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What is a molar pregnancy?
Trophoblastic disease is an uncommon complication of pregnancy. To understand it we must first look at a normal pregnancy. This consists of two 'parts' developing in the womb.
The foetus or developing baby, the placenta (or after-birth), which has many functions including the feeding of the baby and the removal of its waste products. The placenta is made of millions of cells called trophoblasts.
These two parts normally develop together, in parallel, the end result being a healthy baby and a placenta which is no longer needed, so the latter is expelled just after the baby is born (afterbirth).
In trophoblastic disease there is an abnormal overgrowth of all or part of the placenta, causing what is called a molar pregnancy or hydatidiform mole. The term seems strange but is similar to that used for a harmless growth on the skin, which is also called a mole.
As with skin moles, a hydatidiform mole is often harmless. However, it can keep growing and, if left untreated, can bury itself into the organs around it, including the uterus (womb) and even spread via the blood to other distant organs including the lungs, liver or brain. It is once it has reached this stage that it can have serious effects.
Although a hydatidiform mole is not cancer and rarely even becomes cancerous, it can behave in similar ways. Most of the treatment is aimed at stopping the disease process long before any of these things happen.
Different types/stages of moles:
- Hydatidiform mole
- Partial Mole
- Complete Mole
- Persistent Gestational Trophoblastic Disease
The commonest kind of trophoblastic disease, where the overgrowth is benign but may spread to other parts of the body if not treated. This is further subdivided into:
Where part of an apparently normal placenta overgrows (proliferates) and part develops normally. There may be a developing foetus present, but this is genetically abnormal and cannot survive outside the womb. This is where two sperm enter the egg and instead of forming twins forms an abnormal foetus.
Where the whole placenta is abnormal and usually grows very rapidly. There is no developing foetus in these pregnancies. This is where one sperm enters the egg but only half of one set of chromosomes are present and do not develop into a foetus.
Where part of the mole remains in any part of the body despite initial treatment by the gynaecologist. Even a tiny amount of mole anywhere in the body can grow quickly and cause problems, so active treatment of this condition is very important.
A very rare but curable form of cancer where the placenta becomes malignant. This can arise from a molar pregnancy or an otherwise normal pregnancy or miscarriage. Choriocarcinoma can also spread throughout the body, usually to organs like the lungs, liver and brain.
What causes it?
Molar pregnancy is thought to be caused by a problem with the genetic information of an egg or sperm. Factors that may increase your risk of having a molar pregnancy include:
- Age. Risk for complete molar pregnancy steadily increases after the age of 35
- History of molar pregnancy, particularly if you've had two or more
- Possible ovulatory disorders
- History of miscarriage
- A diet low in carotene (a form of vitamin A). Women with low carotene or vitamin A intake have a higher rate of complete molar pregnancy
- Living in certain geographic locales (especially Southeast Asia and Mexico)
It is however, worthwhile noting, that the number of times a women has been pregnant doesn't influence her risk.
Up to 10% of diagnoses require additional treatment other than the D and C and urine testing follow up. This is in the form of chemotherapy.
Each individual’s case is different but the vast majority of patients begin on Methotrexate. This is also used for arthritis and skin conditions. It is administered by intra-muscular injections (buttock) followed by a Folinic Acid (NOT folic acid) tablet exactly 24 hours later. The usual regimen is to have four injections on alternate days with Folinic Acid in between but regimens differ at different treatment centres. You will stay as an in-patient for the first part of the course of treatment as the chemotherapy could cause heavy bleeding and other side effects. You will then continue as an outpatient either at your treatment centre or it may be possible to arrange it at your local hospital to avoid commuting long distances.
As mentioned previously measurements of BhCG are used to monitor treatment response. It is essential with all chemotherapy regimens that BhCG is measured regularly. In general an adequate treatment response is defined by a 50% reduction after each course of chemotherapy.
The level of BhCG may reach normal (different regions aim for different levels between 2-5) or become undetectable when there is still a residual tumour burden of cells. Therefore with all regimens, treatment is continued for at least six weeks.