APGO Educational Objectives:

Gestational trophoblastic disease, relatively uncommon in the United States, is important because of its malignant potential and the risk of mortality from infection and hemorrhage.

The student will be able to demonstrate knowledge of the:

1. symptoms and physical findings suggestive of the disease
2. methods used to confirm the diagnosis
3. approach to the management and follow-up of patients

Recommended Reading Assignment:

1. Gestational Trophoblastic Disease, Chapter 42 Obstetrics and Gynecology, 3rd Edition, Beckmann, et al, pp. 490-498, 1998

Questions:

1. What is the differential diagnosis for this patient? What laboratory or radiographic tests should be obtained to aid in your diagnosis of this patient's disease?

The patient's pretreatment quantitative ÿ-HCG was 64,000 mIU/ml. Her titer dropped on a weekly basis to 400 mIU/ml. At eight weeks post-evacuation her titer began to rise and was 1230 mIU/ml.

2. What risk factors, if any, does this patient have for gestational trophoblastic disease? Describe your management of this patient, including follow up and your recommendations to the patient regarding possibility for recurrence with subsequent pregnancies.
3. Describe the work up that should be undertaken in this patient at the present time.
4. If the patient's chest x-ray reveals multiple metastatic nodules, what is the patient's clinical classification? If her chest x-ray and metastatic work up are negative for metastatic disease, what is her clinical classification? What factors does the World Health Organization's prognostic scoring system for gestational trophoblastic disease take into account?
5. What type of therapy would you initiate for this patient at the present time?