Gestational trophoblastic disease

1. A 42-year-old woman has bleeding for 12 months following her third-term vaginal delivery. Uterine evacuation identifies choriocarcinoma on histological diagnosis. Ultrasound shows a 5-cm lesion in the myometrium and chest x-ray shows multiple (more than eight) lung nodules and serum beta hCG is 12045iu/l

A. EMA-CO regimen
B. Hysterectomy
C. Methotrexate and hysterectomy
D. Methotrexate/Folinic acid
E. Repeat suction evacuation

2. 44 year-old woman has a molar pregnancy evacuated uneventfully. The hCG decreases from a pre-evacuation value of 80 000 to 1000 IU/l 4 weeks after the evacuation but then persists at 1000 mIU/ml for 4 weeks. Clinical examination shows no abnormality or evidence of metastases. Ultrasound of the uterus shows a 2-cm lesion in the myometrium. Chest x-ray is normal

A. EMA-CO regimen
B. Hysterectomy
C. Methotrexate and hysterectomy
D. Methotrexate/Folinic acid
E. Repeat suction evacuation

3. Which one of the following factors is most likely to significantly increase the FIGO prognostic risk factor scoring for histologically diagnosed choriocarcinoma?

A. Pre-treatment hCG 103 to 104 IU/l
B. Residual uterine tumour mass measuring 2 × 2 cm
C. Diagnosis occurred within 4 months following complete molar pregnancy
D. Metastases to the brain
E. Age <40 with metastases to the lungs

4. Which one of the following factors is characteristically associated with partial hydatidiform mole?

A. No evidence of fetal tissue or fetal red blood cells on histology
B. Arise due to dispermic fertilisation of an ovum
C. All cases have triploid karyotype
D. Histology shows diffuse villous hydrops and diffuse trophoblast hyperplasia
E. Higher risk of requiring chemotherapy than complete hydatidiform mole

5. Which statement is correct in relation to histological examination of the products of conception (POC) in the diagnosis of gestational trophoblastic disease?

A. In women with a history of molar pregnancy, for all future pregnancies, serum or urine hCG concentrations should be routinely checked 6 and 10 weeks after delivery to ensure no reactivation of previous molar disease
B. Complete molar pregnancies are associated with fetal parts
C. In women with a history of molar pregnancy, for all future pregnancies, the placenta is routinely sent for histological examination to ensure no reactivation of previous molar disease
D. POC from all terminated pregnancies should be routinely sent for histological examination
E. Histological appearance is consistently more reliable than DNA ploidy status and immunohistochemistry for P57 in distinguishing partial from complete molar pregnancy

6. Which statement is correct in relation to contraception and future pregnancy outcome for women whose last pregnancy was a complete or partial hydatidiform mole?

A. There is an increased risk of future congenital fetal malformation and infertility
B. Hormone replacement therapy is contraindicated
C. Intrauterine contraceptive devices are contraindicated because of an increased risk of uterine perforation
D. The combined oral contraceptive pill may be safely used once hCG level has normalised
E. Women who required chemotherapy are advised not to conceive for 6 months following completion of chemotherapy treatment

7. Which one of the following is not an indication for chemotherapy for gestational trophoblastic disease in the UK?

A. Raised hCG concentration 6 months after evacuation, even when still decreasing
B. Evidence of metastases in the brain, liver, gastrointestinal tract or lung
C. Histological diagnosis of complete hydatidiform mole
D. Heavy vaginal bleeding persisting after uterine evacuation
E. Plateaued or rising hCG concentration after uterine evacuation

8. Women with partial or complete mole diagnosed is advised:

A. Women can use the contraception of their choice following treatment of GTD
B. Women who undergo chemotherapy are advised not to conceive for a year after completion of treatment
C. HRT is not safe in women who have had GTD
D. All women should be followed up for a year after surgical evacuation for molar pregnancy

9. A 38-year-old woman underwent a suction evacuation procedure following a diagnosis of a missed miscarriage 8 weeks ago. Histopathology results confirmed a molar pregnancy. She had a blood sample taken to assess serum HCG 2 days ago at her GP surgery, which was 500 iu/ml. She presents to you for her follow up appointment.

What is the most appropriate duration of follow up?

A. Follow up for 3 months from date of uterine evacuation
B. Follow up for 3 months from normalisation of hCG
C. Follow up for 6 months from date of uterine evacuation
D. Follow up for 6 months from normalisation of hCG
E. Follow up for 6 months from diagnosis of molar pregnancy

10. A 36-year-old woman presents to her GP after a miscarriage with confirmation of gestational trophoblastic disease in the histology. Her HCG levels have not yet normalised and she was using combined oral contraceptive pills prior to her pregnancy. What is the most suitable contraceptive advice that you would offer her?

A. Barrier methods are contraindicated
B. Continue to use the combined pill and advise that progesterone only pill is contraindicated
C. Change to intrauterine contraceptive device as these are safe
D. Stop the oral contraceptives immediately
E. Continue with the oral contraception and she should be advised that there is a potential but low increased risk of developing GTN

11. A 42-year-old woman presents with hyperemesis and irregular vaginal bleeding. She had an ultrasound scan that showed snowstorm vesicular appearance. Her bHCG levels were 120,000 iu/l. Which one of the statements below are true?

A. Cervical ripening with Misoprostol immediately prior to surgical evacuation is contraindicated as it increases the risk of embolization of trophoblastic tissue in complete molar pregnancies
B. Medical evacuation is a suitable option for complete molar pregnancies as these are less likely to embolise & disseminate than partial moles
C. Suction curettage is the method of choice of evacuation for complete molar pregnancies
D. Suction evacuation should be avoided in complete molar pregnancies due to increased risk of uterine perforation due to the enlarged uterine cavity
E. The use of oxytocic agents during the operative procedure must not be used even if bleeding is severe as it increases the risk of tissue embolization

12. A 44-year-old para 2 presented for her fetal viability scan at 12 weeks. Ultrasound showed twin gestation with one live fetus and possibility of a coexistent complete mole. What advice will you offer her?

A. The outcome for a normal pregnancy with a coexisting complete mole is poor, with approximately a 25% chance of achieving a live birth
B. Continuation of pregnancy should be offered as there is a 60% chance of achieving a live birth with a coexisting complete mole
C. Termination of pregnancy is advisable in all cases as there is a 100% increased risk of congenital fetal abnormalities, perinatal mortality and malignant GTN in the viable twin
D. Termination of pregnancy should be only offered in those cases where there is a coexistent partial mole as opposed to a complete mole
E. Termination of pregnancy should not be offered as there are no risks to the viable twin

13. A 23-year-woman had an ultrasound scan that was suggestive of a missed miscarriage. She underwent evacuation of the uterus and products of conception were sent for histology. The histology report confirmed that this had been a partial molar pregnancy.

What are the most likely genetic features of the partial molar pregnancy?

A. 46 XY
B. 46 YY
C. 46 YYY
D. 69 XYY
E. 69 YYY

14. What is the most common symptom in women who develop gestational trophoblastic disease after a miscarriage?

A. Abdominal pain with period of amenorrheoa
B. Nausea and vomiting
C. Enlarged uterus than period of gestation
D. Symptoms of hyperthyroidism
E. Irregular Vaginal bleeding with a period of amenorrhoea

Gestational trophoblastic disease

Gestational trophoblastic disease

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