Gestational Trophoblastic Disease- Case1.docx

Gestational Trophoblastic Disease Case 1: A 19 year old G1, 10 weeks AOG, consults for vaginal bleeding. She has been experiencing severe nausea and vomiting. Physical examination: BP-130/80 mmHg; CR- bpm; FH-16cm ; no fetal heart tones appreciated Speculum exam: + minimal bleeding per os Internal exam: cervix soft, closed, uterus enlarged to 4 months size 1. Give 3 differential diagnoses and the reason for considering these conditions. -Ectopic pregnancy -Hydatidiform mole Vaginal bleeding, nausea, vomiting, no FHT appreciated - Infection 2. What initial examinations should be requested to arrive at a diagnosis? Give the expected results. Criteria for Diagnosis of Gestational Trophoblastic Neoplasia 1. Plateau of serum β-hCG level (± 10 percent) for four measurements during a period of 3 weeks or longer—days 1, 7, 14, 21 2. Rise of serum β-hCG level > 10 percent during three weekly consecutive measurements or longer, during a period of 2 weeks or more—days 1, 7, 14 3. Serum β-hCG level remains detectable for 6 months or more 4. Histological criteria for choriocarcinoma Serum B- HCG measurements -Serum β-HCG Measurements With a complete molar pregnancy, serum β-hCG levels are commonly elevated above those expected for gestational age. With more advanced moles, values in the millions are not unusual. Importantly, these high values can lead to erroneous falsenegative urine pregnancy test results because of oversaturation of the test assay by excessive βhCG hormone. In these cases, serum β-hCG determinations with or without sample dilution will clarify the conundrum. With a partial mole, β-hCG levels may also be significantly elevated, but more commonly concentrations fall into ranges expected for gestational age. Sonography -Sonography Although sonographic imaging is the mainstay of trophoblastic disease diagnosis, not all cases are confirmed initially. Sonographically, a complete mole appears as an echogenic uterine mass with numerous anechoic cystic spaces but without a fetus or amnionic sac. The appearance is often described as a “snowstorm”. A partial mole has features that include a thickened, multicystic placenta along with a fetus or at least fetal tissue.

3. What are the other laboratory examinations to be requested? Laboratory studies used in the diagnosis of GTN are as follows:  Serum quantitative hCG – To assess response to therapy and disease status  CBC – May help detect anemia secondary to bleeding  Liver enzymes – May become elevated in patients with metastasis to the liver  Pelvic ultrasonography – May show persistent molar tissue in the uterus  Chest radiograph – Recommended because the lung is the most frequent site of metastasis  Laboratory Hemogram  Free T4 levels Type and Rh  Group and screen or crossmatch Chest radiograph Consider hygroscopic dilators 4. What is the most appropriate method of evacuation? -Suction curettage is the preferred method of evacuation regardless of uterine size in patients who desire to preserve fertility. It is best to avoid prior cervical preparation, oxytocic drugs and sharp curettage or medical evacuation, to minimize the risk of dissemination of tissue leading to metastatic disease . Oxytocic agents and prostaglandin analogues are best used only after uterine evacuations when there is significant hemorrhage. 5.

Give the post-evacuation plan for the management? -Close biochemical surveillance for persistent gestational neoplasia should follow hydatidiform mole evacuation. Concurrently, reliable contraception is imperative to avoid confusion caused by rising β-hCG levels from a new pregnancy. Most recommend either combination hormonal contraception or injectable medroxyprogesterone acetate. The latter is particularly useful if there is poor compliance. Intrauterine devices are not used until β-hCG levels are undetectable because of the risk of uterine perforation if there is an invasive mole. Finally, barrier and other methods are not recommended because of their relatively high failure rates.