Life-threatening rupture of interstitial ectopic pregnancy: a rare presentation of metastatic invasive mole.

An invasive mole is an uncommon type of gestational trophoblastic disease, and if considering its implantation in an interstitial extrauterine location, we are facing a rarer condition.There are 14 cases described of interstitial ectopic gestational trophoblastic disease. As far as we know, we present the third case of invasive mole within interstitial location, in this case with pulmonary metastases.The diagnosis of an interstitial implantation is challenging. Our patient was initially diagnosed with an intrauterine hydatidiform molar pregnancy, and a uterine aspiration was performed. Two weeks later, she presented with haemodynamical instability due to a severe haemoperitoneum. A laparotomy was immediately performed and revealed a ruptured interstitial pregnancy with molar vesicle extrusion. Besides its rarity, we highlight the clinical presentation with hypovolaemic shock due to rupture of ectopic pregnancy in a young nulliparous woman, which required an emergent surgical approach with lifesaving purpose while preserving future fertility.

An invasive mole with pulmonary metastases in a 55-year-old postmenopausal Syrian woman: a case report and review of the literature.

BACKGROUND: Invasive mole is a subtype of gestational trophoblastic neoplasms (GTNs) that usually develops from the malignant transformation of trophoblastic tissue after molar evacuation. Invasive moles mostly occur in women of reproductive age, while they are extremely rare in postmenopausal women. CASE PRESENTATION: We present the case of a 55-year-old postmenopausal Syrian woman who was admitted to the emergency department at our hospital due to massive vaginal bleeding for 10 days accompanied by constant abdominal pain with diarrhea and vomiting. Following clinical, laboratory and radiological examination, total hysterectomy with bilateral salpingo-oophorectomy was performed. Histologic examination of the resected specimens revealed the diagnosis of an invasive mole with pulmonary metastases that were diagnosed by chest computed tomography (CT). Following surgical resection, the patient was scheduled for combination chemotherapy. However, 2 weeks later the patient was readmitted to the emergency department due to severe hemoptysis and dyspnea, and later that day the patient died in spite of resuscitation efforts. CONCLUSION: Although invasive moles in postmenopausal women have been reported previously, we believe our case is the first reported from Syria. Our case highlights the difficulties in diagnosing invasive moles in the absence of significant history of gestational trophoblastic diseases. The present study further reviews the diagnostic methods, histological characteristics and treatment recommendations.

A case report of pelviscopic resection of invasive hydatidiform mole.

RATIONALE: Invasive moles occur in the fertile period, with about 95% occurring after previous mole removal and the remaining 5% occurring after several other pregnancies. PATIENT CONCERNS: A 27-year-old patient developed a rare invasive mole two months after a missed abortion. DIAGNOSES: A transvaginal ultrasound scan revealed a 3.6 × 2.9 × 2.4 cm sized lesion with cystic vascular areas within it, within the myometrium of the right fundal posterior region of the uterus. There was no metastasis to other organs. INTERVENTIONS: After administration of methotrexate, the level of beta-human chorionic gonadotropin (ß-hCG) was elevated and liver enzymes were also markedly elevated. She wanted to retain fertility for future pregnancies. After laparoscopic removal of the myometrial invasive mole, the incision site was sutured with a 3-0 V-Loc. OUTCOMES: One year later, a natural pregnancy occurred and a cesarean section was performed at 36 weeks. LESSONS: This is the first reported case of its type. Our case demonstrated that pelviscopic removal of an invasive mole is possible if there are no other metastases, and that future pregnancy and childbirth are still feasible in women of reproductive age.

Histopathological and clinical features of molar pregnancy.

OBJECTIVE: To analyse own set of molar pregnancies and to develop clinically relevant procedures. TYPE OF STUDY: Review article with analysis of own data. SETTINGS: Department of Pathology 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague; Department of Obstetrics and Gynecology 3rd Faculty of Medicine, Charles University, Faculty Hospital Královské Vinohrady, Prague. INTRODUCTION: The study monitors the decrease of laboratory values of beta-subunit of hCG gonadotropin (beta-hCG) after evacuation of partial and complete hydatidiform moles in a set of 45 partial and 46 complete moles. Two case reports of invasive moles. RESULTS: In cases of partial hydatidiform moles there was complete regression of beta-hCG in all cases, 89% regressed in six weeks, none of the women showed no subsequent elevation after reaching negativity. In cases of complete hydatidiform moles the decrease was less gradual, the negativity after six weeks was confirmed in 78%, three complete moles became malignant. CONCLUSION: The decrease of beta-hCG after molar pregnancy termination is variable. Even if in cases of complete hydatidiform moles the risk of malignization after reaching negativity is low, beta-hCG checks are recommended at monthly intervals for 6 months. Correct diagnosis of complete mole and its differentiation from partial mole can be achieved using immunohistochemistry - p57 antibody.

A metastatic invasive mole arising from iatrogenic uterus perforation.

BACKGROUND: Invasive mole derives from hydatidiform mole, but its pathogenesis remains unknown. Invasive mole arising from iatrogenic uterine perforation has not been reported yet. CASE PRESENTATION: A reproductive woman was admitted because she suffered form severe abdominal pain and acute intra-abdominal hemorrhage after suction evacuation due to misdiagnosis as inevitable abortion. The patient underwent hysteroscopy and laparoscopy, by which an iatrogenic uterine perforation and omentum and pelvic peritoneum metastases were confirmed. All lesions were removed and the final pathological diagnosis was metastatic invasive mole. The patient underwent post-operative chemotherapy with methotrexate and presented a good prognosis. CONCLUSION: Invasive mole arising form iatrogenic uterine perforation displays an unusual metastatic manner other than general invasive moles. The prevention of uterine perforation should be emphasized during suction evacuation for mole pregnancy.

Laparoscopic Management of an Invasive Mole Perforating the Uterus.

STUDY OBJECTIVE: To show the possibility of conservative laparoscopic management in a case of invasive mole perforating the uterus. DESIGN: Video with explanations. SETTING: An invasive mole is a potentially life-threatening complication of gestational trophoblastic disease [1]. This is a case of a 24-year-old female presenting with abdominal pain and vaginal bleeding. There have been several previous reports of cases of uterine perforation by an invasive mole, all of which were managed with abdominal hysterectomy [2-7]. To our knowledge, this is the first report of an invasive mole perforation with active bleeding managed by laparoscopy without hysterectomy. INTERVENTIONS: Sonography revealed a large amount of fluid and a 3 × 3-cm heterogeneous lesion next to the posterior uterine wall. Her hemoglobin level dropped from 10.6 mg/dL to 8.6 mg/dL, and her ß-human chorionic gonadotropin level was 19,004 mIU/mL. On laparoscopy, ∼2500 mL of hemoperitoneum was found, along with an actively bleeding bulging mass in the posterior uterine wall. This mass was dissected, and hemostasis was secured with sutures and electrocoagulation. Pathology confirmed the diagnosis of a complete mole. After surgery, the patient was treated with 5 courses of a methotrexate-folinic acid regimen. Her recovery was uneventful. CONCLUSION: Uterine perforation by an invasive mole can be managed conservatively with laparoscopic surgery and postoperative chemotherapy. The transmural lesion will increase the risk of future uterine rupture during pregnancy in this patient.

Methotrexate and actinomycin D chemotherapy in a patient with porphyria: a case report.

BACKGROUND: Despite their broadly recommended use as chemotherapeutic agents, the porphyrogenicity of methotrexate and actinomycin D have not been confirmed. Accordingly, it is not known whether these agents are safe for use in patients with porphyria. CASE PRESENTATION: In this report, we present a case of an invasive mole with lung metastasis in a 49-year-old Japanese woman who had previously been diagnosed with acute intermittent porphyria at 27 years of age but had no recent history of acute intermittent porphyria attacks. Her serum human chorionic gonadotropin level was elevated 1 month after hysterectomy, and she was referred to our center for chemotherapy. After she received 100 mg of methotrexate, drug eruptions were observed starting on day 3 and grew progressively worse. Erythema and mucosal erosion spread throughout her body, whereupon she was administered prednisolone. In addition, our patient experienced febrile neutropenia and required granulocyte colony- stimulating factor treatment. No changes in our patient's urinary coproporphyrin or uroporphyrin levels were detected during this entire episode. Methotrexate was replaced by actinomycin D (0.5 mg/body intravenously on days 1-5 every 2 weeks). After five uneventful cycles of actinomycin D, our patient achieved and maintained a normal serum human chorionic gonadotropin level for 3 years. CONCLUSIONS: Methotrexate and actinomycin D did not induce acute porphyric attacks in this patient with acute intermittent porphyria; however, severe adverse effects were noted with methotrexate. Although further investigation is required, our data suggest that these agents are nonporphyrinogenic and can therefore be used to treat patients with comorbid porphyria.

Invasive mole in a perimenopausal woman: a case report and systematic review.

OBJECTIVE: Gestational trophoblastic disease (GTD) is a term used for a group of pregnancy-related tumors. We present a case of a perimenopausal woman with invasive mole. A systematic review was performed to identify reports on GTD in older women and to determine adequate treatment options. CASE: A 51-year-old perimenopausal woman was admitted to hospital with abdominal feeling of pressure and nausea. Diagnostic curettage revealed hydatidiform mole. She also presented symptomatic hyperthyroidism with hypertensive blood pressure and uneasiness. After treatment with beta blockers and carbimazole, the patient underwent abdominal hysterectomy and bilateral oophorosalpingectomy. Histopathological examination confirmed an invasive hydatidiform mole (IHM). Serum ß-hCG has decreased from initially 300,000-100 unit/L after 4 weeks. DATA SOURCES: A systematic review was performed to identify all prior cases of GTD in women over 50. We searched in Medline, The Cochrane Library and Embase, to identify any articles published in the English language after 1970 and before Oct 31, 2013 pertaining to GTD in older woman (50 years or older). TABULATION, INTEGRATION, AND RESULTS: Ten records were included in the systematic review, involving 203 cases of trophoblastic disease in older women. Although the diagnosis of GTD in older women is rare, it should be considered especially in patients with suspicious intrauterine findings in transvaginal ultrasound examinations. Different treatments were performed. In a limited number of reports, older women with GTD underwent initial hysterectomy. Benefits are avoidance of chemotherapy-induced toxicity and reduced risk of recurrence. Hysterectomy should be performed by an experienced surgeon. CONCLUSION: It is concluded that GTD is very rare in peri- or postmenopausal women. Treatment has to be individualized, and hysterectomy can be considered as an appropriate option.

Hypotensive Response Magnitude and Duration in Hypertensives: Continuous and Interval Exercise / Magnitude e Duração da Resposta Hipotensora em Hipertensos: Exercício Contínuo e Intervalado

Background: Although exercise training is known to promote post-exercise hypotension, there is currently no consistent argument about the effects of manipulating its various components (intensity, duration, rest periods, types of exercise, training methods) on the magnitude and duration of hypotensive response. Objective: To compare the effect of continuous and interval exercises on hypotensive response magnitude and duration in hypertensive patients by using ambulatory blood pressure monitoring (ABPM). Methods: The sample consisted of 20 elderly hypertensives. Each participant underwent three ABPM sessions: one control ABPM, without exercise; one ABPM after continuous exercise; and one ABPM after interval exercise. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR) and double product (DP) were monitored to check post-exercise hypotension and for comparison between each ABPM. Results: ABPM after continuous exercise and after interval exercise showed post-exercise hypotension and a significant reduction (p < 0.05) in SBP, DBP, MAP and DP for 20 hours as compared with control ABPM. Comparing ABPM after continuous and ABPM after interval exercise, a significant reduction (p < 0.05) in SBP, DBP, MAP and DP was observed in the latter. Conclusion: Continuous and interval exercise trainings promote post-exercise hypotension with reduction in SBP, DBP, MAP and DP in the 20 hours following exercise. Interval exercise training causes greater post-exercise hypotension and lower cardiovascular overload as compared with continuous exercise. .

Fundamento: Embora se saiba que o exercício promova hipotensão pós-exercício, até o momento não há argumentações consistentes sobre os efeitos da manipulação de seus diversos componentes (intensidade, duração, intervalos de descanso, tipos de exercício, métodos de treinamento) na magnitude e duração da resposta hipotensora. Objetivo: Comparar os efeitos dos exercícios dinâmicos, contínuo e intervalado, sobre a magnitude e duração da resposta hipotensora em hipertensos por meio da monitorização ambulatorial da pressão arterial (MAPA). Métodos: A amostra foi composta por 20 idosos hipertensos. Cada participante realizou três sessões de MAPA, sendo uma controle (sem exercício), uma após exercício contínuo e uma após exercício intervalado. O monitoramento de pressão arterial sistólica (PAS), pressão arterial diastólica (PAD), pressão arterial média (PAM), frequência cardíaca (FC) e duplo produto (DP) foi realizado para verificação da hipotensão pós-exercício e comparação entre cada MAPA. Resultados: As MAPAs após exercício contínuo e intervalado demonstraram hipotensão pós-exercício e redução significativa (p < 0,05) de PAS, PAD, PAM e DP por 20 horas, na comparação com a MAPA controle. Na comparação entre as MAPAs após exercício contínuo e intervalado, verificou-se redução significativa (p < 0,05) de PAS, PAD, PAM e DP após exercício intervalado. Conclusão: Os exercícios contínuo e intervalado promovem hipotensão pós-exercício, com redução significativa de PAS, PAD, PAM e DP ao longo das 20 horas subsequentes à atividade. O exercício intervalado gera maior magnitude de hipotensão pós-exercício e menor sobrecarga cardiovascular, medida por menor DP. .

[Value of laparoscopic surgery in the diagnosis of suspected gestational trophoblastic neoplasia cases with uterine mass].

OBJECTIVE: To evaluate the value of laparoscopic surgery in the diagnosis of suspected gestational trophoblastic neoplasia (GTN) cases with uterine mass. METHODS: The clinical characteristics of patients underwent laparoscopic surgery for a suspected diagnosis of GTN with uterine mass in Peking Union Medical College Hospital from November 2009 to November 2014 were retrospectively reviewed and analyzed. GTN and other pregnant-related disease were definitely diagnosed by pathological findings. The prognoses of the GTN cases were also investigated. RESULTS: Sixty-two patients with a suspected diagnosis of GTN with uterine mass were studied. Among them, 17 cases were definitely diagnosed as GTN, including 8 choriocarcinoma, 5 invasive mole and 4 placental site trophoblastic tumor (PSTT). The other 45 cases were diagnosed as benign pregnancy-related diseases, including 29 cornual pregnancy, 6 cesarean scar pregnancy, 5 placenta accreta, 4 intramural uterine pregnancy and 1 exaggerated placental site. There were no significantly differences between the two groups in average age, preoperative value or tendency of ß-hCG, and location or size of lesions (P>0.05). More GTN patients showed a history of hydatidiform mole [5/17 vs 4% (2/45) , P>0.05], and more patients with benign pregnancy-related disease showed a history of cesarean section [38% (17/45) vs 1/17, P>0.05]. No serious perioperative complication was found in these patients received laparoscopic surgery. All GTN patients achieved complete remission by chemotherapy later. Except for 1 case loss, no recurrence was found in 11 low-risk stage I cases with an average follow-up period of 11- 66 months, 1 high-risk stage I case with a follow-up period of 61 months and 4 cases PSTT with a follow-up period of 13-66 months. CONCLUSIONS: There were some atypical GTN cases with uterine mass, which were difficult to be differentiated from benign pregnancy-related diseases according to the clinical characteristics. Laparoscopic surgery with a pathologic diagnosis could be an essential way with efficiency and safety.

Laparoscopically diagnosed invasive mole presenting as acute hemoperitoneum.

A young multipara presented with acute abdominal pain. She had history of dilatation and evacuation for a missed miscarriage 2 months back. The diagnosis of ectopic pregnancy was made on the basis of clinical presentation and laboratory investigations. Laparoscopy was performed which revealed features of invasive mole. The procedure was converted to laparotomy and hysterectomy was performed. Patient recovered well. Histopathology confirmed the diagnosis of invasive mole. Follow-up till 12 weeks reported return to normal ßhCG (beta subunit of human Chorionic Gonadotropin) levels.

Invasive mole of the uterus- a rare case diagnosed by ultrasound: a case report.

Gestational trophoblastic neoplasias (GTN) are rare tumours that constitute less than 1% of all gynecological malignancies. Invasive mole is a distinct subgroup of GTN, which if not diagnosed and treated early, can result in serious complications like uterine perforation and haemoperitoneum. We present a rare case of an invasive mole of the uterus, which developed following the evacuation of a molar pregnancy. It was accurately diagnosed by transvaginal ultrasound and color Doppler, and successfully treated before any major complications could arise.

Ovarian hyperstimulation syndrome in a spontaneous pregnancy with invasive mole: report of a case.

It is known that most cases of Ovarian Hyperstimulation Syndrome (OHSS) are associated with the therapies for ovulation induction. However, OHSS may rarely be associated with a spontaneous ovulatory cycle, usually in the case of multiple gestations, hypothyroidism or polycystic ovary syndrome. We report a case of severe OHSS in spontaneous pregnancy with invasive mole in a 34 years old woman. The clinical picture showed abdominal pain, massive ascites, nausea, dyspnea and amenorrhea. After imaging examinations and laboratory tests, the diagnosis was established. The patient was managed expectantly with no complications. Although spontaneous ovarian hyperstimulation is a rare entity, it is important that the physician recognizes this condition. Prompt diagnosis and successful management is likely to avoid serious complications, which may develop rapidly.

Nephrotic syndrome associated with invasive mole: a case report.

Gestational trophoblastic disease describes a number of gynaecological tumours that originate in the trophoblast layer, including hydatidiform mole (complete or partial), placental site trophoblastic tumour, choriocarcinoma and gestational trophoblastic neoplasia (GTN). Invasive moles are responsible for most cases of localized GTN. Two cases of GTN previously reported in the literature exhibited membranous glomerulonephritis (MGN). However, histologic examinations in our case did not reveal evidence of MGN. Clinical features and pathologic findings were consistent with minimal change disease associated with an invasive mole. In the present case, we observed complete remission of nephrotic syndrome following removal of the invasive mole.

Invasive mole--case report of massive uterine destruction.

Patient with malignant Gestational Trophoblastic Neoplasm (GTN) was treated by mean of MTX-FA, MAC, EMA-CO and EMA-EP. Changes in serum human chorionic gonadotropine (beta hCG) levels and changes in ultrasonographic findings were checked weekly. Finally transabdominal hysterectomy with ovaries conservation was done and polychemotherapy administrated after the operation until three consecutive serum chorionic gonadotropine values were negative. This is a case report of Invasive mole in 32 years old patient without possibility to preserve reproductive health. GTN developed two months after spontaneous abortion in 13th week gestation. No changes in uterine structure were found during the first ultrasonographic examination. Three months after abortion and one month after GTN confirmed, massive destruction of lateral uterine wall was detected during transvaginal Doppler ultrasound examination. Resistance index of 0,366 was significantly lower than normal, with hypervascularisation in affected tissue. Serum beta hCG confirmed poor effect of polychemotherapy treatment and decision for operative treatment was made. Hystological findings after the operation confirmed malignant GTN- invasive mole. Specific changes in ultrasonographic picture could have an impact in therapy making decision and could not be refereed without the most relevant parameter such is serum human chorionic gonadotropine.

Invasive mole: Indonesian perspective.

OBJECTIVE: To share our experiences concerning the characteristics of invasive mole (IM), including transformation and progression, its propensity to perforate, diagnostic and therapeutic procedures and prognosis. STUDY DESIGN: A cross-sectional, descriptive, analytic study, conducted at Hasan Sadikin Hospital, Bandung, Indonesia. RESULTS: There were 27 cases of IM, histologically confirmed. Seventy and three tenths percent were preceded by complete mole, 18.5% by partial mole and 11.2% by uncertain pathology. The average patient age, gravidity, transformation period and uterine size were 34.4 years, 4.4 pregnancies, 2.6 months and 14.3 weeks, respectively. Ultrasound findings in 20 cases were: 9 (45%) diagnosed as IM, 8 (40%) as choriocarcinoma, 2 (10%) as hydatidiform mole and 1 (5%) doubtful. Perforation occurred in 18 (66.7%) cases, 61.1% to the abdominal cavity, 5.5% to the uterine cavity and parametrium, 11.1% to the abdominal and uterine cavity and 16.7% to the abdomen and parametrium. There were 3 deaths, 2 due to perforation to the parametrium and 1 to the abdomen. Two cases developed metastasis, 1 to the vagina and the other to the lungs. Both survived. The surgical intervention rate was 96.3%, with all patients having hysterectomy except for 1 exploratory laparotomy. CONCLUSION: IM should be suspected in multiparous patients with a history of mole and short transformation period. Ultrasound as a diagnostic tool is promising, but still needs further study. The incidence of perforation is high with possibility of death, yet the prognosis remains good provided that the acute period is managed appropriately. The method of follow-up is similar to mole.

[Study on the indication of surgical resection of pulmonary metastasis of malignant trophoblastic tumor].

OBJECTIVE: To investigate the indication of lung lobectomy in patients of malignant trophoblastic tumor with lung metastasis. METHODS: Data on a total of 629 cases of malignant trophoblastic tumor of stage III-IV in Peking Union Medical College Hospital from 1990 to 2003 were reviewed. Ninety-five cases including those that underwent lung lobectomy and cases with normal level of serum human chorionic gonadotropin-beta subunit (beta-hCG, < 2 IU/L) and residual pulmonary nodules after chemotherapy were selected and studied. RESULTS: Lung lobectomies were performed on six cases of invasive mole with lung metastasis and the pathological results were all necrotic nodules;another 35 cases of invasive mole with normal level of serum beta-hCG but residual pulmonary nodules after chemotherapy have been followed up for 6 months to 11 years and all were stable of diseases (SD). Lung lobectomies were performed on 29 cases of choriocarcinoma with lung metastasis. Among them, there were 17 cases whose pathological results were hemorrhage and necrotic tissue without trophoblastic cells (negative pathological results), while trophoblastic cells could still be detected in 12 cases of resected lung specimens (positive pathological results). Twenty-five cases of choriocarcinoma with normal serum beta-hCG but residual pulmonary nodules after chemotherapy were followed up, five cases had progress of disease (PD) and 20 were SD. There were no significant differences of age, stage and the last pregnancy between the positive and negative pathological results, SD and PD groups, respectively. However, the number of chemotherapeutic courses for decreasing beta-hCG from 10 IU/L to 2 IU/L and the total courses in the group of positive pathological results and PD group were significantly more than that of negative pathological results group and SD group (P = 0.01, P = 0.001). CONCLUSIONS: For invasive mole, lung metastasis can be successfully treated by chemotherapy alone. Patients with residual pulmonary nodules but normal serum beta-hCG after chemotherapy can be followed up and spared lung lobectomy. For choriocarcinoma, slowly decreasing of beta-hCG from 10 IU/L to 2 IU/L is a high risk for chemoresistance, and it is an indication for thoracotomy. Progression of disease after multiple chemotherapy courses should be treated with lung lobectomy.

[Evaluation of surgical resection of pulmonary metastasis of trophoblastic tumour].

OBJECTIVE: To evaluate the role of lung lobectomy in the patients of tumor with lung metastases. METHODS: A total of 45 cases of trophoblastic tumor with pulmonary metastases treated by lung lobectomy from 1985-2002 at PUMC hospital was retrospectively analyzed. Seven cases were diagnosed as invasive mole and thirty-eight as choriocarcinoma. RESULTS: Lung lobectomy was performed in all of these patients after several courses of chemotherapy. Seven cases of invasive mole reached complete remission. Eleven cases of choriocarcinoma with stage IIIa had received average 13 courses of chemotherapy, 10 of them reached complete remission. Seventeen cases of choriocarcinoma with stage IIIb had received average 14.3 courses of chemotherapy, 11 of them reached complete remission. Ten cases of choriocarcinoma with stage IV had received average 15 courses of chemotherapy, six of them reached complete remission. In the 45 patients, histologic examination disclosed haemorrhagic necrotic tissue in 27 patients, 17 of them reached complete remission (63%). Histologic examination also revealed fibrosis around the focus in 16 patients, 14 of them reached complete remission (88%). Tuberculosis was found in 2 patients. CONCLUSIONS: Although the development of effective chemotherapy has resulted in improved survival of patients with gestational trophoblastic tumor, lung lobectomy remains an important adjunct treatment in a selected subset of patients. Pathological examinations can help to estimate the prognosis.