From: <Saved by Microsoft Internet Explorer 5>
Subject: OBGYN.net Molar Pregnancy -- Ashley Hill, MD
Date: Sun, 16 Sep 2007 07:54:59 -0700
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            <META content=3D"pregnancy, miscarriage, gtn, abnormal =
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                <TD width=3D"100%">
                  <H3 align=3Dcenter><FONT color=3D#000000>Issues and =
Procedures in=20
                  Women's Health</FONT></H3></TD></TR>
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                        <H3 align=3Dcenter><IMG height=3D93=20
                        =
src=3D"http://www.obgyn.net/all_advisors/images/dahill_sm_m.jpg"=20
                        width=3D75 align=3Dright border=3D0><FONT =
color=3D#000000>Molar=20
                        Pregnancy</FONT></H3>
                        <P align=3Dcenter>by <B><A=20
                        =
href=3D"http://www.obgyn.net/meet.asp?page=3D/all_advisors/D_Hill">D.=20
                        Ashley Hill, MD</A></B>, <B><FONT=20
                        color=3D#ce0000>OBGYN.net</FONT></B><FONT =
color=3Dred=20
                        size=3D2> </FONT>Editorial Advisor, =
<BR>Associate Director=20
                        - Department of Obstetrics and Gynecology, =
<BR>Florida=20
                        Hospital Family Practice Residency, Orlando, =
Florida=20
                      </P></TD></TR></TBODY></TABLE></DIV></TD></TR>
              <TR>
                <TD width=3D"100%"></TD></TR>
              <TR>
                <TD width=3D"100%">
                  <BLOCKQUOTE>Molar pregnancies are an uncommon and very =

                    frightening complication of pregnancy. The formal =
medical=20
                    term for a molar pregnancy is =93hydatidiform =
mole.=94 Simply=20
                    put, a molar pregnancy is an abnormality of the =
placenta=20
                    (afterbirth), caused by a problem when the egg and =
sperm=20
                    join together at fertilization. The following is a =
brief=20
                    review of this complicated subject.<BR><BR><B><FONT=20
                    color=3D#000000>Types of Molar Pregnancy =
</FONT><FONT=20
                    face=3D"Arial, Helvetica" color=3D#4210a0=20
                    size=3D2><BR></FONT></B>There are two types of molar =

                    pregnancy, complete and partial. Complete molar =
pregnancies=20
                    have only placental parts (there is no baby), and =
form when=20
                    the sperm fertilizes an empty egg. Because the egg =
is empty,=20
                    no baby is formed. The placenta grows and produces =
the=20
                    pregnancy hormone, called HCG, so the patient thinks =
she is=20
                    pregnant. Unfortunately, an ultrasound (sometimes =
called a=20
                    sonogram) will show that there is no baby, only =
placenta. A=20
                    partial mole occurs when 2 sperm fertilize an egg. =
Instead=20
                    of forming twins, something goes wrong, leading to a =

                    pregnancy with an abnormal fetus and an abnormal =
placenta.=20
                    The baby has too many chromosomes and almost always =
dies in=20
                    the uterus. Thus, molar pregnancies are =93accidents =
of=20
                    nature=94 that are not anyone=92s fault. They are =
not caused by=20
                    behavior, but they are more common in older women =
and in=20
                    certain geographic locations. Also, although most =
molar=20
                    pregnancies occur after a miscarriage, some occur =
after an=20
                    ectopic (tubal) pregnancy or even a normal=20
                    delivery.<BR><BR><B><FONT color=3D#000000>Risk =
Factors=20
                    </FONT><FONT face=3D"Arial, Helvetica" =
color=3D#4210a0=20
                    size=3D2><BR></FONT></B>The incidence of molar =
pregnancy=20
                    varies depending on where one lives. For example, in =
the US=20
                    about 1 out of every 1000 pregnancies is a molar =
pregnancy.=20
                    In Southeast Asia the incidence is 8 times higher.=20
                    Interestingly, women from Mexico, Southeast Asia, =
and the=20
                    Philippines have higher rates than white US women, =
who=20
                    themselves have higher rates than black US women. =
Age over=20
                    40 is a risk factor for molar pregnancy, as is =
having a=20
                    prior molar pregnancy. In fact, the chance of having =
another=20
                    molar pregnancy is about 1 out of 100. The reasons =
for the=20
                    geographic and age differences are currently=20
                    unknown.<BR><BR><B><FONT color=3D#000000>Symptoms =
and=20
                    Diagnosis </FONT><FONT face=3D"Arial, Helvetica" =
color=3D#4210a0=20
                    size=3D2><BR></FONT></B>Women with a molar pregnancy =
usually=20
                    feel pregnant and complain of vaginal spotting or =
bleeding.=20
                    Many women with molar pregnancies develop nausea and =

                    vomiting. Some even develop rare complications like =
thyroid=20
                    disease or very early preeclampsia (toxemia). =
Preeclampsia=20
                    occurring earlier than 20 weeks is very worrisome =
for a=20
                    molar pregnancy. The doctor or midwife more than =
likely will=20
                    check them for a possible miscarriage, and may order =
or=20
                    perform an ultrasound (sonogram). The pelvic exam =
may reveal=20
                    a larger, or smaller, than expected uterus. It may =
also=20
                    reveal enlarged ovaries, caused by non-cancerous =
ovarian=20
                    cysts stemming from abnormally high amounts of the =
pregnancy=20
                    hormone HCG. The ultrasound will often show a =
=93cluster of=20
                    grapes=94 appearance or a =93snowstorm=94 =
appearance, signifying=20
                    an abnormal placenta. If a baby is present it=92s a =
possible=20
                    partial mole, while if the baby is absent it=92s =
probably a=20
                    complete mole. Treatment consists of a D&amp;C =
(dilation and=20
                    curettage) of the uterus, where a small vacuum =
device is=20
                    inserted into the uterus, under anesthesia, to =
remove the=20
                    molar pregnancy. This must be done very carefully or =

                    excessive bleeding and blood clots to the lungs can =
occur.=20
                    The placental tissue is sent to the pathologist, who =
looks=20
                    under the microscope to make the final diagnosis. An =
HCG=20
                    level, and sometimes a thyroid level, are also =
obtained. In=20
                    unusual cases, where the patient has completed her=20
                    childbearing, a hysterectomy may be preferable. =
Although=20
                    most cases of molar pregnancy occur after a =
miscarriage,=20
                    some occur after ectopic pregnancies or a normal =
pregnancy.=20
                    Therefore, women with abnormal bleeding or a =
persistent=20
                    cough (especially if it produces blood) should see =
their=20
                    doctor for an HCG level to make sure they do not =
have a=20
                    molar pregnancy.<BR><BR><B><FONT=20
                    color=3D#000000>Follow-up</FONT><FONT face=3D"Arial, =
Helvetica"=20
                    color=3D#4210a0 size=3D2><BR></FONT></B>After =
evacuating a molar=20
                    pregnancy it is critically important that the =
patient see=20
                    her doctor frequently, as molar pregnancies can =
recur.=20
                    Follow-up usually consists of a baseline chest =
x-ray, review=20
                    of the pathology specimen, physical examination of =
the=20
                    vagina and uterus every 2 weeks until the uterus =
returns to=20
                    normal then every 3 months for a year, contraception =
like=20
                    the pill or shot with no attempt to become pregnant =
for 1=20
                    year, and, most importantly, weekly HCG blood levels =
until=20
                    zero then every month for a year. As one can see, =
this=20
                    involves a lot of trips to the lab and the =
doctor=92s office!=20
                    This is important because molar pregnancies can =
=93come back=94=20
                    even after a thorough D&amp;C. When they come back =
the=20
                    patient may need chemotherapy to prevent the =
microscopic=20
                    placental cells from spreading to other organs like =
cancer.=20
                    Fortunately, this only occurs in about 20% of =
complete molar=20
                    pregnancies; it is even more uncommon with partial =
molar=20
                    pregnancies. Many women are frustrated when their =
doctor=20
                    recommends waiting one year to become pregnant. This =
is=20
                    actually important, because a rise in HCG levels may =

                    indicate a normal pregnancy when the patient is =
trying to=20
                    get pregnant, or a recurrent molar pregnancy, which =
requires=20
                    chemotherapy. To avoid this confusion we ask for a 1 =
year=20
                    period without becoming pregnant.<BR><BR><B><FONT=20
                    color=3D#000000>Treatment for recurrent molar=20
                    pregnancy</FONT><FONT face=3D"Arial, Helvetica" =
color=3D#4210a0=20
                    size=3D2><BR></FONT></B>When the HCG levels drop =
then increase=20
                    again it means that the molar pregnancy has grown =
from=20
                    microscopic cells in the wall of the uterus to =
larger cells.=20
                    These cells can act like a cancer, and metastasize =
(spread)=20
                    to other organs, like the lungs, brain, bones, and =
vagina.=20
                    Treatment for recurrent molar pregnancy, called =
gestational=20
                    trophoblastic neoplasia, or GTN, in medical terms, =
usually=20
                    consists of a chemotherapy medication called =
methotrexate.=20
                    Fortunately, methotrexate is a pretty =93easy=94 =
chemotherapy on=20
                    the system, and can be given as an intramuscular =
shot.=20
                    Sometimes only 1 shot is necessary. In other cases, =
multiple=20
                    shots, or even the addition of other medications, is =

                    necessary. Also, when GTN is suspected, the patient =
usually=20
                    gets a CT scan of the brain, lungs, and abdomen, and =
a=20
                    battery of blood tests. Again, weekly HCG tests are =
obtained=20
                    until they fall to zero, then careful follow-up is=20
                    undertaken for a year. Patients can expect an almost =
100%=20
                    cure rate using chemotherapy.<BR><BR><B><FONT=20
                    color=3D#000000>Future Pregnancy</FONT><FONT=20
                    face=3D"Arial, Helvetica" color=3D#4210a0=20
                    size=3D2><BR></FONT></B>Fortunately, the risk of =
having=20
                    another molar pregnancy is about 1% (1 in 100). Most =
doctors=20
                    will perform an ultrasound to make sure the =
pregnancy is=20
                    normal when a patient has had a prior molar =
pregnancy. It is=20
                    also a good idea to send the placenta to the =
pathologist=20
                    after the delivery just to make sure there are not =
abnormal=20
                    areas. </BLOCKQUOTE></TD></TR>
              <TR>
                <TD width=3D"100%">D. Ashley Hill, M.D.<BR>Associate=20
                  Director<BR>Department of Obstetrics and =
Gynecology<BR>Florida=20
                  Hospital Family Practice Residency<BR>Orlando, =
Florida<BR><A=20
                  href=3D"http://home.mpinet.net/dahmd"=20
                  =
target=3D_blank>http://home.mpinet.net/dahmd</A></TD></TR>
              <TR>
                <TD width=3D"100%"><A=20
                  =
href=3D"http://www.obgyn.net/displayarticle.asp?page=3D/women/articles/hi=
ll_ar"><B>Other=20
                  Articles by Dr. =
Hill</B></A></TD></TR></TBODY></TABLE></CENTER>
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