https://orcid.org/0000-0002-3757-0205
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ABSTRACT
Background: The use of obstetric ultrasound in the diagnosis of gestational trophoblastic disease (GTD) in high-income settings is well established, leading to prompt management and high survival rates. Evidence from low-income settings suggests ultrasound is essential in identifying complicated pregnancies, but with limited studies reviewing specific conditions including GTD.
Objective: The aim of this study is to review the role of ultrasound in diagnosis and management of GTD in a marginalized population on the Thailand–Myanmar border. Antenatal ultrasound became available in this rural setting in 2001 and care for women with GTD has been provided by Thailand public hospitals for 20 years.
Design: Retrospective record review.
Results: The incidence of GTD was 103 of 57,004 pregnancies in Karen and Burmese women on the Thailand–Myanmar border from 1993–2013. This equates to a rate of 1.8 (95% CI 1.5–2.2) per 1000 or 1 in 553 pregnancies. Of the 102 women with known outcomes, one (1.0%) died of haemorrhage at home. The median number of days between first antenatal clinic attendance and referral to hospital was reduced from 20 (IQR 5–35; range 1–155) to 2 (IQR 2–6; range 1–179) days (p = 0.002) after the introduction of ultrasound. The proportion of severe outcomes (death and total abdominal hysterectomy) was 25% (3/12) before ultrasound compared to 8.9% (8/90) with ultrasound (p = 0.119). A recurrence rate of 2.5% (2/80) was observed in the assessable population. The presence of malaria parasites in maternal blood was not associated with GTD.
Conclusions: The rate of GTD in pregnancy in this population is comparable to rates previously reported within South-East Asia. Referral time for uterine evacuation was significantly shorter for those women who had an ultrasound. Ultrasound is an effective method to improve diagnosis of GTD in low-income settings and an effort to increase availability in marginalized populations is required.
Responsible Editor Stig Wall, Umeå University, Sweden
Responsible Editor Stig Wall, Umeå University, Sweden
Acknowledgments
We are grateful to the women at Shoklo Malaria Research Unit who follow the antenatal clinics. We would like to thank the staff who helped to ensure the smooth implementation of antenatal care, delivery and logistical support required for the GTD women.
SMRU is part of the Wellcome Trust Mahidol University Oxford Tropical Medicine Research Programme. The funding bodies had no role in the design, collection, analysis or interpretation of data, nor in the writing or submission of the manuscript for publication. The University of Oxford is the sponsor of this study.
Disclosure statement
No potential conflict of interest was reported by the authors.
Ethics and consent
Retrospective review of anonymised data from antenatal records was approved by the local Tak Community Advisory Board (TCAB-4/1/2015) and the Oxford Tropical Research Ethics Committee (OXTREC 28–09).
Paper context
Evidence linking the use of obstetric ultrasound to reduced maternal mortality in limited-resource settings is lacking. This study demonstrates a significant reduction in referral time for definitive management of molar pregnancy, and a trend for lower mortality and morbidity, following introduction of ultrasound, in a challenging low-resource setting with a highly mobile population. Improving access to obstetric ultrasound in these settings to aid identification and management of complicated pregnancies is likely to improve outcomes.
Additional information
Funding
Notes on contributors
Kathryn McGregor
KM, AMM and RM conceived the study. KM, AMM, NK, SK, MET, NWT, GH, MB, KC, FN and RM participated in the design of the study, data acquisition, data analysis and interpretation and drafted the manuscript. KM, AMM, MJR, FN and RM helped to draft the manuscript and provided general supervision of the research. All authors read and approved the final manuscript.
Aung Myat Min
KM, AMM and RM conceived the study. KM, AMM, NK, SK, MET, NWT, GH, MB, KC, FN and RM participated in the design of the study, data acquisition, data analysis and interpretation and drafted the manuscript. KM, AMM, MJR, FN and RM helped to draft the manuscript and provided general supervision of the research. All authors read and approved the final manuscript.
Noaeni Karunkonkowit
KM, AMM and RM conceived the study. KM, AMM, NK, SK, MET, NWT, GH, MB, KC, FN and RM participated in the design of the study, data acquisition, data analysis and interpretation and drafted the manuscript. KM, AMM, MJR, FN and RM helped to draft the manuscript and provided general supervision of the research. All authors read and approved the final manuscript.
Suporn Keereechareon
KM, AMM and RM conceived the study. KM, AMM, NK, SK, MET, NWT, GH, MB, KC, FN and RM participated in the design of the study, data acquisition, data analysis and interpretation and drafted the manuscript. KM, AMM, MJR, FN and RM helped to draft the manuscript and provided general supervision of the research. All authors read and approved the final manuscript.
Mary Ellen Tyrosvoutis
KM, AMM and RM conceived the study. KM, AMM, NK, SK, MET, NWT, GH, MB, KC, FN and RM participated in the design of the study, data acquisition, data analysis and interpretation and drafted the manuscript. KM, AMM, MJR, FN and RM helped to draft the manuscript and provided general supervision of the research. All authors read and approved the final manuscript.
Nay Win Tun
KM, AMM and RM conceived the study. KM, AMM, NK, SK, MET, NWT, GH, MB, KC, FN and RM participated in the design of the study, data acquisition, data analysis and interpretation and drafted the manuscript. KM, AMM, MJR, FN and RM helped to draft the manuscript and provided general supervision of the research. All authors read and approved the final manuscript.
Marcus J. Rijken
KM, AMM and RM conceived the study. KM, AMM, NK, SK, MET, NWT, GH, MB, KC, FN and RM participated in the design of the study, data acquisition, data analysis and interpretation and drafted the manuscript. KM, AMM, MJR, FN and RM helped to draft the manuscript and provided general supervision of the research. All authors read and approved the final manuscript.
Gabie Hoogenboom
KM, AMM and RM conceived the study. KM, AMM, NK, SK, MET, NWT, GH, MB, KC, FN and RM participated in the design of the study, data acquisition, data analysis and interpretation and drafted the manuscript. KM, AMM, MJR, FN and RM helped to draft the manuscript and provided general supervision of the research. All authors read and approved the final manuscript.
Machteld Boel
KM, AMM and RM conceived the study. KM, AMM, NK, SK, MET, NWT, GH, MB, KC, FN and RM participated in the design of the study, data acquisition, data analysis and interpretation and drafted the manuscript. KM, AMM, MJR, FN and RM helped to draft the manuscript and provided general supervision of the research. All authors read and approved the final manuscript.
Kesinee Chotivanich
KM, AMM and RM conceived the study. KM, AMM, NK, SK, MET, NWT, GH, MB, KC, FN and RM participated in the design of the study, data acquisition, data analysis and interpretation and drafted the manuscript. KM, AMM, MJR, FN and RM helped to draft the manuscript and provided general supervision of the research. All authors read and approved the final manuscript.
François Nosten
KM, AMM and RM conceived the study. KM, AMM, NK, SK, MET, NWT, GH, MB, KC, FN and RM participated in the design of the study, data acquisition, data analysis and interpretation and drafted the manuscript. KM, AMM, MJR, FN and RM helped to draft the manuscript and provided general supervision of the research. All authors read and approved the final manuscript.
