misoprostol and Gestational-Trophoblastic-Disease

To evaluate the percentage change in total βeta-unit human chorionic gonadotropin (βhCG) levels (%ΔβhCG) in the prediction of treatment outcomes following intravaginal misoprostol for missed miscarriage before 13 weeks.. A secondary analysis of a randomised controlled study of medical management of miscarriage was performed. Total βhCG 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. %ΔβhCG ((baseline βhCG - follow-up βhCG)/baseline βhCG × 100) was evaluated in the prediction of a sac at TVUS and surgery on clinical criteria.. %ΔβhCG was calculated for cases with βhCG levels within two days of misoprostol and TVUS; calculation interval determined case number. The median %ΔβhCG 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 %ΔβhCG 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. %ΔβhCG > 87% predicted no sac at TVUS. %ΔβhCG > 94.5% predicted no surgery on clinical criteria.. %ΔβhCG calculation over one week reliably predicted treatment outcomes after medical management of missed miscarriage.

Topics: Abortifacient Agents, Nonsteroidal; Abortion, Missed; Area Under Curve; Chorionic Gonadotropin, beta Subunit, Human; Endosonography; Female; Gestational Sac; Gestational Trophoblastic Disease; Humans; Misoprostol; Predictive Value of Tests; Pregnancy; ROC Curve

Early elective medical abortion is performed frequently in different countries of the world. Serious complications like gestational trophoblastic neoplasia (GTN) are uncommon and mostly nonmetastatic. High risk metastatic GTN following medical abortion is a rare event which may occur coincidentally.. A 26 year-old-woman, gravida 2 para 1, 6 weeks after misoprostol abortion presented with sever nausea, vomiting, and right upper abdominal pain. Human chorionic gonadotropin (hCG) level was 2,500,000 mIU/ml and metastatic work up revealed multiple liver metastases. She totally received nine cycles of EMA-CO (ethoposide- methotrexate- actinomycin- cyclophosphamide, vincristine) regimen for treatment and consolidation. Six months after treatment she is in complete remission.. Follow up of patients after medical abortion by means of single serum hCG measurement is highly recommended for early diagnosis of complications including gestational trophoblastic tumor. EMA-CO regimen seems to be an effective and safe treatment for liver metastatic gestational trophoblastic neoplasia.

Topics: Abortifacient Agents, Nonsteroidal; Abortion, Induced; Adult; Antineoplastic Combined Chemotherapy Protocols; Cyclophosphamide; Dactinomycin; Etoposide; Female; Gestational Trophoblastic Disease; Humans; Liver Neoplasms; Methotrexate; Misoprostol; Pregnancy; Uterine Neoplasms; Vincristine

Vaginal bleeding in the first trimester occurs in about one fourth of pregnancies. About one half of those who bleed will miscarry. Guarded reassurance and watchful waiting are appropriate if fetal heart sounds are detected, if the patient is medically stable, and if there is no adnexal mass or clinical sign of intraperitoneal bleeding. Discriminatory criteria using transvaginal ultrasonography and beta subunit of human chorionic gonadotropin testing aid in distinguishing among the many conditions of first trimester bleeding. Possible causes of bleeding include subchorionic hemorrhage, embryonic demise, anembryonic pregnancy, incomplete abortion, ectopic pregnancy, and gestational trophoblastic disease. When beta subunit of human chorionic gonadotropin reaches levels of 1,500 to 2,000 mIU per mL (1,500 to 2,000 IU per L), a normal pregnancy should exhibit a gestational sac by transvaginal ultrasonography. When the gestational sac is greater than 10 mm in diameter, a yolk sac must be present. A live embryo must exhibit cardiac activity when the crown-rump length is greater than 5 mm. In a normal pregnancy, beta subunit of human chorionic gonadotropin levels increase by 80 percent every 48 hours. The absence of any normal discriminatory findings is consistent with early pregnancy failure, but does not distinguish between ectopic pregnancy and failed intrauterine pregnancy. The presence of an adnexal mass or free pelvic fluid represents ectopic pregnancy until proven otherwise. Medical management with misoprostol is highly effective for early intrauterine pregnancy failure with the exception of gestational trophoblastic disease, which must be surgically evacuated. Expectant treatment is effective for many patients with incomplete abortion. Medical management with methotrexate is highly effective for properly selected patients with ectopic pregnancy. Follow-up after early pregnancy loss should include attention to future pregnancy planning, contraception, and psychological aspects of care.

Topics: Abortifacient Agents, Nonsteroidal; Abortion, Spontaneous; Chorionic Gonadotropin; Counseling; Diagnosis, Differential; Evidence-Based Medicine; Female; Gestational Trophoblastic Disease; Grief; Humans; Methotrexate; Misoprostol; Practice Guidelines as Topic; Pregnancy; Pregnancy Complications; Pregnancy Trimester, First; Pregnancy, Ectopic; Risk Factors; Ultrasonography, Prenatal; Uterine Hemorrhage

Nonmetastatic gestational trophoblastic tumor occurring after early elective medical abortion using mifepristone and misoprostol is unusual.. A young woman at 6 to 7 weeks' gestation presented with brown spotting requesting medical abortion. Pretreatment ultrasound was consistent with an abnormal pregnancy. Passage of tissue ensued after mifepristone-misoprostol administration. Recovery was normal, with a postabortion ultrasound on day 16 showing a reduction in intracavitary contents. The patient declined surveillance with serial beta-human chorionic gonadotropin (beta-hCG) levels and was lost to follow-up. Sixty days after initial treatment, she presented to a hospital with a history of intermittent bleeding and underwent curettage, revealing a complete hydatidiform mole. Chemotherapy was instituted when levels of hCG plateaued. Complete hCG regression occurred after three weekly injections of methotrexate, and postmolar surveillance is uneventful to date.. Gestational trophoblastic tumor may occur after early medical abortion.

Topics: Abortifacient Agents, Steroidal; Abortion, Therapeutic; Adult; Antineoplastic Agents; Female; Gestational Trophoblastic Disease; Humans; Methotrexate; Mifepristone; Misoprostol; Oxytocics; Pregnancy; Pregnancy Trimester, First