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Diagnosis and management of hydatidiform mole and its complications: 2000 years of a medical challenge

2016; Wiley; Volume: 123; Issue: 7 Linguagem: Inglês

10.1111/1471-0528.13940

1471-0528

Eric Jauniaux, R.H.M. Verheijen,

Genetic Syndromes and Imprinting

Spontaneous resolution of hydatidiform mole (HM) has been reported since the first description of a molar pregnancy by Hippocrates (c.400 bc). Nicolaes Tulp (1593–1674), a Dutch surgeon famously depicted in Rembrandt's painting The Anatomy Lesson of Dr Nicolaes Tulp (1632), reported on the outcome of two of his patients in his Observationes Medicae (1672). One of them expulsed no less than a 'bucket full of water and blood', and both 'recovered quickly their former health'. A decade later, Jan Baptist van Lamzweerde, a Dutch physician, wrote, in the first monograph textbook on HM, Naturalis molarum uteri historia (1687), that 'the great' Harvey favoured surgical evacuation by means of 'a delicate silver instrument' over medical or spontaneous expulsion. In 1903, John D Malcolm a consultant surgeon at the Samaritan free hospital, London published the unusual case of ovarian bilateral cystic changes in a woman with HM. She fully recovered, but the authors note that 'had not hysterectomy and bilateral oophorectomy been performed before the malignant growth had time to trespass beyond the walls of the uterus' she would have perished (Malcolm DM et al. J Obstet Gynaecol Br Emp 1903;4:521–31). At that time the diagnosis was still made by (microscopic) inspection of tissue expulsed or evacuated from the uterus. Selmar Aschheim (1878–1965) and Bernhard Zondeck (1891–1966) were the first to publish on a practical pregnancy test using immature female mice whose ovarian follicles became visibly enlarged if injected with urine from pregnant women (Aschheim & Zondek, Klin Wchnschr 1928;730). They also reported remarkably high levels of human chorionic gonadotrophin (hCG) in the liquid and tissue of HM. Their work led to the bioassay for hCG, known as the Aschheim & Zondek, or A–Z, test. Other semi-quantitative urine bioassays using rabbits, rats and frogs were developed in the 1950s and 1960s to aid the prenatal differential diagnosis of HM. Ernest Kohorn and Roland Blackwell (J Obstet Gynaecol Br Commonw 1955;75:1014–18) at the Obstetric Hospital, London, were the first to publish on the prenatal diagnosis of HM using B-mode ultrasound (Figure 1), changing the antenatal management of this placental disease forever. Improvement in ultrasound imaging has allowed the diagnosis and evacuation of the molar tissue at an early stage, so reducing the risks of severe secondary complications such as eclampsia. In 1955, BM Hobson (J Obstet Gynaecol Br Emp 1955;62:354–63) demonstrated that hCG regression depends on the disappearance of the HM. This led to the concept of using hCG for the follow up of HM, which was greatly facilitated by the introduction of quantitative and more reproducible in vitro tests (Vaitukatis et al. Am J Obstet Gynecol 1972;113:751–8). Monitoring with a validated normal regression curve can now detect persistent trophoblastic disease at an early stage and prompt treatment with chemotherapy. A cohort study of 35 women with molar pregnancies with raised hCG over a long period after evacuation indicates that failure to regress to normal hCG serum values does not also warrant prompt treatment with chemotherapy(Taylor et al. BJOG 2016;123:xxx–xxx). None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.