Clinicopathologic characteristics and subsequent pregnancy outcome in 139 complete hydatidiform moles

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Abstract

Objective

The most common form of gestational trophoblastic disease is the complete hydatidiform mole (CHM). The study reports our experience of clinicopathologic characteristics and subsequent pregnancy outcome of patients with CHM.

Study design

One hundred fifty-one subsequent cases with initial diagnosis of CHM were re-evaluated histopathologically. Clinical characteristics, the need for chemotherapy and subsequent pregnancy outcome were evaluated.

Results

Twelve out of 151 cases were re-evaluated as hydropic abortion, as partial hydatidiform moles or were insufficient for morphologic examination and therefore excluded from further analysis. The leading clinical symptoms of the remaining 139 cases were irregular vaginal bleeding (67%) and uterine enlargement (41%). Twenty-six patients (19%) required chemotherapy because of gestational trophoblastic neoplasia (GTN; low-risk: 23 out of 26). All patients were cured successfully. The subsequent pregnancy rate was 15% (21/139). Five patients suffered from abortions, 12 women delivered a healthy offspring. Four women presented with recurrent CHM with a spontaneous normalization of HCG levels after D&C.

Conclusions

The clinical and morphologic diagnosis of CHM is a challenge, and diagnosis as well as treatment should be multidisciplinary and centralised. One fifth of CHM are at risk of a GTN, but the cure rate is 100% with adequate management. Pregnancy outcome following CHM is complicated by an increased risk of abortion.

Introduction

Gestational trophoblastic disease (GTD) includes a spectrum of conditions, all arising from placental tissue. The villous forms of GTD include partial and complete hydatidiform moles as well as invasive moles [1], [2]. The non-villous forms consist of the placental site nodule, exaggerated placental site, placental site trophoblastic tumor (PSTT), choriocarcinoma and the epitheloid trophoblastic tumor [1], [2]. The frequency of gestational trophoblastic lesions in Europe is low, with a reported incidence of 1.54/1000 live births [3], but higher in Asia with one case in 500 deliveries [4]. Moodley et al. [5] reported an incidence of molar pregnancy and choriocarcinoma of 1.2/1000 and 0.5/1000 deliveries for South Africa.

The most common form of GTD is the complete hydatidiform mole (CHM). It arises as a result of abnormal fertilisation with a genome that is almost entirely of paternal origin [6], [7], [8]. CHM most often arises from the fertilisation of an empty ovum by a haploid spermatozoon that subsequently duplicates without cytogenesis to restore the diploid number of chromosomes [9]. Occasional cases occur where the empty ovum is fertilised by a diploid spermatozoon (resulting from a failure of the second meiotic division in spermatogenesis). Both of these events result in a diploid karyotype (most often 46,XX); tetraploid CHMs are exceptionally rare [10]. Partial hydatidiform moles (PHM), in contrast, usually arise from the dispermic fertilisation of a haploid ovum, probably with a defective zona pellucida. This results in a triploid chromosomal constellation [6], [7].

The present study was performed to evaluate the clinicopathologic characteristics of CHM, the morphologic features associated with the development of gestational trophoblastic neoplasia [11], [12], [13] as well as the reproductive experience after treatment. Cases of PHM with a comparably low reported risk of less than 3% for persistent disease [14], [15] were not considered.

Section snippets

Material and methods

One hundred fifty-one cases of CHM were obtained from the files at the Department of Obstetrics and Gynecology, University of Leipzig. The study period covered all women who were treated between January 1985 and December 1996 at our department. Patients’ age, gestational week, last reproductive event, clinical presentation at admission and follow-up data were retrieved from the clinical charts. Subsequent pregnancy outcome was recognised.

All hematoxylin-eosin stained slides of the cases were

Results

In 12 cases, the diagnosis was changed during histopathologic re-evaluation into either hydropic abortion (n = 5) or partial hydatidiform mole (n = 5). Two cases showed marked regressive change, so definitive diagnosis was not possible. These cases were excluded from further evaluation. It is important to state that none of the excluded cases developed persistent disease or recurrence.

The overall study population consisted of 139 cases. During the study period, 73,498 deliveries occured. Therefore,

Discussion

Molar pregnancy is an unique disease and can be divided into partial and complete hydatidiform mole (CHM), based on genetic background and different risk of developing gestational trophoblastic neoplasia [6], [7], [16], [17]. While CHM represents a relative common disease in Asia, the incidence in the Western countries is quite low [3], [19]. The relatively high-incidence at our institution (one CHM in 530 deliveries) is probably due to selection bias and that most cases were referred from

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