Complete Molar Pregnancy Research Articles

Ethnic disparities in complete and partial molar pregnancy incidence: a retrospective analysis of arab and jewish women in single medical center

BackgroundMolar pregnancies, encompassing complete and partial moles, represent a rare and enigmatic gestational disorder with potential ethnic variations in incidence. This study aimed to investigate relations of ethnicity with risks of complete and partial molar pregnancies within an Israeli population while accounting for age differences.MethodsA retrospective study was conducted of data recorded during 2007–2021 in an academic medical center in Israel. The study population comprised 167 women diagnosed with complete or partial moles, for whom data were obtained through histological examination and P57 immunostaining. Maternal age and ethnicity were extracted from electronic medical records. Incidence rates were calculated per 10,000 live births, and a nested case-control study compared demographic characteristics and molar pregnancy incidences between Arab and Jewish women. Statistical analyses included age-adjusted comparisons, relative risk calculations and multivariate logistic regression.ResultsThe overall risk of molar pregnancy was 22 per 10,000 live births (95% confidence interval [CI] 18–25). Among Arab women, the overall risk was 21 (95% CI 17–25), and for PM and CM: 14 (95% CI 11–17) and 7 (95% CI 5–10), respectively. Among Jewish women, the overall risk was 23 (95% CI 18–29), and for PM and CM: 12 (95% CI 8–17) and 11 (95% CI 7–16), respectively. Among Arab women compared to Jewish women, the proportion of all the partial moles was higher: (65.3% vs. 51.6%, p = 0.05). The incidence of partial mole was higher among Arab than Jewish women, aged 35–39 years (26 vs. 8 per 10,000, p = 0.041), and did not differ in other age groups. After adjusting for age, the relative risk of partial moles was lower among Jews than Arabs (0.7, 95% CI 0.4-1.0, p = 0.053). For Arab compared to Jewish women, the mean age at molar pregnancies was younger: 31.0 vs. 35.1 years. However, other factors did not differ significantly between Arab and Jewish women with molar pregnancies. In multivariate analysis, Jewish ethnicity was significantly associated with a higher risk of complete molar pregnancies (OR = 2.19, 95% CI 1.09–4.41, p = 0.028).ConclusionThis study highlights ethnic differences in molar pregnancy risk within the Israeli population. Jewish ethnicity was associated with a higher risk of complete molar pregnancies, while Arab women had a significantly higher risk of partial moles. These findings underscore the need to consider ethnicity when studying gestational disorders. Further research should seek to elucidate the underlying factors contributing to these differences.

Comparative Investigation of Color Doppler Ultrasonography Parameters of the Uterine Artery in Patients with Post-molar GTN and Patients Recovered from Molar Pregnancy and its Role in Predicting the Probability of Occurrence

Objectives: Hydatiform mole can progress to gestational trophoblastic neoplasia (GTN), and we are looking for non-invasive methods to predict it. Old age, higher serum BHCG levels, and expression of genes, such as VEGF-EG, HIF-1α, and TGF-ß are known as predictive factors. We performed this study to evaluate the role of bilateral uterine artery doppler ultrasound in predicting postmolar- GTN. Methods: In this prospective cohort study, 42 patients with complete molar pregnancy were examined. Inclusion criteria confirmed molar pregnancy by histopathological examination. Exclusion criteria were patients more than 40 years old, patients with completed family childbearing planning, and diagnosis of GTN during the routine histopathological study. Before molar evacuation and four weeks later, bilateral uterine artery doppler sonography to determine the PI, RI, and PSV was performed. Serum BHCG levels were also measured before molar evacuation and weekly after evacuation until it exhibited spontaneous remission or developed GTN. Results: About 36 patients were cured, and six others developed post-molar GTN. The bilateral uterine artery doppler sonography between the two groups showed a lower UA RI in the post-molar-GTN group before evacuation (P=0.048). Data demonstrated significant increases in Right.UA.RI (P=0/008), Left.UA.PI (P=0/037), and Right.UA.PSV (P=0/024) in the spontaneous remission group during 28 days follow-up period. There were no significant differences in these parameters in the GTN group throughout the time of follow-up. Conclusion: It seems that Doppler ultrasound plays a role in predicting GTN following uterine evacuation. A lower resistance in the uterine artery before evacuation and the remaining uterine artery blood flow constant after evacuation is associated with the development of post-molar- GTN.

Role of continuing regular follow-up of serial B-human chorionic gonadotropin measurements with health education following initial surgical management of complete molar pregnancy cases

Objective: Our goal to confirm complete cure, early detection of persistent gestational trophoblastic disease and more effective and less complex treatment. Methods: Fifty-one patients from 12,960 were admitted to the Department of Obstetrics and Gynecology at Tobruk Medical Center between August 2018 and July 2021 with complete molar pregnancy, the diagnosis was confirmed with histopathology after initial surgical management. Following identification of these patients, due to lack of registration centers, the patient's telephone was required to complete the data for continuing regular follow-ups over a period of time these patients were evaluated prospectively according to their age, number of deliveries, history of normal and abnormal pregnancy, the quantity of beta-human chorionic gonadotropin (B-HCG) at the time of diagnosis and follow-up and treatment type. Persistent gestational trophoblast disease was diagnosed on the basis of a rise of B-HCG after initial evacuation, and just one patient in our study diagnosed with invasive mole and underwent second evacuation and none of these patients developed choriocarcinoma during the follow-up period. Analysis was conducted by using the social package of statistical science (SPSS) version 25 software. Results: 51 patients (0.39%) were diagnosed with complete molar pregnancy (CMP), the mean age was 31.90 (8.169) years range (17-47 years). Among 51 patients with CMP over three years, seventeen patients (33.3%) were diagnosed with persistent gestational trophoblast disease (PGTD), the incidence is about 1.3 per 1000 per deliveries, thirty-four patients (66.7%) reached spontaneous remission of molar gestation in a median time of 61 days and had a total follow-up time of 24 months. Conclusion: Follow-up women with complete molar pregnancy especially after initial management is challenging task as the incidence of molar pregnancy increasing and exposed to the risk of developing persistent gestational trophoblastic disease, and there are no specialist centres for documentation and surveillance programme. And due to wide geographical area in Libya and difficulty in the follow-up patients with molar pregnancies, especially after initial treatment has been performed. Therefore, we must create multiple centers throughout the country to cover all cases as much as possible and the communication between the patients and centers via internet, to ensure early detection of pregnancy complications.

Perioperative Considerations for Hysterectomy in Second-Trimester Molar Pregnancy.

Second-trimester complete molar pregnancies are rare. Due to a later presentation, means to reduce surgical and long-term morbidity from hemorrhage, hyperthyroidism, and gestational trophoblastic neoplasia risk should be considered. A 48-year-old woman presented at 17 6/7 weeks of gestation with vaginal bleeding, with a human chorionic gonadotropin (hCG) level of 483,906 milli-international units/mL, biochemical hyperthyroidism, and ultrasonographic suspicion for complete molar pregnancy. The patient received preoperative uterine artery embolization and antithyroid medication before undergoing total abdominal hysterectomy. Her thyroid function and hCG level normalized by 1 week and 69 days postoperatively, respectively. Uterine artery embolization and hysterectomy may reduce surgical blood loss and lower the risk of malignancy for patients at high risk for gestational trophoblastic neoplasia. Preoperative treatment of hyperthyroidism with gestational trophoblastic disease can reduce morbidity from thyrotoxicosis.

A One-Year Epidemiological Perspective of Molar Pregnancies at Orotta Maternity Referral Hospital: Asmara, Eritrea

Gestational trophoblastic diseases (GTD) are a group of diseases originating from the placenta, with significant morbidity and mortality, especially in developing countries. A one-year prospective study on GTD was done to determine the incidence of GTD identify the risk factors; explain the clinical presentation; describe the management; and record the outcomes at Orotta Maternity Referral Hospital (OMRH) Asmara, Eritrea; A protocol for the prospective study of GTD was prepared with involvement of colleagues. All collected data was reviewed and finalized by the author. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS). During the study period a total of 6845 deliveries and 45 cases of GTD were recorded at OMRH. This gives an incidence of 6.6 per 1000 deliveries. Primgravid mothers were more affected. The majority of cases were complete molar pregnancy (87%) and vaginal bleeding was the main presentation. Pregnancy test result was read as negative in 7% of cases. Of the cases followed, 77.7% recovered while 11.1% required chemotherapy because of persistent disease and 8.9% were lost to follow up. The study confirms higher incidence, of GTD in Eritrea as compared to results of some African countries. The need to strengthen histological services and quantitative serum tests were identified as crucial in the effective management of GTD at OMRH. A standard and systematic approach of diagnosis, treatment and strict fellow-up of cases is required for better outcome.

Twin pregnancy: Live fetus with complete hydatidiform molar—A case report

Gestational trophoblastic disease encompasses a range of lesions, each culminating in varied clinical manifestations. Among these, the simultaneous occurrence of molar changes within the placenta and a viable fetus remains a particularly elusive and challenging presentation, posing intricate dilemmas for obstetricians. In this article, we delineate a distinct case involving a 21-year-old woman with a history of consanguineous marriage. She was referred from Médecins Sans Frontières to the Rafic Hariri University Hospital during her 19th week of gestation. With an unremarkable medical history and uncomplicated previous pregnancies, her presentation to the Rafic Hariri University Hospital was punctuated by symptoms of premature labor. Clinical evaluations revealed ruptured membranes, a fetus-positioned breech, and discernible complications tied to the placental morphology. Given these clinical findings, a decision was made in favor of a Cesarean delivery. Prior to this, the patient had been administered corticosteroids and tocolytics. Subsequent delivery produced a live male infant at 34 + 5 gestational days, and further assessment unveiled a complete molar pregnancy. The coexistence of a viable fetus alongside a complete molar pregnancy is an infrequently documented phenomenon, underlining the clinical significance of this case. A comprehensive literature survey reinforced the exceptional nature of our findings. Postpartum, both the mother and neonate were monitored for a month, ensuring their well-being. This case accentuates the paramountcy of prompt and precise diagnostic interventions when faced with atypical presentations. It further underscores the imperative for obstetricians to possess nuanced expertise in confronting the intricate challenges posed by gestational trophoblastic disease, ensuring optimal maternal and neonatal outcomes.

RARE CASE OF PARTIAL MOLE WITH LIVE FETUS PROGRESSION TO INVASIVE MOLE WITH LUNG METASTASIS FOLLOWING SPONTANEOUS CONCEPTION

Hydatiform mole belongs to a group of diseases classified as gestational trophoblastic disease,that results from an impaired fertilization.Moles have been divided into complete or partial moles on the basis of distinctive histopathological features and genetic abnormalities.Partial molar pregnancy with coexisting fetus is a rare complication with an incidence of 0.005%-0.01% of all the pregnancies.It usually derives from dispermic fertilization of all a haploid normal oocyte and produce a triploid set of chromosomes (69XXX69XXYor 69XYY)and is most commonly associated with the presence of a malformed fetus. We report a case of 21 year old primigravida with 19week +1dyay gestational age with pregnancy induced hypertension with? complete molar pregnancy with anemia presented to delivery room which was referred from private hospital in view of molar pregnancy for termination and correction of anemia.

Understanding of already known fact: Evaluating frequency and determinants of Hydatidiform Molar Pregnancy

Introduction: Sporadic presentation of hydatidiform has been reported previously as 1 in 1000 pregnancies. In rare cases asymptomatic molar pregnancies can cause problems if not identified in early radiological investigations. The aim of this study is to evaluate the frequency of hydatidiform (molar pregnancy) presenting with associated symptoms, analysis of determinants and management in Sindh, Pakistan. Methodology: This is a cross sectional study, patients were divided into categories according to maternal age, gravida while Beta HCG values were reported along with radiological investigation reporting to confirm hydatidiform molar pregnancy. Statistical package of social science version 21 was used to analyze the data. Results: Total 51 patients were identified with hydatidiform molar pregnancy during study period of 12 months from more than 1000 full term reported pregnancies, indicating 5.1% prevalence of disorder. The diagnosis has been confirmed only 1 (1.9%) case of partial molar pregnancy while 50 (99.1%) were complete molar pregnancy cases, managed by suction evacuation method, risks factors of hydatidiform molar pregnancy with advanced maternal age, recurrent molar pregnancy and positive family history the odds ratio has indicated positive association between first two determinants with OR of 1.71 and 1.21 respectively. Conclusion: Overall recorded frequency of hydatidiform in our institute is 5.1% within 1 year. Advanced maternal age and previous history of molar pregnancies are risk factors of hydatidiform.

HISTOMORPHOLOGICAL EVALUATION OF TUMOURS OF FEMALE GENITAL TRACT AND ITS CHANGE IN TUMOUR PROFILE OVER A PERIOD OF 12YRS IN A TERTIARY CARE REFERRAL HOSPITAL IN CHENNAI.

Background: The most common cause of morbidity & mortality among females are due to cancers arising from female reproductive organs next to breast cancers. The most common sites include uterine cervix, corpus uteri & ovary followed by least common sites like vulva, vagina, fallopian tubes and gestational trophoblastic diseases. Aim of the study: 1. To evaluate the trend in the prole of benign, premalignant & malignant lesions of female genital tract (FGT) tumours at primary tertiary care hospital in Chennai. 2. To study frequency, age distribution & diverse histomorphological spectrum of tumours of female genital tract. 3. To compare and analyze our data with other published studies in the literature. Materials & Methods: This cross sectional retrospective observational study was conducted at tertiary care gynaecological center at Chennai over a period of 12 years from Jan 2008 to Dec 2019. The medical records were retrieved, data analyzed and the results were expressed in descriptive statistics. Results: During the study period we received 44752 histopathological specimens out of which 12477 cases were gynaecological malignancies. Cervix uteri (66.38%) was the most common site followed by ovary (16.65%), corpus uteri (10.71%), gestational trophoblastic disease (4.13%), vulva (0.82%), vagina (0.36%), fallopian tube (0.02%), and vault carcinoma (0.93%). Squamous cell carcinomas were most common type of malignancy in cervix (93.15%), vulva (91%), vagina (82%) & vault (78%). Endometrial adenocarcinomas (81%) were more frequent tumour in corpus uteri while surface epithelial tumours constitute 78.72% of cases in ovary. For gestational trophoblastic disease, 78.25% of cases had complete molar pregnancy. 41-50yrs of age groups were commonly affected for cervical, ovarian & endometrial malignancies where as in vulval lesions the most common age group was 61-70yrs. In case of gestational trophoblastic disease the majority of patients were presented at 21-30yrs of age. Conclusion: This is one of the largest studies conducted with more than 10000 cases being reported in female genital tract. Cervical carcinomas are the leading gynecological malignancy followed by ovary & corpus uteri at our institute. There is a declining trend in the distribution of cases among cervical cancers were as there is an increasing trend in distribution of cases in other site like ovary & corpus uteri.

A Case of Persistent Intrauterine Molar Pregnancy with Final Diagnosis of Heterotopic Molar Pregnancy: A Very Rare Entity

Introduction: Gestational trophoblastic disease (GTD) includes hydatiform mole, choriocarcinoma, placental site trophoblastic tumor, and epithelial trophoblastic tumor. Also, molar pregnancy can happen as an ectopic pregnancy. The coincidence of these complicated pregnancies seems to occur extremely rarely. Case presentation: Here, we presented a 26-year-old woman, nulli gravida with the first presentation of intrauterine complete molar pregnancy; she underwent suction curettage but was prompted to Gestational Trophoblastic Neoplasm (GTN) and she received chemotherapy. During chemotherapy, she had severe abdominal pain and underwent laparotomy, and found an ectopic molar pregnancy in the fallopian tube. Salpingectomy was done and followed up with serum human chorionic gonadotropin (hCG) level and again due to improper decrease of hCG levels, she was diagnosed as a heterotopic post-molar GTN and received methotrexate (MTX) in multiple doses, but she did not respond to MTX, so we started actionomycine-D (Act-D) for her. She was cured after receiving 5 courses of Act-D and now she is on her monthly follow-up with an hCG level. Conclusions: It is important to notice the likelihood of ectopic molar pregnancy or a heterotopic molar pregnancy in the case of managing molar pregnancy, especially when we encounter a case’s poor response to medical or surgical therapy.

EP27.10: Complete molar pregnancy with a coexisting fetus: expectant management

EP27.10: Complete molar pregnancy with a coexisting fetus: expectant management

The Rare Association of Ectopic Pregnancy and Hydatidiform Mole: A Case Report

An ectopic molar pregnancy is a rare event, occurring in 1 in every 20,000–100,000 pregnancies. The condition may present as a complete or partial molar pregnancy and the ectopic site can vary as in a non-molar ectopic pregnancy. When a molar pregnancy presents as a tubal ectopic pregnancy, the risks related to both conditions, including tubal rupture and progress to malignancy, are compounded. The definitive diagnosis is normally reached by histopathology of the surgical specimen, since imaging tests are usually unable to differentiate between a molar and a non-molar ectopic pregnancy. While the specific histological findings may confirm the diagnosis of hydatidiform mole, immunohistochemistry is essential to differentiate between a complete and a partial molar pregnancy. Although in the majority of cases surgical resection is considered the definitive treatment, it is estimated that 20% of patients with a molar pregnancy may develop gestational trophoblastic neoplasia, hence requiring a risk-specific follow-up. This report describes a case of a tubal molar pregnancy and includes a review of clinical, diagnostic and therapeutic aspects, as well as a discussion on the particularities of this rare association.

Emergency department point-of-care ultrasound diagnosis of a complete molar pregnancy presenting as first trimester bleeding.

Emergency department point-of-care ultrasound diagnosis of a complete molar pregnancy presenting as first trimester bleeding.

ABO Blood Grouping in Partial and Complete Hydatidiform Molar Pregnancy

Objective: The present study was conducted to analyze the correlation of ABO blood groups in pregnant mother’s suffering from partial and complete Hydatidiform mole (HM) reporting at our tertiary care hospital. Study Design: Observational study Place and Duration: Liaquat University Hospital, Hyderabad/Jamshoro from May 2018 to October 2018. Methods: The present observational study analyzed the ABO blood groups of diagnosed cases of partial and complete type HM reporting at the Department of Obstetrics and Gynecology. A sample of 100 pregnant women suffering from Partial and complete HM and of their husbands was studied by inclusion criteria. ABO blood groups of these patients were determined as A, B, AB and O groups. Blood samples were processed for complete blood counts. Tests were performed at the Diagnostic and Research Laboratory, Liaquat University Hospital Hyderabad by forward and reverse ABO blood typing. Severity of GTD was assessed by WHO index score. Statistical comparisons of continuous and categorical variables run on SPSS ver. 21.0 at 95% confidence interval (P≤0.05). Results: Clinical presenting features bleeding PV, pain, hyperemesis gravidarum, grape like vesicles passage PV, no fetal heart sound, ovarian enlargement and hyperthyroidism. Partial and complete Hydatidiform mole was common in blood group A noted in 53 and 13 respectively. While Partial and complete Hydatidiform mole in blood group O was noted in 20 and 8 patients respectively (P=0.0001). The β–hCG ranged from 50,000 to 10, 00,000 mIU/mL. Conclusion: It is concluded, the hydatidiform mole proves strong association with blood groups A and O. Pregnant women complaining of bleeding PV, hyperemesis gravidarum, grape like vesicles passage with blood group A and O should be thoroughly investigated to minimize the maternal health risk. Keywords: Hydatidiform mole, Molar pregnancy, ABO blood groups

Intraplacental choriocarcinoma prsenting as post-partum abnormal vaginal bleeding – A case report

Gestational choriocarcinoma is a rare gestational trophoblastic disease with an incidence of 1 in 40,000 pregnancies,1 is usually intrauterine and diagnosed following a complete hydatidiform molar pregnancy. Intraplacental choriocarcinoma may be diagnosed incidentally after sampling of a macroscopic lesion in the placenta and may be followed by post-partum abnormal vaginal bleeding.2

A case of cornual molar ectopic pregnancy: Salutary lesson from a rare disease

Cornu of the uterus is one of the uncommon sites of ectopic pregnancy. Molar cornual ectopic pregnancy is extremely rare and only few cases are reported in the literature. A 25-year-old gravida 3, para 1, abortion 1 lady reported with complaints of amenorrhea of 9 weeks and pain in the lower abdomen for 1 day. Sonography revealed an anechoic structure of 20 mm at the left adnexa with evidence of hemoperitoneum. The patient was managed with laparoscopic cornuostomy. Histopathologic analysis demonstrated placental tissue with features consistent with a complete molar pregnancy. It is emphasized that histopathological examination of the retrieved tissues should be considered after each case of surgical management of ectopic pregnancy to rule out molar pregnancy.

Prediction of Neoplastic Transformation of Hydatidiform Mole: Current Evidence.

Gestational trophoblastic disease is not an uncommonly encountered pathology in clinical practice. The rate of post-molar neoplastic transformation is around 5-20% with higher rates after complete versus partial molar pregnancies. Recently, a role for molecular and genetic markers in the prediction of neoplastic transformation has emerged. We read with interest the article by St. Laurent et al. published in this issue ofReproductive Sciences. The authors compared miRNA profiles between complete hydatidiform moles (CHMs) and pre-gestational trophoblastic neoplasia CHM samples at three distinct tropho-miRNA clusters, 14q32, C19MC, and miR-371-3,as well as the expression of the contiguous DLK1, DIO3, and RTL1 genes. They found significant differences in expression of the 14q32 miRNA cluster and a fivefold decrease in protein expression of DIO3 but no difference in DIO3 mRNA expression. We reviewed the literature for similar studies looking at predictive tools for neoplastic transformation. We encourage future randomized controlled trials using these 2 novel risk predictors postulated by St. Laurent et al. to validate and guide future prophylactic chemotherapy for prevention of post-molar GTN.

Diagnostic value of glycophorin-A in comparison with P57 immunohistochemical staining method in differentiating complete and partial molar pregnancies

IntroductionCurrent histomorphological criteria in distinguishing two subtypes of hydatidiform moles has considerable inter-observer variability and limitations. In this regard, ancillary studies can aid pathologist to obtain an accurate diagnosis. Herein, we evaluated the utility of Glycophorin-A (GLA) in differentiating complete and partial moles. Materials and methodsIn this case-control study, formalin-fixed paraffin-embedded blocks of 47 patients with pathologic diagnosis of complete and 42 partial hydatidiform moles were included and the diagnoses were confirmed by immunohistochemistry (IHC) for P57. Sections from all samples were stained for GLA using IHC method. Using 2 × 2 tables, the sensitivity, specifity, Positive and Negative Predictive Values (PPV and NPV) as well as accuracy of GLA were determined. ResultsPrimary pathologic diagnosis was changed in 7.1% and types of hydatidiform mole were specified in 11.9% of the cases after review of the slides and IHC study for P57. NRBCs were found in 52.7% of the PM cases and none of CMs by pathologist in H&E sections. IHC study for GLA revealed positive result in one case of complete moles (2%) and 31 case of partial mole samples (73.8%). It was negative in 98% of the complete mole and 11 (26.2%) of partial mole cases. DiscussionThe results of this study showed a significant association between GLA immunoreactivity and type of molar pregnancy. Diagnostic sensitivity, specificity and accuracy of this marker for discrimination of molar pregnancy were 73.8%, 98% and 86.5%, respectively. Therefore, this marker can be utilized in differentiating partial and complete hydatidiform mole.

Surveillance for gestational trophoblastic neoplasia following molar pregnancy: a cost-effectiveness analysis

Historically, published guidelines for care after molar pregnancy recommended monitoring human chorionic gonadotropin levels for the development of gestational trophoblastic neoplasia until normal and then for 6 months after the first normal human chorionic gonadotropin. However, there are little data underlying such recommendations, and recent evidence has demonstrated that gestational trophoblastic neoplasia diagnosis after human chorionic gonadotropin normalization is rare. We sought to estimate the cost-effectiveness of alternative strategies for surveillance for gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after complete and partial molar pregnancy. A Markov-based cost-effectiveness model, using monthly cycles and terminating after 36 months/cycles, was constructed to compare alternative strategies for asymptomatic human chorionic gonadotropin surveillance after the first normal (none; monthly testing for 1, 3, 6, and 12 months; or every 3-month testing for 3, 6, and 12 months) for both complete and partial molar pregnancy. The risk of reduced surveillance was modeled by increasing the probability of high-risk disease at diagnosis. Probabilities, costs, and utilities were estimated from peer-reviewed literature, with all cost data applicable to the United States and adjusted to 2020 US dollars. The primary outcome was cost per quality-adjusted life year ($/quality-adjusted life year) with a $100,000/quality-adjusted life year willingness-to-pay threshold. Under base-case assumptions, we found no further surveillance after the first normal human chorionic gonadotropin to be the dominant strategy from both the healthcare system and societal perspectives, for both complete and partial molar pregnancy. After complete mole, this strategy had the lowest average cost (healthcare system, $144 vs maximum $283; societal, $152 vs maximum $443) and highest effectiveness (2.711 vs minimum 2.682 quality-adjusted life years). This strategy led to a slightly higher rate of death from gestational trophoblastic neoplasia (0.013% vs minimum 0.009%), although with high costs per gestational trophoblastic neoplasia death avoided (range, $214,000 to >$4 million). Societal perspective costs of lost wages had a greater impact on frequent surveillance costs than rare gestational trophoblastic neoplasia treatment costs, and no further surveillance was more favorable from this perspective in otherwise identical analyses. No further surveillance remained dominant or preferred with incremental cost-effectiveness ratio of <$100,000 in all analyses for partial mole, and most sensitivity analyses for complete mole. Under the assumption of no disutility from surveillance, surveillance strategies were more effective (by quality-adjusted life year) than no further surveillance, and a single human chorionic gonadotropin test at 3 months was found to be cost-effective after complete mole with incremental cost-effectiveness ratio of $53,261 from the healthcare perspective, but not from the societal perspective (incremental cost-effectiveness ratio, $288,783). Largely owing to the rare incidence of gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after molar pregnancy, prolonged surveillance is not cost-effective under most assumptions. It would be reasonable to reduce, and potentially eliminate, current recommendations for surveillance after human chorionic gonadotropin normalization after molar pregnancy, particularly among partial moles. With any reduction in surveillance, patients should be counseled on symptoms of gestational trophoblastic neoplasia and established in routine gynecologic care.

Gestational trophoblastic neoplasia after human chorionic gonadotropin normalization in a retrospective cohort of 7761 patients in France

The risk of malignant transformation of molar pregnancies after human chorionic gonadotropin levels return to normal is low, roughly 0.4%, but may justify an adaptation of monitoring strategies for certain patients. This study aimed to determine the risk of gestational trophoblastic neoplasia after human chorionic gonadotropin normalization in women with molar pregnancy and identify risk factors for this type of malignant transformation to optimize follow-up protocols after human chorionic gonadotropin normalization. This was a retrospective observational national cohort study based at the French National Center for Trophoblastic Diseases of 7761 patients, treated between 1999 and 2020 for gestational trophoblastic disease, whose human chorionic gonadotropin levels returned spontaneously to normal. Among 7761 patients whose human chorionic gonadotropin levels returned to normal, 20 (0.26%) developed gestational trophoblastic neoplasia. The risk of malignant transformation varied with the type of mole, from 0% (0 of 2592 cases) for histologically proven partial mole to 0.36% for complete mole (18 of 5045) and 2.1% (2 of 95) for twin molar pregnancy. The median time to diagnosis of malignant transformation after human chorionic gonadotropin normalization was 11.4 months (range, 1-34 months). At diagnosis, 16 of 20 patients (80%) had the International Federation of Gynecology and Obstetrics stage I tumor, and 10 of 20 patients (50%) had a tumor classified as low risk in terms of the International Federation of Gynecology and Obstetrics score. In 9 of 20 patients (45%), the most common first-line treatment was combination chemotherapy. A quarter of these tumors (5 of 20) were histologically proven placental site or epithelioid trophoblastic tumors. In univariate analysis, the factors significantly associated with a higher risk of developing gestational trophoblastic neoplasia after the end of the normal human chorionic gonadotropin monitoring period were age of ≥45 years (odds ratio, 8.3; 95% confidence interval, 2.0-32.7; P=.004) and time to human chorionic gonadotropin normalization of ≥8 weeks (odds ratio, 7.7; 95% confidence interval, 1.1-335; P=.03). The risk was even higher for human chorionic gonadotropin normalization times of ≥17 weeks (odds ratio, 19.5; 95% confidence interval, 3.3-206; P<.001). In this group of patients with gestational trophoblastic disease, none of the those with pathologically verified partial mole had malignant transformation, supporting the current recommendation of stopping human chorionic gonadotropin monitoring after 3 successive negative tests. In cases of complete mole or twin molar pregnancy, weproposed to extend the monitoring period with quarterly human chorionic gonadotropin measurements for an additional 30 months in patients with the identified risk factors for late malignant transformation (age, ≥45 years; time to human chorionic gonadotropin normalization, ≥8 weeks).