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A doença trofoblástica gestacional (DTG) agrupa um conjunto de anomalias do desenvolvimento trofoblástico, que incluem formas clínicas benignas como a mola hidatiforme completa e parcial, o nódulo do sítio placentário atípico e o sítio trofoblástico exagerado, e malignas, caracterizando a neoplasia trofoblástica gestacional (NTG). De modo geral, seu diagnóstico precoce antecipa complicações clínicas que podem estar associadas a near miss obstétrico. Diante da suspeição clínica, é a ultrassonografia (US) precoce o exame de escolha pa ra o diagnóstico, associado à dosagem sérica de gonadotrofina coriônica humana, capaz de minimizar a ocorrência de complicações clínicas associadas à gravidez molar. Nos casos de NTG, é a US também de grande valia para estadiamento, avaliação de prognóstico e acompanhamento da mulher tratada para DTG. Este estudo faz uma revisão sobre o papel da US na DTG, sendo importante para familiarizar os tocoginecologistas com essa doença e salientar o papel da US consoante as melhores práticas clínicas.(AU)

Gestational trophoblastic disease (GTD) includes a set of trophoblastic developmental anomalies, which include benign forms such as complete and partial hydatidiform mole, atypical placental site nodule and exaggerated trophoblastic site, and malignant forms, characterizing gestational trophoblastic neoplasia (GTN). In general, its early diagnosis anticipates clinical complications that could be associated with obstetric near miss. In view of clinical suspicion, early ultrasonography (US) and serum levels of human chorionic gonadotropin are the best diagnostic screening techniques, able to minimizing the occurrence of medical complications associated with molar pregnancy. In cases of GTN, US is also of great value for staging, assessment of prognosis and follow-up of women treated for GTN. This study reviews the role of US in GTD, being important to familiarize tocogynecologists with this disease and highlight the role of US according to best clinical practices to minimize the morbidity of these patients and maximize the remission rates of this disease.(AU)

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Dentro de las neoplasias no trofoblásticas gestacionales de tipo vascular, el corioangioma es la más común. Se caracteriza por presentar una proliferación exagerada de estructuras vasculares, con células endoteliales y vellosidades coriónicas que generan una alteración de los vasos sanguíneos tanto arteriales como venosos. Tiene una incidencia menor al 1%, con tasas de mortalidad perinatal aproximadas entre 18% a 40%. Se presenta el caso de un corioangioma placentario diagnosticado a las 26 semanas de gestación en una paciente de 21 años de edad sin controles prenatales previos, el cual generó un lóbulo accesorio de 7 cm con tinción positiva en el análisis inmunohistoquímico para anticuerpos antimúsculo liso y CD34, y negativa para Ki67. El corioangioma desencadenó complicaciones en el embarazo, con parto pretérmino, hidropesía fetal y retardo en el crecimiento intrauterino, que llevaron a la muerte fetal. La falta de control prenatal en nuestra paciente impidió que se detectaran las anomalías placentarias oportunamente, con un desenlace fatal para el feto. Un control prenatal adecuado con seguimiento ecográfico puede evitar eventos fatales como el presentado. El análisis macroscópico y microscópico de la placenta puede favorecer la identificación de los casos y el aporte a las estadísticas de incidencia y mortalidad.

Among vascular gestational nontrophoblastic tumors, chorioangioma is the most common. It is characterized by an exaggerated proliferation of vascular structures, with endothelial cells and chorionic villi that generate abnormalities of both arterial and venous blood vessels. It has an incidence of less than 1%, with perinatal mortality rates between 18% to 40%. We present the case of a 21-year-old patient without previous prenatal controls, with a placental chorioangioma diagnosed at 26 weeks of gestation that formed a 7 cm accessory lobe, with positive staining during immunohistochemical analysis for smooth anti-muscle antibodies and CD34, and negative for Ki67. The placental chorioangioma triggered complications during pregnancy, with preterm delivery, hydrops fetalis, and intrauterine growth retardation leading to fetal death. The lack of prenatal control in our patient prevented an early detection of placental abnormalities with a fatal outcome for the fetus. Adequate prenatal control with ultrasound monitoring can avoid fatal events such as the one presented. Macroscopic and microscopic analysis of the placenta can help identify cases and contribute to incidence and mortality statistics.

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Doença trofoblástica gestacional (DTG) é uma anomalia que engloba formas clínicas benignas (mola hidatiforme completa e parcial) e malignas (mola invasora, coriocarcinoma, tumor trofoblástico do sítio placentário e tumor trofoblástico epitelioide). O objetivo deste estudo é realizar levantamento epidemiológico retrospectivo de prontuários de 40 pacientes internadas entre abril de 2014 e fevereiro de 2016 com hipótese diagnóstica de DTG atendidas no Hospital Regional Norte/ Centro de Apoio à Saúde Reprodutiva da Mulher em Sobral, no Ceará, traçando o perfil de cada paciente (idade, paridade), além de fazer correlação dos parâmetros clínicos, laboratoriais e anatomopatológico. Entre as pacientes que obtiveram o diagnóstico de DTG, observou-se que em torno de 93,33% possuíam exame ultrassonográfico evidenciando possível mola hidatiforme; o anatomopatológico confirmou doença trofoblástica em aproximadamente 52,5% da população estudada. Este estudo é inédito, por ser o primeiro a realizar um levantamento de dados em pacientes com DTG na cidade de Sobral.(AU)

Gestational trophoblastic disease (GTD) is an anomaly that encompasses benign clinical forms (complete and partial hydatidiform mole) and malignant (invasive mole, choriocarcinoma, placental site trophoblastic tumor and epithelioid trophoblastic tumor). The objective of this study was to carry out a retrospective epidemiological survey of medical records of 40 hospitalized patients between April 2014 and February 2016 with diagnostic hypothesis of GTD attended at the Regional Hospital Norte/Center for Support to Women's Reproductive Health in Sobral, Ceará, drawing the profile of each patient (age, parity), in addition to correlating the clinical, laboratory and anatomopathological parameters. Among the patients who had the diagnosis of GTD, it was observed that about 93.33% had ultrasonographic examination evidencing a possible hydatidiform mole; the anatomopathological confirmed trophoblastic disease in about 52.5% of the study population. This study is unprecedented because it is the first to perform a data collection in patients with GTD in the city of Sobral.(AU)

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ABSTRACT Objective: To report the case of a placental site tumour which presented clinically in the form of a nephrotic syndrome secondary to IgA nephropathy. Case presentation: A 24-year-old woman, primigravida, referred to a Level IV complexity institution in Bogotá (Colombia), where she was diagnosed with IgA nephropathy as a paraneoplastic manifestation of a placental site trophoblastic tumour. After total hysterectomy as treatment, the patient evolved well, with oedema resolution and a drop in proteinuria. The patient completed one year of medical follow-up, with no evidence of disease. Discussion: Placental site trophoblastic tumour is rare, is part of the differential diagnosis for gestational trophoblastic disease and may present as a renal paraneoplastic manifestation which usually resolves once the tumour is treated. IgA nephropathy may be secondary to chronic inflammatory diseases and neoplastic diseases, as in this case.

RESUMEN Objetivo: reportar un caso de tumor del lecho placentario, cuya manifestación clínica fue síndrome nefrótico secundario a nefropatía IgA. Presentación del caso: se describe el caso de una paciente de 24 años, primigestante, quien fue remitida a una institución de cuarto nivel de complejidad localizada en Bogotá (Colombia), en donde se le hizo diagnóstico de nefropatía por IgA como manifestación paraneoplásica de un tumor trofoblástico del lecho placentario. Se realizó histerectomía total como tratamiento, con evolución satisfactoria, con resolución de los edemas y descenso de proteinuria; completó un año en seguimiento médico, sin evidencia de enfermedad. Discusión: el tumor trofoblástico del lecho placentario es infrecuente, hace parte del diagnóstico diferencial de la enfermedad trofoblástica gestacional (ETG), y puede manifestarse con fenómenos paraneoplásicos a nivel renal, que generalmente se resuelven con el tratamiento del tumor. La nefropatía por IgA puede ser secundaria a enfermedades inflamatorias crónicas y a patologías neoplásicas, como en este caso.

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Chorangiomas are the most common non-trophoblastic tumors, generally appearing as incidental findings at the moment of delivery. The presence of leiomyomas inside placental parenchyma has been also described sporadically. In these cases, leiomyomas were primary maternal uterine neoplasms incorporated into the placenta during pregnancy. This case report presents a very unusual case of mesenchymal lesion, located in the fetal surface of the placenta, characterized by combined histopathologic and immunohistochemical features of chorangioma and leiomyoma. A single case reported with these characteristics was found in the international scientific literature, named as "chorangioleiomyoma". To our knowledge, this is the first case reported in our country.

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Los corangiomas son los tumores placentarios no trofoblásticos más frecuentes; generalmente aparecen como hallazgos al momento del alumbramiento. La presencia de leiomiomas en las placentas también ha sido descripta esporádicamente, siendo por lo general tumores maternos uterinos incorporados a la placenta durante la gestación. En este trabajo se informa un caso muy inusual de lesión mesenquimática, localizada en la cara fetal placentaria, caracterizada por la combinación de rasgos histopatológicos e inmunohistoquímicos de corangioma y leiomioma. Se encontró un solo caso informado en la bibliografía científica internacional con estas características, denominado "corangioleiomioma". En nuestro conocimiento, el caso aquí expuesto es el primero comunicado en nuestro país.

Chorangiomas are the most common non-trophoblastic tumors, generally appearing as incidental findings at the moment of delivery. The presence of leiomyomas inside placental parenchyma has been also described sporadically. In these cases, leiomyomas were primary maternal uterine neoplasms incorporated into the placenta during pregnancy. This case report presents a very unusual case of mesenchymal lesion, located in the fetal surface of the placenta, characterized by combined histopathologic and immunohistochemical features of chorangioma and leiomyoma. A single case reported with these characteristics was found in the international scientific literature, named as "chorangioleiomyoma". To our knowledge, this is the first case reported in our country.

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Chorioangiomas are the most common benign placental tumors, with an estimated prevalence of 1%. Whilst small chorioangiomas usually remain asymptomatic and are of no clinical significance, larger tumors (>4cm) can be associated with a variety of complications, ranging from fetal anemia to in-utero demise in up to 40% of cases. Despite size being a major determinant for the risk of complications, the degree of the chorioangioma's vascularity also seems to play a role. In fact, in selected cases, occluding the tumors vessels (e.g. with alcoholic instillation) appears to improve the prognosis due to the subsequent tumor ischemia. We present the case of a 40-year-old woman who at 29 weeks was found to have a large placental hypervascular mass (93mm×66mm) and polyhydramnios, with an elevated peak systolic volume in the middle cerebral artery. She was given corticosteroids for fetal lung maturation, and throughout her admission both the volume of amniotic fluid stabilized and the peak systolic volume in the middle cerebral artery normalized, with changing of the ultrasonographic characteristics of the chorioangioma, with apparent progressive necrosis. At 34 weeks, a large subchorionic hematoma was found and, due to the risk of impending placental abruption, we opted to deliver by cesarean section, with a favorable outcome.(AU)

Corioangiomas são os tumores placentários benignos mais comuns, com uma prevalência estimada de 1%. Embora pequenos corioangiomas geralmente permaneçam assintomáticos e não tenham significância clínica, tumores maiores (> 4cm) podem estar associados a diversas complicações, que variam de anemia fetal até a morte intraútero em até 40% dos casos. Ainda que o tamanho do tumor seja um determinante principal para o risco de complicações, o grau da vascularidade do corioangioma também parece desempenhar um papel importante. De fato, em casos selecionados, a oclusão dos vasos tumorais (por exemplo, através de instilação de álcool) parece melhorar o prognóstico devido à subsequente isquemia tumoral. Apresentamos o caso de uma mulher de 40 anos a qual, com 29 semanas de gestação, apresentava grande massa hipervascular placentária (93×66mm) e poli-hidrâmnio, com elevação do peak systolic volume in the middle cerebral artery. Ela recebeu corticosteroides para a estimulação da maturação pulmonar fetal e durante a sua internação o volume de líquido amniótico foi estabilizado e o peak systolic volume in the middle cerebral artery normalizado, com mudança nas características ultrassonográficas do corioangioma, com necrose progressiva aparente. Com 34 semanas de gestação, observou-se a presença de hematoma subcoriônico de grande porte e, devido ao risco de descolamento prematuro da placenta, optou-se por parto cesariano, com desfecho favorável.(AU)

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El coriocarcinoma es una patología infrecuente pero potencialmente fatal si no se trata. Se incluye dentro de las neoplasias trofoblásticas gestacionales, un grupo de tumores malignos altamente invasivos, metastáticos y muy vascularizados. Su presentación tras una gestación a término conlleva peor pronóstico que tras un aborto o una mola hidatiforme porque refleja un retraso en el diagnóstico y tratamiento. Describimos el caso de una paciente que acudió al servicio de urgencias, refiriendo metrorragia escasa desde un parto normal hace dos meses y posteriormente presentó un sangrado grave durante su hospitalización. Los elevados niveles de β-hCG, la ecografía-Doppler, las pruebas de imagen y las manifestaciones clínicas fueron suficientes para diagnosticar un coriocarcinoma postparto. El tratamiento precoz con poliquimioterápicos permitió una evolución favorable de la paciente.

Choriocarcinoma is an infrequent disease but potentially fatal if untreated. It is included in trophoblastic gestational neoplasia, a range of malignant tumors highly invasive, metastatic and very vascular. Its presentation after term pregnancies carries a worse prognosis than after a miscarriage or a hydatidiform mole because it reflects a delay in diagnosis and treatment. We report the case of a patient who presented to the emergency department referring little metrorrhagia from a normal delivery two months ago and severe bleeding later during her hospital stay. The high serum β-hCG level, the Doppler ultrasonography, the imaging test and the clinical manifestation were enough to diagnose a non-metastatic postpartum choriocarcinoma. Early treatment with polychemotherapy allowed a favorable evolution of the patient.

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Mola hidatiforme parcial recorrente é evento em que há repetição da mola hidatiforme parcial. Há cerca de 100 casos relatados na literatura e dúvida se essa entidade pode evolver para neoplasia trofoblástica gestacional pós-molar. Apresenta-se relato de caso de paciente com recorrência de mola hidatiforme parcial em que houve aumento de embriopatia, bem como transformação maligna da mola parcial recorrente. Empregou-se quimioterapia com Methotrexate para induzir cura. Não obstante seja ocorrência rara, a importância deste relato encontra-se na evidência de neoplasia trofoblástica gestacional em recorrência de mola hidatiforme parcial, determinando vigilância hormonal rigorosa para detectar a malignização desses blastomas.

Recurrent partial hydatidiform mole is an event of repetitive partial hydatidiform mole. It has been reported around 100 cases in the literature and it is still unclear if this entity can evolve to postmolar gestational trophoblastic neoplasia. In this report, it is presented a case of recurrent partial hydatidiform mole with an increase in embriologic alterations, as well as malignization of recurrent partial hydatidiform mole. Chemotherapy with Methotrexate regimen was used to induce remission. Although rare, the importance of this report relies on the evidence of gestational trophoblastic neoplasia in recurrent partial hydatidiform mole, demanding straight hormonal surveillance to detect malignization of these tumors.

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Se presenta el caso de una mola hidatiforme completa y feto vivo a término coexistente en una paciente de 30 años, II gestas I para, con embarazo de 29 semanas y elevación de la presión arterial. La imagen ecográfica al ingreso de la placenta sugirió la presencia de mola hidatiforme junto a un feto normal. Se realizó seguimiento expectante hasta las 37 semanas, cuando presentó un episodio de sangrado genital por lo que se realizó una cesárea y se obtuvo un recién nacido vivo masculino normal, placenta y una tumoración de un tejido vesicular. El examen de anatomía patológica del tejido vesicular reportó mola hidatiforme completa.

A case of complete hydatiform mole with live term coexisting fetus in a 30-year-old patient, II gravida, 1 para, with a pregnancy of 29 weeks and rise of blood pressure is presented. Ultrasound image at admission suggested the presence of hydatiform mole together a live fetus. Patient was followed until 37 weeks, when presented an episode of vaginal bleeding cause a cesarean section was done and a live normal male newborn, placenta and a vesicular tissue tumor were obtained. Pathology exam of vesicular tissue reported complete hydatiform mole.

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