•It affects women in reproductive age and even after initial management it has the potentiality to
progress to malignant forms which threat the life of these young women.
•The malignant form so fit is curable if the patient under goes close follow up and the changes are
discovered in early stages
DEFINITION:
-GTD refer to the spectrum of proliferative abnormalities of the trophoblast associated with
pregnancy. In GTD abnormal growth and development of trophoblast continue after end of pregnancy
It is charachterized by production of high quantity of human chorionic gonado tropin hormone which
is used as amarker for diagnosis and Mainly follow up of the disease
Ectopic pregnancy referred to the implantation of fertilized ovum on tissue other
than endometrium of the uterus or out side the uterine cavity.
CLASSIFICATION -Ectopic pregnancy is a major problem in gynecology because there is evidence of
A)hyditidiform mole:- increasing incidence Ectopic pregnancy is the 2nd most common cause of maternal
1-Complete mortality in USA and impairment or loss of fertility may also result .It is difficult to
2-Partial diagnose
B)Trophoblastic neoplasm:- SITES:
1-Persistent T. disease 1)Fallopian tube over than 95%
2-Invasivemole - Ampulla’s55%.
3-Choriocarcinoma - Isthmus25%.
Non metastasis - Fembriatedend.
Metastasis - Interstitial most complicated site.
Low risk–good prognosis 2)Other sites:
Highrisk–poorprognosis • Uterine:
-Rudimentary born.
-Cervical .
ETIOLOGY: -Angular(corneal).
-Cause is not definitely known but:
• Ovary
• It is highest in teenagers and >35.
• Abdominal cavity
• Race and ethnic group.
• Inadequate diet low protein
• Blood group A ,AB. Etiology(Riskfactors):
• Cytogenitic abnormality :complete mole is 46xx karyotype (father origin). The basic cause is due to impede passage of fertilized ovum down the tube:
• History of priormole pregnancy -The common pathology is damage to the ciliated epithelium and peristalitic activity
of fallopian tube due to infection by Gonococci .Clamydia .PID Post abortion and
puerperal infection.
PATHOLOGY • Damage due to pelvic and in particular tubalmsurgery
• It is principally disease of chorion • Gross pelvic pathology i.e.endometriosis
•Death of ovum or failure of embryo to growth is essential to develop complete • Congenital abnormalities of tubes:
vesicular mole. • Use of IUCD mainly if contain progesterone.
NAKED EYE: • Use of POP. (Progesteroneonlypills).
• uterus is filled with clusters of cysts of varying size • I.V.F.(in vitro fertilization) and E.T.(embryo transfer)
• No trace of embryo or amniotic sac. • History of infertility..
MICROSCOPICALLY:- • Previous ectopic pregnancy
• Proliferation of cys to- cyncytio trophoblast.
• Thinning of stroma with accumulation of fluid. Pathologic anatomy:
• Absence of blood vessels
-The embryo implants in similar way as in uterine cavity but there is no endometrium
• Villous pattern is maintained
and trophoblast penetrate the epithelium and eroded maternal blood vessels and
intraperitoneal hemorrhage may occur .
CLINICAL FEATURES: -there are many variation to this pattern of ectopic pregnancy, abortion out .the end
•Age and parity of the tube, chronic hemtoma formation ,regression,or reimplantation in abdominal
• Teenagers and elderly patient with high parity cavity.
• History of amnorrhea 8-12 weeks with symptoms of pregnancy.
• Vaginal bleeding (comments90%).
• Varying degree of lower abdominal pain due to:-
On Examination
DIFFERENTIAL DIAGNOSIS:- – uterine over distension -Patient lie quite, conscious.
• Threatened abortion – concealed accidental hemorrhage. -Pallor severe but depended on intraperitoneal hemorrhage.
• Fibroid or ovariantumor with pregnancy. -Feature of shock: Increase pulse rate thready, decrease blood
• Acute hydramnios or twin pregnancy. constitutionalsymptom:- pressure and cold clammy skin
• Vomiting of pregnancy is excessive. -Abdominal exam: Tense, tender ,mostly in lower abdomen. No mass.
• Breathlessness, embolization. -Shifting dullness may be positive. Gut may be distended. Muscle
COMPLICATIONS: guarding usually absent.
-Immediate:- • thyrotoxic feature. 1-ACUTE ECTOPIC RUPTURE~30%:
• Lower limb edema. -Age 20-30. -Bimanual:It is less informative and may precipitate intraperitoneal
• hemorrhage and shock hemorrhage vaginal mucosa white.
• sepsis • Expulsion of grape like vesicles through the vagina. -Multipara or long period infertility.
• History of quickening is absent. -Onset : Acute but rarely fulminating . -Uterus is Normal Size or bulky.
• perforation of the uterus -Extreme tenderness on move cervix or fornix palpation.
• pre-eclampsia Symptoms :
SIGNS:- Classic triad of disturbed pregnancies . -No mass felt through fornix.
• acute pulmonary insufficiency embolism
• coagulation failure embolism. • Feature of early months of pregnancy Amenorrhea:
• The patient look like ill short period of 6-8 week. Spotting on day of expected period .Amenorrhea may be less
Late:-
• Pallor is usually prominent
Differential diagnosis:
•development of chorio carcinoma HYDITIDIFORM MOLE In interstitial amenorrhea up to 10-12 week .
• Feature of PET (increase BP, protein, edema). Pain: Acute. Agonizing or colicky. Locate to one side- spread to lower abdomen then Acute type : Any condition-producing emergency.
RISK FACTORS:- DEFINITION:
Per abdomen:- -Abnormal pregnancy in which there is partly degeneration and generalized. Pain may refer to shoulder.
That are associated with malignant change. 1)Acute Salpingitis: Symptoms follow mensis.
• Uterine size > expected for period of Amenorrhea (70%). partly hyperplasic of young chorionicvilli Vaginal bleeding no important
• Age > 30 IncreaseinTemp. Bilateral swelling of tubes increase of WBC.
• Uterine size = Amenorrhea (20%) .This results in formation of small cysts of varying size, grape like Faint affects with nausea, vomiting to syncope.
• Grand multiparae 2)Abortion:
• Uterinesize<Amenorrhea (10%) (vesicles) fill the uterine cavity
• Initial HCGinurineofover100,000IU/24hours. Bleeding followed by pain while in ectopicpregnancy the reveres.
• Feel of uterus is doughy.Fetal part is not felt no fetal movement TYPES :Depend on morphology, histopathology and karyotype:
• Histopathology infiltrative molar. Bleeding is profuse. Enlarged abdomen=Ao .
• Absence of fetal heart sound (by Doppler). • Complete
• Previous history of molar pregnancy No mass or tenderness infrinx.
• Women with group • Incomplete ECTOPIC PREGNANCY 3)Twisted or rupture ovarian cyst Irregular menstrual humoring No
evidence of pregnancy
Vaginal examination:-
• Internal ballottement cannot be elicited.
Bleeding In 4)Appendicitis: Pain at umbilicus then spread tendernes sat
McBurney,s Abdominal rigidity.
•Uni or bilateral enlargement (theca luteal cystic). Most of ovary due to increase HCG.
• Findings of vesicles in the vaginal discharge is pathgnomonic G.T. D Early Pregnancy on Examination of patient
• Pale ,may be hypotension or tachycardia
INVESTIGATIONS:- GESTATIONAL • Destinded tender lower abdomen
• Tender adnexial mass may be palpated
• Full blood count, ABO +Rh group.
• Hepatic, renal, thyroid test. TROPHOBLASTIC DISEASE • Bulgy Cul-De-Sac into the posterior fornix of vagina
•Sonography(snow storm appearance) some time confused with missed abortion or Investigations
degeneration fibroid. • Serum β-hCG show failure to double in 48hours
• Quantitative estimation of HCG:- CLINICAL FEATURES: • ULTASOUND is very helpful in diagnosis
• βHCG level diagnosis ,(treatment and follow up). • Vaginal ultrasound has much diagnostic power than abdominal
• Straight X-ray:- • presence of an intrauterine pregnan cyrule out ectopic
– chest (embolism) and follow up •the visualization of gestational sac and an embryo with heart beat out
side the uterus is proof of ectopic pregnancy
. correlation of serum β-hCG level and ultrasound finding is the most
Evacuation of Molar Pregnancies: diagnostic significance
– if β-hCG is above the “Discrimintory zone” as around 1800 mI U/ml ,a
gestational sac should be visible on TVS
–if the intrauterine gestational sac is not visible by the time the β-hCG is
at or above this level the pregnancy has the likelihood of being ectopic
– other US signs
– Echogenic mass with fluid 100%
2-CHRONICOLDECTOPIC: – Moderate to large amount of fluid 95%
• Commonest type: – Echogenic mass 85%
– It associated with pelvic haematocele followed tubal abortion or tubal mole rarely – Any free fluid 71
ectopicrupture. 3-Serum progesterone
– On set is insidious. - >25ng/mlis suggestive of viable intrauterine pregnancy.
– Patient has H/O of acute pain from which she had covered or she may have chronic - >5mg/ml is suggest ectopicor abnormal pregnancy Rupture corpus
feature from beginng. luteal cyst may see complex mass atadnexia and free fluid.
4-Culdocentesis:
#Symptoms: passing of 18 or 20gauge needle through the posterior fornix of vagina
• Amenorrhea short 6-8weeks. and aspirate for fluids old uncloted blood
• Abdominal pain 5-Laparascopy:
• acute with fainting then persists of dull pain in lower abdomen.Colicky pain of lesser is the gold standard for diagnosis when patient is stable
magnitude. hemodynamically in some cases diagnosis and treatment can be done
Prognosis after evacuation:- •Vaginal bleeding: 6-D&C:
• In 90% of patients with v.mole tissue dies out spontaneously -Followingthepain. done if patient is stable deciduas with out villiis very much suggestive
•In the remaining 10% the trophoblastic tissue does not diecompletely treatment -Scanty and Arias
and may persist or recur either as invasive moleor choriocarcenoma -Sanguineous or dark continual. -stellareaction .Chorionicvilliin intrauterinepregnancy.
-In 80% vaginal bleeding preceded by pain.
PROPHYLACTIC CHEMOTHERAPY:-
• Not use as routines &OtherSymptoms:
–due to it’s risk • bladder Irritation, dysurea, urine retention.. Differential diagnosis:
• Use in:- • Rectal tensesmus common. Chronic type:
– If HCG fail to become –ve by 4-6weeks • Increase temp(infection)
– Evidence of metastasis regardless to HCG level
– Incarcinated gravid retroverted uterus.
– Presence of risk factor for malignancy develop – Tuboovarian mass.
– Where follow up facilities are not available
Duration of follow up
– Impacted ovarian cyst.
• For 1-2years for complete vesicular mole – Uterine fibroid with pregnancy.
• For 6months for partial mole
Follow up:-
– Loaded rectum.
• Routine follow up is mandatory to all case for 1 to2years .
Interval:- •The types of treatment must be individualized and depends more on clinical presentation
Protocols:- .• Acute:
• H/O&P/E •(No investigations only Hb. Rh, group or cross matching). After drawa blood sample for grouping volume replacement with colloid Dextran
• Irregularbleeding •Principal is resuscitation and laparatomy and no tresuscitation followed by laporatomy.
• Persistencecough, • Laparoscopy:
• Breathlessness, • It’s golden method to diagnose ectopic pregnancy
• Hemoptysis • Used only when patient conditionis stable.
• Uterineinvolution • Used when confusion with other pelvic lesion.
• HCG Management of Ectopic • Can be used for diagnosis and treatment
• weekly till β-HCG in serum is negative for three consecutive weeks pregnancy:- • Laparotomy:• When in doubt and life of patient is in danger should not be shie when having negative abdominal exploration.
• monthly for 1year • On contrary one may bed is graced for mistakes in diagnosis with eventual fatality.
• 3monthly for year • Operation:
• ChestX-ray: to see any metastasis deposit • Salpengectomy.
•patient must use combined oral contraceptive during period of follow up • Unruptured–salpengotomy
.• By laparoscopy–linear salpengostomy
.•medical method for treatment :
Invasive mole: “Methotrexate“ can be used systemically if size of mass is small and patient is hemodynamically stable and can do proper monitoring for β-hcg and
• When the trophoplastic tissue penetrate deeply to the myometrium consent for laparotomy if any signs of internal bleeding
• It persist after evacuation of V.mole
• It can be present with persistent bleeding after evacuation
• It is confirmed by high level of HCG
Choriocarcinoma
• It is highly chemosensitive malignant disease
•50% of cases follow V.mole ,25% follow ectopic pregnancy and 25% follow normal
pregnancy
• The tissue contain malignant cyncitio-cytotrophoplasts
by fatema okoff •It is devided to metastatic and non-metastic and to good prognostic and bad prognostic
cases
•Suspected when bleeding persists after evacuation of V.mole or abortion and when there is
persistently raised HCG
• A diagnosis may be done histologically on curettage
•Persistent level of high β-HCG is diagnostic with or without histological
Treatment
•Tumor confined to uterus single agent chemotherapy Methotrexate with folinic acid to
protect the bone-cure is 100 % although hystrectomy occasionally is necessary tocomplete
treatment
poor prognosis
• HCG > 40000mIU/ml
• Tumor occurs more than 4months after the antecedent pregnancy
• May be metastasis to liver, brain
• Patient have had previous chemotherapy
• Patient need combination chemotherapy
Goodprognostic
• β-HCG titer of less than 40000mIU/ml
• Occur within 4months of antecedent pregnancy
•Without metastasis to liver or brain and with no previous chemotherapy
•Treatment as for nonmetastatic diseases but combination chemotherapy may be necessary
• Hystrectomy maybe required
progress to malignant forms which threat the life of these young women.
•The malignant form so fit is curable if the patient under goes close follow up and the changes are
discovered in early stages
DEFINITION:
-GTD refer to the spectrum of proliferative abnormalities of the trophoblast associated with
pregnancy. In GTD abnormal growth and development of trophoblast continue after end of pregnancy
It is charachterized by production of high quantity of human chorionic gonado tropin hormone which
is used as amarker for diagnosis and Mainly follow up of the disease
Ectopic pregnancy referred to the implantation of fertilized ovum on tissue other
than endometrium of the uterus or out side the uterine cavity.
CLASSIFICATION -Ectopic pregnancy is a major problem in gynecology because there is evidence of
A)hyditidiform mole:- increasing incidence Ectopic pregnancy is the 2nd most common cause of maternal
1-Complete mortality in USA and impairment or loss of fertility may also result .It is difficult to
2-Partial diagnose
B)Trophoblastic neoplasm:- SITES:
1-Persistent T. disease 1)Fallopian tube over than 95%
2-Invasivemole - Ampulla’s55%.
3-Choriocarcinoma - Isthmus25%.
Non metastasis - Fembriatedend.
Metastasis - Interstitial most complicated site.
Low risk–good prognosis 2)Other sites:
Highrisk–poorprognosis • Uterine:
-Rudimentary born.
-Cervical .
ETIOLOGY: -Angular(corneal).
-Cause is not definitely known but:
• Ovary
• It is highest in teenagers and >35.
• Abdominal cavity
• Race and ethnic group.
• Inadequate diet low protein
• Blood group A ,AB. Etiology(Riskfactors):
• Cytogenitic abnormality :complete mole is 46xx karyotype (father origin). The basic cause is due to impede passage of fertilized ovum down the tube:
• History of priormole pregnancy -The common pathology is damage to the ciliated epithelium and peristalitic activity
of fallopian tube due to infection by Gonococci .Clamydia .PID Post abortion and
puerperal infection.
PATHOLOGY • Damage due to pelvic and in particular tubalmsurgery
• It is principally disease of chorion • Gross pelvic pathology i.e.endometriosis
•Death of ovum or failure of embryo to growth is essential to develop complete • Congenital abnormalities of tubes:
vesicular mole. • Use of IUCD mainly if contain progesterone.
NAKED EYE: • Use of POP. (Progesteroneonlypills).
• uterus is filled with clusters of cysts of varying size • I.V.F.(in vitro fertilization) and E.T.(embryo transfer)
• No trace of embryo or amniotic sac. • History of infertility..
MICROSCOPICALLY:- • Previous ectopic pregnancy
• Proliferation of cys to- cyncytio trophoblast.
• Thinning of stroma with accumulation of fluid. Pathologic anatomy:
• Absence of blood vessels
-The embryo implants in similar way as in uterine cavity but there is no endometrium
• Villous pattern is maintained
and trophoblast penetrate the epithelium and eroded maternal blood vessels and
intraperitoneal hemorrhage may occur .
CLINICAL FEATURES: -there are many variation to this pattern of ectopic pregnancy, abortion out .the end
•Age and parity of the tube, chronic hemtoma formation ,regression,or reimplantation in abdominal
• Teenagers and elderly patient with high parity cavity.
• History of amnorrhea 8-12 weeks with symptoms of pregnancy.
• Vaginal bleeding (comments90%).
• Varying degree of lower abdominal pain due to:-
On Examination
DIFFERENTIAL DIAGNOSIS:- – uterine over distension -Patient lie quite, conscious.
• Threatened abortion – concealed accidental hemorrhage. -Pallor severe but depended on intraperitoneal hemorrhage.
• Fibroid or ovariantumor with pregnancy. -Feature of shock: Increase pulse rate thready, decrease blood
• Acute hydramnios or twin pregnancy. constitutionalsymptom:- pressure and cold clammy skin
• Vomiting of pregnancy is excessive. -Abdominal exam: Tense, tender ,mostly in lower abdomen. No mass.
• Breathlessness, embolization. -Shifting dullness may be positive. Gut may be distended. Muscle
COMPLICATIONS: guarding usually absent.
-Immediate:- • thyrotoxic feature. 1-ACUTE ECTOPIC RUPTURE~30%:
• Lower limb edema. -Age 20-30. -Bimanual:It is less informative and may precipitate intraperitoneal
• hemorrhage and shock hemorrhage vaginal mucosa white.
• sepsis • Expulsion of grape like vesicles through the vagina. -Multipara or long period infertility.
• History of quickening is absent. -Onset : Acute but rarely fulminating . -Uterus is Normal Size or bulky.
• perforation of the uterus -Extreme tenderness on move cervix or fornix palpation.
• pre-eclampsia Symptoms :
SIGNS:- Classic triad of disturbed pregnancies . -No mass felt through fornix.
• acute pulmonary insufficiency embolism
• coagulation failure embolism. • Feature of early months of pregnancy Amenorrhea:
• The patient look like ill short period of 6-8 week. Spotting on day of expected period .Amenorrhea may be less
Late:-
• Pallor is usually prominent
Differential diagnosis:
•development of chorio carcinoma HYDITIDIFORM MOLE In interstitial amenorrhea up to 10-12 week .
• Feature of PET (increase BP, protein, edema). Pain: Acute. Agonizing or colicky. Locate to one side- spread to lower abdomen then Acute type : Any condition-producing emergency.
RISK FACTORS:- DEFINITION:
Per abdomen:- -Abnormal pregnancy in which there is partly degeneration and generalized. Pain may refer to shoulder.
That are associated with malignant change. 1)Acute Salpingitis: Symptoms follow mensis.
• Uterine size > expected for period of Amenorrhea (70%). partly hyperplasic of young chorionicvilli Vaginal bleeding no important
• Age > 30 IncreaseinTemp. Bilateral swelling of tubes increase of WBC.
• Uterine size = Amenorrhea (20%) .This results in formation of small cysts of varying size, grape like Faint affects with nausea, vomiting to syncope.
• Grand multiparae 2)Abortion:
• Uterinesize<Amenorrhea (10%) (vesicles) fill the uterine cavity
• Initial HCGinurineofover100,000IU/24hours. Bleeding followed by pain while in ectopicpregnancy the reveres.
• Feel of uterus is doughy.Fetal part is not felt no fetal movement TYPES :Depend on morphology, histopathology and karyotype:
• Histopathology infiltrative molar. Bleeding is profuse. Enlarged abdomen=Ao .
• Absence of fetal heart sound (by Doppler). • Complete
• Previous history of molar pregnancy No mass or tenderness infrinx.
• Women with group • Incomplete ECTOPIC PREGNANCY 3)Twisted or rupture ovarian cyst Irregular menstrual humoring No
evidence of pregnancy
Vaginal examination:-
• Internal ballottement cannot be elicited.
Bleeding In 4)Appendicitis: Pain at umbilicus then spread tendernes sat
McBurney,s Abdominal rigidity.
•Uni or bilateral enlargement (theca luteal cystic). Most of ovary due to increase HCG.
• Findings of vesicles in the vaginal discharge is pathgnomonic G.T. D Early Pregnancy on Examination of patient
• Pale ,may be hypotension or tachycardia
INVESTIGATIONS:- GESTATIONAL • Destinded tender lower abdomen
• Tender adnexial mass may be palpated
• Full blood count, ABO +Rh group.
• Hepatic, renal, thyroid test. TROPHOBLASTIC DISEASE • Bulgy Cul-De-Sac into the posterior fornix of vagina
•Sonography(snow storm appearance) some time confused with missed abortion or Investigations
degeneration fibroid. • Serum β-hCG show failure to double in 48hours
• Quantitative estimation of HCG:- CLINICAL FEATURES: • ULTASOUND is very helpful in diagnosis
• βHCG level diagnosis ,(treatment and follow up). • Vaginal ultrasound has much diagnostic power than abdominal
• Straight X-ray:- • presence of an intrauterine pregnan cyrule out ectopic
– chest (embolism) and follow up •the visualization of gestational sac and an embryo with heart beat out
side the uterus is proof of ectopic pregnancy
. correlation of serum β-hCG level and ultrasound finding is the most
Evacuation of Molar Pregnancies: diagnostic significance
– if β-hCG is above the “Discrimintory zone” as around 1800 mI U/ml ,a
gestational sac should be visible on TVS
–if the intrauterine gestational sac is not visible by the time the β-hCG is
at or above this level the pregnancy has the likelihood of being ectopic
– other US signs
– Echogenic mass with fluid 100%
2-CHRONICOLDECTOPIC: – Moderate to large amount of fluid 95%
• Commonest type: – Echogenic mass 85%
– It associated with pelvic haematocele followed tubal abortion or tubal mole rarely – Any free fluid 71
ectopicrupture. 3-Serum progesterone
– On set is insidious. - >25ng/mlis suggestive of viable intrauterine pregnancy.
– Patient has H/O of acute pain from which she had covered or she may have chronic - >5mg/ml is suggest ectopicor abnormal pregnancy Rupture corpus
feature from beginng. luteal cyst may see complex mass atadnexia and free fluid.
4-Culdocentesis:
#Symptoms: passing of 18 or 20gauge needle through the posterior fornix of vagina
• Amenorrhea short 6-8weeks. and aspirate for fluids old uncloted blood
• Abdominal pain 5-Laparascopy:
• acute with fainting then persists of dull pain in lower abdomen.Colicky pain of lesser is the gold standard for diagnosis when patient is stable
magnitude. hemodynamically in some cases diagnosis and treatment can be done
Prognosis after evacuation:- •Vaginal bleeding: 6-D&C:
• In 90% of patients with v.mole tissue dies out spontaneously -Followingthepain. done if patient is stable deciduas with out villiis very much suggestive
•In the remaining 10% the trophoblastic tissue does not diecompletely treatment -Scanty and Arias
and may persist or recur either as invasive moleor choriocarcenoma -Sanguineous or dark continual. -stellareaction .Chorionicvilliin intrauterinepregnancy.
-In 80% vaginal bleeding preceded by pain.
PROPHYLACTIC CHEMOTHERAPY:-
• Not use as routines &OtherSymptoms:
–due to it’s risk • bladder Irritation, dysurea, urine retention.. Differential diagnosis:
• Use in:- • Rectal tensesmus common. Chronic type:
– If HCG fail to become –ve by 4-6weeks • Increase temp(infection)
– Evidence of metastasis regardless to HCG level
– Incarcinated gravid retroverted uterus.
– Presence of risk factor for malignancy develop – Tuboovarian mass.
– Where follow up facilities are not available
Duration of follow up
– Impacted ovarian cyst.
• For 1-2years for complete vesicular mole – Uterine fibroid with pregnancy.
• For 6months for partial mole
Follow up:-
– Loaded rectum.
• Routine follow up is mandatory to all case for 1 to2years .
Interval:- •The types of treatment must be individualized and depends more on clinical presentation
Protocols:- .• Acute:
• H/O&P/E •(No investigations only Hb. Rh, group or cross matching). After drawa blood sample for grouping volume replacement with colloid Dextran
• Irregularbleeding •Principal is resuscitation and laparatomy and no tresuscitation followed by laporatomy.
• Persistencecough, • Laparoscopy:
• Breathlessness, • It’s golden method to diagnose ectopic pregnancy
• Hemoptysis • Used only when patient conditionis stable.
• Uterineinvolution • Used when confusion with other pelvic lesion.
• HCG Management of Ectopic • Can be used for diagnosis and treatment
• weekly till β-HCG in serum is negative for three consecutive weeks pregnancy:- • Laparotomy:• When in doubt and life of patient is in danger should not be shie when having negative abdominal exploration.
• monthly for 1year • On contrary one may bed is graced for mistakes in diagnosis with eventual fatality.
• 3monthly for year • Operation:
• ChestX-ray: to see any metastasis deposit • Salpengectomy.
•patient must use combined oral contraceptive during period of follow up • Unruptured–salpengotomy
.• By laparoscopy–linear salpengostomy
.•medical method for treatment :
Invasive mole: “Methotrexate“ can be used systemically if size of mass is small and patient is hemodynamically stable and can do proper monitoring for β-hcg and
• When the trophoplastic tissue penetrate deeply to the myometrium consent for laparotomy if any signs of internal bleeding
• It persist after evacuation of V.mole
• It can be present with persistent bleeding after evacuation
• It is confirmed by high level of HCG
Choriocarcinoma
• It is highly chemosensitive malignant disease
•50% of cases follow V.mole ,25% follow ectopic pregnancy and 25% follow normal
pregnancy
• The tissue contain malignant cyncitio-cytotrophoplasts
by fatema okoff •It is devided to metastatic and non-metastic and to good prognostic and bad prognostic
cases
•Suspected when bleeding persists after evacuation of V.mole or abortion and when there is
persistently raised HCG
• A diagnosis may be done histologically on curettage
•Persistent level of high β-HCG is diagnostic with or without histological
Treatment
•Tumor confined to uterus single agent chemotherapy Methotrexate with folinic acid to
protect the bone-cure is 100 % although hystrectomy occasionally is necessary tocomplete
treatment
poor prognosis
• HCG > 40000mIU/ml
• Tumor occurs more than 4months after the antecedent pregnancy
• May be metastasis to liver, brain
• Patient have had previous chemotherapy
• Patient need combination chemotherapy
Goodprognostic
• β-HCG titer of less than 40000mIU/ml
• Occur within 4months of antecedent pregnancy
•Without metastasis to liver or brain and with no previous chemotherapy
•Treatment as for nonmetastatic diseases but combination chemotherapy may be necessary
• Hystrectomy maybe required
