Severe hemorrhage in choriocarcinoma: three scenarios and treatment strategies.

Introduction: Massive hemorrhage originating from the primary tumor site or metastases is a feared complication of choriocarcinoma. We present three cases of severe hemorrhage in patients with gestational choriocarcinoma and their clinical management. Case series: The first case is a 27-year old woman, who presented with acute hepatic hemorrhage due to metastases of choriocarcinoma 5 months after the birth of her first child. After abdominal packing via laparotomy and transfer of the patient in stable condition to our intensive care unit embolization of several hepatic arteries was performed by interventional angiography. The second case, a 28-year old primipara, presented with hemoperitoneum as a result of uterus perforation by choriocarcinoma. Surgical sutures of the perforated lesion were applied via laparotomy, preserving the uterus. The third case is a 28-year old primigravida with massive vaginal hemorrhage of a choriocarcinoma with pulmonary metastases. Stabilization of the bleeding was achieved by embolization of uterine arteries.All patients were classified as high-risk (FIGO classification) gestational choriocarcinoma and received EMA/CO chemotherapy until ßHCG reached normal levels as well as up to three additional cycles as consolidation. To date, all patients are in remission. Conclusion: In case of severe hemorrhage in patients with choriocarcinoma a skilled interdisciplinary team is needed. In case of acute hemorrhage in choriocarcinoma embolization of arteries should be preferred since these are safe and effective measures. In the vast majority of cases fertility-preserving strategies can safely be applied. Hysterectomy is not recommended as first-line treatment.