|Year : 2015 | Volume
| Issue : 1 | Page : 65-67
Management of life-threatening uterine hemorrhage in a young patient with choriocarcinoma
Dasari Papa, Haritha Sagili
Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
|Date of Web Publication||23-Jun-2015|
Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry
Source of Support: None, Conflict of Interest: None
A 22-year-old primigravida who underwent medical abortion at 45 days of amenorrhea was diagnosed to have choriocarcinoma by histopathological examination after dilatation and curettage (D and C) for persistent bleeding per vaginum. Her serum β human chorionic gonadotropin values were less than 1 lakh and she was treated initially with methotrexate monotherapy elsewhere. She needed 10 units of packed cell transfusion for persistent hemorrhage and she was referred to our Institute because of persistent gestational trophoblastic neoplasia and intractable hemorrhage. She needed multiple transfusions and underwent laparotomy and bilateral internal iliac artery ligation with intrauterine packing as she had a severe bout of bleeding resulting in hemorrhagic shock. Post-operatively she was managed with chemotherapy employing EMACO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine/oncovine) and EMA (etoposide, methotrexate, actinomycin D) and thus her fertility was preserved.
Keywords: Choriocarcinoma, medical abortion, post-abortal bleeding
|How to cite this article:|
Papa D, Sagili H. Management of life-threatening uterine hemorrhage in a young patient with choriocarcinoma. Int J Adv Med Health Res 2015;2:65-7
| Introduction|| |
Choriocarcinoma is a rare malignancy but its incidence is high in South East Asia and Japan (9.2 and 3.3 per 40,000 pregnancies, respectively) when compared to Europe and North America.  In USA, the reported incidence is 2 to 7 per 100,000 pregnancies. In India, its incidence was reported to be 1 in 2958 pregnancies. 
The risk factors for its development include molar pregnancy, abortion and older age. It rarely occurs after medical termination of pregnancy for the first time. There are no cases reported in the literature regarding the development of choriocarcinoma following medical termination of pregnancy. Hence, this case is unique in that it occurred following termination of very early pregnancy by medical methods.
The most common symptom of choriocarcinoma occurring at any site is hemorrhage, more so if it occurs in the uterus. Hemorrhage is life threatening at times and it is challenging to manage such cases to preserve life as well as the uterus. Medical therapy is curative in more than 90% of cases of high-risk gestational trophoblastic disease but surgery is required in 50% of cases to save the life of the patient. 
| Case Report|| |
A 22-year-old primigravida married 6 months back underwent medical abortion at 45 days of amenorrhea at her home town and had undergone dilatation and curettage at a state medical college for persistent hemorrhage. The histopathology of the curettings showed choriocarcinoma and she was treated with single-dose methotrexate therapy for four cycles and received 10 units of blood transfusion in the same hospital. Her initial β human chorionic gonadotropin (β hCG) was 54,957 mIU/ml and it decreased to 818 mIU/ml in 4 weeks and then subsequently increased to 57,219 mIU/ml after a week of stopping methotrexate. She was diagnosed with persistent gestational trophoblastic neoplasia (GTN) and was referred to us. CT abdomen and thorax did not show any evidence of metastasis.
When she presented to us she was having persistent bleeding on and off and was suffering from vomiting and giddiness. She had moderate pallor clinically and received 3 units of packed cells over 2 days. Her serum β hCG was >2 lakhs and she was being evaluated for methotrexate toxicity. On ultrasound (USG), there was a diffuse echogenic area in the endometrial cavity and myometrium appeared normal except for hyperplasia [Figure 1].
|Figure 1: Trans abdominal USG of anteverted uterus with a diffuse echogenic mass lesion in the uterus|
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She had a large bout of hemorrhage and went into shock on fifth day of admission and her Hb fell to 6 gm%. She was resuscitated and an emergency laparotomy and bilateral internal iliac artery ligation was performed as facilities for embolization were unavailable. Uterus appeared normal size and there were no theca lutein cysts. At the end of laparotomy, persistent bleeding was seen through cervical os and the uterine cavity and vagina were packed with acriflavin-soaked ribbon gauze which was removed after 24 hours. She was given 4 units of packed cells, 4 fresh-frozen plasma (FFP) and tranexamic acid during the perioperative period. There was no bleeding after 24 hours and she was started on EMACO regimen on the seventh day and her β hCG fell to 1.5 lakhs after one course and 37.9 mIU/ml after the second course. But she developed high grade fever and neutropenia and hence she was started on GCF (granulocyte colony stimulating factor) and later she was treated with EMA regimen. Her β hCG was 0.6 mIU/L after one course of EMA and she received one more course after this and she is on follow up, and she has been clinically and radiologically normal for the last 6 months and her β hCG was within normal limits at the last follow up 2 months ago.
| Discussion|| |
Hemorrhage in choriocarcinoma can occur from the primary site or from the site of metastasis. The tumor bleeds heavily because of its high vascularity and as the vessels are highly fragile. Hemorrhage can be very severe requiring massive transfusion at times more than 20 units.  The present case already received 10 units of blood transfusion before she presented to us. The management options to control hemorrhage in choriocarcinoma include balloon tamponade like Bakri balloon, uterine artery embolization, radiotherapy, chemotherapy and hysterectomy. Hysterectomy was necessary to save life due to hemorrhage in almost 40% of patients in the Sheffields group.  Hysterectomy is the last option especially in young women who desire fertility but it may have to be undertaken to save life.  Conservative myometrial resection with uterine reconstruction may be undertaken in selective cases with localized disease without any metastasis.  In the present case, the lesion was in diffuse state involving the entire cavity. Uterine artery embolization followed by chemotherapy  is a good option but because of lack of facilities she was managed by bilateral internal iliac artery ligation when she had a severe bout of hemorrhage leading to shock. Radiotherapy can be employed to minimize hemorrhagic complications especially when brain and liver metastases are present and chemoradiation is both hemostatic and tumoricidal.  Radiation is not an option in young patients who desire fertility preservation as it affects the ovarian function. Chemotherapy could not be started immediately as her hematological parameters were not optimum for the same. The cure rate for choriocarcinoma even in the presence of metastasis is 80-90% with chemotherapy. Perforation and hemorrhage are the main reasons for hysterectomy and also for mortality. , Selective arterial embolization is the method of choice in cases of hemorrhage as it is found to be successful in 79% of cases as reported by Lim and colleagues.  Only 2 out of 14 patients required laparotomy for control of hemorrhage in this series. In the absence of facilities for embolization, internal iliac artery ligation and tamponade are the alternatives to control hemorrhage before deciding to do hysterectomy to save the life of the patient.
| References|| |
Lurian JR. Gestational trophoblastic disease I: Epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. Am J Obstet Gynecol 2010;203:531-9.
Krishna Menon MK, Palaniappan B. Diseases and abnormalities of the fetal membrane and placenta. In: Mudaliar AL, editor. Mudaliar and Menon's Clinical Obstetrics. 9 th
ed. Hyderabad: Orient Longman Limited; 1990. p. 200.
Lurin JR, Singh DK, Schink JC. Role of surgery in the management of high-risk gestational trophoblastic neoplasia. In: Yildirim Y, editor. Cytoreductive Surgery in Gynecologic Oncology: A Multidisciplinary Approach. Transworld Research Network; 2010. p. 153-60.
Eguzo K, Umezurike CC, Akwuruoha E. Uterine choriocarcinoma: A Gynaecological masquerader case report and review of literature. Modern Chemotherapy 2013;2:69-72.
Hanna RK, Soper JT. The role of surgery and radiation therapy in the management of gestational trophoblastic disease. Oncologist 2010;15:593-600.
Chandacham A, Kietpeerakool C, Khunamornpong S, Suprasert P, Srisomboon J, Charoenkwan K, et al
. Successful conservative treatment of large cervical choriocarcinoma with profuse vaginal bleeding. J Med Assoc Thai 2009;92:120-3.
Shetty SK, Lobo F, Harindar, Shetty M, Geetanjali, Anjali, et al
. Post-mortem diagnosis of Gestation Choriocarcinoma: A case report. J Ind Acad Forensic Med 2007;29:59-61.
Lim AK, Agarwal R, Seckl MJ, Newlands ES, Barrett NK, Mitchell AW, et al
. Embolization of bleeding residual uterine vascular malformations in patients with treated gestational trophoblastic tumours. Radiology 2002;222:640-4.