Gestational trophoblastic neoplasia with pulmonary embolism mimicking tuberculosis.

Gestational trophoblastic neoplasia (GTN) comprises a group of human neoplastic diseases that derive from fetal trophoblastic tissues. They are proliferative as well as degenerative disorders of placental elements and include complete hydatidiform mole (CHM) or partial hydatidiform mole (PHM) (90%), invasive mole (IM) (5-8%), which could also be metastatic, villous, or villous choriocarcinoma (CC) (1-2%), and placental site trophoblastic tumor (PSTT) (1-2%). We present three cases of GTN, two mimicking tuberculosis radiologically, and all three are associated with pulmonary embolism.

Rhabdomyosarcoma in Adults: De Novo or Conversion From Non-seminomas?

Rhabdomyosarcoma (RMS) is a highly sporadic, very aggressive, and fatal soft tissue tumor in adults. Although more common and treatable in the pediatric population, the occurrence of pleomorphic RMS in adults has a low incidence. Hence, it is not easy to treat. Surgery is the primary definitive treatment, along with radiation therapy, while adjuvant chemotherapy has recently gained popularity. We present an infrequent case of RMS in a patient with a recent history of mixed non-seminomatous germ-cell tumor testicular cancer. Therefore, it was challenging to treat the RMS as a new malignancy or as a recurrence of non-seminomatous testicular cancer. Our patient passed away, unfortunately, but we hope this case can help the minimal data in this regard in order to save more lives in the future.

Beta-human chorionic gonadotrophin point of care testing for the management of pregnancy of unknown location.

RESEARCH QUESTION: Does a commercially available quantitative beta-human chorionic gonadotrophin (BHCG) point of care testing (POCT) device improve workflow management in early pregnancy by performing comparably to gold standard laboratory methods, and is the performance of a validated pregnancy of unknown location (PUL) triage strategy maintained using POCT BHCG results? DESIGN: Women classified with a PUL between 2018 and 2021 at three early pregnancy units were included. The linear relationship of untreated whole-blood POCT and serum laboratory BHCG values was defined using coefficients and regression. Paired serial BHCG values were then incorporated into the validated M6 multinomial logistic regression model to stratify the PUL as at high risk or at low risk of clinical complications. The sensitivity and negative predictive value were assessed. The timings required for equivocal POCT and laboratory care pathways were compared. RESULTS: A total of 462 PUL were included. The discrepancy between 571 laboratory and POCT BHCG values was -5.2% (-6.2 IU/l), with a correlation coefficient of 0.96. The 133 PUL with paired 0 and 48 h BHCG values were compared using the M6 model. The sensitivity for high-risk outcomes (96.2%) and negative predictive values (98.5%) was excellent for both. Sample receipt and laboratory processing took 135 min (421 timings), compared with 12 min (91 timings) when using POCT (P < 0.0001). CONCLUSIONS: POCT BHCG values correlated well with laboratory testing measurements. The M6 model retained its performance when using POCT BHCG values. Using the model with POCT may improve workflow and patient care without compromising on effective PUL triage.

Carcinoembryonic Antigen, Carbohydrate Antigen 19-9, Cancer Antigen 125, Prostate-Specific Antigen and Other Cancer Markers: A Primer on Commonly Used Cancer Markers.

Cancer markers are molecules produced by cancer cells which may serve to identify the presence of cancer. Cancer markers can be differentiated as serum-based, radiology-based and tissue-based, and are one of the most important tools in diagnosing, staging and monitoring of treatment of many cancers. The most used cancer markers are serum cancer markers due to its relative ease and lower cost of testing. However, serum cancer markers have poor mass screening utilization due to poor positive predictive value. Several markers such as prostate-specific antigen (PSA), beta-human chorionic gonadotropin (B-hCG), alpha-fetoprotein (AFP), and lactate dehydrogenase (LDH) are used to aid in diagnosis of cancer in cases of high suspicion. Serum markers such as carcinoembryonic antigen (CEA), AFP, carbohydrate antigen 19-9 (CA 19-9), and 5-hydroxyindoleacetic acid (5-HIAA) play a significant role in assessing disease prognosis as well as response to treatment. This work reviews the role of some of the biomarkers in the diagnosis and treatment of cancer.

Interstitial ectopic pregnancy rupture at 17 weeks of gestation: A case report and literature review.

Interstitial pregnancy is a rare type of ectopic pregnancy that commonly results in uterine rupture and life-threatening haemorrhage. Interstitial ectopic pregnancies are associated with a 2-5% mortality rate and a high risk of uterine rupture before 12 weeks of gestation when compared to tubal pregnancy. Due to the thickness and distensibility of the interstitial segment of the Fallopian tube, ectopic pregnancy in this location attains a considerable size before complications arise. Unfortunately, this clinical entity may prove to be a diagnostic challenge, leading to delays in treatment and significant morbidity and mortality in women of reproductive age. Herein, we report a case of a ruptured interstitial ectopic pregnancy occurring at 17 weeks of gestation that was successfully managed with surgical intervention, after proving to be a diagnostic challenge.

Metastatic choriocarcinoma with hemorrhagic complications and spontaneous ovarian hyperstimulation syndrome: A case report.

Gestational choriocarcinoma is a malignant trophoblastic tumor arising from any gestational event, even with a long latency period, generally in the reproductive female. It is associated with a high level of beta-human chorionic gonadotropin. Its primary site is usually the uterus but not all patients have a detectable lesion in this site. Regression of the primary tumor after it has metastasized is not uncommon, and one-third of cases manifest as complications of metastatic disease. In this report we present an uncommon case of gestational choriocarcinoma with lung, liver and jejunal metastases at the time of diagnosis without evidence of pelvic disease, in 34-year-old woman. The main points of interest of our case were the development of the ovarian hyperstimulation syndrome with massive multicystic ovarian enlargement induced by high level of beta-human chorionic gonadotropin and the bleeding of jejunal and liver metastases, due to the high vascularity of the tumor tissue, a condition known as "Choriocarcinoma Syndrome". We will focus on the radiological findings of metastases, bleeding complications and ovarian hyperstimulation syndrome.

The Management of Scar Ectopic: A Single-Center Experience.

PURPOSE: This study aimed to highlight the clinical features, diagnosis, and different modalities of the treatment of cesarean scar pregnancy (CSP). METHODS:  This study was done in the tertiary referral hospital of India for one year. A total of 11 cases were enrolled prospectively. In each case, the diagnostic ultrasonography and measurement of baseline beta-human chorionic gonadotropin (ß-HCG) levels were done. The treatment was given based on the hemodynamic status of the patient and desire for future fertility. Various treatment modalities used were medical, surgical, or interventional digital subtraction angiography to control hemorrhage. Also, in some cases, ultrasound-guided methotrexate was injected into the scar ectopic. Medically treated cases were followed up until their ß-HCG levels became normal. RESULTS: Out of 11 patients, six had a history of two cesarean sections in the past, four patients had a history of one cesarean section and one patient with a previous three low segments cesarean section (LSCS). Seven out of 11 patients underwent medical management with either methotrexate with potassium chloride (KCl) or methotrexate alone. The success of the medical management was monitored by serial ß- HCG values. The mean time for the resolution of these 10 patients was 86.7 ± 53.6 days. Three patients underwent emergency uterine artery embolization due to uncontrolled bleeding and one patient required laparotomy. CONCLUSION: CSP is a life-threatening condition that can be diagnosed with the help of transvaginal ultrasonography. The treatment, however, depends on the hemodynamic status of the patient and desire for future fertility. Well-defined diagnostic criteria coupled with structured management and follow-up protocol can help in treating this challenging form of ectopic pregnancy.

First-trimester serum biomarker screening for fetal Down syndrome as a predictor of preterm delivery: a population-based study.

Objective: To examine the relationship between the first-trimester serum biomarker levels (pregnancy-associated plasma protein A:PAPP-A; and free beta-human chorionic gonadotropin: b-hCG) and preterm birth; and to create the predictive models for preterm birth in case of strong correlation.Methods: Secondary analysis on a large prospective database of singleton pregnancies undergoing first-trimester serum screening with complete follow-up for pregnancy outcomes. The multiples of medians (MoM) of the biomarkers were compared between the group of term and preterm/early preterm birth. Predictive models were developed based on adjusted MoMs and logistic regression analysis, and then diagnostic performances in predicting preterm birth were assessed.Results: Of 24,611 pregnancies eligible for analysis, 1908 (7.8%) and 500 (2.0%) had preterm and early preterm birth, respectively. Medians MoMs of both biomarkers were significantly lower in preterm and early preterm birth group. The predictive models were constructed. Performance in predicting preterm birth of these models yielded the area-under-ROC-curve of 0.560, 0.652, and 0.653 for b-hCG, PAPP-A, and combined biomarkers, respectively. In predicting early preterm birth, the areas-under-the-curve were found to be 0.551, 0.675, and 0.674 for b-hCG, PAPP-A, and combined biomarkers, respectively.Conclusion: The routine first-trimester serum screening of fetal Down syndrome could also be used as a tool of risk identification of preterm birth. We could take advantage of the screening by incorporating the predictive models into the Down syndrome screening software to report the preterm risk in the same test without extra effort and extra cost.

A five-year review of the clinicopathologic profile of patients with hydatidiform mole at the Philippine General Hospital / Philippine Journal of Obstetrics and Gynecology

Background@#The clinical presentation of patients with hydatidiform mole have changed in recent years due to earlier diagnosis as a result of widespread use of ultrasonography and availability of assays for human chorionic gonadotrophin.@*Objective@#To determine the clinicopathologic profile of patients diagnosed with hydatidiform mole at the Philippine General Hospital from January 2013 to August 2018.@*Methods@#This retrospective cross-sectional study included all patients with histologically confirmed diagnosis of hydatidiform mole managed at the Philippine General Hospital from January 2013 to August 2018. Medical records of patients were retrieved. All abstracted variables were analyzed retrospectively. The level of significance for all sets of analysis was set at p-value < 0.05 using two-tailed comparisons.@*Results@#From January 2013 to August 2018, a total of 435 patients diagnosed with hydatidiform mole were managed at the Philippine General Hospital with a prevalence rate of 15.7/1,000 pregnancies. Diagnosis was made in the first trimester in 52% of patients. A quarter of the patients had pre-evacuation B-hCG levels of more than 1 million mIU/mL. Vaginal bleeding was the most frequent presenting symptom but only 59% of the patients had anemia requiring blood transfusion. Majority (90.57%) had a histopathologic diagnosis of complete hydatidiform mole.@*Conclusion@#The prevalence and clinicopathologic profile of patients with hydatidiform mole in the Philippine General Hospital have remained largely unchanged.

Various BhCG monitoring protocols for predicting the success of single-dose methotrexate in the treatment of ectopic pregnancy.

We investigated various monitoring protocols on the success of methotrexate therapy in patients with tubal ectopic pregnancy. The data from patients who received single-dose methotrexate therapy as their first-line treatment was reviewed. The Beta-human chorionic gonadotropin (BhCG) days 1-4 and days 1-7 follow-up protocols were compared with the BhCG day 4-7 follow-up protocol, in terms of the treatment. Cut-off values were determined for the reduction of BhCG between the days 1-4 and days 1-7. There were no significant differences between the groups in terms of the demographic data, except for BhCG fourth- and seventh-day values. There was a 21% decrease in BhCG between days 1 and 4 and a 32% decrease for BhCG between days 1 and 7 as good predictors for treatment success. These follow-up protocols allow earlier and more cost-effective methods than the protocol based on a 15% reduction in BhCG levels between days 4 and 7. Impact statement What is already known on this subject? A decrease of 15% BhCG levels between days 4 and 7 is a common protocol for predicting the success of a single-dose methotrexate therapy of an ectopic pregnancy. What do the results of this study add? This clinical study offers the cut-off values for the various BhCG follow-up protocols recently found in the literature for single-dose methotrexate therapy for the treatment of ectopic pregnancy. What are the implications of these findings for clinical practice and/or further research? We identified the importance of fourth-day BhCG for measuring the success of single-dose methotrexate therapy. Therefore, after randomised, multicentre, prospective clinical trials, the most common follow-up protocol can be changed to a single-dose methotrexate therapy for ectopic pregnancy.

Effects of fetal gender and low first trimester aneuploidy screening markers on preterm birth.

OBJECTIVE: To show the relation between fetal gender and preterm birth (PTB) in low values of first trimester aneuploidy test markers. MATERIAL AND METHOD: A total of 29,528 patients included the study of them 7382 was PTB and all patients grouped according to fetal gender. Demographic data and perinatal complications were determined. According low PAPP-A MoM (<0.4) and low free BhCG MoM (<0.5) values PTB subgroup relative risks were calculated for each fetal gender. RESULTS: The PTB rate and birth weight was significantly higher in male gender. At low PAPP-A MoM values Late PTB in male infant (aRR 95% CI 2.028) and late miscarriage (LM) category with low free BhCG MoM values in female infant (aRR 95% CI 0.907) was determined statistically significant. CONCLUSIONS: Male gender has an effect on PTB rate. In low values of first trimester aneuploidy test markers late PTB risk is increasing in male gender and also LM risk is decreasing in female gender. Further studies are required in order to determine the relation between PTB and fetal gender and first trimester aneuploidy screening test.

Incidentally found hyperreactio luteinalis in pregnancy.

Hyperreactio luteinalis (HL) is a rare pregnancy-related condition in which the ovaries become massively enlarged bilaterally, occupied by multiple benign theca lutein cysts, secondary to increased ovarian stimulation by beta-human chorionic gonadotropin (B-hCG). HL should resolve spontaneously postpartum, however, their occurrence has led some physicians unfamiliar with the natural history of the condition to perform unnecessary ovarian cystectomies or oophorectomies. A healthy 32-year-old woman was incidentally found to have new onset multicystic ovaries on ultrasound at 31 + 3 weeks gestational age, which continued to enlarge, with a maximum volume of ∼448.0 cm3 and ∼323.5 cm3 in right and left ovaries, respectively. She also developed signs and symptoms of hyperandrogenism, and later abdominal pain which ultimately expedited delivery. This paper demonstrates that familiarity with HL as a clinical entity, its typical presentation and natural history, and targeting conservative management is paramount in minimizing iatrogenic harm by obstetricians given the increased use of ultrasound in pregnancy. Patients presenting after the first trimester with bilateral multicystic ovaries with a "spoke wheel" appearance on ultrasound, hyperandrogenism, abnormally elevated B-hCG, or symptoms consistent with elevated B-hCG should prompt a possible diagnosis.

Hyperthyroidism in a complete molar pregnancy with a mature cystic ovarian teratoma.

BACKGROUND: The hallmark of gestational trophoblastic disease is the production of human chorionic gonadotropin (hCG) due to the hyperproliferation of extraembryonic trophoblast cells. Previous studies show hCG has thyrotropic action due to its structural similarity with thyroid stimulating hormone (TSH) molecules. Germ cell tumors represent 15-20% of all ovarian tumors and can be malignant or benign. CASE PRESENTATION: We present a case of a 53-year old African American female with a history of hyperthyroidism secondary to a complete hydatidiform mole and an associated finding of a mature cystic ovarian teratoma. She presented with nausea, vomiting, nervousness, weight gain, abdominal pain and a b-hCG of greater than 450,000mIU/mL. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed and curative for her symptoms. Lung nodules were noted with slight increases in b-hCG levels in the months following the surgery. Propranolol and methimazole were used to treat the acute hyperthyroid symptoms. CONCLUSION: This case presents the rare occurrence of a complete hydatidiform mole causing hyperthyroidism and an associated finding of a mature cystic teratoma. It also highlights the importance of monitoring b-hCG levels following a complete molar pregnancy due to an increased risk of choriocarcinoma.

Multidosing Intramuscular Administration of Methotrexate in Interstitial Pregnancy With Very High Levels of ß-hCG: A Case Report and Review of the Literature.

Ectopic pregnancy (EP) is the implantation of an embryo outside the endometrial cavity of the uterus. Signs and symptoms of EP may arise between the 6th and the 8th week of gestation and include vaginal bleeding, lower abdominal and pelvic pain. Frequently EPs implant in the fallopian tubes. A rare EP is the interstitial pregnancy, a life-threatening condition being responsible for nearly 20% of all deaths caused by EPs. Because of its unique location, the diagnosis is difficult and based on signs and specific criteria together with measuring of serum ß-hCG. Usually, EP is treated by surgical approach, which is associated with increased morbidity, decreased fertility and increased likelihood of hysterectomy and uterine rupture in a subsequent pregnancy. Early diagnosis is crucial to life saving and allowing alternative therapeutic interventions such as pharmacological treatments. Methotrexate (MTX) represents the mainstay therapy. There is no standard care for the interstitial pregnancy for what concerns either surgical or pharmacological approaches. We reported a case of a 36-year-old woman admitted to the Hospital of Salerno-Italy with a value of serum ß-hCG of 35,993 IU/L. Transvaginal ultrasonography revealed an empty uterine cavity and a mass of 35.7 mm in diameter characterized by a hypoechoic central area. The patient was in stable haemodynamic condition and no haematologic, renal and hepatic impairments were recorded. Despite the high serum ß-hCG levels, a pharmacological approach was preferred to a surgical one. The patient was treated with intramuscular administration of MTX in daily dose of 1 mg/Kg alternated with 0.1 mg/kg folinic acid for 5 days. The patient remained hospitalized for 20 days and no side effects were reported. The decrease of the serum ß-hCG was monitored and more than 15% reduction was detected between the 4th and the 7th day after the beginning of the treatment. The serum ß-hCG became undetectable 35 days after. A multidosing intramuscular administration of MTX was effective and safe even in the presence of very high serum ß-hCG levels. Together with similar cases reported in literature, the present results can contribute to improve the decision making in the treatment of the interstitial pregnancy.

Effect of Combination Therapy of Methotrexate with Vitamin A in Patients with Low Risk GTN (Gestational Trophoblastic Neoplasia).

Methotrexate as a single agent chemotherapy in most women with low risk gestational trophoblastic neoplasia (GTN) has been associated with high treatment rate. Combination of methotrexate with Vitamin A due to reduced number of chemotherapy regime courses is one of the treatment options for patients with low-risk GTN. Therefore, this study was performed with aim to determine the efficacy of combination therapy of Methotrexate with Vitamin A in low risk GTN treatment. This randomized clinical trial was performed on 49 patients with low risk gestational trophoblastic neoplasia. The treatment group (Group A = 19 cases) weekly received Methotrexate 50 mg/m2, and Vitamin A 200000 IU, intra-muscular, and the control group (Group B = 30 cases) only received Methotrexate 50 mg/m2 weekly. All patients were followed up for 8 weeks. Then, treatment outcomes were compared between two groups, and response to therapy was assessed in two groups by evaluation of HCG serum level. P < 0.05 was considered significant.Mean of B-HCG serum level after 4 weeks in Group A and Group B was 68.5 mIu/mL and 360 mIu/mL, respectively (P = 0.018), and after 8 weeks was 1 mIu/mL and 12 mIu/mL, respectively (P = 0.074). Combination therapy of Methotrexate and Vitamin A in low risk GTN is associated with shorter duration of chemotherapy.

The value of a registry negative urine pregnancy test for the prediction of a future unintended pregnancy among young women.

BACKGROUND: Performance of urine pregnancy test in general adolescents' clinic reflects caregiver or woman's concern that there might be a pregnancy. We aimed to assess whether young-unmarried women in whom a negative urine pregnancy test was registered would be at increased risk of a future unintended pregnancy. METHODS: The study cohort included consecutive women drafted by the Israeli military between 2013 and 2015. The risk of unintended pregnancy was compared between women with a negative urine pregnancy test (n = 2774), the study group, and those in whom urine pregnancy test was not carried out (n = 126,659), the control group. RESULTS: During the study period, 2147 (1.7%) women experienced an unintended pregnancy. The risk of unintended pregnancy was significantly higher in patients in whom a past pregnancy test was negative 4.3% (n = 118), as compared with the control group 1.6% (n = 2028) (odds ratio [OR], 2.7; 95% confidence interval [CI], 2.23-3.26). In multivariate analysis history of a negative pregnancy test results was an independent predictor for a future unintended pregnancy (adjusted OR, 2.0; 95% CI, 1.63-2.52). CONCLUSIONS: A history of a negative pregnancy test among young conscripted women is a significant risk indicator for a future unintended pregnancy. Directed efforts should be made in this particular vulnerable group of patients.

microRNA-371a-3p as informative biomarker for the follow-up of testicular germ cell cancer patients.

PURPOSE: α-fetoprotein (AFP) and human chorionic gonadotropin subunit beta (B-HCG) are informative serum biomarkers for the primary diagnosis and follow-up of testicular germ cell cancer (TGCC) patients. About 20% of TGCC patients with a non-seminoma (NS) and about 80% with a seminoma (SE) are, however, negative for these biomarkers. Embryonic stem cell microRNAs (miRs) may serve as promising alternative serum biomarkers. Here we investigated a retrospective series of serum samples from selected TGCC patients who developed a relapse in time to test the possible additional value of the serum-based ampTSmiR test compared to the conventional serum-based protein biomarkers for follow-up. METHODS: We investigated 261 retrospective serum samples of six selected fully evaluated TGCC patients with a proven relapse using the ampTSmiR test for miR-371a-3p, miR-373-3p, and miR-367-3p and compared the results to those of the conventional protein biomarkers. RESULTS: At primary diagnosis, elevated serum B-HCG, AFP and LDH levels were found to be informative in 4/6, 3/6 and 3/6 patients, respectively. At primary diagnosis the levels of miR-371a-3p and miR-373-3p were elevated in 4/4, and miR-367-3p in 3/4 patients. For two cases no starting serum sample was available for retrospective miR analysis. Residual disease (overlooked by histopathological examination) was detected in one case by miR-371a-3p only. The miR-371a-3p level was increased in one patient two months before detection of an intracranial metastasis. B-HCG was informative in 3/4 and the ampTSmiR test in 4/4 patients with a relapse or residual disease. None of the biomarkers were informative for the detection of residual mature teratoma. CONCLUSIONS: The ampTSmiR test is more sensitive than the conventional TGCC protein biomarkers for the detection of residual disease and relapse, excluding mature teratoma.

Marcadores séricos del primer trimestre y riesgo obstétrico en una población con alta prevalencia de obesidad / First-trimester serum markers and obstetric risk in a population with a high prevalence of obesity

Objetivo: La detección precoz del riesgo de complicaciones de la gestación como preeclampsia, parto pretérmino, y aborto, permitiría evitar morbimortalidad y secuelas. Hemos estudiado la relación entre niveles bajos de PAPP-A y BhCG con malos resultados obstétricos en una población con alta prevalencia de obesidad. Material y métodos: Estudio retrospectivo de casos y controles anidado en una cohorte de pacientes que acudieron para tamizaje de aneuploidías el I trimestre. Los casos fueron las pacientes con MoM PAPPA y/o BhCG por debajo del percentil 5 y el grupo control una muestra aleatorizada de pacientes con marcadores normales. Se ajustó por obesidad, edad, paridad, tabaquismo, y técnicas de reproducción. Resultados: La cohorte estuvo formada por 9111 pacientes. Se obtuvieron 382 casos con MoM PAPP-A inferior al percentil 5 y 325 con MoM BhCG por debajo del percentil 5, y 50 casos con ambos marcadores por debajo del percentil 5. Se tomaron 1417 controles. La prevalencia de obesidad fue del 20,7% y de sobrepeso el 28,4%. Los niveles bajos de PAPP-A se relacionaron con abortos, preeclampsia, crecimiento intrauterino retardado, pequeños para la edad gestacional, parto pretérmino y diabetes gestacional. Los niveles de BhCG por debajo del percentil 5 se relacionaron con la enfermedad hipertensiva gestacional. Los niveles de ambos marcadores por debajo del percentil 5 tuvieron relación significativa con aborto, preeclampsia precoz y parto pretérmino. Conclusión: Los niveles bajos de PAPP-A y BhCG se relacionan con malos resultados obstétricos en una población de alta prevalencia de obesidad.

Background: Early identification of pregnant women at risk of developing intrauterine growth restriction, preeclampsia, preterm birth, stillbirth, among other complications would allow more intensive surveillance to reduce the risk of severe disease. We aimed to study whether low levels of maternal serum markers PAPP-A and BHCG are associated with adverse pregnancy outcomes in an obese population. Methods: Cases were obtained from a cohort of 9111 patients who attended first trimester screening. We included women with PAPP-A and/or BHCG below the 5th percentile. A randomized group of women with serum markers above the 5th percentile was used as control group. Results were adjusted for age, parity, smoking status, BMI or reproductive techniques. Results: Prevalence of obesity was 20,7%. We found 382 women with PAPP-A below the 5th percentile, 325 with BHCG below the 5th percentile, 50 with both markers low, and recruited 1417 controls. The cases with low PAPP-A were significantly more likely to experience abortion, preeclampsia, low birth weight, preterm birth, or gestational diabetes. Low BHCG was significantly associated with gestational hypertension. Low BHCG and PAPP-A in the same patient correlated with abortion, early preeclampsia and preterm birth. Conclusions: Low levels of maternal serum markers correlate with adverse pregnancy outcomes in an obese population. We recommend to develop further calculators of obstetric risk to improve positive predictive value and to establish a maternal-fetal surveillance plan.

Utility of ßhCG monitoring in the follow-up of medical management of miscarriage.

OBJECTIVE: To evaluate the percentage change in total ßeta-unit human chorionic gonadotropin (ßhCG) levels (%ΔßhCG) in the prediction of treatment outcomes following intravaginal misoprostol for missed miscarriage before 13 weeks. METHODS: A secondary analysis of a randomised controlled study of medical management of miscarriage was performed. Total ßhCG levels were collected before misoprostol (baseline) and after a planned seven day interval (follow-up), when a transvaginal ultrasound (TVUS) reported a gestational sac as present or not. If no sac at TVUS, surgery was indicated on clinical criteria. %ΔßhCG ((baseline ßhCG - follow-up ßhCG)/baseline ßhCG × 100) was evaluated in the prediction of a sac at TVUS and surgery on clinical criteria. RESULTS: %ΔßhCG was calculated for cases with ßhCG levels within two days of misoprostol and TVUS; calculation interval determined case number. The median %ΔßhCG for 24 cases with a persistent sac (6-9 day interval) was significantly lower than for 145 with no sac (58.75% (interquartile range (IQR): 37.59-76.69; maximum 86.54) vs 97.65% (IQR: 95.44-98.43); P < 0.0001). The median %ΔßhCG for eight cases needing surgery on clinical criteria (5-9 day interval) was significantly lower than for 140 cases with no sac not needing surgery (79.68% (IQR: 64.63-91.15; maximum 94.06) vs 97.68% (IQR: 95.61-98.50); P < 0.0001). The area under the receiver-operator curve was 0.975 for prediction of a persistent sac and 0.944 for prediction of surgery on clinical criteria, respectively. %ΔßhCG > 87% predicted no sac at TVUS. %ΔßhCG > 94.5% predicted no surgery on clinical criteria. CONCLUSION: %ΔßhCG calculation over one week reliably predicted treatment outcomes after medical management of missed miscarriage.