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.