Week 8

Question 1

Pelvic Organ Prolapse
- Definition: Partial vs. Total?
- 3 Components of the endopelvic fascia?
- Layers of the pelvic floor?

Answer 1

Definition: herniation into or descent of pelvic organs to or beyond the vaginal walls
- Partial/subtotal prolapse: pelvic organs are only partially outside the vaginal opening.
- Total prolapse: pelvic organs are everted and located outside of the vaginal opening.

Anatomical overview: The pelvic floor is supported by a continuous endopelvic fascia, which consists of:
1. Uterosacral ligament complex (suspends the uterus and vaginal apex from the sacrum and lateral pelvis)
2. Paravaginal attachments
3. Perineal body, perineal membrane, and the perineal muscles

Question 2

Pelvic Organ Prolapse
- 5 Specific Sites/Types?

Answer 2

Types of pelvic organ prolapse
1. Apical compartment prolapse (uterine prolapse, vaginal vault prolapse): herniated vaginal apex (uterus and cervix, cervix alone, or vaginal vault) into the lower vagina, hymen, or beyond the vaginal introitus.
2. Posterior compartment prolapse: herniated posterior vaginal segment, often associated with rectocele (descent of the rectum) or enterocele (herniated section of the intestines).
3. Anterior compartment prolapse: herniated anterior vaginal wall, which is often associated with a cystocele (descent of the bladder) or urethrocele (descent of the urethra)

Question 3

Describe 12 risk factors associated with uterovaginal prolapse.

Answer 3

Aetiology: insufficiency of the pelvic floor muscles and the ligamentous supportive structure of the uterus and vagina.
- These include a network of levator muscles and ligaments (endopelvic fascia).

Question 4

Describe the symptoms in relation to sexual function, bowel function and urinary function as they relate to uterovaginal prolapse.
- 5 Clinical Features?

Answer 4

Clinical features
1. Feeling of pressure on or discomfort around the perineum (“sensation of vaginal fullness”)
2. Lower back and pelvic pain (may become worse with prolonged standing or walking)
3. Rectal fullness, constipation, incomplete rectal emptying
4. Prolapse of the anterior (most common) or the posterior vaginal wall - Occurs at rest and with increased abdominal pressure. Possibly with excessive vaginal discharge on inspection, bimanual examination, and speculum examination of the patient in lithotomy position.
5. Weakened pelvic floor muscle and anal sphincter tone

Question 5

Outline the Pelvic Organ Prolapse Quantification system?

Answer 5

POP is usually a clinical diagnosis that relies on the Pelvic Organ Prolapse Quantification system (POP-Q):
- Stage 0: no prolapse
- Stage 1: The most distal portion of prolapse is more than 1 cm above the level of the hymen.
- Stage 2: The most distal portion of prolapse is 1 cm or less proximal or distal to the hymenal plane.
- Stage 3: The most distal portion of prolapse is more than 1 cm from the hymenal plane but no more than 2 cm less than the vaginal length.
- Stage 4: The vagina is completely everted or uterine procidentia has occurred.

Question 6

Explain in detail the investigations and examination of the patient with uterovaginal prolapse.
- 11 points?

Answer 6

Question 7

Explain the broad conservative approach versus the broad surgical approach to uterovaginal prolapse.

Answer 7

Question 8

Explain the following types of Urinary Incontinence:
- Stress Incontinence?
- Urge Incontinence (Overactive Bladder)?
- Overflow Incontinence / Voiding dysfunction?
- Continual Incontinence?

Answer 8

Question 9

What questions will you ask a woman with urinary incontinence to distinguish between the 4 different types?

Answer 9

HISTORY - General
A woman presenting with a complaint of urinary incontinence requires careful examination. The social inconvenience caused by the incontinence should be evaluated. The woman should be asked if she is taking any medications, as some drugs may cause symptoms of urinary incontinence. General medical conditions, such as parkinsonism, Multiple sclerosis and diabetic neuropathy, must be looked for and excluded, as should local bladder causes, such as bladder stone or pressure on the bladder from a myoma.

Question 10

What will you look for on examination of a woman presenting with urinary incontinence depending on the different types?

Answer 10

Question 11

What 8 tests will you order for a woman presenting with urinary incontinence?
- What are Urodynamic Studies?

Answer 11

What tests to order
1. All patients presenting with a complaint of incontinence require Urinalysis and Culture.
2. Further investigations may be required to dispel doubt about the diagnosis or to exclude intravesical or kidney disorders; these include
3. Cystometry
4. Uroflowmetry
5. Cysto-urethroscopy
6. Micturating cystourogram
7. Intravenous Urogram
8. An assessment of post-micturition volume should be made, either by post-micturition ultrasound or catherterisation (>100mL is abnormal)

Question 12

What will urodynamic studies look like for the different types of urinary incontinence?

Answer 12

Question 13

What treatments are available for Stress Urinary Incontinence? How successful are they?

Answer 13

Stress Incontinence - Treatment Success
Physical therapy and medical treatment measures effectively relieve urinary sphincter incontinence in up to 60% of affected women. With surgical treatment, the available operations have similar success rates of over 90% in the immediate post-operative years, long term studies available, vary between 75% - 85% of women who are still continent 6-8 yrs after the operation, with 15-20% having detrussor instability.

Question 14

What treatments are available for Urge Urinary Incontinence? How successful are they?

Answer 14

Urge Incontinence - Treatment Success
Bladder retraining programmes for urge incontinence have a success rate of 80-90% when used alone or along with anticholinergics and TCA. Adrenergic agents, such as phenylpropanolamine, are sometimes used with studies suggesting they are more effective than placebo, but a definitive treatment still appears to be lacking.

Question 15

What treatments are available for Overflow / Voiding Dysfunction Incontinence?

Answer 15

Question 16

Why do treatments for Urinary incontence fail?
- What are 6 Risk factors for possible sling failure?
- 4 Complications of Sling insertion for urinary incontinence?

Answer 16

• Treatment failures can arise from a number of problems, including technical problems with the sling placement, or from patient- oriented factors such as persistently high intra-abdominal pressures (obesity) or poor urethral tissue quality (radiation, aging). Technical problems with the surgery include sling laxity, poor sling placement (either proximal to the bladder neck or too distally near the meatus), or sling placement into the urethra, which can sometimes lead to simultaneous recurrent stress incontinence and obstructive/irritative symptoms.
• The first steps in management in the patient with treatment failure is a vaginal exam and cystoscopic evaluation to rule out a major complication (perforation or erosion) and urodynamic evaluation to objectively define the patient’s current voiding pattern as best as possible.

Question 17

UTEROVAGINAL PROLAPSE
- Definition?
- Incidence?
- Types?
- Grading system?

Answer 17

Definition
- Prolapse - A protrusion of an organ or structure beyond its normal confines.
- Pelvic organ prolapse – one or more pelvic organs drop or prolapse into the vagina due to weakened muscles, ligaments and/or fascia, which fail to hold the organs in their correct positions.

Incidence
- Common; ~1 in 3 multiparous women
- Women’s Health Initiative findings: 41% of women aged 50 to 79 years had pelvic organ prolapse: cystocele (34%), rectocele (19%), and uterine prolapse (14%). Only 10% to 20% of women will seek help for their problem.

Question 18

UTEROVAGINAL PROLAPSE
- Pathophysiology?
- 9 Risk factors?

Answer 18

Pathophysiology
- Predominantly a disorder of parous women whereby there is damage to the musculature, ligaments, and nerves.
- Decline of normal levator ani tone by direct muscle trauma or a denervation injury may occur during vaginal delivery, which results in an open urogenital hiatus and changes to the horizontal orientation of the levator plate, which causes a prolapse
- Endopelvic fascia – supports and connects pelvic organs to musculature and pelvic bones. Disruption or stretching of these connective tissue (CT) attachments happens during vaginal delivery or hysterectomy (by any route), as a consequence of chronic straining, altered CT metabolism or as part of normal ageing.

Question 19

UTEROVAGINAL PROLAPSE
- What to elicit on history?

Answer 19

Question 20

UTEROVAGINAL PROLAPSE
- Physical Examination?

Answer 20

Question 21

UTEROVAGINAL PROLAPSE - Treatment
- Conservative?
- Surgical?

Answer 21

Treatment
- Depends on severity of symptoms
- If asymptomatic – pelvic floor exercise + monitor

Question 22

List 7 Complications of Surgical treatment of Uterovaginal prolapse?
Why do they fail?

Answer 22

Complications
1. Dyspareunia after posterior repair
2. Post-repair urinary incontinence
3. Faecal incontinence after posterior repair
4. Vaginal erosion
5. Urinary retention
6. Post-repair recurrent prolapse
7. Mesh erosion

Question 23

A 75 year old woman with a minor degree of cystocoele gives a confusing history of recurrent urinary incontinence, sometimes associated with coughing and laughing but often because she “can’t make it to the lavatory in time”. How would you differentiate the major mechanism of her symptom? Consider history, examination and special tests. How would you manage her? What are the major treatment options?

Answer 23

The 75-year-old woman’s urinary symptoms are suggestive of both stress urinary incontinence and urgency urinary incontinence. To differentiate between these mechanisms and formulate an appropriate management plan, a thorough assessment including history, examination, and special tests would be necessary.

Differentiating Mechanism:
To differentiate between SUI and UUI, the patient’s history can provide clues:
- If the leakage occurs mainly during activities that increase intra-abdominal pressure (coughing, laughing), it’s likely stress urinary incontinence.
- If the leakage is associated with a strong, sudden urge to urinate and occurs even when the bladder isn’t full, it’s likely urgency urinary incontinence.

Question 24

A 56 year old woman whose menopause occurred at 50 years and who has not received oestrogen therapy has noted urinary urgency becoming progressively worse over the last year. How should she be investigated (5) and treated? (8)

Answer 24

The 56-year-old woman’s symptoms of worsening urinary urgency could be indicative of urgency urinary incontinence (UUI) or overactive bladder (OAB). Given her age and the onset of symptoms after menopause, hormonal changes and the potential impact on the pelvic floor muscles should also be considered.

Question 25

A 70 year old woman has recently been commenced on medication for her hypertension. She has had urinary incontinence since then. What 6 groups of drugs are associated with altered urinary function? What can be done to help her? (5 management points)

Answer 25

Urinary retention has been described with the use of drugs with anticholinergic activity (e.g. antipsychotic drugs, antidepressant agents and anticholinergic respiratory agents), opioids and anaesthetics, alpha-adrenoceptor agonists, benzodiazepines, NSAIDs, detrusor relaxants and calcium channel antagonists.

Question 26

An 18 year old woman in her first pregnancy, presents to your office at 34 weeks with amenorrhoea. On examination you measure the symphysial-fundal height to be 28 centimetres. She was observed to be smoking outside your waiting room. What further clinical history would assist in assessing this case? What investigations could be helpful? (3) How would you manage her? What advice should she be given?

Answer 26

**Investigations:** 1. **Ultrasound**: A detailed ultrasound can provide accurate information about fetal growth, amniotic fluid levels, placental position, and other factors affecting pregnancy. 2. **Non-Stress Test (NST) or Biophysical Profile (BPP): **These tests can assess fetal well-being by monitoring fetal heart rate and evaluating fetal movements, breathing, and amniotic fluid volume. 3. **Doppler Flow Study**: A Doppler study of the umbilical artery can assess blood flow to the fetus and placenta.

Question 27

What are the possible causes for intra-uterine growth restriction? How can they be diagnosed antenatally? What do the terms symmetric and asymmetric growth restriction refer to? How can the risk of asphyxia or death for a “small for dates” fetus be monitored?

Answer 27

**Diagnosing IUGR Antenatally:** 1. **Ultrasound**: Regular ultrasounds help monitor fetal growth and assess the estimated fetal weight and measurements. 2. **Doppler Flow Studies**: These assess blood flow through the umbilical cord and other fetal vessels, giving insights into placental function. 3. **Maternal Blood Tests**: These might include monitoring the mother's blood pressure, blood sugar levels, and other indicators of her health. 4. **Amniotic Fluid Volume**: Measuring the volume of amniotic fluid can give indications of fetal well-being. **Symmetric Growth Restriction:** In this pattern, all parts of the fetus are proportionally small. It's often associated with early insults during pregnancy, such as genetic factors or early infections. **Asymmetric Growth Restriction:** Here, the head of the fetus is of normal size while the body is smaller. This pattern usually occurs later in pregnancy and is often linked to placental insufficiency.

Question 28

A 36 year old woman who is 39 weeks pregnant, reports that she has not felt fetal movements for the last week. On examination, the symphysial-fundal height is 34 cms, and you are unable to hear the fetal heart on auscultation or with a 'Doppler'. What investigation and management should follow?

Answer 28

**Intrauterine fetal demise **(also called IUFD or stillbirth) occurs when a child dies in the womb at or after the 20th week of pregnancy. **Diagnostics** 1. **Ultrasonography**: to confirm absence of fetal cardiac activity 2. **Evaluation of underlying cause**: indicated in all cases 3. Maternal and family history 4. Examination of the placenta, fetal membranes, and umbilical cord 5. Fetal autopsy 6. Genetic analysis (e.g., fetal karyotype)

Question 29

If the baby has died, what is the utility of an autopsy for a perinatal death? (8)

Answer 29

1. Determining Cause of Death 2. Identifying Genetic or Congenital Conditions 3. Assessing Pregnancy Complications 4. Evaluating Fetal Development 5. Preventing Future Deaths 6. Providing Closure 7. Supporting Medical Research 8. Legal or Medical Documentation

Question 30

An 18 year old woman is 34 weeks pregnant, presents with right sided abdominal pain, vomiting and diarrhoea for 24 hours. What will help determine whether she has appendicitis or not? How will you manage her?

Answer 30

**Differentials** 1. Ectopic pregnancy 2. Pseudoappendicitis 3. Meckel diverticulum 4. Diverticulitis (especially in elderly patients) 5. Inflammatory bowel disease 6. Gastroenteritis 7. Colon cancer 8. Urolithiasis and renal colic 9. Urinary tract infections 10. Psoas abscess (in patients with a positive psoas sign) 11. Gynecological diseases (e.g., pelvic inflammatory disease, ovarian cyst)

Question 31

Two weeks after delivery, a 27 year old woman presents complaining of fever, sweats with a painful right breast. How should she be managed? What are the indications for surgical drainage? (5)

Answer 31

The symptoms described by the woman—fever, sweats, and a painful right breast—raise concern for a potential breast infection, which could be mastitis or even an abscess. These conditions can occur in postpartum women, especially if there are issues with breastfeeding.

Question 32

A 32 year old G2P1 at 24 weeks complains of discomfort from varicose veins and haemorrhoids. How do you manage this?

Answer 32

- Varicose veins are swollen blood vessels that develop if blood pools in your veins. - They usually appear on your legs, but can also affect your vulva or rectum. - They can cause leg pain that gets worse at the end of the day. - Varicose veins are common in pregnancy, but they usually get better by the time your baby is 3 to 4 months old. - You can improve your symptoms by wearing compression stockings, avoiding standing for too long, putting your feet up when you can, and doing ankle exercises.

Question 33

An 18 year old G2P1 presents with heavy bleeding 2 weeks post normal delivery. How should this be managed?

Answer 33

**Subinvolution of placental implantation site:** A condition in which the uterus remains abnormally large following delivery because of the persistence of dilated uteroplacental vessels **Epidemiology**: Occurs most commonly in the second week postpartum. Second most common cause of secondary postpartum hemorrhage (13% of affected individuals) **Risk factors** 1. Multiparity 2. Cesarean delivery 3. Uterine atony 4. Endometritis 5. Coagulopathy 6. Retained products of conception

Question 34

A 28 year old woman came off the COCP pill 6 months ago to become pregnant. She has had no periods since then. What are some possible causes? What is the most common cause of secondary ammenorrhoea?

Answer 34

**Secondary amenorrhea**: the absence of menses for more than 3 months in individuals with previously regular cycles, or 6 months in individuals with previously irregular cycles.

Question 35

A 28 year old woman came off the COCP pill 6 months ago to become pregnant. She has had no periods since then. How would you invstigate her?

Answer 35

Investigation of Secondary amenorrhea

Question 36

A 28 year old woman came off the COCP pill 6 months ago to become pregnant. She has had no periods since then. How would you treat her?

Answer 36

Question 37

A 17 year old girl has not yet commenced menstruating but has had a normal feminising puberty and her height and weight are normal. What is the most likely diagnosis? What are some possible causes?

Answer 37

**Primary amenorrhea**: the absence of menarche at 15 years of age despite normal development of secondary sexual characteristics, or absence of menses at 13 years of age in female individuals with no secondary sexual characteristics.

Question 38

A 17 year old girl has not yet commenced menstruating but has had a normal feminising puberty and her height and weight are normal. What is the most likely diagnosis? How would you investigate and treat her?

Answer 38

**Treatment** - Management of the underlying cause - Anatomical abnormalities: surgery - Hypogonadism: hormone replacement therapy with estrogens and progesterone - The goal of treatment is the progression of normal pubertal development.

Question 39

A 23 year old woman presents with a history of 12 months amenorrhoea following the birth of her first baby. She breast fed for only 4 weeks. The delivery was complicated by a major post partum haemorrhage requiring transfusion and a D&C for retained placental tissue. What are the differential diagnoses and how would you manage her?

Answer 39

Question 40

What is Turner's syndrome? You have just diagnosed the condition in a 19-year-old girl. How would you counsel her, and does she require any treatment? (6)

Answer 40

Turner syndrome is a genetic condition that occurs in females when one of the X chromosomes is partially or completely missing. Typically, females have two X chromosomes (XX), but in Turner syndrome, there is either a complete absence of one X chromosome (45,X) or structural abnormalities of the X chromosome. It leads to a range of physical and medical features, including short stature, reproductive issues, and various health concerns. **Treatment** 1. Hormone Replacement Therapy (HRT): Hormone therapy, typically estrogen and progesterone, can be initiated to induce puberty, promote secondary sexual characteristics, and maintain bone health. 2. Growth Hormone Therapy: Growth hormone therapy might be considered to help improve final adult height, especially if treatment is initiated at an early age. 3. Cardiac and Renal Monitoring 4. Regular hearing assessments 5. Psychosocial Support 6. Surgical removal of streak gonads

Question 41

A 21 year old woman presents complaining of slowly increasing hirsutism and irregular periods. What are 5 possible causes and which is the most likely? How should you investigate and treat her?

Answer 41

**Possible Causes:** 1. **Polycystic Ovary Syndrome (PCOS)**: This is a leading consideration due to the combination of hirsutism and irregular periods. 2. **Hyperprolactinemia**: Elevated levels of prolactin hormone can lead to irregular periods and hirsutism. 3. **Cushing's Syndrome**: This rare condition can lead to excess cortisol levels, causing hirsutism and menstrual irregularities. 4. **Congenital Adrenal Hyperplasia (CAH):** A group of genetic disorders affecting adrenal gland function, leading to hormonal imbalances and hirsutism. 5. **Androgen-Secreting Tumors**: Rare tumors that produce excessive androgens can lead to hirsutism and menstrual irregularities.

Question 42

What is premenstrual syndrome? What are useful management strategies for the woman presenting with the presenting complaint "I have PMT"?

Answer 42

**Premenstrual Syndrome (PMS)**: a combination of physical, emotional, and behavioral symptoms that occur in the days to weeks before a woman's menstrual period. PMS is quite common and can vary in severity from mild to severe. Symptoms typically improve or disappear with the onset of menstruation. **Common Symptoms of PMS:** **Physical Symptoms:** - Breast tenderness - Bloating - Fatigue - Headaches - Joint or muscle pain **Emotional and Behavioral Symptoms:** - Mood swings - Irritability - Anxiety or depression - Changes in sleep patterns - Changes in appetite or food cravings

Question 43

Define perinatal and maternal mortality. What are the major contributors to these? (6 Fetal +7 Maternal)

Answer 43

**Perinatal mortality**: the death of a fetus or newborn during the perinatal period, which includes the last trimester of pregnancy (from 28 weeks' gestation) through the first week of life (up to 7 days after birth). Perinatal mortality is often subdivided into early neonatal mortality (deaths within the first 7 days after birth) and late fetal mortality (deaths after 28 weeks' gestation but before birth). **Maternal Mortality:** the death of a woman during pregnancy, childbirth, or within 42 days of the termination of pregnancy, regardless of the duration and site of the pregnancy. It includes both direct maternal deaths (resulting from complications of pregnancy, childbirth, or postpartum period) and indirect maternal deaths (resulting from preexisting health conditions aggravated by pregnancy).

Question 44

What are some successful strategies to reduce perinatal and maternal mortality?

Answer 44

Question 45

List 6 Evidence-Based Interventions that Reduce Maternal Morbidity and Mortality.

Answer 45

Question 46

Aboriginal women have much higher perinatal mortality in their pregnancies than for Australian women generally; suggest ways to reduce this.

Answer 46

**Key messages** - During the 5-year period 2015–2019, there were 1,031 babies of Indigenous women who died during the perinatal period: 715 (69%) were stillborn, and 316 (31%) died within 28 days of birth. - In 2015–2019, for babies born to Indigenous women, the perinatal mortality rate was 15 per 1,000 births, compared with 9.0 per 1,000 for babies born to non-Indigenous women. - Over the decade from 2010 to 2019, the perinatal mortality rate among babies of Indigenous women did not change significantly, nor did the gap between rates for Indigenous and non-Indigenous women. - The most common causes of perinatal death among babies born to Indigenous women were congenital anomalies (21% of perinatal deaths) and spontaneous pre-term birth (20%). - A study among Indigenous women in Townsville showed that sustained access to community-based, integrated, shared antenatal services significantly reduced the perinatal mortality rate compared with a control group (from 60 to 14 deaths per 1,000 births).

Question 47

Outline the epidemiology of multiple pregnancies.

Answer 47

Question 48

4 Predisposing factors to multiple pregnancy? - Monozygotic vs. dizygotic twins?

Answer 48

**Predisposing factors** 1. Advanced maternal age (≥ 35 years) 2. Previous multiple pregnancy 3. Use of assisted reproductive technology 4. Maternal family history of dizygotic twins

Question 49

What are the types of twins? (Special features in the development of monozygotic twins)

Answer 49

- Dizygotic pregnancy results in a dichorionic-diamniotic pregnancy. In individual cases, the placentas of dizygotic twins merge, thereby simulating a monozygotic twin pregnancy. - In monozygotic pregnancies, there are various ways in which the amniotic sac and placenta are shared. Pregnancies with more than two fetuses may also assume a variety of forms (e.g., triplets, where two fetuses are monochorionic and the other has its own placenta).

Question 50

Diagnosis of multiple pregnancies?

Answer 50

**Physical examination** - The presence of more than one fetus may, in some cases, be confirmed by palpation. - Fundal height and abdominal girth are unusually large for the gestational age. - Two or more fetal heart rates can be heard on auscultation.

Question 51

Issues/Complications associated with Multiple pregnancies?

Answer 51

1. Premature Birth 2. Low Birth Weight 3. 3. Twin-to-Twin Transfusion Syndrome (TTTS) 4. Gestational Diabetes 5. Preeclampsia 6. C-Section 7. IUGR due to limited space in the uterus

Question 52

Management of Multiple pregnancies?

Answer 52

Question 53

You discover a patient is using intravenous heroin during pregnancy. What are the risks? What management plan would you suggest?

Answer 53

Question 54

How would you suspect that a woman has postnatal depression? How would you confirm your suspicion?

Answer 54

**Confirming Postnatal Depression:** Confirming a suspicion of postnatal depression requires a comprehensive assessment by a healthcare professional, such as a doctor, psychiatrist, or mental health counselor. This assessment may involve a clinical interview, standardized questionnaires, and discussions about the woman's thoughts, emotions, and daily functioning. It's important to rule out other medical conditions that can mimic depressive symptoms.

Question 55

How do you help a woman with postnatal depression? Can these problems be predicted and avoided?

Answer 55

**Treatment of peripartum depression** **Antenatal considerations** - Offer psychotherapy as an alternative to pharmacotherapy in mild to moderate depression. - Antidepressants - Avoid paroxetine during pregnancy because of the potential risk of cardiac anomalies. **Postpartum considerations** - In patients starting antidepressants, begin with a medication that has few side effects and minimal transfer to breastmilk, e.g., sertraline. - Newer alternatives include : Brexanolone infusion, Zuranolone - ECT can be safely offered to pregnant and lactating patients who prefer to avoid pharmacotherapy. **Prevention** - Consider psychiatry referral prior to conception. - Recommend psychotherapy.

Question 56

What is Gestational trophoblastic disease? Types?

Answer 56

Gestational trophoblastic disease (GTD) is a class of neoplastic conditions characterized by abnormal trophoblast-cell growth in the uterus. GTD is classified into hydatidiform moles (molar pregnancy), which are subclassified into complete and partial moles, and gestational trophoblastic neoplasia (GTN), which is subclassified into choriocarcinoma, invasive moles, placental site trophoblastic tumors, and epithelioid trophoblastic tumors. Hydatidiform moles are benign but have a malignant potential, whereas GTN are malignant lesions with a tendency to metastasize, especially to the lungs.

Question 57

Classification/Types of Gestational trophoblastic disease? (2 + 4)

Answer 57

Question 58

Answer 58

The risk of malignant GTN is higher in complete mole than in partial mole.

Question 59

Answer 59

Question 60

Answer 60

Question 61

Answer 61

Question 62

Answer 62

Question 63

**Hydatidiform mole** - 3 Risk Factors? - 2 Characteristics? - Prognosis? - Approach to management?

Answer 63

**Risk factors** 1. Prior molar pregnancy 2. Age ≤ 15 and ≥ 35 years 3. History of miscarriage and infertility **Characteristics** 1. Proliferates within the uterus without myometrial infiltration or hematogenic dissemination 2. May undergo malignant transformation to an invasive mole **Prognosis** - Most patients achieve normal reproductive function after recovery. - Risk of subsequent GTN is 15–20% - The recurrence risk of hydatidiform mole in a subsequent pregnancy is 1.8%.

Question 64

**Gestational trophoblastic disease - Complete mole** - Aetiology? - 3 Fetal karyotypes? - Pathophysiology? - Clinical features?

Answer 64

Question 65

**Gestational trophoblastic disease - Complete mole** - Diagnostics? - Treatment?

Answer 65

**Treatment** 1. Uterine dilation and evacuation (D&E) 2. Monitor β-HCG levels: until within reference range (usually 8–12 weeks) 3. Chemotherapy (usually methotrexate) if unresolved, as indicated by either of the following: - β-HCG values do not decrease. - Features of malignant GTN on histology or imaging

Question 66

**Gestational trophoblastic disease - Partial mole** - Aetiology? - 3 fetal Karyotypes? - Clinical features? - Diagnostics?

Answer 66

Question 67

**Gestational trophoblastic neoplasia - Choriocarcinoma** - Definition? - Aetiology? - Pathophysiology? - Clinical features?

Answer 67

Question 68

**Gestational trophoblastic neoplasia - Choriocarcinoma** - Diagnostics? - Treatment? - Prognosis?

Answer 68

Question 69

**Gestational trophoblastic neoplasia - Invasive Mole** - Definition? - Aetiology? - Pathophysiology? - Clinical Features? - Diagnostics? - Treatment? - Prognosis?

Answer 69