Thinking back, I had to give honorable mention to some other items that I love, but aren't in that lifesaving category or didn't last the entire first 6 months, etc:
Ergo Performance Carrier: I have two carriers, the My Baby Nest, which is a wrap style carrier, and the Ergo. The My Baby Nest was great when Vy was little. The Ergo is IT when it comes to carrying her around while we're out and about (she gets sick of the car seat) and when I need full mobility of both arms. The performance is super light and like all Ergo models, it's super comfy for all body types.
Puj Tub: The Puj tub was perfect for bathing Vy when she was littler. It would have continued to be great if she wasn't such a tall baby and our sinks were bigger. As a new mom I felt secure bathing her in the Puj and it was really easy and fast to set up. I think if we had a larger sink with a different faucet I would have used it longer.
Camera: Specifically, a camera with a burst mode or fast shutter. I use my iPhone a lot since I can take several photos at a time to get that perfect picture. But I've been slowly using my point and shoot digital since the quality is better and it has a burst mode where it takes one picture every second.
Water Boiler: We have a Zoshirushi water boiler that keeps water at a boil all day long. Having boiling water is great when you have a little one. Its great for warming bottles, flash sterilizing dropped pacifiers (depending on where they were dropped), and helps the dinner process along.
Baby Nail Scissors: Don't know what's wrong with me but I am a klutz when it comes to trimming Violette's nails with a baby nail cutter. I always seem to leave a jagged end and it's annoying. This weekend I got some Tweezerman Baby Nail Scissor/File set and it is SO much easier to cut her nails. There's safety guard that helps you not cut too short.
Wednesday, December 29, 2010
Wednesday, December 22, 2010
Ten Best Items for Baby and Mama-the First 6 Months
My baby is almost 6 months old! I seriously have no idea how 6 months have passed already, although it seems so long ago that she was a tiny baby. Reflecting back, here is my list of 10 items that have been invaluable these past 6 months:
1. iPad: I spend so much time rocking Violette for naps and I got really sick of watching tv after the first two weeks. At first I had a laptop but it was really hard to type on it. Since the iPad has the touch function it’s super easy to browse the web, read online magazines, play games, and correspond that way. It’s expensive (and mine was a gift), but made my life a lot easier and happier.
2. Anything Aden and Anais: This brand is the best! Cotton muslin gets softer and softer with each washing and retains heat in a way that avoids overheating or getting too cold. Violette has the sleepers (regular weight and cozy), swaddles, cozy blanket, issie, and burpy bibs. The burpy bibs go at the top of my list since they are multiuse: burpies, bibs, and they work great when you’re pumping. They are bean shaped so they nicely right under your breasts to catch any leaks.
3. Good quality glider: In retrospect I would have bought a glider that also reclined, but having a good quality glider is essential. I must have spent the entire first two months sitting in mine. Springing for the ottoman was great as well because it allowed me to keep my feet up after my c-section.
4. Sophie the Giraffe: Sophie is Violette’s favorite teething toy! Ours did smell like rubber at first, but after a few washings and lots of use the smell has gone away. She can be a huge crabby pants and Sophie cheers her right up.
5. Brest Friend: The unfortunately named Brest Friend actually will become your best friend while nursing! I had both the Boppy and the Brest Friend and preferred the latter. It straps around your waist which is nice because it has a little back support section that helps you sit up straighter. At first I used pillows but it made getting set up for feedings a pain in the ass and my back would still burn. Violette nursed in the football hold position exclusively for the first 3 months until she big enough not to get smothered by my breast and I just put the Brest Friend on sideways and it worked perfectly.
6. NoseFrida: Oh the wondrous NoseFrida! This was recommended to me by our photographer who is a new dad himself. It’s the best thing since sliced bread! Violette was very congested the first few months and would SCREAM when we’d put saline drops in her nose and try to suction out the mucous with a bulb aspirator. The NoseFrida is totally hygienic and really gets that snot out of the little one’s noses.
7. Orajel Medicated Swabs: Way easier to get the Orajel actually on the gums using these instead of the gel. Instant relief (for Violette and my ears).
8. Glow Worm (comfort item) for diaper changes: At first Vy didn’t like diaper changes, not sure why. Her glow worm plays a little song and glows. It provided her with a familiar comfort item when being changed. Now that she’s bigger it gives something to play with so during diaper changes. If anything, it’s a roll over deterrent on the high changing table.
9. Baby Bjorn lightweight pack and play: I’ll be honest, we’re freaking spoiled. We have both the conventional Graco pack and play and the Baby Bjorn. The bells and whistles of the Graco are great for home, but it’s really heavy and bulky for trips. The Baby Bjorn packs up very compactly, and like they claim, you can set it up in 20 seconds flat. Vy really likes it, I think the shape makes her feel safe and secure, especially in random environments.
10. King Sized Bed: We co-slept with Violette in a queen bed the first two months or so, but I got really tired of being squished in the middle. The king bed was an essential buy for everyone’s sleep. Vy has plenty of room on her side, she’s safe with the baby guard rail, and I don’t have to worry.
So there are the 10 things I can’t live without! I’m sure I’ll find more as the year progresses and the adventure continues!
Sunday, October 24, 2010
Cloth Diaper Reviews
Someday I won't be so exhausted and unable to come up with repartee about any and all subjects, so for now, a diaper review.
My take on Cloth Diapering: I started Violette out with 7th Generation disposable diapers, just to get the hang of a newborn, then over the second and third month switched to cloth diapers at home. Disposables are too easy when we're out in public (plus I opted for large designer purse instead of a traditional diaper bag so there's not exactly enough room to tote clothies around). I comfort myself in knowing that the 7th Gen are compostable (although I've yet to put Violette's wet diapers into our compost yet). I prefer cloth to disposables for many reasons, one of which is Violette's comfort. Although she's never had a complaint from disposables, she's almost four months old and has never had a diaper rash (knock on wood). I like the green aspect of cloth diapering, now that I have enough diapers we only do laundry ever other day and it's really not that bad. Some cloth diapers can be a little bulky and I have to plan to dress her in a footy sleeper or her larger size cloths to accommodate the extra size. All reviews are for diapers used from 2-4 months on an exclusively breast fed girl.
gDiapers all in Two Hybrid
http://www.gdiapers.com/
Flushable Insert: I didn't care for the flushable insert. I tried them when Violette was pretty small so I wasn't totally into leaving her to flush the insert for every diaper change, just seemed like a pain in the ass. Many of the inserts ended up in the diaper genie. The paper insert didn't do well with poos, especially blow outs (more on that later).
Cloth Insert: I really love the cloth insert. One side is nice fleecy cotton and the other is hemp. The hemp is ULTRA absorbent. Even with a super wet diaper the fleece stays pretty dry. Handles poos great, but blow outs soil the liner.
I like gDiapers and would recommend them. Going in, I wasn't prepared that blow out poops would leak into the liner (they rarely leak into the little pant-the only time was with the flushable inserts). But I was unprepared for blow out poops at all, luckily they're infrequent. Buying extra liners solved that problem. The absorbency of the cloth insert is the best of all the inserts I've used. Violette has outgrown her first set of little pants and I still use her small size inserts as doublers in her Bum Genius and Flip diapers. I experienced bunching (in the front) with both the flushable and the cloth inserts, usually only when wet. One downside is that gDiapers come in sizes so you'll end up buying at least two sets. They come in Tiny (5-8 lbs), Small (8-14 lbs), Medium (13-28 lbs) and Large (26-36 lbs). We get by with six pairs of little gpants, 12 liners, and 12 inserts (along with other diapers). Now that Violette is in the Med/Larges I don't think I'll buy the next size up, opting for cloth diapers that will span the life of her diaper days although gdiapers has frequent deals and sales, so I'm not totally opposed to buying more.
GroVia all in Two Hybrid (Velcro Closures with sizing snaps)
http://www.gro-via.com/index.php
GroVia diapers have a snap in soaker pad with two layers of cloth and a layer of waterproof cloth. I like all in twos because all you have to do is change the liner. They are a little expensive, the new line just came out so they're hard to find on sale. I like GroVias a lot because they are very slim fitting and the organic cotton in the inserts is very easy to clean with the toilet sprayer. The GroVias come in one size, all you have to do is snap it open as the baby grows. The diaper grows with the baby, although their size chart shows inches, I'm guessing they are similar to the gDiapers in sizing. GroVia also makes a disposable insert, similar to a maxi pad (has a sticky side you adhere to the diaper), but I haven’t tried them yet. These are definitely my favorite cloth diaper for ease of use.
GroVia All in One (formerly Dream Eze)
This review is of Dream Eze, I haven’t tried the new GroVia all in one yet and probably won’t. These diapers have the easy clean up of the all in twos, but instead of an insert have two soakers sewn into the diaper. The back is attached, but the front is not. They take a long time to dry, usually needing two rounds on permanent press in the dryer. They get really bulky if you buy the organic ones without the cover. The soaker pads are a little unruly and bunch up in the dryer. After using the hybrids I wouldn’t go with an all in one again.
Bum Genius 4.0 Pocket, Hook Loop Closure
http://www.bumgenius.com/index.php
Bum Genius have a nice microfleece type covering over the pocket, and a waterproof inner lining. The inserts are plushy terry cloth and have good absorbency. They are one size with snaps for sizing. They come with two inserts: a newborn insert and an insert that also has snaps for sizing. You can use the newborn insert as an extra soaker, and I also use my old gdiaper inserts for this as well. These diapers are great for people who are not used to cloth diapers like caregivers or grandparents since you can have them put together and they look and go on like disposable diapers. The diapers have to be air dried to extend the life of the waterproof lining, but even in cold weather mine line dry in about 16 hours. These diapers are fairly bulky but handle poos like a champ. They clean easily too. I like that they are one size so I won’t have to buy anymore. So far, no stains.
Gerber Organic Prefolds (with Flip Diaper Cover)
It took me awhile to warm up to the idea of prefolds, I thought they’d take a long time to load up while Violette was on the changing table, but that’s not the case at all. I fold them up after washing so I really just have to grab one or two and set them in the diaper cover. You can use them with any diaper cover, I use Flip diaper covers because that’s what my local cloth diapering source carries. They are one size and work great with any insert or prefold.
Bum Genius Diaper Sprayer
Eric installed the Bum Genius Diaper Sprayer on our toilet. It was easy to install, but he had to go back and tighten some of the parts since it leaked at first. If I turn on the sprayer full blast (which I generally don’t need to, it has terrific pressure) it sometimes leaks. The sprayer is almost too good; I have to be careful about aiming it correctly otherwise water will splash around the toilet and the bathroom. Best used with toilet seat up. Super convenient, I’m sure any brand would work fine.
FuzziBunz Doorknob Wetbag
Giant wetbag that has hooks to fit over the doorknob. Has a zipper on the bottom so you don’t have to unload diapers into the dryer, just unzip, dump, and throw it in. I don’t observe any odors.
Hospital Bed Pads
I use hospital bed pads over my changing pad cover and when Violette was very little while changing her in our bed at night. I rarely need them anymore, but I got a bunch on sale so I always have one stocked on the changing pad. I recommend them to first time moms and dads just getting the hang of diaper changes.
Hospital Bed Pads
I use hospital bed pads over my changing pad cover and when Violette was very little while changing her in our bed at night. I rarely need them anymore, but I got a bunch on sale so I always have one stocked on the changing pad. I recommend them to first time moms and dads just getting the hang of diaper changes.
Wednesday, October 20, 2010
Stay at Home Mom-Why do I have to be so literal?
Violette has settled in nicely with us, it's like she was always here. Eric and I find ourselves saying things like, "It was so BORING without her," "What did we ever do without her? Same old shit." Violette fits in so perfectly with us.
Things are a lot busier though, so that's been taking some getting used to. Some days I only get out of the house to go on our daily walk. That's been hard. With so many naps to schedule in I feel like it's not worth it do go on needless errands (like picking up my gossip at the newsstand every Thursday for instance) aren't worth it if Violette is going to miss her naps. Who have I become?
Mostly I miss going to the gym everyday. GTL had it's great renaissance with me last summer and those days are over for now. I just can't stand the thought of leaving my infant at the gym day care. I know it's a pretty bourgeois gym, but who is to say there aren't lice on the children of the bourgeoisie?
This is time is so precious though, we won't get it back. So if I spend my day playing with my daughter and reading televisionwithoutpity.com while she naps, so be it. It is weird-the complete change in perspective. When Eric and I go out on dates I revel in crossing an empty parking space (true story). Being able to step into a slightly hazardous situation feels like wild abandon these days, simply because I only have to think about my safety and not someone else's.
I'm going to have to join a play group soon. I'm sort of looking forward to that and sorta not. We'll see.
Things are a lot busier though, so that's been taking some getting used to. Some days I only get out of the house to go on our daily walk. That's been hard. With so many naps to schedule in I feel like it's not worth it do go on needless errands (like picking up my gossip at the newsstand every Thursday for instance) aren't worth it if Violette is going to miss her naps. Who have I become?
Mostly I miss going to the gym everyday. GTL had it's great renaissance with me last summer and those days are over for now. I just can't stand the thought of leaving my infant at the gym day care. I know it's a pretty bourgeois gym, but who is to say there aren't lice on the children of the bourgeoisie?
This is time is so precious though, we won't get it back. So if I spend my day playing with my daughter and reading televisionwithoutpity.com while she naps, so be it. It is weird-the complete change in perspective. When Eric and I go out on dates I revel in crossing an empty parking space (true story). Being able to step into a slightly hazardous situation feels like wild abandon these days, simply because I only have to think about my safety and not someone else's.
I'm going to have to join a play group soon. I'm sort of looking forward to that and sorta not. We'll see.
Friday, October 15, 2010
L&D of Violette Sophia/My Recovery
After two days of cramping, my water broke at 6:45 am on Sunday, June 27, 2010. I called the Dr and was sent to L&D. We arrived at 9:00 am and were monitored in triage for about an hour and half. Although my contractions were strong by then, my uterus was deemed “unorganized” but they decided to admit me to the unit because of my elevated blood pressure and a bit of dehydration. We had trouble monitoring the baby from the outside and while I tried to hydrate orally I just wasn’t getting enough so we decided to get some IV fluids in me. They stuck me 5 times before calling the anesthesiologist to install the IV, ultimately in my inner wrist (ack! It later came out and I had to be stuck 6 more times in the middle of the night to find a new vein, I looked like a complete junkie by the time I left the hospital).
I labored using hypnotic birth techniques for the next twelve hours. I spent some time in the Jacuzzi tub, but eventually asked for some pain assistance. I had no idea I had been laboring so long, but I knew my limits and was about to reach my pain/panic threshold-it was becoming very difficult to stay focused through the pain because the back labor was so strong. I took one dose of fentanyl and was feeling great for about 45 minutes. By then I knew that I wanted the epidural. I was so proud to later learn that I did go 12 full hours unmedicated and was able to experience that part of labor. I was scared of the epidural but knew it was the best thing. I had full confidence in the anesthesiologist (the same who installed my IV) and was able to get in a comfortable and optimal position for him to quickly install the epidural, again the hypnotic birth training helping with my uneasiness with the procedure.
I was so relieved when they turned on the medicine! I knew then that my chances of needing pitocin after that were amplified I was only 5/6 cent dilated but 90% effaced, but I figured I’d cross that bridge when I got there. We had had trouble monitoring the baby externally all day and we had to install the internal monitoring in the evening. I was upset that there was a screw in my baby’s head, but I knew it was best to know what was going on. Her heartbeat was excellent the entire labor, but she wasn’t having the expected accelerations and decelerations during surges. I labored through the night and was able to nap, listening to Harry Potter audiobooks to relax.
I went through two more nurse shifts throughout the night and was seen by a midwife while the OB on call was attending some more complicated births at another hospital. The midwife was able to tell that my cervix was dilating unevenly-my cervix is “tilted” so one side was dilating more than the other. She also told us that the baby had a lot of hair! That definitely got me through the rest night with a lot of motivation. We tried several labor positions (which was so hard to move around with my legs completely numb, but I am so glad I worked out my entire pregnancy, I impressed the nurses and myself with my ability to move myself with my upper body strength), ending up on my side with my husband gently rocking my hip to encourage the slow side of the cervix to ripen.
As we hit the 24 hour mark since the water had broke, I had an ultrasound to estimate the baby’s size; they thought she was about 7 lbs. We talked C section possibility around 12:15 pm, but after the next check I was fully dilated and 100% effaced. I pushed for 4 hours with little progress, even though I was able to squat once they turned off the epidural. The anesthesiologist had a shift change and I was flattered and encouraged that my original one came by to visit me before he left to tell me what a great job I was doing and that I was a “model patient.”
After 4 hours passed, a specialist was called in. He roughed me up a little while checking the babies position, which was ROA but slightly transverse due to my tilted cervix. He recommended a C section and when my Dr came back it was time to go. I was exhausted and started shaking uncontrollably. They told me this was normal but it freaked me out. They gave me a drug to drink, I don’t remember what it was for, but it came back up and I dry heaved for a bit while my mom and Eric changed into scrubs. Then I was rushed to OR and prepped for surgery. Everything was going by so fast, but the anesthesiologist was very nice and explained everything that I was going to feel. Eric and my mom were allowed to come in and they started the surgery.
The surgery is really a blur until the baby was born and even then I felt disconnected and numb. The nurses expounded that she was still a girl, and big girl at that, 9 lbs 11 oz. The baby was crying and a purply red color and I could only catch glimpses of her while they worked on her under the heat lamps. I saw her mess of black curls and flashes of her hands and feet but I was so dissatisfied I stopped looking because I decided I would rather see her full on then disappointing glances, I would wait. I wanted so badly to see her face. They brought her over to Eric but he was sitting a bit behind me and they wouldn’t let me hold her while they were finishing the surgery. The nurses kept telling me to look at my baby but craning my neck hurt and I started shaking again. I had intense shoulder pain and my sinuses were filling up from crying, I was a mess. My mom told me that her eyes were violet and that she was really pretty. Once they had sewed me back up I was rolled to get on a back board to move me back to the maternity bed. I got a nice view of a wall of bloody gauze but I tried to put it out of my mind.
I don’t remember much until they put the baby in my arms back in our room. It’s all kind of blurry now, I was on a lot of medication, but I had her skin to skin immediately and did not let go of her for a long time. I declined the nurses offers to bathe her for several hours because I just wanted to hold this precious girl. We decided on her name (none of our choices fit like Violette did) did some haggling over spelling, and I was able to have some broth and jello, I was starving.
The next 5 days are also very blurry and kind of run together. Leaving the hospital was difficult. The night before we got very little sleep, Violette was very fussy. The night nurse discovered that Violette was feverish and possibly dehydrated at around 3 am. She suggested that I had no milk and set me up with a pump, although she admitted she really didn’t know how to work it. I was completely upset thinking my milk was gone after having been praised by the lactation staff all week for my abundant and superior colostrum. Nothing came of 15 minutes of pumping and I tearfully accepted a bottle of formula for my inconsolable baby.
It was unclear all morning if they would discharge us, with Violette’s bad night and my staples unready to be removed (my Dr had removed 3 the day before, but decided to leave the rest another day) a few nurses implied I would have to stay one more day. This possibility made ME inconsolable and the stress and lack of sleep came to a head and I had a big breakdown, loud uncontrollable sobs. It was embarrassing and a for whatever reason the thought of not going home, not bringing a baby home that day brought out intense feelings about my pmp baby. I was also sick of the uncomfortable hospital bed and not having Eric sleep next to me, I just couldn’t relax there. Eric helped calm me down and we were able to go home in the afternoon. I am still upset that I walked in to the hospital with a natural birth/breastfeeding goal and walked out with a dinnertime c-section and a bag full of formula, a complete statistic.
Once we were home things were a lot better. I had a lot of swelling from the surgery and it started to come down in earnest once I was in my own comfort zone (although it didn’t completely go away until about 2 weeks later and self imposed bed rest-25 lbs in water total!). We did end up being on the go too much the first week home. We had to visit the hospital again on Saturday for a weight check for Violette since she had lost about a pound those first 5 days. Why that was discovered only hours before our discharge I don’t know, it seemed like our care was hit or miss depending on the nurse. We met with the lactation consultant, who is AWESOME and so sensitive to all the emotions that go into breastfeeding and having difficulties with it. She helped us make a breastfeeding plan and it is working.
I had two days at home with no outside commitments, but on Tuesday I woke up at 2 am feeling weird. After using the bathroom I checked my incision to find that I was bleeding from it. Since I am still afraid to look at it, I had my mom check it and she told me I needed to go the ER. Leaving Violette was the hardest thing and I cried all the way there and through the check in process. I was so scared that something was really wrong with me; I couldn’t shake the feeling that I was going to end up losing my uterus. After all the pmp stuff my mind instantly goes to the worst case scenario. My heart was hurting knowing I left my daughter home and that she would wake up for her next feeding and I wouldn’t be there. Luckily it wasn’t a busy night at the ER and I was home by 4 am with new butterflies on the part of my incision that had had the staples removed. I had the rest of the staples removed that day and was assured that things were healing well.
The next morning I had just finished feeding Violette around 6:30 am and noticed my pants were wet. I though it might just be spilled milk or a diaper leak but checked my wound just in case. I was gushing blood from my incision (the other side this time) and had to have my mom do a triage since I was making pools on the floor-thank God she was there and was an OR Tech before she became an attorney! I definitely needed her calm and experienced hands. Again, Eric bundled me in the car (much less emotional, much more resigned) and off to the ER we went, leaving Violette in my mom’s good care. This time my surgeon met us in the ER and let me know that the next course of action would be opening up my incision and keeping it packed with medical gauze to let it (slowly) heal from the inside out alleviating fluid build up. I was completely horrified at having to walk around with an open wound for the next 2-4 weeks, but it had to be done. After going into the Dr’s office for dressing changes the next 3 days, we found out that the VNA had no nurses to come help me so Eric and my mom had to learn how to pack my incision.
Eric took off 6 weeks of work to help me heal. I really regret that more of that time wasn't spent bonding and just enjoying Violette without having to deal with the seroma twice a day. All in all it took 9 weeks to fully heal (it also took 9 weeks to get to negative after the seroma and for my pinky to heal from a break in 2009 so I've decided that all medical bs takes 9 weeks). My incision scar is awful looking, I avoid looking at it. I'll have to have a mini tummy tuck or another child by c section to fix it.
I have very mixed feelings about the whole thing. I modulate from feeling extremely cheated out of a normal and happy birth experience (the pmp, the emergency c section, the unexpected breastfeeding issues, and the incision complication), to optimistic resignation about the whole process. This is my experience, this is what my journey needed to be, and I am accepting it. I do have mixed feelings about having another child. My Dr, my surgeon, and another one of their partners have all informed me that I am not a candidate for VBAC. It’s not something I would have thought about attempting anyway, but it does feel crappy to have that option completely taken off the table. I don’t even know if we want another child, and I know a planned C section would be much easier, but I’m not keen on putting my body through this again. I am starting to grieve my pregnancy a bit, but I know it will pass. Every time I get upset about it I try to remind myself that it’s not a decision I have to make right now, or even in the next 18 months.
Even though it’s been disappointing and upsetting, none of the complications have taken anything away from how lovely our Violette is and how wonderful it is to bond with her and hold her in my arms. I keep concentrating on that because if I don’t I’m afraid I would become overwhelmed at all the hurdles I’ve continued to have to jump over to get to motherhood. I’ve been lauded as a trooper, and although I’m sincerely tired of having to be so tough, I do take some pride that I might just be able to compare myself to nails after all of this. The end result yielded such amazing things: Violette is happy and healthy, Eric and my relationship is stronger than ever, and I'm a mom. Even when I want to feel sorry for myself, I remember that I have been blessed and there is no question that Violette is worth more than every challenge I’ve faced and met.
New Pregnancy
I had begun using an iPhone app to track my cycles when I got my iPhone so I was no longer used to paying close attention to my cycles on my own. In September of 2009 I had to go off birth control after my partial molar pregnancy because they were causing me to have 5 day migraines. When it came time for me to cycle again I didn’t really notice I was late for a few days. I told Eric I thought I was pregnant and sent him to get a pregnancy test. He brought back a conventional test and there was a faint line. From my time in my molar support group I’d learned that when it comes to hcg, a line is a line. I didn’t let myself get too excited and waiting the next day to test fresh, first thing. The test was a little bit darker, but not by much. We had plans to go up to my best friend’s, Nicole, house so we bought a digital test on the way up. Nicole was out when we got there but always leaves a key so we let ourselves in and I took the digital test. It was positive. I couldn’t believe it. I was surprised and scared, but I had a sense of peace about the pregnancy from the start. When Nicole came in I told her that there was something in her bathroom, and she said, “Oh, is it ants?” and I told her, “You could say that.” And when she went in I said, “Now there’s an Aunt in your bathroom.” We jumped around and squealed and had a really nice day working in her garden.
I called my Dr the next day and told them I was going in for hcg quants every other day and was going to use my existing order. Having these blood tests come back ok (hcg was doubling only ever 24 hours indicating a normal, singleton pregnancy) made me feel better, but I was still nervous. I checked for bleeding every time I used the bathroom (actually I did this my entire pregnancy). Finally November rolled around and we went in for the first appointment. We looked and felt as morose as the Adaams family. Both Eric and I were very scared. He kept asking me when we could rule out another molar, but I had already ruled it out in my mind since the hcg quants looked so good. My Dr didn’t waste anytime lecturing us for getting pregnant too soon after the molar, nor did she wait to get down to business. She did an internal ultrasound and on the screen was a little dot with an amazing heart flickering away. It was viable.
We went on our merry way, surprised and more than a little happy. Part of my depression with the molar was that my plan for the year had been shot. I had turned in 30 in July and was set to ovulate over our 10th wedding anniversary weekend. I had thought we would start trying then, and figured I wouldn’t get pregnant until October resulting in a Summer baby, maybe one even born right in between Eric and my birthdays. Ideal. I had given up on this dream, and here I was, 2 months out of the molar and I got it. It felt too good to be true, but I still had that sense of peace. I didn’t completely trust it, but I thought that this baby was here to stay. The second appointment had a little scary moment when we couldn’t find the baby’s heartbeat on the Doppler but my Dr swiftly got the ultrasound machine out and there was my little Mexican jumping bean, jumping all around my womb with it’s arms and legs flailing like it was happy to see me. We took to calling it Babalou.
Waiting a whole month in between appointments was really hard. I would ride a high two weeks after an appointment knowing that my baby was safe and secure in my belly. Then I would start to have my doubts and the anxiety would creep in. Everyone was telling me the baby was going to be a boy, something people had told my mom with me. This baby also had the same due date as me, July 1st. I walked around looking at boy clothes, cute sailor suits and geek chic onesies with ties. But I really wanted a girl. I had been imaging my daughter since I was a little girl. I think it stems from loving my mom so much I wanted to feel the other side of it from a very young age. In fact, the only career I’ve consistently wanted growing up was that of wife and mother. Even in the exciting days spent in Italy studying opera, so close to my dream of performing and singing in front of hundreds was so close I could taste it, motherhood was foremost in my heart.
We had our anatomy scan in February, and I couldn’t wait. I schedule it for the afternoon and Eric left work early so we could go shopping afterwards for gender themed clothes. The Dr kept me waiting a good hour and I had to use the bathroom in between because I was in serious pain after all the water I had drunk. The ultrasound techs I’d had before had harangued me for not drinking enough water so I made sure to drink A LOT before this appointment since I was dying to know the gender. The Dr said right away that she was pretty sure it was a girl, but I had to do some maneuvering to know for sure. She was and we got some lovely pictures. I could tell by her profile that she would probably look like me. We were elated, and went to do our shopping, but nothing was near good enough to buy for MY LITTLE GIRL.
The rest of the second trimester went well. I was receiving acupuncture and chiropractic treatments and working out 3-4 times a week so I was feeling great. In April we took a baby moon to Hawaii. I found a boat that would take me snorkeling and we went to the Makaha beach area where there is a “turtle cleaning station.” The turtles were awesome, so mellow, the stoners of the sea. We moved up the coast following a few pods of dolphins and the boat let us off into the water to follow them. They explained that they would pick us up once the pod ditched us. I swam with my mom and Eric, enjoying using my new fins and snorkel and seeing the baby dolphins. I was hoping they were using their sonar because for them, it’s just like ultrasound so they could see my baby. They weren’t but I kept up pretty well with the pod. When they finally moved on, I stopped, assuming my mom and Eric were with me, just behind. They were behind me, I had out swam them by about 20 yards! I could see the boat coming and my mom’s face was a little incredulous, and a lot worried. I started laughing. I met up with my buddies that I had ditched, and they were asking me if I was ok. I was perfectly fine, having one of the proudest moments of my life! I was 30 weeks pregnant and I had just swam with dolphins in the open ocean, AND had out swam two able bodied adults (actually 4 since there was another couple in the water with us). I felt strong and alive.
The last weeks of my pregnancy went along swimmingly. I was having a lot of sciatic nerve pain so I changed from circuits to swimming for my exercise. I never was miserably pregnant. I certainly had a day or two in the last two weeks where I was OVER it though. I wanted to meet my baby. I was a little scared knowing that my birth had been a huge drama (emergency vertical C), but I felt like I had prepared at our birth class and had done home study of hypnotic birth techniques so I was ready. Once I reached 39 weeks I was ready to have my acupuncturists induce my labor and the next day things got started.
Tuesday, October 5, 2010
June 2009 Partial Molar Pregnancy
On May 15th 2009 I missed my period. I have always been very regular and April was the first month my husband, Eric, and I had not been careful with birth control. We were turning 30 that year and thought after almost 10 years of marriage the time was right to see if we could have a baby. I started spotting brown and called the doctor to confirm my pregnancy. I was pregnant, and because of the spotting I was sent at 6 weeks pregnant for an early ultrasound.
At the first ultrasound the tech saw a sac, a yolk, and a fetal pole. There was no heartbeat and the fetus measured 6 weeks 6 days. I asked if this was something to be concerned about and I was told it was very early in the pregnancy and it was still iffy if we would see a heartbeat by ultrasound at this point. I let the tech know that we had a vacation to DisneyWorld in Florida we were leaving for the following Monday and let her know that if something was wrong I didn't want to get on a plane. I never received a call, so thinking everything was fine (apart from missing all the good roller coasters), we left for Florida as planned.
On a lay-over in Denver I received an email from my medical group letting me know the ultrasound results were ready for me to read online. I quickly navigated to my online chart and my heart sank. The radiologist recommendation was for immediate care. I googled and googled and debated de-boarding and going home then. I left a message with my doctor's office and decided to continue on despite the massive anxiety attack I was having.
I KNEW something was very wrong. I had already been having severe morning sickness and was more comfortable in maternity pants. When we landed in Orlando I had voice mails waiting. My doctor instructed me to go to an urgent care or emergency room as soon as possible. I checked in, and after waiting hours to be seen had my miscarriage confirmed. The attending doctor wanted me to schedule a d&c for the next morning but I couldn't do it in an unknown public hospital and I wasn't ready to let the baby go. I couldn't leave her in Florida when I knew I had a good chance at being allowed to miscarry naturally at home. I checked out against doctors orders and returned to our hotel where I promptly threw up. It took a lot of finagling but we were able to leave at 2 pm the next day. I passed some tissue on the way home and went to the doctor the next day.
I was given misoprostol, a drug that would make my uterus contract and abort the baby. I took along with some painkillers as soon as I got home from that appointment and spent the weekend in bed, mourning and bleeding. I had a follow up appointment and was told we could try to conceive after I had had one normal period. I mentioned that I had not been feeling well, but we chalked it up to the shock and all the sudden travel. A few days later I was still feeling nauseous and sick so I went back to my regular doctor. She did a pelvic and had me go for a blood test.
By this time I had read up on miscarriage and a small paragraph I had read about molar pregnancy stuck with me because of the things I had seen while I miscarried. The blood test confirmed that I was still producing hCG, the pregnancy hormone and that at the very least I had retained tissue and it was very likely I had had a molar. All this required a d&c. In hindsight, I wish I had gotten the d&c over with in Florida. After the surgery I spent another week in a painkiller daze, the pain in my heart worse than anything I could feel in my body. On July 1st my molar pregnancy was confirmed. I had to have weekly blood tests until my hCG was normal. I had a HUGE needle phobia, consistently needing to lie down because I would get so anxious I would pass out. Weekly needling sounded like hell. I decided since I was invariably going to get over this needle phobia, I better go balls out and started acupuncture to try to get my levels to drop more quickly. My hcg ran it's course in 9 weeks:
pre D&C 6/20 – 255,000
7/2 - 1322
7/9 - 276
7/16 – 100
7/23 - 44
8/6-17
8/13- 11
8/19 - 7
8/26- 5
The wait was emotionally excruciating . It was bad enough that I had lost my first baby after having wanted one, wanting to be a mother from as early age as I can remember. On top of that, to now have to wait 6 months to try to conceive was a very hard pill to swallow. I had plans. The molar pregnancy was NOT in my plan. I had planned to start trying on our 10th wedding anniversary in August, figuring I wouldn't get pregnant until October resulting in a late June/early July baby--right in between Eric and my birthdays. Being a controlled person, thriving on order, the chaos of emotions and bodily trauma and the threat of chemo completely broke me down. I had to rearrange my feelings and self through the molar process. At the time, it was hell. All I was really capable of us devoting myself to further weight loss by going to the gym daily, tanning at the local tanning bed, making dinners, and smoking my head off. I was in a haze of smoke, tanning lotion, and pain.
I named the baby Abigail, meaning "Joy of the Father." Since my daughter was now in heaven, she would be God's joy, not mine. Doing that helped. I had been on hormonal birth control since the molar diagnosis since it was imperative that I NOT get pregnant while my hCG was abnormal. I had warned my doctor that this might not work for me since it would make my hormonal migraines sometimes last up to 5 days. I was right, and in September I had to stop taking the pills. I had a normal period and 3 weeks later was having a really off day. I was super crabby and by the end of the day I had a very strong feeling I was pregnant. I told Eric that I felt pregnant and he sadly told me I just wanted to be pregnant and reminded me that we had been preventing. I had a feeling he was wrong and the next week I got to prove him so.
To be continued...
At the first ultrasound the tech saw a sac, a yolk, and a fetal pole. There was no heartbeat and the fetus measured 6 weeks 6 days. I asked if this was something to be concerned about and I was told it was very early in the pregnancy and it was still iffy if we would see a heartbeat by ultrasound at this point. I let the tech know that we had a vacation to DisneyWorld in Florida we were leaving for the following Monday and let her know that if something was wrong I didn't want to get on a plane. I never received a call, so thinking everything was fine (apart from missing all the good roller coasters), we left for Florida as planned.
On a lay-over in Denver I received an email from my medical group letting me know the ultrasound results were ready for me to read online. I quickly navigated to my online chart and my heart sank. The radiologist recommendation was for immediate care. I googled and googled and debated de-boarding and going home then. I left a message with my doctor's office and decided to continue on despite the massive anxiety attack I was having.
I KNEW something was very wrong. I had already been having severe morning sickness and was more comfortable in maternity pants. When we landed in Orlando I had voice mails waiting. My doctor instructed me to go to an urgent care or emergency room as soon as possible. I checked in, and after waiting hours to be seen had my miscarriage confirmed. The attending doctor wanted me to schedule a d&c for the next morning but I couldn't do it in an unknown public hospital and I wasn't ready to let the baby go. I couldn't leave her in Florida when I knew I had a good chance at being allowed to miscarry naturally at home. I checked out against doctors orders and returned to our hotel where I promptly threw up. It took a lot of finagling but we were able to leave at 2 pm the next day. I passed some tissue on the way home and went to the doctor the next day.
I was given misoprostol, a drug that would make my uterus contract and abort the baby. I took along with some painkillers as soon as I got home from that appointment and spent the weekend in bed, mourning and bleeding. I had a follow up appointment and was told we could try to conceive after I had had one normal period. I mentioned that I had not been feeling well, but we chalked it up to the shock and all the sudden travel. A few days later I was still feeling nauseous and sick so I went back to my regular doctor. She did a pelvic and had me go for a blood test.
By this time I had read up on miscarriage and a small paragraph I had read about molar pregnancy stuck with me because of the things I had seen while I miscarried. The blood test confirmed that I was still producing hCG, the pregnancy hormone and that at the very least I had retained tissue and it was very likely I had had a molar. All this required a d&c. In hindsight, I wish I had gotten the d&c over with in Florida. After the surgery I spent another week in a painkiller daze, the pain in my heart worse than anything I could feel in my body. On July 1st my molar pregnancy was confirmed. I had to have weekly blood tests until my hCG was normal. I had a HUGE needle phobia, consistently needing to lie down because I would get so anxious I would pass out. Weekly needling sounded like hell. I decided since I was invariably going to get over this needle phobia, I better go balls out and started acupuncture to try to get my levels to drop more quickly. My hcg ran it's course in 9 weeks:
pre D&C 6/20 – 255,000
7/2 - 1322
7/9 - 276
7/16 – 100
7/23 - 44
8/6-17
8/13- 11
8/19 - 7
8/26- 5
The wait was emotionally excruciating . It was bad enough that I had lost my first baby after having wanted one, wanting to be a mother from as early age as I can remember. On top of that, to now have to wait 6 months to try to conceive was a very hard pill to swallow. I had plans. The molar pregnancy was NOT in my plan. I had planned to start trying on our 10th wedding anniversary in August, figuring I wouldn't get pregnant until October resulting in a late June/early July baby--right in between Eric and my birthdays. Being a controlled person, thriving on order, the chaos of emotions and bodily trauma and the threat of chemo completely broke me down. I had to rearrange my feelings and self through the molar process. At the time, it was hell. All I was really capable of us devoting myself to further weight loss by going to the gym daily, tanning at the local tanning bed, making dinners, and smoking my head off. I was in a haze of smoke, tanning lotion, and pain.
I named the baby Abigail, meaning "Joy of the Father." Since my daughter was now in heaven, she would be God's joy, not mine. Doing that helped. I had been on hormonal birth control since the molar diagnosis since it was imperative that I NOT get pregnant while my hCG was abnormal. I had warned my doctor that this might not work for me since it would make my hormonal migraines sometimes last up to 5 days. I was right, and in September I had to stop taking the pills. I had a normal period and 3 weeks later was having a really off day. I was super crabby and by the end of the day I had a very strong feeling I was pregnant. I told Eric that I felt pregnant and he sadly told me I just wanted to be pregnant and reminded me that we had been preventing. I had a feeling he was wrong and the next week I got to prove him so.
To be continued...
Molar Research: Hydatiform Mole Q & A
Hydatidiform Mole (excerpted)
Source: The Women's the royal women's hospital 2007
The following information is for patients who have been diagnosed as having a hydatidiform mole. Hydatidiform mole occurs in approximately 1 in 1500 pregnancies. This uncommon condition may be difficult to understand; especially at a time of disappointment for you and your partner, after the loss of your pregnancy.
What occurs in a normal pregnancy?
The woman's ovum (eff) is fertilised in the fallopian tube and two or three days later the fertilized egg moves into the uterus (womb) where it attaches to the inner wall. The outer part of the fertilised egg forms the placenta (after birth) and the inner part develops into a fetus (baby). The placenta produces a pregnancy hormone called Human Chorionic Gonadotrophin (hCG). This hormone is what gives you pregnancy symptoms such as morning sickness, tender breasts, and lack of energy.
What occurs in a hydatidiform mole pregnancy?
In a hydatidiform mole pregnancy, the baby does not develop and only the placenta forms. This placenta is abnormal, larger and contains many cysts (sacs of fluid).
Why is it called a hydatidiform mole?
The first part of the name comes from the Greek work 'hydatis', meaning droplet. These droplet like structures appear to burrow into the wall of the uterus, hence the name mole.
Why did I develop a hydatidiform mole?
Hydatidiform mole occurs because of a breakdown in the normal joining of chromosomes at fertilization. Neither you or your partner contributed to this abnormal pregnancy.
Why do I need to be monitored?
Although it may seem like the hydatidiform mole has been completely removed, in about ten percent of cases some cells may remain. These cells continue to produce the pregnancy hormone hCG. We monitor you by testing for this hormone in your urine or blood. If the hormone level does not decrease, then it is likely that some abnormal cells remain.
How often will I have to give urine or blood samples and for how long?
Samples are analysed each week until the hormone level becomes normal. If a normal level is achieved within two months, then there is no need for any further follow up. If a normal level is not achieved within two months, we will continue to monitor you with weekly urine or blood samples until the level becomes normal and then monthly samples for the next 12 months.
If the hormone level rises, what treatment will I need?
If the hormone level does not decrease you will be asked to attend the hospital for some tests. these will include blood tests, a chest x-ray, and an ultrasound.
What is a partial mole and will I still need treatment?
A partial mole means that the changes in the placenta are less obvious. Usually a baby does develop, but dies in the womb. The likelihood of needing drug treatment after a partial mole is extremely rare. Patients registered with a partial mole will be monitored by weekly urine or blood samples until the hCG hormone level becomes normal. Once this occurs monitoring will stop.
When can I get pregnant again?
After a partial mole: Before trying to get pregnant again, your doctor will need to confirm you had a partial mole and that you have a normal hormone level in your urine or blood. You will also need one final check up and to have had one normal period.
After a complete mole: If a normal hormone level is achieved within two months, then testing can stop and you can try to get pregnant. If you have been monitored for more than two months, we recommend that you should not try to get pregnant until 12 months have passed, following a normal hormone level. This is because if you get pregnant before then, we will not know if the hormone increase is due to a normal pregnancy, or due to cells from the hydatidiform mole.
What contraception should I use?
You can use any contraception you and your partner are happy with.
What are the chances of a hydatidiform mole in the future?
The chance of a hydatidiform mole occurring again is about one percent. When you think you are pregnant, let your doctor know so that an early ultrasound examination can be arranged. Six weeks after the delivery of your baby, we would like you give the registry one further urine/blood sample for hormone analysis.
To have this information sent to you in pdf form, please email me at isis715@yahoo.com
Source: The Women's the royal women's hospital 2007
The following information is for patients who have been diagnosed as having a hydatidiform mole. Hydatidiform mole occurs in approximately 1 in 1500 pregnancies. This uncommon condition may be difficult to understand; especially at a time of disappointment for you and your partner, after the loss of your pregnancy.
What occurs in a normal pregnancy?
The woman's ovum (eff) is fertilised in the fallopian tube and two or three days later the fertilized egg moves into the uterus (womb) where it attaches to the inner wall. The outer part of the fertilised egg forms the placenta (after birth) and the inner part develops into a fetus (baby). The placenta produces a pregnancy hormone called Human Chorionic Gonadotrophin (hCG). This hormone is what gives you pregnancy symptoms such as morning sickness, tender breasts, and lack of energy.
What occurs in a hydatidiform mole pregnancy?
In a hydatidiform mole pregnancy, the baby does not develop and only the placenta forms. This placenta is abnormal, larger and contains many cysts (sacs of fluid).
Why is it called a hydatidiform mole?
The first part of the name comes from the Greek work 'hydatis', meaning droplet. These droplet like structures appear to burrow into the wall of the uterus, hence the name mole.
Why did I develop a hydatidiform mole?
Hydatidiform mole occurs because of a breakdown in the normal joining of chromosomes at fertilization. Neither you or your partner contributed to this abnormal pregnancy.
Why do I need to be monitored?
Although it may seem like the hydatidiform mole has been completely removed, in about ten percent of cases some cells may remain. These cells continue to produce the pregnancy hormone hCG. We monitor you by testing for this hormone in your urine or blood. If the hormone level does not decrease, then it is likely that some abnormal cells remain.
How often will I have to give urine or blood samples and for how long?
Samples are analysed each week until the hormone level becomes normal. If a normal level is achieved within two months, then there is no need for any further follow up. If a normal level is not achieved within two months, we will continue to monitor you with weekly urine or blood samples until the level becomes normal and then monthly samples for the next 12 months.
If the hormone level rises, what treatment will I need?
If the hormone level does not decrease you will be asked to attend the hospital for some tests. these will include blood tests, a chest x-ray, and an ultrasound.
What is a partial mole and will I still need treatment?
A partial mole means that the changes in the placenta are less obvious. Usually a baby does develop, but dies in the womb. The likelihood of needing drug treatment after a partial mole is extremely rare. Patients registered with a partial mole will be monitored by weekly urine or blood samples until the hCG hormone level becomes normal. Once this occurs monitoring will stop.
When can I get pregnant again?
After a partial mole: Before trying to get pregnant again, your doctor will need to confirm you had a partial mole and that you have a normal hormone level in your urine or blood. You will also need one final check up and to have had one normal period.
After a complete mole: If a normal hormone level is achieved within two months, then testing can stop and you can try to get pregnant. If you have been monitored for more than two months, we recommend that you should not try to get pregnant until 12 months have passed, following a normal hormone level. This is because if you get pregnant before then, we will not know if the hormone increase is due to a normal pregnancy, or due to cells from the hydatidiform mole.
What contraception should I use?
You can use any contraception you and your partner are happy with.
What are the chances of a hydatidiform mole in the future?
The chance of a hydatidiform mole occurring again is about one percent. When you think you are pregnant, let your doctor know so that an early ultrasound examination can be arranged. Six weeks after the delivery of your baby, we would like you give the registry one further urine/blood sample for hormone analysis.
To have this information sent to you in pdf form, please email me at isis715@yahoo.com
Molar Research: Predictors of low risk of persistent trophoblasitic disease in mp
Predictors of Low Risk of Persistent Trophoblastic Disease in Molar Pregnancies
Isa Niemann, MD, Lone Kjeld Petersen, DM, Estrid S. Hansen, MD, and Lone Sunde, PhD
Source: From the Departments of Clinical Genetics, Gynecology and Obstetrics, and Pathology, University Hospital of Aarhus, Aarhus, Denmark.
OBJECTIVE: To search for predictive factors for low risk of persistent trophoblastic disease in patients with molar pregnancies.METHODS: A total of 270 consecutively collected, histologically confirmed hydatidiform moles were classified by ploidy using karyotyping and flow cytometry. The parental origin of the genome was determined by analysis of microsatellite polymorphisms. Data on clinical featuresand pathology reports were collected for each patient.
RESULTS: The observed frequency of persistent trophoblastic disease in patients with triploid moles was 0 of
105, (95% confidence interval 0–2.8%), whereas 28 of 162 patients with diploid molar pregnancies developed persistent trophoblastic disease (P < .001). Patients with a diploid mole and an initial hCG level lower than 49,000 units per liter did not develop persistent trophoblastic disease (P .03).CONCLUSION: The risk of persistent trophoblastic disease after a triploid mole is very low. By combining the present data with data from published studies with valid ploidy assessment, the frequency of persistent trophoblastic disease in patients with triploid moles is 0 of 196 (95% confidence interval 0–1.5%). We suggest that the surveillance program for patients with triploid molar pregnancies is shortened. Initial hCG less than 49,000 units per liter is a possible predictor of low risk of persistent trophoblastic disease in women with diploid molar pregnancies, but this observation needs confirmation in larger studies.
LEVEL OF EVIDENCE: II-2
In the majority of cases, hydatidiform mole resolves spontaneously, but approximately 10% of the patients
with molar pregnancies develop persistent trophoblastic disease and receive chemotherapy to obtain remission. To identify patients without spontaneous remission, all molar patients are surveyed with serial hCG
measurements after evacuation until 6–12 months after undetectable hCG levels have been reached.
Traditionally, a hydatidiform mole is classified as either a complete or a partial mole based on gross
morphology and histopathology.3,4 Complete moles most frequently have a diploid karyotype as opposed
to partial moles, which most often are triploid. Usually, diploid moles derive from fertilization of an
“empty” egg with either a haploid sperm (homozygosity) or by dispermy (heterozygosity).5,6 A minority
of diploid moles have biparental genomes. Triploid moles arise by dispermy and thus have 2 paternal sets
and 1 maternal set of chromosomes to the genome. Several attempts to describe risk factors for postmolar
persistent trophoblastic disease have been made. Persistent trophoblastic disease is mainly associated
with complete moles but has also been reported with partial moles.7,8 Some studies have shown
that patients with high maternal age, excessive uterine size, markedly elevated initial hCG, positive history
of hydatidiform mole, and marked trophoblastic proliferation have an increased risk of persistent trophoblastic
disease after a complete mole.9–12 Other studies, however, could not confirm these findings.13,14
In this study we took the complementary view: Can we find predictive factors to identify molar
patients without a risk of developing persistent trophoblastic disease? In an earlier study on 105 moles,
we found that of 42 women with triploid moles, none developed persistent trophoblastic disease.15 This
study extends our previous work.
MATERIALS AND METHODS
Fresh samples of evacuated tissue and 10 mL of heparinized blood were consecutively collected from patients with pregnancies clinically suspected of hydatidiform mole. When possible, a blood sample from
the father was also collected. The inclusion period went from April 1986 to June 2003. Thirteen gynecologic
wards, covering approximately 40% of the Danish population, participated in submitting the samples.
No patients contributed more than 1 sample. We received and inspected 387 samples with the
naked eye and under a dissection microscope (x25), finding 313 samples with vesicular villi (Ø 1 mm)
possibly representing hydatidiform mole. To diagnose molar pregnancy, 1 pathologist (E.S.H.) reviewed
the original slides using the criteria of Szulman and Surti4 without knowledge of the ploidy or primary histopathologic diagnosis. After the review, 270 conceptuses were diagnosed as hydatidiform moles. Of the 43 excluded samples, 14 could not be revised due to lack of original histopathologic material. We used karyotyping and flow cytometry to determine the ploidy of the molar tissue. Karyotyping was successful in 246 (91%) molar samples. Infection and formalin fixation were the main reasons for not obtaining metaphases. Eight moles were hypotriploid or hypertriploid, and 2 were hypodiploid or hyperdiploid and were classified as triploid or diploid, respectively. In 135 moles the DNA ploidy was determined by flow cytometry of unfixed interphase nuclei using the preparation techniques described by Vindelov16 with trout and chicken erythrocyte nuclei as controls. In 2 moles, the ploidy was determined by analysis of microsatellite polymorphisms.
The parental origin of the genome in the diploid moles was assessed by analysis of polymorphic DNA
markers. Standard techniques were used to isolate DNA from molar tissue and parental blood samples.
The analyses of DNA markers in the early part of the study have been described previously (Sunde L.
Genetic analyses of hydatidiform mole with conceptual and practical implications. PhD thesis, University
of Aarhus, Denmark 1990). In 109 diploid moles, DNA was amplified by polymerase chain reaction
using 10 primer pairs (D13S634, D13S305, D13S258, D18S51, D18S391, D18S978, D21S11, D21S141,
D21S1435, X22) flanking microsatellite loci with a heterozygosity frequency of 67–93%. The polymerase
chain reaction products were resolved by capillary electrophoresis with an ABI prism 310 Genetic Analyzer
(Applied Biosystems, Naerum, Denmark). The polymorphisms were analyzed using ABI prism GeneScan
software (Applied Biosystems). A mole was classified as androgenetic when the mole and the patient had no identical alleles in at least 2 loci. Androgenetic moles were classified as homozygous (P1P1) if all, and at least 4, successfully analyzed loci showed homozygosity. Androgenetic moles were classified as heterozygous (P1P2) when having a XY karyotype or when the mole was heterozygous in at least 1 locus or both. In 3 cases, maternal DNA was lacking and the moles were classified as androgenetic and homozygous, because they were homozygous in all of 10 loci. Data on clinical features and chemotherapy was collected from gynecologic and oncologic hospital records. All patients had at least 6 months of follow-up from evacuation date, and the median follow-up time was 10.4 years. We classified patients as having persistent trophoblastic disease if they were treated with chemotherapy. Methotrexate was the first choice of treatment to all patients. The Regional Committee on Biomedical Research Ethics of Aarhus County approved the project, and all patients gave informed consent. Logistic regression model, confidence intervals (assuming binomial distribution), and differences between groups (using the 2 test or Fisher exact test where appropriate) were analyzed with Stata 8.2 statistical software (StataCorp LP, College Station, TX).
RESULTS
We classified 162 moles as diploid, 105 as triploid, and 3 as tetraploid. Eight of the diploid moles were
part of twin pregnancies with a coexisting fetus.Twenty-eight patients were subsequently treated with
chemotherapy (Table 1). Seventeen patients were diagnosed with invasive mole, 2 with choriocarcinoma,
and 9 had persistently elevated serum hCG. Two of 8 twin pregnancies with diploid mole and a coexisting fetus were followed by persistent trophoblastic disease. Another 8 patients, 1 with a triploid and 7 with
diploid moles, had delayed normalization of hCG levels but were cured without chemotherapy. Five of
these achieved normal hCG values after a second evacuation. Three patients (with diploid moles) had
persistently low hCG values ( 60 units per liter) for 4, 12, and 23 months, reaching undetectable values
eventually. All of the 242 molar patients with spontaneous remission remained free of disease through the
follow-up period (6 months to 17 years). None of the patients with triploid or tetraploid molar pregnancies were treated with chemotherapy; 28 of 162 patients (17.3%) with a diploid mole developed persistent trophoblastic disease (P .001) The observed frequency of persistent trophoblastic disease after a triploid mole was 0 of 105, (95% confidence interval [CI] 0–2.8%).were excluded by the histopathologic review. Among these, 26 gestations were triploid. None of the 26 additional patients with triploid gestations developed persistent trophoblastic disease, and thus, 0 of 131 (95% CI 0–2.3%) patients with triploid gestations originally suspected of hydatidiform mole developed persistent trophoblastic disease (data not shown). Secondarily, we looked for factors that could point out patients with a low risk of persistent trophoblastic disease after a diploid mole. Table 2 gives the frequency of persistent trophoblastic disease after
diploid moles stratified by the parental origin of the molar genome. Among the 162 diploid moles, 149
(92.0%) were androgenetic and 12 were biparental. Of the androgenetic moles, 18 (12.1%) were heterozygous. In 1 mole the parental origin could not be determined. Although not significant, the frequency
of persistent trophoblastic disease was lower in patients with androgenetic, homozygous, or biparental
moles (16.7% and 16.8%) than in patients with androgenetic, heterozygous moles (22.2%). In Table 3,
maternal age less than 40 years, nonexcessive uterine size, initial hCG level less than 100,000 units per liter,
and parental origin of the genome were evaluated as predictors of low risk of persistent trophoblastic disease
among women with diploid moles. Using a multiple logistic regression model, none of the variables were predictors of spontaneous remission in diploid molar patients, although all parameters, though not significantly, reduced the risk of persistent trophoblastic disease. However, we did observe that none of 19 patients with an initial hCG level below 49,000 units per liter developed persistent trophoblastic disease (P .03).
DISCUSSION
This study aimed at identifying factors predicting a low risk of persistent trophoblastic disease after a
hydatidiform mole. As of now, all patients have serial hCG measurements after evacuation for a molar pregnancy, regardless of type. We observed no cases of persistent trophoblastic disease after 105 triploid moles. We could not identify predictors for low risk of persistent trophoblastic disease in women with diploid molar pregnancies, but in all of 19 patients with a diploid mole and an initial hCG level below 49,000 units per liter, spontaneous remission was observed (P .03). One problem in identifying predictive factors for
spontaneous remission is the identification of the group of patients with true gestational trophoblastic neoplasia. We defined patients with persistent trophoblastic disease as those who were given chemotherapy.
Our data were consecutively collected in a well-organized public health care system with reliable registration and central treatment of gestational trophoblastic disease. Because the frequency of persistent trophoblastic disease was as low as 17.3% among the patients with diploid moles, because all but 2 patients needed at least 3 courses of methotrexate to obtain remission, and because all of the patients in the nonpersistent trophoblastic disease group remained free of disease in the follow-up period, we believe that by far most of our patients with persistent trophoblastic disease truly had gestational trophoblastic neoplasia and that we did not overlook any case of gestational trophoblastic neoplasia. To secure the validity of the ploidy, we avoided flow cytometry on formalinfixed, paraffin-embedded tissue. Our observation of no cases of persistent trophoblastic disease after triploid moles substantiates those of Lawler et al17 and Ohama et al.18 These 2 studies were also based on consecutively collected samples and determination of ploidy by reliable genetic techniques. Combining our results with theirs, the observed frequency of persistent trophoblastic disease in
patients with triploid molar pregnancies adds to 0 of 196 (95% CI 0–1.5%). Cases of triploid mole succeeded by choriocarcinoma have been reported.19,20 This is expectable because choriocarcinoma can succeed every type of pregnancy. Thus, the confidence intervals for the risk of persistent trophoblastic disease after a triploid mole and after a normal pregnancy probably overlap. The risk of persistent trophoblastic disease after a triploid mole is very low and may even approach zero. We suggest that the surveillance program for patients with triploid molar pregnancies be shortened. An abbreviated follow-up period would imply less anxiety and shorter delay of child bearing for these women. To apply molar triploidy as a predictor of low risk of persistent trophoblastic disease, obtaining a valid ploidy is crucial. It is thus important to use
reliable techniques like karyotyping or flow cytometry on fresh tissue with 2 external controls.14,21 We secondarily evaluated possible predictors of spontaneous remission in women with diploid molar pregnancies. The observed frequency of persistent trophoblastic disease after a diploid mole was 17.3% in this study as in other studies.13,22–24 Wake et al25 observed that patients with androgenetic, homozygous moles less frequently required chemotherapy treatment (0%) compared with patients with androgenetic, heterozygous moles (60%). Studies by Lawler et al17 and Fisher and Lawler26 could not confirm that patients with androgenetic, heterozygous moles had a higher frequency of persistent trophoblastic disease. Likewise, we found no significant differences in the frequency of persistent trophoblastic disease in moles stratified by parental origin. Maternal age younger than 40 years, nonexcessive uterine size, and an initial hCG less than 100,000 units per liter reduced, however not significantly, the risk of persistent trophoblastic disease. With an initial hCG lower than 49,000 units per liter, though, we observed a significantly reduced frequency of persistent trophoblastic disease (P .03). Two studies report that women reaching a serum hCG value less than 50 units per liter or a urinary hCG less than 40 units per liter within 4 to 8 weeks after the first evacuation have a low risk of persistent trophoblastic disease.27,28 A prompt predictor of low risk of persistent trophoblastic disease would be of greater benefit to the patients. Low initial hCG is a potential predictor of spontaneous remission in women with diploid moles, but the best estimate of a cutoff level and its clinical applicability need to be studied in larger studies. Triploid hydatidiform moles carry a very low risk of persistent trophoblastic disease. Further studies of low risk factors, such as low initial se-hCG, for diploid
molar pregnancies are important. Our observations furthermore imply that diploid and triploid moles possibly represent 2 different biologic entities with different clinical properties.
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Molar Research: hcg follow up in patients with mp: A Time for Reevaluation
Human Chorionic Gonadotropin Follow-up in Patients
With Molar Pregnancy: A Time for Reevaluation
With Molar Pregnancy: A Time for Reevaluation
Colleen M. Feltmate, MD, Jozsef Batorfi, MD, Vilmos Fulop, MD, PhD, Donald P. Goldstein, MD,
Jozsef Doszpod, MD, and Ross S. Berkowitz, MD
Jozsef Doszpod, MD, and Ross S. Berkowitz, MD
Source: From the New England Trophoblastic Disease Center, Donald P. Goldstein, MD Trophoblastic Tumor Registry, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Gillette Center for Women’s Cancer, Dana-Farber Cancer Institute, Dana-Farber Harvard Cancer Center, Harvard Medical School, Boston, Massachusetts; and Department of
Obstetrics and Gynecology, National Health Center, Budapest, Hungary.
OBJECTIVE: To determine how often patients with molar pregnancy do not complete recommended follow-up and to identify factors that may predict failure to complete human chorionic gonadotropin (hCG) monitoring. This study also sought to determine how often patients with molar pregnancy who do not complete follow-up relapse after attaining at least one undetectable hCG value.Obstetrics and Gynecology, National Health Center, Budapest, Hungary.
METHODS: Four hundred randomly selected patients with molar pregnancy were analyzed regarding the serum hCG levels after molar evacuation. Demographic factors were determined for each patient: age, marital status, gravidity, parity, health insurance type, and distance from patient residence to trophoblastic center.
RESULTS: Recommended hCG follow-up was completed in 63% of the uncomplicated 333 cases. Three
hundred twenty patients achieved at least one undetectable serum hCG level. Among the 320 patients, 33% achieved undetectable hCG values but did not complete recommended follow-up. However, none had any evidence of relapse. A distance of greater than 20 miles from the patient’s residence to our center was associated with failure to complete hCG follow-up.
CONCLUSION: Because none of the 320 patients who achieved at least one undetectable hCG level has been diagnosed with gestational trophoblastic tumor relapse, it may be appropriate to reassess the duration of hCG monitoring for patients with molar pregnancy. Gestational trophoblastic disease includes a spectrum of
diseases with varying propensity for local invasion and metastasis including partial and complete hydatidiform
moles (partial mole and complete mole), placental site trophoblastic tumor, and choriocarcinoma.1–5 Both complete and partial moles may develop persistent gestational trophoblastic tumor with local uterine invasion
and dissemination.1–7 Importantly, gestational trophoblastic tumor is remarkably curable with chemotherapy,
even with the occurrence of multiple metastases. Furthermore, after attaining complete remission with chemotherapy, patients may preserve their fertility and still have a normal future reproductive outcome.8–11
All gestational trophoblastic disease produces human chorionic gonadotropin (hCG), which can be measured
in both the serum and the urine. The serum hCG level is a sensitive indicator for following the disease process,
including treatment response and detection of persistent tumor and relapse. After molar evacuation patients are generally followed up with serial hCG values to assure the attainment of complete sustained remission. The
American College of Obstetricians and Gynecologists12 suggests that patients with hydatidiform mole should
obtain hCG levels 48 hours after evacuation and every 1 to 2 weeks until levels are undetectable. Once undetectable levels are attained, follow-up measurements are made at 1–2-month intervals for an additional 6–12 months.12 Although current recommendations for hCG follow-up safely ensure remission, the advised monitoring is often not completed. Investigators at the University of Southern California reported that 19% of their patients with molar pregnancy did not complete their gonadotropin follow-up.13 Additionally, studies from Korea and Chicago noted that 27% and 81% of patients with molar pregnancy, respectively, prematurely discontinued the recommended hCG monitoring.14,15 In this study we analyzed hCG follow-up data from 400 patients treated at the New England Trophoblastic Disease Center for complete or partial hydatidiform mole. We wanted to determine how often patients did not complete the advised follow-up and to identify possible factors associated with the failure to complete hCG monitoring. This study also sought to determine howoften patients with molar pregnancy who do not complete follow-up relapse after attaining at least one undetectable hCG value.
MATERIALS AND METHODS
Data were collected using the New England Trophoblastic Disease Center database, which contains the data of patients with gestational trophoblastic disease from June 1, 1965 to the present. Beginning in 1975, when the hCG radioimmunoassay was available at our institution, every fourth patient with molar pregnancy was
selected as a participant in the study until a study population of 400 patients was accrued. Patient information
regarding medical history, obstetric history, social history, details of their presenting gestational trophoblastic
disease, treatment, the staging and the histological diagnoses, and serum hCG values was collected from this
database. This study was approved by the Institutional Review Board at our institution. Four hundred patients with molar pregnancy were randomly selected to analyze the above data and hCG levels during follow-up. All patients were observed at our center from the time of evacuation until either remission or persistence. If persistence was documented, treatment was administered at our center. The following demographic factors were determined in each patient: age, gravidity, parity, marital status, insurance type, and distance from patient residence to trophoblast center. All patients selected had to obtain at least three serum hCG levels after molar evacuation to be included in the study. The following recommendations for molar pregnancy follow-up are made to our patients at the New England Trophoblastic Disease Center: All patients with molar pregnancy should obtain serum hCG levels weekly until undetectable for 3 consecutive weeks. Patients with partial
mole who attain undetectable hCG levels within 7 weeks after evacuation are then followed up with
monthly hCG levels until undetectable for 3 months. The remaining patients with partial mole as well as all
patients with complete mole are followed up with monthly hCG values until undetectable for 6 months.
Patients who miss one or two serum hCG levels are telephoned by a physician or nurse and their primary
physician is also contacted to ascertain if any hCG data had been collected through his or her office. All patients and their primary physicians are also regularly contacted to determine whether any tumor relapse is detected. If there is continued lack of follow-up, a registered letter is sent to the patients warning them of potential serious risks to their health if they neglect to complete their follow-up. All patients are provided a patient information booklet written in simple English or Spanish, which explains the risks of molar pregnancy and the extreme importance of reliable contraception and careful followup. The statistical significance of data was evaluated by using the Student two-tailed t and Pearson 2 tests. The level of significance was assigned at P .05. All analyses were performed using SPSS (SPSS Inc., Chicago, IL) 10.0 and Excel 97 (Microsoft Corp., Redmond, WA).
RESULTS
Patient ages ranged from 13 to 54 years, with a mean age of 26.5 (standard deviation 6.2). The histological
diagnosis was complete mole in 293 cases (73%) and partial mole in 107 cases (27%). Among the 400 patients with molar pregnancy, 320 (80%) achieved remission, 67 (16.8%) developed persistent
gestational trophoblastic tumor, and 13 (3.2%) were lost to follow-up before attaining an undetectable hCG
value. Complete molar pregnancy was diagnosed in 293 cases (73%), and 62 of these patients (21%) developed persistent gestational trophoblastic tumor. The mean preevacuation hCG value in patients with complete mole was 248,817 IU/L. The mean preevacuation hCG level in patients who achieved remission or developed persistent gestational trophoblastic tumor was 195,826 IU/L or 423,688 IU/L, respectively
(P .001). Among patients who achieved spontaneous remission, the mean time to attain an undetectable
hCG value was 8.4 weeks. Partial molar pregnancy was diagnosed in 107 cases (27%), and five of these patients (4.7%) developed persistent gestational trophoblastic tumor. The mean preevacuation
hCG value in patients with partial mole was 80,657 IU/L. The mean preevacuation hCG level in
patients who achieved remission or developed persistent gestational trophoblastic tumor was 75,411 IU/L or
259,000 IU/L, respectively. Because of the small number of patients with persistent gestational trophoblastic tumor after partial mole, statistical significance in differences between preevacuation hCG levels could not be
evaluated. Among patients who achieved spontaneous remission after partial mole, the mean time to attain an
undetectable hCG value was 5.8 weeks. There were significant differences between complete
and partial mole in preevacuation serum hCG levels (P.02) and in the number of weeks until hCG became
undetectable (P .001). There was no significant difference in the gestational age at the time of presentation and subsequent evacuation (mean of 13.5 weeks of amenorrhea for complete mole and 13.9 weeks for partial mole). In 36.6% of complete mole and 24% of partial mole the mole was the first pregnancy for the patient. The frequency of prior mole was 3% in complete mole and 4% in partial mole. Among the 333 patients (231 cases of complete mole and 102 cases of partial mole) who did not develop persistent gestational trophoblastic tumor, only 211 patients (63%) completed the recommended hCG follow- up. Thirteen patients (4%) were lost to follow-up without attaining even one undetectable hCG value. One hundred nine patients (33%) achieved undetectable hCG values but did not complete their entire follow-up. In eight patients (2.4%) the reason for discontinuing follow-up was their conceiving before the follow- up had been completed. All of these patients had attained undetectable hCG values before the conception and in all cases had confirmation of a normal intrauterine pregnancy by ultrasound. The following factors were evaluated as possible predictors
of failure to complete hCG follow-up: patients’ age, gravidity, parity, marital status, insurance type, and
distance from residence to trophoblast center. Because only 13 patients were lost to follow-up without attaining even one undetectable hCG level, this small group of patients did not lend itself to statistical analysis. We therefore included 42 patients who achieved weekly undetectable hCG values but did not begin monthly
hCG follow-up and 67 patients who attained at least three undetectable weekly hCG values but did not complete monthly follow-up. The only factor associated with discontinuation of follow-up in these 122 patients was the distance from patient residence to trophoblast center. Women who lived farther than 20 miles from the New England Trophoblastic Disease Center versus those who lived closer were more likely to prematurely discontinue follow-up (P .001). The percentages of patients who failed to complete follow-up as related to the distance from the trophoblastic center were as follows: distance from the trophoblastic center 0–20 miles, 26.1%; 21–100 miles, 56.5%; and farther than 100 miles, 50.0%. Patients’ age, gravidity, parity, marital status, and insurance type were not significantly associated with failure to complete follow-up. Importantly, among 320 patients who achieved at least one undetectable hCG level, no patient had any
evidence of relapse of gestational trophoblastic tumor.
DISCUSSION
It is well recognized that complete and partial molar pregnancies have the potential of developing persistent
gestational trophoblastic tumor.1–5 Careful postevacuation hCG monitoring is therefore recommended for
patients with molar pregnancy to assure the attainment of remission and to prevent the development of undetected persistent gestational trophoblastic tumor. Preevacuation hCG levels were significantly higher in complete versus partial molar pregnancies (P .02), and the number of weeks until hCG became undetectable was significantly higher in complete moles (P.001). These data were consistent with previously reported results. 16,17 Unfortunately, despite strong efforts of patient education and support, many patients with molar pregnancy do not complete hCG follow-up. Among the 333 patients who did not develop persistent gestational trophoblastic tumor, only 211 patients (63%) completed the recommended gonadotropin monitoring. Thirteen patients (4%) were lost to follow-up without achieving even one undetectable hCG value, and 109 patients (33%) attained undetectable hCG values but did not complete
their entire follow-up. We decided to randomly select 400 patients with molar pregnancy for this study because it was felt that this number of patients would provide useful information concerning predictors of failure to complete hCG follow-up and the potential consequences of failing to complete follow-up. Our experience with postmolar hCG monitoring is similar to the published data from the University of Southern California, Korea, and Chicago.13–15 We evaluated several potential factors that may be associated with failure to complete gonadotropin followup, including patients’ age, gravidity, parity, marital status, insurance type, and distance from residence to trophoblast center. Only the distance from the patient residence to the trophoblast center was significantly associated with the likelihood of not completing follow-up. Patients who lived farther than 20 miles from our center were more likely not to complete their hCG monitoring. Special efforts should therefore be made to encourage the completion of hCG monitoring in patients with
molar pregnancy who live at a greater distance from the follow-up center. Importantly, among the 320 patients who achieved at least one undetectable hCG level, none developed any evidence of relapse of gestational trophoblastic tumor. Prolonged hCG monitoring can be an economic, social, and emotional burden for patients with molar pregnancy. It would be helpful if other centers with considerable experience in observing patients with molar pregnancy reported their data concerning the frequency of relapse of gestational trophoblastic tumor in patients who achieve undetectable hCG levels. It appears that once a patient with molar pregnancy achieves undetectable hCG values, the risk of gestational trophoblastic tumor relapse is extraordinary low. Patients with molar pregnancy are strongly encouraged to use reliable contraception and to complete recommended hCG follow-up to assure the attainment of remission and to minimize the risk of undetected gestational trophoblastic tumor relapse. However, it is possible that the interval of hCG monitoring of patients with molar pregnancy may be shortened without compromising patient health and safety. As more data are published concerning the risk of gestational trophoblastic tumor relapse in patients with molar pregnancy who achieve undetectable hCG levels, it may be appropriate to reevaluate current follow-up recommendations.
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Molar Research: Duration of hcg surveillance for pmp
RESIDENTS’ PAPERS
GYNECOLOGY
Duration of human chorionic gonadotropin surveillance for partial hydatidiform moles
Isaac Lavie, MD,a Gautam G. Rao, MD,b Diego H. Castrillon, MD, PhD,c
David S. Miller, MD,b John O. Schorge, MDb,*
Source: Department of Obstetrics and Gynecology,a Division of Gynecologic Oncology,b Southwestern Trophoblastic Disease Center, and Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Tex
Received for publication August 25, 2004; revised December 16, 2004; accepted December 20, 2004
Objective: Partial hydatidiform moles infrequently progress to gestational trophoblastic neoplasia. The purpose of this study was to determine the optimal duration of human chorionic gonadotropin surveillance.
Study design: We retrospectively reviewed the clinical follow-up of all women who were diagnosed with partial hydatidiform mole at our institution from 1983 to 2003. Results: One hundred sixty-three patients were identified with a median age of 23 years (range, 14-42 years). Seventy-four patients (45%) attained undetectable levels of human chorionic gonadotropin; none of the patients had gestational trophoblastic neoplasia. Forty patients completed the 6 months of recommended follow-up; 6 patients conceived during surveillance, and 28 patients did not return for any further office visits 1 to 5 months after achieving remission. Eighty-three patients (51%) were lost to follow-up before normalization of human chorionic gonadotropin. Six women (4%) had stage I gestational trophoblastic neoplasia during surveillance.
Conclusion: Our results support the suggestion that a single undetectable human chorionic gonadotropin level after evacuation is sufficient follow-up to ensure remission in patients with partial hydatidiform moles. Serum human chorionic gonadotropin (hCG) is a sensitive indicator of persistent disease after the evacuation of a molar pregnancy. This marker can be used effectively to diagnose postmolar gestational trophoblastic neoplasia (GTN), assess treatment response, and detect recurrent disease. After evacuation, hCG levels are monitored at least biweekly until they are undetectable. The American College of Obstetricians and Gynecologists currently recommends hCG followup evaluations at monthly intervals for 6 months thereafter. Indigent patients are poorly compliant with postmolar follow-up evaluations. We observed that only 34%of women at Parkland Memorial Hospital who did not haveGTNwere fully compliant with surveillance. Fifteen percent of these patients never returned for a single office visit after evacuation.2 Massad et al reported that 18% of patients were fully compliant at Cook County Hospital in metropolitan Chicago. Poverty and patient apathy pose many potential obstacles to follow-up evaluation. A shorter postevacuation follow-up period is 1 option that would focus limited public health system resources without compromising patient care. Feltmate et al5 reviewed hCG serum titers after molar evacuation in patients who are diagnosed with complete mole, with the database from the New England Trophoblastic Disease Center. None of the 1029 patients who received this diagnosis between 1973 and 2001 had GTN after normalization of hCG. They concluded that patients who achieved undetectable serum hCG levels of <5 mIU/mL may be considered to be in remission and excused from further follow-up visits. Women with partial hydatidiform moles have GTN in only 5% of cases, compared with approximately 20% of complete hydatidiform moles. he purpose of this study was to determine the optimal duration of hCG surveillance.
Material and methods
Institutional Review Board approval was obtained to retrospectively identify all women who were diagnosed with partial hydatidiform mole from 1983 to 2003 with the hospital tumor registry and Society of Gynecologic Oncology Database. The Parkland Health and Hospital System provides care for the uninsured and underinsured inner-city population of Dallas County and serves as the main teaching facility of the University of Texas Southwestern Medical School. Partial moles were diagnosed histopathologically. DNA ploidy analysis was incorporated routinely since becoming available at our institution in 1999. Women who received a diagnosis of molar pregnancy were referred to the gynecologic oncology clinic for follow-up. At the initial visit, patients were encouraged to begin hormonal contraception and return biweekly for hCG measurements (Bayer Centaur Immunoassay, Diamond Diagnostics, Holliston, Mass). Three biweekly hCG measurements !5 mIU/mL were required to confirm remission. Thereafter, the recommended postmolar surveillance included monthly hCG levels for a total of 6 months. Patients with a !10% decrease of hCG over 3 consecutive titers were considered to have plateaued and were diagnosed with GTN. Frequent attempts were made to contact patients by telephone, particularly if they failed to keep appointments. When patients could not be reached, certified letters that described the malignant potential of molar pregnancy and the importance of follow-up were sent to the last known address. Medical records were reviewed for demographics, clinical outcome, and follow-up. Chi-squared test and independent samples t test were performed with SPSS software (version 12.0; SPSS, Inc, Chicago, Ill). The level of significance was set at .05.
Results
One hundred sixty-three patients received a diagnosis of partial hydatidiform mole during the study interval. The median age was 23 years (range, 14-42 years). One hundred thirty-five women (83%) were Hispanic; 15 women (9%) were black; 10 women (6%) were white, and 3 women (2%) were Asian. The median estimated gestational age at evacuation was 13 weeks (range, 5-30 weeks). Mean pre-evacuation hCG level was 210,682 mIU/mL (range, 356-2,023,000 m IU/mL). Seventy-four of 163 patients (45%) attained undetectable hCG levels. These women subsequently had an additional 278 office visits (mean, 3.8 office visits) where hCG levels were !5 mIU/mL. None of the women had GTN. Forty women completed the 6 months of recommended follow-up visits; 6 women conceived during surveillance, and 28 women did not return for further office visits 1 to 5 months after achieving remission. Eighty-three patients (51%) were lost to follow-up before normalization of hCG. Six women(4%) were diagnosed with GTN on the basis of plateauing or rising hCG levels. None of the women achieved undetectable levels of hCG before diagnosis of GTN. The mean pre-evacuation hCG level was significantly higher in the group that subsequently had GTN (690,953 vs 174,500 mIU/mL; P ! .001). All were stage I low-risk (World Health Organization score, 0-6) and resolved with chemotherapy.
Comment
Our results support the suggestion that a single undetectable hCG level after evacuation is sufficient follow-up to ensure remission in patients with partial hydatidiform moles. None of the 74 women in our study who achieved hCG normalization subsequently had GTN. At the New England Trophoblastic Disease Center, Feltmate et al7 reached the same conclusion after observing no relapses among 107 patients with partial mole who had at least 1 undetectable hCG level. Batorfi et al8 reported that none of 120 molar patients who were treated at the National Health Center in Hungary experienced relapse after achieving normalization of hCG levels. Trophoblastic disease centers that serve indigent women should explore the feasibility of simplified surveillance strategies. Excusing patients from further follow-up evaluation after they have achieved 1 hCG level !5 mIU/mL may result in cost savings without compromising care. This strategy would have prevented 278 serum hCG office visits to our public hospital system. Noncompliance with postmolar pregnancy surveillance is particularly problematic among the indigent population. Fifty-one percent of our partial mole patients were lost to follow-up without achieving remission. A shorter follow-up period would not appear to impact patient health or safety negatively and certainly would improve compliance. Resources would be best directed at encouraging follow-up until the normalization of hCG levels.
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