Clinical-pathological Characteristics and Factorsassociated With Mortality in Patients Managed Forgestational Trophoblastic Neoplasia in Kenyatta Nationalhospital,2012 – 2020. A Cross-sectionalstudy

Abstract

Background: Gestational trophoblastic neoplasia (GTN) comprises of invasive mole (IM),choriocarcinoma(CCM),placentalsitetrophoblastictumour(PSTT)andepithelioidtrophoblastic tumour (ETT). Choriocarcinoma is the most common tumour in this categoryand more fatal than the rest. Little is known about GTN in the developing countries includingthe East African region. This study aims to determine the spectrum of GTN affecting thepopulationseekingmanagementinatertiaryhospitalinKenyaandthemortalityratesassociatedwith the disease. Objective:Todeterminetheclinical-pathologicalcharacteristics,themortalityrateandfactors associated with mortality in patients managed for GTN in Kenyatta National Hospital(KNH). Methodsandmaterials Studydesign andsite:This wasadescriptivecross-sectionalstudyconductedinKNH. Participants and methods: The study population consisted of women with a documented diagnosis of GTN, fully or partly managed at KNH in the period 2012 to 2020. Datawerecollectedbyreviewingpatients’files.Thepatientswithundocumentedoutcomeswereexcluded from the study. Clinic and admission registers were used to generate a list ofpatientsdiagnosedwithGTNforparticipationinthestudy.Patients’chartswerereviewedand data abstracted into a structured pre-designed data collection tool. Data on the socio-demographic characteristics, clinical-pathological features, GTN management given and the out comes as per their last review were collected. Data management: Data was entered and analysed in SPSS version 23.0 statistical software.The population was described by summarizingvariablesintopercentagesandmeansormediansforcategoricalandcontinuousdata,respectively.Clinical pathological characteristics and mortality were presented as proportions.The factors associated with mortality were tested using chisquaretest and oddsratios. Point estimates and 95%confidence limits were reported. Findings were considered statistically significant at a p-value<0.05. Results: Two hundred and fifty (250) charts of patients managed for GTN were reviewed. Their points of entry were mainly asgynaecology admissions(59.6%)and referrals from other hospital services (30.8%). The mean age of the women was 32.8 years and their paritywas a median of 2.0. In the study group the reported previous history of molar pregnancieswere in 23.6%, term pregnancies in 82.4% while abortions were in 62% of the women. The initial hCG level was a median of 31000 IU/mL which declined in 90% of the patients after chemotherapy. Most patients (97.6%) presented with per vaginal bleeding and 89.6% had an abnormal ultrasound. The mean haemoglobin was9.1g/ dland40%were anaemic. Choriocarcinoma was diagnosed in 77.2% of the patients while 18.8% were complete moles.The type of surgery given was mainly D&C in 63.2%. The mean WHO risk score was 7.4with FIGO stage I in 86% of the cases. The second line chemotherapy was administered to30.8%ofthepatientswhile6.4%receivedsalvagetherapy.ThemedianhCGlevelattheend xi of treatment was 0.9 IU/mL. Mortality rate among the women was 19.2% with the risk higherin those with previous mole (p=0.036), those with higher median initial hCG levels (p<0.001)andthe patients with higher median WHO risks core(p<0.001). Conclusion: Choriocarcinoma is the commonest type of GTN in this study population,occurring in young women in their reproductive period with a high proportion of them inFIGO stage I disease. Patients with previous history of molar pregnancy, higher levels of initial hCG and higher median WHO risks coreareata higher risk of death