Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole

doi:10.1016/j.ajog.2010.06.073

American Journal of Obstetrics and Gynecology

Volume 203, Issue 6, December 2010, Pages 531-539

https://doi.org/10.1016/j.ajog.2010.06.073 Get rights and content

Gestational trophoblastic disease includes hydatidiform mole (complete and partial) and gestational trophoblastic neoplasia (invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor). The epidemiology, pathology, clinical presentation, and diagnosis of each of these trophoblastic disease variants are discussed. Particular emphasis is given to management of hydatidiform mole, including evacuation, twin mole/normal fetus pregnancy, prophylactic chemotherapy, and follow-up.

Section snippets

Epidemiology

The incidence and etiologic factors contributing to the development of GTD have been difficult to characterize. The problems in accumulating reliable epidemiologic data can be attributed to a number of factors, such as inconsistencies in case definitions, inability to adequately characterize the population at risk, no centralized databases, lack of well-chosen control groups against which to compare possible risk factors, and rarity of the diseases.⁴

Epidemiologic studies have reported wide

Pathology

Molar pregnancies and gestational trophoblastic neoplasms all take their origin from the placental trophoblast. Normal trophoblast is composed of cytotrophoblast, syncytiotrophoblast, and intermediate trophoblast. Syncytiotrophoblast invades the endometrial stroma with implantation of the blastocyst and is the cell type that produces human chorionic gonadotropin (hCG). Cytotrophoblast functions to supply the syncytium with cells in addition to forming outpouchings that become the chorionic

Complete hydatidiform mole

Complete hydatidiform mole most commonly presents with vaginal bleeding, usually occurring at 6-16 weeks of gestation in 80-90% of cases. The other classic clinical signs and symptoms, such as uterine enlargement greater than expected for gestational dates (28%), hyperemesis (8%), and pregnancy-induced hypertension in the first or second trimester (1%), occur less frequently in recent years because of earlier diagnosis as a result of widespread use of ultrasonography and accurate tests for hCG.

Ultrasonography

Ultrasonography plays a critical role in the diagnosis of both complete and partial mole, and it has virtually replaced all other means of preoperative diagnosis.38, 43, 44, 45 Because the chorionic villi of complete moles exhibit diffuse hydropic swelling, a characteristic vesicular ultrasonographic pattern can be observed, consisting of multiples echoes (holes) within the placental mass and usually no fetus (Figure 6). Ultrasonography may also facilitate the early diagnosis of a partial mole

Treatment

Once the diagnosis of molar pregnancy is suspected by history, physical examination, hCG levels, and ultrasound findings, the patient should be evaluated for the presence of medical complications (anemia, preeclampsia, hyperthyroidism) by way of vital signs and laboratory tests, such as complete blood cell counts, basic chemistry, hepatic and thyroid panels, urinalysis, and chest x-ray. The preoperative evaluation should also include blood type and crossmatch, serum hCG level, and

Follow-up after molar evacuation

Follow-up after evacuation of a hydatidiform mole is essential to detect trophoblastic sequelae (invasive mole or choriocarcinoma), which develop in approximately 15-20% with complete mole and 1-5% with partial mole.59, 70, 71, 72, 73, 74 Clinical findings of prompt uterine involution, ovarian cyst regression, and cessation of bleeding are all reassuring signs, however, definitive follow-up requires serial serum quantitative hCG measurements every 1-2 weeks until 3 consecutive tests show normal

References (77)

R.S. Berkowitz et al.
Current management of gestational trophoblastic disease
Gynecol Oncol
(2009)
H.K. Atrash et al.
Epidemiology of hydatidiform mole during early gestation
Am J Obstet Gynecol
(1986)
K.D. Bagshawe et al.
Hydatidiform mole in England and Wales 1973-1983
Lancet
(1986)
H.O. Smith et al.
Trends in gestational choriocarcinoma: a 27-year perspective
Obstet Gynecol
(2003)
N.J. Sebire et al.
Risk of partial and complete molar pregnancy in relation to maternal age
Br J Obstet Gynecol
(2002)
R.S. Berkowitz et al.
Risk factors for complete molar pregnancy from a case-control study
Am J Obstet Gynecol
(1985)
F. Parazzini et al.
Dietary factors and risk of trophoblastic disease
Am J Obstet Gynecol
(1988)
A.E. Szulman et al.
The syndromes of hydatidiform mole, I: cytogenetic and morphologic correlations
Am J Obstet Gynecol
(1978)
A.E. Szulman et al.
The syndromes of hydatidiform mole, II: morphologic evolution of the complete and partial mole
Am J Obstet Gynecol
(1978)
R.N. Baergen et al.
Placental site trophoblastic tumor: a study of 55 cases and review of the literature emphasizing factors of prognostic significance
Gynecol Oncol
(2006)

V. Soto-Wright et al.

The changing clinical presentation of complete molar pregnancy

Obstet Gynecol

(1995)

M. Ozturk et al.

Differential production of human chorionic gonadotropin and free subunits in gestational trophoblastic disease

Am J Obstet Gynecol

(1988)

C. Palmieri et al.

Management and outcome of healthy women with a persistently elevated β-hCG

Gynecol Oncol

(2007)

S. Rotmensch et al.

False diagnosis and needless therapy of presumed malignant disease in women with false-positive human chorionic gonadotropin concentrations

Lancet

(2000)

L.A. Cole et al.

Gestational trophoblastic diseases, 2: hyperglycosylated hCG as a tumor marker of active neoplasia

Gynecol Oncol

(2006)

J.A. Tidy et al.

Gestational trophoblastic disease: a study of mode of evacuation and subsequent need for treatment with chemotherapy

Gynecol Oncol

(2000)

D.A. Fishman et al.

Management of twin pregnancies consisting of a complete hydatidiform mole and normal fetus

Obstet Gynecol

(1998)

N.J. Sebire et al.

Outcome of twin pregnancies with complete hydatidiform mole and healthy co-twin

Lancet

(2002)

J.R. Lurain et al.

Natural history of hydatidiform mole after primary evacuation

Am J Obstet Gynecol

(1983)

C.M. Feltmate et al.

Human chorionic gonadotropin follow-up in patients with molar pregnancy: a time for reevaluation

Obstet Gynecol

(2003)

S. Goto et al.

Development of postmolar trophoblastic disease after partial molar pregnancy

Gynecol Oncol

(1993)

S.L. Curry et al.

Hormonal contraception and trophoblastic sequelae after hydatidiform mole (a gynecologic oncology group study)

Am J Obstet Gynecol

(1989)

J.T. Soper