ABSTRACT
@#Gestational trophoblastic neoplasia (GTN) with a concurrent cervical malignancy is very rare, making the case both a diagnostic dilemma and a therapeutic challenge. Currently, there has only been one reported case worldwide. We present a case of GTN Stage I:11 with non‑keratinizing squamous cell carcinoma of the cervix Stage II‑B. Initial treatment, in the form of chemotherapy, was directed toward the GTN, as this appeared to be the more aggressive disease. Surgery was not feasible during diagnosis due to the cervical carcinoma. However, the GTN proved resistant to chemotherapy due to the increasing beta human chorionic gonadotropin titers. An attempt to decrease the size of the cervix for surgery to be possible through chemoradiation was instituted, but due to complications and tumor progression to the lungs, she succumbed to the malignancy.
Subject(s)
Uterine Cervical Neoplasms , Gestational Trophoblastic DiseaseABSTRACT
@#Choriocarcinoma is a malignant subtype of gestational trophoblastic disease that follows any type of pregnancy. It is characterized by rapid hematogenous spread to multiple organs, associated with high human chorionic gonadotropin levels with good response to chemotherapy. We present the case of a 31‑year‑old Filipina who initially presented with severe headaches and blurring of vision 3 years after an unremarkable term pregnancy. The transvaginal ultrasound was normal. After a series of diagnostic tests, the initial working impression was a primary brain tumor with metastases to the lungs, adrenal, kidney, and vulva. Emergency craniotomy was done due to deteriorating status secondary to an intracranial hemorrhage. The histopathology report showed choriocarcinoma. Chemotherapy using Etoposide‑Methotrexate‑Actinomycin D‑Cyclophosphamide‑Vincristine with high‑dose methotrexate and concomitant whole‑brain irradiation was then instituted with good response. This case highlights the importance of having a high index of suspicion for gestational trophoblastic neoplasia to prevent the performance of unnecessary procedures, leading to a delay in diagnosis and the institution of the appropriate treatment.
Subject(s)
Gestational Trophoblastic DiseaseABSTRACT
@#Precision medicine is a form of medicine that utilizes information about a person’s own genes to prevent, diagnose, or treat disease. In trophoblastic disease, precision medicine is important for accurate diagnosis, risk stratification, prognostication, and management. Immunohistochemistry, particularly p57kip2, has become an important ancillary procedure for the accurate identification of complete hydatidiform mole (HM). Molecular genotyping, on the other hand, is now considered the gold standard for the accurate classification of HM. Both tests are important for prognostication and the determination of the appropriate follow‑up plan. For gestational trophoblastic neoplasia, immunohistochemical markers can confirm the histologic diagnosis of its various types. Molecular genotyping differentiates gestational from nongestational tumors with overlapping histology and allows for precise identification of the index or causative pregnancy of a choriocarcinoma.
Subject(s)
Gestational Trophoblastic Disease , Hydatidiform Mole , Precision MedicineABSTRACT
Objective@#To describe the experience of the Division of Trophoblastic Diseases of the Philippine General Hospital with the various third‑line chemotherapeutic regimens among high‑risk gestational trophoblastic neoplasia (GTN) patients who experienced resistance after receiving the etoposide, cisplatin–etoposide, methotrexate, actinomycin (EP‑EMA) regimen@*Materials and Methods@#This was a 17‑year descriptive study that included all patients who used various salvage chemotherapy after resistance to EP‑EMA as treatment for metastatic, high‑risk GTN at the Philippine General Hospital from January 2002 to December 2018. The medical records of eligible patients were retrieved and assessed. All abstracted data were analyzed retrospectively. Descriptive statistics were used to compute for percentages for the various demographic characteristics of the sample population@*Results@#From January 2002 to December 2018, a total of 291 patients with metastatic, high‑risk gestational GTN were treated at the Philippine General Hospital. Of these, only seven patients received various third‑line chemotherapy regimens after resistance to EP‑EMA. One patient was excluded due to incomplete data. Among the third‑line chemotherapeutic regimens used, 3 patients received paclitaxel/carboplatin, two of whom went into remission while one expired. One patient had vincristine, bleomycin, and cisplatin (VBP) with two adjunctive surgeries in the form of hysterectomy and thoracotomy. She also went into remission. Two patients received paclitaxel–cisplatin/paclitaxeletoposide (TP/TE) as third line of treatment. The first was shifted back to EP‑EMA and eventually developed chemoresistance to EP‑EMA and had multiple toxicities. After multidisciplinary conference with the patient and family, they decided to go home and refused further chemotherapy. The other patient had TP/TE followed by bleomycin–etoposide–cisplatin, with adjunctive hysterectomy. Despite multiple cycles of chemotherapy, the disease persisted. She was offered palliative care and the family decided to bring her home. Both patients eventually expired at home@*Conclusion@#No conclusion can be made about the most effective third line chemotherapy for resistant high‑risk GTN because of the limited cases included in this study. An individualized approach is still recommended. Physicians and centers for patients caring for such patients are encouraged to report their experience to improve the management of future patients
Subject(s)
Gestational Trophoblastic DiseaseABSTRACT
Background@#With the increasing number of COVID positive cases still being reported in the country, coupled with the possible vulnerability of pregnant patients to the disease, aggressive measures must be taken by all institutions to ensure safety of the patients.@*Objective@#This study aimed to the determine the clinical profile and pregnancy outcome of patients who were admitted at a tertiary private hospital in Metro Manila from March 16, 2020 to June 15, 2020 in relation to the protocols that were implemented in response coronavirus disease 2019 pandemic.@*Methods@#The protocols and guidelines implemented by the Department of Obstetrics and Gynecology of a private tertiary hospital in Metro Manila from March 16, 2020 to June 15, 2020 were retrieved. The case record of patients who were admitted and delivered during this period were retrieved and reviewed for pertinent data, which were recorded in a patient data collection form. @*Results@#During the 3-month study period, COVID positive pregnant patients were effectively separated from COVID negative patients from admission to discharge based on a health declaration form and universal reverse transcriptase polymerized chain reaction (RT-PCR) testing. Discharge was facilitated after 12–48 h for uncomplicated deliveries and post partum follow-up was done via telemedicine. @*Conclusion@#The separation of COVID positive from COVID negative patients based on symptoms and RT-PCR results were effective in ensuring the safety of patients.
Subject(s)
Pandemics , QuarantineABSTRACT
Background@#For the past decade, advanced maternal age (AMA) became more common in developed and developing countries due to the postponement of pregnancy because of career goals, widespread use of family planning, and advances in assisted reproductive techniques. This increase bears an impact on maternal and perinatal outcomes. The link between AMA and adverse maternal, perinatal, and neonatal outcome showed contradicting results. This study was conducted to investigate the association between AMA and adverse outcomes among nulliparous, Filipino with singleton pregnancies who gave birth in a private tertiary hospital. @*Methodology@#Medical records of patients admitted for delivery between January 2015 and December 2019 were reviewed retrospectively. The control (20–34 years), AMA 35–39 years, very AMA 40–44 years, and extremely advanced maternal age (EAMA) 45 years and above groups included 206, 111, 18, and 2, respectively. @*Results@#Five-year total deliveries at a private tertiary hospital were 8495 with a prevalence of 38.9% (95% confidence interval CI: 33.6%–44.3%) for elderly Filipino primigravids. AMA is a risk factor for diabetes mellitus and small for gestational age newborn in all 3 advanced age groups. Pregnancy induced hypertension, having cesarean section, admission of newborn to neonatal intensive care unit, and administration of antibiotics were more common to AMA but same risk for EAMA. AMA predisposes to having oligohydramnios, placenta previa and preterm delivery but pregnancy at EAMA predisposes more complications in maternal and neonatal outcomes such as having polyhydramnios, abruptio placenta, postpartum hemorrhage, maternal and neonatal death, low Appearance Pulse Grimace Activity and Respiration score, and stillbirth. There is no noted association between AMA and large for gestational age newborn, having meconium staining and delivering by classical cesarean section. @*Conclusion@#AMA in Filipino gravida patients is markedly linked with adverse obstetrical, perinatal, and neonatal outcomes. This study confirms the current trend among women over 45 years that leads to more significant obstetric complications and neonatal morbidities.
Subject(s)
Pregnancy OutcomeABSTRACT
@#Gestational trophoblastic neoplasias (GTN) are extremely aggressive tumors derived from placental trophoblasts. These tumors are always the sequalae of a pregnancy. Choriocarcinoma, which is the most common of these, is typically characterized by early extra-pelvic hematogenous spread. Since the progression of illness is rapid, timely diagnosis and treatment will favor improved chances for cure, whereas late commencement of therapy will make resolution difficult. The diagnosis of GTN is straightforward with an elevated beta-human chorionic gonadotropin (β-hCG) and distinct sonographic features of the tumor inside the uterus. However, very rarely, this disease may occur in the absence of uterine tumors. Practicing physicians must be mindful that GTN may initially manifest with pulmonary symptoms and/or radiographic evidence of metastatic lung lesions. In this series, the features pertaining to the clinical course of three patients are described, all of whom presented with pulmonary masses, elevated β-hCG, and normal transvaginal sonograms.
Subject(s)
Choriocarcinoma , Gestational Trophoblastic DiseaseABSTRACT
Background@#Approximately 20%–25% of high-risk gestational trophoblastic neoplasia (GTN) patients initially treated with first-line chemotherapy regimen develop resistance to the regimen. The EP-EMA (Etoposide-cisplatin and etoposide, methotrexate and actinomycin D) regimen is the most commonly utilized second-line agent. @*Objective@#This study aimed to identify factors leading to remission using etoposide and cisplatin-etoposide, methotrexate, and Actinomycin D (EP-EMA) as salvage chemotherapy among resistant high-risk GTN.@*Methods@#This is a retrospective descriptive study that reviewed the medical records of patients admitted in the section of trophoblastic diseases diagnosed with high-risk GTN from January 2006 to December 2015. @*Results@#The medical records of 20 patients were retrieved and reviewed. The complete remission rate with EP-EMA is 60% (12/20). The overall survival rate for 1 year is 70% (14/20). Only 20% of the patients went home against advice and did not complete treatment. This regimen reported toxicities ranging from Grade 2–4 myelosuppression and electrolyte imbalance. Forty-five percent had Grade 4 neutropenia and Grade 2 anemia and 20% had Grade 2 thrombocytopenia. Hypokalemia and hypomagnesemia were noted in 8 patients (40%). Although not statistically significant, a trend showed that those in the remission group mostly had Stage III diseases with metastasis only in the lungs, prognostic score of between 7 and 12, and with beta-human chorionic gonadotropin (β-hCG) levels <10,000 mIu/ml at the start of EP-EMA treatment.@*Conclusion@#There is an improved response with EP-EMA chemotherapy across the years in our institution. Factors such as stage of disease, pulmonary metastasis, and low β-hCG at the start EP-EMA chemotherapy denote a possible good response and may contribute to patients' complete remission with EP-EMA chemotherapy. However, further studies with larger patient sample size are recommended to support the latter.
Subject(s)
Gestational Trophoblastic DiseaseABSTRACT
Introduction@#Physician burnout (BO) is an increasing global concern due to its rising prevalence and effect on patient care@*Objective@#This study determined the prevalence of BO, compassion fatigue (CF), and compassion satisfaction (CS), among residents of obstetrics and gynecology in the Philippines, and identified the factors associated with these@*Methods@#This was a cross‑sectional study, which used stratified random sampling. The strata comprised public and private hospitals that were subdivided into Luzon, Visayas, Mindanao, and National Capital Region. From these, 33 training hospitals were randomly selected, which served as clusters wherein all resident physicians of obstetrics and gynecology were invited to answer either an online or printed version of the Professional Quality of Life Scale Version 5 questionnaire@*Results@#Majority of the 311 participants included had average level of BO (n = 281, 90.4%), CF (n = 237, 76.2%), and CS (n = 213, 68.5%). CS was negatively correlated with burnout (r = −0.31, P < 0.001) and CF (r = −0.34, P < 0.001), whereas BO and CS were positively correlated (r = +0.48, P < 0.001). Type of institution, sleeping hours, and interrupted leaves were the common factors that yield significant differences in BO (P = 0.037, P < 0.001, and P < 0.001) and CF (P = 0.002, P = 0.043, and P = 0.005). Significant differences were observed in CS scores in terms of age (P = 0.016), marital status (P = 0.038), child dependents (P = 0.006), level of training (P = 0.005), and location and type of institution (P ≤ 0.001 and P = 0.003).@*Conclusion@#There is a need to develop active awareness of BO and CF among resident physicians to effect interventions at the individual and institutional level.
Subject(s)
Burnout, Psychological , Compassion FatigueABSTRACT
Background@#Recent studies have shown poorer outcomes for patients with prognostic score above 12. Authors have proposed categorizing these patients as ultra high-risk to emphasize the need for a different treatment regimen.@*Objectives@#This study was conducted to compare the clinical response of high-risk and ultra high-risk Gestational Trophoblastic Neoplasia (GTN) patients who were managed at the Philippine General Hospital, from January 1, 2010 to December 31, 2015, after receiving the EMACO regimen as first line treatment.@*Methods@#All patients diagnosed with metastatic high-risk GTN who were managed at the Philippine General Hospital from January 1, 2010 to December 31, 2015 and given the EMACO regimen as first-line treatment were included in the study. Patients were divided into high-risk disease or patients with a WHO prognostic score of 7-11 and ultra high-risk disease or patients with WHO prognostic score of 12 and above. Using the Z-test on two proportion, treatment outcome between the two groups were compared.@*Results@#A total of 57 patients diagnosed with metastatic high-risk GTN were included in the study. Of these, 35 or 61% were classified as high-risk while 22 or 39% were ultra high-risk. The primary remission rate of the high-risk group was 89% compared to 77% for the ultra high-risk group. The difference was not statistically significant (p=0.2542). Out of the 57 patients included in the study, 48 patients achieved remission after being treated with EMACO. An additional 4 patients achieved remission after being shifted to EPEMA due to resistance to the first line agent. All patients were alive after one year of follow-up, giving a one-year survival rate of 91.2%.@*Conclusion@#The result of this study showed a relatively higher remission rate for high-risk (89%) than ultra highrisk GTN (77%) with EMACO as first line chemotherapy regimen, but statistical analysis revealed no significant difference. This finding suggests that EMACO may still be used as first line regimen for ultra high-risk GTN to attain remission.
Subject(s)
Gestational Trophoblastic Disease , Etoposide , Dactinomycin , Antineoplastic Combined Chemotherapy Protocols , Cyclophosphamide , Methotrexate , VincristineABSTRACT
@#The first documented description of hydatidiform mole dates back to 400 BC when Hippocrates (470–410 BC) explained its formation through the consumption of dirty water by the pregnant woman. Interestingly, in 1276, the countess of Henneberg reportedly died after giving birth to “as many children as there were days in the year”. In 1752, William Smelie coined the terms mole and hydatidiform to describe the pathology as a bunch of grapes consisting of different sizes. Indeed, this condition that we have come to recognize as a hydatidiform mole (HM) has fascinated humans for centuries. But, it was not until 1903 when it was formally recognized as a clinical entity.
ABSTRACT
@#Isolated massive vulvar edema in pregnancy is rare. The causative mechanisms remain poorly understood but it is probably related to mechanical, osmotic and hormonal factors. The differential diagnoses of vulvar edema include infections, tumors, lymph birth defects, trauma, inflammatory and metabolic diseases. This is a case of a 24-year-old primigravid with twin pregnancy who was admitted at 24 weeks age of gestation for massive vulvar edema. Reported causes of vulvar edema were ruled out. The aim of this report is to discuss the clinical aspects, differential diagnosis, causes and evolution of vulvar edema in pregnancy.
Subject(s)
Pregnancy , Female , Vulvar Diseases , EdemaABSTRACT
@#Primary ovarian pregnancy accounts for less than 1% of all cases of ectopic pregnancies. Its diagnosis is most commonly made intra-operatively and the approach in its management has been geared towards conservative measures such as oophorectomy and resection. Use of intrauterine device still remains the most established risk factor for the development of ovarian pregnancy. The diagnosis is established following the criteria first described by Spiegelberg in 1878. Several cases of ovarian gestation have been described in literature, although very few cases with live term fetus have been reported. Majority of the cases were diagnosed intra-operatively, and the management was tailored depending on the complexity of each of the different cases. This paper reports a case of primary ovarian pregnancy with a live term fetus, which was only diagnosed intra-operatively. Total hysterectomy with right salpingo-oophorectomy was performed due to difficulties encountered brought about by dense adhesions.
Subject(s)
Pregnancy , Female , Pregnancy, Ectopic , Pregnancy, OvarianABSTRACT
Background@#The clinical presentation of patients with hydatidiform mole have changed in recent years due to earlier diagnosis as a result of widespread use of ultrasonography and availability of assays for human chorionic gonadotrophin.@*Objective@#To determine the clinicopathologic profile of patients diagnosed with hydatidiform mole at the Philippine General Hospital from January 2013 to August 2018.@*Methods@#This retrospective cross-sectional study included all patients with histologically confirmed diagnosis of hydatidiform mole managed at the Philippine General Hospital from January 2013 to August 2018. Medical records of patients were retrieved. All abstracted variables were analyzed retrospectively. The level of significance for all sets of analysis was set at p-value < 0.05 using two-tailed comparisons.@*Results@#From January 2013 to August 2018, a total of 435 patients diagnosed with hydatidiform mole were managed at the Philippine General Hospital with a prevalence rate of 15.7/1,000 pregnancies. Diagnosis was made in the first trimester in 52% of patients. A quarter of the patients had pre-evacuation B-hCG levels of more than 1 million mIU/mL. Vaginal bleeding was the most frequent presenting symptom but only 59% of the patients had anemia requiring blood transfusion. Majority (90.57%) had a histopathologic diagnosis of complete hydatidiform mole.@*Conclusion@#The prevalence and clinicopathologic profile of patients with hydatidiform mole in the Philippine General Hospital have remained largely unchanged.
Subject(s)
Pregnancy , Female , Hydatidiform Mole , Gestational Trophoblastic DiseaseABSTRACT
Objective@#This study evaluated the knowledge, attitude and practice of Filipino gynecologists towards hormonal therapy for menopausal symptoms. @*Methods@#This was a cross-sectional study carried out among practicing Filipino gynecologists in different regions of the Philippines from April to October 2018. A self-administered questionnaire was used to identify the current knowledge, attitude and practice of gynecologists regarding the use of hormonal replacement therapy. @*Results@#There were 369 respondents included in the study. Our findings indicate that the most common indication for MHT are vasomotor symptoms and vaginal dryness. Almost all Filipino gynecologists participating in this study were aware that MHT will improve vasomotor and urogenital symptoms, sexual dysfunction and mood. Majority of them correctly agreed that MHT will decrease the risk of osteoporosis and coronary artery disease. On the other hand, at least half of the respondents falsely believed that MHT can decrease the risk for cognitive dysfunction, cerebrovascular disease, Parkinson’s disease and vascular thrombosis. Only 68% of the respondents agreed that they have adequate knowledge about the treatment options for postmenopausal symptoms and as much as 32% of them are still not confident with their knowledge. Majority (65%) of Filipino gynecologists do not routinely recommend or offer the use of MHT to every postmenopausal woman. @*Conclusion@#The knowledge and attitude of gynecologists on hormonal therapy play an important role in the decision making of a woman during her climacteric period. Basic knowledge on menopausal symptoms and indications for hormonal therapy are known to the respondents but these knowledge do not translate to practice.
Subject(s)
Hormone Replacement Therapy , Menopause , PostmenopauseABSTRACT
High gravidity hydatidiform mole (HM) without normal pregnancy is very rare. The challenge of managing such cases will dwell on the concern of having normal conception versus having another molar gestation and its neoplastic sequelae.Presented in this paper is a case of a 32-year-old, gravida 5 para 0 (0040) who was admitted for the management of her fifth molar pregnancy. She underwent suction curettage and administration of methotrexate chemoprophylaxis. Genetic testing was done, which revealed a homozygous mutation in NLRP7, the gene implicated in recurrent molar gestations. This paper discusses the proper approach to determine the cause of recurrent molar pregnancies, as well as the management and prognosis of such cases.
Subject(s)
Humans , Female , Adult , Gravidity , Methotrexate , Vacuum Curettage , Hydatidiform Mole , Homozygote , Genetic Testing , Mutation , Prognosis , Chemoprevention , MolarABSTRACT
OBJECTIVE: The study aims to correlate the histopathologic characteristics of patients diagnosed with complete hydatidiform moles with the risk of developing postmolar gestational trophoblastic neoplasia.METHODOLOGY: A retrospective review of 71 histopathologically-confirmed cases of complete hydatidiform moles was made. Group 1 consisted of 65 patients who achieved normal titers and remained to have normal ?-hCG titers after at least 1 year of follow up. Group 2 included 6 patients who developed postmolar gestational trophoblastic neoplasia. Histopathologic slide review was done to assess the following: trophoblastic proliferation, nuclear atypia, hemorrhage, necrosis along with measurement of the shortest diameter of the largesthydropic villus. The association of the histopathologic features and the development of postmolar gestational trophoblastic neoplasia was done using chi square. Analysis of the association of histopathologic features included in the study predictive of the development of postmolar gestational trophoblastic neoplasia was done.RESULTS: Analysis of several histopathologic parameters which may precisely identify which patients with complete hydatidiform moles were more likely to develop postmolar gestational trophoblastic neoplasia failed to produce statistically significant results. However, among all the features studied, the presence of extensive necrosis favored the occurrence of postmolar sequela.CONCLUSION: Trophoblastic proliferation, nuclear atypia, hemorrhage and villus size of complete hydatidiform moles do not predict progression to postmolar disease. In spite of this, all patients with complete hydatidiform moles should be considered for prophylactic chemotherapy should be monitored closely.
Subject(s)
Humans , Gestational Trophoblastic Disease , Hydatidiform Mole , Trophoblasts , RiskABSTRACT
INTRODUCTION: Serial beta human chorionic gonadotropin (?hCG) monitoring after molar evacuation is advised for early detection of persistent trophoblastic disease. The aim of this study was to determine the percentage of patients who developed post-molar gestational trophoblastic neoplasia during a 6-month follow up period after normalization of ?hCG surveillance for patients who underwent treatment for molar pregnancy.METHODS: Data was analyzed from the Section of Trophoblastic Diseases at the Philippine General Hospital- Department of Obstetrics and Gynecology to estimate the incidence of persistent trophoblastic disease among 258 women with molar pregnancy form 2000-2011.RESULTS: Among the 258 registered hydatidiform mole patients, 205 patients (79.5%) attained normal ?hCG titers titer levels after evacuation of molar products. There was no occurrence of postmolar gestational trophoblastic neoplasia among patients who achieved normalization of ?hCG titers after treatment. ?hCG levels did not attain normalization following evacuation in 53 patients (20.5%). Out of the 53 patients, 50 patients (94.3%) were detected to have gestational trophoblastic neoplasia within the first six months post-treatment. Only 3 patients (5.7%) were determined to have disease progression after six months during the one-year follow-up period.CONCLUSION: The follow-up period after a molar pregnancy may be reduced for patients whose serum ?hCG levels spontaneously decline to normal levels after evacuation. The results of this study showed that the median time to obtain normal ?hCG levels is 88 days for those who received chemoprophylaxis and 85 days for those with lower initial ?hCG values (less than 100,000 mlU/ml).