OBSTETRICS II

3D GESTATIONAL TROPHOBLASTIC DISEASES

OBII-03 Dr. Arellano / JULY 2019
GESTATIONAL TROPHOBLASTIC DISEASES
 Used to encompass a group of tumors typified by
abnormal trophoblast proliferation
 Incidence: US – 0.05/1000 pregnancies
Phil – 10.6/1000 pregnancies

Human chorionic gonadotropin (hCG)

 produced by trophoblast of placenta
 prevent disintegration of corpus luteum
 essential for GTD diagnosis, management and
surveillance
 Gold standard; highly sensitive and specific
 Glycoprotein with similar a-subunit (same with TSH, LH,
FSH)and unique b-subunit Pathogenesis

Classification of GTD
1. Hydatidiform mole “kiawa”
 Complete h. Mole = no fetal components
 Partial h. Mole = with fetal components
 Can be mistaken as Malignant invasive mole
 Abnormal pregnancy
 Included in gravidity, not in parity

2. Nonmolar trophoblastic malignant disease

 Choriocarcinoma
 Placental site trophoblastic tumor
 Epitheliod trophoblastic tumor

HYDATIDIFORM MOLE
Epidemiology and risk factors (2/1000 deliveries)
 Maternal age: >40yo and adolescent
 Previous H. mole: Prior CHM (1.5%), Prior PHM (2.7%),
Prior 2 HM (23%)
 Diet
 Race: Increased prevalence in Asian, Hispanics,
American Indian
 Oral Contraceptive Pills (OCP)

Classic histological findings:

 Trophoblast proliferation and villi with stromal edema
 Enlarged, edematous and vesicular chorionic villi and
with avascular stroma

Gross Findings:
 Abnormal conceptus resembling a bunch of grapes
with or without fetal components

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3. Chest Radiograph – baseline

4. Cytogenetic and Molecular biological examinations

 When diagnosis is in doubt
a. Ploidy studies
b. P57 immunostaining

5. Laboratory Examinations
a. CBC with Differential and platelet counts
b. Blood typing
c. Clotting Function studies
d. Liver Function studies (ALT, AST)
e. Renal Function studies (BUN and Crea)
f. Thyroid Function studies (FT4, TSH)
g. Urinalysis
*In some rare twin pregnancies, one chromosomally normal
fetus is paired with a complete diploid molar pregnancy (0.001- Management
0.01%). Diagnosis is through amniocentesis and karyotyping. A. Preoperative
1. CBC
Clinical findings of Hydatidiform Mole 2. Serum beta hCG
 Amenorrhea 3. Creatinine
 Vaginal bleeding 4. Electrolytes
5. Hepatic aminotransferase levels
 Anemia
6. TSH, ft4
 Acute abdomen
7. Blood typing and Rh
 Passage of Vesicular tissue from vagina 8. Chest X-ray
 Excessive Uterine enlargement 9. Consider hygroscopic dilators
 Presence of theca lutein cyst
 Preeclampsia; Pregnancy induced hypertension before B. Intraoperative
20weeks AOG 1. Large bore IV catheters
 Nausea/Vomiting; Hyperemesis gravidarum 2. Regional or general anesthesia
 Hyperthyroidism 3. Oxytocin (20 units in 1L)
 Pulmonary insufficiency 4. Other uterotonics
 methylergometrine maleate
Diagnosis  Carboprost tromethamine
1. Serum Beta Hcg  Misoprostol
 Get pre-evacuation serum B-hCG (baseline) 5. Karman cannula
 “hook effect” 6. Consider sonography machine
 excessive beta hCG hormone levels over saturate the
assays targeting antibody and create a false-negative C. Post evacuation
urine pregnancy test results. 1. Anti-D immunoglobulin (rhogam) if RhD negative
2. Initiate effective contraception
2. Pelvic Sonography 3. Review pathology report
 most accurate, non-invasive imaging but sonographic 4. Serum hCG levels: within 48 hours of evacuation,
features may not be evident in early moles weekly until detectable then monthly for 6 months
PARTIAL MOLE
 Thickened focal multicystic placenta along with a fetus Summary of Management of H Mole
or at least a fetal tissue. I. Recognition  Anemia
COMPLETE MOLE and Treatment  Preeclampsia
 echogenic uterine mass of Medical  Hyperthyroidism
 numerous anechoic cystic spaces but without a fetus or Complications  Electrolyte Imbalance
amnionic sac  Hyperemesis Gravidarum
 snow storm appearance  Pulmonary Insufficiency
 DIC
II. Molar  Suction Curettage
Evacuation  Hysterectomy with mole-in-situ
*Theca lutein cysts are best left alone;
regresses spontaneously (8-12weeks
post evacuation)
III. Identification of  Advanced Maternal Age >35yo
Patients at risk  Gravidity >4
for Malignant  Uterine size >6weeks
Degeneration  Serum BhCG >100,000mIU/mL
 Theca Lutein Cysts >6cm
 Any Medical Complication: Pre-
eclampsia, thyrotoxicosis, Pulmonary
Insufficiency, DIC

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 Poor compliance to follow-up Causative Pregnancy (UP-PGH, OB-Gyne Section):
*1 course of Chemoprophylaxis: H mole – 65%
- Methotrexate (IV not orally given) and Abortion – 20%
Actinomycin D Term Pregnancy – 15%
Contraindications:
- Hgb <100g/L, Hct <0.3 DESCRIPTION
- WBC <3x109L  Malignant end of GTD
- Platelet count <109L  Aggressive invasion into myometrium and propensity to
- Any active infection metastasize
- Presence of liver or renal dysfunction  Irregular bleeding with uterine subinvolution = most
- Known allergy to drug common finding
IV. Post  B hCG follow up:
evacuation - one week after molar evacuation then DIAGNOSIS
Follow up every 2 weeks til normal (5mIU/mL) 1. Plateau of serum hCG level (+/-10 percent) for four
- after 3 consecutive normal levels, once a measurements during a period of 3 weeks or longer, days
month x 6months 1, 7, 14, 21
*For young patients with intact uteri, 2. Rise of serum hCG level >10% during 3 weekly
pregnancy maybe allowed after 6 months consecutive measurements or longer, during a period of 2
of normal serum BhCG weeks or more, days 1, 7, 14
 Contraception 3. Serum b-hCG level remains detectable for 6 months or
- Low dose combined oral contraceptive more
pill is preferred 4. Histological criteria for choriocarcinoma

Transvaginal Ultrasound
MOLAR PREGNANCY TERMINATION  Determines:
 Suction curettage  Myometrial invasion
 molar evacuation regardless of uterine size  Tumor recurrence
 Appropriately typed and cross matched blood  Response to chemotherapy
should be available prior
 Oxytocin should be started (10U in 1L of LR Color Flow Doppler
solution as sidedrip)  Determines extent of disease
 Patient is in semifowlers dorsolithotomy position
especially when uterus is >14weeks gestation size
 Mechanical cervical dilatation can be done ALGORITHM FOR DIAGNOSIS OF GTN
 Sharp curettage follows suction to ensure
complete removal Clinical History Serum BhCG Radiograph and
 Hysterectomy in situ and PE titer Imaging
 for women who finished child bearing

*Hysterotomy and use of oxytocin or prostaglandin (Misoprostol)

 Not recommended
 Due to risk of significant hemorrhage GESTATIONAL TROPHOBLASTIC
 Higher incidence of post molar GTD NEOPLASIA
 Incomplete evacuation
 Need blood

INDICATIONS FOR IMMEDIATE REFERRAL TO A

TROPHOBLASTIC DISEASE SPECIALIST
1. High BhCG beyond 4 weeks post evacuation (serum;
20,000mIU/mL; urine: 30,000mIU/mL)
2. Persistently elevated BhCG at 14weeks post evacuation
3. A rise in BhCGof 10% or greater (2 consecutive INITIAL LABORATORY WORK UP
determinations) 1. B-hCG level
4. Plateauing of BhCG (<10% fall or rise) at any time after 2. CBC with APC
evacuation (minimum of 3 consecutive determinations) 3. Blood typing, Rh antibody screen
5. Clinical or histological evidence of metastasis at any site 4. Urinalysis
6. Elevation of a previously normal BhCG after evacuation, 5. Renal Function Tests: BUN, Crea
provided not pregnant 6. Liver Function Tests: ALT, AST
7. Thyroid Function Tests: FT4, TSH
8. Coagulation studies
GESTATIONAL TROPHOBLASTIC NEOPLASIA 9. Serum electrolytes
INCIDENCE 10. Chest Xray
 Europe and South America: 1/40,000 pregnancies 11. Whole Abdominal UTZ
 Southeast Asian: 3.3-9.2/40,000 pregnancies 12. Chest CT Scan
 Philippine National Prevalence Rate: 22.4/40,000 13. Chest MRI
pregnancies 14. Cranial CT scan

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FIGO ANATOMICAL STAGING – extent of disease 2. GESTATIONAL CHORIOCARCINOMA
 Most common type of trophoblastic neoplasm to follow a
term pregnancy or miscarriage
 Only a third of cases follow a molar gestation
 Composed of cells reminiscent of early cytotrophoblast and
syncytiotrophoblast.
 Contains no villi.
 Rapidly growing tumor invades both myometrium and blood
vessels
 Metastasis are blood borne
 Most common sites (lungs, kidneys, liver, brain, ovaries and
WHO SCORING – predicts possible resistance of tumor to single
bowel)
agent chemotherapy
3. PLACENTAL SITE TROPHOBLASTIC TUMOR
 Arise from intermedia tetrophoblast at the placental site.
 Serum b-hCG= modestly elevated
 Produces variant forms of hCG.
 Identification of free hCG= considered diagnostic.
Management: hysterectomy
 Chemoresistant
 For higher stage and stage1 and for later stages= multidrug
chemotherapy.

4. EPITHELIOD TROPHOBLASTIC TUMOR

 Rare
 Develops from chorionic-type intermediate trophoblast.
 Uterus= main site of involvement
eg. Gestational Trophoblastic Neoplasia IV: 14  Bleeding and low hCG= typical findings
(Choriocarcinoma) Management:
 hysterectomy
 Chemoresistant
CLINICAL PRESENTATION  Metastatic disease is common: combination
o Vaginal bleeding chemotherapy
o Uterine enlargement
o Anemia
o Acute Abdomen secondary to tumor perforation ALGORITHM FOR THE MANAGEMENT OF GTN
o Infection from necrotic metastasis
o Signs pertaining to metastasis: GESTATIONAL TROPHOBLASTIC
o Vaginal mass NEOPLASIA
o Pulmonary insufficiency
o Tumor bleed (hemoptysis, CVA, ruptured
viscus, hepatic bleed, intraperitoneal bleed)
o Lateralizing neurologic manifestations
Stage I Stage II/ III Stage IV
HISTOLOGICAL CLASSIFICATION
 Made by persistently elevated serum b-hCG without
confirmation by tissue study.
Low risk High risk
1. INVASIVE MOLE
 Most common trophoblastic neoplasm that follow
hydatidiform moles Single Agent EMACO +/- EMACO/ High dose
 Almost all invasive moles arise from partial or complete Chemotherapy Hysterectomy EMACO +/- Hysterectomy
moles +/- +/- Irradiation or
 Characterized by trophoblastic hyperplasia and persistence Hysterectomy Intrathecal Methotrexate
of chorionic villi
 Previously known as chorioadenoma destruens.
 Although locally invasive, less prone to metastasis. st
*Methotrexate – 1 line Chemotherapeutic Drug for GTN

*Salvage Single agent Chemotherapy Regimens if MTX fails

 Actinomycin Etoposide-Actinomycin EMACO

*Stage IV with Brain Metastasis

 High Dose EMACO + Radiotherapy or Intrathecal
Chemotherapy

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th
*Multi-agent Chemotherapy 24 STUDY GUIDE QUESTIONS
 EMA-EP/ EP-EMA 20–1. As a group, gestational trophoblastic disease is typified by
 TP/TE which of the following?
 5-FU a. Scant cytotrophoblast
 BEP b. Perivillous ibrin deposition
 FAEV c. Villous mesenchymal hyperplasia
d. Abnormal trophoblast proliferation
Stage Number of Recurrence
Consolidation Rate 20–2. As illustrated by differences seen here between invasive
Courses mole (A) and choriocarcinoma (B), hydatidiform moles as a
Non-metastatic GTN 2 2% group are differentiated histologically from other nonmolar
Low risk GTN 2 4% neoplasms by the presence of which of the following?
a. Villi
High Risk GTN 3 14%
b. Cytotrophoblast
IV 3
c. Syncytiotrophoblast
d. Marked angiogenesis
*BhCG are monitored to check response to chemotherapy:
1. Adequate response – one log fall or >50% fall from baseline 20–3. Gestational trophoblastic neoplasia includes all EXCEPT
2. Partial Response which of the following?
3. Plateau - <10% fall or rise from baseline a. Invasive mole
4. Resistance – 2 plateauing values, 1 rising weekly BhCG or b. Choriocarcinoma
appearance of new metastasis c. Partial hydatidiform mole
- For multiple chemoresistance, treat with Anti Endoglin d. Placental site trophoblastic tumor
Antibody; Direct enzyme pro drug therapy (DEPT);
Genetically engineered Neural stem cells; 20–4. Which of the following histological changes are
Immunotherapy characteristic of hydatidiform moles?
5. Biochemical Remission – 3 consecutive normal BhCG a. Chronic villitis and villous inclusion bodies
(≤5mIU/mL) b. Villous mesenchymal hyperplasia and acute villitis
c. Villous lymphocytic infiltrates and syncytial knots
PSSTD Recommendation for Follow Up
d. Trophoblast proliferation and villous stromal edema
a) Complete history and PE every visit
b) Diligent serum BhCG monitoring 20–5. A predominant maternal risk factor for molar pregnancy
- Schedule: includes which of the following?
st
o Monthly for 1 6months a. Advanced maternal age
o Every 2months for next 6months b. Prior cesarean delivery
nd
o Every 3months for 2 year c. Type 2 diabetes mellitus
o Every 6months thereafter d. African American ethnicity
c) Serial radiologic and sonologic exam
- Chest Xray every 6mos if with residual lung tumor 20–6. Your patient has completed treatment or a complete
- Transvaginal UTZ every 6mos if with intact uteri hydatidiform mole. Compared with women without a prior molar
d) Counseling on: pregnancy, those with one prior mole have which of the following
 Contraception – Low dose OCP risks of developing this condition again in a subsequent
 Appearance of secondary malignancies pregnancy?
 Early menopause a. 2%
e) Psychosocial Counseling b. 13%
c. 26%
d. 42%
SUBSEQUENT PREGNANCY
 Delay pregnancy for 12months after chemo 20–7. This molar pregnancy lacked a fetal component. All

st
Avoid pregnancy for 1 2years following remission EXCEPT which of the following features are also characteristic of
 Fertility not impaired this type of hydatidiform mole?
 Pregnancy outcomes are usually normal but with risk of a. Diploid karyotype
subsequent GTD b. Focal villous edema
 No increase congenital anomaly c. Theca-lutein ovarian cysts are frequently associated
d. Approximate 15% risk of subsequent gestational
What to Do: trophoblastic neoplasia
- Early UTZ
- Serum BhCG during and after each succeeding 20–8. All EXCEPT which of the following features are
pregnancy: characteristic of partial hydatidiform mole?
 Antenatally: Monthly starting 20weeks AOG a. Triploid karyotype
 Postpartum: At 6 and 10weeks b. Focal villous edema
- All placentas should be sent for histopathologic exam c. Fetal tissue present
d. Approximate 15% risk of subsequent gestational
_______________________________________________ trophoblastic neoplasia

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20–9. With regard to molar pregnancies, what does the term 20–17. Prior to surgical intervention or a hydatidiform mole, all
“androgenesis” refer to? EXCEPT which of the following are typically completed?
a. Increased placental androgen production that promotes a. Type and screen
villous edema b. Complete blood count
b. Development of a zygote that contains only maternal c. Chest computed tomography
chromosomes d. Serum testing of liver, renal, and thyroid function
c. Increased placental androgen production that leads to
maternal virilization 20–18. Prior to molar pregnancy evacuation, a preoperative
d. None of the above chest radiograph is typically obtained to exclude which of the
following associated conditions?
20–11. Your patient is a 39-year-old G2P1 with one prior a. Cardiomegaly
uncomplicated pregnancy and vaginal delivery. Her current twin b. Pleural effusion
pregnancy is made up of a complete mole and a coexistent c. Hilar lymphadenopathy
karyotypically normal fetus. Magnetic resonance imaging was d. Trophoblastic deportation
completed and cross-sectional image shows the complete mole,
a normal placenta above the mole, and a cross section of the 20–19. What is the treatment of choice or a 20-week size
normal fetus’ abdomen. Complications that may be reasonably complete mole in a 28-year-old G2P1?
anticipated during this pregnancy include all EXCEPT which of a. Hysterectomy
the following? b. Hysterotomy and evacuation
a. Preeclampsia c. Dilatation and suction curettage
b. Fetal demise d. Intramuscular systemic methotrexate
c. Preterm delivery
d. Placenta accreta 20–20. Steps during dilatation and curettage that may hasten
evacuation and lessen intraoperative blood loss include which of
20–12. Patients with complete hydatidiform molar pregnancy the following?
frequently present with all EXCEPT which of the following clinical a. Preoperative laminaria
findings? b. Large-bore suction cannula
a. Vaginal bleeding c. Uterotonic administration during curettage
b. Multiple simple ovarian cysts d. All of the above
c. Increased thyroid-stimulating hormone levels
d. Greater than expected serum β-human chorionic 20–21. Which of the following uterotonics are contraindicated in
gonadotropin (hCG) levels the setting of molar pregnancy evacuation?
a. Misoprostol
20–13. Your patient is diagnosed with a complete hydatidiform b. Synthetic oxytocin
mole. Sonographic examination of the adnexa reveals the c. Carboprost tromethamine
findings below. The underlying etiology stems from increased d. None of the above
placental production of which of the following?
a. Estrogen 20–22. In the United States, routine post evacuation treatment of
b. Thyroxine molar pregnancy typically includes which of the following?
c. Progesterone a. Methotrexate chemotherapy
d. β-Human chorionic gonadotropin b. Intrauterine device insertion
c. Rhogam administration to Rh-negative women
20–14. The condition shown in Question 20–13 is best managed d. All of the above
by which of the following?
a. Oophoropexy 20–23. In the United States, a reasonable alternative to dilatation
b. Oophorectomy and curettage or the management of complete hydatidiform mole
c. Ovarian cystectomy includes which of the following?
d. Molar pregnancy uterine evacuation a. Hysterectomy
b. Hysterotomy and uterine evacuation
20–15. Increased serum free thyroxine levels in women with c. Misoprostol labor induction ollowing laminaria placement
hydatidiform moles stem from increases in which of the d. All of the above
following?
a. Maternal estrogen levels
b. Fetal thyroxine production
c. Maternal progesterone levels
d. Maternal β-human chorionic gonadotropin levels

20–16. A 24-year-old G3P2 presents with vaginal bleeding, a β-

human chorionic gonadotropin (β-hCG) level of 300,000 mIU/mL,
uterine size consistent with a 12-week gestation, B negative
blood type. What is the most appropriate management?
a. Plan or hysterectomy
b. Rhogam administration and bed rest
c. Plan or dilatation and curettage
d. Repeat a serum β-hCG level in 48 hours

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20–24. Your patient, who is pregnant with an estimated 20–29. The patient from Question 20–28 presents again in 48
gestational age of 8 weeks by last menstrual period, presents to hours and has a β-human chorionic gonadotropin level of 6000
the emergency department with heavy vaginal bleeding and mIU/mL. What is the next most appropriate step in her care?
passage of tissue. Sonographic examination reveals an a. Transvaginal sonography
endometrial cavity filled with blood and tissue exhibiting b. Preparation or dilatation and curettage
inhomogeneous echoes. You perform a dilatation and curettage c. Initiation o intramuscular methotrexate therapy
with no complications. A week later, you receive the pathology d. Chest and abdominopelvic computed tomography (CT)
report or the evacuated products of conception: imaging and brain magnetic resonance imaging
Specimen: uterine contents
DNA interpretation by image cytometry: diploid 20–30. The patient rom Question 20–28 undergoes transvaginal
Immunostaining: p57KIP2 positive sonography, which reveals no intrauterine or adnexal gestation.
These histological findings are consistent with which of the Appropriate managemsent includes which of the following?
following diagnoses? a. Hysterectomy
a. Partial mole b. Initiation of intravenous dactinomycin therapy
b. Complete mole c. Initiation of intramuscular methotrexate therapy
c. Spontaneous abortion d. International Federation of Gynecology and Obstetrics
d. None of the above (FIGO) staging

20–25. Which of the statements below are true regarding 20–31. In practice, the diagnosis of gestational trophoblastic
surveillance practices ollowing evacuation of a molar pregnancy? neoplasia typically is determined by which of the following?
a. Endometrial biopsy and chest radiograph should be a. Histologic tissue evaluation
performed every 3 months or 1 year. b. Physical examination findings
b. Endometrial biopsy, chest radiographs, and β-human c. Computed tomography (CT) imaging
chorionic gonadotropin levels are obtained serially, but each at d. Serum β-human chorionic gonadotropin levels
different intervals.
c. Serum β-human chorionic gonadotropin levels should be 20–32. Criteria or the diagnosis of gestational trophoblastic
monitored every 1 to 2 weeks until undetectable, after which neoplasia includes which of the following?
monthly levels are drawn or the next 6 months. a. Rising β-human chorionic gonadotropin levels
d. None of the above b. Plateaued β-human chorionic gonadotropin levels
c. Persistent β-human chorionic gonadotropin levels
20–26. Which of the following statements is true regarding d. All of the above
contraceptive practices after evacuation of a molar pregnancy?
a. Intrauterine devices should not be inserted until the β- 20–33. Gestational trophoblastic neoplasia may develop after
human chorionic gonadotropin (β-hCG) level is undetectable. which of the following?
b. Pregnancies that occur during the monitoring period a. Evacuation of a partial mole
increase the risk of progression to gestational trophoblastic b. Delivery of a normal term pregnancy
neoplasia. c. Miscarriage of a genetically normal abortus
c. Hormonal contraception, such as oral contraceptive pills and d. All of the above
injectable medroxyprogesterone acetate, should not be
initiated until the β-hCG level is undetectable. 20–34. The hallmark sign of gestational trophoblastic neoplasia
d. All of the above is which o the following?
a. Seizures
20–27. During surveillance, all EXCEPT which of the following b. Hemoptysis
portend a greater risk or development of gestational c. Uterine bleeding
trophoblastic neoplasia? d. Pelvic vein thrombosis
a. Maternal age > 40 years
b. 8-cm theca lutein cysts 20–35. Evaluation of abnormal bleeding or more than 6 weeks
c. Rapidly declining β-human chorionic gonadotropin level following any pregnancy may include which of the following?
d. β-Human chorionic gonadotropin level >100,000 mIU/mL a. Transvaginal sonography
prior to uterine evacuation b. Serum β-human chorionic gonadotropin level
c. Endometrial sampling to exclude placental site trophoblastic
20–28. Your patient is a 32-year-old G1P0A1 who has tumor or epithelioid trophoblastic tumor
undergone molar pregnancy evacuation and is using d. All of the above
combination oral contraceptive pills. During postevacuation
surveillance, her serum β-human chorionic gonadotropin levels 20–36. According to the World Health Organization (WHO)
had previously dropped to an undetectable level. Today, as part modified prognostic scoring system that was adapted by the
of her monthly surveillance, her value is 900mIU/mL. Appropriate International Federation of Gynecology and Obstetrics (FIGO),
initial management includes which of the following? which of the following is assessed and assigned a rating score
a. Preparation or dilatation and curettage during staging of gestational trophoblastic neoplasia?
b. Initiation of intramuscular methotrexate therapy a. Parity
c. Repeat β-human chorionic gonadotropin level in 48 hours b. Severity of thyrotoxicosis
d. International Federation o Gynecology andObstetrics c. Number of months from the antecedent pregnancy
(FIGO) staging d. Presence and diameter o largest theca-lutein cyst

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20–37. Following dilatation and curettage or a complete mole, 20–44. Your patient has International Federation of Gynecology
your patient is surveilled with serial β-human chorionic and Obstetrics (FIGO) stage III gestational trophoblastic
gonadotropin (β-hCG) levels. For the past 3 weeks, the β-hCG neoplasia. Which of the following is considered typical
values have plateaued. Diagnostic evaluation reveals a treatment?
metastatic lesion in the liver. Given this extent of disease, what is a. Radical hysterectomy
the International Federation of Gynecology and Obstetrics b. Combination chemotherapy
(FIGO) stage? c. Radical hysterectomy plus adjuvant methotrexate
a. Stage I d. External beam pelvic radiation plus adjuvant methotrexate
b. Stage II
c. Stage III 20–45. Chemotherapeutic agents in the EMA-CO regimen
d. Stage IV include all EXCEPT which of the following?
a. Cisplatin
20–38. According to the World Health Organization (WHO) b. Etoposide
modified prognostic scoring system that was adapted by the c. Methotrexate
International Federation of Gynecology and Obstetrics (FIGO), d. Actinomycin-D
patients with scores below which of the following thresholds are
assigned to the low-risk gestational trophoblastic neoplasia 20–46. True evidenced-based risks or future pregnancy following
group? treatment of gestational trophoblastic disease include which of
a. ≤ 4 the following?
b. ≤ 6 a. Decreased fertility
c. ≤ 8 b. Increased risk of preterm labor
d. ≤ 10 c. Increased risk of placenta accreta
d. Increased risk of a second molar pregnancy
20–39. Which of the following characteristics are most typical of
invasive moles?
a. Follows a term pregnancy
b. Penetrates deeply into the myometrium
c. Displays minimal trophoblastic growth
d. Is almost invariably associated with widespread pulmonary
metastasis

20–40. Metastatic disease is most commonly due to which of the

following?
a. Invasive mole
b. Choriocarcinoma
c. Epithelioid trophoblastic tumor
d. Placental site trophoblastic tumor

20–41. Metastatic spread of choriocarcinoma is most commonly

by which of the following routes?
a. Lymphatic
b. Hematogenous
c. Peritoneal fluid
d. Cerebrospinal fluid

20–42. What is the most common site of metastatic spread of

choriocarcinoma?
a. Brain
b. Liver
c. Lungs
d. Spleen

20–43. Your patient has International Federation of Gynecology

and Obstetrics (FIGO) stage I gestational trophoblastic
neoplasia. Preferred and effective treatment includes
methotrexate or which of the following?
a. Radical hysterectomy
b. Combination chemotherapy
c. External beam pelvic radiation
d. Actinomycin-D single-agent chemotherapy

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