Abortion, Ectopic Pregnancy, and Molar Pregnancy PDF

1st trimester vaginal bleeding By dr. SUAD TAHER YASEN FICOG UNIVERSITY OF DUHOK Miscarriage (Abortion)  Abortion is pregnancy loss before age of viability. Its classified in to; 1_miscarriage. 2_ induced abortion, either its therapeutic or illegal abortion.  A26-...

1st trimester vaginal bleeding By dr. SUAD TAHER YASEN FICOG UNIVERSITY OF DUHOK Miscarriage (Abortion)  Abortion is pregnancy loss before age of viability. Its classified in to; 1_miscarriage. 2_ induced abortion, either its therapeutic or illegal abortion.  A26-year-oldwoman, gravida 2,para l at20 weeks of gestation sees you in the office for prenatal care. Her fundus measures 16 weeks and you are unable to hear fetal heart tone by Doppler. You perform an ultrasound and confirm lack of fetal heart activity and lack of fetal movement or breathing. Her last pregnancy was complicated by severe preeclampsia at 34 weeks that forced her to deliver a preterm baby. She has no medical problems other than mild asthma. Upon further inquiry she tells you she had one episode of spotting 4 weeks ago but did not have cramping nor did she pass any clots or tissue from the vagina. What is the most descriptive diagnosis?  Name and define this diagnosis ? In relation to the history what could be the risk factor, and how we can confirm it? Mention methods of treatment ?  A miscarriage is the natural death or (pregnancy loss) of an embryo or fetus in the uterus. in the early stages of prenatal development prior to fetal viability (the stage of potential independent survival). Among women who know they are pregnant, the miscarriage rate is roughly 15-20% and it is the most common complication of early pregnancy in humans.  Signs and symptoms The most common symptom of a miscarriage is vaginal bleeding. This can vary from light spotting or brownish discharge to heavy bleeding and bright red blood. The bleeding may come and go over several days. Bleeding during pregnancy may be referred to as a threatened miscarriage. Of women who seek clinical treatment for bleeding during pregnancy, about half will miscarry.  The physical symptoms of a miscarriage vary according to the length of pregnancy: At up to six weeks only small blood clots may be present, possibly accompanied by mild cramping or period pain. At 6 to 13 weeks a clot will form around the embryo or fetus, and the placenta, with many clots up to 5 cm in size being expelled prior to completion of the process. The process may take a few hours or be on and off for a few days. At more than 13 weeks the fetus may be passed easily from the uterus, however the placenta is more likely to be fully or partially retained in the uterus, resulting in an incomplete miscarriage. The physical signs of bleeding, cramping, and pain may be similar to an early stage abortion, but sometimes more severe and labor-like.  Causes A Miscarriage may occur for many reasons, not all of which can be identified. Some of these causes include genetic, uterine, or hormonal abnormalities, reproductive tract infections, and tissue rejection. Miscarriage caused by invasive prenatal diagnosis chorionic villus sampling (CVS) and amniocentesis) is rare (about 1%).  First trimester Most clinically apparent miscarriages (two-thirds to three-quarters in various studies) occur during the first trimester. National Institutes of Health report that "around half of all fertilized eggs die and are lost (aborted) spontaneously, usually before the woman knows she is pregnant.  Chromosomal abnormalities are found in more than half of embryos miscarried in the first 13 weeks. Chromosomal problems due to a parent's genes are, however, a possibility. This is more likely to have been the cause in the case of a woman suffering repeated miscarriages, or if one of the parents has a child or other relatives with birth defects. Genetic problems are more likely to occur with older parents; this may account for the higher rates observed in older women.  Progesterone deficiency may be another cause. Women diagnosed with low progesterone levels in the second half of their menstrual cycle (luteal phase) may be prescribed progesterone supplements, to be taken for the first trimester of pregnancy.  Second trimester Second trimester losses may be due to uterine malformation, growths in the uterus (fibroids), or cervical problems. These conditions also may contribute to premature birth. One study found that 19% of second trimester losses were caused by problems with the umbilical cord. Problems with the placenta also may account for a significant number of later-term miscarriages.  A 32 years old (G2 P1A1) her 1st pregnancy was 28wks of gestation(PPROM) delivery, 2nd pregnancy was miscarriage at 20 weeks of gestation. Now she is at 18 weeks of gestation come to the maternity unit complaining of pelvic pressure and increase mucus discharge. She denies any uterine contraction. On pelvic examination cervical os is open and membrane is visible through speculum examination. She had previous history of cone biopsy for cervical intraepithelial neoplasia before her 1st pregnancy.  What is diagnosis? most common risk factor for this condition: How we can diagnose the condition? What is the management?  Risk factors Multiple pregnancy Pregnancies of more than one fetus, i.e. twins, triplets, etc., are considered at increased risk. Intercurrent diseases Several intercurrent diseases in pregnancy can potentially increase the risk of miscarriage, including:  Diabetes mellitus. prospective study found that the risk increased by 3.1% The risk was not found to be significantly increased in women with good controlled Diabetes mellitus; The risk of miscarriage is increased in women with poorly controlled insulin-glycaemic control in early pregnancy.  Polycystic ovary syndrome, which may increase the risk of miscarriage, but this is disputed. studies suggested treatment with the drug metformin significantly lowers the rate of miscarriage in women with PCOS.  Hypothyroidism; Severe cases of hypothyroidism increase the risk of miscarriage. The effect of milder cases of hypothyroidism on miscarriage rates has not been established. The presence of certain immune conditions such as autoimmune diseases is associated with a greatly increased risk. The presence of anti-thyroid autoantibodies is associated with an increased risk.  Autoimmune disease; Some research suggests autoimmunity as a possible cause of recurrent or late- term miscarriages. Autoimmune disease occurs when the body's own immune system acts against itself. Therefore, in the case of an autoimmune-induced miscarriages the woman's body attacks the growing fetus or prevents normal pregnancy progression. Vertically transmitted infections; Certain vertically transmitted infections (such as rubella and chlamydia) increase the risk.  Smoking Tobacco (cigarette) smokers have an increased risk of miscarriage. An increase in the rates also is associated with the father being a cigarette smoker. The husband study observed a 4% increased risk for husbands who smoke fewer than 20 cigarettes/day, and an 81% increased risk for husbands who smoke 20 or more cigarettes/day. Age The age of the mother is a significant risk factor. Miscarriage rates increase steadily with age, with more substantial increases after age 35.  Exercise A study of more than 92,000 pregnant women found that most types of exercise (with the exception of swimming) correlated with a higher risk of miscarrying prior to 18 weeks. Increasing time spent on exercise was associated with a greater risk.  Caffeine Caffeine consumption also has been correlated to miscarriage rates, at least at higher levels of intake. However, such higher rates have been found to be statistically significant only in certain circumstances.  Other Sexual intercourse during the first trimester has often been said or assumed by doctors to be a cause of miscarriage. However the association has never been proved or disproved. Loop electrosurgical excision procedure (LEEP) is one of the most commonly used approaches to treat high grade cervical dysplasia  Cocaine use increases the rates. Physical trauma, exposure to environmental toxins. use of an IUD during the time of conception have also been linked to increased risk. Antidepressants, especially paroxetine and venlafaxine, can lead to a miscarriage.  Diagnosis A miscarriage may be confirmed via obstetric ultrasound and by the examination of the passed tissue. Microscopically, these include villi, trophoblast, fetal parts, and background gestational changes in the endometrium. As many as half the embryos miscarried have a chromosomal abnormality. genetic testing ; When chromosomal abnormalities are found in more than one miscarriage, genetic testing of both parents may be done.  Classification Threatened miscarriage describes any bleeding seen during pregnancy prior to viability, that has yet to be assessed further. At investigation it may be found that the fetus remains viable and the pregnancy continues without further problems. Incomplete abortion , when part of fetus expelled out of uterus and other parts still is inside. Complete abortion, when all fetus is aborted.  An empty sac is a condition where the gestational sac develops normally, while the embryonic part of the pregnancy is either absent or stops growing very early. Other terms for this condition are blighted ovum and anembryonic pregnancy. An inevitable miscarriage describes a condition in which the cervix has already dilated open, but the fetus has yet to be expelled. This usually will progress to a complete miscarriage.  A missed miscarriage is when the embryo or fetus has died, but a miscarriage has not yet occurred. A septic miscarriage occurs when the tissue from a missed or incomplete miscarriage becomes infected. The infection of the uterus carries risk of spreading infection (septicaemia) and is a grave risk to the life of the woman. Recurrent pregnancy loss (RPL) or recurrent miscarriage is the occurrence of three consecutive miscarriages. A large majority (85%) of women who have had two miscarriages will conceive and carry normally afterward.  Prevention Prevention of miscarriage is mainly based on avoiding or mitigating any risk factors of it. Currently there is no known way to prevent an impending miscarriage. Identifying the cause of the miscarriage may help prevent it from happening again in a future pregnancy. In recurrent miscarriage, various tests are indicated to identify any underlying cause.  Management Bleeding during early pregnancy is the most common symptom of both impending miscarriage and ectopic pregnancy. Pain does not strongly correlate with the former, but is a common symptom of ectopic pregnancy. Typically, in the case of blood loss, pain, or both, transvaginal ultrasound is performed. If a viable intrauterine pregnancy is not found with ultrasound, serial βHCG tests should be performed to rule out ectopic pregnancy, which is a life-threatening situation.[  bed rest has been advocated in the past to help ensure that a threatened pregnancy might continue. There is no good evidence based that the use of Rho(D) immune globulin after a spontaneous miscarriage is needed and a Cochrane review recommends that local practices be followed. In the UK, Rho(D) immune globulin is recommended in Rh-ve women after 12 weeks gestational age and before 12 weeks gestational age in those who need surgery or medication to complete the miscarriage.  In cases of an incomplete miscarriage, empty sac, or missed abortion there are three treatment options: With no treatment (watchful waiting), most of these cases (65–80%) will pass naturally within two to six weeks.This path avoids the side effects and complications possible from medications and surgery, but increases the risk of mild bleeding, need for unplanned surgical treatment, and incomplete miscarriage. Medical management usually consists of using misoprostol (a prostaglandin, brand name Cytotec) to encourage completion of the natural process. About 95% of cases treated with misoprostol will complete within a few days. Vacuum aspiration, sometimes referred to as dilation and evacuation (D&E), uses aspiration to remove uterine contents through the cervix.  In cases of repeated spontaneous abortions, D&C is also the most convenient way to obtain tissue samples for karyotype analysis (cytogenetic or molecular), although it is also possible to do with expectant and medical management, including the following techniques:Surgical treatment is the fastest way to complete the process. It also shortens the duration and heaviness of bleeding, and avoids the physical pain  Dilation and curettage (D&C), which involves dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping (curettage). D&C has a higher risk of complications compared to non- surgical treatment, including risk of injury to the cervix (e.g. cervical incompetence) and uterus, perforation of the uterus, and potential scarring of the intrauterine lining (Asherman's syndrome). This is an important consideration for women who would like to have children in the future and want to preserve their fertility and reduce the chance of future pregnancy complications.  In missed abortion; Gestational sac greater than 30-35mm, embryo larger than ~25mm (corresponding to 9+0 weeks of gestational age): Surgery is recommended. It poses a high risk of pain and bleeding with passage of products of conception. Alternative methods may still be considered. Gestational sac 15-35mm, embryo smaller than 25mm (corresponding to between 7 and 9+0 weeks of gestational age): Medication is recommended. Surgery or expectant management may be considered. Gestational sac smaller than 15-20mm, corresponding to a gestational age of less than 7 weeks: Expectant management or medication is preferable. The products of conception may be difficult to find surgically with a considerable risk of failed surgical procedure. In 2nd trimester – medical termination is recommended.  Incomplete miscarriage; Retained products of conception smaller than 15mm: Expectant management is generally preferable. There is a high chance of spontaneous expulsion. Retained products of conception measuring between 15 and 20mm: Medical or expectant management are recommended. Surgery should only be considered upon specific indication.  At retained products of conception measuring over 35 to 50mm, the following measures are recommended: Administration of misoprostol to hasten passage of products of conception. Admission to inpatient care for observation for a few hours or overnight until the majority of the products of conception has passed and bleeding subsided. After apparent failure of misoprostol, a gynecologic examination should be done prior to considering surgical evacuation of the uterus or the patient leaving the hospital. Ectopic pregnancy  objective What are types of ectopic pregnancy? What are risk factor for increase incidence of ectopic pregnancy? How we can diagnose and treat the condition?  A 28 years old patient visit an emergency department complaining of unilateral left-sided abdominal pain and vagina bleeding (spotting) of 3 days duration , her last menstrual period was 8 weeks ago and she has 28 days regular cycle. She had previous a live normal term vaginal delivery, and she used intrauterine contraception device for 3 years ago. On pelvic exa. Uterus is slightly enlarged and there is left adnexal tenderness but no palpable mass, B- HCG value is 1200mIU. What is this differential diagnosis? What are risk factor? How we can diagnose and treat the condition?  An ectopic pregnancy, is an embryonic implantation outside the uterine cavity. Furthermore, they are dangerous for the mother, since internal haemorrhage is a life-threatening complication. Most ectopic pregnancies occur in the Fallopian tube (so- called tubal pregnancies 98%), but implantation can also occur in the cervix, ovaries, and abdomen. An ectopic pregnancy is a potential medical emergency, and, if not treated properly, can lead to death. In a normal pregnancy, the fertilized egg enters the uterus and settles into the uterine lining where it has plenty of room to divide and grow.  In a typical ectopic pregnancy, the embryo adheres to the lining of the fallopian tube and burrows into the tubal lining. Most commonly this invades vessels and will cause bleeding. This intratubal bleeding hematosalpinx expels the implantation out of the tubal end as a tubal abortion. The pain is caused by prostaglandins released at the implantation site, and by free blood in the peritoneal cavity, which is a local irritant. Sometimes the bleeding might be heavy enough to threaten the health or life of the woman. Usually this degree of bleeding is due to delay in diagnosis, but sometimes, especially if the implantation is in the proximal tube (just before it enters the uterus), it may invade into the nearby Sampson artery, causing heavy bleeding earlier than usual. If left untreated, about half of ectopic pregnancies will resolve without treatment. These are the tubal abortions. The advent of methotrexate treatment for ectopic pregnancy has reduced the need for surgery; however, surgical intervention is still required in cases where the Fallopian tube has ruptured or is in danger of doing so. This intervention may be laparoscopic or laparotomy.  Classification Tubal pregnancy The vast majority of ectopic pregnancies implant in the Fallopian tube. Pregnancies can grow in the fimbrial end (5% of all ectopic pregnancies), the ampullary section (80%), the isthmus (12%), and the cornual and interstitial part of the tube (2%). Mortality of a tubal pregnancy at the isthmus or within the uterus (interstitial pregnancy) is higher as there is increased vascularity that may result more likely in sudden major internal hemorrhage.  Nontubal ectopic pregnancy Two percent of ectopic pregnancies occur in the ovary, cervix, or are intra abdominal. Transvaginal ultrasound examination is usually able to detect a cervical pregnancy.  While a fetus of ectopic pregnancy is typically not viable, very rarely, a live baby has been delivered from an abdominal pregnancy. In such a situation the placenta sits on the intraabdominal organs or the peritoneum and has found sufficient blood supply. This is generally bowel or mesentery, but other sites, such as the renal (kidney), liver or hepatic (liver) artery or even aorta have been described. Support to near viability has occasionally been described, but even in third world countries, the diagnosis is most commonly made at 16 to 20 weeks gestation. Such a fetus would have to be delivered by laparotomy. Maternal morbidity and mortality from extrauterine pregnancy are high as attempts to remove the placenta from the organs to which it is attached usually lead to uncontrollable bleeding from the attachment site. If the organ to which the placenta is attached is removable, such as a section of bowel, then the placenta should be removed together with that organ.  Heterotopic pregnancy In rare cases of ectopic pregnancy, there may be two fertilized eggs, one outside the uterus and the other inside. This is called a heterotopic pregnancy. Often the intrauterine pregnancy is discovered later than the ectopic, mainly because of the painful emergency nature of ectopic pregnancies. Since ectopic pregnancies are normally discovered and removed very early in the pregnancy, an ultrasound may not find the additional pregnancy inside the uterus. When hCG levels continue to rise after the removal of the ectopic pregnancy, there is the chance that a pregnancy inside the uterus is still viable. This is normally discovered through an ultrasound. Although rare, heterotopic pregnancies are becoming more common, likely due to increased use of IVF. The survival rate of the uterine fetus of an ectopic pregnancy is around 70%  Signs and symptoms Early symptoms are either absent or subtle. Clinical presentation of ectopic pregnancy occurs at a mean of 7.2 weeks after the last normal menstrual period, with a range of 4 to 8 weeks. Early signs include: Pain in the lower abdomen, and inflammation (pain may be confused with a strong stomach pain, it may also feel like a strong cramp). Pain while urinating.  Pain and discomfort, usually mild. A corpus luteum on the ovary in a normal pregnancy may give very similar symptoms. Vaginal bleeding, usually mild.. Pain while having a bowel movement.  Patients with a late ectopic pregnancy typically experience pain and bleeding. This bleeding will be both vaginal and internal and has two discrete pathophysiologic mechanisms: External bleeding is due to the falling progesterone levels. Internal bleeding (hematoperitoneum) is due to hemorrhage from the affected tube. The differential diagnosis at this point is between miscarriage, ectopic pregnancy, and early normal pregnancy. The presence of a positive pregnancy test virtually rules out pelvic infection as it is rare indeed to find pregnancy with an active pelvic inflammatory disease (PID). The most common misdiagnosis assigned to early ectopic pregnancy is PID.  More severe internal bleeding may cause: Lower back, abdominal, or pelvic pain. Shoulder pain. This is caused by free blood tracking up the abdominal cavity and irritating the diaphragm, and is an ominous sign. There may be cramping or even tenderness on one side of the pelvis.  Ectopic pregnancy can mimic symptoms of other diseases such as appendicitis, other gastrointestinal disorder, problems of the urinary system, as well as pelvic inflammatory disease and other gynaecologic problems.  Causes There are a number of risk factors for ectopic pregnancies. However, in as many as one third to one half no risk factors can be identified. Risk factors include: pelvic inflammatory disease, infertility, use of an intrauterine device (IUD), previous exposure to DES, tubal surgery, intrauterine surgery (e.g. D&C), smoking, previous ectopic pregnancy, and tubal ligation.  Cilial damage and tube occlusion Hair-like cilia located on the internal surface of the Fallopian tubes carry the fertilized egg to the uterus. Women with pelvic inflammatory disease (PID) have a high occurrence of ectopic pregnancy. This results from the build-up of scar tissue in the Fallopian tubes, causing damage to cilia. Tubal surgery for damaged tubes might increase the risk of ectopic pregnancy Intrauterine adhesions (IUA) present in Asherman's syndrome can cause ectopic cervical pregnancy or, if adhesions partially block access to the tubes via the ostia, ectopic tubal pregnancy..]  Reversal of tubal sterilization (Tubal reversal) carries a risk for ectopic pregnancy. This is higher if more destructive methods of tubal ligation (tubal cautery, partial removal of the tubes) have been used than less destructive methods (tubal clipping). A history of a tubal pregnancy increases the risk of future occurrences to about 10%. This risk is not reduced by removing the affected tube.  Other smoking is associated with ectopic risk. Vaginal douching is thought by some to increase ectopic pregnancies. Women exposed to diethylstilbestrol (DES) in utero (also known as "DES daughters") also have an elevated risk of ectopic pregnancy, up to 3 times the risk of unexposed women It has also been suggested that pathologic generation of nitric oxide through increased iNOS production may decrease tubal ciliary beats and smooth muscle contractions and thus affect embryo transport, which may consequently result in ectopic pregnancy. The low socioeconomic status may be risk factors for ectopic pregnancy.  Diagnosis An ectopic pregnancy should be considered as the cause of abdominal pain or vaginal bleeding in every woman who has a positive pregnancy test. An ultrasound showing a gestational sac with fetal heart in the fallopian tube is clear evidence of ectopic pregnancy.  An abnormal rise in blood -human chorionic gonadotropin (β- hCG) levels may indicate an ectopic pregnancy. While some physicians consider that the threshold of discrimination of intrauterine pregnancy is around 1500 IU/ml of β-hCG, Instead, the best test in a pregnant women is a high resolution, transvaginal ultrasound. The presence of an adnexal mass in the absence of an intrauterine pregnancy on transvaginal sonography increases the likelihood of an ectopic pregnancy 100-fold. An empty uterus with levels higher than 1500 IU/ml may be evidence of an ectopic pregnancy, but may also be consistent with an intrauterine pregnancy which is simply too small to be seen on ultrasound. If the diagnosis is uncertain, it may be necessary to wait a few days and repeat the blood work. This can be done by measuring the β-hCG level approximately 48 hours later and repeating the ultrasound. The serum hCG ratios and logistic regression models appear to be better than absolute single serum hCG level. If the β-hCG falls on repeat examination, this strongly suggests a spontaneous abortion or rupture.  An ectopic pregnancy as seen on ultrasound A laparoscopy or laparotomy can also be performed to visually confirm an ectopic pregnancy. Often if a tubal abortion or tubal rupture has occurred, it is difficult to find the pregnancy tissue. A laparoscopy in very early ectopic pregnancy rarely shows a normal looking fallopian tube. Culdocentesis, in which fluid is retrieved from the space separating the vagina and rectum, is a less commonly performed test that may be used to look for internal bleeding. In this test, a needle is inserted into the space at the very top of the vagina, behind the uterus and in front of the rectum. Any blood or fluid found may have been derived from a ruptured ectopic pregnancy.  Treatment Medical Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment since at least 1993. If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; this may cause an abortion, or the developing embryo may then be either resorbed by the woman's body or pass with a menstrual period. Contraindications include liver, kidney, or blood disease, as well as an ectopic embryonic mass > 3.5 cm. Surgical If hemorrhage has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound  Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883. Although extremely rare, there have also been at least two successful cases of transplation of the fetus into the womb. Both of these cases reportedly resulted in live births; therefore, it may not always be necessary to terminate the pregnancy. However, this has been rarely attempted, as there is much greater risk to the life of the mother, and it is only possible in very early stages of pregnancy. Gestational trophoblastic disease  objective What is the definition and types of hydatidform mole? How we can treat and follow up the condition? What is the role of chemotherapy in treatment of Hydatidiform mole  Gestational trophoblastic disease (GTD) is a term used for a group of pregnancy-related tumors. These tumours are rare,The cells that form gestational trophoblastic tumours are called trophoblasts and come from tissue that grows to form the placenta during pregnancy.  Types GTD is the common name for five closely related tumors (one benign tumor, and four malignant tumours) The benign tumor Hydatidiform mole Its characterized by abnormal prolifration of the placental trophoblastic cells. There are two subtypes of hydatidiform mole: complete hydatidiform mole, and partial hydatidiform mole.  Difference between molar pregnancy Complete hydatidiform moles have no fetal tissue and no maternal DNA. A single sperm duplicates and this duplicated sperms fertilize an empty ovum, or, two sperms fertilize an empty ovum (dispermic fertilisation). An empty ovum is a maternal egg which has no functional maternal DNA. Karyotype xx or xy. Partial hydatidiform moles have a fetus or fetal cells. They are triploid in origin, i.e. one set of maternal haploid genes and two sets of paternal haploid genes. They almost always occur following dispermic fertilisation of a normal ovum (fertilisation of one egg by two sperm). Karyotype 69xxx or xxy Malignant forms of GTD are very rare. About 50% of malignant forms of GTD develop from a hydatidiform mole.  The four malignant tumors Invasive mole Choriocarcinoma Placental site trophoblastic tumor Epithelioid trophoblastic tumor All five closely related tumors develop in the placenta. All five tumors arise from trophoblastic cells. The trophoblast is the membrane that forms the wall of the blastocyst in the early development of the fetus. In a normal pregnancy, trophoblastic cells aid the implantation of the fertilised egg into the uterine wall. But in GTD, they develop into tumor cells.  Risk Factors Two main risk factors increase the likelihood for the development of GTD: 1) The woman being under 20 years of age, or over 35 years of age. 2) previous GTD. Although molar pregnancies affect women of all ages, women under 16 years of age have a six times higher risk of developing a molar pregnancy than those aged 16–40 years, and women> 40 years of age or older have a 5-10% increase in the risk of having a molar pregnancy. Being from Asia/of Asian ethnicity is an important risk factor. The ABO blood groups of the parents appear to be a factor in choriocarcinoma development, i.e. women with blood group A have been shown to have a greater risk than blood group O women.  Diagnosis Cases of GTD can be diagnosed through routine tests given during pregnancy, such as blood tests and ultrasound, or through tests done after miscarriage or abortion. But GTD also leads to elevated serum hCG (human chorionic gonadotropin hormone). Since pregnancy is by far the most common cause of elevated serum hCG, clinicians generally first suspect a pregnancy with a complication. However, in GTD, the beta subunit of hCG (beta hCG) is also always elevated. Therefore, if GTD is clinically suspected, serum beta hCG is also measured. Vaginal bleeding, enlarged uterus, pelvic pain or discomfort, and vomiting too much (hyperemesis) are the most common symptoms of GTD. The initial clinical diagnosis of GTD should be confirmed histologically, which can be done after the evacuation of pregnancy However, malignant GTD is highly vascular. If malignant GTD is suspected clinically, biopsy is contraindicated, because biopsy may cause life threatening haemorrhage.  Treatment The treatment for hydatidiform mole consists of the evacuation of pregnancy. Evacuation will lead to the relief of symptoms, and also prevent later complications. Suction curettage is the preferred method of evacuation. Hysterectomy is an alternative if no further pregnancies are wished for by the female patient. The treatment for invasive mole or choriocarcinoma generally is the same. Both are usually treated with chemotherapy. Methotrexate and actinomycin D are among the chemotherapy drugs used in GTD. Only a few women with GTD suffer from poor prognosis metastatic gestational trophoblastic disease. Their treatment usually includes chemotherapy. Radiotherapy can also be given to places where the cancer has spread, e.g. the brain. Women who undergo chemotherapy are advised not to conceive for one year after completion of treatment. These women also are likely to have an earlier menopause. It has been estimated by the Royal College of Obstetricians and Gynaecologists that the age at menopause for women who receive single agent chemotherapy is advanced by 1 year, and by 3 years for women who receive multi agent chemotherapy  Follow up Follow up is necessary in all women with gestational trophoblastic disease, because of the possibility of persistent disease, or because of the risk of developing malignant uterine invasion or malignant metastatic disease even after treatment in some women with certain risk factors. The use of a reliable contraception method is very important during the entire follow up period, because the follow-up depends on measuring hCG. If a reliable contraception method is not used during the follow-up, there can be great confusion if hCG rises: Why did it rise? Because the patient became pregnant again? Or because the gestational trophoblastic disease is still present? Therefore, during the prescribed follow up period, the patients must not become pregnant.  In women who have a malignant form of GTD, hCG concentrations stay the same (plateau) or they rise. Persistent elevation of serum hCG levels after a non molar pregnancy (i.e., normal pregnancy [term pregnancy], or preterm pregnancy, or ectopic pregnancy always indicate persistent GTD (very frequently due to choriocarcinoma or placental site trophoblastic tumour), but this is not common, because treatment mostly is successful.  Prognosis and staging Women with a hydatidiform mole have an excellent prognosis. Also women with a malignant form of GTD usually have a very good prognosis. Choriocarcinoma, for example, is an uncommon, yet almost always curable cancer. Although choriocarcinoma is a highly malignant tumour and a life threatening disease, it is very sensitive to chemotherapy. Virtually all women with non-metastatic disease are cured and retain their fertility; the prognosis is also very good for those with metastatic (spreading) cancer, in the early stages, but fertility may be lost. Hysterectomy (surgical removal of the uterus) can also be offere to patients > 40 years of age or those for whom sterilisation is not an obstacle. Only a few women with GTD have a poor prognosis, e.g. some forms of stage IV GTN. The FIGO staging system is used. The risk can be estimated by scoring systems such as the Modified WHO Prognostic Scoring System, where in scores between 1 and 4 from various parameters are summed together:  Modified WHO Prognostic Scoring System 0 1 2 4 Age