Conclusiones y discusión

20–1.

As a group, gestational trophoblastic disease is typi ied by which o the ollowing?

a.

Scant cytotrophoblast

b.

Perivillous ibrin deposition

c.

Villous mesenchymal hyperplasia

d.

Abnormal trophoblast proli eration

20–2.

As illustrated by di erences seen here between invasive mole (A) and choriocarcinoma (B), hydatidi orm moles as a group are di erentiated

histologically rom other nonmolar neoplasms by the presence o which o the ollowing?

a.

Villi

b.

Cytotrophoblast

c.

Syncytiotrophoblast

d.

Marked angiogenesis

20–3.

Gestational trophoblastic neoplasia includes all

EXCEPT which o the ollowing?

a.

Invasive mole

b.

Choriocarcinoma

c.

Partial hydatidi orm mole

d.

Placental site trophoblastic tumor

A

B

A

B

A. Used with permission rom Dr. Ona Faye-Peterson. B. Reproduced with permission rom Schorge JO: Gestational trophoblastic disease. In Hof man BL, Schorge JO, Schaf er JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 37-8.

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20–4.

Which o the ollowing histological changes, as

shown here, are characteristic o hydatidi orm moles?

Used with permission rom Dr. Y. Erika Fong. Reproduced with permission rom Schorge JO: Gestational trophoblastic disease. In Hof man BL, Schorge JO, Schaf er JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 37-1B.

a.

Chronic villitis and villous inclusion bodies

b.

Villous mesenchymal hyperplasia and acute villitis

c.

Villous lymphocytic in iltrates and syncytial knots

d.

Trophoblast proli eration and villous stromal edema

20–5.

A predominant maternal risk actor or molar pregnancy includes which o the ollowing?

a.

Advanced maternal age

b.

Prior cesarean delivery

c.

Type 2 diabetes mellitus

d.

A rican American ethnicity

20–6.

Your patient has completed treatment or a complete hydatidi orm mole. Compared with women without a prior molar pregnancy, those with one prior mole have which o the ollowing risks o developing this condition again in a subsequent pregnancy?

a.

2%

b.

13%

c.

26%

d.

42%

20–7.

This molar pregnancy lacked a etal component. All

EXCEPT which o the ollowing eatures are also

characteristic o this type o hydatidi orm mole?

Used with permission rom Dr. Sasha Andrews. Reproduced with permission rom Schorge JO: Gestational trophoblastic disease. In Hof man BL, Schorge JO, Schaf er JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 37-3.

a.

Diploid karyotype

b.

Focal villous edema

c.

Theca-lutein ovarian cysts are requently associated

d.

Approximate 15% risk o subsequent gestational trophoblastic neoplasia

20–8.

All EXCEPT which o the ollowing eatures are characteristic o partial hydatidi orm mole?

a.

Triploid karyotype

b.

Focal villous edema

c.

Fetal tissue present

d.

Approximate 15% risk o subsequent gestational trophoblastic neoplasia

20–9.

With regard to molar pregnancies, what does the term “androgenesis” re er to?

a.

Increased placental androgen production that promotes villous edema

b.

Development o a zygote that contains only maternal chromosomes

c.

Increased placental androgen production that leads to maternal virilization

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20–10.

The pathogenesis o which o the ollowing is shown in this diagram?

a.

Partial mole

b.

Complete mole

c.

Mature cystic teratoma

d.

Complete mole with coexistent twin

23,X 23,X 23,Y 23,Y 23,X 23,X 69,XXY 69,XXY 69,XXY Triploid 69, XXY Ce lls Ma te rna l a nd Pate rna l

Chromos omes

Dis pe rmy

20–12.

Patients with complete hydatidi orm molar

pregnancy requently present with all EXCEPT which o the ollowing clinical indings?

a.

Vaginal bleeding

b.

Multiple simple ovarian cysts

c.

Increased thyroid-stimulating hormone levels

d.

Greater than expected serum β-human chorionic gonadotropin (hCG) levels

20–13.

Your patient is diagnosed with a complete

hydatidi orm mole. Sonographic examination o the adnexa reveals the indings below. The underlying etiology stems rom increased placental production o which o the ollowing?

a.

Estrogen

b.

Thyroxine

c.

Progesterone

d.

β-Human chorionic gonadotropin

20–14.

The condition shown in Question 20–13 is best managed by which o the ollowing?

a.

Oophoropexy

b.

Oophorectomy

c.

Ovarian cystectomy

d.

Molar pregnancy uterine evacuation

Reproduced with permission rom Schorge JO: Gestational trophoblastic disease. In Schorge JO, Schaf er JI, Halvorson LM, et al (eds): Williams Gynecology. New York, McGraw-Hill, 2008, Figure 37-1B.

20–11.

Your patient is a 39-year-old G2P1 with one prior uncomplicated pregnancy and vaginal delivery. Her current twin pregnancy is made up o a complete mole and a coexistent karyotypically normal etus. Magnetic resonance imaging was completed, and one view is presented below. This cross-sectional image shows the complete mole (asterisk), a normal placenta above the mole, and a cross section o the normal etus’s abdomen on the le t. Complications that

may be reasonably anticipated during this pregnancy include all EXCEPT which o the ollowing?

Used with permission rom Dr. April Bleich.

a.

Preeclampsia

b.

Fetal demise

c.

Preterm delivery

d.

Placenta accreta

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20–15.

Increased serum ree thyroxine levels in women with hydatidi orm moles stem rom increases in which o the ollowing?

a.

Maternal estrogen levels

b.

Fetal thyroxine production

c.

Maternal progesterone levels

d.

Maternal β-human chorionic gonadotropin levels

20–16.

A 24-year-old G3P2 presents with vaginal bleeding, a β-human chorionic gonadotropin (β-hCG) level o 300,000 mIU/mL, uterine size consistent with a 12-week gestation, B negative blood type, and the sonographic indings below. What is the most appropriate management?

a.

Plan or hysterectomy

b.

Rhogam administration and bed rest

c.

Plan or dilatation and curettage

d.

Repeat a serum β-hCG level in 48 hours

20–17.

Prior to surgical intervention or a hydatidi orm mole, all EXCEPT which o the ollowing are typically completed?

a.

Type and screen

b.

Complete blood count

c.

Chest computed tomography

d.

Serum testing o liver, renal, and thyroid unction

20–18.

Prior to molar pregnancy evacuation, a preoperative chest radiograph is typically obtained to exclude which o the ollowing associated conditions?

a.

Cardiomegaly

b.

Pleural e usion

c.

Hilar lymphadenopathy

d.

Trophoblastic deportation

20–19.

What is the treatment o choice or a 20-week size complete mole in a 28-year-old G2P1?

a.

Hysterectomy

b.

Hysterotomy and evacuation

c.

Dilatation and suction curettage

d.

Intramuscular systemic methotrexate

20–20.

Steps during dilatation and curettage that may hasten evacuation and lessen intraoperative blood loss include which o the ollowing?

a.

Preoperative laminaria

b.

Large-bore suction cannula

c.

Uterotonic administration during curettage

d.

All o the above

20–21.

Which o the ollowing uterotonics are

contraindicated in the setting o molar pregnancy evacuation?

a.

Misoprostol

b.

Synthetic oxytocin

c.

Carboprost tromethamine

d.

None o the above

20–22.

In the United States, routine postevacuation treatment o molar pregnancy typically includes which o the ollowing?

a.

Methotrexate chemotherapy

b.

Intrauterine device insertion

c.

Rhogam administration to Rh-negative women

d.

All o the above

20–23.

In the United States, a reasonable alternative to dilatation and curettage or the management o complete hydatidi orm mole includes which o the ollowing?

a.

Hysterectomy

b.

Hysterotomy and uterine evacuation

c.

Misoprostol labor induction ollowing laminaria placement

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20–24.

Your patient, who is pregnant with an estimated gestational age o 8 weeks by last menstrual period, presents to the emergency department with heavy vaginal bleeding and passage o tissue. Sonographic examination reveals an endometrial cavity illed with blood and tissue exhibiting inhomogeneous echoes. You per orm a dilatation and curettage with no complications. A week later, you receive the pathology report or the evacuated products o conception:

Specimen: uterine contents

DNA interpretation by image cytometry: diploid Immunostaining: p57KIP2 positive

These histological indings are consistent with which o the ollowing diagnoses?

a.

Partial mole

b.

Complete mole

c.

Spontaneous abortion

d.

None o the above

20–25.

Which o the statements below are true regarding surveillance practices ollowing evacuation o a molar pregnancy?

a.

Endometrial biopsy and chest radiograph should be per ormed every 3 months or 1 year.

b.

Endometrial biopsy, chest radiographs, and β-human chorionic gonadotropin levels are obtained serially, but each at di erent intervals.

c.

Serum β-human chorionic gonadotropin levels should be monitored every 1 to 2 weeks until undetectable, a ter which monthly levels are drawn or the next 6 months.

d.

None o the above

20–26.

Which o the ollowing statements is true regarding contraceptive practices a ter evacuation o a molar pregnancy?

a.

Intrauterine devices should not be inserted until the β-human chorionic gonadotropin (β-hCG) level is undetectable.

b.

Pregnancies that occur during the monitoring period increase the risk o progression to

gestational trophoblastic neoplasia.

c.

Hormonal contraception, such as oral contraceptive pills and injectable

medroxyprogesterone acetate, should not be initiated until the β-hCG level is undetectable.

d.

All o the above

20–27.

During surveillance, all EXCEPT which o the ollowing portend a greater risk or development o gestational trophoblastic neoplasia?

a.

Maternal age > 40 years

b.

8-cm theca lutein cysts

c.

Rapidly declining β-human chorionic gonadotropin level

d.

β-Human chorionic gonadotropin level > 100,000 mIU/mL prior to uterine evacuation

20–28.

Your patient is a 32-year-old G1P0A1 who has undergone molar pregnancy evacuation and is

using combination oral contraceptive pills. During postevacuation surveillance, her serum β-human chorionic gonadotropin levels had previously

dropped to an undetectable level. Today, as part o her monthly surveillance, her value is 900 mIU/mL. Appropriate initial management includes which o the ollowing?

a.

Preparation or dilatation and curettage

b.

Initiation o intramuscular methotrexate therapy

c.

Repeat β-human chorionic gonadotropin level in 48 hours

d.

International Federation o Gynecology and Obstetrics (FIGO) staging

20–29.

The patient rom Question 20–28 presents

again in 48 hours and has a β-human chorionic gonadotropin level o 6000 mIU/mL. What is the next most appropriate step in her care?

a.

Transvaginal sonography

b.

Preparation or dilatation and curettage

c.

Initiation o intramuscular methotrexate therapy

d.

Chest and abdominopelvic computed

tomography (CT) imaging and brain magnetic resonance imaging

20–30.

The patient rom Question 20–28 undergoes transvaginal sonography, which reveals no intrauterine or adnexal gestation. Appropriate management includes which o the ollowing?

a.

Hysterectomy

b.

Initiation o intravenous dactinomycin therapy

c.

Initiation o intramuscular methotrexate therapy

d.

International Federation o Gynecology and Obstetrics (FIGO) staging

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20–31.

In practice, the diagnosis o gestational trophoblastic neoplasia typically is determined by which o the ollowing?

a.

Histologic tissue evaluation

b.

Physical examination indings

c.

Computed tomography (CT) imaging

d.

Serum β-human chorionic gonadotropin levels

20–32.

Criteria or the diagnosis o gestational trophoblastic neoplasia includes which o the ollowing?

a.

Rising β-human chorionic gonadotropin levels

b.

Plateaued β-human chorionic gonadotropin levels

c.

Persistent β-human chorionic gonadotropin levels

d.

All o the above

20–33.

Gestational trophoblastic neoplasia may develop a ter which o the ollowing?

a.

Evacuation o a partial mole

b.

Delivery o a normal term pregnancy

c.

Miscarriage o a genetically normal abortus

d.

All o the above

20–34.

The hallmark sign o gestational trophoblastic neoplasia is which o the ollowing?

a.

Seizures

b.

Hemoptysis

c.

Uterine bleeding

d.

Pelvic vein thrombosis

20–35.

Evaluation o abnormal bleeding or more than

6 weeks ollowing any pregnancy may include which o the ollowing?

a.

Transvaginal sonography

b.

Serum β-human chorionic gonadotropin level

c.

Endometrial sampling to exclude placental site trophoblastic tumor or epithelioid trophoblastic tumor

d.

All o the above

20–36.

According to the World Health Organization (WHO) modi ied prognostic scoring system that was adapted by the International Federation o Gynecology and Obstetrics (FIGO), which o the ollowing is assessed and assigned a rating score

during staging o gestational trophoblastic neoplasia?

a.

Parity

b.

Severity o thyrotoxicosis

c.

Number o months rom the antecedent pregnancy

d.

Presence and diameter o largest theca-lutein cyst

20–37.

Following dilatation and curettage or a complete mole, your patient is surveilled with serial β-human chorionic gonadotropin (β-hCG) levels. For the past 3 weeks, the β-hCG values have plateaued. Diagnostic evaluation reveals a metastatic lesion in the liver (shown here). Given this extent o disease, what is the International Federation o Gynecology and Obstetrics (FIGO) stage?

Used with permission rom Dr. John Schorge.

a.

Stage I

b.

Stage II

c.

Stage III

d.

Stage IV

20–38.

According to the World Health Organization (WHO) modi ied prognostic scoring system that was adapted by the International Federation o Gynecology and Obstetrics (FIGO), patients with scores below which o the ollowing thresholds are assigned to the low-risk gestational trophoblastic neoplasia group?

a.

≤ 4

b.

≤ 6

c.

≤ 8

d.

≤ 10

20–39.

Which o the ollowing characteristics are most typical o invasive moles?

a.

Follows a term pregnancy

b.

Penetrates deeply into the myometrium

c.

Displays minimal trophoblastic growth

d.

Is almost invariably associated with widespread pulmonary metastasis

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134

20–40.

Metastatic disease, such as that shown here, is most commonly due to which o the ollowing?

Reproduced with permission rom Schorge JO: Gestational trophoblastic disease. In Schorge JO, Schaf er JI, Halvorson LM, et al (eds): Williams Gynecology. New York, McGraw-Hill, 2008, Figure 37-8.

a.

Invasive mole

b.

Choriocarcinoma

c.

Epithelioid trophoblastic tumor

d.

Placental site trophoblastic tumor

20–41.

Metastatic spread o choriocarcinoma is most commonly by which o the ollowing routes?

a.

Lymphatic

b.

Hematogenous

c.

Peritoneal luid

d.

Cerebrospinal luid

20–42.

What is the most common site o metastatic spread o choriocarcinoma?

a.

Brain

b.

Liver

c.

Lungs

d.

Spleen

20–43.

Your patient has International Federation o Gynecology and Obstetrics (FIGO) stage I

gestational trophoblastic neoplasia. Pre erred and e ective treatment includes methotrexate or which o the ollowing?

a.

Radical hysterectomy

b.

Combination chemotherapy

c.

External beam pelvic radiation

d.

Actinomycin-D single-agent chemotherapy

20–44.

Your patient has International Federation o Gynecology and Obstetrics (FIGO) stage III gestational trophoblastic neoplasia. Which o the ollowing is considered typical treatment?

a.

Radical hysterectomy

b.

Combination chemotherapy

c.

Radical hysterectomy plus adjuvant methotrexate

d.

External beam pelvic radiation plus adjuvant methotrexate

20–45.

Chemotherapeutic agents in the EMA-CO regimen include all EXCEPT which o the ollowing?

a.

Cisplatin

b.

Etoposide

c.

Methotrexate

d.

Actinomycin-D

20–46.

True evidenced-based risks or uture pregnancy ollowing treatment o gestational trophoblastic disease include which o the ollowing?

a.

Decreased ertility

b.

Increased risk o preterm labor

c.

Increased risk o placenta accreta

d.

Increased risk o a second molar pregnancy

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135

CHAPTER 20 ANSw ER KEy

Q uestion

number a nswerLetter Pa ge cited Hea der cited

20–1 d p. 3 9 6 Introduction

20–2 a p. 3 9 6 Introduction

20–3 c p. 3 9 6 Introduction

20–4 d p. 3 9 6 Hyda tidiform Mole—Mola r Pregna ncy

20–5 a p. 3 9 6 Epidemiology a nd Risk Fa ctors

20–6 a p. 3 9 7 Epidemiology a nd Risk Fa ctors

20–7 b p. 3 9 7 Ta ble 2 0 -1

20–8 d p. 3 9 7 Ta ble 2 0 -1

20–9 d p. 3 9 7 Pa thogenesis

20–10 a p. 3 9 8 Figure 2 0 -2 B

20–11 d p. 3 9 8 Twin Pregna ncy Comprising a N orma l Fetus a nd Coexistent Complete Mole

20–12 c p. 3 9 8 Clinica l Findings 20–13 d p. 3 9 8 Clinica l Findings 20–14 d p. 3 9 8 Clinica l Findings 20–15 d p. 3 9 8 Clinica l Findings 20–16 c p. 3 9 9 Sonogra phy 20–17 c p. 4 0 0 Ta ble 2 0 -2

20–18 d p. 4 0 0 Termina tion of Mola r Pregna ncy

20–19 c p. 4 0 0 Termina tion of Mola r Pregna ncy

20–20 d p. 4 0 0 Termina tion of Mola r Pregna ncy

20–21 d p. 4 0 0 Ta ble 2 0 -2

20–22 c p. 4 0 0 Termina tion of Mola r Pregna ncy

20–23 a p. 4 0 0 Termina tion of Mola r Pregna ncy

20–24 c p. 4 0 0 Pa thologica l Dia gnosis

20–25 c p. 4 0 1 Posteva cua tion Surveilla nce

20–26 a p. 4 0 1 Posteva cua tion Surveilla nce

20–27 c p. 4 0 1 Posteva cua tion Surveilla nce

20–28 c p. 4 0 1 Posteva cua tion Surveilla nce

20–29 a p. 4 0 1 Posteva cua tion Surveilla nce

20–30 d p. 4 0 1 Posteva cua tion Surveilla nce

20–31 d p. 4 0 1 Gesta tiona l trophobla stic N eopla sia

20–32 d p. 4 0 2 Ta ble 2 0 -3

20–33 d p. 4 0 1 Gesta tiona l Trophobla stic N eopla sia

20–34 c p. 4 0 1 Clinica l Findings

20–35 d p. 4 0 2 Dia gnosis, Sta ging, a nd Prognostic Scoring

20–36 c p. 4 0 2 Ta ble 2 0 -4

20–37 d p. 4 0 2 Ta ble 2 0 -4

20–38 b p. 4 0 2 Dia gnosis, Sta ging, a nd Prognostic Scoring

20–39 b p. 4 0 2 Inva sive Mole

20–40 b p. 4 0 3 Gesta tiona l Chorioca rcinoma

20–41 b p. 4 0 3 Gesta tiona l Chorioca rcinoma

20–42 c p. 4 0 3 Gesta tiona l Chorioca rcinoma

20–43 d p. 4 0 3 Trea tment

20–44 b p. 4 0 3 Trea tment

20–45 a p. 4 0 3 Trea tment

S e c t i o n 7

138

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