Complete hydatidiform mole with concurrent fetus: Two cases of live, term birth coupled with spontaneous resolution of molar tissue

Pregnancies with a complete hydatidiform mole and co-existing fetus (CMCF) are rare, but increasingly common due to the rising prevalence of assisted reproductive technology. They are frequently associated with adverse obstetric outcomes, providing women with the challenge of pregnancy termination or continuing the pregnancy at the risk of maternal-fetal morbidity and fetal mortality. This report demonstrates two cases of CMCF pregnancy with excellent maternal-fetal outcomes, including spontaneous resolution of the molar tissue antenatally. It is helpful in counselling women who are diagnosed with this rare and frequently morbid condition in considering how to proceed with their pregnancy.

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.

Atypical presentation of hyperthyroidism complicated complete hydatidiform mole in a 24-year-old female: a case report

Introduction and importance

Molar pregnancy is the most common type of gestational trophoblastic disease. It manifests as vaginal bleeding, accompanied by high levels of β-human chorionic gonadotropin (β-HCG). This case aims to highlight the importance of considering gestational trophoblastic disease as a potential diagnosis and its serious complications.

Case presentation

A 24-year-old female presented with vomiting, nausea, and no complaint of vaginal bleeding. Laboratory tests indicated hyperthyroidism as a complication requiring challenging preoperative prophylactic management. Initially, the patient underwent suction and curettage, but a total hysterectomy had to be performed later. The histological study concluded with the diagnosis of a complete hydatidiform mole. Post-surgery follow-up evaluations revealed high blood pressure values, and the patient was appointed for further cardiology assessment.

Discussion and conclusion

Although uncommon, complications of a molar pregnancy include anaemia, severe cardiac distress, and hyperthyroidism. Trophoblastic Hyperthyroidism is a result of extremely high levels of β-HCG levels due to molecular cross-reactivity. History, clinical examination, and ultrasound, in addition to measuring β-HCG levels, could all help in diagnosing a molar pregnancy, but the definitive diagnosis is based on histopathology and a karyotype study. Management procedures include dilation, suction and curettage, and hysterectomy. The treatment depends on the patient's age, desire for future pregnancies, and risk of developing gestational trophoblastic neoplasia. A follow-up with serial β-HCG measurement is recommended to monitor possible complications. Attaining and maintaining euthyroidism is a life-saving procedure before molar pregnancy surgery. Methimazole, Propranolol, Lugol's iodine, and hydrocortisone can all be used in the prophylactic management of the thyroid storm.

Complete Hydatidiform Mole with Lung Metastasis and Coexisting Live Fetus: Unexpected Twin Pregnancy Mimicking Placenta Accreta

Twin pregnancy with a complete hydatidiform mole and coexisting fetus (CHMCF) is an exceedingly rare condition with an incidence of about 1 in 20,000-100,000 pregnancies. It can be detected by prenatal ultrasonography and an elevated maternal serum beta-human chorionic gonadotropin (BhCG) level. Herein, the author reports a case of CHMCF which was incidentally diagnosed through pathologic examination without preoperative knowledge. The 41-year-old woman, transferred due to preterm labor, delivered a female baby by cesarean section at 28 + 5 weeks of gestation. Clinically, the surgeon suspected placenta accreta on the surgical field, and the placental specimen was sent to the pathology department. On gross examination, focal vesicular and cystic lesions were identified separately from the normal-looking placental tissue. The pathologic diagnosis was CHMCF and considering the fact that placenta accreta was originally suspected, invasive hydatidiform mole was not ruled out. After radiologic work-up, metastatic lung lesions were detected, and methotrexate was administered in six cycles at intervals of every two weeks. The author presents the clinicopathological features of this unexpected CHMCF case accompanied by pulmonary metastasis, compares to literature review findings, and emphasizes the meticulous pathologic examination.

Complete Hydatidiform Mole with a Coexisting Viable Male Fetus Detected by Cell-Free DNA

Complete hydatidiform mole with coexisting fetus (CHMCF) is rare, and diagnosis is challenging due to limited data. Here, we present the case of a patient with noninvasive prenatal test (NIPT) resulting in "likely molar pregnancy" in the second trimester. Subsequent ultrasound confirmed a cystic appearing portion of the placenta. At 22 weeks, the patient delivered a demised fetus and two placentas. Pathology was consistent with CHMCF. This case is the first to show primary detection of a CHMCF with single-nucleotide polymorphism (SNP)-based NIPT prior to ultrasound identification. Our case suggests the use of SNP-based NIPT as an alternative noninvasive method to guide shared decision-making and clinical management for patients with this diagnosis.

PD-L1 in gestational trophoblastic disease: an antibody evaluation

INTRODUCTION

Treatment with antibodies directed against programmed-cell death ligand 1 (PD-L1) is a novel therapy for patients with gestational trophoblastic disease. Assessment of PD-L1 expression in tumor tissue is commonly used to identify patients who might benefit from anti-PD-L1 treatment. Multiple antibodies are available to detect PD-L1-expressing cells, and percentages of PD-L1-expressing cells in samples of patients with gestational trophoblastic disease indicated by these antibodies differ substantially. This raises the question which PD-L1 antibody best reflects PD-L1 expression to select patients for treatment.

MATERIAL AND METHODS

Seven commercially available antibodies for PD-L1 staining (E1L3N, 73-10, 22C3, CAL10, SP142, 28-8, SP263) were validated on Chinese hamster ovarian (CHO) cells transfected with PD-L1, PD-L2, wildtype CHO cells and tonsil tissue. Next, four complete hydatidiform moles and four choriocarcinomas were stained. Samples were independently assessed by two pathologists.

RESULTS

All seven antibodies showed membranous staining in the PD-L1-transfected CHO cells. E1L3N and 22C3 scored the highest percentages of PD-L1-positive cells (70%-90% and 60%-70%, respectively). E1L3N stained the cytoplasm of non-transfected CHO cells and was excluded from analysis. The remaining six antibodies predominantly stained syncytiotrophoblast cells of both complete hydatidiform moles and choriocarcinomas. The percentage of PD-L1-stained trophoblast cells and staining intensity varied substantially per used PD-L1 antibody and between complete hydatidiform moles and choriocarcinomas. Agreement between pathologists was best with 22C3 (intraclass correlation coefficient 0.94-0.96).

CONCLUSIONS

Based on staining results of the CHO cells, gestational trophoblastic disease samples and intraclass correlation coefficient, 22C3 seems the most suitable for adequate detection of PD-L1-expressing trophoblast cells. All antibodies detected PD-L1-expressing cells in the gestational trophoblastic disease samples, though with great variability, hampering comparison of results between studies in this rare disease and emphasizing the need for uniformity in detecting PD-L1-expressing cells.

Complete Hydatidiform Mole and Coexisting Fetus With Gastroschisis: A Case Report Highlighting the Importance of Diagnostic Genotyping

Twin pregnancy with a complete hydatidiform mole and a coexisting fetus (CHMCF) is an extremely rare occurrence, described only by a handful of published series and cases reports. The majority of the literature on CHMCF examines prenatal care and follow-up in relation to the increased risk of gestational trophoblastic neoplasia (GTN). At present, few reports elaborate on the diagnostic process and differential diagnosis, especially in the context of recent molecular advances in risk stratification for GTN. Here, we describe the first known case of a CHMCF with gastroschisis with liveborn delivery at 35 weeks gestation. This report aims to review the pre- and postnatal differential diagnosis and discuss recent updates on the importance of ancillary studies in the diagnosis of gestational trophoblastic disease.

A New Stepwise Molecular Work-Up After Chorionic Villi Sampling in Women With an Early Pregnancy Loss

Objective: To explore the use of a new molecular work-up based on the stepwise use of Quantitative Fluorescence PCR (QF-PCR) extended to eight chromosomes and single nucleotide polymorphism array (SNP-array) in chorionic villi obtained by chorionic villi sampling (CVS) offered to women experiencing an early pregnancy loss.

Methods: During a 3-year period (January 2016–December 2018), CVS was offered to women experiencing an early pregnancy loss before the evacuation of the products of conception (POC) to retrieve chorionic villi, irrespective of the number of previous losses. A new molecular work-up was prospectively assayed encompassing a first QF-PCR round (with the 21, 18, 13, 7, X, and Y chromosomes), a second QF-PCR round (with the 15, 16, and 22 chromosomes), and a high resolution SNP-array in those cases with normal QF-PCR results. A control group in which POC were collected after surgical uterine evacuation was used to be compared with the intervention group.

Results: Around 459 women were enrolled in the intervention group (CVS) and 185 in the control group (POC after uterine evacuation). The QF-PCR testing success rates were significantly higher in the intervention group (98.5%: 452/459) as compared to the control group (74%: 109/147; p < 0.001), while the chromosomal anomaly rate at the two QF-PCR rounds was similar between the two groups: 52% (234/452) in the intervention and 42% (46/109) in the control group (p = 0.073). The SNP-array was performed in 202 QF-PCR normal samples of the intervention group and revealed 67 (33%) atypical chromosomal anomalies (>10 Mb), 5 (2.5%) submicroscopic pathogenic copy number variants, and 2 (1%) variant of uncertain significance (VOUS).

Conclusion: Eighty-two percent of women experiencing an early pregnancy loss opted for a CVS. The testing success rates were higher in the intervention group (CVS; 98%) as compared to the control group (POC; 74%). The overall yields were 52% by QF-PCR (including three complete hydatiform moles), and 16% by SNP-array, including 15% atypical chromosomal anomalies and 1.1% submicroscopic pathogenic copy number variants.

[Persistent gestational trophoblastic disease following ectopic molar pregnancy]

A case of persistent gestational trophoblastic disease that developed after ectopic (cervical) pregnancy with complete hydatidiform mole (CHM) in a 56-year-old patient is presented. The diagnosis of CHM was made retrospectively based on immunohistochemical analysis of archival material using p57 and Ki67 antibodies. Observation shows the difficulty of objective diagnosis of hydatidiform mole in early pregnancy due to the lack of typical cystic transformation of the stroma of villi, focal proliferation of villous trophoblast. Application of the p57 marker for the differential diagnosis of CHM and other variants of cystic villi transformation may be especially important in cases of ectopic pregnancy, in which morphological changes in the chorion do not always correspond to the classical picture. The presence of ectopic pregnancy with CHM in a 56-year-old patient requires special attention of clinicians.

Association between antioxidant vitamins and oxidative stress among patients with a complete hydatidiform mole

OBJECTIVES

This study aimed to evaluate the potential relationship between oxidative stress, dietary intake, and serum levels of antioxidants in patients with a complete hydatidiform mole (CHM) compared with controls.

METHODS

This was an observational cross-sectional study conducted in Rio de Janeiro, Brazil. A total of 140 women were enrolled in this study and divided into four groups: 43 patients with CHM, 33 women who had had an abortion, 32 healthy pregnant women, and 32 healthy non-pregnant women. All participants underwent blood sampling, assessment using a semiquantitative food frequency questionnaire, and anthropometric measurement. Blood samples were collected after overnight fasting (10-12 h). Vitamin levels (A, C, and E) were determined by ultra-performance liquid chromatography, and gamma-glutamyl transferase levels were assessed using an automated quantitative analysis system (Dimension®, Siemens).

RESULTS

Although all groups showed sufficient serum vitamin A and E levels, the participants had inadequate dietary intake of these vitamins. Conversely, all groups had an insufficient serum level of vitamin C, despite adequate intake. The gamma-glutamyl transferase values did not differ significantly among the groups. However, elevated serum levels of this enzyme were observed in several patients.

CONCLUSIONS

All groups exhibited high levels of oxidative stress, as evaluated by gamma-glutamyl transferase levels, and had inadequate intake of antioxidant vitamins. Therefore, the high exposure to oxidative stress found in our study, even in healthy pregnant and non-pregnant women, may increase the incidence of CHM in this region.

Loss of p57KIP2 expression confers resistance to contact inhibition in human androgenetic trophoblast stem cells

Complete hydatidiform moles (CHMs) develop from androgenetic conceptuses and are characterized by enhanced proliferation of trophoblast cells and a significantly higher risk of trophoblast tumors. Loss of the maternal genome and duplication of the paternal genome are considered to be responsible for the phenotype, but the detailed mechanism remains unclear. Here, we report the derivation of trophoblast stem (TS) cells from CHMs. These cells have reduced sensitivity to contact inhibition of cell proliferation and exhibit aberrant expression of imprinted genes, which are expressed from only 1 parental allele. We also reveal that the maternally expressed imprinted gene p57^KIP2 would be responsible for the enhanced proliferation of CHM-derived TS cells. Our findings provide an insight into the pathogenesis of CHMs.

A complete hydatidiform mole (CHM) is androgenetic in origin and characterized by enhanced trophoblastic proliferation and the absence of fetal tissue. In 15 to 20% of cases, CHMs are followed by malignant gestational trophoblastic neoplasms including choriocarcinoma. Aberrant genomic imprinting may be responsible for trophoblast hypertrophy in CHMs, but the detailed mechanisms are still elusive, partly due to the lack of suitable animal or in vitro models. We recently developed a culture system of human trophoblast stem (TS) cells. In this study, we apply this system to CHMs for a better understanding of their molecular pathology. CHM-derived TS cells, designated as TS^mole cells, are morphologically similar to biparental TS (TS^bip) cells and express TS-specific markers such as GATA3, KRT7, and TFAP2C. Interestingly, TS^mole cells have a growth advantage over TS^bip cells only after they reach confluence. We found that p57^KIP2, a maternally expressed gene encoding a cyclin-dependent kinase inhibitor, is strongly induced by increased cell density in TS^bip cells, but not in TS^mole cells. Knockout and overexpression studies suggest that loss of p57^KIP2 expression would be the major cause of the reduced sensitivity to contact inhibition in CHMs. Our findings shed light on the molecular mechanism underlying the pathogenesis of CHMs and could have broad implications in tumorigenesis beyond CHMs because silencing of p57^KIP2 is frequently observed in a variety of human tumors.

Histopathological and clinical features of molar pregnancy

OBJECTIVE

To analyse own set of molar pregnancies and to develop clinically relevant procedures.

TYPE OF STUDY

Review article with analysis of own data.

SETTINGS

Department of Pathology 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague; Department of Obstetrics and Gynecology 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague.

INTRODUCTION

The study monitors the decrease of laboratory values of beta-subunit of hCG gonadotropin (beta-hCG) after evacuation of partial and complete hydatidiform moles in a set of 45 partial and 46 complete moles. Two case reports of invasive moles.

RESULTS

In cases of partial hydatidiform moles there was complete regression of beta-hCG in all cases, 89% regressed in six weeks, none of the women showed no subsequent elevation after reaching negativity. In cases of complete hydatidiform moles the decrease was less gradual, the negativity after six weeks was confirmed in 78%, three complete moles became malignant.

CONCLUSION

The decrease of beta-hCG after molar pregnancy termination is variable. Even if in cases of complete hydatidiform moles the risk of malignization after reaching negativity is low, beta-hCG checks are recommended at monthly intervals for 6 months. Correct diagnosis of complete mole and its differentiation from partial mole can be achieved using immunohistochemistry - p57 antibody.

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.

Ultrasound and MRI Findings of Twin Pregnancies with Complete Hydatidiform Mole and Coexisting Normal Fetus: Two Case Reports

BACKGROUND

Both twin pregnancies with complete hydatidiform mole and coexisting normal fetus (CHMCF) and partial hydatidiform mole can be found in association with a live fetus and a placenta displaying a molar degeneration. Two cases of CHMCF using magnetic resonance imaging (MRI) for a diagnosis are reported.

CASE

In the first, CHMCF was suspected at 12 weeks of gestation. At 18 weeks of gestation, the existence of molar placenta and a sac separating from fetus and normal placenta was clearly depicted on MRI. At 19 weeks of gestations, she had termination of pregnancy because of a development of gestational trophoblastic neoplasia (GTN) and started chemotherapy. In the second case, CHMCF was suspected at 14 weeks of gestation. MRI demonstrated the existence of molar placenta and a sac separating from fetus and normal placenta. She chose induced abortion and there was no evidence of GTN during the 1 year-follow up period. Pathological examination in both cases was consistent with a complete hydration mole and a coexisting normal female fetus.

CONCLUSION

MRI was useful for an accurate diagnosis for CHMCF.

Whole-exome sequencing reveals genetic variants in ERC1 and KCNG4 associated with complete hydatidiform mole in Chinese Han women

Complete hydatidiform mole (CHM) is a rare pregnancy-related disease with invasive potential. The genetics underlying the sporadic form of CHM have not been addressed previously, but maternal genetic variants may be involved in biparental CHM. We performed whole-exome sequencing of 51 patients with CHM and 47 healthy women to identify genetic variants associated with CHM. In addition, candidate variants were analyzed using single base extension and Matrix Assisted Laser Desorption/Ionization-Time of Flight Mass Spectrometry in 199 CHM patients and 400 healthy controls. We validated candidate variants using Sanger sequencing in 250 cases and 652 controls, including 205 new controls. Two single nucleotide polymorphisms, c.G48C(p.Q16H) inERC1 and c.G1114A(p.G372S) in KCNG4, were associated with an increased risk of CHM (p<0.05). These variants may contribute to the pathogenesis of CHM and could be used to screen pregnant women for this genetic abnormality.

Uterine artery Doppler flow velocimetry parameters for predicting gestational trophoblastic neoplasia after complete hydatidiform mole, a prospective cohort study

OBJECTIVES:

Doppler ultrasonography can be used to assess neoangiogenesis, a characteristic feature of postmolar gestational trophoblastic neoplasia. However, there is limited information on whether uterine artery Doppler flow velocimetry parameters can predict gestational trophoblastic neoplasia following a complete hydatidiform mole. The purpose of this study was as follows: 1) to compare uterine blood flow before and after complete mole evacuation between women who developed postmolar gestational trophoblastic neoplasia and those who achieved spontaneous remission, 2) to assess the usefulness of uterine Doppler parameters as predictors of postmolar gestational trophoblastic neoplasia and to determine the best parameters and cutoff values for predicting postmolar gestational trophoblastic neoplasia.

METHODS:

This prospective cohort study included 246 patients with a complete mole who were treated at three different trophoblastic diseases centers between 2013 and 2014. The pulsatility index, resistivity index, and systolic/diastolic ratio were measured by Doppler flow velocimetry before and 4-6 weeks after molar evacuation. Statistical analysis was performed using Wilcoxon's test, logistic regression, and ROC analysis.

RESULTS:

No differences in pre- and post-evacuation Doppler measurements were observed in patients who developed postmolar gestational trophoblastic neoplasia. In those with spontaneous remission, the pulsatility index and systolic/diastolic ratio were increased after evacuation. The pre- and post-evacuation pulsatility indices were significantly lower in patients with gestational trophoblastic neoplasia (odds ratio of 13.9-30.5). A pre-evacuation pulsatility index ≤1.38 (77% sensitivity and 82% specificity) and post-evacuation pulsatility index ≤1.77 (79% sensitivity and 86% specificity) were significantly predictive of gestational trophoblastic neoplasia.

CONCLUSIONS:

Uterine Doppler flow velocimetry measurements, particularly pre- and post-molar evacuation pulsatility indices, can be useful for predicting postmolar gestational trophoblastic neoplasia.

Triple paternal contribution to a normal/complete molar chimeric singleton placenta

A comprehensive study of unusual cases of placental pathology may provide insight into mechanisms of normal human fertilization and early embryonic development by examining the exception to the rule. A gravida three para two 39-year-old woman was monitored by ultrasound from 16 weeks of gestation for cystic placenta. A female newborn was born at 36 weeks gestation. Pathologic examination of the partially cystic placenta revealed a singleton placenta comprised of 2/3 normal placenta and 1/3 complete hydatidiform mole, largely degenerated. Immunostaining for p57 was negative in stromal cells of the molar villi. Chromogenic in-situ hybridization revealed diploidy in both normal and molar parts. A total of 16 microsatellites were studied by short tandem repeat analysis, 11 of which were informative. The analysis revealed bipaternal molar tissue of dispermic origin. The paternal monospermic contribution to the normal part was different from that in the molar part, thus resulting in tripaternal contribution to the conceptus. A chimera is a single organism composed of two or more different populations of genetically distinct cells that originated from different zygotes (tetragametic) whereas mosaic is a mixture of two cell lines in one organism originating from one zygote. The possible mechanisms leading to the formation of chimeric/mosaic placenta in our case (one of the components being complete hydatidiform mole), including twinning, fusion at an early embryonic stage and diploidization of triploids, are discussed.

HDLive Silhouette Inversion Mode in Diagnosis of Complete Hydatidiform Mole

We present our experience of using the HDLive silhouette inversion mode to assess complete hydatidiform mole early in pregnancy. The HDLive silhouette inversion mode clearly depicted the number, size, and spatial position of molar vesicles, compared with conventional two-dimensional sonography or the HDLive inversion mode. Moreover, spatial relationships among molar vesicles, intrauterine anechoic fluid collection, and the uterine wall enabled the clear localization of the lesion. This technique provides new insights, and has the potential to supplement conventional two-dimensional sonography in the diagnosis of complete hydatidiform mole.

[Twin pregnancy with complete hydatidiform mole]

The paper describes a case of twin pregnancy with complete hydatidiform mole (CHM). According to the data available in the literature, the concurrence of CHM with a normal placenta and a viable fetus occurs in 1 per 20,000-100,000 pregnancies, requires a differential diagnosis with partial hydatidiform mole and placental mesenchymal dysplasia, and is characterized by a high rate of complications. In this concurrence, the frequency of persistent trophoblastic disease is as high as 50%. In this case, the pregnancy ended in a spontaneous abortion at 16-17 weeks of pregnancy. A morphological examination determined the fetus without congenital malformations with normal placental weight and structure and the adjacent intact placental tissue with the macro- and microscopic signs of CHM. The diagnosis was confirmed by the lack of р57 expression in the villous trophoblast and stroma in the tissue of the hydatidiform mole. The patient was diagnosed with persistent trophoblastic disease at 2 months after the abortion.

Apoptotic index for prediction of postmolar gestational trophoblastic neoplasia

BACKGROUND

Although 85% of patients with a complete hydatidiform mole achieve spontaneous remission after a few months, 15% of them will experience gestational trophoblastic neoplasia, which requires chemotherapy. To date, there is no biomarker to predict post-molar gestational trophoblastic neoplasia before the initiation of human chorionic gonadotropin surveillance.

OBJECTIVE

The purpose of this study was to assess the relationship between the expression of apoptosis markers in the molar villous trophoblasts and the subsequent development of gestational trophoblastic neoplasia after the evacuation of a complete hydatidiform mole.

STUDY DESIGN

This was a retrospective cohort study of patients with complete hydatidiform mole who were diagnosed, treated, and followed at the Center of Trophoblastic Diseases (Botucatu/São Paulo State and Rio de Janeiro/Rio de Janeiro State, Brazil) from 1995-2014. Patients were divided temporally into derivation (1995-2004) and validation (2005-2014) cohorts. Immunohistochemistry was used to examine tissue expression of the apoptosis inhibitor survivin or the pro-apoptotic enzyme caspase-3. Survivin stains for cytoplasmic and nuclear expression were evaluated independently. Caspase-3 expression was measured as an apoptotic index of positive staining cells over negative staining cells multiplied by 100. Receiver operating characteristic curves were then constructed, and the area under the curve was calculated to test the performance characteristics of the staining to predict the subsequent development of gestational trophoblastic neoplasia.

RESULTS

The final study population comprised 780 patients, with 390 patients in each temporal cohort: 590 patients entered spontaneous remission, and 190 patients experienced post-molar gestational trophoblastic neoplasia. Neither nuclear nor cytoplasmic survivin expression performed well as a predictor of subsequent gestational trophoblastic neoplasia. The caspase-3 apoptotic index was a strong risk factor for subsequent gestational trophoblastic neoplasia development. When the apoptotic index was <4%, the risk of gestational trophoblastic neoplasia had an odds ratio of 35.55 (95% confidence interval, 14.02-90.14; P < .0001) in the derivation cohort and an odds ratio of 25.71 (95% confidence interval, 10.13-65.29; P < .0001) in the validation cohort. However, in both cohorts, the positive predictive value for gestational trophoblastic neoplasia of an apoptotic index <4.0% was modest (49% in the derivation cohort and 41% in the validation cohort); the negative predictive value for gestational trophoblastic neoplasia of an apoptotic index ≥4.0% was high (97% in both cohorts).

CONCLUSION

The subsequent development of gestational trophoblastic neoplasia after evacuation of complete hydatidiform mole is tied closely to the apoptotic index, which may be a useful biomarker for future prospective studies.

Complete molar pregnancy in postmenopausal women

Gestational trophoblastic disease (GTD) is an abnormal proliferation of trophoblastic tissue during pregnancy. It is a disease of reproductive age, and a few cases have also been seen in women with advanced age, although it is extremely rare in postmenopausal women. Here, we describe an uncommon case of complete hydatidiform mole (CHM) in a postmenopausal woman, who has presented to us with complaints of bleeding per vagina, vomiting with 22 weeks size gravid uterus. Ultrasound finding along with raised serum beta-human chorionic gonadotropin (β-HCG) 400,000 mIU/ml suggested the diagnosis of CHM. In view of postmenopausal status and future risk of postmolar gestational trophoblastic neoplasia, we performed a total abdominal hysterectomy. Uterus was 20 cm × 15 cm × 15 cm filled with cystic, grapes such as vesicles. Microscopic examination demonstrated generalized trophoblastic proliferation with hydropic degenerated villi suggested of benign CHM. Follow-up showed steady fall in serum β-HCG level and no evidence of any residual disease. A suspicion of GTD should be kept in mind while evaluating a patient with peri- or post-menopausal bleeding so that it will prevent a delay in diagnosis and treatment.

Reproductive outcomes after hydatiform mole and gestational trophoblastic neoplasia

Gestational trophoblastic disease includes complete hydatidiform mole (CHM) or partial hydatidiform mole (PHM) and gestational trophoblastic neoplasia (GTN). Given the very high-curability rate of trophoblastic disease, the risk of further molar pregnancy after CHM or PHM as well as the risk of second primary tumors and fertility compromise after chemotherapy for GTN represent major concerns. The incidence of subsequent molar pregnancy ranges from 0.7 to 2.6% after one CHM or PHM, and is approximately 10% after two previous CHMs. Among patients who have received chemotherapy, there is an increased risk of myeloid leukemia which is mainly related to the cumulative dose of etoposide. Resumption of normal menses occurs in approximately 95% of women treated with chemotherapy, but menopause occurs 3 years earlier compared with those non-treated with chemotherapy. Term live birth rates higher than 70% without increased risk of congenital abnormalities have been reported in these women, and pregnancy outcomes are comparable to those of general population, except a slightly increased risk of stillbirth. Fertility-sparing treatment for placental site trophoblastic tumor is a therapeutic option reserved to highly selected, young women who do not present markedly enlarged uterus or diffuse multifocal disease within the uterus.

First-trimester molecular diagnosis of complete hydatidiform mole associated with dizygotic twin pregnancy conceived by intrauterine insemination

OBJECTIVE

To present first-trimester molecular diagnosis of complete hydatidiform mole (CHM) associated with dizygotic twin pregnancy conceived by intrauterine insemination.

MATERIALS AND METHODS

A 32-year-old woman presented to the hospital with a huge complex cystic mass measuring about 8.5 cm × 4.1 cm in the uterine cavity and a living co-existing fetus with fetal biometry equivalent to 9 weeks. She underwent chorionic villus sampling at 13 weeks of gestation, and microsatellite genotyping for molar pregnancy test was applied. A molar pregnancy test was performed by a short tandem repeat (STR) identifier polymerase chain reaction (PCR) polymorphic marker analysis. The pregnancy was terminated at 14 weeks of gestation. Postnatal polymorphic DNA marker analysis of the placenta by quantitative fluorescent PCR (QF-PCR) was performed. Analysis of maternal blood total β-human chorionic gonadotropin revealed a high level of 551,600 mIU/mL at 10 weeks of gestation and a level of 1.0 mIU/mL at 15 weeks postpartum. The woman was doing well at 4 months after delivery.

RESULTS

The results of STR identifier PCR polymorphic marker analysis showed androgenic conception in the complex cystic mass and biparental conception in the living fetus. Pathological analysis of the cystic mass confirmed the diagnosis of CHM. The results of QF-PCR showed biparental inheritance in the normal fetus and complete paternal homozygosity in the CHM of the abnormal fetus in all STRs, indicating dizygotic twinning and CHM of monospermy.

CONCLUSION

Prenatal sonographic diagnosis of placentomegaly with many grape-like vesicles should include a differential diagnosis of CHM, partial hydatidiform mole (PHM), placental mesenchymal dysplasia (PMD), and recurrent hydatidiform mole. Microsatellite genotyping for molar pregnancy testing and zygosity testing is useful in cases of prenatal diagnosis of placentomegaly associated with many grape-like vesicles and a twin pregnancy with a living fetus in the first trimester.

Hydatidiform mole: age-related clinical presentation and high rate of severe complications in older women

OBJECTIVE

The purpose of this study was to demonstrate differences in clinical presentation of hydatidiform mole between women ≥40 years and younger women.

DESIGN

Retrospective study.

SETTING

A tertiary referral unit in northern Italy.

POPULATION

Three hundred and sixty-five women with hydatidiform mole were divided into group A (<40 years, 318 cases) and group B (≥40 years, 47 cases).

METHODS

Clinical presentation between groups A and B was analyzed, also considering partial hydatidiform mole and complete hydatidiform mole.

MAIN OUTCOME MEASURES

Differences in clinical presentation according to woman's age.

RESULTS

In group B the diagnosis of hydatidiform mole at ≥12 gestational weeks was more frequent (p < 0.001) and the detection of ultrasound features was higher (p < 0.05) than in group A. Vaginal bleeding (p < 0.05), increased uterine volume (p < 0.0001) and hyperemesis (p < 0.05) occurred more frequently in group B. In the women with complete hydatidiform mole, group B women presented with vaginal bleeding (p < 0.001), increased uterine volume (p < 0.05) and hyperemesis (p < 0.05) more frequently than group A women. Complete hydatidiform mole was more commonly diagnosed after 12 weeks of gestation in group B (p < 0.0001). In women ≥50 years, an increased rate of disease-related complications was detected.

CONCLUSIONS

The clinical features of hydatidiform mole in women ≥40 years are different from those seen in younger women. Failures in the early detection of hydatidiform mole in older women may expose them to a higher rate of severe complications.

Rare case of peritoneal complete hydatidiform mole

A 23-year-old woman, gravida 1, para 1, was transferred to our hospital with acute lower abdominal pain and vital signs consistent with shock. Her urine concentration of human chorionic gonadotrophin was 8000 mIU/mL. Transvaginal ultrasound revealed an echo-free space with mosaic echo pattern in the right adnexal area and no gestational sac in the uterus. With a preoperative diagnosis of ruptured ectopic pregnancy, emergency laparotomy was performed. The rectouterine pouch was filled with many clots containing small amounts of villous tissue. After removal of the conceptus, which was infiltrating into the peritoneum of the Pouch of Douglas, bleeding was controlled by Argon laser. Histological examination of the conceptus by immunohistochemical staining with p57(kip2) showed features of complete hydatidiform mole. This case demonstrates that the peritoneum in the Pouch of Douglas is a possible site of ectopic complete hydatidiform mole occurrence and that immunohistochemical stain is useful to confirm the diagnosis of ectopic complete hydatidiform mole.

Two cases of complete hydatidiform mole and coexistent live fetus

The aim of this study was to report the clinical features, management, and outcome of complete hydatidiform mole with a coexisting viable fetus. Two cases are reported. In both cases ultrasound examination demonstrated a normally growing live fetus alongside a normal placenta and an additional intrauterine echogenic mass with features of hydatidiform mole. The hCG levels were significantly increased and fetal karyotypes were normal. A cesarean section performed at 28 weeks' gestation in the first case and at 26 weeks' gestation in the second one resulted in the delivery of live normal infant and two adjoining placentas in both cases. Microscopic examination of the abnormal placentas confirmed complete hydatidiform mole. The babies did well and serial maternal serum hCG levels showed a declining trend and were undetectable by a few months after delivery. Continuation of a twin pregnancy with complete hydatidiform mole (CHMF) is an acceptable option. There is, although, an increased risk of developing maternal and fetal complications. Close surveillance of an ongoing pregnancy is compulsory to detect potential early signs of complications.

A molar masquerading as an ectopic pregnancy in the early first trimester: a salutary lesson

The authors report a case in which a molar pregnancy was mistaken for an ectopic pregnancy in the early first trimester. This confusion delayed diagnosis and caused distress; follow-up led to the final diagnosis of complete hydatidiform mole. Correct preoperative diagnosis of molar pregnancy by ultrasound in early pregnancy may be tricky. It is important to obtain histological evidence to make the final diagnosis of gestational trophoblastic disease. While relatively rare, consideration of molar pregnancy in the differential diagnosis of early pregnancy loss may avoid unnecessary distress.

Twin gestation with complete hydatidiform mole and a coexisting live fetus: case report and brief review of literature

Complete hydatidiform (also referred to as hydatiform) mole with coexisting live fetus is an exceedingly rare event. The fetus usually has a normal karyotype, and approximately 25-40% chance of survival, if pregnancy is allowed to continue until reasonable fetal lung maturity is achieved. However, risk of maternal complications including preeclampsia and subsequent trophoblastic disease are significant. We report a case of a 19-year-old primigravida, at 25 weeks gestation with a complete hydatidiform mole and a coexisting live fetus. She developed severe preeclampsia with uncontrolled hypertension, and pregnancy was terminated by caesarean section, after a short course of dexamethasone to accelerate fetal lung maturity. A morphologically normal live female fetus and placenta were delivered without complications, along with a separate mass of complete mole. The postpartum course was complicated by uterine choriocarcinoma with metastases to lung and left kidney, which responded to chemotherapy. Our case is a rare example of a twin gestation composed of a complete hydatidiform mole with a coexisting live fetus, and illustrates the associated spectrum of maternal complications that mandate close pre- and post-natal surveillance.

A case of twin pregnancy with complete hydatidiform mole and coexisting fetus following IVF-ET

Twin pregnancy consisting of complete hydatidiform mole (H-mole) and a coexisting fetus occurs with an estimated incidence of 1 per 22,000-100,000 pregnancies. The incidence of this unusual twin pregnancy with complete H-mole and a coexisting fetus after in vitro fertilization and embryo transfer (IVF-ET) is not thought to be greater than that of general population. We present an unusual twin pregnancy with complete H-mole and a coexisting fetus that occurred following IVF-ET, which was terminated at 21 weeks of gestation and developed into nonmetastatic gestational trophoblastic tumor.