Perfect 👍 Here’s the **stylishly formatted and complete extracted text** from all the uploaded pages — neat, structured, and ready for notes or website use 👇 --- # 💜 **Gestational Trophoblastic Disease (GTD)** --- ## 🌸 **Classification** **1. Molar pregnancy / Hydatidiform mole** * Partial mole * Complete (vesicular) mole **2. Gestational trophoblastic neoplasia (GTN):** * Invasive mole * Choriocarcinoma * Placental site trophoblastic tumour (PSTT) * Epithelioid trophoblastic tumour (ETT) --- ## 💠 **Molar Pregnancy** ### **Risk Factors** * Previous history of molar pregnancy (most important) * Southeast Asian countries * Extremes of age ### **Pathogenesis** * Undue proliferation of trophoblast → space for inner cell mass * With some fetal tissue → **Partial mole** * With no fetal tissue → **Complete mole** * Hydropic degeneration ### **Features** Benign disease with malignant potential ### **Symptoms** * Bleeding PV (1st or early 2nd trimester) — m/c presentation * Passage of grape-like vesicles PV * Early-onset PIH (<20 weeks due to ↑ placental tissue) * Hyperemesis gravidarum * Thyrotoxicosis * Bilateral theca lutein cysts (↑ hCG) * Pulmonary embolism * Breathlessness --- ## 🩶 **Signs** **Per abdomen:** * Fundal height > period of gestation (rarely ≤ POG) * Fetal parts not palpable * Fetal heart sounds absent * Doughy uterine consistency --- ## 🩺 **Management** ### **Investigations** * **USG:** Snowstorm appearance (IOC) * β-hCG * Blood group & Rh typing * CBC * LFT, KFT * Chest X-ray * TFT ### **Treatment** 1. **Suction evacuation** → followed by **sharp curettage** * ⚠️ Risk: Thyrotoxicosis / thyroid storm, Pulmonary embolism * Oxytocin given after starting suction 2. **Hysterectomy:** * Indicated if ≥40 yrs & family completed ### **Post-op** * Send specimen for histopathology ### **Follow-up** * β-hCG levels → IOC for monitoring **Procedure:** 1. Baseline β-hCG (before) 2. 48 hrs after evacuation 3. Weekly β-hCG till 3 consecutive normal values (<5 IU/L) 4. Monthly β-hCG till 6 months **Advice:** * Pregnancy contraindicated for 6 months * Contraceptives: * OCP ✅ (choice) * IUCD ❌ (contraindicated) --- ## 🧬 **Partial vs Complete Mole** | Feature | Partial Mole | Complete Mole | | --------------------------- | ---------------------------------------------------- | -------------------------------------------------------- | | **Pathogenesis** | 1 ovum + 2 sperms | Empty ovum (no maternal genes) + 2 sperms | | **Karyotype** | Triploid (69, XXY m/c, 69 XXX) | Diploid (46, XX) | | **No. of sperms** | Dispermic | Monospermic | | **Maternal genes** | Present | Absent | | **p57 Kipa staining** | (+) | (−) | | **Symptoms** | Less common | More common | | **Height of uterus** | ≤ POG | > POG | | **USG (IOC)** | Cystic spaces, fetus present, ↓ amniotic fluid | Snowstorm appearance, no fetus, b/l theca lutein cysts | | **HPE** | Some fetal tissue, vascular villi, mild degeneration | No fetal tissue, avascular villi, extensive degeneration | | **Subsequent GTN** | 1% | 15–20% | | **Risk of choriocarcinoma** | <1% | 4% | | **Return of β-hCG** | 6 weeks | 7 weeks | | **β-hCG level** | <10⁵ IU/L | ≥10⁵ IU/L | --- ## 🌺 **Gestational Trophoblastic Neoplasia (GTN)** ### **Causes** | Cause | Invasive Mole | PSTT | Choriocarcinoma | | ------------------- | ------------- | ---- | --------------- | | Molar pregnancy | (+) | (−) | (+) | | Full-term pregnancy | (−) | (+) | (+) | | Ectopic pregnancy | (−) | (−) | (+) | | Abortion | (−) | (−) | (+) | --- ## ⚕️ **Clinical Features (Post-molar pregnancy)** **Symptoms:** * Persistent bleeding PV * Persistent theca lutein cyst * Subinvolution of uterus * Shock (due to invasive mole) * Metastasis **Lab criteria:** * β-hCG plateau for 4 weeks (±10% of prev. value) → invasive mole * β-hCG ↑ ≥10% for 3 weeks → choriocarcinoma * β-hCG present after 6 months → persistent GTN * HPE proven **Metastases:** * **Lung:** m/c site → Stage 3 * CXR: Cannon ball / snowstorm appearance * **Vagina:** Suburethral nodules (2nd m/c site) * Biopsy contraindicated --- ## ⚖️ **Staging & Scoring** ### **FIGO Staging** | Stage | Characteristics | | ----- | ------------------------- | | I | Limited to uterus | | II | Pelvic organs involved | | III | Lung metastasis | | IV | Brain or liver metastasis | ### **WHO Risk Scoring** | Parameter | Low Risk | High Risk | | -------------------- | ----------- | ----------- | | Age | <40 yrs | ≥40 yrs | | Antecedent pregnancy | Molar | Full-term | | Interval | <4 months | ≥4 months | | hCG | <10³ IU/L | ≥10⁵ IU/L | | Tumour size | <3 cm | ≥5 cm | | Site | Lung/Vagina | Brain/Liver | | No. of metastases | <4 | >8 | | Failed chemo | (−) | (+) | **Total score:** * ≤6 → Low-risk GTN * ≥7 → High-risk GTN --- ## 💊 **Management of GTN** **GTN is chemosensitive.** | Stage | Risk | Management | | ------ | --------- | ----------------- | | I | Low-risk | Methotrexate | | II–III | Low (<6) | Methotrexate | | II–III | High (≥7) | Multidrug (EMACO) | | IV | High | Chemotherapy | --- ## 💉 **Chemotherapy Regimens** ### **Single Drug Therapy (Low Risk)** * **Methotrexate (MTX):** DOC * Equally divided doses on days 1, 3, 5, 7 * Alternate with folinic acid * Check β-hCG → repeat till 3 consecutive normal values * Follow-up 12 months ### **Multidrug Therapy (High Risk)** **EMACO (Bagshaw Regimen):** * E: Etoposide (Day 1) * M: Methotrexate (Day 2) * A: Actinomycin D (Day 3) * C: Cyclophosphamide (Day 4) * O: Oncovin (Vincristine) (Day 5) If resistant → EMAEP (Etoposide + Cisplatin added) --- ## ⚡ **Radiotherapy** * Indicated for **brain metastasis** --- ## 🧫 **Management of PSTT / ETT** * **Hysterectomy** → followed by **EMACO** * **Tumour markers:** * PSTT → Placental alkaline phosphatase * ETT → Human placental lactogen **Indications for hysterectomy in GTD:** * Molar pregnancy ≥40 years + completed family * Intractable hemorrhage during evacuation * PSTT or ETT * Stage I GTN + completed family (hysterectomy + MTX) --- ## 🔬 **Histopathological Comparison** | Feature | Invasive Mole | Choriocarcinoma | PSTT | | ----------------- | ------------------------------------- | --------------- | ------------------------ | | Villous structure | Edematous chorionic villi | Absent | Absent | | Cell types | Syncytiotrophoblast + cytotrophoblast | Same | Intermediate trophoblast | --- ### ✅ **Follow-Up Summary** * β-hCG: Weekly till normal (×3), then monthly ×6–12 months * Pregnancy contraindicated ×12 months * Use OCPs for contraception --- Would you like me to now **make 20 hard case-based MCQs** (with explanation + HTML/CSS/JS interactive quiz format) on this entire *Gestational Trophoblastic Disease* topic?