GTD Case StudyDiagnosis and management of hydatidiform

moleDiagnosis and evaluation of postmolar GTN

Case Scenario A 21 year old nulligravida presents with bleeding

during early pregnancy. Last normal menses was 9 weeks ago, home urine pregnancy test was positive 2 weeks ago, and she has been spotting for two days with heavier bleeding the last 6 hours.

Examination: afebrile, BP 130/84, P 112, T 37.4. the patient is anxious and tremulous, oriented X 3. The uterine fundus is not tender and palpable mid-way between symphysis and umbilicus. FHTs not present. Pelvic: Cervical cyanosis, uterus enlarged to 14 weeks’ size, bilateral 6 cm cystic adnexal masses.

QuestionsWhat is your differential diagnosis?

What initial diagnostic tests would you obtain?

What ancillary tests would be helpful for managing this patient?

Laboratory ResultsSerum beta hCG 510,000 mIU/mlUltrasound: mixed echogenic intrauterine

mass with no fetus identified. Bilateral septated ovarian cysts.

CBC: WBC 8,900; hct 27%; plates 252kElectrolytes, Cr, LFTs normalT4 elevated 2 X normal, TSH normalCXR: No effusions, infiltrates, nodules or

edema

Ultrasound Images

QuestionsWhat is your primary diagnosis?

What are secondary diagnoses?

What is your management plan?

Initial ManagementBeta blockers are begun to stabilize the secondary

hyperthyroidism caused by stimulation from hCGBlood is cross-matched in the event that transfusion

is requiredLarge-bore IV is started

The patient is taken to the operating room for an emergent suction D & E to evacuate the hydatidiform mole

Theca lutein cysts will be monitored after evacuation, but do not require operative intervention

Initial ManagementDuring suction D&E a large amount of grape-

like tissue clusters are evacuated. EBL is 500 mL. Pitocin is started by IV infusion after cervical dilatation; there is prompt uterine involution and scant bleeding.

In the recovery room, the patient becomes tacchypneic and tacchycardic, with generalized rales. SaO2 is 88% on 2 liters oxygen via nasal prongs.

QuestionsWhat is your differential diagnosis for this

patient’s acute respiratory decompensation?

What diagnostic tests could be obtained to aid in management?

Post-evacuation CXR

Management of ARDSCXR now demonstrates diffuse pulmonary

edema with no evidence of trophoblasticembolization.

Electrolytes are normal, Cr normal.Hct has fallen to 22%, WBC 11,000, and

plates 300k

The patient is transferred to the ICU for monitoring in the event that intubation is required.

She is transfused, treated with furosemide, and improves with resolution of ARDS over 36 hours

Hospital CourseOn POD #3 the patient is transferred out of

the ICU with SaO2 98% on room air and ambulatory.

Uterine involution to 4-5 weeks’ size, persistent 6 cm cystic adnexal masses. No vaginal bleeding.

Pathology: Complete hydatidiform molehCG 80,000 mIu/mLHct 28%Electrolytes, LFTs normalT4 1.5 X normal

QuestionsHow should this patient be monitored after

evacuation of hydatidiform mole?Why is she being monitored?

How soon can she attempt pregnancy?How should she prevent pregnancy during

monitoring?Are there any risks during subsequent

pregnancy after a hydatidiform mole?

Monitoring after Hydatidiform MoleThe patient is scheduled for weekly serum quantitative beta

hCG testing until normal values (<5 mIu/ml), and then monthly hCG values for at least 6 months.

Follow-up pelvic examination in 2-3 weeks to monitor her ovarian theca lutein cysts. Thyroid function tests will be repeated during that visit.

The patient is offered, and accepts, oral contraceptives to prevent pregnancy during monitoring with hCG values.

She is counseled that she has an increased (1-2%) risk of a second mole in subsequent pregnancies.

She is counseled that her risk of malignant GTN is increased (>50%) because of the very high hCG, theca lutein cysts and medical complications of her molar pregnancy

Monitoring after Hydatidiform MoleThe patient’s hCG rapidly drops to 8,000

mIU/mL by week 4 and examination reveals regressing ovarian cysts. Subsequent monitoring as follows:Week 5: 7,800 mIU/mLWeek 6: 8,500 mIU/mLWeek 7: 10,050 mIU/ml – the patient reports

increased vaginal spotting

QuestionsWhat is your provisional diagnosis?

What additional diagnostic tests should be obtained?What tests will be obtained to aid in

management?

What general category of treatment will be given (eg: surgery, radiation therapy, chemotherapy)?

Evaluation of GTNAn ultrasound reveals persistent tissue in the

uterus and bilateral 4 cm theca lutein cysts.CXR reveals 3 new lesions, each 1-2 cmBrain MRI is negative for metastases.CT of chest/abdomen/pelvis reveals approximately

15 bilateral pulmonary subcentimeter metastases, in addition to the lesions noted above. No other metastases are noted.

hCG is confirmed to be 11,000 mIU/mLCBC, electrolytes, Cr, and LFTs are essentially

normal

Management

This patient has low-risk postmolar GTN.FIGO Stage II by staging studiesFIGO risk score < 8

She is offered single-agent chemotherapy with intramuscular methotrexate

She is counseled that her chance of cure without requiring multiagent chemotherapy or hysterectomy is > 90% and overall cure rates approach 100%If hysterectomy can be avoided, future fertility

is not affected by methotrexate1-2% risk of second mole