Influence of COVID-19 pandemic on molar pregnancy and postmolar gestational trophoblastic neoplasia: An observational study.

OBJECTIVE: To assess whether the incidence and aggressiveness of molar pregnancy (MP) and postmolar gestational trophoblastic neoplasia (GTN) changed during the COVID-19 pandemic. DESIGN: Observational study with two separate designs: retrospective multicentre cohort of patients with MP/postmolar GTN and a cross-sectional analysis, with application of a questionnaire. SETTING: Six Brazilian Reference Centres on gestational trophoblastic disease. POPULATION: 2662 patients with MP/postmolar GTN treated from March-December/2015-2020 were retrospectively evaluated and 528 of these patients answered a questionnaire. METHODS: Longitudinal retrospective multicentre study of patients diagnosed with MP/ postmolar GTN at presentation and a cross-sectional analysis, with application of a questionnaire, exclusive to patients treated during the period of study, to assess living and health conditions during the COVID-19 pandemic compared with previous years. MAIN OUTCOME MEASURES: The incidence of MP/postmolar GTN. RESULTS: Compared with the last 5 pre-pandemic years, MP/postmolar GTN incidence remained stable during 2020 (COVID-19 pandemic). Multivariable logistic regression, adjusted for the patient age, showed that during 2020, presentation with MP was more likely to be >10 weeks of gestation (adjusted odds ratio [aOR] 2.50, 95% confidence interval [CI] 1.90-3.29, P < 0.001), have a pre-evacuation hCG level ≥100 000 iu/l (aOR 1.77, 95% CI 1.38-2.28, P < 0.001) and time to the initiation of chemotherapy ≥7 months (aOR 1.86, 95% CI 1.01-3.43, P = 0.047) when compared with 2015-2019. CONCLUSIONS: Although the incidence of MP/postmolar GTN remained stable during the COVID-19 pandemic in Brazil, the pandemic was associated with greater gestational age at MP diagnosis and more protracted delays in initiation of chemotherapy for postmolar GTN.

Infiltracao Medular Por Leucemia Mieloide Aguda (Lma) E Tumor Solido (Ts) Metastatico: Relato De Caso

Objetivo: Descrever um caso com duas neoplasias concomitantes infiltrando medula ossea (MO), sendo uma delas hematologica e outra, TS. Material e metodos: Relato de caso por meio de coleta de dados de prontuario de paciente acompanhado no HAC. Resultados: Paciente 67 anos, masculino, tabagista (100 anos/maco), ex-etilista, historia de inalacao de tintas com benzeno (pintor de carros por 30 anos), com astenia e anemia ha 4 meses, associado a perda de 25kg. Procurou atendimento em marco/22 com diagnostico de COVID-19 e necessidade de internacao hospitalar. Evoluiu com bicitopenia sendo transferido ao HAC para investigacao. Ao exame fisico: ECOG 3. Hemograma: bicitopenia (Hb 5.8 mg/dL;plaquetas 40000/mm3;leucocitos 13000/mm3;69% blastos). TC: derrame pleural a direita;raros micronodulos pulmonares;enfisema pulmonar difuso acentuado com areas de fibrose associadas;linfonodomegalias mediastinais e hilares, lesoes osteoliticas esparsas. Mielograma: dispoese das tres linhagens, com 24% de celulas blasticas, alem de grumos de celulas nao-hematologicas (TS). Em Citometria de Fluxo (Euroflow): 16% de mieloblastos patologicos, expressando CD7, CD13, CD33, CD34, CD38, CD44, CD71, CD97, CD123. Citogenetica: 47,XY,+8. Nao foi realizada avaliacao molecular. Biopsia de MO: infiltracao macica da medula ossea por tumor solido. Imunohistoquimica com positividade para: CK7 e TTF-1 e negatividade para: CK20, PSA, PAX-8, CD10, CDX-2, GATA-3. Diagnostico final: infiltracao da MO por adenocarcinoma, favorecido sitio pulmonar, e em area residual, infiltracao por Leucemia mieloide aguda, com alteracao citogenetica associada a mielodisplasia (ELN 2022). Como tratava-se de idoso fragil, sem possibilidade de tratamento intensivo das doencas leucemica e oncologica, proposto tratamento paliativo exclusivo, com medidas de suporte. Paciente faleceu apos 2 meses do diagnostico. Discussao: A associacao de LMA com TS nao e rara. O risco de um paciente previamente tratado para TS desenvolver LMA pode ser ate 10 vezes maior que a populacao normal. Relatos de casos de TS recidivados em MO e LMA concomitantes foram descritos, com desfechos sombrios. Contudo, nao ha na literatura a descricao de LMA de novo com TS infiltrando MO concomitantes ao diagnostico. Estudo chines de 2020, analisou 12 casos de LMA associada a TS primario sincronicos, sendo: 3 etiologia pulmonar, 1 mama, 1 mola, e 7 com neoplasia de TGI. O intervalo de tempo mediano para o diagnostico das duas neoplasias foi de 4 meses. O tratamento da LMA foi realizado com quimioterapia (QT) de alta intensidade ou agente hipometilante. A sobrevida global mediana foi de 12.5 meses (porem somente 4/12 tinham TS avancado). Um estudo americano em 2009 analisou 5 pacientes com LMA e tumor de pulmao (2 com doenca avancada) sincronicos. Todos foram tratados com QT de alta intensidade, e a sobrevida media foi de 5 meses (3-21). Conclusao: Este e o primeiro relato de caso de LMA e TS metastatico infiltrando MO concomitantemente ao diagnostico. A LMA deve ser tratada prioritariamente por ser doenca altamente agressiva, levando-se em conta as condicoes clinicas do paciente, com avaliacao individual. E mesmo com tratamento intensivo, o prognostico e reservado. Copyright © 2022

Treatment of Hydatidiform Mole Suspected to COVID 19.

The aim of this study was to report a case of the treatment of hydatidiform mole in Coronavirus pandemic in Iranshahr. A 17-year-old primiparous woman with gestational age of 14 weeks presented with unilateral leg swelling and sudden abdominal distension beginning in the night before referring to the health center. In the abdominal examination of the patient by a healthcare provider, the baby's heartbeat was not heard and a mismatch was observed between gestational age and fundal height, which corresponded to approximately 24 weeks of gestation. She was conscious and pale with hematuria and uterine contractions. After inserting two IV lines, the patient immediately underwent monitoring and was visited by a gynecologist. Complete molar pregnancy was diagnosed with an enlarged heterogeneous uterus 180 cm × 90 cm in size and containing 170 mm × 80 mm cysts. The treatment began with vancomycin AMP, hydrocortisone AMP, oseltamivir CAP 75 mg, kaletra CAP 200 mg, and meropenem AMP.

HEMOPTYSIS AS PRIMARY MANIFESTATION IN A WOMAN WITH CHORIOCARCINOMA WITH PULMONARY METASTASIS

SESSION TITLE: Systemic Diseases Causing Pulmonary Havoc SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Choriocarcinoma is the most common type of gestational trophoblastic neoplasm (GTN) and can occur in association with any pregnancy [1]. The main risk factors are advanced or very young maternal age, ethnicity, ectopic pregnancy, abortion, and prior molar pregnancy. The most common sites of choriocarcinoma metastasis are lungs, liver, and brain [2]. This case describes a patient with choriocarcinoma that presented with hemoptysis. CASE PRESENTATION: The patient is a 22 year-old G2P1 female presenting at 36 weeks-gestation with one week of hemoptysis. She denied any other symptoms. On presentation, she was tachycardic. Physical examination demonstrated bibasilar crackles. Admission chest x-ray revealed diffuse bilateral infiltrates (Fig 1). Hs-troponin was elevated to 144 ng/L;however, EKG did not show ischemic changes. Cultures were obtained prior to empirically initiating antibiotics. Despite antibiotic treatment, hemoptysis worsened over her course and oxygen requirements increased. Infectious workup was negative. CT obtained for pulmonary embolism revealed bilateral patchy airspace opacities in lungs, suspected due to multifocal pneumonia (Fig 2). AFB smear and quantiferon were negative. After an emergent C-section for increased oxygen requirements, bronchoscopy with BAL was obtained and demonstrated diffuse alveolar hemorrhage. BAL was only positive for mildly increased CD4:CD8 ratio. Transbronchial biopsy was aborted due to bleed risk. Subsequent right lobe wedge biopsy confirmed metastatic choriocarcinoma. Her serum human chorionic gonadotropin (ß-hCG) level was found to be 20,713 milli-international units/mL. DISCUSSION: The etiology of hemoptysis was initially thought to be secondary to pneumonia. Differential diagnoses also included an acute COVID infection, alveolar hemorrhage, tuberculosis in a recently-immigrated patient, myocarditis, autoimmune etiology, and malignancy. Patient's risk factors included a prior miscarriage. Rarely, bleeding can occur as a result of metastatic lesions and may result in abdominal pain, hemoptysis, melena, or evidence of increased intracranial pressure from intracerebral hemorrhage [2]. Patients, such as the one described in this case, can exhibit pulmonary symptoms of dyspnea, cough, and chest pain caused by lung metastases. Upon closer examination of the CT scans, several of the opacities are nodular and consistent with GTN. Patients treated with surgery, chemotherapy, or a combination of both demonstrated similar treatment outcomes;chemotherapy may still be the preferred option. The overall cure rate in treating these tumors is currently > 90% [2]. CONCLUSIONS: GTN, although rare, should be considered as a differential diagnosis in women with a pregnancy history and risk factors that present with the primary symptom of hemoptysis. High index of suspicion and awareness of these neoplasms are necessary for timely diagnosis. Reference #1: Savage P. Winter M. Parker V. et al. Demographics, natural history and treatment outcomes of non-molar gestational choriocarcinoma: a UK population study. BJOG. 2020;127: 1102-1107 Reference #2: Lurain, J., 2010. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. American Journal of Obstetrics and Gynecology, 203(6), pp.531-539. DISCLOSURES: No relevant relationships by Crystal Ajja No relevant relationships by Heba Osman No relevant relationships by James Rowley

The etiology of preeclampsia.

Preeclampsia is one of the "great obstetrical syndromes" in which multiple and sometimes overlapping pathologic processes activate a common pathway consisting of endothelial cell activation, intravascular inflammation, and syncytiotrophoblast stress. This article reviews the potential etiologies of preeclampsia. The role of uteroplacental ischemia is well-established on the basis of a solid body of clinical and experimental evidence. A causal role for microorganisms has gained recognition through the realization that periodontal disease and maternal gut dysbiosis are linked to atherosclerosis, thus possibly to a subset of patients with preeclampsia. The recent reports indicating that SARS-CoV-2 infection might be causally linked to preeclampsia are reviewed along with the potential mechanisms involved. Particular etiologic factors, such as the breakdown of maternal-fetal immune tolerance (thought to account for the excess of preeclampsia in primipaternity and egg donation), may operate, in part, through uteroplacental ischemia, whereas other factors such as placental aging may operate largely through syncytiotrophoblast stress. This article also examines the association between gestational diabetes mellitus and maternal obesity with preeclampsia. The role of autoimmunity, fetal diseases, and endocrine disorders is discussed. A greater understanding of the etiologic factors of preeclampsia is essential to improve treatment and prevention.

A possible association between hydatidiform mole and the COVID-19 pandemic: A retrospective cohort study.

OBJECTIVE: To confirm an increase in the number of women with molar pregnancy during the COVID-19 pandemic. METHODS: In this retrospective cohort study, all patients with complete or partial mole diagnosed at our institution between January 1, 2010 and October 31, 2020, were included. To verify whether there was an increase in the incidence of hydatidiform mole (HM) and deliveries in 2020, the incidences for each year from January 2010 to October 2020 were recorded. In addition, we identified all women who were diagnosed with HM from January to October 2020, and compared them with a control group who underwent uterine evacuation for missed abortion of a singleton pregnancy during the same period. We also documented the time taken to diagnose missed abortion or molar pregnancy to check if a delay in diagnosis can explain the increase in HM incidence. RESULTS: Between 2016 and 2019, there was a statistically significant increase in the incidence of molar pregnancy. A further increase occurred in 2020 (odds ratio = 2.071). The mean gestational age of the embryo at the time of diagnosis was smaller in the HM group than in the missed abortion group (6.3 ± 1.67-7.4 ± 2.4, one-sided P = 0.034), meaning that it took more time (days) to diagnose molar pregnancy than missed abortion (22.38 ± 10.32 vs. 15.83 ± 7.83 days, P = 0.012). CONCLUSION: There was a significant increase in the incidence of molar pregnancy during the COVID-19 pandemic, possibly because of the delay in receiving medical care. We recommend providing gynecological primary care services during a crisis, such as a pandemic.

COVID-19 and hydatidiform mole.

The emergence of coronavirus disease 2019 (COVID-19) as a pandemic threatens the entire world resulting in severe consequences for people's health. Pregnant patients with COVID-19 had immune dysregulation that could result in abnormal pregnancy outcomes such as hydatidiform mole (HM), recurrent pregnancy loss, and early-onset preeclampsia. In this article, we tried to summarize the possible association between COVID-19 and the HM's development by reviewing the role of NOD-Like Receptor (NLR) Family Pyrin Domain Containing 7 (NLRP7), cytokines, zinc, and leukocytes in the pathogenesis of HM.

Hydatidiform mole in the era of COVID-19 pandemic. Is there an association?

Coronavirus disease 2019 (COVID-19) is considered a worldwide pandemic. COVID-19 patients had profound immune dysregulation so they could be susceptible for adverse pregnancy outcomes as hydatidiform mole. In this article, we tried to explain the link between hydatidiform mole and COVID-19.