Diagnosis and Management of Gestational Trophoblastic Disease: A Comparative Review of National and International Guidelines

A Twin Pregnancy of Partial Mole Coexisting with a Normal Fetus: A Case Report

Background

Twin pregnancy with partial hydatidiform mole and a co-existing normal fetus (PHMCF) is a very rare clinical condition. It presents with various complications like preterm labor, pre-eclampsia, hyperthyroidism and fetal anomalies.

Case Presentation

We report the case of a 40-year-old G13P10A2 mother who was referred to our hospital at 28 weeks as a case of twin pregnancy and pre-eclampsia. She had headache, epigastric pain, bilateral leg swelling, and decreased fetal movement for two days. Her physical examination was remarkable for raised blood pressure and uterus larger than gestational age. Ultrasound findings showed honeycomb-like echo suggestive of a molar pregnancy with a co-existing normal fetus. After she was admitted and managed for severe pre-eclampsia, a cesarean section was done to affect the delivery of a male neonate weighing 1400 grams. Histopathology confirmed the diagnosis of a partial mole with no malignant features. In follow-up, the serum β-HCG level normalized by the 7th week.

Conclusion

PHMCF is a rare obstetric condition. Despite these pregnancies having a greater risk of complications, strict follow-up at a tertiary care hospital and timely management of complications can result in good outcomes for both the mother and the fetus.

Role of Emergency Surgery for Fatal Complications of Gestational Trophoblastic Neoplasia: A Single-Center Experience

Purpose

High-risk gestational trophoblastic neoplasia (GTN) can lead to fatal complications; however, few reports have assessed emergency surgery as a treatment option for such complications. Thus, this study aimed to analyze the clinical features and prognosis of patients with GTN who underwent emergency surgery.

Patients and Methods

Thirteen patients with high-risk or ultra-high-risk GTN who underwent emergency surgery for fatal complications in the First Affiliated Hospital of Zhejiang University, School of Medicine from 2013 to 2020 were analyzed, and their medical records were reviewed. The patients’ characteristics and treatment were evaluated with respect to outcomes.

Results

Thirteen patients with GTN who underwent 15 emergency surgical procedures were identified in our center. The mean International Federation of Gynecology and Obstetrics score of these patients was 14.8 (range, 11–19). Of the 13 patients, six underwent brain surgeries, such as tumor resection (n = 5) and conservative surgery (n = 1). All the patients received multi-agent chemotherapy after emergency surgery, and the mean time from emergency surgery to subsequent chemotherapy was 12.7 days. Of the 13 patients, 10 (77%) were cured and disease-free, with a follow-up period ranging from 3 months to 8 years. All the patients (n = 6) who underwent emergency brain surgery survived and achieved complete remission.

Conclusion

For patients with high-risk GTN with fatal complications, especially brain lesions, emergency surgery combined with subsequent chemotherapy may provide a favorable prognosis.

Thyroid Disease in Pregnancy: A Descriptive Review of Guidelines

Importance

Thyroid disorders represent one of the most frequent complications of pregnancy associated with adverse obstetric, fetal, and neonatal outcomes, especially in case of delayed diagnosis and suboptimal management.

Objective

The aim of this study was to review and compare the recommendations of the most recently published guidelines on the diagnosis and management of these common conditions.

Evidence Acquisition

A descriptive review of guidelines from the Endocrine Society, the European Thyroid Association, the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the American Thyroid Association, and the American College of Obstetricians and Gynecologists on thyroid disease in pregnancy was carried out.

Results

There is an overall consensus regarding the diagnosis of overt and subclinical hypothyroidism and hyperthyroidism in pregnancy using the pregnancy-specific reference ranges and the definition of postpartum thyroiditis. The reviewed guidelines unanimously discourage universal screening for thyroid function abnormalities before and during pregnancy and support targeted screening of high-risk patients by measuring serum thyroid-stimulating hormone levels. Moreover, they all highlight the need of treating overt hypothyroidism and hyperthyroidism, not only during pregnancy, but also before conception, suggesting similar management policies and treatment targets. There is also agreement regarding the management of gestational transient hyperthyroidism with hyperemesis gravidarum, suspected fetal thyrotoxicosis, postpartum thyroiditis, and thyroid malignancy. Scanning or treating with radioactive iodine is contraindicated during pregnancy and breastfeeding. On the other hand, there is controversy on the management of subclinical thyroid disease, thyroid function surveillance protocols, and iodine nutrition recommendations. Of note, the American College of Obstetricians and Gynecologists makes some specific recommendations on the treatment of thyroid storm and thyrotoxic heart failure in pregnant women, whereas the American Thyroid Association makes a special reference to the management of women with thyroid cancer.

Conclusions

As the disorders of the thyroid gland affect a significant proportion of pregnant women, it is of paramount importance to develop uniform international evidence-based protocols for their accurate diagnosis and optimal management, in order to safely guide clinical practice and eventually improve perinatal outcomes.

Gestational Hypertension and Preeclampsia: An Overview of National and International Guidelines

Importance

Gestational hypertension and preeclampsia are leading causes of maternal and perinatal morbidity and mortality worldwide. Τhe lack of effective screening and management policies appears to be one of the main reasons.

Objective

The aim of this study was to review and compare recommendations from published guidelines on these common pregnancy complications.

Evidence Acquisition

A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the World Health Organization, and the US Preventive Services Task Force on gestational hypertension and preeclampsia was carried out.

Results

There is an overall agreement that, in case of suspected preeclampsia or new-onset hypertension, blood and urine tests should be carried out, including dipstick test for proteinuria, whereas placental growth factor-based testing is only recommended by the National Institute for Health and Care Excellence and the European Society of Cardiology. In addition, there is a consensus on the recommendations for the medical treatment of severe and nonsevere hypertension, the management of preeclampsia, the appropriate timing of delivery, the optimal method of anesthesia and the mode of delivery, the administration of antenatal corticosteroids and the use of magnesium sulfate for the treatment of eclamptic seizures, the prevention of eclampsia in cases of severe preeclampsia, and the neuroprotection of preterm neonates. The reviewed guidelines also state that, based on maternal risk factors, pregnant women identified to be at high risk for preeclampsia should receive low-dose aspirin starting ideally in the first trimester until labor or 36 to 37 weeks of gestation, although the recommended dose varies between 75 and 162 mg/d. Moreover, most guidelines recommend calcium supplementation for the prevention of preeclampsia and discourage the use of other agents. However, controversy exists regarding the definition and the optimal screening method for preeclampsia, the need for treating mild hypertension, the blood pressure treatment targets, and the postnatal blood pressure monitoring.

Conclusions

The development and implementation of consistent international protocols will allow clinicians to adopt effective universal screening, as well as preventive and management strategies with the intention of improving maternal and neonatal outcomes.

Bioinformatics Analysis of Choriocarcinoma-Related MicroRNA-Transcription Factor-Target Gene Regulatory Networks and Validation of Key miRNAs

Objective

The aim of the current research was to construct a miRNA-transcription factor (TF)-target gene regulatory network in order to investigate the mechanism underlying choriocarcinoma and to verify the network through the overexpression or silencing of hub miRNAs in vitro.

Materials and Methods

A mRNA expression dataset and two miRNA expression datasets were analysed to identify differentially expressed genes (DEGs) and miRNAs (DEMs) between normal cells and choriocarcinoma cells. The top 400 upregulated and downregulated DEGs were identified as candidate DEGs, which were then mapped to construct protein–protein interaction (PPI) networks and select hub genes. Moreover, the DGIdb database was utilized to select candidate drugs for hub genes. Moreover, DEM target genes were predicted through the miRWalk2.0 database and overlaid with candidate DEGs to identify the differentially expressed target genes (DETGs). Furthermore, we established miRNA-TF-target gene regulatory networks and performed functional enrichment analysis of hub DEMs. Finally, we transfected mimics or inhibitors of hub DEMs into choriocarcinoma cells and assessed cell proliferation and migration to verify the vital role of hub DEMs in choriocarcinoma.

Results

A total of 140 DEMs and 400 candidate DEGs were screened from choriocarcinoma cells and normal cells. A PPI network of 400 candidate DEGs was established. Twenty-nine hub genes and 99 associated small molecules were identified to provide potential target drugs for choriocarcinoma treatment. We obtained 70 DETGs of DEMs derived from the intersection between predicted miRNA target genes and candidate DEGs. Subsequently, 3 hub DEMs were selected, and miRNA-TF-target gene regulatory networks containing 4 TFs, 3 TFs and 3 TFs for each network were constructed. The RT-PCR results confirmed that miR-29b-3p was highly expressed and that miR-519c-3p and miR-520a-5p were expressed at low levels in choriocarcinoma cells. The overexpression or silencing results suggested that 3 dysregulated hub DEMs jointly accelerated the proliferation and migration of choriocarcinoma.

Conclusion

Association of miRNA-TF-target gene regulatory networks may help us explore the underlying mechanism and provide potential targets for the diagnosis and treatment of choriocarcinoma.

Three atypical presentations of choriocarcinoma, occurring during and shortly after a coexistent viable pregnancy

Gestational choriocarcinoma is a malignant tumour originating from the trophoblastic tissue that can arise during or after any type of pregnancy, but most of the time follows a molar pregnancy. Characteristic for this tumour is its rapid haematogenous spread to various organs, causing atypical presentations often attributable to metastatic disease. We review three cases that occurred during and shortly after a coexistent intrauterine pregnancy. The patient of Case 1 presented with neurological symptoms due to hypercalcaemia, in Case 2 there was initially suspicion of appendicitis and the third patient presented with acute respiratory insufficiency. This case series illustrates that, although highly effective chemotherapy is available, choriocarcinoma can be life-threatening and accurate diagnosis is challenging but critical.