Welcome to your Gestational Trophoblastic Disease

(I)From the following clinical scenarios below, choose the single most appropriate management option from the option list. Where relevant, it can be assumed that in each case the woman has been registered with the nearest Trophoblastic Screening and Treatment Centre. Each answer may be used once, more than once or not at all

Option List
A. Dilatation of the cervix and uterine curettage
B. Hysterectomy and bilateral salpingo-oophorectomy
C. Intramuscular methotrexate and folinic acid
D. Intravenous multiagent chemotherapy
E. Measure serum hCG 6–8 weeks after the pregnancy
F. Medical termination of pregnancy
G. Oxytocin infusion to stop uterine haemorrhage prior to suction evacuation of the uterus
H. Prenatal invasive testing for fetal karyotype
I. Prostaglandin cervical ripening prior to suction evacuation of the uterus
J. Second suction evacuation of the uterus
K. Suction evacuation of the uterus
L. Suction evacuation of the uterus and insertion of Mirena® intrauterine delivery system
M. Suction evacuation of the uterus and postoperative anti-D prophylaxis
N. Suction evacuation of the uterus with antibiotic prophylaxis
O. Tests and treatment not required

1. A 28-year-old woman had a surgical evacuation of the uterus for an incomplete spontaneous miscarriage 3 months ago and the histology confirmed a molar pregnancy. She has had irregular vaginal bleeding since the procedure with  pisodes of dyspnoea and haemoptysis. Investigation results are as follows: full blood count: haemoglobin 9.6 g/l, otherwise normal liver and renal function tests: normal blood group: A Rh positive serum hCG: 98 457 IU/l; CA125: 275 U/l; AFP: 24 u/l; TSH: 1.4 mU/l pelvic ultrasound scan: 4.5-cm intrauterine lesion ? polyp; bilateral ovarian enlargement with multiple small cysts in both ovaries (6 cm and 7 cm maximum diameters); no free fluid CXR: three parenchymal nodules ranging from  1.0–2.5 cm in left upper lobe; heart size normal; no hilar enlargement MRI scan: no evidence of other metastatic lesions
2. A 34-year-old woman, P3, presents with some vaginal bleeding at 16 weeks of gestation and a pelvic ultrasound scan indicates a diagnosis of a partial molar pregnancy. On examination the uterus is palpated at the level of the umbilicus; the cervix looks normal and is closed; there is fresh blood and clots in the vaginal. Investigation results are as follows: full blood count: haemoglobin 9.2 g/l, otherwise normal Liver and renal function tests normal blood group: AB Rh positive serum hCG: 148 457 IU/l; TSH: 3.1 mU/l
3. A 24-year-old nulliparous woman presents with some vaginal bleeding at 10 weeks of gestation and a pelvic ultrasound scan indicates a diagnosis of a molar pregnancy. On examination the uterus is 14-week sized; the cervix looks normal and is closed; there is fresh blood and clots in the vaginal. Investigation results are as follows: full blood count: haemoglobin 10.2 g/l, otherwise normal liver and renal function tests: normal blood group: AB Rh negative serum hCG: 148 457 iu/l; TSH: 1.9 mU/l
4. A 27-year-old woman, P1, presents with heavy vaginal bleeding and crampy period-like pains at 10 weeks of gestation. On examination she looks pale; BP: 100/60 mmHg; pulse rate: 104 bpm; the uterus is 14-week sized; the cervix is open and there is a lot fresh blood and clots in the vaginal together with copious vesicular placental tissue. Investigation results are as follows: full blood count: haemoglobin 7.9 g/l, otherwise normal blood group: O Rh positive
5. A 41-year-old woman has a surgical evacuation of the uterus for an incomplete spontaneous miscarriage in her first pregnancy 6 months ago and the histology showed a molar pregnancy. She has had irregular vaginal bleeding since the procedure with no other symptoms. Investigation results are as follows: full blood count: haemoglobin 10.6 g/l, otherwise normal liver and renal function tests: normal blood group: A Rh negative serum hCG: 488 457 IU/l; CA125: 121 U/l thyroid function tests: normal pelvic ultrasound scan: 5.5-cm intrauterine lesion ? polyp; bilateral ovarian enlargement with multiple small cysts in both ovaries (6-cm and 7-cm maximum diameters); no free fluid CXR: normal MRI scan: no evidence of metastatic lesions
6. A 39-year-old woman, P4, presents at 10 weeks of gestation with recurrent vomiting. On examination the uterus is palpated at approximately 16-week sized. A pelvic ultrasound scan indicates a twin pregnancy with a possible diagnosis of a partial molar pregnancy in one of the twins. Investigation results are as follows: full blood count: haemoglobin 9.2 g/l, otherwise normal liver and renal function tests: normal blood group: AB Rh positive serum hCG: 348 457 IU/l; thyroid function – free T4:  26 pmol/l; free T3: 6.3 pmol/l; TSH < 0.1 mU/l
7. A 39-year-old woman has just delivered a healthy female infant after an uncomplicated second pregnancy and plans to breastfeed; her blood group is B Rh negative. Ten years before she had a termination of pregnancy for a partial molar pregnancy with appropriate monitoring and was discharged after 6 months with no further treatment necessary
8. A 23-year-old nulliparous woman presents with 1 week of brown vaginal bleeding; her LMP was 14 weeks ago; she does not feel as if she is pregnant any more. On examination the uterus is 10 week-sized; the cervix looks normal and is closed; there is old blood and brown discharge in the vagina. A pelvic ultrasound scan shows a small fetus with no fetal heart action and a collapsed gestational sac. Investigation results are as follows: full blood count: haemoglobin 11.2 g/l, otherwise normal blood group: AB Rh negative serum hCG: 2057 IU/l thyroid function: normal. After an evacuation of the uterus the histology confirms fetal parts and normal trophoblast with areas of molar degeneration
(II)For each of the following clinical scenarios, what is the most likely karyotype from the options listed? Each option may be used once, more than once or not at all.

Option List
A. 23,X
B. 23,Y
C. 45,XO
D. 46,XX
E. 46,XY
F. 47,XXO
G. 47,XXX
H. 47,XXY
I. 47,XYY
J. 69,XXX
K. 69,XXY
L. 69,XYY
M. 69,YYY

9. A woman presents with hyperemesis and bleeding to the gynaecology assessment unit. An ultrasound scan suggests a complete molar pregnancy and this is confirmed following histopathological analysis of the evacuated products of conception. What is the karyotype of the sperm that fertilised the oocyte?
10. A woman attends for a routine dating scan at 12 weeks of gestation. This shows an enlarged placenta with cystic spaces and a small fetus. A surgical evacuation is performed, which confirms a partial molar pregnancy. What is the most likely karyotype?
11. A recent immigrant to the UK presents with shortness of breath, haemoptysis and vaginal bleeding. She describes a ‘miscarriage’ a few months earlier. A pregnancy test is strongly positive and an ultrasound scan shows a haemorrhagic cystic mass in the uterus. A chest X- ray shows multiple nodules in both lungs. What is the most likely karyotype of the tumour?