MOLAR PREGNANCY (HYDATIFORM MOLE)

It was still the month, of August 1959; I am still the junior most resident posted in the septic labour ward (labour ward for neglected women who were very ill). Najma a 37 year old woman from a nearby village came in, apparently in labour, with some bleeding, This was her fourth pregnancy; she did not know how pregnant she was. She conceived while she was breast feeding the last baby who was born two years ago. She never had any problems with her previous pregnancies. She had not seen a doula or a village doctor. She was on the obese side; we could not get her weight as she was not so well. I started to examine her; she had a fast pulse and a somewhat low blood pressure. On abdominal examination I was unable to feel any baby parts, there was no foetal heart. The abdominal girth was forty two centimetres. I tested her blood on my small pocket Haemoglobinometer (HB) which we carried in our pockets for emergency. The Haemoglobin was 2.  The average HB in Indian women is often between 8 -12.  In those days we had no Ultrasound (never even heard of it). The x-ray department was about half a kilometer away. The patient could not be moved in any case. It was five AM. I was not sure what was going on. Was it a twin pregnancy with massive fluid or was it a pregnancy with massive bleeding? I sent for my registrar who was a very capable doctor. We decided to put up an IV and emergency blood, which we used to keep O, Rh-negatives. It was only two units. In emergency we had to cross match blood for our need and bleed the donor. The pathology department was also far away in the main hospital. However one of my senior colleagues went to do this cross matching and took the relatives with her .My registrar came over and very gently tried to examine her, by now she was bleeding profusely and passing out tissue which looked like bunch of grapes. Both of us immediately got the diagnosis. It was what we call a molar pregnancy. We had exhausted our emergency blood, the cross matching blood was not yet ready as it takes nearly two hours, and the same doctor had to bleed the donors. The woman was bleeding like a tap, the whole big labour ward full of blood and within two hours of admission, she passed away, as if she had come to the hospital for dying. Her relatives were very angry. They wanted to kill me, as I was their first contact my registrar advised me to hide myself in the duty doctor’s room, in the bathroom, which I did. They hung around the hospital to find me and kill me, I was so frightened. However it all settled in the end. Our professor explained to all of them, that they have to take greater care of their mothers to be. From then on we had a regular flow of pregnant women from that village.

Molar pregnancy and many other complications of placental diseases, are together addressed as gestational (pregnancy) trophoblastic (arising from the placenta) diseases. Molar pregnancy is when; an abnormal fertilized egg plants itself inside the uterus and fails to grow like a normal baby. It is a disease of the placental tissue; it grows like massive tissues which look like grapes. The word mole simple denotes a mass of tissue .It is a noncancerous placental tumour, which can turn cancerous, it is then called Choriocarncinoma. Choriocarcinoma can also rarely arise after a normal miscarriage or a normal birth. There are two types of molar pregnancies, a complete mole or a partial mole; it is called a complete mole when an egg is fertilized by one sperm, all the female chromosomes die. The father’s chromosomes duplicate and make 23 pairs which is the normal chromosome number. No embryo, foetus or a normal placental tissue is formed. A partial mole is when the egg is fertilized by two sperm or one sperm duplicates, mother’s chromosomes remain, hence the embryo has 69 chromosomes. This happens if the egg has no nucleus or an inactive nucleus. Molar pregnancies are common among the Asian population say 1 in 100 as compared to western population where it happens 1 in 1000. The risk factors are, if you are of Asian descent, you are older than 40 (5times) or younger than 20 (1.5 times) you have had a previous mole (30times) and a previous miscarriage (twice as often). I have often seen molar pregnancies in young girls at the time of a miscarriage. It is a part of the same process of pregnancy failure. When a woman has a molar pregnancy she often suffers severe vomiting as compared to a normal pregnancy, intermittent vaginal bleeding and pelvic pressure pain. They can even pass grape like tissue pieces with their bleeding; they often get early rise of blood pressure or even like toxaemia of pregnancy which is a disease of late pregnancy. I have seen excessive vomiting causing liver failure in very malnourished young girls. Najma also had excessive vomiting; her blood pressure was never checked. On admission she had  low blood pressure as she had been bleeding, when a person bleeds the blood pressure goes down. A very small number of women may also develop symptoms of overactive thyroid that is they feel agitated, shaky, anxious, and cannot sleep. This happens because the very high levels chorionic gonadotrophins ( the pregnancy hormone in molar pregnancy )upset the control of thyroid  production. About one third of women with molar pregnancy also develop ovarian cysts on one or both sides because of high levels of pregnancy hormones. They almost always resolve, when the mole is gone. They are not cancerous.

In this day and age the diagnosis of molar pregnancy is easily made by ultrasound as early as eight weeks. Sometimes a vaginal ultrasound is required. The others tests that are done are to measure the blood levels of pregnancy hormones; a Thyroid function test, blood for haemoglobin and blood count, general liver and kidney function tests.

The treatment is simple under general anaesthesia in a hospital the molar pregnancy is removed by vacuum aspiration .Your clinician will explain all the details. All the tissue is sent to pathology. You will be able to go home in 4 hours. Rarely if the molar pregnancy is extensive or it is invading the uterus and you do not want any future pregnancies the uterus is removed.

After this initial treatment you require follow up regular pregnancy hormone tests and ultrasound to make sure there is no molar tissues in your body and your ovarian cysts have also resolved. Thyroid function tests and blood tests are also done to make sure that you are fully recovered. You are advised not to get pregnant for one year while the molar pregnancy is fully resolved.

In about 20 to 30 percent of Molar Pregnancies and rarely after a normal pregnancy and miscarriage a Choriocarcinoma (Cancer of the placental tissues) develops and it requires special investigation, treatment and follow up which we are not discussing in the post.

SURGICAL METHODS OF CONTRACEPTION

SURGICAL METHODS OF CONTRACEPTION

Sterilization for women and men 

What we need to understand

Sterilization with reference to family planning means permanent prevention from getting pregnant. For this to happen; the individual needs an operation. For women it is called tubal ligation or occlusion, for men it is called vasectomy. The partners need to consider it very carefully because it is permanent. Sometimes a single woman feels she never wants to have a baby and has a sterilization fairly young. I feel they need to think about it seriously. It can be reversed, however the success rate cannot be predicted. It also depends on the method of tubal ligation and what method was originally used.  If they were burned or totally removed it cannot be reversed.

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Before the advent of so many methods of contraception, sterilization was very common. In countries like India, when India was trying to control its population the public was encouraged to use sterilization or vasectomy; if they did so they were given a transistor radio as a gift. It was unfortunate that many young men had a vasectomy in the greed of a transistor radio without understanding its serious consequences. Now since we have long term reversible contraceptives such as, intrauterine devices or hormone implants, the frequency of operative contraception has gone down.

VASECTOMY

It is an operative method of contraception for men. The tube called vasdeferens carrying the sperm from the testicles to the penis is cut and tied so that when ejaculation occurs, there are no sperm and the partner cannot get pregnant. This takes few months as the residual sperm will still be there. They are stored in the Epididymis as shown in the diagram below. A test is performed on your ejaculate before you are cleared for sexual relations and that there is no sperm. The sperm in your body is naturally absorbed, and there is no build up.  There may be infection or bleeding as a result of the operation but it is rare. Before you decide to have this operation performed, a man needs to think very carefully about the fact that he will no longer be able to produce any offspring however we now have the medical technology to freeze sperm should a child be desired. A vasectomy can be reversed however the results are uncertain. A vasectomy is simple and has less extra complications; it can be done under local anaesthesia.

TUBAL OCCLUSION

If you decide to have a tubal ligation, you and your partner should discuss that this is what you want. You may also discuss the alternatives with your doctor, maybe one of these appeals to you. Make sure you never want a baby or another baby. It is better if you are, older than thirty years of age. Research has shown that women often regret if they had a tubal ligation very young. The frequency of divorce also complicates matters further. In modern times the tubal occlusion is almost always performed by keyhole surgery called, laparoscopy. In developing countries where there are no surgeons who can do it or there is no equipment, as this is expensive, it is done by open surgery. Give yourself time to think about it. Keep up with your regular contraception until the very last day or to the last tablet.

There are two ways, how tubal ligation is performed.

 OPEN METHOD

This means that you belly is cut open. This is like any other surgical operation. The operation is explained to you and your partner. You have to be very sure that you want this done. In some countries they coerce to have this done by giving you money or electronic, goods. In my view it is safe if you have a good marriage, you have three children and you are above thirty years of age. After the basic things are decided, you go to the operating theatre after having given the, consent. The operation is generally done under general aesthesia by an anaesthetist. The surgeon then makes a cut near the bikini line, which is about 3-4 cms long. He then identifies the tubes and blocks them.  Different methods are used by different surgeons to block them. The urinary bladder which lies in this area is always emptied, to prevent it from being injured. The belly is then closed by sutures that do not need to be removed. Generally you can go home the same day or the next day. This operation is called mini laparatomy. It is done when you are not pregnant and using a proper contraceptive. I had an incidence when a woman who had sex the night before her operation was due, thinking this cannot do any harm, She did not turn up for her six weeks visit in spite of my requests finally when she arrived, she was twenty weeks pregnant. It was worked out that she became pregnant the night before, as she did not use the condom that night which was her normal usual contraceptive. It is best to do tubal ligation soon after a period (Proliferative phase of menstrual cycle) when the woman is not likely to get pregnant .Tubal ligation can be done at the time of caesarean section, however the failure rate of these tubal ligations are slightly higher than the ones done when you are not pregnant. Also the other problem can often be that if the baby is found to have a serious medical condition and he can die, than it can be a disaster. I am not very keen on doing tubal ligation during the time of a caesarean section or at the time of an abortion, as at that time one may not be emotionally ready.

There are several methods of Tubal ligation usually named after the Surgeon who described them. There are different parts of the tube shown in the picture below.

It is best to lift up the tube in a tissue forceps, make sure this is the part of the tube where the blood supply is least. This protects the ovaries from their blood supply being compromised. The tube is then compressed, tied and cut. About one cm loop of the tube is cut and sent to pathology. This confirms that the tube was cut. It is also very useful in any medico legal situations if they arise in case the tubal ligation fails and the cut end of the tubes are diathermied to prevent recanalisation. We make sure there is no bleeding. This is done on both sides. The tubes are put back in the abdominal cavity. When the suture material is absorbed, the cut ends of the tube separate.

This method of tubal ligation is called Pomeroy’s method. It is very simple and can be taught easily. The failure rate is 1 per 1000 at the end of one year, 7.5 per 1000 at the end of10 years. There can be deaths due to bleeding or infection although it is rare. I have seen one death after a postpartum tubal ligation probably due to deep venous thrombosis.

The Aldrige method is more temporary, where the  Fimbrial  end of the tube is tucked in . It is good for a successful reversal.

A number of surgeons remove the whole tube. This can interfere with ovarian blood supply however the recent research has shown it to be protective against ovarian cancer.

 In another method called the Madleners methods, the tube are crushed at two points and tied. No tube is removed. I have seen two cases of hydrosalpinex (swollen tubes full of fluid) following Madleners tubal ligation.

Tubal ligation can also be performed via the vagina. The vaginal tubal ligation is hardly used anywhere in the world. It also has a high risk of infection. The tubal ligation even by laparatomy can sometimes be difficult if, a woman had many pelvic surgeries or infections, as this can make difficult to identify and lift up the tubes. If following a tubal ligation, you feel you may be pregnant see your doctor urgently. If it is an early pregnancy it can be aborted if you so desire otherwise   doctors can look after your pregnancy.  Tubal ligation as such does not do any harm to your pregnancy.  Always call your doctor if you have unusual pain, fever, abnormal bleeding, pain in the calf and any other problem that is worrying you. Complications of tubal ligation are generally minor and easily managed; your surgeon always discusses these with you.

KEYHOLE SURGERY OR LAPARASCOPY

Keyhole surgery is the method used in most countries. It is often not used if the woman is obese, or is likely to have pelvic problems which can make the identification and picking up of the tubes difficult. It is usually done under a general anaesthesia in a well equipped hospital by a properly trained surgeon. The surgeon explains the procedure to you. The complications, failure rate and reversibility is also explained to you depending upon the method he uses. After general anaesthesia, he then makes two cuts one near the belly button and other at the bikini line in the middle or to one side. The belly is filled with gas, he identifies the pelvic organs, once the surgeon has access to fallopian tubes, and he usually seals them off by using, Filshie clips or rings. Sometimes they burn them and then may or may not cut them. It is harder to reverse the tube once they have been burnt.  Filshie clips are expensive and require an extra gadget, so it is not often used.

Some surgeons often prefer either to do the removal of either the tubes, or do a removal of Fimbrial ends of the tubes only. Recent research has shown that it is protective against ovarian cancer, as most of the ovarian cancers seem to arise from the Fimbrial end of the tube. One ovarian cancer is prevented after 100 such operations have been performed.

A new surgical method of achieving tubal occlusion has been added to help women. This is called hysteroscopic sterilization.It is only available in limited countries. It can be done under light sedation even in the surgeon’s office.

The surgeon inserts a small titanium coil, going through the vagina into the uterine cavity and than going through the tubal opening deposits the coil in the tube this coil is called ESSURE. At present this is the only hysteroscopic method available. After this operation you have to wait three months so that your body has created scar tissue around it totally blocking your tubes. At the end of three months a special test is performed to make sure that in fact your tubes are blocked. During this time you have to continue using your normal contraception before they confirmed that they are blocked. This was considered to be a negative factor regarding Essure. The failure rate is higher than laparoscopic sterilization. Reversibility has been tried with some success.
In recent times there has been some controversy about Essure because many women have required repeat operations. Some of these women who had this done in many situations were already compromised because of obesity, previous surgery, and co-morbidities. The repeat procedure had to be performed under a general anesthetic, which was not completely satisfactory. In view of these recent objections, please be sure that you are happy to have this procedure performed upon yourself.