Uterine Rescue in High-Risk Gestational Trophoblastic Neoplasia Treated with EMA-CO by Uterine Arteries Embolization due to Arteriovenous Malformations.

Complete hydatidiform mole (CHM) is a rare type of pregnancy, in which 15 to 20% of the cases may develop into gestational trophoblastic neoplasia (GTN). The diagnostic of GTN must be done as early as possible through weekly surveillance of serum hCG after uterine evacuation. We report the case of 23-year-old primigravida, with CHM but without surveillance of hCG after uterine evacuation. Two months later, the patient presented to the emergency with vaginal bleeding and was referred to the Centro de Doenças Trofoblásticas do Hospital São Paulo. She was diagnosed with high risk GTN stage/score III:7 as per The International Federation of Gynecology and Obstetrics/World Health Organization (FIGO/WHO). The sonographic examination revealed enlarged uterus with a heterogeneous mass constituted of multiple large vessels invading and causing disarrangement of the myometrium. The patient evolved with progressive worsening of vaginal bleeding after chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) regimen. She underwent blood transfusion and embolization of uterine arteries due to severe vaginal hemorrhage episodes, with complete control of bleeding. The hCG reached a negative value after the third cycle, and there was a complete regression of the anomalous vascularization of the uterus as well as full recovery of the uterine anatomy. The treatment in a reference center was essential for the appropriate management, especially regarding the uterine arteries embolization trough percutaneous femoral artery puncture, which was crucial to avoid the hysterectomy and allow GTN cure and maintenance of reproductive life.

Mola hidatiforme completa (MHC) é um tipo raro de gravidez, na qual 15 a 20% dos casos podem desenvolver neoplasia trofoblástica gestacional (NTG). O diagnóstico de NTG deve ser feito o mais cedo possível, pelo monitoramento semanal do hCG sérico após esvaziamento uterino. Relatamos o caso de uma paciente primigesta, de 23 anos de idade, com MHC, sem vigilância de hCG após esvaziamento uterino. Dois meses depois, a paciente compareceu na emergência com sangramento vaginal, sendo encaminhada ao Centro de Doenças Trofoblásticas do Hospital São Paulo, onde foi diagnosticada com NTG de alto risco, estádio e score de risco III:7 de acordo com a The International Federation of Gynecology and Obstetrics/Organização Mundial de Saúde (FIGO/OMS). O exame ultrassonográfico revelou útero aumentado com uma massa heterogênea constituída por múltiplos vasos volumosos invadindo e desestruturando o miométrio. A paciente evoluiu com piora progressiva do sangramento vaginal após quimioterapia com o regime etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO). Ela foi submetida a transfusão de sangue e embolização das artérias uterinas devido aos episódios graves de hemorragia vaginal, com completo controle do sangramento. O hCG atingiu valor negativo após o terceiro ciclo, havendo regressão completa da vascularização uterina anômala, assim como recuperação da anatomia uterina. O tratamento em um centro de referência permitiu o manejo adequado, principalmente no que se refere à embolização das artérias uterinas através da punção percutânea da artéria femoral, que foi crucial para evitar a histerectomia, permitindo a cura da NTG e a manutenção da vida reprodutiva.

Uterine rescue in high-risk gestational trophoblastic neoplasia treated with ema-co by uterine arteries embolization due to arteriovenous malformations / Resgate uterino em neoplasia trofoblástica gestacional de alto risco tratada com EMA-CO por embolização de artérias uterinas devido a malformações arteriovenosas

Abstract Complete hydatidiform mole (CHM) is a rare type of pregnancy, in which 15 to 20% of the cases may develop into gestational trophoblastic neoplasia (GTN). The diagnostic of GTN must be done as early as possible through weekly surveillance of serum hCG after uterine evacuation.We report the case of 23-year-old primigravida, with CHM but without surveillance of hCG after uterine evacuation. Two months later, the patient presented to the emergency with vaginal bleeding and was referred to the Centro de Doenças Trofoblásticas do Hospital São Paulo. She was diagnosed with high risk GTN stage/score III:7 as per The International Federation of Gynecology and Obstetrics/World Health Organization (FIGO/WHO). The sonographic examination revealed enlarged uterus with a heterogeneous mass constituted of multiple large vessels invading and causing disarrangement of the myometrium. The patient evolved with progressive worsening of vaginal bleeding after chemotherapy with etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO) regimen. She underwent blood transfusion and embolization of uterine arteries due to severe vaginal hemorrhage episodes, with complete control of bleeding. The hCG reached a negative value after the third cycle, and there was a complete regression of the anomalous vascularization of the uterus as well as full recovery of the uterine anatomy. The treatment in a reference center was essential for the appropriate management, especially regarding the uterine arteries embolization trough percutaneous femoral

Resumo Mola hidatiforme completa (MHC) é um tipo raro de gravidez, na qual 15 a 20% dos casos podem desenvolver neoplasia trofoblástica gestacional (NTG). O diagnóstico de NTG deve ser feito o mais cedo possível, pelo monitoramento semanal do hCG sérico após esvaziamento uterino. Relatamos o caso de uma paciente primigesta, de 23 anos de idade, com MHC, sem vigilância de hCG após esvaziamento uterino. Dois meses depois, a paciente compareceu na emergência com sangramento vaginal, sendo encaminhada ao Centro de Doenças Trofoblásticas do Hospital São Paulo, onde foi diagnosticada com NTG de alto risco, estádio e score de risco III:7 de acordo com a The International Federation of Gynecology and Obstetrics/Organização Mundial de Saúde (FIGO/OMS). O exame ultrassonográfico revelou útero aumentado com uma massa heterogênea constituída pormúltiplos vasos volumosos invadindo e desestruturando o miométrio. A paciente evoluiu com piora progressiva do sangramento vaginal após quimioterapia com o regime etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA-CO). Ela foi submetida a transfusão de sangue e embolização das artérias uterinas devido aos episódios graves de hemorragia vaginal, com completo controle do sangramento. O hCG atingiu valor negativo após o terceiro ciclo, havendo regressão completa da vascularização uterina anômala, assim como recuperação da anatomia uterina. O tratamento em um centro de referência permitiu o manejo adequado, principalmente no que se refere à embolização das artérias uterinas através da punção percutânea da artéria femoral, que foi crucial para evitar a histerectomia, permitindo a cura da NTG e a manutenção da vida reprodutiva.

Tirotoxicosis por enfermedad trofoblástica gestacional: revisión a partir de 3 casos / Thyrotoxicosis due to gestational trophoblastic disease: clinical cases

La enfermedad trofoblástica gestacional (ETG) es una complicación del embarazo poco común. Corresponde a un espectro de lesiones proliferativas del tejido trofoblástico: Mola Hidatiforme (MH) en sus formas parcial y completa, Coriocarcinoma, Tumor Trofoblástico y Tumor Trofoblástico Epiteloide. Los distintos tipos de ETG presentan en común la hipersecreción de gonadotrofina coriónica humana (hCG). La hCG es una hormona glicoproteica con una estructura muy similar a la TSH, por lo cual puede estimular la función tiroidea en condiciones fisiológicas y en algunas condiciones patológicas. La ETG puede cursar con hipertiroidismo, el cual puede variar en intensidad, desde una presentación asintomática con alteración leve de hormonas tiroideas a un cuadro de hipertiroidismo manifiesto. Se presentan 3 casos clínicos de pacientes con ETG, específicamente MH que evolucionaron con tirotoxicosis transitoria. Los casos presentaron un cuadro leve de hipertiroidismo con pocos síntomas asociados. La taquicardia fue el único síntoma en la mayoría de los casos. En todas las pacientes las hormonas tiroideas se normalizaron después del tratamiento de la ETG. Conclusión: Se debe tener presente la posibilidad de hipertiroidismo en toda paciente con ETG. Un alto nivel de sospecha permitirá identificar a aquellas pacientes que cursen con hipertiroidismo, permitiendo así un diagnóstico y tratamiento oportuno.

Gestational trophoblastic disease (GTD) is a rare complication of pregnancy. GTD includes a group of proliferative lesions of trophoblastic tissue: partial and complete hydatidiform mole, choriocarcinoma, epithelioid trophoblastic tumor, and placental site trophoblastic tumor. The different types of GTD have in common the hypersecretion of human chorionic gonadotropin (hCG). HCG is a glycoprotein hormone with a similar structure to TSH. In physiological and pathological conditions hCG can stimulate thyroid function. GTD can present with hyperthyroidism, which can vary in intensity, from an asymptomatic presentation with mild alteration of thyroid hormones to a manifest hyperthyroidism. We present 3 clinical cases of patients with GTD thyrotoxicosis. All cases presented mild hyperthyroidism. Tachycardia was the only symptom in most cases. In all patients thyroid hormones return to normal after treatment of GTD. Conclusion: In patients with GTD the possibility of hyperthyroidism should be kept in mind. A high level of suspicion will allow to identifying patients with hyperthyroidism.

Mola hidatiforme como manifestación ginecobstétrica en el curso de las enfermedades reumáticas / Hydatiform mole as a gynecological manifestation in the course of rheumatic diseases

Las enfermedades reumáticas pertenecen a un grupo que provocan manifestaciones clínicas en varios sistemas de órganos de la anatomía humana. Las complicaciones ginecobstétricas no son las que con mayor frecuencia se presentan. La enfermedad trofoblástica gestacional agrupa un conjunto de lesiones benignas como la mola hidatiforme y la neoplasia trofoblástica gestacional. Este trabajo se propone presentar un caso con los elementos clínicos e imagenológicos que permiten llegar al diagnóstico de una mola hidatiforme. Se trata de una paciente de 48 años de edad, con diagnóstico de lupus eritematoso sistémico, que acude con manifestaciones clínicas que permitieron llegar al diagnóstico de enfermedad trofoblástica gestacional con mola hidatiforme completa. Las enfermedades reumáticas, en especial el lupus eritematoso sistémico, provocan complicaciones ginecobstétricas. La enfermedad trofoblástica gestacional con mola hidatiforme completa, a pesar de ser una rara entidad, afecta considerablemente el bienestar biopsicosocial de las pacientes y disminuye su percepción de calidad de vida relacionada con la salud(AU)

Rheumatic diseases fit in a group that cause clinical manifestations in various organ systems of the human anatomy. Gyneco-obstetric complications are those that occur less frequently. Gestational trophoblastic disease groups together benign lesions such as hydatidiform mole and gestational trophoblastic neoplasia. This paper intends to present a case with the clinical and imaging elements that allow the diagnosis of hydatidiform mole. We present a 48-year-old female patient with a diagnosis of systemic lupus erythematosus, who presents with clinical manifestations that led to the diagnosis of gestational trophoblastic disease with complete hydatidiform mole. Rheumatic diseases, especially systemic lupus erythematosus, cause gyneco-obstetric complications. Although being a rare entity, the gestational trophoblastic disease with complete hydatidiform mole greatly affects the biopsychosocial wellbeing of patients and decreases their perception of health-related quality of life(AU)

Mola hidatiforme como manifestación ginecobstétrica en el curso de las enfermedades reumáticas / Hydatiform mole as a gynecological manifestation in the course of rheumatic diseases

Las enfermedades reumáticas pertenecen a un grupo que provocan manifestaciones clínicas en varios sistemas de órganos de la anatomía humana. Las complicaciones ginecobstétricas no son las que con mayor frecuencia se presentan. La enfermedad trofoblástica gestacional agrupa un conjunto de lesiones benignas como la mola hidatiforme y la neoplasia trofoblástica gestacional. Este trabajo se propone presentar un caso con los elementos clínicos e imagenológicos que permiten llegar al diagnóstico de una mola hidatiforme. Se trata de una paciente de 48 años de edad, con diagnóstico de lupus eritematoso sistémico, que acude con manifestaciones clínicas que permitieron llegar al diagnóstico de enfermedad trofoblástica gestacional con mola hidatiforme completa. Las enfermedades reumáticas, en especial el lupus eritematoso sistémico, provocan complicaciones ginecobstétricas. La enfermedad trofoblástica gestacional con mola hidatiforme completa, a pesar de ser una rara entidad, afecta considerablemente el bienestar biopsicosocial de las pacientes y disminuye su percepción de calidad de vida relacionada con la salud(AU)

Rheumatic diseases fit in a group that cause clinical manifestations in various organ systems of the human anatomy. Gyneco-obstetric complications are those that occur less frequently. Gestational trophoblastic disease groups together benign lesions such as hydatidiform mole and gestational trophoblastic neoplasia. This paper intends to present a case with the clinical and imaging elements that allow the diagnosis of hydatidiform mole. We present a 48-year-old female patient with a diagnosis of systemic lupus erythematosus, who presents with clinical manifestations that led to the diagnosis of gestational trophoblastic disease with complete hydatidiform mole. Rheumatic diseases, especially systemic lupus erythematosus, cause gyneco-obstetric complications. Although being a rare entity, the gestational trophoblastic disease with complete hydatidiform mole greatly affects the biopsychosocial wellbeing of patients and decreases their perception of health-related quality of life(AU)

Eclampsia como manifestación clínica de enfermedad trofoblástica gestacional: reporte de caso / Eclampsia as clinical presentation of gestational trophoblastic disease: case report

Introducción: La eclampsia es una complicación severa y poco frecuente del embarazo, apareciendo generalmente luego de las 34 semanas de edad gestacional. El diagnóstico de preeclampsia antes de las 20 semanas de edad gestacional se asocia con patología del trofoblasto. Presentación del caso: Paciente femenina de 18 años, 3 embarazos, 0 partos, 2 abortos, cursando embarazo de 14 semanas de edad gestacional, consulta por haber presentado síndrome convulsivo con crisis generalizadas de tipo tónico-clónicas y amaurosis posterior. Se sospecha síndrome de hipertensión endocraneana y se solicita resonancia magnética de encéfalo, que muestra múltiples lesiones córtico-subcorticales, sugiriendo síndrome de encefalopatía posterior reversible. Una ecografía obstétrica informa placenta aumentada de tamaño con múltiples imágenes econegativas con aspecto de panal de abeja, oligohidroamnios y feto con latidos positivos, sin anomalías anatómicas. La gonadotrofina coriónica humana fue de 11538440 U/L. Evoluciona con compromiso de conciencia y tres episodios de convulsión generalizada de tipo tónico-clónica con mala respuesta a diazepam y adecuada respuesta a sulfato de magnesio. Se pesquisa crisis hipertensiva y proteinuria de 24 horas de 8 gramos. Se decide interrupción del embarazo y manejo en Unidad de Paciente Crítico. Legrado aspirativo sin incidentes. La biopsia indica mola hidatidiforme parcial con feto sin malformaciones externas. Evolución favorable con negativización de gonadotrofina coriónica humana en controles posteriores. Discusión: El desarrollo de eclampsia antes de las 20 semanas es anecdótico con pocos casos reportados y su aparición debe hacer sospechar una patología del trofoblasto.

Introduction: Preeclampsia is a severe complication of pregnancy, usually appearing after 34 weeks of gestational age. The diagnosis of preeclampsia before 20 weeks of gestational age is associated with trophoblastic disease. Case report: Female patient, 18 years old, 3 pregnancies, 0 deliveries, 2 abortions, 14 weeks pregnant. Presents with generalized tonicclonic seizures and amaurosis. Clinical evaluation compatible with intracranial hypertension síndrome and magnetic resonance imaging of the brain is requested, showing multiple cortico-subcortical lesions, suggesting posterior reversible encephalopathy syndrome. Ultrasound evaluation informs increased size placenta, multiple echo-negativa images with honeycomb disposition, oligohydramnios and present fetal heartbeats. No fetal anatomic abnormalities. Human chorionic gonadotrophin level was 11538440 U/L. Clinical presentation evolves with impaired conscousness and three generalized tonic-clonic crisis, showing poor response to intravenous diazepam and appropriate response to magnesium sulfate. Hypertensive crisis develops and the result of 24 hour proteinuria is 8 grams. Due to mater nal risk pregnancy was interrupted and uterine aspirage was performed. Patient was managed in the Intensive Care Unit. Biopsy informed partial hydatidiform mole and fetus with no anatomical abnormalities. Clinical evolution was positive and human chorionic gonadotrophin level below detection during follow-up. Discussion: Development of eclapsia before 20 weeks of gestational age is anecdotal with few reported cases and could be indicative of gestational trophoblastic disease.

Pregnancy outcomes after chemotherapy for trophoblastic neoplasia.

INTRODUCTION: The successful development of chemotherapy enabled a fertilitysparing treatment for patients with trophoblastic neoplasia. After disease remission, the outcome of a subsequent pregnancy becomes a great concern for these women. OBJECTIVE: To analyze existing studies in the literature that describe the reproductive outcomes of patients with trophoblastic neoplasia treated with chemotherapy. METHOD: Systematic review was performed searching for articles on Medline/ Pubmed, Lilacs and Cochrane Library databases, using the terms "gestational trophoblastic disease" and "pregnancy outcome". RESULTS: A total of 18 articles were included. No evidence of decreased fertility after chemotherapy for trophoblastic neoplasia was observed. The abortion rates in patients who conceived within 6 months after chemotherapy was higher compared to those who waited longer. Some studies showed increased rates of stillbirth and repeat hydatidiform moles. Only one work showed increased congenital abnormalities. CONCLUSION: The pregnancies conceived after chemotherapy for trophoblastic neoplasia should be followed with clinical surveillance due to higher rates of some pregnancy complications. However, studies in the literature provide reassuring data about reproductive outcomes of these patients.

Pregnancy outcomes after chemotherapy for trophoblastic neoplasia / Futuro reprodutivo após tratamento quimioterápico da neoplasia trofoblástica

SUMMARY Introduction The successful development of chemotherapy enabled a fertilitysparing treatment for patients with trophoblastic neoplasia. After disease remission, the outcome of a subsequent pregnancy becomes a great concern for these women. Objective To analyze existing studies in the literature that describe the reproductive outcomes of patients with trophoblastic neoplasia treated with chemotherapy. Method Systematic review was performed searching for articles on Medline/ Pubmed, Lilacs and Cochrane Library databases, using the terms “gestational trophoblastic disease” and “pregnancy outcome”. Results A total of 18 articles were included. No evidence of decreased fertility after chemotherapy for trophoblastic neoplasia was observed. The abortion rates in patients who conceived within 6 months after chemotherapy was higher compared to those who waited longer. Some studies showed increased rates of stillbirth and repeat hydatidiform moles. Only one work showed increased congenital abnormalities. Conclusion The pregnancies conceived after chemotherapy for trophoblastic neoplasia should be followed with clinical surveillance due to higher rates of some pregnancy complications. However, studies in the literature provide reassuring data about reproductive outcomes of these patients.

RESUMO Introdução o sucesso do desenvolvimento da quimioterapia no tratamento da neoplasia trofoblástica proporcionou a possibilidade de conservação da fertilidade das pacientes, tornando o futuro reprodutivo uma nova preocupação após a remissão da doença Objetivo analisar os estudos existentes na literatura que descrevem o futuro reprodutivo de pacientes com neoplasia trofoblástica tratadas com quimioterapia. Método revisão sistemática que buscou artigos nas bases de dados Medline/Pubmed, Lilacs e Biblioteca Cochrane, utilizando as palavras-chave “gestational trophoblastic disease” e “pregnancy outcome”. Resultados foram selecionados 18 artigos de acordo com critérios de inclusão e exclusão. Não foi observada diminuição da fertilidade após a quimioterapia para neoplasia trofoblástica. Pacientes que engravidaram até 6 meses do término da quimioterapia apresentaram maiores taxas de abortamento quando comparadas às que esperaram mais de 6 meses. Alguns artigos encontraram maiores taxas de natimorto e nova mola hidatiforme. Apenas um estudo mostrou aumento da taxa de malformação. Conclusão as gestações subsequentes à neoplasia trofoblástica devem ser acompanhadas com vigilância clínica em decorrência da maior taxa de complicações na gestação, principalmente nas mulheres que engravidam até 6 meses após o término da quimioterapia. No entanto, os dados encontrados nos estudos tranquilizam quanto ao futuro reprodutivo dessas pacientes.

Mola invasiva / Invasive mole

La mola invasiva es poco frecuente y se caracteriza por la excesiva proliferación trofoblástica y penetración del trofoblasto dentro del miometrio, pero sin tendencia hacia la diseminación metastásica. El objetivo del trabajo es presentar un caso diagnosticado de neoplasia trofoblástica gestacional, tipo mola invasiva. Se realizaron estudios complementarios como: ecografía transabdominal, determinaciones de la fracción beta de la gonadotropina coriónica humana y una biopsia endometrial por legrado uterino. El resultado fue embarazo molar. Al ingreso le fue administrado metotrexato sistémico 25 mg intramuscular y ácido folínico un ámpula intramuscular de 15 mg diariamente, ambos durante cinco días. Posteriormente, a los 20 días se realizó histerectomía total abdominal sin anexectomía. La evolución clínica fue por consulta externa. Además, se realizó: radiografía de tórax, ultrasonografía de pelvis, dosificación de gonadotropina coriónica humana en su fracción beta, hemograma completo, tiempo de coagulación, sangramiento y transaminasa glutámico pirúvica evolutivas. En el manejo de la mola invasiva el tratamiento médico combinado con el quirúrgico fue efectivo y bien tolerado por la paciente(AU)

Invasive mole is an infrequent condition characterized by excessive trophoblastic proliferation and trophoblast penetration into the myometrium, without a tendency to metastatic dissemination. The purpose of the study is to present a case diagnosed with gestational trophoblastic neoplasia of the invasive mole type. The following complementary tests were performed: transabdominal echography, human chorionic gonadotropin beta subunit determinations, and endometrial biopsy by uterine curettage. The result was molar pregnancy. Upon admission the patient was administered systemic methotrexate 25 mg intramuscularly, as well as an intramuscular ampoule of folinic acid 15 mg daily, both during five days. Total abdominal hysterectomy without anexectomy was performed 20 days later. Clinical evolution was followed up on an outpatient basis. The following tests were also performed: chest radiography, pelvic ultrasonography, human chorionic gonadotropin beta dosage, complete blood count, clotting time, bleeding and evolutive glutamic-pyruvic transaminase. During management of the invasive mole, the combination of clinical and surgical treatments proved effective and was well assimilated by the patient(AU)

Caracterización clínica de la enfermedad trofoblástica gestacional, Hospital Ginecobstétrico Ramón González Coro (2008-2012) / Clinical characterization of gestational trophoblastic disease in Ramón González Coro obstetric and gynaecological hospital in the 2008-2012 period

Introducción: numerosas investigaciones han estudiado la enfermedad trofoblástica gestacional, haciendo énfasis en la importancia de su diagnóstico y tratamiento precoz. Se indaga en sus características para disminuir las tasas de incidencia, recaídas y/o complicaciones. Objetivo: se propone determinar el comportamiento clínico de pacientes con Enfermedad trofoblástica gestacional. Métodos: se efectuó un estudio observacional descriptivo transversal, en el Hospital Ginecobstétrico Ramón González Coro. Se trabajó una muestra de 18 historias clínicas de pacientes diagnosticadas o con sospecha de la enfermedad trofoblástica gestacional, de cualquier edad y color de piel, dentro del universo de todas las pacientes atendidas en el periodo 2008-2012. Resultados: predominó como motivo de ingreso el sangramiento vaginal, y al examen físico el principal signo fue la salida de sangre por el orificio cervical externo. La mayoría de los casos obtenidos el 83,4 por ciento fueron pacientes con más de 24 años. Casi el total de la muestra un 94 por ciento presentó un útero aumentado de tamaño. En este estudio más de la mitad de los casos el 83 por ciento fueron por mola hidatiforme parcial. Conclusiones: este estudio caracteriza el comportamiento clínico de pacientes con Trofoblástica gestacional. Los resultados coinciden con lo observado en otros estudios analizados como apoyo para la valoración y discusión de los resultados. Esta dolencia se caracteriza por presentarse en mujeres mayores de 24 años, sin distinción en cuanto al color de la piel; los signos más significativos al examen ginecológico son el sangramiento vaginal y la salida de sangre por el orificio cervical externo(AU)

Introduction: numerous research works have studied gestational trophoblastic disease; making emphasis on the importance of early diagnosis and treatment and have dealt with its characteristics in order to reduce incidence, relapse and/or complication rates Objective: to determine the clinical behavior of patients with gestational trophoblastic disease. Methods: observational descriptive and cross-sectional study was conducted in Ramón González Coro in obstetric and gynecological hospital. The sample was made up of 18 medical records of patients diagnosed with or suspected of gestational trophoblastic disease, regardless of their age and race, within the universe of all patients seen in the period of 2008 through 2012. Results: the main reasons for admission to hospital were vaginal bleeding, and the main sign in physical examination was blood outflow through the external cervical orifice. Most cases (83.4 percent) were over 24 years-old. Almost all the patients (94 percent) presented with augmented uterus. In this study, 83 percent of cases were caused byr partial hydatid form mole. Conclusions: this study characterizes the clinical behavior of patients with gestational trophoblastic disease. The results are consistent with those observed in other studies as a support for evaluation and discussion of the results. This condition is characterized by occurring in women over 24 years of age, regardless of race, and its most significant signs on gynecological examination are vaginal bleeding and blood outflow from the external os(AU)

Caracterización clínica de la enfermedad trofoblástica gestacional, Hospital Ginecobstétrico Ramón González Coro (2008-2012) / Clinical characterization of gestational trophoblastic disease in Ramón González Coro obstetric and gynaecological hospital in the 2008-2012 period

Introducción: numerosas investigaciones han estudiado la enfermedad trofoblástica gestacional, haciendo énfasis en la importancia de su diagnóstico y tratamiento precoz. Se indaga en sus características para disminuir las tasas de incidencia, recaídas y/o complicaciones. Objetivo: se propone determinar el comportamiento clínico de pacientes con Enfermedad trofoblástica gestacional. Métodos: se efectuó un estudio observacional descriptivo transversal, en el Hospital Ginecobstétrico Ramón González Coro. Se trabajó una muestra de 18 historias clínicas de pacientes diagnosticadas o con sospecha de la enfermedad trofoblástica gestacional, de cualquier edad y color de piel, dentro del universo de todas las pacientes atendidas en el periodo 2008-2012. Resultados: predominó como motivo de ingreso el sangramiento vaginal, y al examen físico el principal signo fue la salida de sangre por el orificio cervical externo. La mayoría de los casos obtenidos el 83,4 por ciento fueron pacientes con más de 24 años. Casi el total de la muestra un 94 por ciento presentó un útero aumentado de tamaño. En este estudio más de la mitad de los casos el 83 por ciento fueron por mola hidatiforme parcial. Conclusiones: este estudio caracteriza el comportamiento clínico de pacientes con Trofoblástica gestacional. Los resultados coinciden con lo observado en otros estudios analizados como apoyo para la valoración y discusión de los resultados. Esta dolencia se caracteriza por presentarse en mujeres mayores de 24 años, sin distinción en cuanto al color de la piel; los signos más significativos al examen ginecológico son el sangramiento vaginal y la salida de sangre por el orificio cervical externo(AU)

Introduction: numerous research works have studied gestational trophoblastic disease; making emphasis on the importance of early diagnosis and treatment and have dealt with its characteristics in order to reduce incidence, relapse and/or complication rates Objective: to determine the clinical behavior of patients with gestational trophoblastic disease. Methods: observational descriptive and cross-sectional study was conducted in Ramón González Coro in obstetric and gynecological hospital. The sample was made up of 18 medical records of patients diagnosed with or suspected of gestational trophoblastic disease, regardless of their age and race, within the universe of all patients seen in the period of 2008 through 2012. Results: the main reasons for admission to hospital were vaginal bleeding, and the main sign in physical examination was blood outflow through the external cervical orifice. Most cases (83.4 percent) were over 24 years-old. Almost all the patients (94 percent) presented with augmented uterus. In this study, 83 percent of cases were caused byr partial hydatid form mole. Conclusions: this study characterizes the clinical behavior of patients with gestational trophoblastic disease. The results are consistent with those observed in other studies as a support for evaluation and discussion of the results. This condition is characterized by occurring in women over 24 years of age, regardless of race, and its most significant signs on gynecological examination are vaginal bleeding and blood outflow from the external os(AU)

Impacto da ingestão dietética e do estresse oxidativo em pacientes com doença trofoblástica gestacional / Impact of dietary intake and oxidative stress in patients with gestational trophoblastic disease

A doença trofoblástica gestacional (DTG) é um termo aplicado a um grupo de tumores relacionados à gestação, caracterizando formas benignas (mola hidatiforme - MH) e malignas (neoplasia trofoblástica gestacional - NTG). O estresse oxidativo, a ingestão dietética e o estado nutricional da gestante constituem possíveis fatores de risco para a ocorrência da MH e sua progressão para NTG. A presente revisão tem como objetivo abordar a relação entre essas entidades. Apesar de haver evidências mostrando que a ingestão dietética e o estresse oxidativo possam ter papéis relevantes na etiopatogênese da DTG, ainda são necessários muitos estudos para uma melhor investigação da atuação desses agentes na gravidez molar e suas sequelas malignas e proliferativas.(AU)

The gestational trophoblastic disease (GTD) is a term applied to a rare group of pregnancy related tumors of benign forms (hydatidiform mole - HM) as well as malignant ones (gestational trophoblastic neoplasia - GTN). Oxidative stress, dietetic intake and nutritional status of pregnant women are possible risk factors for the occurrence of HM and its progression to GTN. This review aims to address the relationship between these entities. Besides the evidences supporting that dietetic intake and oxidative stress may have important roles in the GTD etiopathogenesis, many studies are needed to better investigate the role of these agents in molar pregnancy and their proliferative and malignant sequelae.(AU)

Gestação gemelar com mola hidatiforme completa e feto vivo após ovodoação e fertilização in vitro: relato de caso / Twin pregnancy with a complete hydatiform mole and a live fetus following egg donation and in-vitro fertilization: case report

Introdução: a gestação gemelar com mola hidatiforme completa e feto vivo é um evento raro e tem, na maior parte dos casos, evolução para aborto ou interrupção médica por causa dos riscos para a mãe e para o feto. Quando associada à reprodução assistida, a decisão de finalização é mais difícil por causa do desejo do casal em manter a gestação. Método: este artigo apresenta um caso de gestação gemelar dizigótica com mola hidatiforme completa em coexistência com feto diploide e placenta normal em uma paciente de 45 anos após fertilização in vitro por ovodoação. Resultados: paciente optou por manter a gestação e o parto ocorreu com 29 semanas, sem complicações maternas. Recém-nascido evoluiu com bom desenvolvimento neuropsicomotor, sem sequelas. Conclusão: este relato de caso ilustra a possibilidade de conduta expectante, porém não podemos ignorar o fato de que existe um alto risco de permanência da doença trofoblástica gestacional. Infelizmente, a raridade do caso torna o manejo clínico ainda controverso.

Introduction: twin pregnancy with complete hydatiform mole and live fetus is a rare event with the most cases resulting in abortion or medical interruption due to maternal and fetal risks. When associated with assisted reproduction, the decision of pregnancy interruption is more difficult due to the desire of the couple to maintain the pregnancy. Method: this study will present a case of twin dizygotic pregnancy with complete hydatiform mole coexisting with fetus diploid and normal placenta in a patient 45 years old, after in-vitro fertilization by egg donation. Results: patient chose to keep the pregnancy and the delivery occurred at 29 weeks without major maternal complications. Newborn evolved with good psychomotor developmentwithout sequelae. Conclusion: this case report illustrates the possibility of expectant management, but wecannot ignore the fact that there is a high risk of persistent gestational trophoblastic disease. Unfortunately, the rarity of the case makes the clinical management still controversial.

Thyrotoxic crisis associated with gestational trophoblastic disease.

BACKGROUND AND OBJECTIVES: Human chorionic gonadotropin (HCG) and thyrotrophic hormone (TSH) have analogies in their structures, as well as in their receptors. The high levels of HCG seen in gestational trophoblastic diseases may induce secondary hyperthyroidism. The objective of this report was to present a case in which the administration of iodinated contrast triggered a thyrotoxic crisis. CASE REPORT: Patient with complete hydatidiform mole who was admitted to the operating room with severe vaginal bleeding after a tomographic exam with iodinated contrast. During anesthetic induction, the patient presented symptoms compatible with thyrotoxic crisis. CONCLUSIONS: The incidence of severe presentations associated with gestational trophoblastic disease tends to decrease with early diagnosis. Still, the anesthesiologist should be aware of the possibility of those patients developing thyrotoxic crisis.

Maternal and perinatal outcomes of first pregnancy after chemotherapy for gestational trophoblastic neoplasia in Brazilian women.

OBJECTIVE: To evaluate maternal and perinatal outcomes of first pregnancy after chemotherapy for gestational trophoblastic neoplasia (GTN) in Brazilian patients. METHODS: This study included 252 subsequent pregnancies after chemotherapy for GTN treated between 1960-2005. Correlations of maternal and perinatal outcomes with chemotherapy regimen (single or multiagent) and the time interval between chemotherapy completion and first subsequent pregnancy were investigated. RESULTS: There was a significant increase in adverse maternal outcomes in women who conceived <6 months than 6-12 months (76.2% and 19.6%; p<0.0001; OR=13.12; CI 95%=3.87-44.40) and >12 months (76.2% and 21.7%; p<0.0001; OR=11.56; CI 95%=3.98-33.55) after chemotherapy. Spontaneous abortion frequency was higher <6 months (71.4%) than 6-12 months (17.6%; p<0.0001; OR=11.66; CI 95%=3.55-38.22) and >12 months (9.4%; p<0.0001; OR=23.97; CI 95%=8.21-69.91) after chemotherapy. There was no difference in adverse perinatal outcomes (stillbirth, fetal malformation, and preterm birth) related to the interval after chemotherapy and subsequent pregnancy. The overall occurrence of adverse maternal and perinatal outcomes did not significantly differ between patients on single or multiagent regimens. CONCLUSION: Adverse maternal outcomes and spontaneous abortion were more frequent among patients who conceived within 6 months of chemotherapy completion. In these cases, careful prenatal monitoring and hCG level measurement 6 weeks after the completion of any new pregnancy are recommended.