Abstract
ABSTRACT Background: The use of obstetric ultrasound in the diagnosis of gestational trophoblastic disease (GTD) in high-income settings is well established, leading to prompt management and high survival rates. Evidence from low-income settings suggests ultrasound is essential in identifying complicated pregnancies, but with limited studies reviewing specific conditions including GTD. Objective: The aim of this study is to review the role of ultrasound in diagnosis and management of GTD in a marginalized population on the Thailand–Myanmar border. Antenatal ultrasound became available in this rural setting in 2001 and care for women with GTD has been provided by Thailand public hospitals for 20 years. Design: Retrospective record review. Results: The incidence of GTD was 103 of 57,004 pregnancies in Karen and Burmese women on the Thailand–Myanmar border from 1993–2013. This equates to a rate of 1.8 (95% CI 1.5–2.2) per 1000 or 1 in 553 pregnancies. Of the 102 women with known outcomes, one (1.0%) died of haemorrhage at home. The median number of days between first antenatal clinic attendance and referral to hospital was reduced from 20 (IQR 5–35; range 1–155) to 2 (IQR 2–6; range 1–179) days (p = 0.002) after the introduction of ultrasound. The proportion of severe outcomes (death and total abdominal hysterectomy) was 25% (3/12) before ultrasound compared to 8.9% (8/90) with ultrasound (p = 0.119). A recurrence rate of 2.5% (2/80) was observed in the assessable population. The presence of malaria parasites in maternal blood was not associated with GTD. Conclusions: The rate of GTD in pregnancy in this population is comparable to rates previously reported within South-East Asia. Referral time for uterine evacuation was significantly shorter for those women who had an ultrasound. Ultrasound is an effective method to improve diagnosis of GTD in low-income settings and an effort to increase availability in marginalized populations is required.
Highlights
The use of obstetric ultrasound in the diagnosis of gestational trophoblastic disease (GTD) in high-income settings is well established, leading to prompt management and high survival rates
Demographic characteristics and risk factors associated with GTD
The median (IQR) gestational age at presentation was significantly lower in women with GTD compared to no GTD: 11.3 (8.0–15.6) weeks (n = 99) vs 13.6 (8.8– 21.9) weeks (n = 55,524), p < 0.001; as were the haematocrit: 32.8 ± 5.4% (n = 88) and 33.8 ± 4.3% (n = 52,093) respectively, p = 0.024; and the body mass index (BMI) in women who presented in the first trimester: 19.8 ± 3.0 kg/m2 (n = 59) and 21.0 ± 3.0 kg/m2 (n = 18,479), p = 0.003, respectively
Summary
The use of obstetric ultrasound in the diagnosis of gestational trophoblastic disease (GTD) in high-income settings is well established, leading to prompt management and high survival rates. Ultrasound is an effective method to improve diagnosis of GTD in low-income settings and an effort to increase availability in marginalized populations is required. Existing studies estimate the rate of GTD to be higher in South-East Asia compared to high-income countries [1], access to diagnosis and treatment services are likely to be lower [2]. There is evidence that GTD risk is associated with low socio-economic status and nutritional deficiencies in prior generations, and that affected women in SouthEast Asia have a higher rate of malignant disease [4,5,6]. In high-income settings GTD is often recognized early in pregnancy, initial management (uterine evacuation) occurs without delay, and careful follow-up ensures those with persistent disease are treated successfully, resulting in high survival rates [7]. From available data worldwide it is estimated that prior to effective uterine evacuation and chemotherapy, maternal
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