Surveillance for gestational trophoblastic neoplasia following molar pregnancy: a cost-effectiveness analysis.

BACKGROUND: Historically, published guidelines for care after molar pregnancy recommended monitoring human chorionic gonadotropin levels for the development of gestational trophoblastic neoplasia until normal and then for 6 months after the first normal human chorionic gonadotropin. However, there are little data underlying such recommendations, and recent evidence has demonstrated that gestational trophoblastic neoplasia diagnosis after human chorionic gonadotropin normalization is rare. OBJECTIVE: We sought to estimate the cost-effectiveness of alternative strategies for surveillance for gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after complete and partial molar pregnancy. STUDY DESIGN: A Markov-based cost-effectiveness model, using monthly cycles and terminating after 36 months/cycles, was constructed to compare alternative strategies for asymptomatic human chorionic gonadotropin surveillance after the first normal (none; monthly testing for 1, 3, 6, and 12 months; or every 3-month testing for 3, 6, and 12 months) for both complete and partial molar pregnancy. The risk of reduced surveillance was modeled by increasing the probability of high-risk disease at diagnosis. Probabilities, costs, and utilities were estimated from peer-reviewed literature, with all cost data applicable to the United States and adjusted to 2020 US dollars. The primary outcome was cost per quality-adjusted life year ($/quality-adjusted life year) with a $100,000/quality-adjusted life year willingness-to-pay threshold. RESULTS: Under base-case assumptions, we found no further surveillance after the first normal human chorionic gonadotropin to be the dominant strategy from both the healthcare system and societal perspectives, for both complete and partial molar pregnancy. After complete mole, this strategy had the lowest average cost (healthcare system, $144 vs maximum $283; societal, $152 vs maximum $443) and highest effectiveness (2.711 vs minimum 2.682 quality-adjusted life years). This strategy led to a slightly higher rate of death from gestational trophoblastic neoplasia (0.013% vs minimum 0.009%), although with high costs per gestational trophoblastic neoplasia death avoided (range, $214,000 to >$4 million). Societal perspective costs of lost wages had a greater impact on frequent surveillance costs than rare gestational trophoblastic neoplasia treatment costs, and no further surveillance was more favorable from this perspective in otherwise identical analyses. No further surveillance remained dominant or preferred with incremental cost-effectiveness ratio of <$100,000 in all analyses for partial mole, and most sensitivity analyses for complete mole. Under the assumption of no disutility from surveillance, surveillance strategies were more effective (by quality-adjusted life year) than no further surveillance, and a single human chorionic gonadotropin test at 3 months was found to be cost-effective after complete mole with incremental cost-effectiveness ratio of $53,261 from the healthcare perspective, but not from the societal perspective (incremental cost-effectiveness ratio, $288,783). CONCLUSION: Largely owing to the rare incidence of gestational trophoblastic neoplasia after human chorionic gonadotropin normalization after molar pregnancy, prolonged surveillance is not cost-effective under most assumptions. It would be reasonable to reduce, and potentially eliminate, current recommendations for surveillance after human chorionic gonadotropin normalization after molar pregnancy, particularly among partial moles. With any reduction in surveillance, patients should be counseled on symptoms of gestational trophoblastic neoplasia and established in routine gynecologic care.

The management of hydatidiform mole using prophylactic chemotherapy and hysterectomy for high-risk patients decreased the incidence of gestational trophoblastic neoplasia in Vietnam: a retrospective observational study.

The management of hydatidiform mole (HM) and the incidence of post-molar gestational trophoblastic neoplasia (GTN) in Vietnam has not been reported to date. This study aimed to study the incidence of HM and post-molar GTN and identify factors associated with post-molar GTN at a tertiary hospital in Vietnam. Five hundred and eighty-four patients who were treated for HM at Tu Du Hospital between January and December 2010 were included in this study. The mean age and gestational age at the first evacuation were 28.8 years old and 11.0 weeks, respectively. After the initial evacuation and pathological examination, 87 patients who were older than 40 or did not wish to have children underwent a hysterectomy, while the others underwent second curettage. All 472 patients who had human chorionic gonadotropin (hCG) ≥ 100,000 IU/L before treatment received one cycle of methotrexate with folinic acid as prophylactic chemotherapy. The incidence of HM was 11.1 per 1,000 deliveries; 47 patients (8.0%) developed post-molar GTN. Gestational week, hCG level at one week after the first evacuation, and pathological remnants were significantly associated with the development of post-molar GTN. The results of this study suggest that prophylactic chemotherapy and hysterectomy may be useful for high-risk HM patients to reduce post-molar GTN in settings in which the risk of post-molar GTN and loss to follow-up after HM are greater and hCG measurements and appropriate GTN treatments are unavailable. However, future studies on the long-term outcomes and side effects of prophylactic therapies on HM are required.

The incidence, pattern and management outcomes of early pregnancy losses at the Ebonyi State University Teaching Hospital, Abakaliki.

BACKGROUND: Early pregnancy losses are a source of deep emotional trauma to any woman, her family and the attttending Gynaecologist. This study evaluated the prelence, pattern and management outcomes of such losses at a tertiary Health Institution. METHODS: Data of all women who suffered early pregnancy losses between 1st January, 2002 and 31st December, 2004, were reviewed in a descriptive study. Information obtained from their case notes which related to the early pregnancy event, their socio demographics, obstetric history and management outcomes were collated. Univariate analysis was performed and frequency tables and figures were constructed where appropriate. RESULTS: Early pregnancy losses comprised miscarriages, molar pregnancy and ectopic gestations accounted for 32.1% of all gynaecological admissions during the period. Miscarriages were the commonest diagnosis and incomplete abortion constituted the bulk of this. Women of all parities were involved but rate of loss increased down the socio economic class strata. Majority were unbooked. A maternal mortality rate of 1.8% attended all forms of early pregnancy losses during the period. CONCLUSION: Early pregnancy loss constitutes a major gynaecological problem in our centre. Health care providers must institute prompt and appropriate clinical management for a good clinical outcome.

Mola hidatiforme. Aspectos clínicos, incidencia y factores de riesgo / Hydatiform mole: clinical aspects, incidence and risk factors

Del 1o. de septiembre de 1992 al 31 de agosto de 1994 se estudiaron 35 pacientes con embarazo molar comparándolas con 70 pacientes con parto normal atendidas en el Hospital General de Zona 1 del IMSS de San Luis Potosí con el objeto de establecer la incidencia del embarazo molar, conocer los factores de riesgo y estudiar los aspectos clínicos del mismo. La incidencia encontrada fue del 1 embarazo molar por cada 415 partos; 22.85 por ciento de las pacientes con mola fueron de condición socioeconómica baja en contra de 8.57 por ciento del grupo testigo, sugiriendo que dicha condición es un factor de riesgo. La edad promedio fue de 26.28 años en las pacientes con mola y de 26.42 años en el grupo testigo. No hubo diferencias en el número de primigestas en ambos grupos: 17.14 por ciento contra 18.57 por ciento en el grupo. Los síntomas y signos predominantes fueron; sangrado, expulsión de vesículas, náuseas y vómitos. En todas ellas se efectuaron legrados uterinos, cuatro requirieron transfusión sanguínea, una ameritó un legrado sobsecuente, no hubo ninguna muerte. Se concluye que la incidencia es similar a informes de otros autores nacionales, el nivel socioeconómico bajo es un factor de riesgo para la aparición de esta enfermedad y se requiere de un diagnóstico temprano para evitar complicaciones

The epidemiology and management of patients with hydatidiform mole.

The epidemiology, clinical features and method of evacuating the uterus were reviewed in 30 patients with hydatidiform mole. The incidence was greatest in patients with blood group O and among young East Indians. There was no seasonal variation nor was there any progression to choriocarcinoma. Only one partial mole and one invasive mole were encountered. Evacuation was achieved chiefly by suction curettage and concomitant augmentation with a Syntocinon infusion.

The epidemiology and management of patients with hydatidiform mole

The epidemiology, clinical features and method of evacuating the uterus were reviewed in 30 patients with hydatidiform mole. The incidence was greatest in patients with blood group O and among young East Indians. There was no seasonal variation nor was there any progression to choriocarcinoma. Only one partial mole and one invasive mole were encountered. Evacuation was achieved chiefly by suction curettage and concomitant augmentation with a Syntocinon infusion