Routine pre-evacuation ultrasound diagnosis of hydatidiform mole: experience of more than 1000 cases from a regional referral center

Morphology combined with HER2 D-DISH ploidy analysis to diagnose partial hydatidiform mole: an evaluation audit using molecular genotyping

AIMS

A hydatidiform mole (HM) is classified as complete (CHM) or partial (PHM) based on its morphology and genomic composition. Ancillary techniques are often required to confirm a morphologically suspected PHM diagnosis. This study sought to evaluate the clinical accuracy of PHM diagnosis using morphological assessment supported by HER2 dual-colour dual-hapten in situ hybridisation (D-DISH) ploidy determination.

METHODS

Over a 2-year period, our unit examined 1265 products of conception (POCs) from which 103 atypical POCs were diagnosed as PHM or non-molar conceptuses with the assistance of HER2 D-DISH ploidy analysis. We retrospectively audited a sample of 40 of these atypical POCs using short tandem repeat genotyping. DNA extracted from formalin-fixed paraffin-embedded tissue was genotyped using 24 polymorphic loci. Parental alleles in placental villi were identified by comparison to those in maternal decidua. To identify triploid PHM cases, we sought three alleles of equal peak height or two alleles with one allele peak twice the height of the other at each locus.

RESULTS

Thirty-six of the 40 cases (19 PHM and 17 non-molar) were successfully genotyped and demonstrated complete concordance with the original diagnosis. All PHMs were diandric triploid of dispermic origin. In two non-molar diploid cases, we identified suspected trisomies (13 and 18), which potentially explains the pregnancy loss in these cases.

CONCLUSIONS

This study validates the use of HER2 D-DISH ploidy analysis to support the diagnosis of a morphologically suspected PHM in our practice.

A Cross-Sectional Analysis of the Incidence of Hydatidiform Mole in Colombia

Objective: To describe the incidence of hydatidiform mole in Colombia. Design: Cross-sectional descriptive study. Setting: Colombia. Population or Sample: The total population at risk of hydatidiform mole (15-49 years old) from 2015 to 2023 was 117.890.729 women. Methods: A search of the national database of the Ministry of Health and Social Protection of Colombia using ICD-10 for hydatidiform mole and ectopic pregnancy was conducted from 2015 to 2023. Incidences were calculated using data from the National Department of Statistics of Colombia. Main Outcome Measures: The incidence of hydatidiform mole was calculated by ratios compared with the live births, the proportion of pregnancies, and the incidence rate in the at-risk population. Results: In the reviewed period, 2247 cases of hydatidiform mole were reported. The proportion of unspecified hydatidiform moles during the evaluation period was 78.59% of the reports, the incidence ratio was one hydatidiform mole for every 2486 live births, the proportion was 37.7 × 105 pregnancies and the cumulative incidence was 1.90 × 105 women of 15-49 years. The age range with the highest number of cases was 20-29 years with 1039 cases. Conclusions: The high proportion of unspecified hydatidiform mole far exceeds the diagnoses of complete and partial hydatidiform mole. The descriptive design of the study does not allow us to determine the causes of these results. Future studies with more complex methodological designs are required to explain these findings.

Serum hCG levels in the prediction of molar pregnancy below 11 weeks of gestational age

OBJECTIVE

The aim of this study was to evaluate the serum hCG level in the differential diagnosis between non-molar miscarriage and complete hydatidiform mole in<11 weeks gestation.

METHODS

This was a retrospective collaborative cohort study. This study included women with gestational age<11 weeks, with ultrasound evidence of failed pregnancy and available serum hCG pre-uterine evacuation, divided into two groups: the non-molar miscarriage group and the complete hydatidiform mole group. Serum hCG levels were compared according to gestational age. Statistical analysis used a nonparametric test with a 5% significance level (p<0.05).

RESULTS

In total, 416 patients were included, out of which 79 were included in the non-molar miscarriage group and 337 in the complete hydatidiform mole group. The calculated power of the sample was more than 80%. Data analysis showed that the 75th quartile of the median in the non-molar miscarriage group was always lower than the 25th quartile of the median in the complete hydatidiform mole group [9,721 mUI/mL/16,435 mUI/mL (6-7 weeks), 20,229 mUI/mL/64,911 mUI/mL (8-9 weeks), and 29,633 mUI/mL/126,278 mUI/mL (10-11 weeks), respectively; p<0.001].

CONCLUSION

Facing failed pregnancies, hCG>16,435 mUI/mL at 6-7 weeks, hCG>64,911 mUI/mL at 8-9 weeks, and hCG >126,278 mUI/mL at 10-11 weeks were most prevalent on complete hydatidiform mole diagnosis. On the contrary, hCG<30,000 mUI/mL at 10-11 weeks was most prevalent in non-molar miscarriage diagnosis.

Reappraisal and refined diagnosis of ultrasonography and histological findings for hydatidiform moles: a multicentre retrospective study of 821 patients

AIMS

Specific identification of a hydatidiform mole (HM) and subclassification of a complete hydatidiform mole (CHM) or partial hydatidiform mole (PHM) are critical. This study aimed to reappraise the diagnostic performance of ultrasonography and histology with a refined diagnosis.

METHODS

This was a retrospective, multicentre cohort study of 821 patients with histologically suspected HM specimens. Refined diagnostic algorithms with p57 immunohistochemistry and short tandem repeat (STR) genotyping were performed and used as the true standard for assessing the diagnostic performance of the original ultrasonography and morphology methods. The diagnostic performance was calculated using accuracy, agreement rate, sensitivity and the positive predictive value (PPV) compared with refined diagnostic results.

RESULTS

Of the 821 histologically suspected HM cases included, 788 (95.98%) were successfully reclassified into 448 CHMs, 213 PHMs and 127 non-molar (NM) abortuses. Ultrasonography showed an overall accuracy of 44.38%, with a sensitivity of 44.33% for CHM and 37.5% for PHM. The overall classification accuracy of the original morphological diagnosis was 65.97%. After exclusion of the initially untyped HMs, the overall agreement rate was 59.11% (κ=0.364, p<0.0001) between the original and refined diagnoses, with a sensitivity of 40.09% and PPV of 96.05% for diagnosing CHMs and a sensitivity of 84.98% and a PPV of 45.59% for diagnosing PHMs. The interinstitutional variability of morphology in diagnosing HMs was significant among the 15 centres (range, 8.33%-100.00%, p<0.0001).

CONCLUSION

The current diagnosis of HM based solely on ultrasound or morphology remains problematic, and ancillary techniques, particularly p57 immunohistochemistry and DNA genotyping, should be integrated into routine practice as much as possible.

Giant complete hydatidiform mole: a case report and review of the literature

BACKGROUND

This case describes the youngest patient documented in the literature who presented with a giant hydatidiform mole, effectively addressed through conservative treatment.

CASE PRESENTATION

Our department received a 20-year-old Caucasian patient who was admitted due to significant metrorrhagia in an undisclosed pregnancy. During examination, we identified a massive, highly vascularized hydatidiform mole measuring 22 cm (cm). We performed a surgical dilatation and curettage. The anatomopathological findings confirmed the presence of a complete hydatidiform mole (CHM). Following the established guidelines, we conducted weekly monitoring of human chorionic gonadotropin (hCG). Unfortunately, the patient discontinued the follow-up and became pregnant again before achieving hCG negativation.

CONCLUSION

This case suggests that conservative treatment is a viable option regardless of the size of gestational trophoblastic disease (GTD), especially when the preservation of fertility is a crucial consideration, as effectively demonstrated in our case.

Rapid progression from complete molar pregnancy to post-molar gestational trophoblastic neoplasia: a rare case report and literature review

Background

Post-molar gestational trophoblastic neoplasia (pGTN) develops in about 15% to 20% of complete hydatidiform mole (CMH). Commonly, pGTN is diagnosed based on hCG monitoring following the molar evacuation. To date, no detailed information is available on how fast can pGTN develop from CHM. However, the concurrence of CHM and pGTN is extremely rare.

Case presentation

A 29-year-old woman presented to the gynecology department with irregular vaginal bleeding and an elevated hCG serum level. Both ultrasound and MRI showed heterogeneous mass in uterine cavity and myometrium. Suction evacuation was performed and histologic examination of the evacuated specimen confirmed complete hydatidiform mole. Repeated ultrasound showed significant enlargement of the myometrium mass one week after the evacuation. pGTN with prognostic score of 4 was then diagnosed and multi-agent chemotherapy regimen implemented with a good prognosis.

Conclusion

In rare cases, CMH can rapidly progress into pGTN. Imaging in combination with hCG surveillance seems to play a vital role guiding timely diagnosis and treatment in the specific condition. Low-risk gestational trophoblastic neoplasia (GTN) should be managed stratified according to the individual situation.

Outcomes of Gestational Trophoblastic Disease Management: A Single Centre Review

Background and Objectives: Gestational trophoblastic disease (GTD) is a group of pregnancy-related malignant and premalignant diseases. The aim of this study was to assess the prognostic value of clinical characteristics to predict treatment outcomes in women with GTD. Materials and Methods: In this retrospective study, 34 patients treated for GTD at the Division of Gynaecology and Perinatology, University Medical Centre Maribor, between 2008 and 2022 were identified. Clinical and pathological characteristics were obtained by analysing patient data records. Results: Within the cohort of 34 patients with GTD, 29 patients (85.3%) had a partial hydatidiform mole (HM) and five patients545 (14.7%) had a complete HM. Two patients with a complete HM developed a postmolar gestational trophoblastic neoplasia (GTN), which represents 5.8% of all cases. Conclusions: GTD is a rare disease that is frequently asymptomatic. The subsequent consequences of GTD, which can lead to malignant transformation, as well life-threatening disease complications, warrant training for early recognition of HMs and timely treatment and surveillance.

Vaginal Bleeding Before 20 Weeks Gestation

Conditions that often present with vaginal bleeding before 20 weeks are common and can cause morbidity and mortality. Clinically stable patients can choose their management options. Clinically unstable patients require urgent procedural management: uterine aspiration, dilation and evacuation, or surgical removal of an ectopic pregnancy. Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids. Available data on prognosis with expectant management of pre-viable rupture of membranes in the United States are poor for mothers and fetuses.

Gestational trophoblastic disease: an update

Gestational trophoblastic diseases (GTD) encompass a spectrum of rare pre-malignant and malignant entities originating from trophoblastic tissue. This updated review will highlight important radiological features, pathology and classification, and provide insight into the clinical management of these uncommon disorders. There is a wide geographic variation with the incidence of hydatidiform mole varying between 0.57 and 2 per 1000 pregnancies. The use of ultrasound (US) in the management of early pregnancy symptoms and complications has positively impacted the earlier detection of these diseases and resulted in diminished morbidity. Additional imaging modalities are reserved for problem solving or assessment of pulmonary manifestations of molar pregnancy. Having an awareness of their pleomorphic sonographic presentation and additional pathology that can mimic GTD is critical to avoiding pitfalls. Histologic and molecular analysis further aids in differential diagnosis. Gestational trophoblastic neoplasia (GTN) is inclusive of all malignant GTDs, and arises after 20% of molar pregnancies but can also be seen with non-molar gestations. Biochemical monitoring with human chorionic gonadotrophin is imperative for ongoing monitoring and surveillance and allows early detection of this entity. Doppler US is used for confirmation of diagnosis with magnetic resonance imaging (MRI) reserved for problem solving or assessment of myometrial invasion. This is of heightened relevance in patients undergoing surgical management. Cross sectional imaging is reserved for patients in the setting of GTN for the purposes of staging, prognostication and in the setting of recurrent disease. This may require a combination of computed tomography, MRI and positron emission tomography. Doppler US can provide insight into chemotherapeutic response/predict resistance in patients with GTN. As our understanding of these disorders evolves, there has been maturation in management options with a shift from traditional chemotherapy to innovative immunotherapy, particularly in the setting of resistant or high-risk disease.

Ruptured ectopic molar pregnancy and ruptured uterine fibroid: a challenging rare diagnosis

Although rare and unusual occurrences, a ruptured ectopic molar pregnancy (MP) and a ruptured uterine fibroid can lead to significant maternal morbidity and mortality. We present a unique case of these complications developing concurrently-resulting in the haemodynamic compromise of an otherwise healthy young female patient. The patient underwent a diagnostic laparoscopy which converted into a laparotomy, salpingectomy and myomectomy. Comprehensive histopathology confirmed the diagnosis of a ruptured ectopic complete MP and ruptured uterine fibroid. The patient recovered quickly within days. Prompt definitive management, conclusive histopathology and adequate follow-up were the hallmarks of this singular case. These key factors lead to the rare diagnosis of ruptured ectopic MP and uterine fibroid, prevention of adverse outcomes and provision of comprehensive patient care.

The effect of prophylactic chemotherapy on treatment outcome of postmolar gestational trophoblastic neoplasia

OBJECTIVE

To evaluate whether prophylactic chemotherapy (P-chem) increased the drug resistance rate of postmolar GTN and whether the first-line chemotherapy should be different from P-chem.

METHODS

Postmolar GTN received P-Chem was defined as P-Chem group. Postmolar GTN without P-chem was randomly selected as control group according to the ratio of 1:3 (P-chem:control) and matched by age for low risk and high risk GTN separately.

RESULTS

Totally 455 low-risk and 32 high-risk postmolar GTN patients were included. WHO risk score, chemotherapy cycles to achieve hCG normalization and resistant rate were similar between P-chem (27 cases) and control (81 cases) group. Among low-risk GTN patients, interval from hydatidiform mole to GTN was significantly longer in P-chem group than control (44 vs 69 days, P = 0.001). Total chemotherapy cycles and resistant rate were similar between low-risk GTN treated with same agent as P-chem (group A) and alternative agent (group B). But group A needed more chemotherapy cycles to achieve hCG normalization than group B.

CONCLUSIONS

P-chem delayed the time to GTN diagnosis, but didn't increase risk score or lead to drug resistance of postmolar GTN. Alternative agent different from P-chem had the potential of enhancing chemotherapy response in low- risk postmolar GTN.

Ruptured ectopic pregnancy as complete hydatidiform mole: Case report and review of the literature

Usually, a hydatidiform mole (HM) develops inside the uterus. The occurrence of HM in ruptured tubal pregnancy is exceptional. Cases reported in the literature are scarce. In this article, a case of haemoperitoneum secondary to a ruptured fallopian tube by a complete mole is reported. A 50-year-old gravida 2, para 1 was admitted to the emergency department for acute abdominal pain. After the clinical examination, an abdominal sonography and CT scan were done, revealing the presence of an adnexal left mass associated with an important haemoperitoneum. A urine pregnancy test was done and was positive, indicating an immediate laparoscopic exploration. The laparoscopy revealed a haemoperitoneum secondary to a ruptured tubal mass. The pathological exam concluded a complete hydatidiform mole (CHM) invading the wall of the fallopian tube. Any acute abdominal pain in a potentially pregnant woman imposes first the routine realization of a pregnancy test. The occurrence of CHM in a ruptured fallopian tube is particularly rare and has exceptionally been diagnosed before the laparoscopic exploration.

Challenges in diagnosing hydatidiform moles: a review of promising molecular biomarkers

INTRODUCTION

Hydatidiform moles (HMs) are pathologic conceptions with unique genetic bases and abnormal placental villous tissue. Overlapping ultrasonographical and histological manifestations of molar and non-molar (NM) gestations and HMs subtypes makes accurate diagnosis challenging. Currently, immunohistochemical analysis of p57 and molecular genotyping have greatly improved the diagnostic accuracy.

AREAS COVERED

The differential expression of molecular biomarkers may be valuable for distinguishing among the subtypes of HMs and their mimics. Thus, biomarkers may be the key to refining HMs diagnosis. In this review, we summarize the current challenges in diagnosing HMs, and provide a critical overview of the recent literature about potential diagnostic biomarkers and their subclassifications. An online search on PubMed, Web of Science, and Google Scholar databases was conducted from the inception to 1 April 2022.

EXPERT OPINION

the emerging biomarkers offer new possibilities to refine the diagnosis for HMs and pregnancy loss. Although the additional studies are required to be quantified and investigated in clinical trials to verify their diagnostic utility. It is important to explore, validate, and facilitate the wide adoption of newly developed biomarkers in the coming years.

Short tandem repeat polymorphism analysis for primary peritoneal choriocarcinoma: A case report and literature review

The peritoneum is an extremely rare site for primary choriocarcinoma development. Primary peritoneal choriocarcinoma could be either gestational or nongestational, whereas it is straightforward to ascribe uterine or tubal choriocarcinoma to the gestational origin. Herein, we report a case of primary peritoneal choriocarcinoma that is genetically diagnosed as a gestational subtype originating from an occult complete hydatidiform mole. A 46-year-old female patient with two-time induced abortion histories underwent emergency laparotomy under clinical suspicion of ruptured tubal pregnancy. Laparotomy revealed a hemorrhagic tumor in the left mesosalpinx with apparently intact left ovary and fallopian tube. The excised tumor was pathologically diagnosed as choriocarcinoma. Multiplex short tandem repeat polymorphism analysis revealed an androgenetic/homozygous genotype tumor, identifying its origin as a complete hydatidiform mole. Our literature review of nine primary peritoneal choriocarcinoma cases, including ours, highlighted the importance of tumor genotyping in differentiating between gestational and non-gestational subtypes and identifying the causative pregnancy.

The diagnostic value and accuracy of ultrasound in diagnosing hydatidiform mole: A systematic review and meta-analysis of the literature

INTRODUCTION

Hydatidiform moles are the most common type of gestational trophoblastic disease. Internationally the incidence of hydatidiform moles is 1-2:1000 pregnancies. Early detection of women with hydatidiform moles is preferential, as these women are at a higher risk of developing other gestational trophoblastic disease. Despite Ultrasound being the most common modality used to diagnose hydatidiform moles, its diagnostic value and accuracy throughout all trimesters remains uncertain. Thus, the aim of this review was to explore and evaluate the diagnostic value and accuracy of Ultrasound in diagnosing hydatidiform mole throughout all trimesters of pregnancy.

METHODS

The databases MEDLINE and CINAHL were searched between 2004 and 2021. Included studies were quality assessed using the Mixed Methods Appraisal Tool.

RESULTS

A total of 8 studies were included. The narrative synthesis identified four themes: Misdiagnosis, Complete and Partial molar pregnancy, Operator dependency and Gestational age. The meta-analysis highlighted although the sensitivity of ultrasound for diagnosing hydatidiform moles is relatively low at 52.2%, the specificity was high at 92.6%.

CONCLUSION

While histological examination remains the gold standard for detecting hydatidiform moles, our review made evident that ultrasound is a beneficial diagnostic tool in the detection of Hydatidiform moles, especially alongside other diagnostic investigations. This review has highlighted and collated the main barriers and facilitators to diagnosing hydatidiform moles using ultrasound.

IMPLICATION FOR PRACTICE

Findings suggest that although sonographic detection of hydatidiform moles remains a diagnostic challenge, seeking a second opinion or repeating scans before making a final diagnosis should be embedded into clinical practice.

Severe Hyperthyroidism and Complete Hydatidiform Mole in Perimenopausal Woman: Case Report and Literature Review

Gestational trophoblastic disease (GTD) represents a heterogeneous group of disorders within placental trophoblastic cells that are rather rare in perimenopausal ages. One of its complications is the development of secondary clinical hyperthyroidism, which can be potentially complicated if not properly and early recognized. We report the case of a 50-year-old perimenopausal woman, gravida 2 para 2, who presented to the emergency department with severe acute lower abdominal pain and abnormal uterine bleeding for one month. She also reported abnormal sweating and palpitation for a one-week duration and amenorrhea for the previous three months. Abdominal examination showed a pelvic mass resembling a 15-week sized uterus. Serum β-hCG levels were strongly increased, and abdomen ultrasound displayed an enlarged uterus with “snow-storm” features, compatible with the diagnosis of GTD. Laboratory data revealed suppressed TSH levels and high free thyroxine and free triiodothyronine levels (4 and 1.5 times above the upper limit of normality, respectively). Thyrotropin-receptor antibodies (TRAb) levels were negative, and thyroid ultrasound excluded major structural disease. She was managed with anti-thyroid drugs, Lugol’s iodine, beta-blockers, and steroids during preoperative care. Thereafter, she underwent surgery, being diagnosed with a hydatidiform mole postoperatively. Her thyroid function returned to normal after three months, without the further need for antithyroid drugs. This case highlights the importance of considering GTD as an aetiology for thyrotoxicosis in perimenopausal women, especially in the absence of findings suggesting primary thyroid disease.

Advances in the diagnosis and early management of gestational trophoblastic disease

Gestational trophoblastic disease describes a group of rare pregnancy related disorders that span a spectrum of premalignant and malignant conditions. Hydatidiform mole (also termed molar pregnancy) is the most common form of this disease. Hydatidiform mole describes an abnormal conceptus containing two copies of the paternal genome, which is classified as partial when the maternal genome is present or complete when the maternal genome is absent. Hydatidiform mole typically presents in the first trimester with irregular vaginal bleeding and can be suspected on ultrasound but confirmation requires histopathological evaluation of the products of conception. Most molar pregnancies resolve without treatment after uterine evacuation, but occasionally the disease persists and develops into gestational trophoblastic neoplasia. Close monitoring of women after molar pregnancy, with regular measurement of human chorionic gonadotrophin concentrations, allows for early detection of malignancy. Given the rarity of the disease, clinical management and treatment is best provided in specialist centres where very high cure rates are achievable. This review looks at advances in the diagnosis and early management of gestational trophoblastic disease and highlights updates to disease classification and clinical guidelines. Use of molecular genotyping for improved diagnostic accuracy and risk stratification is reviewed and future biomarkers for the earlier detection of malignancy are considered.

The Contribution of QF-PCR and Pathology Studies in the Diagnosis of Diandric Triploidy/Partial Mole

Objective: the aim of our study was to assess the contribution of quantitative fluorescent polymerase chain reaction (QF-PCR) and pathology studies in the diagnosis of diandric triploidies/partial hydatidiform moles. Methods: this study included all fet al triploidies diagnosed by QF-PCR in chorionic villi or amniotic fluid in the 2 centers of BCNatal in which a maternal saliva sample was used to establish its parental origin. Pathology studies were performed in products of conception and concordance between a partial hydatidiform mole diagnosis and the finding of a diandric triploidy was assessed. Results: among 46 fetal triploidies, found in 13 ongoing pregnancies and in 33 miscarriages, there were 26 (56%) diandric triploidies. Concordant molecular (diandric triploidy) and pathology results (partial mole) were achieved in 14 cases (54%), while in 6 cases (23%) pathology studies were normal, and in the remaining 6 cases (23%) pathology studies could not be performed because miscarriage was managed medically. Conclusions: diandric triploidy is associated with partial hydatidiform mole and its diagnosis is crucial to prevent the development of persistent trophoblastic disease. QF-PCR analysis in chorionic villi or amniotic fluid provides a more accurate diagnosis of the parental origin of triploidy than the classical pathology studies.

Complete hydatidiform mole in a 52-year-old postmenopausal woman: A case report and literature review

Benign gestational trophoblastic disease generally occurs in women of reproductive age and is extremely rare in postmenopausal women. Here, the authors describe a case of complete hydatidiform mole in a 52-year-old postmenopausal woman with a history of lower abdominal bloating and vaginal bleeding. The paper summarizes the clinical manifestations, physiopathology, diagnosis, and treatment options for gestational trophoblastic disease in postmenopausal women. This study highlights that gestational trophoblastic disease can occur in postmenopausal women and that it is important to include it in the differential diagnosis of postmenopausal bleeding, to prevent delay in treatment.

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Hydatidiform mole (HM) is extremely rare in postmenopausal women.

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Patients with hydatidiform mole generally present with vaginal bleeding.

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Prophylactic chemotherapy can prevent distant metastasis of hydatidiform mole.

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Follow-up monitoring of serum β-HCG levels is vital after therapy.

Histopathological examination of the curettage material in nonviable pregnancies and evaluation of the frequency of hydatidiform mole

AIM

The study aimed to determine the frequency of possible missed diagnosis of gestational trophoblastic disease in nonviable pregnancies and to evaluate the importance of histopathological examination.

METHODS

In this retrospective study, the results of the histopathological assessment of patients undergoing uterine surgery with a diagnosis of nonviable pregnancy were analyzed before 14 weeks of gestation. Nonviable pregnancy was defined as anembryonic pregnancy and intrauterine exitus (IU-ex) based on ultrasound findings. The frequency and sonographic characteristics of molar pregnancy in nonviable pregnancy were analyzed.

RESULTS

Molar pregnancy was detected in 24 (1.62%) of 1481 patients diagnosed with nonviable pregnancy on ultrasound. One thousand one hundred and twenty-one of the cases were IU-ex (75.69%) and the remaining were anembryonic pregnancy (24.31%). The mean crown-rump length of pregnancies in the IU-ex group was 16.7 mm and the mean gestational age was 8 weeks. The average gestational sac diameter was found to be 26 mm in anembryonic pregnancy patients. The hydatidiform mole ratio was significantly higher in anembryonic pregnancy patients (3.06%) than in IU-ex patients (1.16%) (p = 0.013).

CONCLUSIONS

The appearance of early molar pregnancy on ultrasound evaluation may mimic anembryonic pregnancies. Therefore, histopathological examination of anembryonic pregnancies may be useful in early diagnosis and for the treatment of gestational trophoblastic neoplasia.

ACR Appropriateness Criteria® Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD), a rare complication of pregnancy, includes both benign and malignant forms, the latter collectively referred to as gestational trophoblastic neoplasia (GTN). When metastatic, the lungs are the most common site of initial spread. Beta-human chorionic gonadotropin, elaborated to some extent by all forms of GTD, is useful in facilitating disease detection, diagnosis, monitoring treatment response, and follow-up. Imaging evaluation depends on whether GTD manifests in one of its benign forms or whether it has progressed to GTN. Transabdominal and transvaginal ultrasound with duplex Doppler evaluation of the pelvis are usually appropriate diagnostic procedures in either of these circumstances, and in posttreatment surveillance. The appropriateness of more extensive imaging remains dependent on a diagnosis of GTN and on other factors. The use of imaging to assess complications, typically hemorrhagic, should be guided by the location of clinical signs and symptoms. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Decreasing incidence of registered hydatidiform moles in Denmark 1999-2014

Incidences of hydatidiform mole (HM) registered in European countries varies from 0.98/1000 to 2.17/1000 deliveries, while higher incidences have been reported in other parts of the world. We calculated the incidence by selecting data on HMs classified as ”first”, “second” and “third” from 01.01.1999 to 31.12.2014 registered in the Danish Pathology Registry, which we previously showed to be the most complete data source on the number of HMs in Denmark. In the study period, 1976 first HMs were registered; 1080 (55%) were classified as PHMs (partial HMs) and 896 (45%) as NPHMs (HMs not registered as PHMs). The average incidence of HM was 1.98/1000 deliveries. The incidence of PHM was 1.08/1000 deliveries and the incidence of NPHM was 0.90/1000 deliveries. Forty HMs were registered as second HMs; 85% (34/40) were of the same histopathological type as the first HM. The registered incidence of HM decreased from 2.55/1000 deliveries in 1999 to 1.61/1000 deliveries in 2014 (p < 0.005). The decrease in the incidence of HM was identical with a decrease in the incidence of PHM. New medical practices such as medical abortion and only forwarding selected pregnancy products for histopathologic examination may cause a declining number of HMs registered.

Impact of ultrasound in diagnosis of hydatidiform mole in early pregnancy: A protocol of systematic review

BACKGROUND

This study aims to assess current evidence of ultrasound in diagnosis of hydatidiform mole (HM) in early pregnancy (EP).

METHODS

This study will incorporate case-control study on investigating the impact of ultrasound in diagnosis of HM in EP. Potential articles will be retrieved in electronic databases of Cochrane Library, MEDLINE/PUBMED, EMBASE, PsycINFO, WANGFANG, and CNKI from inception to the present. Conference proceeding, website of clinical trial registry, and reference list of key articles will be examined for additional studies. Two independent researchers will scan and select studies, collect and manage data, and appraise methodological quality of all eligible studies. We will carry out summary effect size, statistical heterogeneity, synthesize, and analyze outcome data.

RESULTS

This study will summarize present evidence to assess the accuracy of ultrasound in diagnosis of HM in EP.

CONCLUSION

This study may provide evidence for ultrasound in diagnosis of HM in EP, which may benefit both patients and clinicians.

STUDY REGISTRATION

INPLASY202080080.

The impact of pre-evacuation ultrasound examination in histologically confirmed hydatidiform mole in missed abortion

BACKGROUND

Early detecting hydatidiform mole in missed abortion is challenge. In this retrospective observational study, we analysed the sensitivity of detecting hydatidiform mole by pre-evacuation ultrasound examination or naked eye after surgical uterine evacuation in missed abortion.

METHODS

Data on 577 cases with histologically confirmed hydatidiform mole were collected over a 10-year period and analysed. Data included serum β-hCG level before surgical evacuation, the ultrasound examination findings, histology findings and naked eye findings. In addition, serum β-hCG level on 2398 cases without hydatidiform mole was also collected.

RESULTS

The median maternal age was 29 (range, 17-53) years and the range of gestational age was 6 to 12 weeks. The sensitivity of detecting hydatidiform mole by ultrasound examination or by naked eye was 25% or 60% respectively. This sensitivity was not increased by the combination of ultrasound and naked eye. There was no difference in the sensitivity of detecting subtypes of hydatidiform mole. The higher β-hCG level was seen in cases with hydatidiform mole, compared to cases without hydatidiform mole. However, there was a lot of overlap in the distributions of β-hCG between the two groups.

CONCLUSIONS

In this study, we found lower sensitivity of detecting hydatidiform mole by ultrasound in missed abortion. β-hCG level was higher in hydatidiform mole than in non- hydatidiform mole in missed abortion. Although higher sensitivity of detecting hydatidiform mole is seen by naked eye (60%), in order to minimise missed opportunity of detecting hydatidiform mole, our study suggests that routine histopathological examination is necessary in missed abortion.

Partial molar pregnancy with live fetus complicated by intrauterine growth restriction and severe preeclampsia. Case report and review of the literature

OBJECTIVE

To report the case of a partial molar pregnancy with live fetus and conduct a review of the literature regarding maternal and fetal complications associated to this condition.

METHODS

Case report of a partial mole with a 33 weeks live fetus complicated by intrauterine growth restriction, oligohydramnios and severe preeclampsia. We report satisfactory maternal and neonatal outcomes and 1-year follow-up. A search was conducted in the Medline via Pubmed, Lilacs, Ovid, Uptodate and Google Scholar databases using the following MESH terms: hiditadiform mole, partial mole, live fetus, coexisting live fetus. Case series and case reports of pregnant women with coexisting partial mole and live fetus at the time of diagnosis were selected and information regarding maternal and fetal prognosis was extracted.

RESULTS

Initially, 129 related titles were identified. Of these, 29 met the inclusion criteria, and 4 articles were excluded due to failed access to the full text. Overall, 31 reported cases were included; 9 ended in miscarriage, 8 in fetal demise or perinatal death, and 14 (45 %) resulted in a live neonate. The most frequent maternal complication was preeclampsia in 6 (19.35 %) cases.

CONCLUSIONS

The coexistence of a partial mole with a live fetus poses a high risk of adverse perinatal outcomes and preeclampsia. The volume of information regarding this rare condition must be increased in order to better determine potential interventions in cases of euploid fetuses and to provide adequate counseling in clinical practice. Therefore, reporting these cases is important to build sufficient evidence about the natural course of this condition.

Diagnosis and outcome of hydatidiform moles in missed-miscarriage: a cohort-study, systematic review and meta-analysis

OBJECTIVE

To evaluate the ultrasound diagnostic rates of complete hydatidiform moles (CHM) and partial hydatidiform moles (PHM) in women presenting with a missed miscarriage, the clinical complications at diagnosis and the risk of gestational trophoblastic neoplasia (GTN) after surgical evacuation and to compare our findings with those of the published literature by completing a systematic review and meta-analysis STUDY DESIGN: Retrospective review of the data of 295 women diagnosed with a histologically confirmed hydatidiform moles (HM) over a 15-year period, including 128 CHM and 167 PHM. All women were referred to a regional specialist centre for follow-up and further management. An electronic search of PubMed, Google Scholar and MEDLINE was performed for studies published between September 1973 and September 2017 reporting on the early ultrasound diagnosis of hydatidiform mole. Only cohort studies which provided ultrasound data confirmed by histopathology were included.

RESULTS

In the cohort study, ultrasound imaging diagnosed a significantly (p < 0.001) higher number of CHM (95/128 (74.2%) than PHM (68/167 (40.7%). Ovarian theca lutea cysts were observed in three CHM and one PHM. There were no cases of pre-eclampsia or thyrotoxicosis at the time of diagnosis. Maternal serum β-human chorionic gonadotrophin levels were abnormally low (< 0.5 MoM) in 5/51 (10%) CHM and 23/43 (53%) PHM and abnormally high (> 2.0 MoM) in 20/51 (39%) CHM and 2/43 (5%) PHM. Seventeen (12.3%) CHM and two (1.4%) PHM developed a GTN requiring treatment. In the literature the proportion of histologically diagnosed HM, suspected on ultrasound in early pregnancy, ranged between 34.2 and 90.2% for HM, 57.8 and 95% for CHM and 17.6 and 51.6% for PHM. The meta-analysis indicated substantial heterogeneity in the overall ultrasound diagnosis of HM and in the differential diagnosis between CHM and PHM.

CONCLUSION(S)

As around a third of CHM and two thirds of PHM are not diagnosed on ultrasound in cases of missed miscarriage, histopathological examination of all products of conception in case of early pregnancy failure is essential to detect molar changes. This is particularly important for the management of women with CHM who have a higher risk of developing a GTN.

Complete Molar Pregnancy in Posmenopausal Woman-a Case Report

Introduction:

Gestational trophoblastic desease (GTD) is disease typical for reproductive period of women and is extremly rare in postmenopausal period of woman’s life.

Aim:

To present a rare case of mollar pregnancy in 57 years of age postmenopausal woman.

Case report:

A multiparous woman aged 57 years, and two yars after last menstrual bleeding, was admitted at Clinic, due to hyperplastic endometrium findings and moderate prolonged postmenopausal uterine bleeding. Due to clinical simptoms we performed diagnostic exploratice curettage. During that intervention heavy bleeding was developed resulting in spontaneous expulsion of tumorous mass wich macroscopic looked as a mollar tissue. Imediatelly after intervention level of β HCG was 193,057mlU/mL. Due to very high level of β HCG patient was taken to laparotomy and during the surgery dicision was made to perform total abdominal hysterectomy with bilateral adnexectomy. Eight day after surgery patient was discharged from Clinic in good condition. Hystopathological examination of material obtained by explorative curettage and uterus showed complete mollar pregnancy. Controlled level of β HCG was 1,996 mlU/mL fifth day after surgery.

Conclusion:

Although molar pregnancy in postmenopausal period of woman’s life is very rare disorder, because of potentialy heavy complications it is very important to recognise this disorder at time, to prevent delay of treatment.

Ultrasound diagnosis of complete and partial hydatidiform moles in early pregnancy failure: An inter-observer study

We evaluated the accuracy of the ultrasound signs suggestive of complete hydatidiform mole (CHM) and partial hydatidiform mole (PHM) in a cohort of women with histologically confirmed hydatidiform mole (HM) who presented with early pregnancy failure, including 103 CHM and 95 PHM for which ultrasound images were available. The accuracy of the differential diagnosis was significantly (p < 0.001) greater during secondary examination of ultrasound images compared with the original primary ultrasound examination. The interobserver agreement analysis indicated only a fair to moderate agreement between the two examinations (kappa value 0.41; 95% CI 0.29-0.53). Most HM present as early pregnancy failure and identification of early ultrasound signs can improve the differential diagnosis between CHM and PHM.

A Pictorial Ultrasound Essay of Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD) includes a wide variety of clinical and histopathologic entities that require prompt identification and definition by the integration of clinical, laboratory, and imaging data. Recently, the role of grayscale ultrasound and spectral and power/color Doppler techniques has become pivotal in the diagnosis, staging, and management of GTD, thanks to both technical improvements and the growing expertise of dedicated operators. The aim of this essay is to summarize the most recent data on the ultrasound and Doppler findings of GTD and to provide a pictorial overview, including useful prognostic and therapeutic implications for clinical practice.

Incidence and outcome of gestational trophoblastic disease in lower Egypt

BACKGROUND

Gestational trophoblastic disease (GTD) defines a spectrum of proliferative disorders of trophoblastic epithelium of the placenta. Incidence, risk factors, and outcome may differ from one country to another.

OBJECTIVE

To describe incidence, patient characteristics, treatment modalities, and outcome of GTD at Mansoura University which is a referral center of Lower Egypt.

METHODS

An observational prospective study was conducted at the GTD Clinic of Mansoura University. The patients were recruited for 12 months from September 2015 to August 2016. The patients' characteristics, management, and outcome were reported.

RESULTS

We reported 71 clinically diagnosed GTD cases, 62 of them were histologically confirmed, 58 molar (33 CM and 25 PM) in addition to 4 initially presented GTN cases. Mean age of the studied cases was 26.22 years ± 9.30SD. Mean pre-evacuation hCG was 136170 m.i.u/ml ±175880 SD. Most of the cases diagnosed accidentally after abnormal sonographic findings (53.2%). Rate of progression of CM and PM to GTN was 24.2% and 8%, respectively.

CONCLUSION

The incidence of molar pregnancy and GTN in our locality was estimated to be 13.1 and 3.2 per 1000 live births respectively. We found no significance between CM and PM regarding hCG level, time to hCG normalization, and progression rate to GTN.

Pre-operative classification of molar pregnancy: How good is ultrasound?

BACKGROUND

Histopathology is the reference standard for diagnosing hydatidiform molar pregnancy (HMP).

AIM

To assess the performance of pre-operative transvaginal ultrasound (TVS) to predict HMP.

MATERIALS AND METHODS

A retrospective diagnostic accuracy study was performed on women who had both TVS and histopathological examination of uterine curettings between January 2011-February 2017. TVS diagnosis of partial MP (PMP) included assessment of fetal parts and/or empty gestational sac with small cystic spaces adjacent to gestational sac. TVS diagnosis of complete MP (CMP) included assessment of complex, echogenic intra-uterine mass(es) containing multiple small cystic areas. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratios (PLR/NLR) for TVS were reported. Reference standard was histology.

RESULTS

There were 4917 consecutive women who underwent TVS; 1636 underwent surgical curettage for miscarriage. Forty out of 4917 (0.6%) had HMP histologically; 25/40 (62.5%) had suspected HMP and 15/40 (37.5%) did not; 24/40 (60.0%) had CMP of which 19/24 (79.1%) were suspected on TVS and 5/24 (20.8%) were not; 16/40 (40.0%) had PMP of which 6/16 (37.5%) were suspected on TVS and 10/16 (62.6%) were not. The sensitivity, specificity, PPV, NPV, PLR and NLR of pre-operative TVS to predict HMP were: 60.0, 99.1, 63.2, 99.0% 68.4, 0.4; for CMP: 79.2, 99.8, 86.3, 99.6%, 421.7, 0.2; for PMP: 37.5, 99.3, 35.3, 99.4%, 54.3, 0.6.

CONCLUSION

Histology remains the gold standard for diagnosing HMP. TVS is an acceptable diagnostic tool for HMP. When there are no ultrasound features of HMP, almost all these women will not have an underlying HMP.

MRI evaluation of the placenta from normal variants to abnormalities of implantation and malignancies

Even though the placenta has been known for millennia, it is still considered one of the most complex and least understood human organs. Imaging of the placenta is gaining attention due to its impact on fetal and maternal outcomes. MRI plays a vital role in evaluation of inconclusive cases by ultrasonography. It enables precise mapping of placental abnormalities for proper multidisciplinary planning and management. In this article we provide a comprehensive in-depth review of the role of antenatal MR in evaluating "The Placenta." We will describe the protocols and techniques used for MRI of the placenta, review anatomy of the placenta, describe MRI features of major placental abnormalities including those related to position, depth of implantation, hemorrhage, gestational trophoblastic neoplasia, and retained products of conception and discuss the added value of MRI in the management and preoperative planning of such abnormalities. Level of Evidence: 3 Technical Efficacy Stage: 5 J. Magn. Reson. Imaging 2019;50:1702-1717.

Ultrasound of the First Trimester

Ultrasound is the imaging study of choice for detection and full characterization of early pregnancies based on its accuracy, low cost, safety profile, and abundant availability. This article reviews the goals and utility of first-trimester ultrasound in gestation localization, viability determination, and abnormal pregnancies, including ectopic implantation, retained products, and molar pregnancy.

Imaging in Gestational Trophoblastic Disease

Gestational trophoblastic disease (GTD) is a spectrum of disorders characterized by abnormal trophoblastic proliferation. GTD includes benign conditions such as hydatidiform moles and malignant diseases that are referred as gestational trophoblastic neoplasia (GTN). Ultrasound plays a central role in the diagnosis of patients with hydatidiform mole. Other imaging modalities are useful in molar pregnancy, mainly for evaluating pulmonary complications and atypical presentation of hydatidiform mole. GTN typically arises after 20% of molar pregnancies but can uncommonly occur after nonmolar gestations. After uterine evacuation, serial human chorionic gonadotropin levels are evaluated in patients for early detection of GTN. Once GTN is suspected, Doppler ultrasound is the primary tool to confirm the diagnosis; however, magnetic resonance imaging can also help in selected cases. Metastatic disease workup can involve various modalities, including ultrasound, X-ray, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography. In this article, we review the main imaging modalities used to evaluate patients with GTD.

Atypical presentation of molar pregnancy

The classic features of molar pregnancy are irregular vaginal bleeding, hyperemesis, enlarged uterus for gestational age and early failed pregnancy. Less common presentations include hyperthyroidism, early onset pre-eclampsia or abdominal distension due to theca lutein cysts. Here, we present a case of molar pregnancy where a woman presented to the emergency department with symptoms of acute abdomen and was treated as ruptured ectopic pregnancy. The woman underwent laparoscopy and evacuation of retained products of conception. Histological examination of uterine curettage confirmed the diagnosis of a complete hydatidiform mole. The woman was discharged home in good general condition with a plan for serial beta-human chorionic gonadotropin (beta-hCG) follow-up. Complete follow-up includes use of contraception and follow-up after beta-hCG is negative for a year.

Hydatidiform mole: validity of the registration in the Danish National Patient Registry, the Danish Cancer Registry, and the Danish Pathology Registry 1999-2009

Purpose

To examine the validity of registration of hydatidiform mole (HM) in the Danish National Patient Registry (NPR), the Danish Cancer Registry (DCR), and the Danish Pathology Registry (DPR).

Patients and methods

We selected women registered with a first-time HM code in NPR, DCR, and DPR from 1999 to 2009. We found most women registered in DPR. For a random sample of women registered in DPR, the coding was validated by comparing with the pathology report. Completeness and positive predictive value (PPV) of registration with an HM code in NPR and DCR were calculated using DPR as the reference. Details of women registered in NPR or DCR, but not in DPR, were scrutinized.

Results

In NPR and DPR, 1,520 women were identified in total; 1,057 (70%) were found in both registries, 65 (4%) only in NPR, and 398 (26%) only in DPR. In DCR and DPR, 1,498 women were identified in total; 1,174 (78%) in both registries, 47 (3%) only in DCR, and 277 (19%) only in DPR. For 149/150 randomly selected women registered with an HM code in DPR (99%), the pathology report was consistent with the diagnosis of HM. Completeness of NPR was 73% (95% CI: 70%–75%) and PPV was 94% (95% CI: 93%–95%). Completeness of DCR was 72% (95% CI: 69%–75%) in 1999–2003 and 90% (95% CI: 87%–92%) in 2004–2009. PPV of DCR was 96% (95% CI: 95%–97%) throughout the period.

Conclusion

Validation of registry data is important before using these. For research on the number of HMs in Denmark, DPR is the most valid data source. NPR and DCR appear to be equally valid before 2004. However, for research after 2004, DCR should be preferred rather than NPR.

Obstetric ultrasound aids prompt referral of gestational trophoblastic disease in marginalized populations on the Thailand-Myanmar border

Background: The use of obstetric ultrasound in the diagnosis of gestational trophoblastic disease (GTD) in high-income settings is well established, leading to prompt management and high survival rates. Evidence from low-income settings suggests ultrasound is essential in identifying complicated pregnancies, but with limited studies reviewing specific conditions including GTD.

Objective: The aim of this study is to review the role of ultrasound in diagnosis and management of GTD in a marginalized population on the Thailand–Myanmar border. Antenatal ultrasound became available in this rural setting in 2001 and care for women with GTD has been provided by Thailand public hospitals for 20 years.

Design: Retrospective record review.

Results: The incidence of GTD was 103 of 57,004 pregnancies in Karen and Burmese women on the Thailand–Myanmar border from 1993–2013. This equates to a rate of 1.8 (95% CI 1.5–2.2) per 1000 or 1 in 553 pregnancies. Of the 102 women with known outcomes, one (1.0%) died of haemorrhage at home. The median number of days between first antenatal clinic attendance and referral to hospital was reduced from 20 (IQR 5–35; range 1–155) to 2 (IQR 2–6; range 1–179) days (p = 0.002) after the introduction of ultrasound. The proportion of severe outcomes (death and total abdominal hysterectomy) was 25% (3/12) before ultrasound compared to 8.9% (8/90) with ultrasound (p = 0.119). A recurrence rate of 2.5% (2/80) was observed in the assessable population. The presence of malaria parasites in maternal blood was not associated with GTD.

Conclusions: The rate of GTD in pregnancy in this population is comparable to rates previously reported within South-East Asia. Referral time for uterine evacuation was significantly shorter for those women who had an ultrasound. Ultrasound is an effective method to improve diagnosis of GTD in low-income settings and an effort to increase availability in marginalized populations is required.

Partial molar pregnancy in the cesarean scar: A case report and literature review

RATIONALE

The incidence of molar pregnancy in the cesarean scar is exceedingly low, however, the disease may carry a high risk of uncontrolled hemorrhage or uterine rupture. So far managements of this disease were rarely reported in literature.

PATIENT CONCERNS

We reported a 28-year-old woman presented to our hospital with a complaint of amenorrhea for 48 days and vaginal bleeding for 3 days.

DIAGNOSIS

Transvaginal ultrasonography, serum hCG and pelvic MRI confirmed the cesarean scar pregnancy.

INTERVENTIONS

The patient underwent bilateral uterine arterial embolization and suction evacuation.

OUTCOMES

The postoperative histologic examination of the tissue revealed a partial hydatidiform mole.

LESSONS

Molar pregnancy in the cesarean scar is tough to differentiate from normal cesarean scar pregnancy with serum hCG, sonogram or MRI. This case suggested us that it was necessary to perform a histological examination of postoperative specimen for cesarean scar pregnancy.

Ultrasound diagnosis of molar pregnancy

Introduction

The primary aims of this study were to establish what proportion of ultrasonically suspected molar pregnancies were proven on histological examination and what proportion of histologically diagnosed molar pregnancies were identified by ultrasound pre-operatively. The secondary aim was to review the features of these scans to help identify criteria that may improve ultrasound diagnosis.

Methods

This was a retrospective observational study conducted in the Early Pregnancy Unit at King's College Hospital London over an 11-year period. Cases of ultrasonically suspected molar pregnancy or other gestational trophoblastic disease were identified and compared with the final histopathological diagnosis. In addition, cases which were diagnosed on histopathology that were not suspected on ultrasound were also examined. In discrepant cases, the images were reviewed unblinded by two senior sonographers. Statistical analysis for likelihood ratio and post-test probabilities was performed.

Results

One hundred eighty-two women had gestational trophoblastic disease suspected on ultrasound examination (1:360, 0.3%); 106/182 (58.2%, 95% CI 51.0 to 65.2%) had histologically confirmed gestational trophoblastic disease. The likelihood ratio for gestational trophoblastic disease after a positive ultrasound was 607.27, with a post-test probability of 0.628.The sensitivity of ultrasound for gestational trophoblastic disease was 70.7% (95% CI 62.9% to 77.4%) with an estimated specificity of 99.88% (95% CI 99.85% to 99.91%); 102/143 (71.3%, 95% CI 63.4 to 78.1%) molar pregnancies were suspected on pre-op ultrasound; 60/68 (88.2%, 95% CI 78.2 to 94.2%) of complete moles were suspected on pre-op ultrasound, compared with 42/75 (56.0%, 95% CI 44.7 to 66.7%) of partial moles. On retrospective review of the pre-op ultrasound images, there were cases that could have been suspected prior to surgery.

Conclusion

Detecting molar pregnancy by ultrasound remains a diagnostic challenge, particularly for partial moles. These data suggest that there has been an increase in both the predictive value and the sensitivity of ultrasound over time, with a high LR and post-test probability; however, the diagnostic criteria remain ill-defined and could be improved.

The Usefulness of Ultrasound Imaging in Gynecologic Oncology

Pelvic ultrasound examination is the primary imaging modality for evaluating a wide range of female pelvic symptomatology, and is often the first imaging test to detect a gynecologic malignancy. Ultrasound imaging is particularly useful for evaluating the thickness and appearance of the endometrium in patients with abnormal bleeding, and in detecting and characterizing ovarian lesions. This article reviews the ultrasound appearance of gynecologic neoplasms grouped by anatomic site of origin, the ultrasound appearance of select benign pelvic pathology not to be misinterpreted as malignancy, as well as available ultrasound imaging-based guidelines for managing potential gynecologic neoplasms.

A twin pregnancy with a hydatidiform mole and a coexisting live fetus: prenatal diagnosis, treatment, and follow-up

Twin molar pregnancy with a hydatidiform mole and a coexisting live fetus is a rare form of gestational trophoblastic disease associated with an increased risk of obstetric complications and poor perinatal outcome. Prenatal diagnosis is essential for couple counseling and follow-up in Tertiary Reference Centers. Magnetic resonance imaging is important for the diagnostic differentiation of placental mesenchymal dysplasia and exclusion of myometrial invasion. Here we present a case of twin molar pregnancy with a hydatidiform mole and a coexisting live fetus diagnosed at gestational week 14 using two-dimensional (2D) and three-dimensional (3D) ultrasound and magnetic resonance imaging. We also describe the obstetric management and postmolar follow-up.

New insights in the pathophysiology of complete hydatidiform mole

OBJECTIVE

The majority of complete hydatidiform moles (CHM) are detected on ultrasound examination by the end of the first trimester when they present as multiple sonolucent cysts. To better understand the pathophysiology of this unique placental pathology and improve its prenatal diagnosis and management we have reviewed the ultrasound features of CHM before the appearance of cystic changes.

STUDY DESIGN

We searched our database to identify all women diagnosed with a complete hydatidiform mole confirmed by histopathology who had an ultrasound examination before 9 weeks' gestation. We reviewed their ultrasound reports and all the corresponding images.

RESULTS

The study group included 39 women with a positive pregnancy test and vaginal bleeding, 36 of whom had at least two ultrasound examinations before 9 weeks' gestation. At the first scan (mean gestation age 7 + 1 weeks; SD 1.1), 29 out 39 (74.4%) of CHM presented as a heterogeneous hyperechogenic mass with or without gestational sac and the remaining ten (25.6%) cases as a regular 4-week gestational sac. Cystic molar changes became apparent from the end of the second month of gestation.

CONCLUSION

The development of a CHM follows a well-defined pattern starting with a macroscopically normal gestation sac at 4 weeks, which transforms into a polypoid mass between 5 and 7 weeks of gestation. The hydropic changes of the villous tissue is progressive and rarely visible in utero on ultrasound before 8 weeks of gestation. These findings should allow an earlier diagnosis and assist in the management counselling of women with CHM.

Gestational Trophoblastic Disease: Clinical and Imaging Features

Gestational trophoblastic disease (GTD) is a spectrum of both benign and malignant gestational tumors, including hydatidiform mole (complete and partial), invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. The latter four entities are referred to as gestational trophoblastic neoplasia (GTN). These conditions are aggressive with a propensity to widely metastasize. GTN can result in significant morbidity and mortality if left untreated. Early diagnosis of GTD is essential for prompt and successful management while preserving fertility. Initial diagnosis of GTD is based on a multifactorial approach consisting of clinical features, serial quantitative human chorionic gonadotropin (β-hCG) titers, and imaging findings. Ultrasonography (US) is the modality of choice for initial diagnosis of complete hydatidiform mole and can provide an invaluable means of local surveillance after treatment. The performance of US in diagnosing all molar pregnancies is surprisingly poor, predominantly due to the difficulty in differentiating partial hydatidiform mole from nonmolar abortion and retained products of conception. While GTN after a molar pregnancy is usually diagnosed with serial β-hCG titers, imaging plays an important role in evaluation of local extent of disease and systemic surveillance. Imaging also plays a crucial role in detection and management of complications, such as uterine and pulmonary arteriovenous fistulas. Familiarity with the pathogenesis, classification, imaging features, and treatment of these tumors can aid in radiologic diagnosis and guide appropriate management. ^©RSNA, 2017.

Challenges in the Routine Praxis Diagnosis of Hydatidiform Mole: a Tertiary Health Center Experience

Introduction:

Hydatidiform moles (HM), presenting as complete (CHM) and partial (PHM) form, are rare pregnancy disorder. Diagnosis is based on clinical presentation, ultrasound imaging findings and pathological examination of products of conception. Protein p57, encoded by CKDN1C gene, is paternally imprinted and maternally expressed gene and provides quick insight in genetic basis of HM and allows distinction of CHM from all other conceptions. compare the preevacuational and pathohistological diagnosis with outcome of p57 immunostaining.

Material and methods:

All cases of HM diagnosed between January 2011 and December 2015 were included in this research. Maternal age, gestational age and input diagnosis data were recored. p57 immunostaining was performed in order to evaluate the diagnosis based on tissue slides examination.

Results:

There were 198 cases of histologically confirmed HM, 185 PHM, 12 CHM and one case of undefined HM. Mean maternal age in the CHM group was 24,7 and in the PHM group 26,9 years, with no significant differences among these two groups (p=0,27). For CHM mean gestational age was estimated at eight and for PHM 9,2 gestational weeks. Pregnant woman older than 40 years present significant earlier compared with younger woman (p<0,01), and those younger than 20 years tend to present at the beginning of the second trimester more often than older women (p<0,05). In the CHM group, 9 (75%) input diagnoses were mola in obs, and 3 (25%) of them were signed as abortion, unlike the PHM where 126 (67%) were qualified as abortion, 35 (19%) as blighted ovum, and 26 (14%) were suggestive for molar pregnancy. p57 immunostaining results confirmed all pathohistological diagnosis of CHM whereas 8% of PHM demonstrated divergent p57 expression.

Conclusion:

PHM, compared with CHM, represent a greater diagnostic challenge for both gynecologist and pathologist even when presenting in more advanced pregnancies.

First-trimester emergencies: a radiologist's perspective

The purpose of this article is to help the practitioner ensure early diagnosis and response to emergencies in the first trimester by reviewing anatomy of the developing embryo, highlighting the sonographic appearance of common first-trimester emergencies, and discussing key management pathways for treating emergent cases. First-trimester fetal development is a stepwise process that can be challenging to evaluate in the emergency department (ED) setting. This is due, in part, to the complex anatomy of early pregnancy, subtlety of the sonographic findings, and the fact that fewer than half of patients with ectopic pregnancy present with the classic clinical findings of a positive pregnancy test, vaginal bleeding, pelvic pain, and tender adnexa. Ultrasound (US) has been the primary approach to diagnostic imaging of first-trimester emergencies, with magnetic resonance imaging (MRI) and computed tomography (CT) playing a supportive role in a small minority of cases. Familiarity with the sonographic findings diagnostic of and suspicious for early pregnancy failure, ectopic pregnancy, retained products of conception, gestational trophoblastic disease, failed intrauterine devices, and complications associated with assisted reproductive technology (ART) is critical for any emergency radiologist. Evaluation of first-trimester emergencies is challenging, and knowledge of key imaging findings and familiarity with management pathways are needed to ensure early diagnosis and response.