Gestational trophoblastic disease (GTD) is a spectrum of tumours tumour. The last three are termed gestational trophoblastic .. ACOG Technical Bulletin Gestational trophoblastic disease (GTD) forms a group of disorders spanning the conditions of complete and partial molar pregnancies through to the malignant. Gestational Hypertension and Preeclampsia ACOG Practice Bulletin # Diagnosis and Treatment of Gestational Trophoblastic Disease If you are an ACOG Fellow and have not logged in or registered to Obstetrics & Gynecology, please follow these Thyroid Disease in Pregnancy ยท Practice Bulletin No.

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Diagnosis and treatment of gestational trophoblastic disease: ACOG Practice Bulletin No. 53

To receive news and publication updates for Obstetrics and Gynecology International, enter your email address in the box below. Correspondence should be addressed to Imane Khachani ; moc. This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gestational Trophoblastic Disease GTD management requires clear guidelines for diagnosis, treatment, and follow-up. Unequal management skills among practitioners, inadequate treatment, irregular surveillance, and drop-out are common in resource-limited settings and can lead to life-threatening complications and morbidities.

Methods and Program Description. In-depth review of management protocols was carried out, and concise guidelines were developed, with targeted training for physicians. A physical space and a weekly fixed GTD consultation were set, and personalized follow-up was established for each patient. During the period from October to June50 patients were included in this program. An average of 2. Gestational Trophoblastic Diseases are a heterogeneous group of entities defined by the abnormal growth of trophoblast cells inside the uterus after conception, with different clinical presentations, imaging features, histological characteristics, and therapeutic options [ 1 ].

Their prognosis is generally good but relies on accurate diagnosis, adequate treatment, and thorough posttreatment surveillance for early diagnosis of complications. In Morocco, little research has been conducted on GTD and the few studies published raised alarming concerns regarding late diagnosis, irregular surveillance, frequent drop-out, and common delayed diagnosis of preventable complications [ 67 ].

This prospective study was conducted by descriptive and analytical method from October to June and aimed at assessing the implementation of a GTD management program at the National Center for Reproductive Health in Rabat.

The implementation process included the following: These protocols established the following: Retention diagnosis was followed by readmission and second aspiration. Given the absence of referent histopathologist in GTD in Morocco, this surveillance scheme was adopted for both complete hydatidiform moles CHM and partial hydatidiform moles PHM to ensure higher security for patients and avoid the consequences of a potential underestimated diagnosis.

A section of the Registry indicated the date of the next scheduled consultation and hCG test for each patient, allowing active outreach phone call or text message in case of no show.

From October to June This cohort comprehended all patients consulting directly or referred to the Center with GTD suspicion, for whom histopathological evidence of the disease was established during their management and treatment at the Center. Our Center was not their regional referral institution but they chose it for the reasons reported below: The second group of patients were all beneficiaries of the National Medical Assistance Regimen, which allowed free access to consultations and paraclinical tests in the Center.

Mean gestational age GA was 12 weeks with extremes ranging from 5 to 24 weeks. All vacuum aspirations were performed at the Center and all aspiration products sent for histopathological analysis. The high risk patient was referred to the National Oncology Institute for management. One patient from the Meknes-Tafilalet region dropped out after the first postvacuum aspiration control consultation.

She could not be reached through the contact details she left at her admission. Two patients got pregnant before completing their surveillance protocol, respectively, at 12 and 20 weeks after vacuum aspiration. Their pregnancy was closely monitored at the Pregnancies with High Risk Department of the Center and was carried to term with no complications. Extremes ranged from 1 to 6 phone calls or text messages to remind patient with a missed appointment and get the patient to consult at the hospital.

The results of this study have demonstrated the multiple benefits of implementing a GTD management program in a tertiary hospital in a low-resource setting. The incidence of GTD in our Center was 2. Indeed, since most spontaneous miscarriages and vacuum aspiration products for pregnancy loss are not systematically submitted for histopathological analysis due to cost constraints, the real incidence of GTD in the region remains difficult to establish, and the abovementioned numbers are probably underestimates.


In the rest of Morocco, little data is available on GTD. In the neighboring Great Casablanca region, Boufettal et al.

In the Middle East and North Africa region, data on GTD incidence is also scarce and available statistics from local studies show a great variability.

Similarly to Morocco, the absence of nation-wide data due to the lack of unified reporting mechanisms and absence of a structure centralizing these data makes it challenging to document the real incidence of the disease.

While considering the epidemiological characteristics of our patients in more detail, our study showed that the age group under 25 was particularly affected in our context, accounting for the third of the cohort, along with nulliparous patients who formed nearly half of it. This pattern was reported by Khabouze et al.

These studies also found a low socioeconomic status for most affected patients. In the nineties, Flam et al. Some authors attributed this pattern to poor protein diet; others mentioned the potential role of Vitamin A or Folic Acid deficiency [ 2223 ].

It seems that there are multiple environmental factors involved in increased GTD risk, but further research is necessary to affirm their exact role in generating or favoring the genesis of GTD. This was initially considered as a major challenge for setting an effective GTD management program and ensuring correct adherence to the necessary surveillance. However, the design of an IEC module, using the local dialect and an accessible, culturally sensitive awareness-raising messaging, was likely instrumental in enhancing adherence to the program and fostering an effective patient-practitioner therapeutic partnership.

This observation supports the necessity to include a patient-specific approach to GTD management programs in similar contexts, taking into account the characteristics of the population targeted and their specific IEC needs.

While similar data were found in studies in other low and middle income countries, Egypt, Turkey, Iran, and Tunisia [ 13141819 ], in France, Abboud et al. These findings highlight the importance of systematic first-trimester ultrasound examination, as it allows early diagnosis and management of the disease, key elements for a better prognosis.

First-trimester ultrasound scan is not systematic in Morocco, and it remains rarely performed in the public health sector in absence of clinical warning signs. This is mainly due to limited trained human resources and scarce availability of sonographs and partly explains the delayed gestational age at diagnosis of the disease.

The findings of our study suggest the need to investigate possibilities of implementing routine first-trimester ultrasound scan, at least for populations at risk, which could be determined according to our local context and capacities.

Diagnosis and treatment of gestational trophoblastic disease: ACOG Practice Bulletin No.

All 50 cases were thoroughly documented and their management was approved according to the adopted guidelines. No incidents or complications were reported.

Retention after first evacuation is seldom documented in the literature. The study of Abboud et al. Retention is likely related to the initial size of the mass but also to the skills of the practitioner performing the procedure [ 924 ]. Despite these similarities, the interpretation of our findings should be cautious since, in absence of a referent histopathologist with specific training in GTD diagnosis, strict differentiation between both could be uncertain.

Several cultural, social, and economic factors could contribute to diagnosis delay in our context, including i poor early prenatal care: This was the main driver for canceling all fees for GTD patients and ensuring adherence to the treatment and surveillance.

The correlation between delay in diagnosis and negative outcomes for GTD has clearly been established by several authors. Similarly, Lurain et al. The mean outreach calls or text messages of 2.

This further supports the crucial need for proactive personalized monitoring of GTD in our context, given the literacy and challenging socioeconomic realities of our patients. Indeed, the studies of Cisse et al.

These challenges are common in resource-limited settings and various components of our program were instrumental in addressing them. The first patient dropped out at an diseas stage of the surveillance protocol. She lived diease another region Meknes-Tafilaletlocated approximately miles away from the city of Rabatwhich was probably the cause of nonadherence, due to the costs incurred by regular traveling to Rabat to zcog her surveillance.


This could be done through implementing similar programs, following the same steps and procedures in other regions, particularly those where patients tend to come to Rabat to seek quality healthcare triphoblastic. We also reported 2 cases of contraceptive failure. Both were patients under 25, recently married, and nulliparous. They had voluntarily stopped their contraception to become pregnant again.

Di Mattei et al. Several models highlight how these perceptions and beliefs become a key element of psychological adaptation of patients to their condition and adherence to the therapeutic project [ 3435 ]. This could explain the attitude of rushing into a new pregnancy for our 2 patients, especially in a cultural context where proof of fertility is essential for every young married woman. While its complex and intricate social, cultural, and economic drivers would be difficult to address at the level of our Center, awareness-raising campaigns and educational sessions encouraging women to seek prenatal care early during pregnancy could be developed as part of the overall IEC curricula of the Center, targeting the patients attending the different departments Family Planning, Pregnancies with High Risk, etc.

This led us at the design stage to adopt a unified one-year surveillance scheme for all patients, regardless of the histopathological examination outcome. While recognizing the benefit of this measure in ensuring enhanced security for our patients, it is important to highlight the crucial gsstational for in-depth GTD-specific training for histopathologists in order to avoid unnecessary follow-up and expenses in laboratory tests and achieve better cost-effectiveness and possibility of program duplication in other resource-limited settings [ 36 ].

In the short run, working on the challenges identified through this evaluation is our first goal, in order to further strengthen the program geestational the Center. We would primarily focus trophoblastid the specific training needs trophoblastlc IEC components highlighted in our analysis. This would in the long-term open the possibility of duplicating acov program in other healthcare structures, at the regional and national levels, by organizing targeted training sessions introducing gestatonal program, its organization, management, and materials.

Our acquired expertise through this 3-year experience would support the creation of a network of GTD reference centers and would raise our Center to the level of National Observatory, centralizing nation-wide data, sharing skills and expertise at the national level, and providing periodic quality training for practitioners involved in GTD management.

GTD management requires a competent healthcare structure, with clear diagnosis, treatment, and surveillance guidelines, to ensure an optimal care for patients. Our study documented the first experience of implementing a GTD management program in a public healthcare setting in Morocco. This experience responds to the advocacy calls of various GTD management Centers of Excellence for the creation of reference healthcare structures, with a well-established organization, a codified and acoog management program, and proactive surveillance mechanisms, based on a customized model of patient-practitioner partnership.

Our program is a simple, cost-effective, and easily duplicable model for settings with similar characteristics and constraints and has the gestqtional to greatly contribute to organizing and improving GTD management in such settings.

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Obstetrics and Gynecology International. Indexed in Web of Science. Subscribe to Table of Contents Alerts. Table of Contents Alerts. Introduction Gestational Trophoblastic Diseases are a heterogeneous group of entities defined by the abnormal growth of trophoblast cells inside the uterus after conception, with different clinical presentations, imaging features, histological characteristics, and therapeutic options [ 1 ].

Methods and Program Description This prospective study was conducted by descriptive and analytical method from October to June and aimed at assessing the implementation of a GTD management program at the National Center for Reproductive Health in Rabat. Results From October to June View at Google Scholar J. View at Google Scholar S. View at Google Scholar B.