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Background: High‐risk gestational trophoblastic neoplasia (GTN) is rare and treated with diverse approaches. Limited published institutional data has yet to be systematically reviewed. Objectives: To compile global high‐risk GTN (prognostic score ≥7) cohorts to summarise treatments and outcomes by disease characteristics and primary chemotherapy. Search Strategy: MEDLINE, Embase, Scopus, ClinicalTrials.gov and Cochrane were searched through March 2021. Selection Criteria: Full‐text manuscripts reporting mortality among ≥10 high‐risk GTN patients. Data Collection and Analysis: Binomial proportions were summed, and random‐effects meta‐analyses performed. Main Results: From 1137 records, we included 35 studies, representing 20 countries. Among 2276 unique high‐risk GTN patients, 99.7% received chemotherapy, 35.8% surgery and 4.9% radiation. Mortality was 10.9% (243/2236; meta‐analysis: 10%, 95% confidence interval [CI] 7–12%) and likelihood of complete response to primary chemotherapy was 79.7% (1506/1890; meta‐analysis: 78%, 95% CI: 74–83%). Across 24 reporting studies, modern preferred chemotherapy (EMA/CO or EMA/EP) was associated with lower mortality (overall: 8.8 versus 9.5%; comparative meta‐analysis: 8.1 versus 12.4%, OR 0.42, 95% CI: 0.20–0.90%, 14 studies) and higher likelihood of complete response (overall: 76.6 versus 72.8%; comparative meta‐analysis: 75.9 versus 60.7%, OR 2.98, 95% CI: 1.06–8.35%, 14 studies), though studies focused on non‐preferred regimens reported comparable outcomes. Mortality was increased for ultra‐high‐risk disease (30 versus 7.5% high‐risk; meta‐analysis OR 7.44, 95% CI: 4.29–12.9%) and disease following term delivery (20.8 versus 7.3% following molar pregnancy; meta‐analysis OR 2.64, 95% CI: 1.10–6.31%). Relapse rate estimates ranged from 3 to 6%. Conclusions: High‐risk GTN is responsive to several chemotherapy regimens, with EMA/CO or EMA/EP associated with improved outcomes. Mortality is increased in patients with ultra‐high‐risk, relapsed and post‐term pregnancy disease. Linked article: This article is commented on by Lawrence Impey, pp. 494 in this issue. To view this mini commentary visit https://doi.org/10.1111/1471‐0528.17383 [ABSTRACT FROM AUTHOR]

Objective: To assess whether the incidence and aggressiveness of molar pregnancy (MP) and postmolar gestational trophoblastic neoplasia (GTN) changed during the COVID‐19 pandemic. Design: Observational study with two separate designs: retrospective multicentre cohort of patients with MP/postmolar GTN and a cross‐sectional analysis, with application of a questionnaire. Setting: Six Brazilian Reference Centres on gestational trophoblastic disease. Population: 2662 patients with MP/postmolar GTN treated from March–December/2015–2020 were retrospectively evaluated and 528 of these patients answered a questionnaire. Methods: Longitudinal retrospective multicentre study of patients diagnosed with MP/ postmolar GTN at presentation and a cross‐sectional analysis, with application of a questionnaire, exclusive to patients treated during the period of study, to assess living and health conditions during the COVID‐19 pandemic compared with previous years. Main outcome measures: The incidence of MP/postmolar GTN. Results: Compared with the last 5 pre‐pandemic years, MP/postmolar GTN incidence remained stable during 2020 (COVID‐19 pandemic). Multivariable logistic regression, adjusted for the patient age, showed that during 2020, presentation with MP was more likely to be >10 weeks of gestation (adjusted odds ratio [aOR] 2.50, 95% confidence interval [CI] 1.90–3.29, P < 0.001), have a pre‐evacuation hCG level ≥100 000 iu/l (aOR 1.77, 95% CI 1.38–2.28, P < 0.001) and time to the initiation of chemotherapy ≥7 months (aOR 1.86, 95% CI 1.01–3.43, P = 0.047) when compared with 2015–2019. Conclusions: Although the incidence of MP/postmolar GTN remained stable during the COVID‐19 pandemic in Brazil, the pandemic was associated with greater gestational age at MP diagnosis and more protracted delays in initiation of chemotherapy for postmolar GTN. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the short‐term psychological consequences of gestational trophoblastic disease (GTD). Design: A prospective observational multicentre cohort study. Setting: Nationwide in the Netherlands. Population: GTD patients. Methods: Online questionnaires directly after diagnosis. Main outcome measures: Hospital Anxiety and Depression Scale (HADS), Distress Thermometer (DT), Impact of Event Scale (IES) and Reproductive Concerns Scale (RCS). Results: Sixty GTD patients were included between 2017 and 2020. Anxious feelings (47%) were more commonly expressed than depressive feelings (27%). Patients experienced moderate to severe adaptation problems in 88%. Patients who already had children were less concerned about their reproductivity than were patients without children (mean score 10.4 versus 15.0, P = 0.031), and patients with children experienced lower distress levels (IES mean score 25.7 versus 34.7, P = 0.020). In addition, patients with previous pregnancy loss scored lower for distress compared with patients without pregnancy loss (IES mean score 21.1 versus 34.2, P = 0.002). Discussion: We recommend that physicians monitor physical complaints and the course of psychological wellbeing over time in order to provide personalised supportive care in time for patients who have high levels of distress at baseline. Conclusions: GTD patients experience increased levels of distress, anxiety and depression, suggesting the diagnosis has a substantial effect on the psychological wellbeing of patients. The impact of GTD diagnosis on intrusion and avoidance seems to be ameliorated in patients who have children or who have experienced previous pregnancy loss. Patients with gestational trophoblastic disease (GTD) experience short‐term psychological consequences such as distress, anxiety and depression, suggesting that the diagnosis GTD has a substantial effect on the psychological wellbeing of patients. Various patient characteristics affect the impact of GTD diagnosis. Patients with gestational trophoblastic disease (GTD) experience short‐term psychological consequences such as distress, anxiety and depression, suggesting that the diagnosis GTD has a substantial effect on the psychological wellbeing of patients. Various patient characteristics affect the impact of GTD diagnosis. [ABSTRACT FROM AUTHOR]

Background: Epidemiological data on obstetric and oncologic complications in twin pregnancies combining a complete hydatidiform mole (CHM) coexisting with a normal fetus and placenta are limited.Objectives: To evaluate perinatal and obstetric outcomes for mother and fetus and risk of gestational trophoblastic neoplasia (GTN) in twin pregnancies including a CHM.Search Strategy: PubMed, MEDLINE and EMBASE and the grey literature were searched for articles published between May 1980 and May 2019 using a protocol designed a priori and registered on PROSPERO (CRD42018112524).Selection Criteria: Observational cohort studies of four or more cases confirmed by histopathology and providing data on pregnancy outcomes and GTN.Data Collection and Analysis: Two reviewers independently reviewed abstracts and full-text articles. The quality of the studies was assessed with the Newcastle-Ottawa scale and a meta-analysis was performed.Main Results: Of the 344 abstracts identified, 14 studies (244 cases) met the eligibility criteria. The incidence of maternal complication in ongoing pregnancies was 80.8% and included vaginal bleeding, hyperthyroidism and pre-eclampsia. There were overall 91 (50%) live births in ongoing pregnancies and 83 (34%) of the total cases were subsequently diagnosed with GTN. Substantial and significant (P < 0.001) heterogeneity was found for the incidence of preeclampsia indicating variability in reporting the incidence of some obstetric complications between studies.Conclusions: Patients diagnosed with a twin pregnancy combining a CHM and an apparently normal fetus have a high risk of perinatal complications, low live-birth rates and around a third of them will develop a GTN and should be managed by specialised multidisciplinary teams.Tweetable Abstract: Our study indicates a high rate of obstetric and oncologic complications in patients presenting with a complete hydatidiform mole and coexistent normal fetus. [ABSTRACT FROM AUTHOR]

Objective: To find risk factors for second-line dactinomycin failure in patients with low-risk gestational trophoblastic neoplasia (GTN).Design: Retrospective multicentre study.Setting: Tertiary reference centre.Population: Patients with low-risk GTN, treated with dactinomycin after methotrexate (MTX) failure.Methods: Retrospective analysis of 45 patients with low-risk GTN treated with dactinomycin after MTX failure, registered between 2006 and 2018.Main Outcome Measures: Treatment outcome and risk factors for second-line dactinomycin failure.Results: Thirty patients (66.7%) were cured and 15 patients (33.3%) required third-line therapy. Type of antecedent pregnancy and hCG levels pre-dactinomycin were risk factors for failure in univariate analysis (odds ratio [OR] 19.30, 95% CI 2.04-182.60, P = 0.01 and OR 2.77, 95% CI 1.18-6.50, P = 0.02, respectively). Level of hCG pre-dactinomycin remained a significant risk factor in multivariate analysis (OR 2.93, 95% CI 1.02-8.40, P = 0.045). Complete remission (CR) was achieved in 83.3% of patients with pre-dactinomycin hCG levels <10 ng/ml, in 75% with hCG levels between 10 and 20 ng/ml, in 66.7% with hCG levels between 20 and 30 ng/ml, and in 50% with hCG levels between 30 and 40 ng/ml. No patients with hCG levels >40 ng/ml achieved CR. Patients with dactinomycin failure were treated surgically and/or with multi-chemotherapy; all except one achieved CR.Conclusions: Treatment with dactinomycin after MTX failure in patients with low-risk GTN resulted in CR in 66.7%. Chance of curative treatment with dactinomycin is strongly related to the hCG level.Tweetable Abstract: Chance of curative treatment with dactinomycin after MTX failure in GTN patients is strongly related to the level of hCG pre-dactinomycin. [ABSTRACT FROM AUTHOR]

Objective: Presence of lung metastases in low-risk gestational trophoblastic neoplasia (GTN) is generally considered not to influence prognosis. However, in a recent study in the Netherlands, GTN patients with lung metastases had a higher recurrence rate and more disease-specific deaths compared with patients without metastases. The aim of the present study was to validate these findings in a different country.Design: Historical cohort study.Setting: Charing Cross Hospital, United Kingdom.Population: A total of 1040 low-risk GTN patients treated with methotrexate (MTX) between 2002 and 2016 were identified: 65 with lung metastases (group 1) and 975 without metastases (group 2).Methods: Baseline characteristics, MTX resistance, survival and recurrence rates were recorded and compared between both groups.Main Outcome Measures: MTX resistance, recurrence rate and survival.Results: The occurrence of MTX resistance and median number of MTX courses to achieve remission was significantly higher in patients with lung metastases than patients without metastases (60% versus 38.9%, P = 0.001; and nine versus six courses, P < 0.001). All choriocarcinoma patients (n = 4) with lung metastases developed MTX resistance. The recurrence rate was also higher in group I (9.2% versus 2.7%; P = 0.012). Disease-specific survival was 100% in both groups.Conclusions: The presence of lung metastases at the start of MTX therapy is associated with increased incidence of MTX resistance and recurrence in low-risk GTN without affecting overall survival, which remains 100%. However, individuals with low-risk choriocarcinoma with lung metastases are likely to become resistant to MTX and primary multi-agent chemotherapy should be considered.Tweetable Abstract: The presence of lung metastases appears to increase the risk of recurrence in low-risk GTN, but does not affect overall cure rates and survival. [ABSTRACT FROM AUTHOR]

Background: Distinguishing hydatidiform moles (HMs) from nonmolar specimens and the subclassification of HM are important because complete hydatidiform mole (CHM) is associated with an increased risk of development of gestational trophoblastic neoplasia. However, diagnosis based solely on morphology has poor inter-observer reproducibility. Recent studies have demonstrated that the use of p57KIP2 immunostaining improves diagnostic accuracy for CHM.Objectives: To evaluate the accuracy of p57KIP2 immunostaining compared with molecular genotyping for the diagnosis of CHM.Search Strategy: Major databases were searched from inception to March 2017 using the terms 'hydatidiform mole', 'p57', and 'genotyping', with their variations, and the search limit for the relevant study design.Selection Criteria: Any cross-sectional study, case series, case-control study, cohort study, or clinical trial that evaluated the accuracy of p57KIP2 immunostaining for the diagnosis of CHM compared with genotyping was included. Case reports, narrative reviews, expert opinions, and animal testing were excluded.Data Collection and Analysis: Extracted accuracy data were tabulated and pooled using a hierarchical bivariate random effects model.Main Results: Bivariate meta-analysis produced a summary sensitivity of 0.984 (95% CI: 0.916-1.000) and specificity of 0.625 (95% CI: 0.503-0.736) with significant heterogeneity for specificity (I2 = 71.8, chi-square P = 0.029). The pooled summary diagnostic odds ratio was 56.54 (95% CI: 11.03-289.74) with no heterogeneity (I2 = 0.00%, chi-square P = 0.67). The diagnostic performance of the test was high with an area under the curve of (AUC) 0.980.Conclusions: p57KIP2 immunostaining is accurate when diagnosing CHM. It can be used as an adjunct test in a combination algorithmic approach.Tweetable Abstract: A meta-analysis to evaluate the accuracy of p57KIP2 compared with genotyping to diagnose CHM. [ABSTRACT FROM AUTHOR]

Mental health of Urban Mothers (MUM) study: a multicentre randomised controlled trial, study protocol. We read with great interest the study entitled 'The psychological impact of gestational trophoblastic disease: a prospective observational multicentre cohort study' by Blok et al.1 We congratulate the authors for their commendable work in assessing the psychological consequences such as distress, depression and anxiety among patients with gestational trophoblastic disease (GTD). Secondly, the study mentions three patients (5%) who underwent hysterectomy and ovariectomy, in addition to curettage. [Extracted from the article]

In their letter, Avir Sark and colleagues question whether more information is known about what type of mental health disorder patients suffer and whether patients still use (or have used) any antidepressant medication. The second question raised was why three patients underwent hysterectomy, hysterectomy and tubectomy, and hysterectomy and ovariectomy. This, and no other suspected ovarian tumour, is most likely the reason tubectomy in addition to hysterectomy was performed in one patient, and ovariectomy and hysterectomy in another. [Extracted from the article]

Objective: To evaluate whether gestational trophoblastic neoplasia (GTN) patients with lung metastases have more adverse outcomes such as resistance to chemotherapy, recurrence or death of disease compared with patients without lung metastases.Design: Historical observational cohort study.Setting: The Netherlands.Population: We identified 434 GTN patients (72 patients with lung metastases, 362 patients without metastases) between 1990 and 2012 registered in the Dutch national databases.Methods: Baseline characteristics, recurrence rates, Methotrexate (MTX) remission rates and deaths from disease were compared between patients with lung metastases (group I) and without lung metastases (group II) using the Fisher exact test or Mann-Whitney U-test where applicable.Main Outcome Measures: Methotrexate resistance, recurrences and survival.Results: Methotrexate resistance did not differ between group I and group II (62.9 versus 72.7% P = 0.19). However, the observed recurrence rate was significantly increased in patients with lung metastases compared with patients without metastases (16.7 versus 2.2% P < 0.0001), also after correction for antecedent pregnancy and interval (from the end of the antecedent pregnancy until the start of treatment). Disease-specific survival was 91.7% in the group with lung metastases and 100% in the patients without metastases (P < 0.0001).Conclusions: Although lung metastases are considered to be associated with a low risk of adverse outcomes, their presence appears to increase the risk for recurrence and death of disease. Further research is needed to evaluate whether the presence of lung metastases is an independent risk factor that needs adjustment in the FIGO scoring system and clinical classification system.Tweetable Abstract: In gestational trophoblastic neoplasia (GTN) recurrence is more often observed in the case of lung metastases. [ABSTRACT FROM AUTHOR]

Objective: To re-evaluate the safety of hormonal contraceptives (HC) after uterine evacuation of complete hydatidiform mole (CHM).Design: Historical database review.Setting: Charing Cross Hospital Gestational Trophoblastic Disease Centre, London, United Kingdom.Population: Two thousand four hundred and twenty-three women with CHM of whom 154 commenced HC while their human chorionic gonadotropin (hCG) was still elevated, followed between 2003 and 2012.Methods: We compared time to hCG remission between HC users and nonusers. The relationship between HC use and gestational trophoblastic neoplasia (GTN) development was assessed. The relationship between HC use and a high International Federation of Gynecology and Obstetrics (FIGO) risk score was determined.Main Outcome Measures: Time to hCG remission, risk of developing postmolar GTN and proportion of women with high FIGO risk score.Results: No relationship was observed between HC use with mean time to hCG remission (HC users versus non-users: 12 weeks in both, P = 0.19), GTN development (HC users versus non-users: 20.1 and 16.7%, P = 0.26) or high-risk FIGO score (HC users versus nonusers: 0% and 8%, P = 0.15). Moreover, no association between HC and GTN development was found, even when an age-adjusted model was used (OR = 1.37, 95% CI 0.91-2.08, P = 0.13).Conclusions: The use of current HC is not associated with development of postmolar GTN or delayed time to hCG remission. Therefore, HC can be safely used to prevent a new conception following CHM regardless of hCG level.Tweetable Abstract: Non-concurrent cohort study to re-evaluate the safety of low dose HCs after uterine evacuation of CHM. [ABSTRACT FROM AUTHOR]

Objective: To determine the outcome of women with persistently raised but falling human chorionic gonadotrophin (hCG) levels 6 months after surgical evacuation of a molar pregnancy.Design: An 11-year retrospective review.Setting: The United Kingdom supra-regional trophoblastic disease treatment centres at Weston Park Hospital (Sheffield) and Charing Cross Hospital (London).Population: Women with raised but falling serum human chorionic gonadotrophin (hCG) levels 6 months after evacuation of a molar pregnancy.Methods: Retrospective case note review of eligible women identified by the electronic databases held at each supra-regional centre.Main Outcome Measures: The proportion of women that attain normal hCG levels spontaneously without chemotherapy. In addition, rates of gestational trophoblastic neoplasia (GTN), drug resistance, disease relapse and overall survival are reported.Results: Thirty-five women with molar pregnancy and raised but falling serum hCG levels continued surveillance 6 months after evacuation. Levels of hCG in 30 of the patients (86%) fell to normal levels spontaneously. One woman defaulted follow up prior to hCG normalisation (3%) and the remaining four women (11%) were treated with chemotherapy due to a plateau or rise in serum hCG levels indicating GTN. All treated women were successfully salvaged by either first (n = 1) or second line (n = 2) chemotherapy or found to have persistently raised low level hCG of uncertain clinical relevance (n = 1). No women developed relapsed disease and overall survival was 100%.Conclusions: Women with a molar pregnancy and a raised but falling hCG level beyond 6 months from uterine evacuation can be safely observed with regular hCG monitoring and can usually avoid potentially toxic chemotherapy.Tweetable Abstract: Women with treated molar pregnancy may avoid chemotherapy if 6-month hCG levels are raised but falling. [ABSTRACT FROM AUTHOR]

Objective To determine the risk of recurrent trophoblastic disease after normalisation of human chorionic gonadotrophin ( hCG) levels in women with hydatidiform mole. Design A retrospective review of data from a national gestational trophoblastic disease centre. Setting The Trophoblastic Disease Unit, Dakar, Senegal. Sample Women with pregnancies affected by hydatidiform mole registered between 2006 and 2012. Methods The women were followed up in accordance with the hospital protocol 'Score de Dakar'. For women who progressed to gestational trophoblastic neoplasia ( GTN) the time to onset of GTN, treatment and evolution were evaluated. The rate of evolution to GTN after normalisation of hCG was determined. Main outcome measures Rate of occurrence of GTN after chemotherapy for hydatidiform mole. Results Five hundred and thirty-one women were diagnosed to have molar pregnancies. According to the hospital's protocol, 107 (20.2%) of these had chemotherapy and 224 (42.2%) had prophylactic chemotherapy. Five hundred and thirteen women (96.4%; 95% confidence interval [95% CI] 95.05-98.14%) achieved remission. Eighteen women (3.4%; 95% CI 1.86-4.94%) developed GTN (11 before remission and seven after remission). Seven women out of the 18 developed GTN after hCG normalisation (1.3%). Five of these seven were diagnosed beyond the recommended period of follow up. The mean interval to diagnosis of GTN was 18.7 months. These seven women underwent combination chemotherapy: five achieved complete remission whereas two died from GTN. Conclusions Cytotoxic therapy for hydatidiform mole does not prevent GTN, it delays its diagnosis and promotes GTN after normalisation of hCG. [ABSTRACT FROM AUTHOR]

The article presents abstracts of articles on oncology topics including "Outcome of low-risk gestational trophoblastic neoplasia (GTN) treated with methotrexate," by S. Ahmeed, "A rare case study of extrauterine endometrial stromal sarcoma," by H. Chinthakula, and "Role of intraperitoneal chemotherapy in ovarian cancers," by G. Bharaswadkar and A. Maheshwari.

Objective The Uterine Artery Pulsatility Index ( UAPI) is an ultrasound measure of tumour vascularity. In this study, we hypothesised that a UAPI ≤1 (high vascularity) would identify women with gestational trophoblastic neoplasia ( GTN) at increased risk of resistance to first-line single-agent methotrexate ( MTX- R). Design Single-centre cohort study. Setting Charing Cross Hospital, a UK national centre for the treatment of trophoblastic disease. Population All women with a GTN FIGO score 5-6 treated with methotrexate ( n = 92), between 1999 and 2011, at Charing Cross Hospital. Methods UAPI was measured before the start of chemotherapy, and women were monitored for the development of MTX- R. Main outcome measures Frequency of MTX- R in women with UAPI ≤1 compared with UAPI >1. Results UAPI was measured before chemotherapy in 73 of 92 women with GTN FIGO score 5-6. UAPI ≤1 predicted MTX-R independent of the FIGO score (hazard ratio 2.9, P = 0.04), with an absolute risk of MTX- R in women with a UAPI ≤1 of 67% (95% CI 53-79%) compared with 42% (95% CI 24-61%) with a UAPI >1 ( P = 0.036). Conclusion Our results suggest UAPI is an independent predictor of MTX- R in women with FIGO 5-6 GTN. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Lybol C, Centen D, Thomas C, ten Kate-Booij M, Verheijen R, Sweep F, Ottevanger P, Massuger L. Fatal cases of gestational trophoblastic neoplasia over four decades in the Netherlands: a retrospective cohort study. BJOG 2012;119:1465-1472. Objective To describe fatal cases of gestational trophoblastic neoplasia (GTN) over four decades and evaluate whether treatment was given according to the protocol and reveal possible implications for future management. Design Retrospective cohort study. Setting The Netherlands. Population Women who died from GTN from 1971 to 2011. Methods Records from the Dutch Central Registry for Hydatidiform Moles and the Working Party on Trophoblastic Disease were used to identify fatal cases of GTN. Main outcome measures Disease extent, risk classification, treatment regimens and cause of death. Results Twenty-six women died from GTN. In five cases GTN developed after a hydatidiform mole and in 19 cases following term pregnancy. Half of the women died between 1971 and 1980, when women were not yet classified as having low-risk or high-risk disease and were therefore not yet treated accordingly. A major decline in the number of deaths was seen after the first decade, with a further decrease from 1981 to 2011. Early death occurred in nine women. In four of these women, death was treatment-related. Women who died more than 4 weeks after the start of treatment mostly died from metastatic tumour ( n = 14). Conclusions The yearly number of women who died from GTN decreased considerably over the last four decades. Appropriate risk classification is essential to start optimal initial therapy and to prevent therapy resistance. Women with post-term choriocarcinoma represented a large proportion of the dead women and we propose that these women are considered as having high-risk disease. [ABSTRACT FROM AUTHOR]

We reviewed 25 cases of gestational trophoblastic tumours referred for surgical management from Charing Cross Hospital (the London centre for gestational trophoblastic disease [GTD]) over a 13-year period. The operation performed was total abdominal hysterectomy, with lymph node sampling in 9/25 (36%) women and bilateral salpingo-oophorectomy in 11/25 (44%) women. Radical hysterectomy and unilateral parametrectomy was required in 3/25 (12%) women. Three of 25 (12%) women failed to survive, i.e. the overall rate of survival was 88%. Management by hysterectomy of primary drug-resistant and relapse cases of GTD is a useful and safe adjunct to chemotherapy. [ABSTRACT FROM AUTHOR]

Although gestational trophoblastic neoplasia (GTN) is a rare event, particularly after a non-molar pregnancy, the true incidence of GTN is difficult to establish with certainty because data regarding the incidence of pregnancies and subsequent trophoblastic events are not available in most countries. In the current article, the authors estimate that the incidence of non-molar choriocarcinoma was 1 in 66 775 births or 1 in 84 226 conceptions ( I BJOG i 2020; https://doi.org/10.1111/1471-0528.16202). This information can be useful, however, when considering non-molar choriocarcinoma in the differential of those with advanced maternal age who present with irregular bleeding postpartum or post termination of pregnancy. [Extracted from the article]

In a third of patients with gestational trophoblastic disease (GTD) scored as low risk (FIGO score 0-6), initial methotrexate (MTX) treatment failed. Compared with dactinomycin, EMA/CO had higher rates of human chorionic gonadotropin (hCG) normalisation and lower relapse rates after treatment completion. Without selection based on pretreatment hCG levels, the authors demonstrated the reducing efficacy of second-line dactinomycin with increasing hCG levels and suggested treatment with EMA/CO at an hCG level >40 ng/ml. [Extracted from the article]

The most common groups of patients with gestational trophoblastic neoplasia (GTN) are those with persistently raised serum hCG following evacuation of the uterus and choriocarcinoma. Methotrexate chemotherapy is usually well tolerated and is associated with less toxic adverse effects; however, approximately 44% of low-risk patients treated with this drug will develop drug resistance. It is important to be aware that the above findings do not apply to patients with gestational trophoblastic disease (GTD), i.e. patients with either a partial or complete hydatidiform mole who have an unremarkable follow-up with serum or urinary human chorionic gonadotropin (hCG). [Extracted from the article]

The author discusses the study of L. M. Kindinger and colleagues on the assessment of biomarker to determine birth and obstetrics anomalies. It mentions the move of the researchers to characterize twin pregnancies on the basis of past lessons derived from singleton gestations. It discusses the gestation process that should be considered when assessing the birth scenario.

The article discusses the role of immunostaining in diagnosis of hydatidiform mole. Topics discussed include use of ancillary techniques; information on the molecular genotyping, the process of determining differences in the genetic make-up (genotype) of an individual; and the risk of persistent gestational trophoblastic disease (pGTD).

Deputy Editor‐in‐Chief, Dr. Patrick Chien, discusses his top articles from this issue in an audio podcast available at: https://soundcloud.com/bjog/october-editors-choice-2016. [ABSTRACT FROM AUTHOR]

The author comments on the article "Use of hormonal contraception (HC) after hydatidiform mole" by A. Braga and colleagues, published within the issue. He suggests avoiding use of HC until human chorionic gonadotrophin (hCG) levels normalizes as use of combined HC after molar pregnancy might increase the risk of gestational trophoblastic neoplasia. The study concludes safe use of HC after molar pregnancy.

The author comments on article related to determination of outcome of women with persistently raised but falling human chorionic gonadotrophin (hCG) levels 6 months after surgical evacuation of a molar pregnancy by F. Taylor and colleagues published within the issue. He states that the study used International Federation of Gynecology and Obstetrics (FIGO) criteria for post molar gestational trophoblastic neoplasia (GTN) diagnosis.