’This One Things…’: facilitating communication in antenatal clinics at the National Maternity Hospital

Abstract

Introduction: Gestational trophoblastic neoplasia (GTN) is a collective term for gestational trophoblastic diseases that invade locally or metastasize. Hydatiform mole is the most common form of GTN; others are invasive mole, choriocarcinoma, and placental site trophoblastic tumor (PSTT). A placental site trophoblastic tumour is a rare tumor, representing from 0.23 to 3% of gestacional trophoblastic neoplasms. It mainly affects women of childbearing age. This tumor can arise during or after a normal pregnancy, a miscarriage, an abortion, or a molar pregnancy, and can occur during post-menopause, years after the last pregnancy. Most patients present with abnormal bleeding per vaginum with varying periods of amenorrhea and/or effects of metastasis to various organs. A wide range of other presenting symptoms have been reported including galactorrhoea, virilization, nephrotic syndrome, polycythaemia and cutaneous metastases. Beta-HCG levels are moderately high, unlike the levels found in the hydatiform moles. Rarely is the diagnosis of PSTT made on a dilatation and curettage specimen since this usually presents as intermediate trophoblasts infiltrating the myometrium. Placental site trophoblastic tumor behaviour is characterized by a slower growth, as well as a tendency to diffuse through lymphatic ways. Therefore, they are relatively resistant to chemotherapies. The preferred treatment for PSTT is essentially surgical and is based on hysterectomy with lymphatic sampling. Case report: A 41 years old woman, 7 weeks pregnant, reported to the emergency unit with menorrhagia. We suspected hydatiform mole after performing a pelvic ultrasound showing a distended endometrial cavity containing innumerable, variably sized anechoic cysts with intervening hyperechoic material. In the first assessment beta-HCG levels were 24880 mU/mL. The patient underwent cervical dilation and aspiration of the uterine content. The histological diagnosis showed hydatiform mole. After uterine evacuation have persisted elevated values of beta-HCG despite the pelvic ultrasound show an empty cavity. Due to the hypothesis of invasive mole and after multidisciplinary discussion, total hysterectomy was performed, with conservation of adnexa. Histopathologic examination of the surgical specimen showed placental site trophoblastic tumor. In the consultation after surgery was decided to conduct chemotherapy. After four months of followup beta-HCG levels return to normal range. Conclusion: This case differs from the others by high beta-HCG values that led to the suspicion of hydatidiform mole. Due to its rarity and varied biological behaviour it presents a diagnostic challenge and treatment dilemma to both the pathologist and clinicians. It is important to make this specific diagnosis as it is distinct from other GTN.