Increase in the level of β-HCG after uterine artery embolization in the context of partial molar pregnancy: A case report

This report documents the case of a patient with a previously diagnosed partial molar pregnancy evacuated by dilation and suction curettage with appropriately declining post-operative levels of beta-human chorionic gonadotropin (beta-hCG), who, one month later, underwent uterine artery embolization in the setting of acute bleeding and imaging concerning for arteriovenous malformation. After embolization, beta-hCG levels increased, prompting concern for gestational trophoblastic neoplasia and referral to gynecologic oncology. With further workup, the elevation was found to be transient and benign - a phenomenon not previously described.

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.

Chimeric Singleton Placenta Comprising Placental Mesenchymal Dysplasia and Complete Hydatidiform Mole with Live Birth and Postpartum Diagnosis of Gestational Trophoblastic Neoplasia

INTRODUCTION

Placental mesenchymal dysplasia (PMD) is a benign lesion that is often misdiagnosed as complete (CHM) or partial hydatidiform mole. PMD usually results in live birth but can be associated with several fetal defects. Herein, we report PMD with CHM in a singleton placenta with live birth.

CASE PRESENTATION

A 34-year-old gravida 2, para 1, living 1 (G2P1L1) woman was referred on suspicion of a molar pregnancy in the first trimester. Maternal serum human chorionic gonadotrophin levels were increased during early pregnancy, with multicystic lesions and placentomegaly observed on ultrasonography. Levels decreased to normal with no fetal structural abnormalities observed. A healthy male infant was delivered at 34 gestational weeks. Placental p57KIP2 immunostaining and short tandem repeat analysis revealed three distinct histologies and genetic features: normal infant and placenta, PMD, and CHM. Gestational trophoblastic neoplasia was diagnosed and up to fourth-line chemotherapy administered.

CONCLUSION

Distinguishing PMD from hydatidiform moles is critical for avoiding unnecessary termination of pregnancy. CHM coexisting with a live fetus rarely occurs. This case is unique in that a healthy male infant was born from a singleton placenta with PMD and CHM.

Unexpected association between breast cancer and molar pregnancy in a 52-year-old woman: A case report

INTRODUCTION

There was no prior discussion about the association between breast cancer and molar pregnancy, particularly at an advanced age. Through our case and a systematic review, we will discuss the relevance of ovarian castration in hormone-receptor-positive breast cancer.

CASE PRESENTATION

We reported the case of a 52-year-old woman, not yet menopausal, who was diagnosed with a right breast tumor classified as BI-RADS category 4. The anatomopathological analysis of mammary biopsy revealed an invasive ductal carcinoma of no special type (grade 2). Hormone receptors were positive. It was a HER2-negative Breast cancer. It was then decided to treat the patient with radical surgery followed by chemotherapy, radiotherapy, and hormonotherapy. The patient had a "Patey operation". The postoperative course was without significant complications. No medical or surgical castration was indicated in the expectation that chemotherapy would cause ovarian failure. Unlikely, during chemotherapy course our patient developed a molar pregnancy.

CLINICAL DISCUSSION

Our case illustrates the possibility of pregnancy in non-menopausal women with estrogen-receptor-positive breast cancer. The combination of tamoxifen or aromatase inhibitors with ovarian suppression as standard adjuvant therapy may be recommended in such cases.

CONCLUSIONS

Ovarian function suppression in non-menopausal women with hormone receptor-positive breast cancer seems to be necessary. So that, we can avoid unexpected manifestations like molar pregnancy.

Thyrotoxicosis in the Setting of Hydatidiform Mole with Subsequent Development of Takotsubo Cardiomyopathy Complicated by COVID-19

We present a rare case of hydatidiform molar pregnancy, which led to the development of thyroid storm, followed by a rare complication of takotsubo cardiomyopathy in the setting of a COVID-19 infection. A 21-year-old female of 22 weeks gestational age presented with heavy vaginal blood loss, brown emesis, tachycardia, and lethargy. Through clinical presentation and ultrasound confirmation, a molar pregnancy was diagnosed. Laboratory data and clinical presentation of thyrotoxicosis supported a diagnosis of thyroid storm. Test for COVID-19 was positive. The patient was treated with dilation and curettage, antithyroid medication, and blood transfusions, resulting in symptom resolution. Thereafter, echocardiography confirmed takotsubo cardiomyopathy. It is suspected that the homology in structure between the human chorionic gonadotropin (hCG) and thyroid stimulating hormone subunits resulted in thyroid storm secondary to receptor cross-reactivity. We speculate that subsequent cardiovascular stress of b-hCG-induced thyroid storm with superimposed COVID-19 infection facilitated the development of Takotsubo cardiomyopathy.

Combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios for early prediction of postmolar gestational trophoblastic neoplasia

PURPOSE

To investigate factors predicting postmolar gestational trophoblastic neoplasia (GTN) by combined analysis of clinical features, human chorionic gonadotropin (hCG) value, and hCG ratios.

METHODS

This retrospective study enrolled patients with histopathologically proven molar pregnancy. Patients lost to follow-up before remission or developing postmolar GTN were excluded. Demographic and clinical characteristics and hCG data obtained before and after molar evacuation were collected. Area under the receiver operating characteristic curve (AUC) analysis was used to identify the hCG and hCG ratio cutoff values that predict postmolar GTN. Multivariate analysis was employed to identify independent predictors of GTN.

RESULTS

There were 113 complete moles, 11 partial moles, and 52 unspecified moles included in the final analysis. Of the 176 cases, 90 achieved remission and 86 developed post-molar GTN. The incidence of postmolar GTN was 48.9%, with a median time to GTN development of 5 weeks. Univariate analysis showed age, molar evacuation performed elsewhere, pre-evacuation hCG, hCG at 2nd week post-evacuation, and ratio of hCG at 2nd week post-evacuation to post-evacuation hCG significantly predict GTN. Multivariate analysis revealed an hCG value ≥ 1400 IU/L at 2nd week post-evacuation (AUC: 0.92, aOR: 6.51, 95% CI 1.28-33.16; p = 0.024) and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 (AUC: 0.88, aOR: 12.27, 95% CI 2.15-70.13; p = 0.005) to independently predict GTN.

CONCLUSIONS

An hCG value ≥ 1400 IU/L at 2nd week post-evacuation and a ratio of hCG at 2nd week post-evacuation to post-evacuation hCG of ≥ 0.02 independently and reliably predict postmolar GTN.

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.

How Could One Sperm and One Oocyte Proceed To Molar Pregnancy? Prevalence of Molar Pregnancy during ICSI Procedure in Over 25,000 Fresh Embryo Transfers: A Retrospective Cross-Sectional Study

BACKGROUND

Gestational trophoblastic disease (GTD) is a heterogeneous group of diseases characterized by excessive proliferating trophoblastic tissue. The prevalence of GTD has a varied geographical distribution. However, its frequency following intracytoplasmic sperm injection (ICSI) cycles has not yet been reported. This study aimed to estimate GTD frequency and prevalence after ICSI cycles.

MATERIALS AND METHODS

This retrospective cross-sectional study included all patients diagnosed with GTD subsequent to ICSI and segmental embryo transfer procedure during 2011-2019 at Royan Institute. GTD diagnosis was established for patients who met all three criteria: beta-human chorionic gonadotropin (β-hCG) levels greater than 100,000 mIU/mL, vesicular ultrasonographic pattern, and presence of pathologic features of hydatidiform mole. Although we assessed the GTD frequency in all ICSI cycles, GTD cases were only observed following fresh embryo transfer ICSI procedures.

RESULTS

We evaluated 25,667 fresh embryo transfer ICSI procedures out of 41,540 ICSI cycles. This study identified a total of 10 GTDs confirmed by all criteria which were mentioned previously. Of these 10 GTDs, nine cases had hydatidiform mole, and one had gestational trophoblastic neoplasia. The frequency of GTD was calculated 10 cases in 41,540 (0.240 per 1000) ICSI procedures and 10 in 25,667 (0.389 per 1000) fresh embryo transfers following ICSI cycles. Also, we detected 10 GTD cases in 8,196 (1.220 per 1000) clinical pregnancies.

CONCLUSION

We discuss that the possibility of GTD after ICSI procedure is not as low as expected. Thus, the previous theses are insufficient to explain all aspects of molar pregnancy, and more research is required.

Association of extended culture to blastocyst and pre-malignant gestational trophoblastic disease risk following IVF/ICSI-assisted reproduction cycles: an analysis of large UK national database

PURPOSE

To assess whether there is an association between extended in vitro culture based on embryo developmental stage at transfer and pre-malignant gestational trophoblastic disease (GTD) risk of molar pregnancy during assisted reproduction.

METHODS

A retrospective study was carried out using Human Fertilization and Embryology Authority (HFEA) anonymized register from 1999 to 2016. A total of 540,376 cycles were eligible to be included in the study after excluding any kind of donor treatment or surrogacy, frozen embryo transfers, and cycles with incomplete data. Subgroup analysis was carried out in subjects with primary infertility aiming to exclude an increased risk in those with a previous GTD. Multivariate logistic regression analysis was used to adjust for possible confounders, and the effect of day of embryo transfer in IVF (in vitro fertilization)/ICSI (intracytoplasmic sperm injection) treatment on a molar pregnancy GTD outcome was analyzed.

RESULTS

The prevalence of a molar pregnancy GTD among the study population was 3.4/10,000 livebirths (53/156,683) with a higher risk in the over 40 age category. No significant difference of pre-malignant GTD incidence was seen between IVF and ICSI (0.01% vs 0.009% respectively). No association was seen with GTD based on type/cause of infertility or number of embryos transferred. Crude (1.06; 95% CI 0.852-1.31) and adjusted (1.07; 95% CI (0.857-1.32) odds ratios were calculated to see an association between day of embryo transfer and the occurrence of a GTD. There was no association between day of embryo transfer and molar GTD risk after adjusting for age and secondary infertility.

CONCLUSION

No significant association between pre-malignant molar gestational trophoblastic disease and extended in vitro embryo culture was found after analyzing 540,376 cycles of IVF and ICSI.

Molar pregnancy with a coexisting living fetus: a case series

Background

Coexistence of molar pregnancy with living fetus represents a challenge in diagnosis and treatment. The objective of this study to present the outcome of molar pregnancy with a coexisting living fetus who were managed in our University Hospital in the last 5 years.

Methods

We performed a retrospective analysis of patients who presented with molar pregnancy with a coexisting living fetus to our Gestational Trophoblastic Clinic, Mansoura University, Egypt from September, 2015 to August, 2020. Clinical characteristics of the patients, maternal complications as well as fetal outcome were recorded. The patients and their living babies were also followed up at least 6 months after delivery.

Results

Twelve pregnancies were analyzed. The mean maternal age was 26.0 (SD 4.1) years and the median parity was 1.0 (range 0–3). Duration of the pregnancies ranged from 14 to 36 weeks. The median serum hCG was 165,210.0 U/L (range 7662–1,200,000). Three fetuses survived outside the uterus (25%), one of them died after 5 months because of congenital malformations. Histologic diagnosis was available for 10 of 12 cases and revealed complete mole associated with a normal placenta in 6 cases (60%) and partial mole in 4 cases (40%). Maternal complications occurred in 6 cases (50%) with the most common was severe vaginal bleeding in 4 cases (33.3%). There was no significant association between B-hCG levels and maternal complications (P = 0.3).

Conclusion

Maternal and fetal outcomes of molar pregnancy with a living fetus are poor. Counseling the patients for termination of pregnancy may be required.

Trial registration

The study was approved by Institutional Research Board (IRB), Faculty of Medicine, Mansoura University (number: R.21.10.1492).

Changes in diagnostic sensitivity, incidence and presentation of complete and partial hydatidiform mole over the years

OBJECTIVE

Molar pregnancy is the most common type of gestational trophoblastic disease. Several recent reports have described changes in the clinical representation, the incidence and the diagnostic sensitivity of molar pregnancy. These changes could be due to widespread use of transvaginal ultrasound and beta-hCG testing in the management of routine first-trimester investigations.

STUDY DESIGN

This is a retrospective study of 144 women diagnosed with partial or complete mole at a regional medical center during 2007-2020. Incidence, demographics, clinical features and diagnostic sensitivity were compared between 2007 and 2014 and 2015-2020, and attempts were made to understand the bases of the changes between the time periods.

RESULTS

Sixty-two moles were diagnosed during 2007-2014 and 82 during 2015-2020. The proportions of complete moles in the respective periods were 65% (40) and 18% (15). From the earlier to the later period, the incidence and proportion of complete moles decreased, and of partial moles, increased. The median gestational age at diagnosis of molar pregnancy was 9.3 weeks. In the later period, women presented less frequently with vaginal bleeding, though this remained the most common presenting symptom. The proportion of women who underwent surgical evacuation of the uterus due to suspected molar pregnancy decreased, as did the proportion of moles that was suspected in ultrasound evaluation (P < 0.001).

CONCLUSION

The proportion of complete moles decreased between the periods examined. Gestational age at diagnosis was similar to data from 1994 to 2013. Some typical presenting symptoms of molar pregnancy decreased. However, earlier diagnosis of missed abortion can miss diagnoses of molar pregnancy.

Experience of women on the Irish National Gestational Trophoblastic Disease Registry

OBJECTIVE

Gestational Trophoblastic Disease (GTD) is a rare pregnancy related disorder and the most curable of all gynaecological malignancies. GTD comprises the premalignant conditions of complete or partial hydatidiform mole known as molar pregnancy and a spectrum of malignant disorders termed gestational trophoblastic neoplasia. Clinical management and treatment in specialist centres is essential to achieve high cure rates and clinical guidelines recommend registration with a GTD centre as a minimum standard of care. National GTD registries are valuable repositories of epidemiological data and facilitate clinical audit, centralised pathology review and human chorionic gonadotropin (hCG) monitoring. This study sought the opinion of women enrolled on the Irish National GTD registry to inform future service development and establish a knowledge base for molar pregnancy in Ireland.

STUDY DESIGN

A cross-sectional survey using an anonymised questionnaire was distributed by post to all women on the GTD registry. The questionnaire was designed by a multidisciplinary team and consisted of twenty-five closed-ended questions and two open-ended questions to facilitate feedback. Data collected in the survey included information on the patient experience of registration, knowledge of molar pregnancy, diagnosis at their local hospital, hCG monitoring and overall satisfaction with the service.

RESULTS

The survey had a successful participation rate of 42.6% (215/504). Forty-nine percent (n = 106) of respondents rated a rapid hCG result as their top priority. Forty percent (n = 84) of women had concerns about future pregnancies but acknowledged that these were largely addressed by the GTD specialist nurses. A quarter of respondents reported that other medical professionals with whom they interacted during follow-up treatment did not understand their condition. Many women commented on the emotional stress of attending their local maternity unit for phlebotomy while dealing with pregnancy loss.

CONCLUSION

This study is unique in being the first survey of women on the Irish National GTD registry. It highlights the specific needs of women with molar pregnancy in terms of psychological support, bereavement counselling and peer support groups. It reveals a knowledge gap in molar pregnancy amongst healthcare professionals which should be considered in future planning of medical and nursing curricula.

Short tandem repeat analysis to identify the causative pregnancy of high-risk gestational trophoblastic neoplasia: Molar versus nonmolar pregnancy and its relation to the outcome

INTRODUCTION

Gestational trophoblastic neoplasia (GTN) include a group of malignant neoplasms that originate from the trophoblasts of placental tissue in molar or nonmolar pregnancy. Currently, it is unclear whether the prognosis of high-risk GTN or gestational choriocarcinoma succeeding molar pregnancy or that following a nonmolar one is better. Comparison of the genetic short tandem repeat (STR) patterns of the DNA extracted from the tumor, patient, and her partner allows the genetic origins of the choriocarcinoma to be distinguished - whether it is gestational or non-gestational and whether it is derived from a molar or nonmolar pregnancy in the event it is gestational. This study aimed to investigate the causative pregnancy of patients with high-risk GTN, especially those with poor outcomes, and assess the impact of the causative pregnancy on patient outcome.

METHODS

We evaluated 24 patients who were diagnosed with high-risk GTN between January 2000 and October 2019, including 15 cases of pathologically proven gestational choriocarcinomas and the causative pregnancy was investigated by STR analysis in which tumor DNA could be extracted.

RESULTS

In high-risk GTN without history of anteceding molar pregnancies, nonmolar pregnancy was the causative pregnancy, which was confirmed in three cases. Molar pregnancy appeared be the causative pregnancy of high-risk GTN in patients with a history of antecedent molar pregnancies either with or without interruption by subsequent nonmolar pregnancies prior to developing high-risk GTN. High-risk GTN in most of the evaluated deceased cases (three of four) was due to nonmolar pregnancy, while all but one case with molar pregnancy as the causative pregnancy survived.

DISCUSSION

STR analysis can distinguish the causative pregnancy of high-risk GTN, and nonmolar pregnancy as the causative pregnancy might have negative effects on the outcome of the disease.

Pulmonary metastasis as a primary manifestation of gestational choriocarcinoma in a third trimester pregnancy

•

Choriocarcinomas can follow molar, ectopic, or normal pregnancies.

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The early diagnosis and treatment of choriocarcinomas is imperative.

•

Atypical symptoms in pregnancy should raise suspicion for choriocarcinoma.

•

Choriocarcinoma must always be in the differential in uncomplicated term pregnancies.

Obstetrics outcomes after complete and partial molar pregnancy: Review of the literature and meta-analysis

The hydatidiform mole is a rare gynecological disease rising from the trophoblastic. Post-molar pregnancies have an extremely variable course, varying from repeated abortions, stillbirths, preterm births, live births, or recurring in further molar pregnancies. Literature on obstetric outcomes following molar pregnancy is poor, often including monocentric studies, and with data collected from national databases. This review and meta-analysis aim to analyze the obstetric outcomes after conservative management of complete (CHM) and partial (PHM) molar pregnancies. The meta-analysis was performed following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). Six studies met the inclusion. Of the total 25,222 patients, 13,129 complete (52.1 %) and 12,093 partial (47.9 %) molar pregnancies were included. Live births rate after CHM was statistically higher (p = 0.002) compared to the live births after PHM (53.6 % vs. 51.0 %, 3266 vs. 1807 cases, respectively). Studies showed heterogeneity I² = 57.7 %, pooled proportion = 0.2 %, and 95 % Confidence Interval (CI) 0.6 to 0.9. No statistically significant difference was demonstrated for ectopic pregnancies (p = 0.633), miscarriage (p = 0.637), preterm birth (p = 0.865), stillbirth (p = 0.911), termination of pregnancy (p = 0.572), and complete molar recurrence (p = 0.580) after CHM and PHM. Partial molar recurrence occurred more frequently after PHM than CHM (0.4 % vs. 0.3 %, 52 vs. 37 cases, respectively, p = 0.002). Careful counseling on the obstetric subsequent pregnancies outcomes should be provided to patients eager for further pregnancy and further studies are needed to confirm these results.

Hyperthyroidism in gestational trophoblastic disease - a literature review

OBJECTIVE

Gestational trophoblastic disease (GTD) is a group of pregnancy-related disorders that arise from abnormal proliferation of placental trophoblast. Some patients with GTD develop hyperthyroidism, a rare but potentially life-threatening complication requiring early detection and management. Existing literature on hyperthyroidism in GTD is scant. This review aims to analyse the epidemiology, pathophysiology and management of this phenomenon.

METHODS

A comprehensive search of MEDLINE, EMBASE and Cochrane Library was performed to obtain articles that explored hyperthyroidism in GTD. A total of 405 articles were screened and 228 articles were considered for full-text review. We selected articles that explored epidemiology, pathophysiology and outcomes/management of hyperthyroidism in GTD.

RESULTS

The pathophysiology of hyperthyroidism in GTD is well-investigated. Placental trophoblastic tissue secretes excessive hCG, which is structurally similar to thyroid stimulating hormone and also has enhanced thyrotropic activity compared to normal hCG. The incidence and prevalence of hyperthyroidism in GTD varies worldwide, with lower rates associated with high uptake of early antenatal screening and early GTD detection. No clear risk factors for hyperthyroidism in GTD were identified. While hyperthyroidism can be definitively managed with surgical evacuation of the uterus, severe complications associated with hyperthyroidism in GTD have been reported, including thyroid storm-induced multi-organ failure, ARDS, and pulmonary hypertension.

CONCLUSION

Early detection of GTD is critical to prevent development of hyperthyroidism and its associated complications. Hyperthyroidism should be recognised as an important perioperative consideration for women undergoing surgery for GTD, and requires appropriate management. Future studies should explore risk factors for hyperthyroidism in GTD, which may facilitate earlier identification of high-risk women.

Management of uterine rupture during molar pregnancy

Gestational trophoblastic disease (GTD) is rare and encompasses several clinicopathologic forms from pre-malignant to malignant disorders. Clinical presentation is most of the time dominated by vaginal bleeding. Only few cases of uterine rupture during GTD have been reported in literature. We present the case of a female patient admitted to the hospital for hemorrhagic shock secondary to a uterine rupture due to an undiagnosed GTD. After an emergency laparoscopy, the patient underwent total hysterectomy with bilateral salpingectomy and bilateral ovarian cystectomy. Pulmonary metastasis were discovered on imaging after stagnation of the beta-hCG level. The surgical treatment was completed by 6 cycles of Methotrexate followed by 7 cycles of Actinomycine D with a good response.

Curative effect of second curettage for treatment of gestational trophoblastic disease - Results of the Belgian registry for gestational trophoblastic disease

OBJECTIVE

We assessed the curative effect of a second curettage in patients with persistent hCG serum levels after first curettage for a gestational trophoblastic disease (GTD).

STUDY DESIGN

This prospective observational study used the data of the Belgian register for GTD between July 2012 and January 2017. We analysed the data of patients who underwent a second curettage. We included 313 patients in the database. Primary endpoints were need for second curettage and chemotherapy.

RESULTS

Thirty-seven patients of the study population (12 %) underwent a second curettage. 20 had persistent human chorionic gonadotropin hormone (hCG) elevation before second curettage. Of them, 9 patients (45 %) needed no further treatment afterwards. Eleven patients (55 %) needed further chemotherapy. Nine (82 %) were cured with single-agent chemotherapy and 2 patients (18 %) needed multi-agent chemotherapy. Of the 37 patients, patients with hCG levels below 5000 IU/L undergoing a second curettage were cured without chemotherapy in 65 % versus 45 % of patients with hCG level more than 5000 IU/L. Of the ten patients with a hCG level below 1000 IU/L, eight were cured without chemotherapy.

CONCLUSIONS

Patients with post-mole gestational trophoblastic neoplasia can benefit from a second curettage to avoid chemotherapy, especially when the hCG level is lower than 5000 IU/L.

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.

Role of hysteroscopy and ultrasound in early identification of post-molar gestational trophoblastic neoplasia

OBJECTIVE

To evaluate the role of hysteroscopy and ultrasound in early identification of gestational trophoblastic neoplasia (GTN) after molar evacuation.

METHODS

This was a prospective study involving 52 women with an ultrasound diagnosis of complete hydatidiform mole, attending a tertiary centre in south India between August 2016 and August 2019. Baseline characteristics such as age, serum beta-human chorionic gonadotropin(β-hCG) level, gestational age, and uterine size were noted. After the evacuation of molar pregnancy, weekly follow-up with β-hCG was performed, until three consecutive values were normal and then monthly for six months. Findings of transvaginal ultrasound and diagnostic hysteroscopy, performed on follow up at three weeks, were noted. Primary outcome was the development of GTN. Area under the curve(AUC) was calculated to assess the usefulness of these methods in early identification of GTN.

RESULTS

Thirteen women (25 %) developed GTN during follow up, within 6 months. Twenty six(50 %) cases had high-risk molar pregnancy. Positive findings on hysteroscopy and ultrasonography were noted in 44.2 % and 19.2 % respectively. AUC was 0.83(95 % CI, 0.70-0.97) for ultrasound and 0.82(95 % CI, 0.72-.92) for hysteroscopy. Sensitivity and specificity were 69.2 % and 97.4 % for ultrasound and it was 92.3 % and 71.8 % respectively for hysteroscopy in identifying those who developed GTN on follow-up.

CONCLUSIONS

Transvaginal ultrasound as well as hysteroscopy may help in early identification of women at risk of developing GTN following a molar evacuation. Being a non-invasive method with similar discriminative value, ultrasonographic evaluation may be used for early identification of women with GTN after validation in future studies.

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.

[Epidemioclinical and ultrasonographic profile of hydatidiform moles in Abidjan]

Introduction

The purpose of our study was to describe the epidemioclinical and ultrasonographic features of hydatidiform moles (HM) in Abidjan.

Methods

We conducted a cross-sectional study in the Department of Radiology, University Teaching Hospital of Yopougon over a 6-year period (January 2011-December 2016). In this study we describe the epidemioclinical and ultrasonographic profile of patients with HM. Ultrasonographic exams were performed using a mixed-methods approach (intravaginal and subpubic) based on B-mode and Color Doppler by senior radiologists. Anatomopathological examination of uterine content was performed.

Results

Out of 12190 obstetric ultrasound performed, twenty-five cases of HM were diagnosed reflecting a radiological referral rate of 0.2%. The average age of patients was 33.4 years, ranging from 22 to 50 years. There was no dominant age class. The main clinical signs associated with amenorrhea (100%) included abdominal mass 36% and vaginal bleeding 28%. Ultrasound showed hypertrophic uterus in 100% of cases, homogeneous uterus in 96% of cases and myomatous uterus in 4% of cases. MH had an average thickness of 42.7 mm with vesicular appearance in 68% of cases, "honeycomb" appearance in 16%, multicystic appearance in 12% and snowstorm appearance in 4%. MHs were classified as partial in 4% of cases, complete in 92% of cases and invasive in 4% of cases. Hypertrophic ovaries were found in 44% of cases with macrofollicles in 32% of cases and cysts in 8% of cases. Ultrasonographic diagnosis of HM was confirmed by anatomopathological examination in 100% of cases.

Conclusion

HMs are rare in Abidjan and are dominated by the complete hydatidiform mole. Its occurrence at the extreme ages wasn't found.

Placental mesenchymal dysplasia: An underdiagnosed placental pathology with various clinical outcomes

BACKGROUND

Placental mesenchymal dysplasia (PMD) is a rare vascular and connective placental anomaly, which is often associated with severe fetal and/or maternal complications. The diversity of presentation of PMD challenges diagnosis and effective pregnancy management.

OBJECTIVE

We aimed to review cases presenting at 7 tertiary centers worldwide over the last decade and to study the occurrence of obstetric and neonatal complications.

STUDY DESIGN

Pathology databases from 7 tertiary hospitals were screened for cases of PMD (between 2007-2017). Pregnancy history, outcomes and ultrasound images were then reviewed for each case.

RESULTS

Twenty-two cases of PMD were identified. Mean gestational age at diagnosis was 23 weeks (16-39 weeks). Prenatal biochemical screening was abnormal in 8 cases (36%). Of the 12 cases that underwent invasive genetic testing, 4 were abnormal. Six patients (27%) developed maternal complications (preeclampsia/gestational hypertension). Fetal growth restriction was identified in 11 cases (50%) and fetal death in 4 (18%). Four (18%) pregnancies were terminated, 9/14 (64%) delivered preterm and only three (14%) progressed normally. Fourteen babies were born alive; 5 (35%) died in the first sixty-one days after birth, 5 (35%) had transient thrombopenia and 1 (7%) had developmental delay at last follow-up. Our series identified four potential new associations with PMD: placental triploidy mosaicism, CHARGE syndrome, fetal pleuropulmonary blastoma and fetal skeletal dysplasia.

CONCLUSIONS

PMD was substantially under-diagnosed before delivery in this cohort. Sonographers, fetal medicine specialists, obstetricians and pathologists should all suspect PMD in cases of an enlarged placenta and should look for fetal abnormalities. Diagnostic genetic testing should be discussed to exclude partial molar pregnancy. Close pregnancy follow-up is indicated due to the high risk of associated fetal or maternal adverse outcomes.

Total hysterectomy versus uterine evacuation for preventing post-molar gestational trophoblastic neoplasia in patients who are at least 40 years old: a systematic review and meta-analysis

Background

The clinical value of total hysterectomy for patients with hydatidiform mole (HM) being at least 40 years old remains highly controversial. Since the practice of hysterectomy has been applied globally for decades, there is an urgent need to perform a systematic review to assess its risks and benefits.

Methods

Six electronic databases, including four English databases and one Chinese database, were searched from the inception of each database till October 6th 2017. Studies were included if they: 1) were human studies, 2) explicitly indicated exposure to hysterectomy, 3) explicitly indicated control to uterine evacuation, 4) explicitly indicated the participants were older patients with HM being at least 40 years in age, 5) compared the outcome of interest as the incidence of post-molar GTN. Two authors independently conducted the literature search, study selection, data extraction. Pooled odds ratios were analyzed using Review Manager 5.3.

Results

The overall pooled effect size of total hysterectomy had a significant advantage in preventing post-molar gestational trophoblastic neoplasia over uterine evacuation with an OR of 0.19 (95% CI, 0.08–0.48; P = 0.0004) and a low heterogeneity (I² = 21%, P = 0.28). Subgroup analysis and sensitivity analysis also showed similar results.

Conclusions

Total hysterectomy, as compared to uterine evacuation, is a better therapeutic method for patients with HM being at least 40 years old unless fertility is still desired.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5168-x) contains supplementary material, which is available to authorized users.

Advanced gestational trophoblastic disease: A case report of medical management prior to surgical intervention

BACKGROUND

Gestational trophoblastic disease (GTD) is a rare developmental form of proliferative trophoblastic tissue. Sparse literature exists regarding the optimal management of patients with advanced GTD, but the definitive treatment is urgent surgical intervention.

CASE

A 48-year-old woman presented advanced GTD. She was medically managed for hypertension and hyperthyroidism prior to surgical intervention in order to minimize the risk of anesthetic and surgical complications.

CONCLUSION

Advanced GTD is rare. Undetected GTD can result in complications such as thyrotoxicosis, which poses substantial risks in the peri-operative period. Appropriate identification and management of this clinical problem are essential to prevent complications as well as subsequent malignant sequelae.

Does a human chorionic gonadotropin level of over 20,000 IU/L four weeks after uterine evacuation for complete hydatidiform mole constitute an indication for chemotherapy for gestational trophoblastic neoplasia?

OBJECTIVE

To evaluate whether a human chorionic gonadotropin (hCG) level ≥20,000 IU/L four weeks after uterine evacuation for complete hydatidiform mole (CHM) is an appropriate indicator for initiating chemotherapy for the treatment of gestational trophoblastic neoplasia (GTN).

STUDY DESIGN

Historical database review of 1228 women with CHM who received treatment and follow-up between January 2000 and June 2013 at four Brazilian trophoblastic disease centers. The primary outcome measure was the progression from CHM to GTN. The secondary outcomes were the occurrence of uterine perforation, staging of GTN, WHO/FIGO risk score, and treatment (use of single- or multiagent chemotherapy).

RESULTS

An hCG level ≥20,000 IU/L four weeks after uterine evacuation for CHM, while occurring in only 6.1% of women, was the most important risk factor for the development of postmolar GTN (adjusted RR = 5.83; p < 0.01; CI: 3.47-9.79), with a sensitivity of 36.8%, a specificity of 98.6%, a positive predictive value of 80%, and a negative predictive value of 91.1%. On the other hand, there were no differences in postmolar GTN stage, prognostic score, or need for multiagent chemotherapy relative to hCG level ≥20,000 IU/L versus <20,000 IU/L.

CONCLUSIONS

Although hCG level ≥20,000 IU/L four weeks after uterine evacuation for CHM was very predictive of development of post-molar GTN, delay in treatment until hCG plateau or increase did not affect outcomes, with no uterine perforations or treatment failures.

A case report of Ggeneralized uterine arteriovenous malformation after molar pregnancy in an infertile woman

BACKGROUND

Uterine arteriovenous malformation (UAVM) is a rare vascular condition in reproductive age presented mostly with bleeding. Although this malformation is infrequent, it is potentially life-threatening. Transvaginal Doppler ultrasonography is a widely available, noninvasive and excellent diagnostic method.

CASE

The case is a 30-yr-old woman with a history of eight-yr infertility.following intrauterine insemination treatment, she had a molar pregnancy. Despite methotrexate treatment, there was persistent vaginal bleeding. Assessment of this patient was done with transvaginal sonography and color Doppler. According to suspicious appearances, angiography was planned for confirmation of UAVM.

CONCLUSION

UAVM is one of the molar pregnancy complications. The first step for diagnosis of UAVM is transvaginal ultrasonography and color Doppler assessment. Embolization is the best treatment for women who intend to preserve fertility.

[Maternal deaths due to gestational trophoblastic diseases, results from the French confidential enquiry into maternal deaths, 2010-2012]

Gestational trophoblastic diseases (GTD) correspond to several entities which all have a common pattern: hypersecretion of human chorionic gondotrophin by trophoblastic hyperplasia. Between 2010 and 2012, there were 4 maternal deaths due to GTD (choriocarcinoma). The ratio of maternal death caused by GTD was 0,16/100,000 living births which was similar to the rate from the 2007-2009 period. These deaths represented 1.6% from the whole maternal mortality and 3.3% of the direct maternal mortality. These four deaths occurred after delivery and the diagnosis of GTD was made between 60 and 180 days in the postpartum period. Two cases seemed to be potentially avoidable. The main causes of suboptimal management were linked to delay either in diagnosis of GTD or in initiating the appropriate treatment. The analysis of these maternal deaths gave the opportunity to stress some major lessons to optimize medical management of GTD. Therefore, a patient presenting with persistent bleedings more than six weeks after delivery needs some specific exams such as plasma human chorionic gondotrophin measurement and histopathologic examination to affirm GTD and start early specific treatments generally leading to complete recovery.

Does hormonal contraception during molar pregnancy follow-up influence the risk and clinical aggressiveness of gestational trophoblastic neoplasia after controlling for risk factors?

OBJECTIVE

To evaluate the influence of hormonal contraception (HC) on the development and clinical aggressiveness of gestational trophoblastic neoplasia (GTN) and the time for normalization of human chorionic gonadotropin (hCG) levels.

METHODS

A retrospective cohort study was conducted with women diagnosed with molar pregnancy, followed at the Rio de Janeiro Trophoblastic Disease Center, between January 2005 and January 2015. The occurrence of postmolar GTN and the time for hCG normalization between users of HC or barrier methods (BM) during the postmolar follow-up or GTN treatment were evaluated.

RESULTS

Among 2828 patients included in this study, 2680 (95%) used HC and 148 (5%) used BM. The use of HC did not significantly influence the occurrence of GTN (ORa: 0.66, 95% CI: 0.24-1.12, p=0.060), despite different formulations: progesterone-only (ORa: 0.54, 95% CI: 0.29-1.01, p=0.060) or combined oral contraception (COC) (ORa: 0.50, 95% CI: 0.27-1.01, p=0.60) or with different dosages of ethinyl estradiol: 15mcg (ORa, 1.33, 95% CI 0.79-2.24, p=0.288), 20mcg (ORa: 1.02, 95% CI: 0.64-1.65, p=0.901), 30mcg (ORa: 1.17, 95% CI: 0.78-1.75, p=0.437) or 35mcg (ORa: 0.77, 95% CI: 0.42-1.39, p=0.386). Time to hCG normalization ≥10weeks (ORa: 0.58, 95% CI: 0.43-1.08, p=0.071) or time to remission with chemotherapy≥14weeks (ORa: 0.60, 95% CI: 0.43-1.09, p=0.067) did not significantly differ among HC users when compared to patients using BM, when controlling for other risk factors using multivariate logistic regression.

CONCLUSIONS

The use of HC during postmolar follow-up or GTN treatment does not seem to increase the risk of GTN or its severity and does not postpone the normalization of hCG levels.

Is chemotherapy necessary for patients with molar pregnancy and human chorionic gonadotropin serum levels raised but falling at 6months after uterine evacuation?

OBJECTIVE

To compare the outcomes of Brazilian patients with molar pregnancy who continue human chorionic gonadotropin (hCG) surveillance with those treated with chemotherapy when hCG was still positive, but falling at 6months after uterine evacuation.

METHODS

Retrospective chart review of 12,526 patients with hydatidiform mole treated at one of nine Brazilian reference centers from January 1990 to May 2016.

RESULTS

At 6months from uterine evacuation, 96 (0.8%) patients had hCG levels raised but falling. In 15/96 (15.6%) patients, chemotherapy was initiated immediately per FIGO 2000 criteria, while 81/96 (84.4%) patients were managed expectantly. Among the latter, 65/81 (80.2%) achieved spontaneous remission and 16 (19.8%) developed postmolar gestational trophoblastic neoplasia (GTN). Patients who received chemotherapy following expectant management required more time for remission (11 versus 8months; p=0.001), had a greater interval between uterine evacuation and initiating chemotherapy (8 versus 6months; p<0.001), and presented with a median WHO/FIGO risk score higher than women treated according to FIGO 2000 criteria (4 versus 2, p=0.04), but there were no significant differences in the need for multiagent treatment regimens (1/15 versus 3/16 patients, p=0.60). None of the women relapsed, and no deaths occurred in either group.

CONCLUSION

In order to avoid unnecessary exposure of women to chemotherapy, we no longer follow the FIGO 2000 recommendation to treat all patients with molar pregnancy and hCG raised but falling at 6months after evacuation. Instead, we pursue close hormonal and radiological surveillance as the best strategy for these patients.

Radiographically occult pulmonary metastases from gestational trophoblastic neoplasia

Gestational trophoblastic neoplasia (GTN) is a spectrum of diseases including partial and complete hydatidiform moles, placental site trophoblastic tumor, and choriocarcinoma. One of the most important considerations is recognition of the possibility of GTN after molar pregnancy or even normal pregnancy. It is common practice to use chest x-ray for the detection of pulmonary metastasis. Computed tomography imaging of the lungs is ordered if lung lesions are noted on chest x-rays. However, understanding the limitations of chest x-rays is important for detecting smaller pulmonary lesions. We present a patient with GTN and pulmonary metastasis after having received 2 negative chest x-rays.

Presence of the methylenetetrahydrofolate reductase gene polymorphism MTHFR C677T in molar tissue but not maternal blood predicts failure of methotrexate treatment for low-risk gestational trophoblastic neoplasia

Gestational trophoblastic neoplasia (GTN) is a rare tumor, and its genomic constitution is different from the maternal genome because of its gestational origin. Methotrexate (MTX) is a standard chemotherapeutic agent for low-risk GTN. An association between polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene and MTX treatment outcome has been reported in various diseases. Thus, we examined the association between clinical outcome and MTHFR polymorphisms in both tumor and blood DNA of low-risk GTN patients. MTHFR C677T (rs1801133) and A1298C (rs1801131) were genotyped using high-resolution melting assays in 62 Japanese low-risk GTN patients and in 52 antecedent molar tissues. We compared the genotypes of MTHFR polymorphisms with the clinical outcome of 5-day MTX treatment. Twenty-five patients entered remission and 37 patients developed drug resistance or adverse effects that necessitated a drug change. The MTHFR 677T allele in molar tissue was significantly related to the need for drug change (P=0.006; odds ratio [OR], 3.13; 95% confidence interval [CI], 1.31-7.49), in contrast to MTHFR 1298C (P=0.18; OR, 0.63; 95% CI, 0.32-1.25). The MTHFR 677T and 1298C alleles obtained from patients' blood DNA were not related to MTX treatment outcome (P=0.49; OR 1.31; 95% CI, 0.61-2.91 and P=0.10; OR 0.52; 95% CI, 0.22-1.15, respectively). These data demonstrate for the first time that the genotype of MTHFR 677TT in molar tissue is associated with ineffective MTX treatment in Japanese low-risk GTN patients.

Utilization of Chromogenic In Situ Hybridization to Assess Ploidy in the Diagnosis of Hydatidiform Mole

OBJECTIVES

Ploidy assessment is often required for the diagnosis of partial molar pregnancy. While fluorescence in situ hybridization has been shown to be effective, it is not available in many laboratories. We validated chromogenic in situ hybridization (CISH) for this purpose.

METHODS

CISH using probes to chromosomes 17 and 10 was performed on 20 POC cases with known cytogenetics to establish a reference percentage. This was then used to classify a randomized set of abnormal and normal cases.

RESULTS

An abnormal CISH cutoff of greater than 7% was established. All abnormal cases (six triploid and three tetraploid), 11 "normal" (46, XX or XY or undetectable abnormalities), and one trisomy 10 were all correctly classified by the assay.

CONCLUSIONS

CISH is a useful ancillary technique for the diagnosis of molar pregnancy. Its greater accessibility and ability to score even rare placental tissue in a background of maternal tissue offer advantages over other methods.

The effect of molar pregnancies on platelet parameters

The aim of this study was to compare platelet parameters between abortus groups with gestational trophoblastic disease (GTD) (molar pregnancy, invasive mole, choriocarcinoma, etc) and without disease according to pathological result. The study population consisted of patients with GTD (n = 53) and aborted patients without disease as a control group (n = 53) who were seen in our clinic between January 2010 and December 2013. In this retrospective study, age, gravidity, levels of haemoglobin, white blood cell count, platelets, platelet parameters (mean platelet volume (MPV), platelet distrubition width (PDW), platelet crit (PCT), which shows platelet functions were recorded. The pathological diagnosis of GTD was recorded. The mean platelet count, MPV, PDW and PCT levels were similar between the groups. There is no statistically significiant difference between types of GTN in these parameters according to pathological diagnosis. According to our study results, platelet count and levels of MPV, PDW ve PCT in GTD patients were similar to aborted patients without disease.

Ovarian Malignant Mixed Germ Cell Tumor: A Case of Unusual Presentation as Molar Pregnancy

BACKGROUND

This research was conducted to introduce a patient with rare ovarian mixed germ cell tumor, presented as molar pregnancy.

CASE PRESENTATION

The patient was a 16 year old woman admitted with diagnosis of molar pregnancy. Abdominal enlargement was the only complaint. She had a large pelvic mass in physical examination. The first diagnosis was molar pregnancy due to previous ultrasonic reports and positive βeta HCG. Urine pregnancy test was positive. As suction curettage was performed for her, surprisingly, the size of uterus was normal and no molar tissue was found in pathologic examination. At intraoperative ultrasound exam, an extra-uterine heterogeneous mass was found. Extra-uterine mass was confirmed by CT and MRI done after suction curettage. Mixed germ cell tumor was confirmed by histological examination after laparatomy and removing tumoral mass. Finally, she received Bleomycin, Etoposide and Cisplatin (BEP) regimen in four courses and Vincristine, Actinomycin D (Dactinomycin) and Cyclophosphamide (VAC) regimen in two courses and Diphereline for saving the other ovary.

CONCLUSION

Some young patients misinterpret the early symptoms of an ovarian neoplasm as those of pregnancy which can lead to a delay in the diagnosis.

Uncommon Presentation of Triploidy: A Case Report

A 28-year-old woman presented in her first pregnancy was admitted with severe hyperemesis gravidarium. Increased nuchal translucency with cardiac anomaly and omphalocele at the first trimester was observed at the ultrasound examination. Chorionic villus biopsy confirmed triploidy. The combination of type I and type II triploidy patterns were seen together in the second trimester of the pregnancy. Although the symptoms due to increased human chorionic levels occured, at the pathologic investigation there were no molar changes in the placenta. Here we report a case of uncommon presentation of triploidy.

Abnormally elevated serum hCG in a patient with end-stage renal disease seeking abortion: to be expected or a cause for concern? A case report

A patient with end-stage renal disease on hemodialysis was referred to our abortion clinic with a concern for molar pregnancy. By 12 weeks, her human chorionic gonadotropin (hCG) level was over 500,000. A review of the literature demonstrates that elevated hCG should be expected in this population and should not alter care.

Clinico-epidemiological profile of molar pregnancies in a tertiary care centre of Eastern Nepal: a retrospective review of medical records

Background

The incidence of molar pregnancy has demonstrated marked geographic and ethnic differences. The reported data in Nepal is inconsistent with minimal published literature. Thus, we designed a study to determine prevalence of molar pregnancies and demonstrate clinical and epidemiological characteristics of the patients attending a tertiary care center in eastern Nepal.

Methods

A retrospective review of medical records was conducted to determine the prevalence of molar pregnancies at the B.P. Koirala Institute of Health Sciences (BPKIHS) from the year 2008 to 2012. Secondary data from the medical records were analyzed. Annual and 5-year prevalence of molar pregnancy per 1000 live births was calculated. Demographic characteristics, clinical presentation, management methods and complications of molar pregnancy were studied.

Results

The 5- year prevalence of molar pregnancy at BPKIHS is 4.17 per 1000 live births with annual prevalence ranging 3.8–4.5 per 1000 live births. More than one third of the patients were in the age group of 20–35 years and majority of them were of Hindu religion. For more than one third (41.7 %) of the patients, it was their first pregnancy while about 10 % gave a positive past history of molar pregnancy. Abnormal uterine bleeding (86.3 %) was the most frequent complaint, suction evacuation was the most common method of treatment and more than half of the patients required prolonged care after initial management.

Conclusion

There is a need for studies at country level which will give us a national figure on molar pregnancies. Thus, a standardized clinic-epidemiological profile of molar pregnancy in Nepal can be created.

Human chorionic gonadotrophin as an indicator of persistent gestational trophoblastic neoplasia

BACKGROUND

Gestational trophoblastic neoplasia (GTN) disease is excessive and inappropriate proliferation of trophoblast after termination of the pregnancy. Many attempts have been made to improve follow-up procedures, but no studies have evaluated Human Chorionic Gonadotrophin (HCG) as a post treatment indicator. Thus we aimed to know β-HCG variability in post treatment pregnancies.

METHODS

40 Molar affected pregnancies were followed post-surgical treatment by serum β-HCG level in a tertiary level hospital. All subjects were treated by evacuation and followed by β-HCG every week for three weeks, then every month for six months.

RESULTS

30 women were normal (group I) and 10 (group II) diagnosed as GTN cases. Serum β-HCG which obtained serially shown significant differences between two groups (p=0.001). The quantity of β-HCG/week had significantly higher level than normal females (p<0.001) CONCLUSION: Our results suggested that β-HCG serum level could be used as a strong indicator for identifying affected patients at early stage.

[Hyperthyroidism in molar pregnancy]

INTRODUCTION

Hyperthyroidism is a rare complication of molar pregnancy.

CASE REPORT

We report a 39-year-old woman who presented a thyrotoxic syndrome accompanying a molar pregnancy. Serum thyroid hormones were elevated and returned to normal level after uterine evacuation of a molar pregnancy. The authors detail the role of thyroid stimulating property of human gonadotropin chorionic hormone and its structural changes during the gestational trophoblastic diseases. These changes give the latter the thyroid stimulating properties and signs of hyperthyroidism.

CONCLUSION

Molar pregnancy may be a cause of hyperthyroidism. The diagnosis of molar pregnancy should be a mention to thyrotoxicosique syndrome in a woman of childbearing age.

Hydatidiform mole: A Review of Management Outcomes in a Tertiary Hospital in South-East Nigeria

Background:

Hydatidiform mole (molar pregnancy) is the pre-malignant form of gestational trophoblastic neoplasia. It is of clinical and epidemiological interest because of its significant complication in pregnancy.

Aim:

This study was to determine the incidence, risk factors, clinical presentations, diagnosis, treatment options, and outcomes of molar pregnancy in a Nigerian tertiary health institution.

Materials and Methods:

A 10-year retrospective study of patients with molar pregnancy managed at the hospital from 1^st July 2001 to 30^th June 2010 was undertaken.

Results:

There were 34 cases of molar pregnancy, out of a total delivery of 7,579, giving an incidence of 0.4% or 1 in 223 deliveries. The mean age of the patients was 31.3 (8.7) years, and 29.0% (9/31) of the patients were nulliparous. The mean gestational age of the patients at presentation was 14.7 (3.5) weeks. The most common presenting symptom was abnormal vaginal bleeding, 93.5% (29/31), while anemia was the commonest complication seen in 96.8% (30/31) of patients. Almost all the patients (93.5%) had suction evacuation while 6.5% (2/31) had hysterectomy. As many as 6.5% (2/31) of patients had post-evacuation chemotherapy while 87.1% (27/31) patients had follow-up contraception. As many as 64.5% (20/31) of patients had complete follow-up for less than 6 months. The case fatality rate was 9.7%.

Conclusion:

Molar pregnancy has remained an important cause of maternal morbidity and mortality in our hospital, and the incidence was high. There is need for early recognition, timely referral, prompt and proper treatment of this condition. Adequate follow-up of the patients should be reinforced.

Abnormally low hCG in a complete hydatidiform molar pregnancy: The hook effect

► The hook effect occurs with extremely high levels of hCG, saturating detection antibodies, leading to falsely low laboratory results. ► In the literature, descriptions of the hook effect are rare in cases of gestational trophoblastic diseases. ► If unrecognized, this can lead to delayed therapy or mismanagement of care.

Ectopic molar pregnancy: a rare entity

INTRODUCTION

Ectopic molar pregnancy is a rare occurrence and consequently not often considered as a diagnostic possibility. In this article, an attempt was made to stress on the need for histopathological examination and follow up of every case of ectopic pregnancy. This was substantiated with the help of a case report.

CASE PRESENTATION

A 30-year-old gravida 4, para 3, pregnant woman with a 7-week history of amenorrhea attended hospital with abdominal pain. Per vaginal examination revealed a tender left adnexal mass measuring 4x4 cm and on ultrasonography there was a live fetus corresponding to a 7-week and 6 days gestation with free fluid in the pelvic cavity. Laparotomy, revealed a ruptured left tubal ectopic pregnancy and histopathological examination was suggestive of a molar pregnancy.

CONCLUSION

Although rare, molar changes can occur at any site of an ectopic pregnancy. Clinical diagnosis of a molar pregnancy is difficult but histopathology is the gold standard for diagnosis.