Placental Mosaicism in Multiple Gestation: Complete Hydatidiform Mole with Coexisting Twin Fetus.

Hydatidiform mole coexistent with a live fetus (CMCF) is a rare entity occurring in 1:20,000 to 1:100,000 pregnancies. Three mechanisms of this type are possible: (1) a singleton pregnancy consisting of partial mole with a triploid fetus, (2) a twin gestation consisting of an androgenic complete hydatidiform mole with a biparental diploid fetus, and (3) a twin gestation consisting of a biparental diploid fetus with a normal placenta and a partial hydatidiform mole (PHM) with a triploid fetus. The abnormal triploid fetus in a partial mole tends to die in the first trimester while the fetus coexisting with a complete or partial mole in the dizygotic twin pregnancy has a chance to survive. Early detection and diagnosis of a molar gestation with a viable fetus is needed to allow medical interventions, if available. Three cases of complete mole with a twin fetus (CMTF) that were diagnosed in the prenatal period by ultrasonography will be presented. This report will also discuss the indications for continuing the pregnancy, and review the literature on the recommended prenatal care, intrapartum management, and postpartum surveillance. This report aims to encourage others to document cases of CMTF in order to arrive at a consensus regarding its optimal management.

The Effects of Induction Chemotherapy in the Management of Ultra High-Risk Gestational Trophoblastic Neoplasia.

Objectives: This study aimed to determine the clinical outcomes of ultra high-risk gestational trophoblastic neoplasia (GTN) patients managed with and without induction chemotherapy in the Division of Trophoblastic Diseases, Department of Obstetrics and Gynecology, Philippine General Hospital. Methods: Clinical and demographic data were collected retrospectively from ultra high-risk GTN patients admitted in the Division of Trophoblastic Diseases, Department of Obstetrics and Gynecology, Philippine General Hospital from January 2015 to December 2021. Rate of remission and early death of those who received induction chemotherapy were compared to those who did not. Results: A total of 21 patients with ultra high-risk GTN were included in the study, nine of whom underwent induction chemotherapy while 12 had no induction chemotherapy and was given the standard EMACO regimen. There was no significant difference in the rate of early death as well as the rate and time to achieve remission between those who received induction chemotherapy compared to those who were immediately started on EMACO. CONCLUSION: A firm conclusion cannot be drawn from the results considering the small population included in the study. Further studies with larger sample size and prospective study design are recommended.

Recurrent hydatidiform mole with NLRP7 mutation: The first confirmed case in the Philippines / Philippine Journal of Obstetrics and Gynecology

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.

The association of histopathologic features and postmolar gestational trophoblastic neoplasia among patients with complete hydatidifrom mole / Philippine Journal of Obstetrics and Gynecology

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.

Human chorionic gonadotropin surveillance in hydatidiform mole: A need for reevaluation / Philippine Journal of Obstetrics and Gynecology

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).

Etoposide-Actinomycin as Salvage Regimen for the Treatment of Nonmetastatic and Low-Risk Metastatic Gestational Trophoblastic Neoplasia: Experience at the Philippine General Hospital.

OBJECTIVES: Single-agent chemotherapy has been the standard of treatment for nonmetastatic and metastatic low-risk gestational trophoblastic neoplasia (GTN). However, it is estimated that approximately 12% to 32% of patients given single-agent therapy will require a change of chemotherapy regimen because of drug resistance and/or intolerable toxicity. The Section of Trophoblastic Diseases of the Philippine General Hospital started using the combination of etoposide-actinomycin (EA) as salvage chemotherapy in the early 2000s. This study was carried out to describe the local experience with this salvage chemotherapy. MATERIALS AND METHODS: This is a retrospective descriptive study aimed to analyze the efficacy and safety of the EA regimen as salvage treatment for the management of nonmetastatic and low-risk metastatic GTN. Records of the Section of Trophoblastic Diseases of the Philippine General Hospital from January 1, 2002 to June 30, 2014 were reviewed to identify all patients who had a diagnosis of nonmetastatic and metastatic low-risk GTN. Primary remission rate and toxicity profile of all patients who received the EA regimen as salvage treatment were determined. RESULTS: During the study period, a total of 67 cycles of the EA regimen were administered to 15 patients as salvage chemotherapy. Patients received a median of 4 cycles of EA, attaining normal serum beta human chorionic gonadotropin after 2 to 3 cycles. Thirteen of the 15 patients achieved complete remission with the EA regimen, giving a remission rate of 87%. The major toxicity that the patients experienced was myelosuppression. Grade 1/2 anemia was addressed by blood transfusion. Grade 3 neutropenia/myelosuppression was addressed by the administration of granulocyte colony-stimulating factor. Alopecia was seen in all of the patients. One patient experienced dermatitis with accompanying myelosuppression. CONCLUSION: The EA regimen was efficacious and well tolerated for the treatment of refractory nonmetastatic and low- risk metastatic GTN.

Bilateral internal pudendal artery angiographic embolization of labial metastasis from gestational trophoblastic neoplasia / Philippine Journal of Obstetrics and Gynecology

Patients with Gestational Trophoblastic Neoplasia commonly experience bleeding from metastatic sites in the vulvovaginal area. Digital pressure and early institution of chemotherapy usually achieve control of the hemorrhage, but massive hemorrhage ensues in some cases. This paper documents the case of a 48 year-old Gravida8 Para7 (7017) who previously underwent total hysterectomy for endometrial mass. On histopathologic examination, it was diagnosed as Choriocarcinoma. Patient was then advised multiagent chemotherapy indicated for high-risk metastatic gestational trophoblastic neoplasia. Chemotherapy was discontinued due to intermittent, profuse, vaginal bleeding that rendered the patient anemic, a contraindication to starting another cycle of chemotherapy. Despite direct pressure on the vulvar mass, the bleeding became intractable, rendering the patient hypotensive and hooked on ionotropes for hemodynamic stability. The only option remaining for the patient was emergency embolization. This paper documents the first embolization to be done in the Philippines for labial metastasis from gestational trophoblastic neoplasia.

Mixed germ cell tumor in Androgen insensitivity syndrome: A case report / Philippine Journal of Obstetrics and Gynecology

Androgen insensitivity syndrome (AIS) is a disorder of sexual development characterized by a female phenotype with a 46 XY karyotype. Most patients present with primary amenorrhea; however,1.1% of patients present with an inguinal mass. Most commonly, seminoma arising from the gonads are found.                                                                                This report represents the case of a 15 year-old female looking adolescent who initially presented with an abdominopelvic mass. A diagnosis of AIS was made based on the physical examination findings, endocrine profiling, imaging studies and karyotyping. She underwent cytoscopy, exploratory laparotomy,adhesiolysis, tumor debulking, frozen section, bowel run, repair of serosal tear, Jackson-Pratt drain insertion, bilateral percutaneous nephrostomy under combined spinal and epidural anesthesia. Histopathologic examination of the excised mass revealed a mixed germ cell tumor. This paper will discuss the diagnostic approach as well as the management and prognosis of patients with AIS associated with mixed germ cell tumor.

Uterine arteriovenous malformation in pregnancy: A case report / Philippine Journal of Obstetrics and Gynecology

BACKGROUND: Uterine arteriovenous malformation (AVM) is a web of arteries and veins lacking an intervening capillary network. Color flow Doppler is a popular method of diagnosis of uterine AVM. The definitive management is hysterectomy. However, for patients desirous of pregnancy, transarterial embolization is a safe and effective option. Although rare, uterine AVM can complicate pregnancy with torrential bleeding due to hormonal changes and significant remodeling of the myometrium.CASE: We report a case of a term pregnancyin a 33 year old with a uterine AVM and a previous transarterial embolization procedure who developed a uterine AVM during multi-agent chemotherapy for gestational trophoblastic disease. She consulted for prenatal checkup. Due to the risk of massive bleeding during labor, she underwent elective cesarean section at term and delivered a baby with good outcome.CONCLUSION: This case suggests that uterine AVM in pregnancy can be managed conservatively with serial ultrasound monitoring and close follow up.

Efficacy of single dose antenatal corticosteroid on reducing the morbidity and mortality of preterm infants: A retrospective cohort study / Philippine Journal of Obstetrics and Gynecology

OBJECTIVE: To determine the efficacy of a single dose of antenatal dexamethasone on the neonatal morbidity and mortality of preterm infants born between 24 weeks to 33 weeks and six days age of gestation at a tertiary government hospital. METHODS: A detailed chart review of both maternal and neonatal records of all neonates born between 24 weeks and 33 weeks and 6 days age of gestation at a tertiary government hospital from January 1, 2011 to December 31, 2013 was done. Patients were grouped based on maternal exposure to antenatal dexamethasone. After which, rate of neonatal deaths and morbidities were recorded. Chi-square test for categorical variables, independent t-test for continuous data and logistic regression were used for analysis. RESULTS: Seven hundred and three maternal-neonatal dyads were included. Of these, 120 (17.1%) were not exposed to any antenatal corticosteroid prior to delivery, 347 (49.4%) were exposed to a single dose of 6-mg dexamethasone, and 236 (33.5%) received a complete course of four doses of 6-mg dexamethasone before preterm delivery. There were better neonatal outcomes from mothers who received completed doses of antenatal corticosteroids than those who received only a single dose, however in comparison to those who have not received any antenatal corticosteroids, the group that received only a single dose had significantly better neonatal outcome. Logistic regression analysis demonstrated that exposure to a single dose of dexamethasone before delivery was associated with reduction in neonatal mortality, and select neonatal morbidities. CONCLUSION: It was observed that there was improved neonatal outcomes in neonates given a single dose dexamethasone compared to those who didn't receive any antenatal corticosteroid. Obstetrician gynecologists should not hesitate in administering antenatal dexamethasone even if completion may not seem feasible.

Juvenile granulosa cell tumor of the ovary presenting as isosexual precocious puberty: A case report / Philippine Journal of Obstetrics and Gynecology

lsosexual precocious puberty is rare and a thorough investigation must be done in order to identify the cause of the precocity. This paper presents the case of a 4 year-old girl who was brought to the emergency room due to vaginal bleeding associated with onset of secondary sexual characteristics. Estradiol and anti-mullerian hormone levels were elevated. Abdominal ultrasound revealed an abdominopelvic mass probably an ovarian new growth with benign sonologic features. Computer tomography of the brain with contrast showed normal findings. Elective surgery was planned after correction of the anemia and other causes of precocious puberty were excluded. She underwent an exploratory laparotomy and left salpingooophorectomy with frozen section. Final histopathology report showed juvenile granulosa cell tumor of the left ovary.

A randomized controlled trial on the efficacy of methotrexate in preventing postmolar gestational trophoblastic disease among patients with high-risk complete hydatidiform mole / Philippine Journal of Obstetrics and Gynecology

OBJECTIVE: This study aimed to determine the efficacy of methotrexate in preventing postmolar gestational trophoblastic disease (PMGTD) among patients with high-risk complete hydatidiform mole. METHODS: This was a double-blind randomized controlled trial carried out from 2007 to 2013. A total of 99 patients with high-risk complete hydatidiform mole who underwent suction curettage were randomly allocated to either the treatment or control group. The treatment group received methotrexate while the control group received a vitamin B complex. The number of patients who developed PMGTD in each group was recorded. All tests of significance were carried out at a .05 alpha level of significance, 95% confidence interval. RESULTS: There was no significant difference between the two groups in terms of age, gravidity, baseline ?hCG, age of gestation, and corpus size. The overall incidence of PMGTD was 27.9%. For the per protocol analysis, a total of 30 patients received chemoprophylaxis while 31 patients received placebo treatment. The total incidence of PMGTD was 16.67% for the treatment group and 38.71% for the control group. The computed risk ratio was 0.43 (95% C.I.: 0.17-1.07, p value = 0.07). CONCLUSION: Results failed to reach statistical significance but the large fall-out rate may have significantly affected the outcome of the study. Methotrexate chemoprophylaxis may still be useful in preventing PMGTD, particularly in settings where the incidence of hydatidiform mole is high and there is high probability that patients will fail to follow the stringent ?hCG monitoring schedule after molar evacuation.

Transcervical foley catheter versus laminaria: A randomized controlled trial comparing efficacy and safety in facilitating cervical dilatation in cases of molar pregnancies / Philippine Journal of Obstetrics and Gynecology

OBJECTIVE: This study aimed to compare the efficacy and safety of foley catheter versus laminaria in facilitating cervical dilatation among patients with molar pregnancy. METHODS: This was a randomized controlled trial carried out from September 1, 2013 to September 30, 2014. Fifty-two patients with hydatidiform mole were randomly allocated to either the control or treatment group. Laminaria was used in the control group to facilitate cervical dilatation prior to molar evacuation while foley catheter was used in the treatment group. The primary outcome was the rate of successful cervical dilatation. Amount of bleeding, level of pain, presence of foul smelling vaginal discharge, and febrile episode were noted. The two-tailed Wilcoxon rank sum test was used to determine difference between the two groups. RESULTS: A significantly higher rate of successful cervical dilatation was seen in the foley catheter group (1.6 mm/hr vs 1 mm/hr), as evidenced by shorter duration from placement of mechanical dilator to successful cervical dilatation (9.5 hours vs 12 hours) and the lack of need for insertion of additional cervical dilator (0 vs 1). Compared to laminaria, foley catheter took a significantly shorter time to insert (5 mins vs 1 min) and was significantly less painful (VAS 5 vs VAS 0). Estimated blood loss, relative risk for pelvic pain, febrile episodes, profuse bleeding, and foul smelling discharge did not differ significantly between the two groups. CONCLUSION: Foley catheter may be an alternative in facilitating cervical dilatation for molar pregnancies. Foley catheter has the advantage of being readily available, with lower cost and lack of systemic or serious side effects.

Successful pregnancy after treatment of a cervical gestational trophoblastic neoplasia: a case report.

BACKGROUND: Primary gestational trophoblastic neoplasia of the uterine cervix is exceptionally rare, with fewer than 100 cases reported worldwide. CASE: A 33-year-old, gravida 1, para 1, Filipino woman was admitted due to vaginal bleeding nearly 7 months after delivery of a full-term, stillborn infant. Transvaginal ultrasound revealed a heterogeneous, predominantly solid, vascular mass at the upper half of the cervix measuring 3.05 x 3.75 x 3.6 cm. Serum beta human chorionic gonadotropin (beta-hCG) on admission was 101,922.5 mIU/mL. She was initially treated with single-agent chemotherapy in the form of methotrexate. Rising levels of serum beta-hCG after the third cycle necessitated a shift to multiagent chemotherapy in the form of etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine. The patient achieved remission after 6 cycles and eventually achieved a successful pregnancy. CONCLUSION: Primary gestational trophoblastic neoplasia of the cervix can be treated successfully using chemotherapy.

Conservative management of uterine rupture in gestational trophoblastic neoplasia: a report of 2 cases.

Cases of gestational trophoblastic neoplasia (GTN) with uterine rupture are often catastrophic owing to profuse bleeding, which could be potentially lethal. Management often entails removal of the uterus. Among patients in the reproductive age who have not completed their desired family size, such a procedure could be unacceptable. To address this, uterine resection of localized disease has been performed to preserve fertility. However, in some cases, resection would not leave much of the uterus for future fertility. Hence, primary repair of the rupture could be done. Two cases of uterine rupture in low-risk GTN conservatively managed with primary uterine rupture repair using hemostatic stitches and postoperative single-agent chemotherapy are presented. Both patients were in their early reproductive years and with a great desire to preserve future fertility. The extent of the disease was evaluated in both cases intraoperatively before considering this conservative approach. Such management proved to be effective for both cases. The 2 cases presented are the first reported successful cases in literature on which primary repair of uterine tumor rupture by oversewing with figure-of-eight stitches were done. One should then consider this as a new option in the management of patients who have GTN with uterine rupture, highly desirous of pregnancy, with large uterine tumors but relatively small areas of rupture for which simple stitches would suffice in providing adequate hemostasis.