妊娠滋養(yǎng)細(xì)胞疾?。▼D產(chǎn)科）

GestationaltrophoblasticDiseaseGTD醫(yī)院婦產(chǎn)科妊娠滋養(yǎng)細(xì)胞疾病葡萄胎(hydatidiformmole)侵蝕性葡萄胎(invasivemole)絨毛膜癌

(choriocarcinoma)胎盤部位滋養(yǎng)細(xì)胞腫瘤

(placentalsitetrophoblastictumor,PSTT)葡萄胎

60%，流產(chǎn)30%、足月妊娠+異位妊娠10%10%-20%妊娠滋養(yǎng)細(xì)胞疾病

(gestationaltrophoblasticdisease,GTD)妊娠滋養(yǎng)細(xì)胞腫瘤（gestationaltrophoblasticneoplasia，GTN）臨床分類組織學(xué)分類2HydatidiformMole

[Definition]

anabnormalpregnancycharacterizedgrosslybymultiplegrapelikevesiclesfillinganddistendingtheuterus,proliferationofsyncytiotrophoblasticorcytotrophoblasticelement,edemaofthevillousstroma.3[Classification]

completehydatidiformmole,CHM(morecommon)

partialhydatidiformmole,PHMAIIarebenigndisease.HydatidiformMole4Epidemiology

Theincidencevariesgreatlybetweendifferentpartsoftheworld.TheincidencefromEuropeandNorthAmericaissignificantlylowerthanAsiaandSouthAmerica.morbidity:290/100,0000.78/1000pregnancyinourcountryHighrisk:<20yearsofage,or>40yearsoldLackofcarotineandanimalfat5

EtiologyRaceandregiondifferencemalnutrition:lackoffolicacid,lackofcarotinevirusinfectionhydatidiformmolehistoryendocrinedyscrasia：lackofestrogendefectoffertilizedeggimmunologyfactor:humanleucocyteantigen(HLA)6Cellchromosomemutation:

completmole:diploid,enucleateeggfertilization,90%is46XX,10%is46XY

incompletemole:triploid,formedbythefertilizationofamonoploideggandtwomonoploidsperm,orbyamonoploidegg(sperm)andameioticdeficiencysperm(egg),mostis69XXY,andthenis69XXXor69XYY.

Etiology7Macroscopy：grapelikevesiclesMicroscopy：

?trophocytehyperplasia

edemaofvillousstroma

stromalvascularabsentorrare

Pathology8

CompletemoleincompletemoleEmbryoticorfetaltissue

-

+VillusstromaledemadiffusedlocalizedTrophoblastichyperplasiadiffusedlocalizedVillusoutlineregularirregularVillusstromalbloodvessel-

+Karyotypetetraploiddiploidtriploid9Hydatidiformmole101112

vaginalbleeding:mostoccur2-4monthsafterpostponemenstruation

vomitting

abdominalpain

pregnancy-inducedhypertensionsyndrome

hyperthyroidism

Symptoms13

abnormalenlargeduterus,soft,nofetusheartbeat,movement,andbody

theca

luteinovariancyst(卵巢黃素化囊腫)

Physicalexamination14ＨCGisanidealtumormarkerofgestationaltrophoblastictumorＨCGαchainsimilartoLH、FSH、TSHβchainspecificity

InmoletheHCGisover100,000iu/L,evenover1,000,000iu/L

Laboratoryexamination15

Animportantaccessorydiagnosingmethodhoneycombsign,"snowstorm"pattern.

normalgestationalsacorfetusisnotpresent

luteininzingcyst

ultrasoundcharacteristic?16Differentdiagnosis

vaginalpregnantuterusHCGultrasoundbleedingtestsizeabortion++=gestationalagelowerembryobigeminal-+>gestationalagehigherbigeminal

polyhydramnios-+late>normalnormalAFIhydatidiform+++>gestationalagesnowstorm171.Emptyinguterinecavitytheuterinecavityshouldbeemptiedassoonaspossiblea.uterineaspirationandcurettageb.applicationofoxytocinduringoperationc.indicationofthesecondcurettage(>12week)2.Hysterectomya.over40yearsoldwithhigh-riskfactorsb.uterinesizeisover14gestationalweeks3.managementofluteinizingcystTreatment18themalignantchangerateis14.5%Highriskfactor1.over40yearsold2.theβ-HCGisover100kIU/Lbeforeemptyingmole3.theHCGregressioncurveisnotprogressivelydeclined4.uterusisobviouslylargerthanthesizeoftheamenorrhea5.luteinizingcystis>6cm6.hyperplasiaoftrophoblasticcellsinthesecondcurettage7.repeatedmolePreventivechemotherapy19

Afterhydatidiformmoledischarge，HCGonceaweek

Normalfor

3timeslateronceamonth

halfayearlaterhalfayear

2ndyear

halfayear

2yearssymptom:cough,irregularbleeding,hemoptysisX-ray,ultrasoundscanningContraception:condom,OCPIUDisnotrecommended.?Followup?20Invasivemole

侵蝕性葡萄胎

21Amolewhichhaveinvadedtheuterinemyometriumormetastasizetoextrauterinetissue.Itcomesfromahydatidiformmole,commonlyoccurs6monthsafterhydatidiformmoleclearance.Definition22PathologyMacroscopy:watervacuoletissue，bloodclot，necrotictissueMicroscopy:

--villusstructure，orvillusnecroticshadow--trophocytehyperplasiaindifferentdegree--absenceofstromalvascular--pathplogyoflungandvaginalmetastasisaresimilartoprimarylesion23Diagnosis

continousvaginalbleeding

postponeofuterusrecovery

existenceofluteininzingcystofovary

abdominalpainorintra-abdominalhemorrhage

metastasissignoflung,brain,vagina,liver24

HCGtest：--serumHCGpersisthigherthannormalfor3weeksevenlonger--serumHCGgoesupfor2weeksevenlonger--serumHCGisabnormalformorethan6months.

laboratoryexamination25ultrasound：uterusmyometriuminvasive

histologicaldiagnosis：vilistructure26Choriocarcinom

絨癌

絨癌a27Choriconomaistrophoblastictumorsecondarytonormalandabnormalpregnancy,which60%afterhydatidiform(generallyoccursover1yearafteremptyingthemole),30%afterabortion,10%aftertermpregnancyandectopicpregnancy.highmalignancy28PathologyMacroscopy:blueandpurpleprominentonsurface，madderredoncrosssection，withbleeding、necrosis、infection

Microscopy:novillusstructure，tumortissuearrangedisorderly，hyperplastictrophocyteinvademyometriumandvessels29metastasisviavesselmainly

earlylung(80%)characteristicwidelyvagina,pelvic,brain,liver

30--irregularvaginalbleeding--vaginalsecretion--abdominalpain--pelvicmass--metastasismanifestationDiagnosis31labor