Clinical aspects of gestational trophoblastic disease: A review based partly on 25-year experience of a statewide registry

Molecular genetic studies of complete hydatidiform moles

Complete hydatidiform moles (CHM) are abnormal pregnancies with no fetal development resulting from having two paternal genomes with no maternal contribution. It is important to distinguish CHM from partial hydatidiform moles, and non-molar abortuses, due to the increased risk of gestational trophoblastic neoplasia. We evaluated a series of products of conception (POC) (n=643) investigated by genome-wide microarray comparative genomic hybridisation (CGH) with the aim of refining our strategy for the identification of complete moles. Among 32 suspected molar pregnancies investigated by STR genotyping to supplement microarray CGH testing, we found 31.3% (10/32) CHM; all identified among 3.6% (10/272) early first trimester POC. We suggest that when using microarray CGH that genotyping using targeted STR analysis should be performed for all POC referrals to aid in the identification of CHM.

Asbestos exposure and gestational trophoblastic disease: a hypothesis

Among 2,968 women and girls exposed to crocidolite (blue asbestos) at Wittenoom, three cases of choriocarcinoma and three cases of hydatidiform mole have been identified (crude incidence rate of 9.9 per 1000 women and 1.7 per 1000 deliveries for choriocarcinoma and hydatidiform mole, respectively). The women with choriocarcinoma were resident at Wittenoom at the time of disease development, whereas hydatidiform mole occurred much later in women who had first been exposed to asbestos as young girls. Four of the six cases were known to have lived with asbestos company workers who brought their dusty work-clothes home for washing. Asbestos fibers have been reported in the lung, the pleural and peritoneal mesothelium, and the human ovary. They have also been detected in placental digests of live and stillborn infants. This cluster of gestational trophoblastic diseases has some biological plausibility for asbestos causation. Taking an occupational and residential history and examining pathologic specimens for asbestos fibers or bodies may prove useful in patients with gestational trophoblastic disease.

A medical management of interstitial ectopic pregnancy: A 5-year clinical study

BACKGROUND

Medical treatment of the rare interstitial ectopic pregnancy with methotrexate has been considered an alternative to surgical resection.

AIM

To determine the treatment success rate with a single-dose intravenous methotrexate/folinic acid regimen and to identify predictors of treatment outcome.

METHODS

A 5-year audit (April 2000-August 2005) was carried out, collecting clinical imaging data and serum beta-human chorionic gonadotrophin (beta-hCG). Time taken for complete beta-hCG resolution was recorded, and a negative beta-hCG result was used as an endpoint of successful outcome.

RESULTS

Of the 13 cases, two required urgent surgery for rupture on presentation. In the remaining 11 cases, intravenous methotrexate (300 mg) was used, with oral folinic acid rescue (15 mg x 4 doses). There were no side-effects. Complete beta-hCG resolution was achieved in 10 of the 11 medically treated cases (91% success rate), requiring 21-129 days. Successful outcome was seen with initial beta-hCG level as high as 106 634 IU/L and gestation sac as large as 6 cm and a live fetus.

CONCLUSION

The methotrexate/folinic acid regimen used as a one-dose treatment is safe and effective for unruptured interstitial pregnancy, with no side-effects and the advantage of avoiding invasive surgery. Subsequent tubal patency and reproductive function are yet to be ascertained.

Sonographic and Doppler imaging in the diagnosis and treatment of gestational trophoblastic disease: a 12-year experience

OBJECTIVE

To evaluate the clinical utility of sonography with Doppler examination in the diagnosis and treatment of gestational trophoblastic disease (GTD).

METHODS

A retrospective analysis of 355 cases of GTD seen over a 12-year period in 2 large university referral hospitals in China was performed. Clinical appearances, sonographic findings, Doppler waveforms, and patient outcomes were reviewed. Sonographic and Doppler examinations were performed to diagnose the presence of molar tissue, detect invasive disease, assess disease recurrence, and monitor the efficacy of chemotherapy. Doppler waveforms of 13 patients with normal early pregnancies were also examined for comparison.

RESULTS

Of the 355 patients with GTD, 106 had a classic hydatidiform mole (CHM), 33 had a partial hydatidiform mole (PHM), 184 had an invasive hydatidiform mole (IHM), and 32 had choriocarcinoma. Sonography showed abnormal molar tissue confined to the endometrial cavity in all cases of CHM. In cases of IHM and choriocarcinoma, soft tissue invasion and cystic vascular spaces within the myometrium were shown. Cases of PHM had a thickened, hydropic placenta with a concomitant fetus. Doppler waveforms showed resistive indices of 0.55 (SD, 0.06) for CHM, 0.56 (SD, 0.04) for PHM, 0.28 (SD, 0.06) for IHM, 0.25 (SD, 0.05) for choriocarcinoma, and 0.66 (SD, 0.04) for normal pregnancies. The abnormal sonographic and Doppler findings in invasive disease resolved when chemotherapy was successful.

CONCLUSIONS

Sonography and Doppler imaging were helpful in diagnosing GTD, in determining whether invasive disease was present, in detecting recurrence of disease, and in following the effectiveness of chemotherapy.