Diagnosis Of Hydatidiform Mole Research Articles

Factors Contributing to Molar Pregnancy Through a Study in Jiblah University Hospital, IBB: Study from 2017 to 2022

Background: The reported prevalence rates of hydatidiform mole (HM) vary greatly across geography and time, making worldwide comparisons challenging, especially in developing countries and resource-limited settings. To date, few studies have been reported in Yemen regarding the epidemiology, management, and outcome of patients with HM. The current study sought to investigate the prevalence of HM among women who visited a large tertiary center at Jiblah University Hospital in Yemen. Method: A retrospective study was conducted between Jun 2017 and Sep 2022 at Jiblah University Hospital, Ibb, Yemen including all women with a diagnosis of HM. Complete medical histories for all HM patients were collected and analyzed. Results: A total of 160 women diagnosed with HM at Jiblah University Hospital -Ibb study from 2017 to 2022 years were included in the study. The mean gestational age on admission was 25.2 years. Sixty-two patients (38.7%) have Hb less than normal range and 94 of patients (58.8 %) have Hb normal range 12- 15g/dl and 4 patients (2.5 %) have Hb more than normal range 15g/dl. However, the percentage blood types (A+, A-, B-, B+, O+, O- and AB+) were 40.6%, 0.6%, 5%, 0.6%, 41.9 %, 7.5% and 3.8%, respectively. On the other hand, among the sample, 4 (2.5%) women were diagnosed histopathologically to have previous V.M and while 156 (97.5%) women were diagnosed histopathologically to have no previous V.M. A number of women who had previous abortion were recorded 46(28.7%) and while the women had not previous abortion was 114(41.4%). Among the women who had smoking and no smoking were recorded 2(1.3%) and 158(98.7%), respectively. Finally, unfortunately the researchers didn’t find following risk factors in the register of patients, such as (Ovulation induction, genes mutation, infertility and birth control pills), by researching the record of patients with HM or registered as having HM. However, our study found the relationship between age groups and the previous abortion about associate risk factors of molar pregnancy. There is statistically significant difference between previous abortion and age, with P-value =0.007. Conclusion: The present study showed that incident hydatidiform mole were higher in 20-29 years of maternal age, so we found that the incidence of HM in younger age patients is the most common. Also, we found that the significant positive correlation was found between age with previous abortions. Therefore, it is recommended that women should undergo health care before pregnancy and further studies are required to provide solutions to reduce the cases of HM.

Diagnosis of hydatidiform moles using circulating gestational trophoblasts isolated from maternal blood

IntroductionIdentifying hydatidiform moles (HMs) is crucial due to the risk of gestational trophoblastic neoplasia. When a HM is suspected on clinical findings, surgical termination is recommended. However, in a substantial fraction of the cases, the conceptus is actually a non-molar miscarriage. If distinction between molar and non-molar gestations could be obtained before termination, surgical intervention could be minimized. MethodsCirculating gestational trophoblasts (cGTs) were isolated from blood from 15 consecutive women suspected of molar pregnancies in gestational week 6–13. The trophoblasts were individually sorted using fluorescence activated cell sorting. STR analysis targeting 24 loci was performed on DNA isolated from maternal and paternal leukocytes, chorionic villi, cGTs, and cfDNA. ResultsWith a gestational age above 10 weeks, cGTs were isolated in 87% of the cases. Two androgenetic HMs, three triploid diandric HMs, and six conceptuses with diploid biparental genome were diagnosed using cGTs. The STR profiles in cGTs were identical to the profiles in DNA from chorionic villi. Eight of the 15 women suspected to have a HM prior to termination had a conceptus with a diploid biparental genome, and thus most likely a non-molar miscarriage. DiscussionGenetic analysis of cGTs is superior to identify HMs, compared to analysis of cfDNA, as it is not hampered by the presence of maternal DNA. cGTs provide information about the full genome in single cells, facilitating estimation of ploidy. This may be a step towards differentiating HMs from non-HMs before termination.

Impact of ultrasound in diagnosis of hydatidiform mole in early pregnancy: A protocol of systematic review.

This study aims to assess current evidence of ultrasound in diagnosis of hydatidiform mole (HM) in early pregnancy (EP). This study will incorporate case-control study on investigating the impact of ultrasound in diagnosis of HM in EP. Potential articles will be retrieved in electronic databases of Cochrane Library, MEDLINE/PUBMED, EMBASE, PsycINFO, WANGFANG, and CNKI from inception to the present. Conference proceeding, website of clinical trial registry, and reference list of key articles will be examined for additional studies. Two independent researchers will scan and select studies, collect and manage data, and appraise methodological quality of all eligible studies. We will carry out summary effect size, statistical heterogeneity, synthesize, and analyze outcome data. This study will summarize present evidence to assess the accuracy of ultrasound in diagnosis of HM in EP. This study may provide evidence for ultrasound in diagnosis of HM in EP, which may benefit both patients and clinicians. INPLASY202080080.

Diagnosis and outcome of hydatidiform moles in missed-miscarriage: a cohort-study, systematic review and meta-analysis

ObjectiveTo evaluate the ultrasound diagnostic rates of complete hydatidiform moles (CHM) and partial hydatidiform moles (PHM) in women presenting with a missed miscarriage, the clinical complications at diagnosis and the risk of gestational trophoblastic neoplasia (GTN) after surgical evacuation and to compare our findings with those of the published literature by completing a systematic review and meta-analysis Study designRetrospective review of the data of 295 women diagnosed with a histologically confirmed hydatidiform moles (HM) over a 15-year period, including 128 CHM and 167 PHM. All women were referred to a regional specialist centre for follow-up and further management. An electronic search of PubMed, Google Scholar and MEDLINE was performed for studies published between September 1973 and September 2017 reporting on the early ultrasound diagnosis of hydatidiform mole. Only cohort studies which provided ultrasound data confirmed by histopathology were included. ResultsIn the cohort study, ultrasound imaging diagnosed a significantly (p < 0.001) higher number of CHM (95/128 (74.2%) than PHM (68/167 (40.7%). Ovarian theca lutea cysts were observed in three CHM and one PHM. There were no cases of pre-eclampsia or thyrotoxicosis at the time of diagnosis. Maternal serum β-human chorionic gonadotrophin levels were abnormally low (< 0.5 MoM) in 5/51 (10%) CHM and 23/43 (53%) PHM and abnormally high (> 2.0 MoM) in 20/51 (39%) CHM and 2/43 (5%) PHM. Seventeen (12.3%) CHM and two (1.4%) PHM developed a GTN requiring treatment. In the literature the proportion of histologically diagnosed HM, suspected on ultrasound in early pregnancy, ranged between 34.2 and 90.2% for HM, 57.8 and 95% for CHM and 17.6 and 51.6% for PHM. The meta-analysis indicated substantial heterogeneity in the overall ultrasound diagnosis of HM and in the differential diagnosis between CHM and PHM. Conclusion(s)As around a third of CHM and two thirds of PHM are not diagnosed on ultrasound in cases of missed miscarriage, histopathological examination of all products of conception in case of early pregnancy failure is essential to detect molar changes. This is particularly important for the management of women with CHM who have a higher risk of developing a GTN.

Clinical application of short tandem repeat polymorphism analysis in the differential diagnosis of early hydatidiform mole and hydropic abortion

Objective: To determine the clinical differential diagnosis value of short tandem repeat polymorphism (STR) analysis in early hydatidiform moles (HMs) and non-molar gestations. Methods: Four hundred eighty-one patients with suspected HMs were examined using traditional pathology methods and STR analysis. The value of the STR method in distinguishing HMs from non-molar gestations was evaluated. Results: Among 481 patients with suspected HMs, 177 were diagnosed with HMs and 304 with non-molar gestations based on histopathologic examination. The STR genotypic results show that 151 patients were diagnosed with HMs, including 63 complete HMs and 88 partial HMs. Three hundred thirty patients were diagnosed with non-molar gestations, including 43 patients with chromosome abnormalities. Among 63 complete HMs, 56 were monosyllabic and 7 were dispermic. All 88 partial HMs were dispermic. The histopathologic diagnoses in 84 patients were not in agreement with STR analyses. Among the 84 cases, 29 were incorrectly diagnosed with non-molar gestations and the others were incorrectly diagnosed with HMs by histopathologic examinations. The chi-test result demonstrated that the two methods were quite different. Conclusion: STR polymorphism analysis is a rapid, simple, and accurate method that can be utilized for accurate diagnosis of early HMs and hydropic abortions.

Epidemioclinical and ultrasonographic profile of hydatidiform moles in Abidjan

IntroductionDécrire les aspects épidémio-cliniques et échographiques des môles hydatiformes (MH) à Abidjan.Méthodesétude transversale de 6 ans (janvier 2011 à décembre 2016) réalisée au CHU de Yopougon au Service de Radiologie. Elle a consisté en la description du profil épidémio-clinique et échographique des patientes porteuses de MH. Les examens échographiques ont été réalisés par voie mixte (endovaginale et sus pubienne) en modes B et Doppler Couleur par des radiologues seniors. Une étude anatomo-pathologique du contenu utérin a été effectuée.RésultatsVingt-cinq cas de MH ont été diagnostiquées sur 12,190 échographies obstétricales réalisées soit 0,2% d'incidence radiologique. L’âge moyen des patientes était de 33,4 ans avec des extrêmes de 22 et 50 ans. Il n'y avait pas de classe d'âge dominante. La notion de masse abdominale 36% et de métrorragies 28% étaient les signes cliniques prédominants qui accompagnaient l'aménorrhée (100%). Sur le plan échographique, l'utérus était hypertrophique dans 100% des cas, homogène dans 96% et myomateux dans 4% des cas. La MH avait une épaisseur moyenne de 42,7mm. Son aspect était décrit comme vésiculaire dans 68%, en nid d'abeille dans 16%, multikystique dans 12% et en tempête de neige dans 4%. Les MH étaient classées partielles dans 4% des cas, complètes dans 92% des cas et invasives dans 4% des cas. Les ovaires étaient hypertrophiques dans 44% des cas avec une notion de macrofollicules dans 32% et des kystes dans 8% des cas. Le diagnostic échographique de MH a été confirmé à l'anatomopathologie dans 100% des cas.ConclusionLes MH demeurent rares à Abidjan et sont dominées par la forme complète. La notion de survenue à des âges extrêmes n'a pas été retrouvée.

Incidence and clinicopathological profile of gestational trophoblastic disease in tertiary care centre

Introduction: Gestational trophoblastic disease (GTD) arises from abnormal proliferation of placental trophoblastic tissue. The aim of this study was to determine the incidence and clinicopathological profiles with treatment outcome of gestational trophoblastic disease in Jigme Dorji Wangchuck National Referral Hospital, a tertiary hospital in Bhutan.&#x0D; Method: A prospective and retrospective observational study was conducted over a period of 18 months.&#x0D; Results: A total of 121 cases of gestational trophoblastic disease were diagnosed with an incidence rate of 19.7 per 1000 deliveries. Majority comprised hydatidiform moles(115);of which, 30 (26.1%) were complete and 85(73.9%) partial moles. The mean gestational age at diagnosis of hydatidiform mole was 9.8± 1.6 weeks and the most common symptom being vaginal bleeding (72.8%). Nine (7.8%) of these progressed to gestational trophoblastic neoplasia and was strongly associated with high pre-evacuation beta-hCG level (&gt; 100,000 mIU/ml) and larger uterine size (&gt; 14 weeks).&#x0D; Conclusions: This study revealed a high incidence of gestational trophoblastic disease in national referral hospital. Further in-depth research and instituting a GTD registry can be useful to validate these findings and find the true incidence. A substantial number of molar pregnancies can progress to GTN, and thus requires strict follow-up.

Hydatidiform mole: validity of the registration in the Danish National Patient Registry, the Danish Cancer Registry, and the Danish Pathology Registry 1999-2009.

PurposeTo examine the validity of registration of hydatidiform mole (HM) in the Danish National Patient Registry (NPR), the Danish Cancer Registry (DCR), and the Danish Pathology Registry (DPR).Patients and methodsWe selected women registered with a first-time HM code in NPR, DCR, and DPR from 1999 to 2009. We found most women registered in DPR. For a random sample of women registered in DPR, the coding was validated by comparing with the pathology report. Completeness and positive predictive value (PPV) of registration with an HM code in NPR and DCR were calculated using DPR as the reference. Details of women registered in NPR or DCR, but not in DPR, were scrutinized.ResultsIn NPR and DPR, 1,520 women were identified in total; 1,057 (70%) were found in both registries, 65 (4%) only in NPR, and 398 (26%) only in DPR. In DCR and DPR, 1,498 women were identified in total; 1,174 (78%) in both registries, 47 (3%) only in DCR, and 277 (19%) only in DPR. For 149/150 randomly selected women registered with an HM code in DPR (99%), the pathology report was consistent with the diagnosis of HM. Completeness of NPR was 73% (95% CI: 70%–75%) and PPV was 94% (95% CI: 93%–95%). Completeness of DCR was 72% (95% CI: 69%–75%) in 1999–2003 and 90% (95% CI: 87%–92%) in 2004–2009. PPV of DCR was 96% (95% CI: 95%–97%) throughout the period.ConclusionValidation of registry data is important before using these. For research on the number of HMs in Denmark, DPR is the most valid data source. NPR and DCR appear to be equally valid before 2004. However, for research after 2004, DCR should be preferred rather than NPR.

Temporal trends in incidence and outcome of hydatidiform mole: a retrospective cohort study

Background: Reported incidence rates of hydatidiform mole (HM) show wide geographic and temporal variations, making reliable international comparisons difficult. The aim of the current study was to examine temporal trends in the incidence of HM and post-molar gestational trophoblastic neoplasia (GTN) in Stockholm County.Material and methods: Data of all women with a diagnosis of HM in Stockholm County 1991–2010 was collected. The incidence of HM was assessed both in relation to number of births and viable conceptions (births and pregnancy terminations). The risk of post-molar GTN was analysed for all HM, as well as for the subtypes complete (CHM) and partial hydatidiform mole (PHM). Temporal trends were analysed by stratifying the study period into five-year intervals.Results: The overall incidence rate of HM was 2.08/1000 deliveries and 1.48/1000 viable conceptions. A significant temporal increase in the incidence rate of HM, as well as in the total number and proportion of PHM, was seen. Among 956 women with HM, 77 (8%) progressed into post-molar GTN. There was evidence of a slight, but non-significant increase in the risk of malignancy in the two last five-year periods under study.Conclusions: We found evidence of a significant temporal increase in the incidence rate of HM, which could not fully be explained by an increase in maternal age over time. Changes in diagnostic methods probably contributed to the increased incidence rate of PHM. The risk of post-molar GTN remained constant over time.

Role of Surgery in the Management of Hydatidiform Mole in Elderly Patients: A Single-Center Clinical Experience.

Women older than 40 years develop gestational trophoblastic neoplasia (GTN) after a hydatidiform mole (HM) more often than do younger women. Therefore, in elderly women, primary hysterectomy has been advocated as first-line treatment. The aim of the present study was to evaluate whether hysterectomy could reduce the incidence of GTN after a diagnosis of HM. Seventy-six of 442 patients referred to our unit for an HM between 1994 and 2015 were older than 40 years old. Among these, 12 patients were treated by primary hysterectomy. We compared clinical features, serum human chorionic gonadotrophin (hCG), incidence of GTN, and further treatments in these patients and in those who underwent evacuation and serum hCG monitoring, using univariate and multivariate analyses. Patients treated by primary hysterectomy all had a diagnosis of a complete or invasive HM, had more hyperemesis than did control subjects (82% vs 37%, P = 0.008), and had an increased uterine volume (100% vs 41%, P = 0.001). Seven of them developed a subsequent GTN, whereas 5 patients achieved complete remission of disease after surgery (58% vs 30%, P = 0.094). All the patients who developed a GTN after surgery showed lower hCG levels than did control subjects (mean, 671.4 [SD, 1178.4] IU/L vs 23,919.4 [SD, 34,284.9] IU/L; P = 0.005), but there were no significant differences in the amount and type of chemotherapy needed to achieve remission. Primary hysterectomy after 40 years old in women affected by HM does not reduce the incidence of GTN and amount of chemotherapy. Although further studies are needed to confirm these results, a careful hCG monitoring should be recommended in these high-risk patients.

The Value of Ultrasonography in Predicting Invasive Mole

Background: Gestational trophoblastic neoplasm (GTN) during pregnancy includes an associated heterogeneous group of lesions that originates from abnormal proliferation of placenta. It includes invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. Objectives: The aim of this study was to predict the risk of invasive mole in patients with a molar pregnancy in association with -hCG level after the evacuation of molar pregnancy. Methods: The current study was a prospective cross-sectional cohort research conducted as a diagnostic study on 110 patients with molar pregnancy referring to Department of Gynecology and Oncology of Vali-Asr, Imam Khomeini Hospital of Tehran between the years of 2015 and 2016. Patients with molar pregnancy, who were hospitalized with a diagnosis of hydatidiform mole by transvagi- nal ultrasonography, were examined in the study. The ability to perform ultrasonography before and after evacuation as well as the consent to participate in the study was among the inclusion criteria for patients. The patients were studied for invasive mole fol- lowed by two ultrasonography examinations, one 48 hours and the other 21 days after evacuation. -hCG levels were also measured in successive periods of one week to six months. The association of sonography findings 48 hours and 21 days after evacuation with post-evacuation -hCG levels was investigated using Chi-square test and multinomial regression. Results: In the current study conducted on 110 patients with hydatidiform mole, the results showed that 46 patients (41.8%) suered from invasive mole. In 23 patients (50%) with invasive mole, the results of both ultrasonography 48 hours and 21 days after evacuation were positive. There was a significant correlation between ultrasonography after evacuation (positive and negative results) and the progress of -hCG after evacuation in women with invasive mole (P = 0.001); this means that in 73% of women with invasive mole, the positive -hCG results corresponded with positive 21-day sonography after evacuation, and in 41% cases, ultrasound results on day 21 were reported positive before the results of -hCG. Conclusions: Positive results of sonography accompanied with positive results of -hCG have a high eciency in the diagnosis of 1. Background Gestational trophoblastic disease (GTD) includes a het- erogeneous group of related lesions resulted from abnor- mal proliferation of placenta. GTD may be either benign or malignant. Benign lesion includes complete and par- tial hydatidiform mole and its diagnosis is based on histo- logical findings. Malignant lesion includes invasive mole, placental site trophoblastic tumors, and choriocarcinoma. Trophoblastic disease during pregnancy has the potential for local invasion and distant metastasis. This group of ma- lignant lesions is called gestational trophoblastic neopla- sia (GTN), which is a rare complication of pregnancy. GTN, occurs after normal delivery, spontaneous abortion or ec- topic pregnancy. The risk of its occurrence increases by 2,000 times after the occurrence of hydatidiform mole (1-

G07 - The complex management and treatment of hydatidiform mole: our experience

Background: Hydatidiform mole (HM) is a rare disorder of trophoblast. HM comprises two distinct entities, the partial mole (PM) and complete mole (CM). The HM usually occurs with vaginal bleeding, increased serum levels of beta-hCG and, sometimes, uterus larger than typical gestational age. The PM comes up with a more moderate symptoms.Patients and methods: From April 2012 to April 2016 were evaluated all patients with histopathologic diagnosis of HM, partial or complete, and we monitored the progress of disease through beta-hCG, transvaginal ultrasonographic examination (TVUS) and abdominal ultrasound and chest x-ray in patients with indication for chemotherapy, and we have undergone them suction curettage (SC) at the moment of diagnosis. All patients were given the opportunity to psychological support.Results: In the 4 years of study we have been taken over by our center 10 patients, 5 with histopathologic diagnosis of MC and 5 patients with PM. Median age at diagnosis was 26 years. All patients were submitted in response to a symptomatology characterized by abdominal pain, bleeding and subsequent finding of miscarriage between 8 and 12 weeks of gestation. The dosage of beta-hCG serum before surgery presented values between 38689.0 mU/ml and 223900.0 mU/ml. Of all patients evaluated, 3, two with CM and one with PM, showed high levels after 8 weeks after SC and were then subjected to treatment with methotrexate 50mg im on days 1,3,5,7 and folic acid 7.5mg 2 tablets in the days 2,4,6,8 every 2 weeks until detection of 3 negative consecutive doses of beta–hCG. In all the patients the treatment was carried out for 6-8 weeks with negative levels of beta-hCG already after the first 2 weeks of treatment. The treatment was well tolerated and not burdened by side effects (expecially grade 3-4). At the end of chemotherapy patients have continued follow up with monthly beta-hCG for 6 months in the case of PM and for 12 months in the case of CM. A gynecological examination with TVUS was performed every 4 months. To date none of the patients showed signs of relapse.Conclusions: Given the young age of patients and the delicate nature of the disease, HM should be treated in reference institutions where a multidisciplinary team including oncologist, radiologist, gynecologist and psychologist can manage the diagnosis and the treatment of this pathology and any sequelae related to it. Background: Hydatidiform mole (HM) is a rare disorder of trophoblast. HM comprises two distinct entities, the partial mole (PM) and complete mole (CM). The HM usually occurs with vaginal bleeding, increased serum levels of beta-hCG and, sometimes, uterus larger than typical gestational age. The PM comes up with a more moderate symptoms. Patients and methods: From April 2012 to April 2016 were evaluated all patients with histopathologic diagnosis of HM, partial or complete, and we monitored the progress of disease through beta-hCG, transvaginal ultrasonographic examination (TVUS) and abdominal ultrasound and chest x-ray in patients with indication for chemotherapy, and we have undergone them suction curettage (SC) at the moment of diagnosis. All patients were given the opportunity to psychological support. Results: In the 4 years of study we have been taken over by our center 10 patients, 5 with histopathologic diagnosis of MC and 5 patients with PM. Median age at diagnosis was 26 years. All patients were submitted in response to a symptomatology characterized by abdominal pain, bleeding and subsequent finding of miscarriage between 8 and 12 weeks of gestation. The dosage of beta-hCG serum before surgery presented values between 38689.0 mU/ml and 223900.0 mU/ml. Of all patients evaluated, 3, two with CM and one with PM, showed high levels after 8 weeks after SC and were then subjected to treatment with methotrexate 50mg im on days 1,3,5,7 and folic acid 7.5mg 2 tablets in the days 2,4,6,8 every 2 weeks until detection of 3 negative consecutive doses of beta–hCG. In all the patients the treatment was carried out for 6-8 weeks with negative levels of beta-hCG already after the first 2 weeks of treatment. The treatment was well tolerated and not burdened by side effects (expecially grade 3-4). At the end of chemotherapy patients have continued follow up with monthly beta-hCG for 6 months in the case of PM and for 12 months in the case of CM. A gynecological examination with TVUS was performed every 4 months. To date none of the patients showed signs of relapse. Conclusions: Given the young age of patients and the delicate nature of the disease, HM should be treated in reference institutions where a multidisciplinary team including oncologist, radiologist, gynecologist and psychologist can manage the diagnosis and the treatment of this pathology and any sequelae related to it.

Comparison of p57, c-erbB-2, CD117, and Bcl-2 expression in the differential diagnosis of hydatidiform mole and hydropic abortion.

To explore the utility of p57, c-erbB-2, CD 117, and Bel-2 immunostaining in the differential diagnosis of complete hydatidiform mole (CHM), partial hydatidiform mole (PHM), and hydropic abortion (HA). Immunohistochemical expression of the p57, c-erbB-2, CD117, and Bel-2 proteins were investigated semi-quantitatively using paraffin-embedded tissue sections from histologically unequivocal cases of CHM (n = 20), PHM (n = 23), and HA (n = 17). All cases of CHM exhibited a striking absence of p57 expression. The percentage of positive p57 staining was similar between PHMs (73.9%) and HAs (76.5%) (p >0.05). The comparison of c-erbB-2 expression revealed a significantly higher percentage of positive c-erbB-2 staining in CHMs (45%) compared with that in PHMs (8.7%) and HAs (5.9%) (p = 0.006 and 0.01, respectively). The CD 117 expression pattern (immunoreactivity score, percentage of positive cells, and staining intensity) was significantly lower in HAs compared with that in PHMs and CHMs (p < 0.05 for all). A significantly increased Bel-2 expression pattern was observed in HAs compared with that in PHMs and CHMs (p < 0.05 for all). Immunohistochemical examination of p57, c-erbB-2, CD 117, and Bel-2 expression represents a relatively simple, reliable, and cost-efficient procedure to definitively distinguish among CHM, PHM, and HA.

Utilization of Chromogenic In Situ Hybridization to Assess Ploidy in the Diagnosis of Hydatidiform Mole

Ploidy assessment is often required for the diagnosis of partial molar pregnancy. While fluorescence in situ hybridization has been shown to be effective, it is not available in many laboratories. We validated chromogenic in situ hybridization (CISH) for this purpose. CISH using probes to chromosomes 17 and 10 was performed on 20 POC cases with known cytogenetics to establish a reference percentage. This was then used to classify a randomized set of abnormal and normal cases. An abnormal CISH cutoff of greater than 7% was established. All abnormal cases (six triploid and three tetraploid), 11 "normal" (46, XX or XY or undetectable abnormalities), and one trisomy 10 were all correctly classified by the assay. CISH is a useful ancillary technique for the diagnosis of molar pregnancy. Its greater accessibility and ability to score even rare placental tissue in a background of maternal tissue offer advantages over other methods.

Fatal Cases of Gestational Trophoblastic Neoplasia in a National Trophoblastic Disease Reference Center in Dakar Senegal.

The objectives of this study were to analyze deaths after gestational trophoblastic neoplasia and to determine the factors of treatment failure. This is a retrospective study in Aristide Le Dantec teaching Hospital in Dakar, Senegal, between 1 January 2006 and 31 December 2014. We took into account socio-epidemiological characteristics of patients, initial diagnosis, time between uterine evacuation and admission, time to onset of gestational trophoblastic neoplasia (GTN), treatment received (deadlines, protocols), difficulties experienced in the diagnosis and the initiation of treatment and survival. In total, 1044 patients were admitted during the study period; 164 cases of GTN were diagnosed (15.7%); and 21 deaths occurred leading to a specific lethality of 12.8%. The average age was 30 years. Almost all patients (n = 18; 85.7%) had low income or no income. Eight out of 21 patients (38.1%) were seen in our department after GTN onset. The mean time to onset of GTN of all patients was 22.1 weeks. For 66.6%, histology was not available; the diagnosis of hydatidiform mole was made on the clinical history and sonographic features and GTN on human chorionic gonadotrophin (hCG) evolution and ultrasound findings. None of the patients had regular chemotherapy due to financial reasons. Patients who died within 3 months after diagnosis had metastatic tumors (7 of 21). All these women had resistance to treatment or progressed after three courses of chemotherapy. Ten of the 12 women with high-risk GTN were not treated with multi-agent chemotherapy (EMA-CO) for purely financial reasons. The high incidence and mortality require a profound reorganization of our health system and a high awareness of practitioners to refer to time or to declare all suspected cases of hydatidiform mole or gestational trophoblastic neoplasia.

Hydatidiform mole with uncontrolled hyperthyroidism: An anesthetic challenge.

Sir, Molar pregnancy, an uncommon complication of pregnancy, presents in 5% of cases with clinical hyperthyroidism[1] and rarely with severe thyrotoxicosis. This occurs as, the alpha subunit of human chorionic gonadatropin (hCG) is structurally similar to thyroid stimulating hormone (TSH).[12] Continuation of pregnancy carries the risk of hemorrhage, preeclampsia, and pulmonary emboli. Patients at times present with uncontrolled bleeding per vaginum (P/V) and require emergency termination of pregnancy. A 24-year-old 2nd gravida, 15-week pregnant woman was referred to our labor room with bleeding P/V. Her abdominal ultrasound showed large mixed cystic and hyperechoic areas, without any gestational sac. The patient's laboratory investigations revealed hemoglobin level of 7 g%, severely elevated beta-hCG (2,250,000 mIU/ml), and thyroid hormone (T3 −4.36 ng/ml, T4 −28 µg/dl) levels, with markedly decreased TSH (0.01 µIU/ml) levels. A diagnosis of hydatidiform mole (H-mole) with uncontrolled hyperthyroidism was made. The patient was started on tablets propranolol 40 mg OD, carbimazole 30 mg OD, amlodipine 5 mg OD, and was prepared for emergency suction evacuation. Her baseline vitals were a heart rate of 135 beats per minute, noninvasive blood pressure of 140/90 mm Hg, and SpO2 of 98%. Two 16 gauge intravenous cannulae were secured. Keeping the possibility of high risk of perioperative thyroid storm in mind, all emergency drugs and equipments were kept ready. Regional anesthesia was administered using 10 mg of bupivacaine with 25 µg fentanyl in the subarachnoid space. Injection phenylephrine was kept ready to counteract any episode of postspinal hypotension. She was sedated with 1 mg injection midazolam intravenously. The surgical procedure lasted for 45–50 min, during which time there was approximately 500 ml of blood loss, for which one unit of blood was transfused. Rest of the intraoperative course was uneventful. Gestational trophoblastic diseases (GTDs) are neoplastic disorders arising from the trophoblastic epithelium of the placenta and can be categorized into H-mole, persistent invasive gestation trophoblastic neoplasia, choriocarcinoma, and placental site trophoblastic tumors.[3] The incidence of H-mole varies from 1 in 1200 to 1 in 2500. Each GTD produces a different quantity of beta hCG, with a progression in concentrations from the H-mole (least) to the placental site trophoblastic tumors (most). Complicating the diagnosis of this condition is the fact that the ultrasound detection rate is only 30–50%, and majority of H-moles appear as a missed or incomplete miscarriage.[3] Termination of pregnancy should be done if patients present with significant bleeding, thyrotoxicosis, or severe hypertension. Patients of H-mole with uncontrolled hyperthyroidism pose a challenge to the anesthesiologist, as there is not enough time available for optimizing patients' clinical condition, which generally requires a minimum of 3–4 weeks.[4] In such patients, the possibility of perioperative thyroid storm should be kept in mind. Further, hyperthyroidism may go undetected, since patients, with no past thyroid dysfunctional history, may present in emergencies, with no time available for getting the blood investigations done. The clinical picture may also be confusing as tachycardia in such patients could be due to both bleeding P/V as well as hyperthyroidism, thus requiring a high index of suspicion for diagnosis. Perioperatively, it is important to ensure hemodynamic stability. In literature, both regional and general anesthesia has been described for management of molar pregnancy.[4] General anesthesia is preferred in hypotensive patients, who are bleeding profusely. In stable patients, spinal anesthesia is preferable due its nontocolytic properties and safety in hyperthyroid patients.[5] We preferred to give regional anesthesia to our patient as we considered that the sympathetic block resulting from spinal anesthesia would be beneficial. Further, tocolytic effect of volatile agents can result in further blood loss.[15] Postoperatively, patients need to be observed carefully, preferably in a high dependency unit for initial 24–48 h, as the incidence of thyroid storm is high in the perioperative period. Further, thyroid function tests and b-hCG values should be monitored regularly until levels return to normal, to exclude the persistence of trophoblastic tissue. To conclude, a coordinated team approach and high index of clinical suspicion are essential in the successful management of H-mole with uncontrolled hyperthyroidism. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Septicaemia caused by Myroides spp.: a case report

Introduction: Myroides spp. are aerobic, yellow-pigmented, non-fermentative Gram-negative rods considered to be low-grade opportunistic pathogens. However, their intrinsic resistance to commonly used antibiotics necessitates prompt identification and evaluation. Case presentation: Here, we report a case of septicaemia caused by Myroides sp. A 36-year-old pregnant female was admitted to the intensive care unit at week 18 of gestation with a diagnosis of hydatidiform mole with acute renal failure and anaemia. Blood culture under aerobic conditions showed growth of round, smooth, convex, yellow-pigmented colonies on blood agar but which failed to grow on MacConkey agar, and the organism was identified as Myroides sp. Susceptibility testing showed that it was susceptible only to piperacillin+tazobactam and, following treatment, the patient recovered. Conclusion: Myroides spp. has, until now, been regarded as an opportunistic pathogen and a rare cause of serious disease in immunocompromised subjects. However, it may cause serious disease, even in immunocompetent hosts, and its intrinsic resistance warrants appropriate testing and timely intervention.

Placental Molar Disease: What are the Benefits and Barriers to the Adoption of a Comprehensive Diagnostic Service?

The molecular cytogenetic analysis of specimens (genotyping) suspicious for hydatidiform mole (HM) significantly improves diagnostic accuracy over histopathology and immunohistochemical analysis alone, particularly in the classification of partial mole. However, the implementation of this advance in diagnostics has been slow. This study sought to identify the major benefit and potential barriers to the adoption of genotyping. A pilot Placental Molar Diagnostic (PMD) Service was established combining histopathology, p57 immunohistochemistry, and molecular genotyping analysis for both in-house and referred-in cases suspicious for HM or with a preliminary diagnosis of HM. A retrospective analysis of 117 cases received in the first 16 mo was conducted to identify the utility of the PMD Service and factors or barriers which precluded optimal results. A final diagnosis of HM was made in 73 cases (37 complete HMs and 36 partial HMs). The remaining 44 cases were hydropic abortuses. Three potential barriers were identified that could lead to less than optimal results from a PMD Service: prevalence of noninformative genotyping, lack of any available or appropriate paraffin blocks, and inappropriate deferral of genotyping. The major utility of this pilot PMD Service was to increase the specificity of a diagnosis of HM, and avoid unnecessary clinical follow-up in 37% of cases with an initial suspicion or diagnosis of HM. Measures can be undertaken to address potential barriers to the implementation of a comprehensive placental diagnostic platform. Underutilization of molecular genotyping in the diagnosis of HM likely leads to inappropriate management and "downstream" costs in a significant proportion of patients suspected of having HM.

Differential expression of p63 in hydropic and molar gestations.

To observe the differential expression of p63 in hydropic and molar gestation. Cross-sectional analytical study. Department of Pathology, Basic Medical Sciences Institute, Jinnah Postgraduate and Medical Centre, Karachi, from January 2006 to June 2013. Ninety placental biopsies including 30 cases each of hydropic abortions, partial hydatidiform mole and complete hydatidiform mole were analyzed for morphological features and results of immunohistochemical staining. Results were described as frequency. Significance was determined using test of proportions with significance at p < 0.05. Out of 30 cases of hydropic abortion, 6 were negative, 15 were weak, 4 were moderate and 5 showed strong degree of intensity for p63. Out of 30 cases of partial hydatidiform mole, 3 were negative, 2 showed weak, 4 showed moderate and 21 cases showed strong degree of intensity for p63. All 30 cases of complete hydatidiform mole strongly stained for p63. The intensity of staining of p63 was stronger in cases of molar pregnancy as compared to hydropic abortion. There was loss of p63 expression in cytotrophoblastic cells in all abortions. In limited resources settings, where facilities for PCR/FISH and DNA ploidy analysis is not available, the authors advocate p63 in routine clinical practice to provide the most refined diagnosis of hydatidiform moles.

Immunohistochemistry and other ancillary techniques in the diagnosis of gestational trophoblastic diseases.

Gestational trophoblastic disease (GTD) encompasses entities ranging from ubiquitous hydatidiform moles to rare neoplastic gestational trophoblastic tumors. In practice, the histological diagnosis of GTD continues to have significant diagnostic inaccuracy with marked inter- and intra-observer variability, even among expert pathologists. Studies in correlation with genotypic evidence have confirmed a lack of accuracy in diagnosis of hydatidiform moles using histology alone. Applications of new immunohistochemical markers and molecular techniques have significantly enhanced the diagnostic precision of various GTDs in recent years. p57 Immunohistochemistry is a highly useful marker in confirming complete hydatidiform mole. PCR-based DNA genotyping has emerged as a powerful diagnostic measure to precisely classify both complete and partial hydatidiform moles. With acquisition of molecular diagnostic capabilities at most medical centers, these ancillary techniques have been increasingly integrated into the routine diagnostic workup of GTD. We propose an algorithmic approach combining histology and these ancillary tests to provide the best diagnostic practice possible. Under this algorithm, all cases with histological suspicion for complete mole are subject to p57 immunohistochemical confirmation, and all cases with histological suspicion for partial mole undergo DNA genotyping workup. Beyond hydatidiform mole, recognition of gestational trophoblastic tumors requires a high index of suspicion and application of immunohistochemical markers of trophoblast is helpful to accurately diagnose these rare tumors.