Gestational trophoblastic disease is a common gynaecological problem in Malaysia. The incidence of molar pregnancy is 2.8 per 1000 deliveries, being more common amongst the Chinese. The preferred method of evacuation is suction curettage; complete evacuation of the uterus was not achieved at the first attempt in 25 per cent of cases. Partial moles in our centre comprised 30 per cent of all moles. This is potentially malignant and needs follow-up for a complete mole. In the management of an invasive mole, chemotherapy should not be withheld in the presence of metastases and failure of regression of hCG. The role of prophylactic hysterectomy and prophylactic chemotherapy in the management of molar pregnancy is discussed "Selective preventive chemotherapy" in patients at "risk" appears appropriate. Chemotherapy remains the main modality of treatment for gestational trophoblastic tumours (GTT). We categorised our patients into low, medium and high-risk groups; survivals were 100, 98, and 61.7 percent respectively. These patients when categorised according to FIGO staging had survivals of 100, 80, 78.6 and 68.2 per cent respectively for stages 1, 2, 3 and 4 respectively. The reasons for the poor survival in the 'high-risk' group are discussed. Colour doppler blood flow studies are now being carried out; its role needs further evaluation. Surgery and radiotherapy have only a limited role in the management of these cases.
Eighty-nine patients who had hydatidiform moles evacuated at the General Hospital, Kuala Lumpur, were followed with serum beta hCG determinations from October 1988 to June 1991. A regression curve for serum beta hCG, as measured by RIA, was derived from the results of 47 of the patients who demonstrated spontaneous regression of serum beta hCG titres. All 47 patients had normal serum titres at 135 days after evacuation. The mean time taken to reach normal level was 82.6 days, while the range was 39 to 135 days (5 to 19 weeks).
2a 2b dihomo 15(S) 15 methyl PGF2 alpha methyl ester (dihomo 15 me PGF2 alpha) in intramuscular doses of 0.5 mg 8 hourly was used in 631 patients with abnormal intrauterine pregnancy comprising 282 cases of intrauterine fetal death, 233 cases of missed abortion, 34 and 82 cases respectively anencephalic and molar pregnancies. The study was carried out as a collaborative project between the University Departments of Obstetrics and Gynaecology in Singapore (Singapore), Medan (Indonesia) and Kuala Lumpur (Malaysia) during the period June 1974 and November 1979. Six hundred patients (95.1%) aborted or delivered in a mean time of 11.3 hours (S.D. +/- 7.0) with an average of 1.8 injections of the prostaglandin analogue per patient. Side effects included vomiting (23.6%; mean 0.45 episodes per patient), diarrhoea (44.4%; mean 1.00 episode per patient), cold and shivering (11.9%) and pyrexia (12.4%). One patient sustained a cervical laceration which did not require repair. There were no complications.
We illustrate a case of giant placental chorioangioma presenting at 20 weeks of gestation. Subsequent monitoring revealed enlargement of the lesion, associated with fetal anemia and cardiac failure, prompting in utero intervention. Amnioreduction followed by percutaneous embolization of the tumour with enbucrilate:Lipiodol Ultra-Fluid™ at a dilution of 1:5 was successfully performed. No repeat intervention or additional supportive measures were required throughout pregnancy and the baby was delivered at 36 weeks of gestation, following spontaneous labour. Due to prolonged neonatal jaundice, further investigations were undertaken, demonstrating subacute right portal vein thrombosis. Other previously reported causes of neonatal portal vein thrombosis such as umbilical vein thrombosis, neonatal umbilical vein catheterization, thrombophilia and sepsis were excluded. There was resolution of the thrombus by 6 months of life. A brief discussion of measures to minimize the risk of such an event and the long-term outcomes of neonatal portal vein thrombosis was included. Whilst the simplicity and efficacy of the procedure has been demonstrated in a handful of patients, judgment on its safety is best deferred. Counselling should be comprehensive, as even rare complications can result in significant postnatal morbidity.
A malignancy discovered in pregnancy is often difficult to manage; the optimal maternal therapy has to be balanced with the fetal well-being. Generally, the cancer is managed as though the patient is not pregnant. For the various site-specific cancers, surgery is the main modality of treatment; this should be individualized. Chemotherapeutic agents are highly teratogenic in the first trimester, with some adverse effects when used after 12 weeks' gestation. The overall survival rate for pregnancy-associated breast cancer is poor; the reasons for this are discussed. For cervical cancer, delivery by caesarean section appears to be the method of choice, with significantly better survival rates compared with those who deliver vaginally. Other gynaecological and non-gynaecological malignancies are discussed.
Pregnancy after treatment of choriocarcinoma with cerebral metastases is uncommon. We treated a patient successfully with less-toxic chemotherapeutic agents than those advocated by others together with whole brain irradiation. She subsequently had two uneventful pregnancies.
Uterine leiomyosarcoma (LMS) is rare but primary ovarian LMS is even rarer constituting less than 0.1% of all gynecologic disorders. Neither histologic features nor immunohistochemistry could be utilized to distinguish between uterine or ovarian origin. We illustrate a clinical case of metastatic LMS to the ovary in a woman with underlying uterine fibroid presenting with anemia with heavy menses.