Gestational Trophoblastic Disease And Its Complications: Review Of Patient Profiles And Management At A Tertiary Care Centre

Abstract

Gestational trophoblastic Disease refers to a spectrum of pregnancy related placental tumors, which is Classified into Hydatidiform Mole and Gestational Trophoblastic Neoplasia. This disease is characterized by abnormalities of chorionic villi in the form of excessive trophoblastic proliferation, oedema of villous stroma, invasion and metastasis. The incidence of Hydatiform mole is 1-2 per 1000 pregnancies. The risk factors are Adolescent and elderly women, Prior molar pregnancy, OC pill use, Smoking, various vitamin deficiency and increase paternal age. Clinical presentation is usually of varing duration of amenorrhea followed by irregular bleeding. Ultrasound appearance is characteristic snow storm pattern i.e a complex echogenic mass with numerous cystic Spaces with no fetus or amniotic sac in complete mole. The two basic tenets for management is Suction Evacuation and regular follow up to detect trophoblastic disease. Most clinicians obtain pre operative x-ray chest hemogram , baseline beta HCG, blood grouping, liver enzymes routinely before suction Evacuation. Prophylactic chemotherapy is routinely not recommended. If no further pregnancy is required, hysterectomy preferred over suction curettage ion women aged more than 40 years. It is also an important adjunct to treatment of chemo resistant tumors. Post evacuation Surveillance is done for a minimum of 6 months using hormonal contraception with beta HCG follow up 48 hours after evacuation and every 1-2 weeks, while still elevated and every month for another 6 months after it falls to normal levels. Gestationla trophoblastic neoplasia almost always develops with or follow some form of recognized pregnancy. Most follow a hydatidiform mole. Invasive mole are localy invasive but generally lack the pronounced tendency to wide spread metastasis. Choriocarcinoma is extremely malignant tumor. Metastasis often develop early in choriocarcinoma and are generally blood borne and most common sites are lungs and vagina. Placental site trophoblastic tumors are rare variant characterized by prolactin producing intermediate trophoblast with relatively low beta HCG, a high proportion of free beta HCG, chemo resistant and hysterectomy being the best treatment. Epitheliod tumors are rare characterized by non conformation of preceding pregnancy, nodular growth and microscopically resembles placental site tumors but the cells are smaller and display less pleomorphism. Risk assessment is done by using modified WHO prognostic scoring system. Score 0-6 generally include low risk neoplasia. In general methotrexate is given for non meta static or low risk metastatitic neoplasia. High risk GTN{score more then 7}usually requires EMA-CO regimen, surgery, radiotherapy. Survillence is one year for GTN and upto 2 years if there is metastasis. The purpose of this study was to study the incidence, epidemiological correlates of GTN, the clinical behavior, the complications and management of this disease in our hospital, and to review the literature on this uncommon disease.