Objective : To describe the place of ultrasound in the diagnosis and management of Gestational Trophoblastic Diseases (GTD) at the Ouagadougou UTH-YO, Ouagadougou, Burkina Faso . Materials and Patients: It was a prospective and descriptive study over a 3-year period from 1 January 2015 to 31 December 2017. It took place in the gynecology and obstetrics department of at the University Teaching Hospital Yalgado Ouedraogo (UTH-YO) of Ouagadougou. Monitoring was based on clinical examination data, ultrasound and kinetics of β-gestational chorionic hormone (GCH) levels. Results: During the study period, we recorded 34 cases of trophoblastic diseases. The average age of the patients was 35 years with extremes of 22 and 52 years. Physical examination revealed a uterus larger than gestational age in 17 patients (56.67%) of cases. Eight (26.67%) patients were asymptomatic. The initial mean β-GCH was 453 , 747.8 IU/l with extremes of 5903 IU/l and 1 , 890 , 000 IU/l. Ultrasound was used to evoke the diagnosis in 23 patients, that to say 76.67% of the cases. Ultrasound identified 10 complete mole cases, 20 partial mole cases. For the 3 cases of invasive mole, pelvic ultrasound revealed heterogeneous intrauterine multi-vesicular images. In a case of choriocarcinoma, ultrasound found an enlarged uterus with a poorly limited intracavitary heterogeneous fundic image. Conclusion: This short series shows the central role of ultrasound in the diagnosis and follow-up of gestational trophoblastic diseases. Indeed, the sensitivity of ultrasound is excellent in the early diagnosis of complete moles. Ultrasonography remains a good examination choice for the diagnosis of gestational trophoblastic tumors despite their great polymorphism. The place of ultrasound in prognostic evaluation and treatment monitoring deserves to be studied by more important series .
Gestational trophoblastic diseases (GTD) constitute a real public health problem for African countries because of their high incidence, their evolutionary potential and the difficulties related to their diagnosis and management [
Our study took place in the gynecology and obstetrics department of at the University Teaching Hospital Yalgado Ouedraogo (UTH-YO) of Ouagadougou. It was a prospective and descriptive study over a 3-year period from 1 January 2015 to 31 December 2017. All histologically confirmed cases where diagnosis was based on imaging and kinetics of the βGCH rate were comprehensively included in the study. Patients were collected from outpatient, gynecological and obstetrical emergency records at the UHC-YO. We worked in collaboration with the anatomopathology department and the Medical Oncology Department respectively for histological diagnosis and complementary management. Magnetic resonance imaging examinations were performed by the radiology team at the Saint Camille medical centre in Ouagadougou. We chose to divide our patients into two groups according to the classification of the International Federation of Obstetrical Gynecologists (FIGO) in 2000 [
The oral informed consent of the gestants was obtained prior to the start of this investigation. To ensure confidentiality in this study, no sonographer or structure name to identify a health professional was mentioned on a data collection sheet. The data will be used exclusively to make recommendations for the harmonization of the practice for the benefit of pregnant women. We also got the approval of the Ethics Committee on Research.
During the study period, we recorded 34 cases of trophoblastic diseases. At the same time 3560 patients were received in obstetrics, a frequency of 9.5 trophoblastic diseases per 1000 pregnancies. The distribution of GTD cases is presented in
・ Clinical aspects
The average age of the patients was 35 years with extremes of 22 and 52 years. The 30 to 40 age group was in the majority and represented 53% of the workforce. The average number of gestures was 3 and the average parity was 2. 6 patients out of 30 had at least a history of spontaneous miscarriage (20%) and 5 patients (16.67%) had a history of at least one abortion (abortion). only one patient in this group had a history of molar pregnancy. The mean gestational age at diagnosis was 11 years with extremes of 4 and 25 years. Clinically, 4 patients (13.33%) had exaggerated signs of pregnancy and 25 patients (83.33%) had metrorrhagia. We did not find any signs of preeclampsia or hyperthyroidism in our series. Physical examination revealed a uterus larger than gestational age in 17 patients (56.67%) of cases. Eight patients were asymptomatic (26.67%) of cases. The initial mean β-GCH was 453747.8 IU/l with extremes of 5903 IU/l and 1,890,000 IU/l.
・ Ultrasound data
Ultrasound was used to evoke the diagnosis in 23 patients, 76.67% of the cases.
• Complete moles
Ultrasound identified 10 complete mole cases. Histological examination was consistent in all 10 cases. Ultrasound contributed to the diagnosis in 100% of cases. The ultrasound aspects were those of an enlarged uterus containing intravesicular multi-vesicular images without embryos or gestational sac (
Type of gestational trophoblastic disease | Number | Details |
---|---|---|
Hydatiform moles | 30 | complete mole: 10 cases partial mole: 20 cases |
Persistent trophoblastic tumours | 4 | invasive mole: 3 cases choriocarcinoma: 1 case |
Total | 34 |
• Partial moles
We handled 20 partial mole cases. Ultrasound identified 5 histologically confirmed cases with a sensitivity of 25% (
The other aspects of the ultrasound were (
in 4 cases, latero-uterine image in cocarde with effusion in the cul de sac of Douglas evoking an ectopic pregnancy in 2 cases and an image of hematometry in 1 case.
In addition, the images were rather typical of a complete mole in 8 cases (
• Other imaging examinations
All patients in the first group were radiographed for chest metastases. No anomalies were found. One patient received a pelvic magnetic resonance imaging (MRI) examination because the ultrasound scan suspected myometrial invasion. The MRI didn’t confirm this invasion.
・ Treatments received
All patients in the first group received manual intrauterine aspiration under ultrasound control. Two patients received a red blood cell transfusion during a hemorrhagic molar abortion. One patient in this group received anti D serum
Ultrasound aspects | Number |
---|---|
Complete mole: image in snowfall without embryo | 8 |
Partial mole: multivesicular intrauterine images of the trophoblast with the presence of gestational sac and/or embryo | 5 |
Appearance of stopped pregnancy: embryo without cardiac activity | 4 |
Latero-uterine image in a cockade with effusion in the cul de sac of Douglas (ectopic pregnancy) | 2 |
Heterogeneous hematometry images | 1 |
Total | 20 |
and a hysterectomy was performed in 2 patients 47 and 52 years of age who no longer had a desire for procreation. A second aspiration was necessary in 11 cases (55%). During the systematic ultrasound inspection, they presented heterogeneous images with an average diameter of 24.7 mm in favour of retaining molar debris. Four of the 11 patients had a reactivation of GCH levels.
・ Evolution
The average turnaround time for βGCH was 6.5 weeks. The average length of hospital stay was 7 days. All patients had a favorable outcome.
・ Patients characteristics
The characteristics of the patients with invasive moles are presented in
All patients had a history of abortion. Symptomatology was dominated by metrorrhagia and in all patients the uterus was larger than gestational age. No signs of sympathetic pregnancy were found in any of the 3 patients, nor were there any signs of pre-eclampsia or hyperthyroidism. The average rate of βGCH in these patients was 355,125 IU/l with extremes of 150,000 IU/l and 543,000 IU/l.
・ Ultrasound data
For the 3 cases of invasive mole, pelvic ultrasound revealed heterogeneous intrauterine multi-vesicular images that evoked the diagnosis of complete mole. For one of the patients, case 2, ultrasound revealed multivesicular intrauterine images invading the myometrium with a 5 mm safety wall (
Case number | Ages | Miscarriage | GA at the time of diagnosis (GA) | Suspicion of ultrasound | Histological diagnosis |
---|---|---|---|---|---|
1 | 17 | 1 | 9 | yes | confirmed |
2 | 31 | 3 | 8 | no | confirmed |
3 | 46 | 1 | 12 | yes | confirmed |
GA: Gestational Age.
・ Other imaging examinations
All patients were given a chest X-ray. We have not objectified any image in favour of pulmonary metastases. The Case #2 received a pelvic MRI (
・ Treatments received
All patients received monochemotherapy. A hysterectomy was performed in case 3; and uterine artery embolization in case 2. All patients had a favourable outcome.
We’ve taken over a case of choriocarcinoma. This was a 29 year old patient who had 3 full term pregnancies with a history of molar pregnancy in the year prior to diagnosis. She had been out of sight. The circumstances of the diagnosis were a cough with hemoptoic sputum, weight loss and altered general condition. On ultrasound, we found an enlarged uterus measuring 110 mm × 63 mm with a poorly limited intracavitary heterogeneous fundic image measuring 56 mm × 42 mm. There was no sign of local invasion. Abdominal ultrasound did not reveal liver metastases. Chest X-rays and chest scans showed metastases in both pulmonary fields. The initial level of βGCH in this patient was 168,721 IU/l.
Anatomopathological examination was not performed with histological confirmation. The patient received multidrug therapy.
The first quarter metrorrhagia was the main circumstance of GTD discovery in our series (88.33%) of cases. This has been reported by several authors [
The value of ultrasound is clearly established in the early diagnosis of GTD. In the first trimester, transabdominal ultrasound or the use of high-frequency vaginal catheters and Doppler techniques allows for the earlier and earlier diagnosis of GTD [
・ Complete hydatiform moles
Transabdominal first trimester ultrasound most often shows an enlarged uterus containing a relatively echogenic intracavitary mass sometimes surrounded by a gestational sac [
・ Partial hydatiform moles
Ultrasound is less efficient and the distinction between partial and complete mole can be very difficult [
• presence of a placenta that is larger and thicker than a pregnancy of the same term would like and, in some places, has a molar appearance, i.e. multiple cysts;
• presence of an empty gestational sac or one containing amorphous echoes corresponding to a macerated fetus;
• pregnancy is usually terminated;
• When a well-formed or live fetus is observed, there is frequently intrauterine growth retardation;
• Sometimes it shows microvesicles difficult to distinguish from the focal hydropic degeneration of the villi of a dead egg [
However, when ultrasound shows cysts dispersed in the placenta and the diameter of the gestational sac is increased, the predictive diagnosis of a partial mole is estimated at 90% [
・ Persistent trophoblastic tumors(PTT)
Persistent trophoblastic tumors have a high ultrasound polymorphism. Diouf and cervix [
• a “gap” type with the association of rounded, regular gaps;
• a heterogeneous tissue “hyperdense” type, but without posterior shadow cone;
• a “swampy” type with wide anechoic beaches separated by more or less thick partitions with irregular vegetation;
• a “mite” type has small rounded gaps not exceeding 3 to 5 mm in a more echogenic and heterogeneous structure.
According to Diouf [
The current practice of complementary examinations (pelvic ultrasound and dosage of βGCH) has allowed an early diagnosis of GTD. Indeed, systematic first trimester ultrasound was the circumstance of discovery in 26.67% of cases in completely asymptomatic patients. Before the advent of ultrasound, the diagnosis was essentially based on the dosage of βGCH plasma and urinary. Currently, thanks to the widespread use of ultrasound in the first trimester, molar pregnancies are diagnosed earlier. The mean gestational age at diagnosis was 11GA in our series. This average age is respectively 8.7 GA, 9.25 and 10 GA in the referral centres in the United States, France and England [
In our study, ultrasound contributed to the diagnosis of hydatidiform mole in 76.67% with a clear predominance for complete mole. Boufettal [
The contribution of ultrasound in complete mole diagnosis is excellent [
In our series, the contribution of ultrasound in partial mole diagnosis was 25%. Similar rates are observed by other authors such as Chelliand al [
Despite their great polymorphism, the particularities of GTD give some authors an interest in ultrasound for the diagnosis of choriocarcinoma [
For several authors, ultrasound is also used to evaluate myometrial extension and invasion [
Doppler has several interests in the management of trophoblastic diseases [
This short series shows the central role of ultrasound in the diagnosis and follow-up of gestational trophoblastic diseases. Indeed, the sensitivity of ultrasound is excellent in the early diagnosis of complete moles. In the case of partial moles, this sensitivity is less important; however, ultrasound coupled with βGCH kinetics allows in most cases to establish an early diagnosis of partial moles. It should nevertheless be pointed out that the systematic anatomopathological examination of any expulsion product remains the gold standard diagnosis. Ultrasonography also remains an examination of choice for the diagnosis of gestational trophoblastic tumors despite their great polymorphism. Ultrasound is also involved in staging the pelvic localization process. The place of ultrasound in prognostic evaluation and treatment monitoring deserves to be studied by more important series
The authors declare no conflicts of interest regarding the publication of this paper.
Adama, O., Astrid, O.N.N., Natacha, L.B., Aline, T.S., Alexis, S.Y., Francoise, M.T., Charlemagne, O.M., Ali, O. and Blandine, T.B. (2018) The Role of Ultrasound in the Diagnosis and Management of Trophoblastic Diseases (TMD) at the University Teaching Hospital Yalgado Ouedraogo (UTH-YO) of Ouagadougou. Open Journal of Obstetrics and Gynecology, 8, 1376-1388. https://doi.org/10.4236/ojog.2018.813139