Table II-6-3. Gestational Trophoblastic Neoplasia—Basic Approach
| b-hCG titer | Baseline for future comparison |
| Chest x-ray | Lung metastasis is ruled out |
| Suction D&C | Empty uterus contents |
| Oral contraceptive pills | Prevent confusion: recurrent disease and normal pregnancy |
| for 1 year | |
• Treatment is then based on histology and location of metastasis.
– Benign GTN: Weekly serial b-hCG titers until negative for 3 weeks, then monthly titers until negative for 12 months. Follow-up is for 1 year. If serial b-hCG titers plateau or rise and normal intrauterine pregnancy is ruled out by vaginal sono-gram, the patients are diagnosed with persistent gestational trophoblastic disease. They should undergo a metastatic workup (CT scans of the brain, the thorax, the abdomen and the pelvis) and be managed as below.
– Non-metastatic or Good Prognosis metastatic disease: Single agent (methotrex-ate or actinomycin D) until weeklyb-hCG titers become negative for 3 weeks, thenmonthly titers until negative for 12 months. Follow-up is for 1 year.
– Poor Prognosis metastatic disease: Multiple agent chemotherapy (which includes methotrexate, actinomycin-D and cytoxan) until weekly b-hCG titers become neg-ative for 3 weeks, then monthly titers for 2 years, then every 3 months for another 3 years. Follow-up is for 5 years.
Table II-6-4. Gynecologic Malignancy
| Clinical staging | Cervical cancer |
| Surgical staging | Endometrial, ovarian, vulvar, and trophoblastic cancer |
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SPECTRUM OF ORGANISMSBacterial. These include chancroid, lymphogranuloma venereum, granuloma inguinale, chla-mydia, gonorrhea, syphilis.Viral. These include condyloma acuminatum, herpes simplex, hepatitis B virus, and human immunodeficiency virus.Protozoan. This includes trichomoniasis.STDs WITH ULCERSHerpes Simplex Virus (HSV ) Refer to Obstetrics, Chapter 7, Perinatal Infections.SyphilisRefer to Obstetrics, Chapter 7, Perinatal Infections.ChancroidChancroid is caused by Haemophilus ducreyi, a Gram-negative bacterium. It is uncommon in the United States. It is a cofactor for HIV transmission. Symptoms. This is one of the two STDs that presents with a painful ulcer. A pustule, usually on the vulva, becomes a painful ulcer within 72 hours, with a typically “ragged edge.” Diagnosis. A positive culture confirms the diagnosis, although a diagnosis is often made clini-cally after excluding syphilis and genital herpes.Management. CDC-recommended treatment includes a single oral dose of azithromycin, a single IM dose of ceftriaxone, or oral erythromycin base for 7 days.
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Figure II-7-1. Pathophysiology of Chancroids
Sexually Transmitted Diseases
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USMLE Step 2 l Gynecology
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