(777) Navigating Gestational Trophoblastic Neoplasia With Advanced Viable Pregnancy: A Case Report

Introduction: Gestational trophoblastic neoplasia (GTN) is a spectrum of malignant disorders arising from trophoblastic tissue, often following a molar pregnancy but can occur after any gestation. GTN with a concurrent viable pregnancy is rare and poses significant maternal and fetal complications, including preterm birth, miscarriage, hemorrhage, and disease progression. We describe a patient presenting with GTN and concurrent advanced viable pregnancy.

Description: A 34-year-old G4P3 woman presented at 28+5 weeks gestation with worsening dyspnea, cough, and hemoptysis for one month. Initially treated with amoxicillin for presumed sinus infection without improvement, her symptoms worsened, leading to coughing up blood clots. An ultrasound confirmed a viable intrauterine pregnancy. CTA chest revealed numerous bilateral lung masses, highly suspicious for GTN, with a serum β-hCG level greater than 5 million mIU/mL. Workup included normal cardiac function on TTE, slightly elevated liver function tests, and thyroid tests indicating evolving hyperthyroid state. Endocrine consult recommended starting propylthiouracil (PTU) and early cesarean delivery to expedite chemotherapy initiation due to high risk for pulmonary hemorrhage. Induction chemotherapy with etoposide/cisplatin started on POD 2. The patient experienced progressive hypoxic respiratory failure requiring intubation. Chemotherapy continued while intubated, leading to respiratory improvement and extubation within a week. During hospitalization, she completed 3 cycles of etoposide/cisplatin before transitioning to the EMA/CO regimen (etoposide, methotrexate, actinomycin D/cyclophosphamide, vincristine). Placenta pathology confirmed gestational choriocarcinoma. She was discharged on hospital day 24 with plan to return for cycle 2 of EMA/CO. Her baby was cared for in the NICU for 2 months before discharge.

Discussion: The rarity of GTN with concurrent advanced viable pregnancy poses significant diagnostic and management challenges. Hypoxic respiratory failure from hemorrhage of pulmonary metastases is a serious complication. Our case emphasizes recognition and aggressive management, including a multidisciplinary approach with early cesarean and induction chemotherapy. Our case underscores the potential benefits of an aggressive treatment approach.