Pregnancy and trophoblastic disease. Skid cystic - description, causes, symptoms (signs), diagnosis, treatment Etiology and pathogenesis

Trophoblastic (gestational) disease is a general term for a spectrum of pregnancy-related proliferative abnormalities derived from the trophoblast. An important sign of trophoblastic disease is the formation of luteal ovarian cysts, which is observed in 50% of cases. Most patients have bilateral luteal cysts, which can reach large sizes and fill the entire abdominal cavity.

ICD-10 code

O01 Blistering skid

Epidemiology

The frequency of trophoblastic disease has a certain geographical pattern - ranging from 0.36% in Asian to 0.008% in European countries (in relation to the number of pregnancies). This epidemiology is associated with impaired immune status in women with big amount pregnancies and a short interval between them. However, no exact explanation for this fact has yet been found.

, , , , , , , , , , , ,

Symptoms of trophoblastic disease

The leading symptom of trophoblastic disease - after amenorrhea, uterine bleeding occurs, sometimes accompanied by the release of many bubbles with transparent contents.

Other symptoms of trophoblastic disease:

• pronounced early preeclampsia (nausea, vomiting), preeclampsia;
• the size of the uterus exceeds the expected gestational age;
• during vaginal examination - the uterus has a tight elastic consistency, longer than the expected pregnancy;
• palpation of the uterus large sizes- no signs of a fetus);
• lack of heartbeat and fetal movement;
• the absence of signs of the fetus in the uterine cavity (according to ultrasound);
• qualitative and quantitative detection of chorionic gonadotropin in the urine and blood (with cystic drift, the level of chorionic gonadotropin exceeds its rate during normal pregnancy by 50-100 times).
• pain in the lower abdomen with the development of chorioncarcinoma;
• symptoms due to the predominant localization of tumor metastases (hemoptysis, neurological symptoms, etc.).

Forms

Trophoblastic disease includes:

• blistering,
• invasive (malignant) drift,
• chorioncarcinoma,
• trophoblastic tumor of the placental site.

, , , , , , , , , ,

bubble skid

A cystic drift is characterized by edema and an increase in placental villi with hyperplasia of both layers of the trophoblast. It has two varieties - full and partial; the latter is distinguished by the presence of the fetus or its parts, along with intact villi.

Invasive drift - cystic drift with germination of the myometrium, trophoblast hyperplasia and preservation of the placental structure of the villi.

With hydatidiform mole, luteal cysts may appear within the first 2 weeks. Their presence serves as an unfavorable prognostic sign. The reverse development of luteal cysts is noted within 3 months. after removal of the hydatidiform mole.

Trophoblastic tumor of the placental site

A trophoblastic tumor at the site of the placenta arises from the trophoblast of the placental bed and consists mainly of cytotrophoblast cells, it can be of low and high degree of malignancy.

chorioncarcinoma

Chorionic carcinoma associated with pregnancy arises from cyto- and syncytiotrophoblast, i.e. from both layers of the trophoblast, is localized most often in the uterus, can occur both during and after the completion of a normal or pathological pregnancy (abortion, miscarriage, childbirth, cystic drift, ectopic pregnancy). In the case of an ectopic pregnancy, it is localized in the tube or ovary, which is extremely rare. Choriocarcinoma of the ovary can develop from germ cells, it is not associated with pregnancy and belongs to germ cell tumors (i.e., it is not trophoblastic).

Macroscopically, choriocarcinoma can be in the form of a nodular tumor located on the inner surface of the uterine cavity, intermuscularly, under the serous cover, or in the form of diffuse growths. The tumor is dark purple in color, has a soft texture, does not contain blood vessels, the size is from 0.5 to 12 or more centimeters. In most cases, it is located submucosally.

Microscopically, chorionic carcinoma has 3 histotypes: syncytial, cytotrophoblastic and mixed. Characterized by invasion of the chorionic epithelium, extensive fields of necrosis and hemorrhage, isolated clusters of Langhans cells.

, , , , , ,

Diagnosis of trophoblastic disease

Diagnosis of trophoblastic disease is based on data:

• history;
• clinical examination;
• radiation, histological and hormonal research methods.

Clinically important: a detailed history, gynecological examination with the detection of cyanosis of the mucous membranes of the vagina and cervix, enlargement and tenderness of the uterus, possible metastases.

Radiation diagnostics includes ultrasound, dopplerography, angiography, magnetic resonance imaging (MRI) and X-ray computed tomography (CT).

Ultrasound and Dopplerography are informative, simple, reliable and can be used to diagnose cystic and invasive mole and chorionic carcinoma, as well as metastases to the liver, kidneys, and ovaries. Being non-invasive and harmless, they are indispensable for monitoring the effectiveness of chemotherapy. Contrast angiography makes it possible to clarify the diagnosis of choriocarcinoma, especially with negative data from histological examination of endometrial scrapings and trophoblastic hormones.

, , , ,

Treatment of trophoblastic disease

Trophoblastic disease is one of rare forms malignant diseases, characterized by a high cure rate with chemotherapy, even in the presence of distant metastases.

The main method of treatment of trophoblastic disease is chemotherapy, which is used both independently and in complex therapy. In the complex treatment of certain forms of trophoblastic disease, surgical and radiation therapy are used.

Principles of treatment of hydatidiform mole

1. Vacuum aspiration or removal of the hydatidiform mole by curettage of the uterus with the appointment of uterine contracting agents (intravenous oxytocin, etc.).
2. Hysterectomy with large sizes of hydatidiform mole, significant bleeding, lack of conditions for emptying the uterus; woman's reluctance to have a pregnancy in the future. Ovaries with teco-luteal cysts are not removed.
3. After removing the skid, observation is carried out for two years (monitoring the content of chorionic gonadotropin in the urine once a month).
4. Prophylactic chemotherapy (methotrexate), after emptying the hydatidiform mole using vacuum aspiration, is carried out in the following cases: age over 40 years, discrepancy between the size of the uterus for the expected pregnancy, the presence of luteal cysts during the period of hydatidiform mole, elevated levels of chorionic gonadotropin more than 20,000 IU / ml after 2-3 evacuations or after surgical treatment of invasive mole, lack of dynamic control of the level of chorionic gonadotropin.

Principles of treatment of choriocarcinoma

1. 1st line chemotherapy (methotrexate, actinomycin D, chlorambucil, 6-mercaptopurine, adriamycin, platinum preparations and alkaloids).
2. Surgery. Indications: profuse uterine bleeding, tendency of the tumor to perforate, large size of the uterus, tumor resistance to ongoing chemotherapy. The scope of the operation: in young women with a tumor without metastases - extirpation of the uterus without appendages, after 40 years - extirpation of the uterus with appendages.
3. An extract is made after 3 negative tests for chorionic gonadotropin, carried out with an interval of 1 week.
4. observation. Within 3 months determination of the titer of chorionic gonadotropin (1 time in 2 weeks), then for 2 years 1 time in 6 months. Chest x-ray once every 3 months. (during a year). Contraception (COC) is recommended for a year.

The choice of treatment regimen is currently carried out taking into account the risk of developing tumor resistance to chemotherapy according to the WHO scale.

According to the WHO scale, 3 degrees of risk of developing resistance are distinguished: low (the sum of points is less than 5), moderate (5-7 points) and high (8 or more points).

With a low risk of developing tumor resistance to chemotherapy (lack of metastases, small, up to 3 cm, the size of the uterine tumor, low level HCG in the blood serum and the duration of the disease is less than 4 months) monochemotherapy of the "first" line with the use of methotrexate or dactinomycin is carried out. The effectiveness of monochemotherapy ranges from 68.7 to 100%.

The earliest sign of tumor resistance to chemotherapy is the absence of a decrease or increase in serum hCG in two repeated analyzes with an interval of 1 week.

WHO scale for determining the resistance of choriocarcinoma to chemotherapy

risk factor	Number of points
Age, years
Outcome of previous pregnancy	bubble skid
Interval*, month
HCG level, IU/l
blood group
Largest tumor, including uterine tumor	Less than 3cm		More than 5 cm
Localization of metastases		Spleen, kidney	Gastrointestinal tract, liver	Brain
Number of metastases
Previous chemotherapy			1 drug	2 cytostatics or more

• * Interval between the end of a previous pregnancy and the start of chemotherapy.
• ** A low level of human chorionic gonadotropin can be with trophoblastic tumors at the site of the placenta.

For the treatment of patients with resistant forms of the tumor, various chemotherapy regimens are used (2nd line) with an increase in the dose of administered drugs and the frequency of courses.

With a moderate and high risk of developing tumor resistance (the presence of metastases, the tumor size is more than 3 cm, a high level of chorionic gonadotropin, the duration of symptoms is more than 4 months, the onset of the disease immediately after childbirth), combined polychemotherapy is used according to various schemes: MAC (methotrexate, dactinomycin, chlorambucin) ; EMA-SO (etoposide dactinomycin, methotrexate, vincristine, cyclophosphamide, leucovorin), CHAMOSA (hydroxyurea, dactinomycin, methotrexate, leucovorin, vincristine, cyclophosphamide, doxorubicin); PVB (cisplatin, vinblastine, bleomycin), ENMMAC (etoposide, hydroxyurea, dactinomycin, methotrexate, vincristine). The most effective and less toxic combination of 2nd line drugs is the EMA-CO regimen.

For the treatment of resistant tumor foci, the combination of their surgical removal and chemotherapy of the 2nd line is important. With distant metastases to the brain, combined polychemotherapy is performed in combination with radiation therapy for the entire brain; radiation therapy is possible with metastasis to the parametrium.

Thus, surgical treatment and radiation therapy are additional methods of treatment.

Prevention

Clinical examination of patients after cystic drift is carried out for 4 years. It is aimed at early diagnosis of possible chorionic carcinoma and includes the following: monitoring of the menstrual cycle, contraception for 2 years, general examination and gynecological examination, determination of the level of hCG in the blood serum I every 2 weeks. until normalization of indicators and then every 6 weeks. in the first six months, then every 8 weeks. in the next 6 months.

1 time in 4 months. - in the second year and once a year during the third and fourth years; Ultrasound of the pelvic organs and radiography of the lungs after 2 weeks. after evacuation of the cystic drift and then 1 time per year for the first two years. Patients who received prophylactic chemotherapy after hydatidiform mole are recommended the following follow-up periods: the first 3 months. - 1 time in 2 weeks, then for 3 months. - monthly, then - according to the specified scheme.

Medical examination of patients with chorionic carcinoma is carried out for 5 years and also includes the maintenance of a menogram, contraception for 2 years, a general examination with a study of the mammary glands, a gynecological examination, determination of the level of hCG in the blood serum monthly in the first year, 1 time in 3 months. 2 years, 1 time in 4 months in the third year and 2 times a year in the fourth and fifth years, then 1 time per year. Ultrasound of the pelvic organs and radiography or CT of the lungs 1 time in 2 months. in the first year and then 1 time per year during dispensary observation.

bubble skid- a condition accompanied by the proliferation of trophoblast (the outer layer of embryonic cells involved in the implantation of the embryo into the uterine wall and the formation of the placenta), which fills the uterine cavity. Vesicular drift can be complete (classic) or incomplete (partial). With complete cystic drift, changes capture the entire chorion, with partial - only part of it. In addition, a malignant form of hydatidiform mole is distinguished - destructive hydatidiform mole.

Code according to the international classification of diseases ICD-10:

Statistical data. In the USA, 1 case of hydatidiform drift occurs in 1200 pregnancies, in the countries of the Far East - 1 case in 120 pregnancies, in Russia - 1 case in 820-3000 births. The predominant age is up to 30 years. More often, gestational trophoblastic disease (including hydatidiform mole, malignant trophoblast tumors, and placental site trophoblastic tumor) occurs in women of low socioeconomic status, as well as in underdeveloped regions (for example, Southeast Asia).

Causes

Etiology. Complete mole occurs with uniparental disomy, when for unknown reasons there is a loss of maternal genes and duplication of the paternal haploid genome (the zygote has a 46,XX karyotype). Occasionally (5%), a complete mole is caused by the fertilization of an "empty" (nucleated) egg by two sperm, resulting in a 46,XY or 46,XX karyotype. The embryo dies in the early stages of development, before the establishment of placental circulation. Incomplete hydatidiform mole is caused by triploidy resulting from the fertilization of an egg by two spermatozoa (dyspermia) with a delay in the haploid set of maternal chromosomes. Conceptus cells contain one haploid set of maternal chromosomes and a diploid set of paternal chromosomes - the karyotype can be 69,XXY, 69,XXX or 69,XYY. The fetus dies.

Pathomorphology. Complete, or classic, hydatidiform drift Severe edema and enlargement of the villi with transparent contents Disappearance of the blood vessels of the villi Proliferation of the trophoblastic lining of the villi, much less often degeneration Absence of fetus, umbilical cord or amniotic membrane Normal karyotype (usually XX, less often XY). Incomplete or partial mole. Pronounced swelling of the villi with atrophy of trophoblast cells. Presence of normal villi. Presence of fetus, umbilical cord and amniotic membrane. Abnormal karyotype, usually triploidy or trisomy.

Symptoms (signs)

clinical picture. Bleeding, usually occurring in the first trimester of pregnancy. The uterus is larger than you would expect, given the date of the last menstrual period, at a given gestational age. Nausea and vomiting occurring in about a third of patients. Signs of preeclampsia in the first trimester of pregnancy. There are no reliable signs of pregnancy in the form of determining the parts of the fetus, heartbeat, fetal movements, with ultrasound in the uterus, only small cystic tissue is detected in the absence of the fetus. Sometimes hyperthyroidism develops. It is believed that with an excessive increase in the level of HCG, this hormone binds to TSH receptors, causing hyperfunction of the thyroid gland. Abdominal pain disturbs 15% of patients. The cause of pain is the formation of tecalyutein cysts under the influence of CHT in 50% of patients.

Destructive form of hydatidiform mole. The tissue of the hydatidiform drift penetrates into the thickness of the uterine wall and metastasizes to the lungs, vagina, parametric fiber. The clinical picture is ongoing bloody discharge from the uterus after removal of the hydatidiform mole; the uterus does not contract; pain in the lower abdomen, sacrum, lower back persists; with germination to the peritoneum - a picture of "acute abdomen"; thecalutein cysts do not undergo regression, the HCG level is high. Treatment - see Gestational trophoblastic disease.

Diagnostics

Diagnostics. The main evidence of a hydatidiform drift is the presence of many vesicles with clear contents in the vaginal discharge. An increase in the content of HCG over 100,000 mIU / ml with an increase in the uterus and bleeding. On ultrasound, there are no signs of a normal gestational sac or fetus.

TNM classification- see Gestational trophoblastic disease.

Treatment

TREATMENT

. Vacuum - aspiration. To remove the mole, it is used more often than other methods, even if the uterus is enlarged to the size corresponding to 20 weeks of pregnancy. After vacuum aspiration, oxytocin is administered intravenously to better reduce the myometrium. Laparotomy with hysterectomy may be performed.

. primary hysterectomy. If a woman does not want to have children in the future, a hysterectomy can be performed. The ovaries are not removed. If multiple thecalutein cysts are present in the ovaries, they regress after a drop in HCG levels.

. prophylactic chemotherapy. Prophylactic chemotherapy is carried out after removal of the hydatidiform mole, if the HCG titer increases or remains at a constant level for a long time, as well as when metastases are detected. In 80% of patients with hydatidiform mole spontaneous remission occurs without additional therapy. Systematic determination of the content of HCG helps to timely identify developing chorionepithelioma; therefore, given the high likelihood of toxic effects, prophylactic chemotherapy is not performed in all patients.

observation. The time of complete elimination of HCG (average - 73 days) depends on the initial concentration of HCG, the amount of viable trophoblast tissue left after vacuum aspiration, and the half-life of HCG. Follow-up of patients after removal of the hydatidiform mole includes a number of activities. Determination of the level of HCG with an interval of 1-2 weeks until 2 negative results are obtained. Then the studies are carried out monthly for 2 years. Patients are advised to protect themselves from pregnancy for 2 years with oral contraceptives that reduce LH levels. Physical examination of the pelvic organs every 2 weeks until remission, then every 3 months for 1 year. In the absence of a decrease in the HCG titer, an X-ray examination of the chest organs is performed to exclude lung metastases.

Complications. The development of malignant tumors of the trophoblast (destructive, or invasive, hydatidiform mole, choriocarcinoma) with or without metastases. Bleeding. DIC is a syndrome. Embolism of the branches of the pulmonary artery by trophoblast cells.

Forecast. In 20% of cases of complete hydatidiform drift, the development of a malignant tumor is observed in the future.

Synonyms. chorionadenoma. The disease is persistent trophoblastic. The drift is invasive.

ICD-10. O01 Blistering skid.

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2015

Classical hydatidiform mole (O01.0), Incomplete and partial hydatidiform mole (O01.1), Unspecified hydatidiform mole (O01.9)

obstetrics and gynecology

general information

Short description

Recommended
Expert Council
RSE on PVC "Republican Center
health development"
Ministry of Health
And social development
dated August 27, 2015
Protocol #7

Protocol name: Anomaly of conception

bubble skid refers to trophoblastic disease, is its benign variant. Cystic mole is characterized by proliferation of syncytio-and cytotrophoblast, mucus and disappearance of stromal vessels. With a complete hydatidiform mole, such changes capture all fertilized egg, elements of the embryo are absent. With partial PZ, changes in the trophoblast are focal in nature, elements of the embryo/fetus may be preserved.
The frequency of molar pregnancy is approximately 3:1000 and 1:1000.
Vesicular mole is 1.3 times more common in adolescents and 10 times more common in women over 40 years of age.

Code (codes) according to ICD-10:
O01 Bubble skid
O01.0 Bubble skid classic
O01.1 Mole, partial and incomplete
O01.9 Blistering mole, unspecified

Abbreviations used in the protocol:
BP - blood pressure
WHO - World Organization health care
PZ - blistering skid
TN - trophoblastic neoplasm
Ultrasound - ultrasonography
HCG - human chorionic gonadotropin
ECG - electrocardiography

Protocol development date: 2015

Protocol Users: general practitioners, obstetrician-gynecologists, oncogynecologists, emergency physicians medical care, paramedics.

Evaluation of the evidence level of the given recommendations.

Table No. 1 Evidence level scale:

A	High-quality meta-analysis, systematic review of RCTs, or large RCTs with a very low probability (++) of bias whose results can be generalized to an appropriate population.
IN	High-quality (++) systematic review of cohort or case-control studies or High-quality (++) cohort or case-control studies with very low risk of bias or RCTs with low (+) risk of bias, the results of which can be generalized to the appropriate population .
WITH	Cohort or case-control or controlled trial without randomization with low risk of bias (+). Results that can be generalized to an appropriate population or RCTs with very low or low risk of bias (++ or +) that cannot be directly generalized to an appropriate population.
D	Description of a case series or uncontrolled study or expert opinion.
GPP	Best Pharmaceutical Practice.

Classification

Clinical classification:
hydatidiform mole classic (complete);
hydatidiform drift partial and incomplete.

WHO classification of trophoblastic diseases:
precancerous: partial and complete molar pregnancy;
malignant: invasive molar pregnancy, choriocarcinoma.

Histological classification :
Complete hydatidiform mole
· partial hydatidiform mole;
Invasive hydatidiform mole
choriocarcinoma;
trophoblastic tumor of the placental bed;
epithelioid cell trophoblastic tumor.
Note: Invasive hydatidiform mole, choriocarcinoma, placental bed tumor, and epithelioid cell tumor are referred to as trophoblastic neoplasm (TN).

Clinical picture

Symptoms, course

Diagnostic criteria:

Complaints and anamnesis:
Complaints:
Vaginal spotting (90%);
Departure of elements of cystic mole (rarely);
Pain in the lower abdomen (35%).
Anamnesis:
delayed menstruation;
After 18-20 weeks, the absence of fetal movement (with full PZ).

Physical examination:
the size of the uterus exceeds the gestational age on bimanual examination in early dates and when determining the height of the fundus of the uterus in late pregnancy (UD - GPP);
An increase in the size of the ovaries, a dense consistency on bimanual examination;
parts of the fetus are not determined (in the second half of pregnancy);
fetal heartbeat is not audible;
softened consistency of the uterus (excessive peculiar testiness);
bloody discharge from the genital tract of varying intensity and duration (UD - GPP), there may be a discharge of vesicles in the form of grapes.

Diagnostics

List of basic and additional diagnostic measures

The main (mandatory) diagnostic examinations carried out on an outpatient basis:
collection of complaints and anamnesis;
physical examination;
examination on the mirrors and vaginal examination;
determination of the concentration of β-hCG in blood serum (UD - A);
Pelvic ultrasound (UD-C).

Additional diagnostic measures at the outpatient level

X-ray of the lungs (if choriocarcinoma is suspected).

The minimum list of examinations that must be carried out upon referral for planned hospitalization: in accordance with the internal regulations of the hospital, taking into account the current order of the authorized body in the field of healthcare.

Basic (mandatory) diagnostic examinations carried out at the hospital levelduring emergency hospitalizationand after more than 10 days from the date of testing in accordance with the order of the Ministry of Defense:
Determination of the concentration of β - hCG in blood serum (UD - A);
Ultrasound of the small pelvis (UD-C);
histological examination of biological material.

The minimum list of examinations carried out to prepare for surgical treatment in case of emergency hospitalization (repeating the minimum examination is carried out if the date of the examination has exceeded more than 14 days when referring the patient for planned hospitalization ):
· general analysis blood;
· general urine analysis;
· coagulogram (PTI, fibrinogen, INR, APTT);
· biochemical analysis blood (total protein, bilirubin, ALT, AST, creatinine, residual nitrogen, urea, sugar);
Wasserman reaction in blood serum;
determination of HBsAg in blood serum by ELISA method;
determination of total antibodies to hepatitis C virus in blood serum by ELISA method;
determination of the blood group according to the ABO system;
Determination of the Rh factor of the blood;
EKG.

Additional diagnostic examinations carried out at the hospital level during emergency hospitalization and after more than 10 days from the date of testing in accordance with the order of the Ministry of Defense:
Color Doppler mapping of the pelvic organs (to determine the level of invasion);
· in cases of abnormal placenta (suspected mesenchymal placental hyperplasia), prenatal testing for fetal karyotype (UD-C) is recommended;
Ultrasound of the abdominal organs (if choriocarcinoma is suspected);
X-ray of the lungs (if choriocarcinoma is suspected)

Diagnostic measures taken at the stage of emergency care:
collection of complaints and anamnesis;
Assessment of the patient's condition (BP, pulse, respiratory rate).

Instrumental research:
Ultrasound of the pelvis: with full PZ, enlarged uterus, the absence of an embryo, the presence of homogeneous small cystic tissue in the uterine cavity are visualized. Half of the patients have bilateral luteal ovarian cysts. With incomplete PZ, an embryo (often with signs of developmental delay) and focal edema of the chorionic villi can be determined.

Indications for consultation of narrow specialists:
Consultation of an oncogynecologist - in case of suspected TN (hCG level more than 20,000 IU / l within 4-8 weeks after removal of the prostate gland, the presence of histological malignant changes in the biological material);
Consultation of an oncologist - in case of suspected metastases in organs;
consultation of the therapist - in preparation for the surgical treatment of the patient;
consultation of an anesthesiologist-resuscitator in preparation for surgical treatment.

Laboratory diagnostics

Laboratory examinations:
- determination of the level of β-hCG in blood serum; excretion of hCG reaches maximum values ​​between 40 - 80 days of pregnancy, and the peak of excretion varies between 100,000-500,000 IU / day. In the II trimester, the excretion of hCG decreases to 5000-1000 U / day (if the excretion of hCG does not decrease by a certain period, then this is the basis for suspecting PZ, UD-D);
- histological examination of the biomaterial - proliferation of the villus epithelium, edema of villi and intermediate substance are detected, due to edema, cellular elements are displaced to the periphery, blood vessels are often not visible.

Differential Diagnosis

Differential Diagnosis

Table 2 . Differential diagnosis of hydatidiform mole.

Symptoms	Nosological form
	Nonbubble skid	bubble skid	Threat of abortion	Physiological pregnancy
Delayed menstruation	+	+	+	+
Bloody discharge from the vagina	+/-	+/-, sometimes with PZ elements resembling grapes	+/-	-
Pain symptom (pulling / cramping pains in the lower abdomen)	+/-	rarely	+	-
HCG in blood serum*	below the expected gestational age	exceeds normative indicators 5-10 times	rarely below normal	corresponds to the gestational age
Bimanual examination	the size of the uterus is less than the gestational age	the size of the uterus usually exceeds the gestational age, the consistency of the uterus is soft, bilateral ovarian cysts, easily torn,	the size of the uterus corresponds to the gestational age	the size of the uterus corresponds to the gestational age
Signs of early toxicosis and preeclampsia	Missing	more pronounced signs of early toxicosis, early start preeclampsia	+/-	+/-
ultrasound	the fetus is not visualized	Absence of an embryo/fetus (with complete PZ), a lot of homogeneous small cystic tissue, bilateral luteal cysts in 50%	the fetus corresponds to the gestational age, thickening	the fetus corresponds to the gestational age

Note*

the maximum increase in hCG in the blood serum during physiological pregnancy at 9-10 weeks of pregnancy (not higher than 150,000 mU / ml), then its concentration decreases.

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals:

surgical removal of a hydatidiform mole from the uterine cavity .

Treatment tactics:
Surgical removal of PZ;
· after removal of the PZ (emptying of the uterine cavity), the introduction of oxytocin 10 units per 1000.0 sodium chloride solution at a rate of 60 drops per minute;
Determination of the level of β-hCG in the blood serum until normative results are obtained (the analysis is repeated once a week).

Non-drug treatment:
Mode - I, II, III.
Diet - table number 15.

Medical treatment:
Uterotonic drugs:
Oxytocin 10 IU per 1000.0 sodium chloride solution at a rate of 60 drops per minute after emptying the uterine cavity (UD-A).
Antibacterial therapy: see KP "Complications caused by abortion, ectopic and molar pregnancy" Protocol No. 10 dated July 4, 2014.

Drug treatment provided at the stage of emergency emergency care:
Sodium chloride solution 0.9% 400 ml intravenously drip infusion for severe uterine bleeding.

Other types of treatment: No.

Surgical intervention:

Surgical intervention provided in a hospital:
· vacuum-evacuation of PZ from the uterine cavity is the method of choice for molar pregnancy evacuation (UD-A).
· manual aspiration of PZ from the uterine cavity safer and accompanied by less blood loss (UD-A).
· curettage of the PP from the uterine cavity with a metal curette high risk of perforation of the uterine wall. Prepare 3 evacuator syringes to rapidly remove uterine contents (LE III-C).

Note:
· repeated curettage is carried out with hCG more than 5000 units, in the presence of metastases, repeated curettage is not recommended (UD -D) .
· after evacuation2-3% of patients may have trophoblastic embolization with the development of a clinic of acute respiratory disorders (cough, tachypnea, cyanosis), more often it develops 4 hours after the evacuation of the PZ.
if there is excessive bleeding, evacuation should be expedited and the need for oxytocin infusion weighed against the risk of embolization.

Treatment effectiveness indicators:
normalization of the level of hCG in the blood serum;
Absence of pathological changes in the pelvic organs according to ultrasound and bimanual examination.

Drugs (active substances) used in the treatment

Hospitalization

Indications for emergency hospitalization:
bleeding from the genital tract.

Indications for planned hospitalization:
Pregnant women with mole according to ultrasound without bleeding.

Prevention

Preventive actions:
In case of partial molar pregnancy, after evacuation of the uterine cavity from the uterine cavity, for pregnant women with an Rh-negative blood factor in the absence of an antibody titer, immunization with anti-Rhesus immunoglobulin (UD - D) is recommended within 72 hours.

Further management
weekly serum hCG until 3 consecutive negative results, then every 8 weeks for a year (LE-B).
Ultrasound of the pelvic organs - after the evacuation of the PZ in 2 weeks, then monthly until the level of hCG normalizes;
Mandatory maintenance of a menogram by the patient for at least 3 years after PZ;
After emptying the PZ, a barrier method of contraception is recommended up to the standard hCG values;
after normalization of hCG values, hormonal contraception is the method of choice in most patients (LE-C);
· the use of the IUD is not recommended due to the risk of uterine perforation;
After removal from dispensary observation, continue regular visits to the gynecologist (2 times a year).

Information

Sources and literature

1. Minutes of the meetings of the Expert Council of the RCHD MHSD RK, 2015
   1. References: 1) Woolf SH, Battista RN, Angerson GM, Logan AG, Eel W. Canadian Task Force on Preventive Health Care. New grades for recommendations from the Canadian Task Force on Preventive Health Care. Can Med Assoc J 2003;169(3):207-8. 2) Aylamazyan E.K. 3) Oncology: National Guide / ed. Chissova V.I., Davydova M.I. 2013.-1072. 4) WOMEN AND NEWBORN HEALTH SERVICE. CLINICAL GUIDELINES GYNAECOLOGY ABNORMALITIES OF EARLY PREGNANCY. REFERENCES (STANDARDS) 1. Charing Cross Hospital Trophoblast Disease Service: Info for Clinicians. 5) Available at http://www.hmole-chorio.org.uk/index.html. 6) Meshcheryakova L.A. Standard treatment for trophoblastic disease. Practical oncology. T.9. No. 3-2008. pp.160-170. 7) American College of Obstetricians and Gynecologists (ACOG). Management. Diagnosis and treatment of gestational trophoblastic disease. Washington, DC; 2004 June 13 p. (ACOG Bulletin of Practice, no 53).. . 8) Alessandro Cavaliere, Santina Ermito, Angela Dinatale, Rosa Pedata Management of molar pregnancy / Journal of Prenatal Medicine 2009; 3(1):15-17. 9) THE MANAGEMENT OF GESTATIONAL TROPHOBLASTIC DISEASE. - Royal College of Obstetricians and Gynaecologists.Green-topGuidelineNo. February 38, 2010. 10) IVBR; WHO Guidelines "Care for complicated pregnancy and childbirth"; Geneva; 2000.

Information

List of protocol developers with qualification data:
1) Ryzhkova Svetlana Nikolaevna - Doctor of Medical Sciences, Head of the Department of Obstetrics and Gynecology, Faculty of Postgraduate and additional education RSE on REM "ZKGMU named after A.I. M. Ospanova, doctor of the highest category.
2) Layla Altynbekovna Seydullayeva - Candidate of Medical Sciences, Associate Professor of the Department of Obstetrics and Gynecology Internship of JSC "MUA", doctor of the highest category
3) Gurtskaya Gulnara Marsovna - Candidate of Medical Sciences, Associate Professor of the Department of General Pharmacology of JSC "Astana Medical University", clinical pharmacologist.

Indication of no conflict of interest: No

Reviewers: Kaliyeva Lira Kabasovna - Doctor of Medical Sciences, Head of the Department of Obstetrics and Gynecology No. 2, RSE on REM “S.D. Asfendiarov".

Indication of the conditions for revising the protocol: Revision of the protocol 3 years after its publication and from the date of its entry into force or in the presence of new methods with a level of evidence.

Attached files

Attention!

• By self-medicating, you can cause irreparable harm to your health.
• The information posted on the MedElement website and in the mobile applications "MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: a therapist's guide" cannot and should not replace an in-person consultation with a doctor. Be sure to contact medical facilities if you have any diseases or symptoms that bother you.
• Choice medicines and their dosage, should be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and the condition of the patient's body.
• MedElement website and mobile applications"MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Handbook" are solely information and reference resources. The information posted on this site should not be used to arbitrarily change the doctor's prescriptions.
• The editors of MedElement are not responsible for any damage to health or material damage resulting from the use of this site.

Trophoblastic disease - related forms pathological condition trophoblast: simple mole, invasive mole, choriocarcinoma, placental bed tumor, and epithelioid cell trophoblastic tumor. In the last revision of the classification in 2000, FIGO recommends replacing the term trophoblastic tumors with trophoblastic neoplasias (TN).

ICD-10 CODE
M910 Trophoblastic neoplasms.
O01 Blistering skid.
O01.0 Classic blistering.
O01.1 Mole, incomplete and partial.
O01.9 Mole, unspecified.
O02 Other abnormal products of conception.

EPIDEMIOLOGY

In Europe, TN occur with a frequency of 0.6-1.1 per 1000 pregnancies, in the USA - 1 per 1200, in Asia and Latin America - 1 per 200, in Japan - 2 per 1000 pregnancies.

The incidence of various forms of trophoblastic disease according to one of the largest trophoblastic centers (interregional Center in Sheffield, UK): complete hydatidiform mole - 72.2%, partial hydatidiform mole - 5%, choriocarcinoma - 17.5%, other forms - 5.3%.

CLASSIFICATION

There are two types of cystic drifts: complete and partial. The most common form of hydatidiform mole is complete hydatidiform mole.

A complete hydatidiform mole is detected at 11–25 weeks of gestation, it often turns out to be diploid - it contains a 46XX chromosome set, both paternal chromosomes. In 3–13% of cases, a 46XY combination occurs. Complete mole is characterized by the absence of signs of embryonic and embryonic development. Malignant transformation occurs in 20% of cases, with a set of 46XY chromosomes, a metastatic tumor develops more often. The first clinical sign is a discrepancy between the size of the uterus and the gestational age (the size of the uterus exceeds the gestational age). Macroscopically reveal edematous chorionic villi, vesicles.

Partial hydatidiform mole is detected in 25-74% of all hydatidiform moles, usually between 9 and 34 weeks of gestation. Partial hydatidiform mole cells are always triploid, while the diploid set is from the father, the haploid set is from the mother (more often 69XXY, 69XXX, less often 69XYY). Perhaps the development of fragments of the normal placenta and fetus. Previously, it was believed that partial hydatidiform mole is not malignant. Currently, the possibility of malignant transformation (up to 5%) has been proven. Clinically, the size of the uterus is smaller or corresponds to the gestational age, macroscopically determine fragments of the fetus, placenta and edematous chorionic villi.

Histological classification of TN (FIGO, 2000)
Bubble skid (ICD-10 code M9100/0):
- complete hydatidiform mole;
- partial hydatidiform mole (ICD-10 code M9103/0).
Invasive hydatidiform mole (ICD-10 code M9100/1).
Choriocarcinoma (ICD-10 code M9100/3).
Trophoblastic tumor of the placental bed (ICD-10 code M9104/1).
Epithelioid cell trophoblastic tumor (ICD-10 code M9105/3).

The histological form of a trophoblastic tumor has an important prognostic value. Invasive hydatidiform mole, choriocarcinoma, placental bed tumor, and epithelioid cell tumor are all malignant trophoblastic tumors (MTTs).

The modern clinical classification of TN (Table 50-3) combines the stages of tumor growth and risk groups for the emergence of tumor resistance - the main prognostic criterion.

Table 50-3. Classification of trophoblastic neoplasms FIGO and WHO, 2000

Stage	Localization of the neoplasm
I	The disease is limited to the uterus
II	Spread of the neoplasm outside the uterus, but limited to the genitals (adnexa, broad ligament of the uterus, vagina)
III	Lung metastases with or without genital involvement
IV	All other metastases
	Number of points
	0	1	2	4
Age, years	up to 40 years	>40 years	–	–
Outcome of previous pregnancy	bubble skid	Abortion	childbirth	–
Interval*, months	<4	4–6	7–12	>12
HCG level, IU/l	<10 3 **	10 3 –10 4	10 4 –10 5	>10 5
Largest tumor, including uterine tumor, cm	<3	3–5	>5	–
Localization of metastases	Lungs	Spleen, kidney	gastrointestinal tract	liver brain
Number of metastases	–	1–4	5–8	>8
Previous chemotherapy	–	–	1 drug	Two or more cytostatics

Note: *interval between end of previous pregnancy and start of chemotherapy; ** low level of hCG may be with trophoblastic tumor of the placental bed.
Sum of points< 6 соответствует низкому риску развития резистентности опухоли, ³7 баллов - высокому.

ETIOLOGY AND PATHOGENESIS

Vesicular drift is most common among trophoblast tumors (1:1000 pregnancies), the cause of its development are genetic disorders of pregnancy. The cystic drift is localized in the uterus (less often in the fallopian tube), more often occurs in young and elderly pregnant women, in a poor socioeconomic environment. Cystic skid does not have invasive growth, does not metastasize. The cure rate is 100%.

TN is the result of genetic disorders of pregnancy, in which the missing or inactivated egg nucleus undergoes fertilization either by two spermatozoa (with the formation of a set of chromosomes 46XX or 46XY), or duplication of paternal genetic material occurs. As a result, a cystic mole develops from the mesoderm of the embryo (according to the latest ideas about the genesis of the disease).

TN are characterized by two different biological processes: persistence of trophoblastic cells in the mother's body after pregnancy (the phenomenon most often occurs after partial or complete hydatidiform mole) and trophoblastic malignancy (invasive hydatidiform mole, choriocarcinoma, placental bed tumor, epithelioid cell tumor). Malignant transformation of trophoblast elements (cyto-, syncytiotrophoblast, intermediate cells) can occur both during pregnancy (normal and ectopic) and after its completion (delivery, abortion), but most often this occurs after complete mole.

TN make up 1% of oncogynecological tumors and mainly affect women of reproductive age. TN are unique tumors in their biological behavior and clinical manifestations, characterized by a high degree of malignancy, rapid distant metastasis and, at the same time, a high cure rate with chemotherapy alone, even with distant metastases. After treatment, the reproductive function of the vast majority of young women is preserved.

OST in 50% of cases develop after hydatidiform mole, in 25% - after normal pregnancy and childbirth, in 25% - after abortion and ectopic pregnancy. As the number of pregnancies increases, the risk of developing OST increases.

Invasive hydatidiform mole may develop simultaneously with simple (abdominal) hydatidiform mole. Morphological confirmation of invasive mole is possible only in the remote uterus or metastatic focus (signs of villus invasion into the myometrium and other tissues). Invasive cystic drift is characterized by the presence of edematous chorionic villi, the absence of embryonic vessels, and the invasion of proliferating elements of cyto- and syncytiotrophoblast into the myometrium. The tumor has the ability to rapidly and deeply invade the myometrium and can cause severe intraperitoneal bleeding.

Trophoblastic chorioncarcinoma has a mixed structure of trophoblast epithelium, with elements of cyto-, syncytiotrophoblast and intermediate cells, villi are absent. The tumor has the ability to quickly and deeply invade the surrounding tissues and vessel walls. The rapid growth of the tumor is accompanied by extensive central necrosis with the preservation of viable cells along the periphery.

A trophoblastic tumor of the placental bed is a rare nonvillous tumor that occurs on the placental part of the trophoblast mainly from syncytiotrophoblast cells. The tumor is capable of infiltrating growth, penetration into the vessel wall and replacement of their smooth muscle elements with hyaline material. Often occurs with the destruction of the serous membrane of the uterus and massive bleeding. A trophoblastic tumor of the placental bed is characterized by a slight increase in the concentration of hCG, a more informative determination of PL in the blood serum and an immunohistochemical study of removed tissues with PL.

Epithelioid cell trophoblastic tumor - first described by morphologists in 1995, the rarest TO, develops from trophoblast intermediate cells, is characterized by the absence of villi, accumulation of atypical mononuclear trophoblastic cells and elements of syncytiotrophoblast, appearance similar to epithelial cells. Microscopic examination reveals "islands" of trophoblastic cells, which are surrounded by extensive necrosis and interconnected by structures similar to hyaline, creating a "geographic map" pattern. Immunohistochemical examination of an epithelioid cell trophoblastic tumor is positive for the presence of a-inhibin, cytokeratin, epidermal growth factor, and only central part the tumor is positive for PL and hCG. The tumor is characterized by a nodular form of growth with invasion into the myometrium, without foci of necrosis and hemorrhages.

CLINICAL PICTURE (SYMPTOMS) OF TROPHOBLASTIC DISEASE

The main clinical symptoms of hydatidiform mole usually occur before 18 weeks of gestation:
Vaginal bleeding (more than 90% of cases);
The size of the uterus exceeds the proper size for a given gestational age (in 50% of cases);
Bilateral thecalutein cysts 8 cm or more (20–40%).

With cystic drift, various complications can develop:
Uncontrollable vomiting of pregnant women (20-30% of cases);
Hypertension, preeclampsia (10–30%);
symptoms of hyperthyroidism [warm skin, tachycardia, tremor, enlargement of the thyroid gland (2–7%)];
Rupture of ovarian cysts, bleeding, infectious complications;
trophoblastic embolization occurs in 2-3% of patients with acute respiratory disorders (cough, tachypnea, cyanosis) with a uterus size corresponding to a period of 20 or more weeks (more often develops after 4 hours of evacuation of the PZ);
ICE.

Clinical features of IPD:
The tumor is usually local, with invasive growth and rarely metastasizes (20-40%) - mainly in the vagina, vulva, lungs;
Significantly more often than with a simple hydatidiform mole, it transforms into choriocarcinoma;
Spontaneous regression of the tumor is possible;
The main clinical marker is an increase in the concentration of hCG in the blood serum;
The main method of tumor visualization is ultrasonic CT;

cure in 100% of cases.

Clinical features of trophoblastic chorionic carcinoma:
Occurs with a frequency of 1:20,000 pregnancies (1:160,000 normal births, 1:15,380 abortions, 1:5,330 ectopic pregnancies, 1:40 cystic drifts);
The primary tumor grows rapidly, is capable of deep invasion into the uterine wall and its destruction with the development of bleeding;
High frequency of metastasis to distant organs (lungs - 80%, vagina - 30%, pelvic organs - 20%, liver, brain - 10%, spleen, stomach, kidneys - 5%);
The first clinical symptoms - bleeding or symptoms of the growth of distant metastases;
high sensitivity to chemotherapy;
cure in 90% of cases.

Clinical features of trophoblastic tumor of the placental bed:
in 95% of cases occurs after childbirth;
more often - a solid tumor growing in the lumen of the uterine cavity, penetrating into the myometrium and serous membrane of the uterus, as well as adjacent organs;
unpredictable clinical course (in 90% of cases it either regresses or is treatable, in 10% of cases it metastasizes and is poorly sensitive to standard chemotherapy);
· optimal treatment of the primary tumor - hysterectomy, with metastatic lesions - chemotherapy for a high risk of tumor resistance.

Clinical features of epithelioid cell trophoblastic tumor:
The tumor is more often localized in the fundus of the uterus, isthmus or mucous membrane of the cervical canal (the latter localization can simulate a picture of cancer of the cervical canal);
Clinical manifestations often develop in reproductive age, but are possible at a later age
period, years after the last pregnancy;
possible manifestation of the disease in the form of distant metastases (without signs of primary damage to the uterus);
For a differentiated diagnosis, it is necessary to determine the concentration of hCG in the blood serum, to conduct a histological and immunohistochemical study of the removed tissues with markers;
· optimal treatment - surgical removal of the primary tumor and metastases with chemotherapy for high-risk tumor resistance;
The prognosis is difficult to predict.

DIAGNOSTICS

To make a diagnosis of hydatidiform mole, you must:
assess clinical symptoms during pregnancy;
Perform ultrasound, CT of the pelvic organs;
determine the concentration of hCG in the blood serum (during normal pregnancy, the peak of hCG is noted at 9–10 weeks, it is not higher than 150,000 mIU / ml, and then the concentration decreases).

DIAGNOSTICS OF MALIGNANT TROPHOBLASTIC TUMORS

ANAMNESIS

Most often, the disease occurs in women of reproductive age, although it can occur in patients in perimenopause. A history of pregnancy that ended in childbirth, abortion (artificial or spontaneous), including ectopic, is a necessary criterion for making a diagnosis. The tumor may also develop during
developing pregnancy. But more often, OST develops after a previous hydatidiform mole.

Complaints

The vast majority of women of reproductive age with OST complain of menstrual irregularities (amenorrhea, acyclic blood discharge, oligomenorrhea, uterine bleeding of varying intensity and duration). The data of the patient's menogram after the end of pregnancy can provide useful information for timely diagnosis.

Less commonly, patients complain of pain in the lower abdomen, in chest, cough, hemoptysis, headache, various manifestations of toxicosis of pregnant women, symptoms of thyrotoxicosis may appear. In some cases, patients independently detect metastases in the vagina or a tumor in the small pelvis, palpated through the anterior abdominal wall.

PHYSICAL EXAMINATION

During a gynecological examination, it is often possible to detect an increase in the size of the uterus, a mismatch between them due to the given gestational age or duration postpartum period. In addition, it is possible to palpate tumor formations in the wall of the uterus, in the small pelvis, in the vagina (more often they are detected when viewed in the mirrors).

The pathognomonic sign of TN is tecalutein ovarian cysts, often very large. In this regard, torsion of the cyst leg and the development of an "acute abdomen" clinic are possible.

External manifestations of the disease occur only with a significant spread of the tumor and a long course.

As a rule, the general condition of the patient is not disturbed, with the exception of rare observations in patients with a significant spread of the tumor (massive damage to the lungs, brain, liver and other organs).

LABORATORY RESEARCH

Determination of the concentration of hCG in the blood serum

Normally, hCG is formed in the syncytiotrophoblastic cells of the placenta, which causes a high concentration of the hormone in pregnant women. It is known that any increase in the level of hCG, not associated with a developing pregnancy, indicates the occurrence of TN. The diagnostic sensitivity of hCG in TN is close to 100%.

Certain difficulties have the diagnosis of TN during pregnancy. One of the diagnostic criteria may be the absence of a decrease in the level of hCG in the blood serum after 12 weeks of pregnancy. It is advisable to evaluate the dynamics of the growth of another pregnancy hormone - AFP, the concentration of which normally from 11 weeks begins to progressively increase. If the hCG content rises after 11 weeks of pregnancy, and at the same time there is a decrease in the concentration of AFP, one can think of the occurrence of TN. At the same time, the concentration of hCG in the blood serum is several times higher than the norm corresponding to this period.

The presence in a patient of reproductive age of menstrual disorders, acyclic bleeding and a history of pregnancy always requires determining the concentration of hCG to exclude her TN.

A plateau or increase in hCG levels in three subsequent studies within 14 days indicates the development of OST.

Determination of PL concentration

Such a study can be carried out if a trophoblastic tumor of the placental bed or an epithelioid cell trophoblastic tumor is suspected - rare TN, characterized by a low concentration of hCG even with a widespread process and a significant expression of PL. These relationships underlie differential diagnosis. But the most informative in this case is an immunohistochemical study for the presence of PL in the tumor tissue.

Criteria for the diagnosis of "trophoblastic neoplasia" (WHO and FIGO recommendations, 2000):
plateau or increase in the concentration of hCG in the blood serum after removal of the mole in three consecutive studies for 2 weeks (1st, 7th, 14th day of the study);
High levels of hCG 6 or more months after removal of the hydatidiform mole;
histological verification of the tumor (chorioncarcinoma, trophoblastic tumor of the placental bed, epithelioid cell trophoblastic tumor).

The earliest sign of the development of a trophoblastic tumor is an increase in the concentration of hCG in the blood serum during dynamic control in patients with a history of pregnancy.

All women with various menstrual irregularities and a history of pregnancy, as well as detected metastases of unclear etiology, should determine the concentration of hCG in the blood serum.

INSTRUMENTAL STUDIES

Morphological study data

TN are the only tumors for which morphological verification is not required. Despite this, a thorough morphological study of the removed tissues (during curettage of the uterine cavity, excision of formations in the vaginal wall, etc.) of women of reproductive age is necessary for the purpose of early detection of TN.

The morphological material should be preserved in the form of paraffin blocks, allowing additional (immunohistochemical) studies to be carried out if necessary to clarify the diagnosis.

In most patients, the diagnosis of TN is made on the basis of morphological examination data. Diagnosis of cystic drift does not cause difficulties for the morphologist.

Verification of choriocarcinoma is often difficult, since when the uterine cavity is scraped, the tumor tissue (often located interstitially in the uterine wall) often does not get into the scraping. Repeated curettage is associated with a high risk of tumor destruction and subsequent profuse uterine bleeding or perforation of the uterine wall infiltrated by the tumor and the development of internal bleeding.

Morphological diagnosis of IPD is possible only in the removed uterus or tumor metastasis.

Morphological diagnosis of epithelioid cell trophoblastic tumor is difficult due to the lack of experience of morphologists, who often do not have data on rare observations described in the literature only in recent years.

The role of morphological research increases in the study of distant tumor metastases. Often this is the key to making a diagnosis in patients with an erased picture of the disease, as well as in patients in menopause.

Immunohistochemical examination of removed tissues with tumor markers makes a significant contribution to the diagnosis of OST in atypical clinical course.

Ultrasound computed tomography

In the diagnosis of a primary uterine tumor, along with determining the concentration of hCG, ultrasound CT is necessarily used - a highly informative and absolutely accessible method.

The use of high-frequency transvaginal sensors makes it possible to detect a trophoblast tumor (with a minimum diameter of 4 mm) already at the first stage of the patient's examination, completely eliminating the need for invasive research methods (repeated curettage, laparoscopy, hysteroscopy, pelvic angiography).

Ultrasound CT allows you to quickly and effectively diagnose metastases in the pelvic organs, abdominal cavity and retroperitoneal space.

Detection of metastases

The following methods are used to detect TO metastases (FIGO).
For the diagnosis of lung metastases and determining the stage of the disease - X-ray of the chest cavity. CT of the lungs can also be used.
Metastases in the liver (and other organs of the abdominal cavity and retroperitoneal space) are detected using X-ray or ultrasound CT.
· Cerebral metastases are detected by MRI or X-ray CT.

X-ray examination of the lungs is necessarily carried out during the initial examination of patients with the development of TN in them.

Metastasis of trophoblast tumors to the lungs is the most common and accounts for up to 80% of all cases of metastasis. Depending on the degree of spread, metastases in the lungs can be determined in the form of solitary foci, focal shadows, or multiple metastases up to a total lesion of the lung tissue. In some patients, the primary tumor of the uterus may not be detected.

X-ray CT is a highly informative method for diagnosing lung metastases, OST metastases in parenchymal organs, mediastinum and retroperitoneal space, as well as in the brain.

In accordance with the agreement adopted by the clinicians of the trophoblastic centers, all patients with a high risk of TO resistance (according to the FIGO scale), with metastases in the lungs and other organs, must undergo X-ray CT of the brain.

MRI is used to diagnose OST metastases in the brain. The diagnostic value of MRI is significantly superior to X-ray CT, especially when performed with contrast.

Positron emission tomography is a new method for the study of patients with trophoblastic tumors, which makes it possible to identify tumor foci in individual observations that were not detected by standard research methods.

SCREENING

Conducted after removal of the cystic drift - the concentration of hCG in the blood serum is examined monthly for a year.

DIFFERENTIAL DIAGNOSIS

TN should be differentiated from normal pregnancy. Ultrasound CT and a dynamic study of hCG in the blood serum make it possible to suspect the development of TN in a timely manner (the first sign is a discrepancy between the concentration of hCG and the gestational age).

In women of reproductive age, when detecting focal shadows in the lungs, tumors in the brain, liver, kidney and other organs, it is always necessary to exclude trophoblast tumors by determining the concentration of hCG in the blood serum.

Indications are symptoms characteristic of extragenital tumor localization (metastases in the central nervous system, kidney, stomach wall, liver, etc.). It is necessary to consult a neurosurgeon, abdominal surgeon, urologist, etc.

EXAMPLE FORMULATION OF THE DIAGNOSIS

Trophoblastic tumor of the uterus, stage I.
Trophoblastic tumor of the uterus, multiple metastases in the lungs and brain, stage IV.

TREATMENT OF VISIBLE MORAL

Tactics of the doctor with hydatidiform mole:
Vacuum extraction of hydatidiform mole with control acute curettage;
histological examination of the material;
• patients with Rh-negative blood and partial hydatidiform mole should receive Rh0-(anti-D)-Ig;
· Subsequently, careful monitoring throughout the year.

Monitoring after mole removal:
weekly determination of the concentration of hCG in the blood serum until three consecutive negative results are obtained, then monthly for up to 6 months, then 1 time in 2 months for the next 6 months;
· Ultrasonic CT scan of the pelvic organs 2 weeks after the extraction of the mole, then monthly normalization of the hCG content;
X-ray of the lungs after the evacuation of the hydatidiform drift, then after 4 and 8 weeks with a dynamic decrease in hCG;
obligatory maintenance by the patient of the menogram for at least three years after bladder drift.

Normally, the concentration of hCG in the blood plasma normalizes 4–8 weeks after the extraction of the hydatidiform mole.

An increased concentration of hCG after 8 weeks may indicate the development of OST, which requires a mandatory re-examination of the patient (gynecological examination, ultrasound CT scan of the pelvic organs and lung radiography). Chemotherapy after removal of the hydatidiform drift with a dynamic decrease in the concentration of hCG to a normal value is not carried out. The exception is patients in whom monitoring is not possible after the removal of the PZ. In this case, three courses of chemotherapy are recommended in the standard regimen (methotrexate, calcium folinate for prophylactic purposes).

Contraception is mandatory within a year after the normalization of the concentration of hCG, preferably with oral contraceptives.

TREATMENT OF TROPHOBLASTIC DISEASE IN PREGNANCY

GOALS OF TREATMENT

Achieve a cure for patients with preservation of reproductive function for young patients.

INDICATIONS FOR HOSPITALIZATION

Conditions that threaten the life of the patient (bleeding, symptoms of brain metastases, massive tumor damage internal organs and etc.);
Lack of opportunities for outpatient examination and treatment (due to the remote place of residence or the general condition of the patient);
treatment requiring inpatient stay (combined chemotherapy, surgical treatment, radiation therapy of metastases in the central nervous system);
The threat of life-threatening complications (more often - in the first month of treatment with large tumor sizes).

Consultation and treatment of patients with OST should be carried out only in a specialized clinic that has all the modern diagnostic capabilities, and most importantly, experience in the successful treatment of such patients.

MEDICAL TREATMENT

Treatment always begins with standard first-line chemotherapy (Table 50-4), the regimen of which is determined by the risk group for developing tumor resistance according to the FIGO scale, 2000 (see above).

Patients who have previously received non-standard chemotherapy regimens, after assessing the risk group, should definitely start standard chemotherapy.

Bleeding from the tumor is not a contraindication to the start of chemotherapy, which must be carried out in parallel with intensive hemostatic therapy.

Table 50-4. I line chemotherapy standards

In the course of treatment, weekly dynamic monitoring of the concentration of hCG in blood plasma is carried out to assess the effectiveness of treatment and early detection of tumor resistance.

SURGERY

Indications for surgical treatment:
Bleeding from the primary tumor or metastasis that threatens the life of the patient;
Tumor perforation of the uterine wall;
resistance of the primary tumor;
resistance of solitary metastases.

Optimal volume of operation:
Organ-preserving hysterotomy with excision of the tumor within healthy tissues in patients of reproductive age;
Resection of the affected organ with resistant metastasis within healthy tissues (possibly endoscopically).

INDICATIONS FOR CONSULTATION OF OTHER SPECIALISTS

The presence of symptoms of the development of OST metastases in the brain, abdominal cavity, retroperitoneal space.

APPROXIMATE TIMES OF INABILITY TO WORK

Patients at low risk of TN resistance with effective treatment without complications, the disabled period lasts 3 months, for high-risk patients without CNS damage and without complications with effective treatment - 4–5 months.

FURTHER MANAGEMENT

Be sure to monitor:
The concentration of hCG in the blood plasma 1 time in 2 weeks during the first three months, then monthly until the sixth month, then 1 time in 2 months up to a year, during the second year - once every 2-3 months, during the third - 1 time in 6 months;
menstrual function - the patient must conduct a menogram (in case of a violation of the menstrual cycle, hCG is determined);
Conditions of the pelvic organs - control ultrasound CT is performed once every 2 months until the ultrasound picture is normalized, then - according to indications;
lung conditions - X-ray examination of the lungs is carried out once a year;
Changes in the CNS (for patients with cerebral metastases) - MRI of the brain is performed 1 time in 6 months - for two years.

Pregnancy is allowed 1 year after the end of treatment - for patients with I-III stages of the disease; after 2 years - patients with stage IV.

PREVENTION

Not currently developed.

INFORMATION FOR THE PATIENT

It is necessary to know that with proper and timely treatment in a specialized institution, trophoblastic disease is curable in the vast majority of cases, regardless of the stage. At the same time, it is possible to preserve the childbearing function in young patients. The main condition for success is to strictly follow all the doctor's recommendations both during treatment and after its completion. Be sure to maintain a menogram, examination at the recommended time and subsequent contraception. In case of violation of the menstrual cycle after the end of treatment, you should immediately contact an oncogynecologist.

FORECAST

Treatment of patients with hydatidiform drift after its removal occurs in 80% of cases, in 20% the development of OST is possible.

For patients with a low risk of resistance to TN, the probability of cure is 100%, for patients with a high risk of resistance without metastases in the central nervous system and liver - 90%, with damage to the liver and brain, cure is possible in 50-80% of cases. The cure rate for patients with recurrent OST is 75%.

The prognosis for TN in the absolute majority of patients is determined by the choice of initial chemotherapy, which is currently standard and accepted by all trophoblastic centers of the world.