopic pregnancy

5%

Karyotype : variable

· Placental site trophoblastic tumor

Unpredictable behavior :

Origin : 95% after a term pregnancy
extremely resistant to chemotherapy
Karyotype : variable

EPIDEMIOLOGY AND RISK FACTORS·

Hydatidiform mole

1/1000 pregnancies

USA and most regions of the world

2/1000 pregnancies

Japan

Japanese in Hawaii

incidence> non-Japanese< in Japan

Maternal age

> 35 year old : 2x for> 35 yo ; 7,5x for> 40 yo

 

< 20 year old

Previous hydatidiform mole

10x

Diet

¯ risk with diets rich in carotene and adequate amounts of fat intake

· Choriocarcinoma

Epidemiology not well understood

USA

1/24000 pregnancies and 1/19920 live births

ASIA

1/6000 to 1/8000 pregnancies

Age over 40 yo

­ risk 8x

Most important risk factor

history of previous hydatidiform mole (29 to 83% cases)

CLINICAL PRESENTATION

METASTATIC DISEASE

Most common metastatic sites

· Lungs

80%

· Vagina

30%

· Pelvis

20%

· Liver

10%

· Brain

10%

 

 

 

 

DIAGNOSIS

TREATMENT

· Hydatidiform mole (non metastatic)

D&C or hysterectomy if no desire of fertility.

Follow up :

WHO Prognostic Index Score to determine the resistance to chemotherapy

 

Score

 

0

1

2

4

Prognostic Factors

 

 

 

 

Age

= 39

= 39

-

-

Previous pregnancy

Mole

Abortion

Term

-

Interval (months

< 4

4-6

7-12

> 12

ß hCG (mIU/ml)

< 10 3

10 3-10 4

10 4-10 5

> 10 5

ABO groups

-

O or A

B or AB

-

Largest tumor, including uterine(cm)

-

3-5

> 5

-

Site of metastases

Lungs, pelvis, vagina

Spleen, Kidney

GI tract, Liver

Brain

Number of Metastases

-

1-3

4-8

> 8

Prior Chemotherapy

-

-

Single

Multiple

Persistent Gestational Trophoblastic Tumor

18-29% of complete moles (USA).

Diagnosis : if plateau of ß hCG for 3 consecutive weeks or if ­ ß hCG.

Histology may be different (Choriocarcinoma or placental site trophoblastic tumor).

Criteria of severity

Risk of persistent trophoblastic disease then 40-50%

Risk diminishes to 10-15% with chemoprophylaxis (Methotrexate or Dactinomycin)

Staging : if pelvic examination and Chest X-Ray(or Chest CT-scan)in order,very low risk of finding metastases elsewhere.

CHEMOTHERAPY

According to WHO prognostic Index Score

Monochemotherapy

Methotrexate (MTX) ® 90% CR.

If failure with MTX, with further ttt® 100% CR.

Polychemotherapy

5 drugs : etoposide,MTX,dactinomycin,cyclophophamide (EMA-CO).

83% CR versus 30-45% CR with monochemotherapy in " high risk " situations.

FOLLOW-UP

· b hCG weekly during treatment until 3 normal levels (3 weeks)
· b hCG every 2 weeks for the next 2-3 months.
· b hCG every 1 month for 6 months then every 2 months

*follow-up after one year

*Efficient contraception during treatment and follow-up. Wait a minimum of one year before starting pregnancy

Pregnancy experience, after GTD

· Fertility:

· Even with chemotherapy

· Risk subsequent molar pregnancy:

· Rate of stillbirth higher after persistent GTT than general population (odd ratio 2, 9)

· Infertility rate same as in general population (4%)

· Rate of premature deliveries, ectopic gestations , congenital anomalies ,C-section same as general population.

 

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