Gestational Trophoblastic Disease

Eclampsia, HELLP and PRES in a 16-week partial molar pregnancy

Eclampsia spectrum disorders are a set of serious complications of pregnancy that commonly present after 20 weeks of gestation. There is an association between molar pregnancy, a gestational trophoblastic disease resulting from abnormal fertilisation and gametogenesis, and eclampsia spectrum disorders which can result in manifestation of pre-eclamptic symptomatology earlier than 20 weeks of gestation. We report a case of a gravida 1 para 0 in her mid 20s at 16-weeks gestation presenting with partial hydatidiform mole who developed eclampsia, haemolysis, elevated liver enzymes and low platelets syndrome and posterior reversible encephalopathy syndrome. Ultrasound findings were consistent with molar pregnancy and pathology confirmed partial molar pregnancy with triploid 69, XYY karyotype. This case highlights the early onset potential of eclampsia spectrum disorders in molar pregnancies while suggesting screening such patients for hypertensive disorders.

Molar pregnancy presenting in the emergency department

A 27-year-old female grava1 para 0 presented to the emergency department with complaints of intractable nausea and vomiting associated with fatigue and shortness of breath for the past 2 weeks with concerns for pregnancy. Physical exam was benign. Labs were significant for a β-hcg level of 348,260 mIU/mL. Ultrasonography showed a 12.4 pelvic mass possibly arriving from the anterior uterus concerning for fibroid. US also showed an anechoic focus suggestive of a gestational sac measuring 2.09 cm. The presentation was concerning for hyperemesis gravidarum due to molar pregnancy.

Gestational and Non-gestational Trophoblastic Neoplasia. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 032/049, April 2022)

Purpose The aim was to develop and update a guideline which would improve the quality of care offered to women with gestational and non-gestational trophoblastic disease, a group of diseases characterized by their rarity and biological heterogeneity.

Methods In accordance with the method used to compile S2k-guidelines, the guideline authors carried out a search of the literature (MEDLINE) for the period 1/2020 to 12/2021 and evaluated the recent literature. No key questions were formulated. No structured literature search with methodical evaluation and assessment of the level of evidence was carried out. The text of the precursor version of the guideline from 2019 was updated based on the most recent literature, and new statements and recommendations were drafted.

Recommendations The updated guideline contains recommendations for the diagnosis and therapy of women with hydatidiform mole (partial and complete moles), gestational trophoblastic neoplasia after pregnancy or without prior pregnancy, persistent trophoblastic disease after molar pregnancy, invasive moles, choriocarcinoma, placental site nodules, placental site trophoblastic tumor, hyperplasia at the implantation site und epithelioid trophoblastic tumor. Separate chapters cover the determination and assessment of human chorionic gonadotropin (hCG), histopathological evaluation of specimens, and the appropriate molecular pathological and immunohistochemical diagnostic procedures. Separate chapters on immunotherapy, surgical therapy, multiple pregnancies with simultaneous trophoblastic disease, and pregnancy after trophoblastic disease were formulated, and the corresponding recommendations agreed upon.

Loss of p57 Expression in Conceptions Other Than Complete Hydatidiform Mole: A Case Series With Emphasis on the Etiology, Genetics, and Clinical Significance

Combined p57 immunohistochemistry and DNA genotyping refines classification of products of conception specimens into specific types of hydatidiform moles and various nonmolar entities that can simulate them. p57 expression is highly correlated with genotyping and in practice can reliably be used to identify virtually all complete hydatidiform moles (CHM), but aberrant retained or lost p57 expression in rare CHMs and partial hydatidiform moles (PHM), as well as loss in some nonmolar abortuses, has been reported. Among a series of 2329 products of conceptions, we identified 10 cases for which loss of p57 expression was inconsistent with genotyping results (none purely androgenetic). They displayed a spectrum of generally mild abnormal villous morphology but lacked better developed features of CHMs/early CHMs, although some did suggest subtle forms of the latter. For 5 cases, genotyping (4 cases) and/or ancillary testing (1 case) determined a mechanism for the aberrant p57 results. These included 3 PHMs-2 diandric triploid and 1 triandric tetraploid-and 1 nonmolar specimen with loss of p57 expression attributable to partial or complete loss of the maternal copy of chromosome 11 and 1 nonmolar specimen with Beckwith-Wiedemann syndrome. For 5 cases, including 2 diandric triploid PHMs and 3 biparental nonmolar specimens, genotyping did not identify a mechanism, likely due to other genetic alterations which are below the resolution of or not targeted by genotyping. While overdiagnosis of a PHM as a CHM may cause less harm since appropriate follow-up with serum β-human chorionic gonadotropin levels would take place for both diagnoses, this could cause longer than necessary follow-up due to the expectation of a much greater risk of persistent gestational trophoblastic disease for CHM compared with PHM, which would be unfounded for the correct diagnosis of PHM. Overdiagnosis of a nonmolar abortus with loss of p57 expression as a CHM would lead to unnecessary follow-up and restriction on pregnancy attempts for patients with infertility. Genotyping is valuable for addressing discordance between p57 expression and morphology but cannot elucidate certain mechanisms of lost p57 expression. Future studies are warranted to determine whether chromosomal losses or gains, particularly involving imprinted genes such as p57, might play a role in modifying the risk of persistent gestational trophoblastic disease for PHMs and nonmolar conceptions that are not purely androgenetic but have some abnormal paternal imprinting of the type seen in CHMs.

Efficacy of Oral Vitamin A in Reducing β-hCG Levels in Low-Risk Gestational Trophoblastic Neoplasia Patients

OBJECTIVE

Low-risk gestational trophoblastic neoplasia (GTN) is generally treated with single agent chemotherapy and methotrexate (MTX) as a first-line therapy. Vitamin A helps to increase trophoblast cell regression, as well as to decrease β-hCG levels. Vitamin A also increases the effectiveness of MTX by inducing more malignant cell death than MTX alone. Therefore, the aim of the current study was to analyze the changes in β-hCG levels in low-risk GTN patients following vitamin A administration.

METHODS

This study was a randomized clinical trial, which examined initial serum vitamin A and β-hCG levels in GTN patients before and after three cycles of MTX therapy. Patients were given vitamin A supplementation of 6,000 IU (1.8 mg RAEs) per day, and the changes in serum β-hCG were observed after three cycles. Patients were grouped by β-hCG levels (decreased or stagnant).

RESULTS

A total of 32 low-risks GTN patients were divided into the intervention group (16 patients who received vitamin A supplementation) and the control group (16 patients who did not receive vitamin A supplementation). In the intervention group, the average initial β-hCG level was 170,949.3 ± 354,452.1 mIU/mL, and the average β-hCG post-cycle level was 1,611.9 ± 3,652.5 mIU/mL. In the control group, the average initial β-hCG level was 178,834.1 ± 2913844.6 mIU/mL, and the average β-hCG post-cycle level was 25,388.5 ± 58,437.7 mIU/mL.

CONCLUSION

In patients with low-risk GTN who underwent MTX chemotherapy, the levels of β-hCG and the incidence of chemo resistance in the intervention group were lower than those in the control group. Older age may also influence the incidence of chemo resistance in GTN patients. Oral administration of 6,000 IU vitamin A could help to reduce β-hCG levels in low-risk GTN patients who receive MTX chemotherapy.<br />.

Psychological aspects and fertility issues of GTD

Gestational trophoblastic disease (GTD) represents a spectrum of rare pregnancy-related disorders, including both premalignant and malignant entities. Although GTD's medical outcomes have been widely explored, limited data are available regarding the related psychological, sexual, and fertility issues. The present chapter aims to enhance comprehension of the psychosocial impact of GTD by discussing the main quantitative and qualitative evidence available in this field. Although patients globally report a good quality of life, clinically significant levels of anxiety and depression have been consistently found across studies. Similarly, despite the quality of couple relationships being generally satisfactory, they often complain of a lack of sexual desire. Moreover, pregnancy loss may raise significant and long-term fertility-related concerns. Specific socio-demographic and clinical factors have been identified as predictors of psychosocial outcomes. At the clinical level, research suggests that there is a need to provide multidisciplinary care to patients.

Pitfalls in the assessment of gestational transient thyrotoxicosis

Gestational transient thyrotoxicosis (GTT) is associated with direct stimulation of the maternal thyroid gland by human chorionic gonadotropin (hCG). It is characterized by slightly higher thyroid hormone and lower thyroid-stimulating hormone (TSH) levels in early pregnancy and mild or no symptoms. While GTT must be distinguished from Graves' disease (GD), which is associated with maternal and fetal complications, treated GD and new-onset GD in pregnancy are occasionally challenging to distinguish. Evaluating serum hCG levels and TSH receptor antibody (TRAb) titers can help, but the results are not irrefutable due to pregnancy-related immunosuppression. Moreover, GTT can follow unusual clinical courses in relation to some pregnancy complications. Excessive hCG production can cause severe GTT symptoms in patients with hyperemesis gravidarum, trophoblastic disease, or multiple pregnancies. Thyrotoxicosis can emerge beyond the second trimester in patients with gestational diabetes mellitus and mirror syndrome, because of delayed elevations in the hCG levels. Detailed knowledge about GTT is necessary for correct diagnoses and its appropriate management. This review focuses on the diagnosis of GTT, and, particularly, its differentiation from GD, and unusual clinical conditions associated with GTT that require comprehensive management.

[IPartial molar pregnancy with liveborn diploid fetus: case study and literature review]

Partial hydatiform mole (MHP) represents a spectrum of trophoblastic-related disorders occurring during pregnancy. Also known as embryonal mole, it is characterized by a recognizable ovum abnormality with vesicular transformation of villi but with recognizable placental appearance and amniotic cavity containing the fetus. First-trimester spontaneous abortion most commonly suggests the diagnosis. Partial moles rarely persist beyond the first trimester and are then a cause of maternal and fetal complications and diagnostic confusion. MHP of genetic origin is triploid with extra chromosome of paternal origin. The coexistence of normal fetal karyotype and MHP is exceptional. We report a rare case of partial molar pregnancy with liveborn diploid fetus in a 36-year-old woman diagnosed with threat of premature labour associated with placenta previa at 27 weeks of amenorrhea (WA).

Comprehensive analysis of 204 sporadic hydatidiform moles: revisiting risk factors and their correlations with the molar genotypes

Hydatidiform mole (HM) is an aberrant human pregnancy characterized by excessive trophoblastic proliferation and abnormal embryonic development. HM has two morphological types, complete (CHM) and partial (PHM), and non-recurrent ones have three genotypic types, androgenetic monospermic, androgenetic dispermic, and triploid dispermic. Most available studies on risk factors predisposing to different types of HM and their malignant transformation mainly suffer from the lack of comprehensive genotypic analysis of large cohorts of molar tissues combined with accurate postmolar hCG follow-up. Moreover, 10-20% of patients with one HM have at least one non-molar miscarriage, which is higher than the frequency of two pregnancy losses in the general population (2-5%), suggesting a common genetic susceptibility to HM and miscarriages. However, the underlying causes of the miscarriages in these patients are unknown. Here, we comprehensively analyzed 204 HM, mostly from patients referred to the Quebec Registry of Trophoblastic Diseases and for which postmolar hCG monitoring is available, and 30 of their non-molar miscarriages. We revisited the risk of maternal age and neoplastic transformation across the different HM genotypic categories and investigated the presence of chromosomal abnormalities in their non-molar miscarriages. We confirm that androgenetic CHM is more prone to gestational trophoblastic neoplasia (GTN) than triploid dispermic PHM, and androgenetic dispermic CHM is more prone to high-risk GTN and choriocarcinoma (CC) than androgenetic monospermic CHM. We also confirm the association between increased maternal age and androgenetic CHM and their malignancies. Most importantly, we demonstrate for the first time that patients with an HM and miscarriages are at higher risk for aneuploid miscarriages [83.3%, 95% confidence interval (CI): 0.653-0.944] than women with sporadic (51.5%, 95% CI: 50.3-52.7%, p value = 0.0003828) or recurrent miscarriages (43.8%, 95% CI: 40.7-47.0%, p value = 0.00002). Our data suggest common genetic female germline defects predisposing to HM and aneuploid non-molar miscarriages in some patients.

ANTEMORTEM DIAGNOSIS AND SUCCESSFUL TREATMENT OF A COMPLETE MOLAR PREGNANCY IN A GERIATRIC BONOBO ( PAN PANISCUS)

A 47-yr-old multiparous female bonobo ( Pan paniscus) tested positive for pregnancy on a routine urine test. Because this geriatric animal was considered postreproductive, oral contraception had been discontinued. Sequential transabdominal ultrasound evaluations were performed under voluntary behavior and revealed that the uterus contained a mass of heterogenous tissue which was rapidly increasing in size. Due to a lack of normal fetal development and the ultrasonographic appearance of the uterine tissue, a molar pregnancy was suspected. Ovariohysterectomy was performed, and a complete hydatidiform mole was confirmed through human chorionic gonadotropin levels as well as gross and histological examination of the uterus. To the authors' knowledge, this is the first time a complete molar pregnancy has been reported antemortem in a nonhuman great ape, although a single case of partial hydatidiform mole was previously documented in a chimpanzee on postmortem examination. This case describes the successful medical and surgical management of complete molar pregnancy in a bonobo and provides support for extending the age range of birth control recommendations in geriatric captive great apes that exhibit active breeding behavior.

Gestational Trophoblastic Disease at Sultan Qaboos University Hospital: Prevalence, Risk Factors, Histological Features, Sonographic Findings, and Outcomes

Objectives

We sought to assess the prevalence of gestational trophoblastic diseases (GTD) among pregnant women at Sultan Qaboos University Hospital (SQUH) and compare our results with the international studies. We also sought to determine the risk factors, histological features, sonographic findings, and outcomes in women with GTD.

Methods

We conducted a retrospective cohort study of all women diagnosed with GTD and followed at SQUH between November 2007 and October 2015. We collected data on maternal demographics, risk factors, sonographic features, histological diagnosis, follow-up period, and chemotherapy treatment from the hospital information system.

Results

Sixty-four women with GTD were included in the study with a mean age of 31.0±7.5 years, mean gravidity 4.0, and parity 2.0. The prevalence of GTD was 0.3% (one in 386 births), and the most common risk factors were increased maternal age and multiparity. A partial hydatidiform mole was diagnosed in 54.7%, complete hydatidiform mole in 43.8%, and invasive mole in 1.6% of women. Eleven percent of women required chemotherapy. Typical ultrasound features for partial molar pregnancy were present in 54.7% of our sample, while snowstorm appearance was seen in 89.3% of those with complete mole. Negative beta-human chorionic gonadotropin was achieved 70 days after diagnosis in 41 women.

Conclusions

The awareness of the risks and complications of GTD among physicians with close follow-up is paramount. There is a need to establish a national registry of GTD cases in Oman.

A promising therapeutic strategy for metastatic gestational trophoblastic disease: Engineered anticancer gene-expressing stem cells to selectively target choriocarcinoma

Gestational trophoblastic disease (GTD) is an unusual disease occurring in pregnancy that originates from abnormal trophoblastic cells and comprises a group of diseases with different properties of invasion, metastasis and recurrence. The GTD group includes hydatidiform moles and gestational trophoblastic neoplasms (GTNs), with GTNs being divided into invasive moles, choriocarcinoma, placental site trophoblastic tumors and epithelioid trophoblastic tumors. The present review focuses on current effective treatments for GTD, including conventional and novel promising direct enzyme prodrug therapies (DEPTs). Conventional therapies, such as chemotherapy and hysterectomy, are currently used in a clinical setting; however, the use of diverse DEPTs, including antibody-DEPT and gene-DEPT is also being attempted to cure GTNs. In addition, gene delivery tools using genetically engineered neural stem cells (NSCs) are presently being examined for the treatment of GTNs. The tumor-tropism of NSCs by chemoattractant factors is a unique characteristic of these cells and can serve as a vehicle to deliver anticancer agents. Previous studies have demonstrated that injection with NSC-expressing suicide genes into xenograft animal models has a significant inhibitory effect on tumor growth. Stem cells can be genetically engineered to express anticancer genes, which migrate to the metastatic sites and selectively target cancer cells, and are considered to effectively target metastatic GTNs. However, the safety issue of stem cell therapy, such as tumorigenesis, remains a challenge. Novel therapies comprising a combination of conventional and novel promising treatments are anticipated to be definitive treatments for metastasized and/or recurrent patients with GTNs.

Hydatidiform Moles: Ancillary Techniques to Refine Diagnosis

Context.—

Distinction of hydatidiform moles from nonmolar specimens and subclassification of hydatidiform moles as complete hydatidiform mole versus partial hydatidiform mole are important for clinical practice and investigational studies. Risk of persistent gestational trophoblastic disease and clinical management differ for these entities. Diagnosis based on morphology is subject to interobserver variability and remains problematic, even for experienced gynecologic pathologists.

Objectives.—

To explain how ancillary techniques target the unique genetic features of hydatidiform moles to establish diagnostic truth, highlight the issue of diagnostic reproducibility and importance of diagnostic accuracy, and illustrate use of p57 immunohistochemistry and polymerase chain reaction–based DNA genotyping for diagnosis.

Data Sources.—

Sources are the author's 10-year experience using ancillary techniques for the evaluation of potentially molar specimens in a large gynecologic pathology practice and the literature.

Conclusions.—

The unique genetics of complete hydatidiform moles (purely androgenetic), partial hydatidiform moles (diandric triploid), and nonmolar specimens (biparental, with allelic balance) allow for certain techniques, including immunohistochemical analysis of p57 expression (a paternally imprinted, maternally expressed gene) and genotyping, to refine diagnoses of hydatidiform moles. Although p57 immunostaining alone can identify complete hydatidiform moles, which lack p57 expression because of a lack of maternal DNA, this analysis does not distinguish partial hydatidiform moles from nonmolar specimens because both express p57 because of the presence of maternal DNA. Genotyping, which compares villous and decidual DNA patterns to determine the parental source and ratios of polymorphic alleles, distinguishes purely androgenetic complete hydatidiform moles from diandric triploid partial hydatidiform moles, and both of these from biparental nonmolar specimens. An algorithmic approach to diagnosis using these techniques is advocated.

Comparison of different therapeutic strategies for complete hydatidiform mole in women at least 40 years old: a retrospective cohort study

BACKGROUND

There are three main therapeutic strategies, namely expectant management (dilation and curettage only), prophylactic chemotherapy and prophylactic total hysterectomy for treating older women with complete hydatidiform mole (CHM). However, the scientific community has so far, not unanimously accepted the above-mentioned methods. The objective of this study was to evaluate the effectiveness of these therapeutic strategies in preventing post-molar gestational trophoblastic neoplasia (GTN) pertaining to patients with CHM who were at least 40 years old.

METHODS

Hundred and seventy-one patients from our hospital who had histologically been diagnosed of CHM and underwent treatment from January 2004 to December 2013 were included. All patients were followed continuously for a minimum of 2 years after which relevant clinical data were extracted and analysed.

RESULTS

All patients were divided to three groups. Group 1 consisted of 124 patients, treated by expectant management, and the incidence of post-molar GTN was 37.1%. Group 2 included 12 patients who received prophylactic chemotherapy, with an incidence of 41.7%. The remaining 35 patients, Group 3, underwent prophylactic total hysterectomy, with the lowest incidence of 11.4%. A significantly lower incidence was noted in group 3 as compared to group 1 (P = 0.004). GTN patients who received prophylactic chemotherapy required, on average, longer time to be diagnosed of GTN and had higher probability of chemotherapy resistance (P = 0.031 and P = 0.024).

CONCLUSIONS

This retrospective analysis showed that prophylactic total hysterectomy was the most effective therapeutic strategy for treating CHM in women at least 40 years old of age.

Molar pregnancy and thyroid storm - literature review

Molar pregnancies results from a tainted fertilization process. Trophoblastic thyroidian hyper function is an unusual complication of a molar pregnancy. The degree of thyroid stimulation and the severity of clinical hyperthyroidism is directly proportional to HCG concentration. Human chorionic gonadotrophin is almost identical with TSH, luteinizing hormone (LH) and follicle-stimulating hormone, this analogy in the structure will cause cross-reactivity with their receptors. Hyperthyroid status can vary from asymptomatic hyper function to thyroid storm. Dilation and curettage represents the treatment for hyperthyroidism in molar pregnancy. Awareness of this condition is important for diagnosis and treatment.

Transient Thyrotoxicosis in Molar Pregnancy

Molar pregnancy is one of the components of a broader spectrum of diseases known as Gestational Trophoblastic Disease (GTD), presenting with amenorrhoea and irregular bleeding which may be rarely associated with passage of vesicles per vagina. However, it can rarely be associated with hyperthyroidism, which may be associated with clinical features of hyperthyroidism. The following is a report of a 20-year-old woman who presented with amenorrhea followed by irregular bleeding per vagina, thyromegaly and abnormal levels of thyroid hormones. Transvaginal ultrasound revealed features consistent with molar pregnancy. A suction evacuation was done following which serum levels of β-hCG reduced and the levels of thyroid hormones also reduced. On follow up, six weeks later, β-hCG and thyroid hormones were within normal limits. The case and relevant literature are presented here.

Clinical Characteristics of Gestational Trophoblastic Neoplasia: A 15-Year Hospital-Based Study

Objective

To analyze the clinical profile of invasive mole (IM) and choriocarcinoma (CCA) in the past 15 years in Western China.

Materials and Methods

A retrospective study was performed on 221 patients with IM and 70 patients with CCA treated in the First Affiliated Hospital of Xi’an Jiaotong University from 1994 to 2009. Patients were assigned into 3 groups by 5 years, and the clinical characteristics were compared among these groups.

Results

The incidence was not significantly changed in the past 15 years, whereas the mean age of gestational trophoblastic neoplasia (GTN) was increased significantly, especially for the patients 40 years or older. The symptoms of the patients with GTN did not show significant variation, but the number of patients with CCA without clinical symptoms was increased significantly. The mean values of beta human chorionic gonadotropin in the patients with IM and those with CCA were 459.43 and 661.70 mIu/L, respectively, and the size of uterine lesion was concentrated at 4 cm or less in both the patients with IM and those with CCA, without significant differences.

Conclusions

In the past 15 years, the incidence of GTN was still higher than in other countries from 1994 to 2009, and the mean age of patients with GTN was increased significantly, especially for the patients older than 40 years. Furthermore, patients with no clinical manifestations increased significantly, which should be paid more attention in the future works. Serum level of beta human chorionic gonadotropin and pelvic ultrasonography are still 2 important indexes for diagnosing and monitoring condition of GTN.

LINE-1 Methylation Patterns as a Predictor of Postmolar Gestational Trophoblastic Neoplasia

Objective. To study the potential of long interspersed element-1 (LINE-1) methylation change in the prediction of postmolar gestational trophoblastic neoplasia (GTN). Methods. The LINE-1 methylation pattern from first trimester placenta, hydatidiform mole, and malignant trophoblast specimens were compared. Then, hydatidiform mole patients from 11999 to 2010 were classified into the following 2 groups: a remission group and a group that developed postmolar GTN. Specimens were prepared for a methylation study. The methylation levels and percentages of LINE-1 loci were evaluated for their sensitivity, specificity, and accuracy for the prediction of postmolar GTN. Results. First, 12 placentas, 38 moles, and 19 malignant trophoblast specimens were compared. The hydatidiform mole group had the highest LINE-1 methylation level (p = 0.003) and the ^uC^uC of LINE-1 increased in the malignant trophoblast group (p ≤ 0.001). One hundred forty-five hydatidiform mole patients were classified as 103 remission and 42 postmolar GTN patients. The %^mC^uC and %^uC^mC of LINE-1 showed the lowest p value for distinguishing between the two groups (p < 0.001). The combination of the pretreatment β-hCG level (≥100,000 mIU/mL) with the %^mC^uC and %^uC^mC, sensitivity, specificity, PPV, NPV, and accuracy modified the levels to 60.0%, 92.2%, 77.4%, 83.8%, and 82.3%, respectively. Conclusions. A reduction in the partial methylation of LINE-1 occurs early before the clinical appearance of malignant transformation. The %^mC^uC and %^uC^mC of LINE-1s may be promising markers for monitoring hydatidiform moles before progression to GTN.

An investigative study into psychological and fertility sequelae of gestational trophoblastic disease: the impact on patients' perceived fertility, anxiety and depression

OBJECTIVES

Gestational Trophoblastic Disease (GTD) comprises a group of disorders that derive from the placenta. Even if full recovery is generally expected, women diagnosed with GTD have to confront: the loss of a pregnancy, a potentially life-threatening diagnosis and delays in future pregnancies. The aim of the study is to evaluate the psychological impact of GTD, focusing on perceived fertility, depression and anxiety.

METHODS

37 patients treated for GTD at San Raffaele Hospital, Milan, took part in the study. The STAI-Y (State-Trait Anxiety Inventory), the BDI-SF (Beck Depression Scale-Short Form) and the FPI (Fertility Problem Inventory) were used. Patients were grouped on the basis of presence of children (with or without), age (< or ≥35) and type of diagnosis (Hydatidiform Mole, HM, or Gestational Trophoblastic Neoplasia, GTN). Differences in the values between variables were assessed by a t-type test statistic. Three-way ANOVAs were also carried out considering the same block factors.

RESULTS

The study highlights that women suffering from GTN had higher depression scores compared to women suffering from HM. A significant correlation was found between anxiety (state and trait) and depression. Younger women presented higher Global Stress scores on the FPI, especially tied to Need for Parenthood and Relationship Concern subscales. Need for Parenthood mean scores significantly varied between women with and without children too.

CONCLUSIONS

We can conclude that fertility perception seems to be negatively affected by GTD diagnosis, particularly in younger women and in those without children. Patients should be followed by a multidisciplinary team so as to be supported in the disease's psychological aspects too.

Women with a partial mole during their first pregnancy and diagnosed earlier in gestation are at increased risk of developing gestational trophoblastic neoplasia

OBJECTIVE

The aim of this study is to identify factors associated with gestational trophoblastic neoplasia (GTN) after partial molar pregnancy.

METHODS

We retrospectively evaluated clinical data from 111 patients with a partial molar pregnancy between 1995 and 2010.

RESULTS

A total of 111 patients with a partial molar pregnancy were available for analysis. There was no significant difference between patients who did and did not develop GTN with respect to patient age, parity, history of prior molar pregnancy, presenting signs/symptoms, uterine size greater than gestational age, clinical diagnosis, preevacuation sonogram findings, or the preevacuation human chorionic gonadotropin value. Patients who developed GTN had fewer prior pregnancies (median, 2 vs 3; P = 0.02) and were more likely to have had a partial molar pregnancy as their first gestational event (37.1% vs 17.1%; P = 0.03). Among the 35 patients who developed GTN, the median time to diagnosis of GTN was 47 days (range, 25-119 days), and the median human chorionic gonadotropin value at the time of GTN diagnosis was 475 mIU/mL (range, 20-52,630 mIU/mL). All women (100%) who developed GTN had stage I disease, and all patients (100%) had low-risk GTN. All 35 women (100%) were able to achieve remission, and most (85.7%) of these patients received methotrexate as first-line chemotherapy.

CONCLUSIONS

Women with a partial molar pregnancy as their first gestational event and diagnosed earlier in gestation are more likely to develop postmolar GTN.

Gestational throphoblastic diseases in North East of Iran: 10 years (2001-2010) prospective epidemiological and clinicopathological study

Background:

Many aspects of epidemiological and clinicopathological features of gestational trophoblastic disease (GTD), one of the important subject in gynecology oncology, needs to be defined so as to recommend the best approach and management toward it. In the present study, we evaluated 10-years incidence of throphoblastic diseases in north east of Iran in prospective epidemiological and clinicopathological study.

Materials and Methods:

We reviewed the registered histopathology database archive (120 records) related to throphoblastic diseases of the Ghaem Hospital, Mashhad University of Medical Sciences from 2001 to 2010.

Results:

Evaluation of the pathological reports revealed 5 (4.2%) choriocarcinom and 115 (95.8%) of hydatidiform mole (HM), with complete and partial HM diagnosis in 29 (25.2%) and 86 (74.8%) patients, respectively. The pregnancy rate of HM patients (2.72 ± 1.86) and choriocarcinoma patients (3.56 ± 2.8) was not significantly different (P = 0.61). There was no statistical significant difference between the number of pregnancies in HM (2.90 ± 3.13) and choriocarcinoma (3.84 ± 3.80) patients (P = 0.46). The ratio of complete to partial mole increased with age, although this correlation was not significant. Most patients in both the groups had no history of abortion. O positive was the predominant blood group among the studied patients.

Conclusion:

Throphoblastic diseases occur during the fertility age mostly, and there is an increased risk with more previous pregnancies; ultrasound sonography is a useful method for primary diagnosis of this disease. Further pathological studies are needed to define the mole type.

NLRP7 and the Genetics of Hydatidiform Moles: Recent Advances and New Challenges

NOD-like receptor proteins (NLRPs) are emerging key players in several inflammatory pathways in Mammals. The first identified gene coding for a protein from this family is Nlrp5 and was originally called Mater for “Maternal Antigen That Mouse Embryos Require” for normal development beyond the two-cell stage. This important discovery was followed by the identification of other NLRPs playing roles in inflammatory disorders and of the first maternal-effect gene in humans, NLRP7, which is responsible for an aberrant form of human pregnancy called hydatidiform mole (HM). In this review, we recapitulate the various aspects of the pathology of HM, highlight recent advances regarding NLRP7 and its role in HM and related forms of reproductive losses, and expand our discussion to other NLRPs with a special emphasis on those with known roles in mammalian reproduction. Our aim is to facilitate the genetic complexity of recurrent fetal loss in humans and encourage interdisciplinary collaborations in the fields of NLRPs and reproductive loss.

Diagnosis of ovarian metastasis from gestational trophoblastic neoplasia by 3D power Doppler ultrasound and dynamic contrast-enhanced magnetic resonance imaging: case report

Choriocarcinoma is a highly malignant disease of trophoblastic cells, which affects young women in the reproductive years. The main sites of metastasis from choriocarcinoma are lung, vagina, liver, gastrointestinal tract and kidneys, and the involvement of the ovaries is extremely rare. The diagnosis of ovarian metastasis is made mainly by two-dimensional ultrasonography (2DUS) with color Doppler, which shows a large vessel in the center of the mass. The three-dimensional power Doppler ultrasound (3D power Doppler) and dynamic contrast-enhanced magnetic resonance imaging (MRI) are new diagnostic modalities not yet published in literature. We report a case of metastatic choriocarcinoma with left ovary involvement in a 48-year-old woman with history of molar pregnancy and irregular follow-up of this disease. We emphasize the main findings by 2DUS with color Doppler, 3D power Doppler and dynamic contrast-enhanced MRI. 3D power Doppler is able to improve the assessment of anatomical relationships of vessels with the ovarian mass, while the resonance angiography allows us to evaluate the anatomic relations of the mass and adjacent structures, as well as the iliac vessels. The 3D power Doppler and dynamic contrast-enhanced MRI are promising methods in the evaluation of metastasis arising from gestational trophoblastic tumors.

Gestational trophoblastic disease: an overview

This article reviews the different disease entities that fall under the classification of gestational trophoblastic disease (GTD). The conditions included range from molar pregnancy to the malignant forms of gestational trophoblastic neoplasm (GTN). These disorders all arise from abnormal placental trophoblastic development. The different types of GTD, symptomatology, and diagnostic modalities are examined. The various methods of treatment are reviewed. Although the management of GTD and GTN falls outside the scope of midwifery practice, midwives need to be aware of the incidence, risk factors, and symptoms for specific types of GTD in order to be able to diagnose and refer for treatment in a timely manner. Psychosocial aspects that affect the woman who has not only had a pregnancy loss but also may be faced with a life-threatening illness are examined. The role of the midwife in the management, counseling, and follow-up of GTD and GTN is discussed.

Hydatidiform mole mimicking an enlarged uterine fibromyoma four months after ART

Hydatidiform mole is a pregnancy disorder, of a benign nature. We present a case of molar tissue within a uterine myoma, the first such entity reported in the literature. In May 2006, a thirty-eight year old infertility patient was admitted for myomectomy. She had anamnesis for chronic pelvic inflammatory disease and surgeries performed for tubal pregnancies. After the sixth intracytoplasmal spermatozoa injection procedure performed in January 2006, she conceived, but curettage was performed in March 2006 for a missed abortion. Following the routine preoperative evaluation in May 2006, four months after the last artificial reproductive technology procedure, myomectomy was performed as uneventful operation, but the histological report appeared unusual, showing degenerated chorionic villi within the uterine myoma. Molar tissue within uterine myoma might evolve even after artificial reproductive procedures. Furthermore, this finding might be misinterpreted as a fibromyoma degeneration. This is the first, and a unique case, of molar tissue within uterine myoma reported in the literature.

Cervical hydatidiform mole pregnancy after missed abortion presenting with severe vaginal bleeding: case report and review of the literature

We report a 28-year-old woman presenting with a complete hyaditiform mole localized to the cervix. She had undergone curettage of missed abortion two months previously and the aborted material showed normal placental tissue on histopathologic examination. Two months after curettage she presented with sudden severe vaginal bleeding. Clinical examination revealed a lesion of the epithelial outer surface of the cervix. Due to the bleeding, immediate surgical intervention was necessary. Histological examination revealed a complete hydatidiform mole. Currently, only three cases of this exceedingly rare diagnosis have been published: two reported a partial mole and one a complete hydatidiform mole. In our case, we hypothesize that the pathogenesis took place in two steps. Initially the curettage of the missed abortion damaged the endometrial lining. During a new rapid re-fertilization after the missed abortion, a hydatidiform molar pregnancy developed. Normally this abnormal trophoblast tissue would adhere to the endometrium but in this case we assume that intrauterine implantation was not possible because of endometrial damage at the prior curettage, allowing the abnormal trophoblast tissue to pass the endocervix and emerge into the vaginal vault. Presumably, during the curettage an epithelial defect was produced on the outer surface of the cervix, due to clamping the cervix during dilatation. We speculate that this weak spot on the epithelial surface was responsible for the adherence to the cervix and subsequent bleeding was caused by injury of maternal blood vessels. We propose that careful holding of the cervix with atraumatic clamps during curettage is important to avoid subsequent complications.

Lack of a y-chromosomal complement in the majority of gestational trophoblastic neoplasms

Gestational trophoblastic neoplasms (GTNs) are a rare group of neoplastic diseases composed of choriocarcinomas, placental site trophoblastic tumors (PSTTs) and epithelioid trophoblastic tumors (ETTs). Since these tumors are derivatives of fetal trophoblastic tissue, approximately 50% of GTN cases are expected to originate from a male conceptus and carry a Y-chromosomal complement according to a balanced sex ratio. To investigate this hypothesis, we carried out a comprehensive analysis by genotyping a relatively large sample size of 51 GTN cases using three independent sex chromosome genetic markers; Amelogenin, Protein Kinase and Zinc Finger have X and Y homologues that are distinguishable by their PCR product size. We found that all cases contained the X-chromosomal complement while only five (10%) of 51 tumors harbored the Y-chromosomal complement. Specifically, Y-chromosomal signals were detected in one (5%) of 19 choriocarcinomas, one (7%) of 15 PSTTs and three (18%) of 17 ETTs. The histopathological features of those with a Y-chromosome were similar to those without. Our results demonstrate the presence of a Y-chromosomal complement in GTNs, albeit a low 10% of cases. This shortfall of Y-chromosomal complements in GTNs may reinforce the notion that the majority of GTNs are derived from previous molar gestations.

Molecular genotyping of hydatidiform moles: analytic validation of a multiplex short tandem repeat assay

Distinction of hydatidiform moles from non-molar (NM) specimens, as well as their subclassification as complete (CHM) versus partial hydatidiform moles (PHM), is important for clinical management and accurate risk assessment for persistent gestational trophoblastic disease. Because diagnosis of hydatidiform moles based solely on morphology suffers from poor interobserver reproducibility, a variety of ancillary techniques have been developed to improve diagnosis. Immunohistochemical assessment of the paternally imprinted, maternally expressed p57 gene can identify CHMs (androgenetic diploidy) by their lack of p57 expression, but cannot distinguish PHMs (diandric monogynic triploidy) from NMs (biparental diploidy). Short tandem repeat genotyping can identify the parental source of polymorphic alleles and thus discern androgenetic diploidy, diandric triploidy, and biparental diploidy, which allows for specific diagnosis of CHMs, PHMs, and NMs, respectively. In this study, a retrospectively collected set of morphologically typical CHMs (n = 8), PHMs (n = 10), and NMs (n = 12) was subjected to an analytic validation study of both short tandem repeat genotyping and p57 immunohistochemistry. Several technical and biological problems resulted in data that were difficult to interpret. To avoid these pitfalls, we have developed an algorithm with quantitative guidelines for the interpretation of short tandem repeat genotyping data.

Thyroid storm caused by a partial hydatidiform mole

Clinical thyrotoxicosis is rare in molar pregnancy and has yet to be reported in a patient with a partial mole. Human chorionic gonadotropin (hCG), which has thyrotropic activity, is believed to be responsible for hyperthyroidism of gestational trophoblastic activity and hyperemesis gravidarum. We report the first case of hyperthyroidism presenting as thyroid storm in a partial molar pregnancy. Normal thyroid function returned after the partial mole was evacuated, and the biochemical improvement correlated with declining hCG levels. This case highlights the importance of including partial mole in the differential of hCG-mediated hyperthyroidism.

Ultrasound of the placenta: a systematic approach. Part I: Imaging

Diagnostic ultrasound has been in use in clinical obstetrics for close to half-a-century. However, in the literature, examination of the placenta appears to be treated with less attention than the fetus or the pregnant uterus. This is somewhat unexpected, given the obvious major functions this organ performs during the entire pregnancy. Examination of the placenta plays a foremost role in the assessment of normal and abnormal pregnancies. A methodical sonographic evaluation of the placenta should include: location, visual estimation of the size (and, if appearing abnormal, measurement of thickness and/or volume), implantation, morphology, anatomy, as well as a search for anomalies, such as additional lobes and tumors. Additional assessment for multiple gestations consists of examining the intervening membranes (if present). The current review considers the various placental characteristics, as they can be evaluated by ultrasound, and the clinical significance of abnormalities of these features. Numerous and varied pathologies of the placenta can be detected by routine ultrasound. It is incumbent on the clinician performing obstetrical ultrasound to examine the placenta in details and in a methodical fashion because of the far reaching clinical significance and potentially avoidable severe consequences of many of these abnormalities.