GESTATIONAL TROPHOBLASTIC DISEASE IN BASRAH

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Zaineb .T. AL Yasin, FICMS, CABOG. Lecturer, Department of Obstetrics & Gynecology. College of Medicine, University of Basrah, Iraq.
Hassna M. Chaied, MBChB, Basrah General Hospital, Basrah, Iraq.
GESTATIONAL TROPHOBLASTIC DISEASE IN BASRAH
Zaineb .T. AL Yasin, Hassna M. Chaied
ABSTRACT
To date few studies have been reported from Basrah regarding Gestational Trophoblastic disease GTD. This study
was a clinical observational study done in Basrah at the 4 main obstetric hospitals based on 137 patients with GTD.
The objective was to study the incidence of Hydatidiform Mole gestation and other Gestational trophoblastic diseases
in Basrah and to review the clinical presentation and management of Hydatidiform Mole gestation in Basrah. Clinical
records of patients were reviewed with regards to presentation, investigation, management and outcome. Of 137
patients, there were 132 patients (96%) treated for hydatidiform mole, 3 patients (2%) were treated for
choriocarcinoma, 1(1%) patient had invasive mole and 1(1%) patient had placental site tumor. The incidence of
molar pregnancy and choriocarcinoma was 1.7/1000 deliveries and 0.04/1000 deliveries, respectively. Molar
pregnancy seems to be a common problem in Basrah but sever complications such as pre-clampsia & thyrotoxicosis
were not reported in this study.
INTRODUCTION
Gestational trophoblastic diseases (GTD)
represent a spectrum of neoplastic disorders that
arise from placental trophoblastic tissue after
abnormal fertilization. Gestational trophoblastic
diseases are classified histologically into four
distinct groups: hydatidiform mole (complete
and partial), chorioadenoma destruens (invasive
mole), choriocarcinoma, and placental site
tumor[1,2]. These tumors are rare and constitute
less than 1% of all gynecological
malignancies[3]. The reported incidence of GTD
varies in different regions of the world. Overall,
approximately 80% of cases of GTD, are
hydatidiform moles, 15% are chorioadenoma
destruens or invasive mole, and 5% are
choriocarcinomas. Choriocarcinoma is
associated with an antecedent mole in 50% of
cases, a history of abortion in 25%, term
delivery in 20%, and ectopic pregnancy in
5%[4]. True estimates of the incidence of molar
pregnancies are difficult to obtain because of
considerable worldwide variation in the
presentation and management of both normal
and abnormal pregnancies[4]. The incidence of
molar pregnancy demonstrated marked
geographic and ethnic differences, ranging from
the highest incidence of 1 in 120-400
pregnancies in Asian countries such as Taiwan,
Philippines and Japan, to the lowest incidence
of 1 in 1000 to 2000 in Europe and the USA[5].
In Iraq the incidence is 1 in 221according to
previous statistics[6]. To date few studies have
been reported from Basrah regarding Gestational
Trophoblastic disease therefore this study was
conducted to study the incidence of
Hydatidiform Mole gestation and other
Gestational trophoblastic diseases in Basrah and
to review the clinical presentation and
management of Hydatidiform Mole gestation in
Basrah.
PATIENTS AND METHODS
This is a retrospective study done in Basrah at
the 4 main obstetric hospitals Basra maternity
and child hospital, Al Basrah general hospital,
AL Faihaa hospital and Al Tahrer hospital
through the period of one year (the first of May
2005 till first of May 2006). A special
questionnaire form was designed to collect
information about those patients who are
included in the study, this included points about
the history, examination, investigations &
management related information about the
progress of the patients collected from the
clinical records in these hospitals and
histopathological laboratories records. Patient
who needed chemotherapy were treated in the
Oncology center in Basrah Teaching hospital.
The management of patients in all 4 hospitals
included history, clinical examination which
was performed to assess patient's general
condition, size of the uterus & presence of
adnexal masses. Full laboratory evaluation
obtained as a part of pretreatment follow-up,
full blood count; urea and electrolytes, thyroid
function test, and serum βHCG level were
obtained. Radiological investigations included
chest X-ray and pelvic ultrasound were done to
all patients. CT scan of the brain and pelvis was
done in patients in which metastasis was

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53
suspected. The diagnosis of malignant GTD was
based on clinical, radiologic, and biochemical
evidence of metastases. After assessment of the
general condition by complete investigations
and correction of anemia and dehydration, cases
of molar pregnancy were treated by evacuation
of the uterus by traditional curettage under
general anesthesia using sponge forceps and
curette since no suction curettage is available. In
most of the patients a second evacuation was
done routinely according to the ultrasound result
in about 10 days later and each time a biopsy
was obtained for histopathological examination.
Other cases of GTD were treated accordingly.
After confirmation of the diagnoses by
histopathology, the patients were followed up
by βHCG level; follow up was difficult because
of the absence of a special referral center and
lack of HCG assay in most of the hospitals but
most of the cases were followed up by private
laboratories.
RESULTS
There were 78674 deliveries during the study
period and 137 cases of (GTD) were reported.
There were 132 patients (96%) of them were
treated for hydatidiform mole, 3 patients (2%)
were treated for choriocarcinoma, 1(1%) patient
had invasive mole and 1(1%) patient had
placental site tumor. As shown in (Table-1).
The incidence of molar pregnancy and
choriocarcinoma was 1.7/1000 deliveries and
0.04/1000 deliveries, respectively. The majority
of hydatidiform mole cases were complete
molar pregnancy 119 (90%) and only 13(10%)
were partial. As shown in (Table-1).
Table 1.Cases of gestational trophoblastic diseases.
Gestational
trophoblastic
diseases
No. %
Hydatidiform mole
132
Partial = 139
Complete = 13
96
Choriocarcinoma 3 2
Invasive mole 1 1
Placental site
tumor 1 1
Total 137 100
The age of patients ranged from 16 to 52 years.
The highest percentage of Gestational
trophoblastic diseases GTD (36%) was found in
patients between 20-29 years of age as shown in
(Table-2).
Table 2. The distribution of gestational
trophoblastic diseases (GTD) according to age
Age in years No. %
< 20 25 18
20-29 50 36
30-40 42 31
40-52 20 15
Total 137 100
Only 6 patients (4%) experienced previous
molar pregnancy. All 137 patients with GDT
presented with vaginal bleeding of varying
severity, while other presentations such as
passage of vesicles, ovarian cyst, hyperemesis
gravidarum, anaemia, abnormal vaginal growth
and acute abdomen, were observed in (6.56%),
(6.56%), (3.6%), (2.9%), (2%), (1.5) of patients
respectively as shown in (Table-4). Regarding
the abnormal vaginal growth, it was found
initially in 1 patient (before evacuation) and
occurred in 2 patients during the period of
follow up together with elevated BHCG level
and they were referred to oncology center in
Basrah Teaching hospital. For chemotherapy 2
patients had acute abdomen and laprotomy was
done which revealed twisted ovarian cyst in one
patient and metastatic disease with uterine
perforation in the other.
Table 4. The distribution of GTD cases according
to their presenting symptoms (Some women had
more than one presenting symptom).
Presentation No. of cases %
Vaginal bleeding 137 100
Passage of vesicles 9 6.56
Ovarian cyst 5 6.56
Hyper emesis
gravidarum 4 3.64
Anemia 3 2.91
Abnormal vaginal
growth 3 2.1
Acute abdomen 2 1.5

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54
Regarding treatment: from total 137 recorded
patients:
1. Two (2%) patients were treated with
hysterectomy as an initial surgery. These
patients were presented with irregular
vaginal bleeding, elevated BHCG level
together with multiple intrauterine masses;
both were older than 40 years of age and did
not desire future pregnancy.
Histopathological examinations revealed
choriocarcinoma in 1 patient and invasive
mole in the other. Both were transferred for
chemotherapy following surgery.
2. One hundred thirty five (98%) patients were
treated with curettage, 61 patients had only
one evacuation, the remaining 74 patients,
had second evacuations about 10 days later
and each time a biopsy was obtained for
histopathological examination.
Five patients had hysterectomy after the
evacuation for the following reasons:
Histopathological examinations revealed
placental site tumor in 1 patient,
choriocarcinoma in 2, two patients had
hysterectomy despite no malignancy. During the
period of follow up 9 patients had persistently
high level of BHCG level (more than 20000
IU/ML) 4-6 weeks after evacuation and they
were transferred to chemotherapy, one of these
patients had partial mole. The total number of
patients who received chemotherapy was 14.
Regarding the fate of the patients:
-The total number of patients who received
chemotherapy was 14.
-Two patients who received chemotherapy died
during the course of treatment
-Seventy three had a normal BHCG level 3-4
months after follow up.
-The remaining 50 patients were lost from follow
up and they did not continue their BHCG follow
up. As shown in (Table-5).
Table 5. The outcome of patients after short term
follows up.
The outcome No. of cases %
Complete remission
after evacuation 73 53.3
Chemotherapy 14 10.2
Lost from follow up 50 36.5
Total 137 100
DISCUSSION
There is considerable variation in the incidence
of molar pregnancy in different part of the
world. The reported incidence of hydatidiform
mole in the present study was (1.7) per thousand
maternities (1 in 574) which is less than the
results of a previous study done in Basrah 5
years ago which is (2.6) per thousand
maternities (1 in 400)[7], This is probably
because that study was conducted only in one
hospital and the number of cases was limited
but still higher than that in neighboring
countries like Saudi Arabia (1 in 676)[8].
However a previous study done in Iraq in 1983
showed higher incidence (1in 221) or 4.5 per
1000[1]. The true number of molar pregnancy
may be under estimated as many cases may
present as missed abortion or anembryonic
pregnancy and the ultrasonic distinction from
missed abortion may be difficult so
histopathological examination of the product of
conception following abortion is important[9,10].
Although the majority of the cases of molar
pregnancy were a complete hydatidiform mole
(113 cases) and only few cases showed a partial
hydatidiform mole (9 cases), persistent
elevation of BHCG level following evacuation
with referral to chemotherapy was reported in
one patient with partial mole. Wiesma et al,
found that 1.7% of all partial mole pregnancy
patients needed treatment for malignant
squeals[11]. These findings support the fact that
even partial mole need regular and close
observation and follow up. Considering
etiologic risk factors. The risk factor most
consistently associated with GTD in all ethnic
groups and geographic regions is maternal age.
Several studies reported that the incidence of
trophoblastic disease increases in patients over
the age of 35 years and the risk is 5-10 fold
greater in women over the age of 40 years[12,13].
In the present study (15%) of patients were
above the age of 40 years and the majority of
patients were at younger age group, these
findings are in agreement to that reported by
(Mageed J)[7]. Nulliparity was found to be
associated with GTD in several studies[14,15].
However, the present study showed that (31%)
of patients were diagnosed with trophoblastic
disease in their first pregnancy and the higher
percentage (52%) of patients having from 1-5
children. Previous history of Molar pregnancy is

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55
another well-established risk factor[16] and in
our study, 4% had a previous molar pregnancy.
Vaginal bleeding of varying severity occurred in
all the patients. Abdominal pain and excessive
vomiting were other important presenting
symptoms, thus indicating the importance of
these symptoms in the diagnosis of
hydatidiform mole. Anaemia, consequent upon
prolonged vaginal bleeding was noticed in few
patients (2%) in our study this may be due to
early diagnosis and management. Experience
from England and the United States reveals that
complete mole is being diagnosed earlier in
gestation[17,14] and rarely presents with
traditional signs and symptoms. In addition, a
study done in Saudi Arabia showed that 54% of
the patients were diagnosed during their first
trimester and present infrequently with the
classical signs and symptoms of GTD[8].
In the present study, all patients except 3 were
diagnosed during the first trimester because of
the practice of routine first trimester ultrasound
examination. The classical literatures on
trophoblastic disorders usually stress on the
descriptions of significant complications such as
trophoblastic embolization to the lung, sever
second trimester pre-eclampsia and
thyrotoxicosis[17]. Fortunately these
complications were not seen in our study which
is due to the fact that the disease has been
diagnosed in an early stage in pregnancy.
However, one should be always bear in mind
that despite earlier diagnosis, the potential for
post molar persistent gestational trophoblastic
disease still remains. Studies[18] have proven
that 20% of complete molar pregnancies can
progress to persistent disease. In this study only
9(7%) patients of those who had regular follow-
up were treated for persistent trophoblastic
disease, this low percentage may be due to the
fact that 50 patients were lost from follow up.
More over in Basrah there was no special center
for trophoblastic disorders and all cases were
managed individually and specific guidelines of
managements were lacking. In addition BhCG
assessment is expensive to many patients and is
rarely available in general hospitals.
Although there have been advances in the
development of effective chemotherapy to
improve the survival rate. Surgery remains an
important role in the management of gestational
trophoblastic disease. In a patient who has
completed her family, abdominal hysterectomy
offers the advantage of evacuation and
sterilization. Additionally, hysterectomy has
been shown to reduce the risk of malignant
sequelae to approximately 3.5% from 20%
anticipated for patients treated with suction
curettage[14]. In our study, hysterectomy was
performed for 7 patients from which 2 with
nonmetastatic trophoblastic disease who did not
desire future conception.
Conclusion and recommendations
-Molar pregnancy seems to be a common
problem; the incidence of hydatidiform
mole in Basrah was 1.7 per thousand
maternities (1 in 574).
-The highest percentage of GTD is found
in the age group between 20-29 years
and in most parous patients having
between 1-5 children.
-Sever complications such as pre-
clampsia, thyrotoxicosis were not
recorded in this study while vaginal
bleeding was the most common clinical
presentation.
-This study emphasizes the need for the
establishment of a specialist centers for
gestational trophoblastic disease in
Basrah for diagnosis, treatment and
regular follow-up.
-Improvement in social circumstances of
the community and providing health
education with regards to the
importance of regular follow-up may
change the outcome of gestational
trophoblastic disease.

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