Your Treatment

Persistence of the disease is usually identified when there is a plateau (does not drop appropriately) or rise in the hCG blood test over a period of weeks or because of heavy vaginal bleeding.  Following the  diagnosis of persistent disease further investigations will be required. These are usually in the form of scans (see below). These may be performed as an out-patient or you may require admission to hospital to facilitate your investigations.

Further Investigations:

These include a pelvic ultrasound (to out-rule a new pregnancy), CT (Computed Tomography) scan of chest, abdomen and pelvis and further blood tests . The results of these investigations will provide necessary information to assist your doctors in determining the type of treatment required.  An individualised treatment plan will be discussed with you.

Treatment:

Chemotherapy drugs are used in this treatment. Your doctor will inform you about which type of chemotherapy is required . A specialised scoring system based on your scans and blood tests is used to determine whether you will receive treatment with one drug or a combination of drugs. Patients with a” low risk” score will be treated with a single chemotherapy drug. Patients with a “high risk” score will usually have disease that is resistant to a single chemotherapy drug and will require a combination of drugs to effectively treat the disease.

You may need to remain in hospital during your initial treatment as there may be a risk of bleeding once it has started. It is important for the medical staff to observe how your body responds and reacts to the treatment. It is normal to feel upset and tearful at times throughout your treatment due to raised hCG levels, reaction to your diagnosis, to the chemotherapy and also the loss of your pregnancy. Emotions can vary from day to day and between individuals.

A chemotherapy drug called methotrexate is most frequently used for this type of treatment. It  causes the trophoblastic cells to die away. This drug is given as an intra-muscular injection on alternate days over one week.  You will also be given a folinic acid tablet to take on the days between the injections.  This is a ‘rescue’ medication to help protect the normal body tissue from the effects of methotrexate.  It is very important that you take this tablet 30 hours after your methotrexate injection.  In one cycle of treatment, you will have four injections and four folinic acid tablets, making a total of eight days.  After each cycle of treatment, you will have a six day rest before commencing the next course.

Are there any side effects associated with Low Risk Treatment:

Methotrexate is generally well tolerated and the side effects are often quite minimal.

Sore Mouth

You are encouraged drink three litres of fluid (such as water, tea or fruit juice) per day. This will help flush the methotrexate through your kidneys which will prevent or greatly reduce the risk of getting a sore mouth. You should brush your teeth with a soft toothbrush three times a day and floss regularly. We will also give you some Corsodyl mouthwash to use after every meal and before you go to bed.

Sore eyes

Your eyes may feel ‘gritty’.  We can provide eye drops to relieve this. You should avoid wearing contact lenses during this time.

Nausea

It is possible you may feel sick. We can give you some anti sickness tablets if needed.

Abdominal (Tummy) pain

This may feel like a period pain. The doctor on the ward will prescribe painkillers to help with this.

Chest pain

Some women experience pain in their chest, particularly on deep breathing. This can be relieved by painkillers and will resolve once all the treatment is finished.

Myelosuppression

As with all chemotherapy, there can be a tendency for your blood count to drop. Although with this type of treatment the risk is minimal, it is routine to check the full blood count before each course of treatment.

These side effects are not necessarily going to affect you, but it is important that you are aware of what could happen. Please inform the nurse or doctor if you experience any of these symptoms so they can treat you promptly.

It is important to note that you will remain fertile and will not lose your hair on this “low risk” treatment.

If the scoring system determines that there is “high risk” disease present then multi-agent (variety of drugs) chemotherapy will be required.

Etoposide, Methotrexate and Actinomycin D (EMA), Cyclophosphamide and Vincristine (CO) is a weekly treatment. EMA is given one week and CO is given the following week. You will need to stay in hospital for 2 – 3 nights when you are having EMA. CO can be given as an outpatient day treatment and this can be arranged at your local hospital.

EMACO related side effects more commonly experienced are:
• Lowered resistance to infection
• Nausea
• Sore mouth
• Abdominal pain
• Heavy vaginal bleeding
• Bladder irritation
• Constipation
• Numbness and tingling in hands and feet
• Hearing loss
This treatment is unlikely to have a major effect on fertility other than to bring the menopause forward by a year or two.Unfortunately all patients receiving this regimen will have a temporary loss of their hair (which may or may not include body hair). Hair does re-grow after the chemotherapy has finished

The standard treatment consists of a combination of chemotherapy drugs. The regime is known as ‘EMA/CO’. All the drugs are given intravenously (via a needle in one of your veins by drip).

Occasionally, women who have received low risk treatment needs to change to a stronger treatment regime because the hCG  levels do not drop appropriately. This is described as resistance and can occur in approximately one in four patients who are receiving low risk treatment.  If your hCG has reached a low level at the time of diagnosis of persistent disease then you will be changed to another single-agent drug called Actinomycin D.  This is administered as a 15-minute infusion every 14 days until the hCG level reaches a normal level.

There will be similar side effects to high risk treatment including some hair loss. However the effects should be milder. A chemotherapy booklet will be provided explaining what symptoms may be experienced.

It is difficult to predict the length of time needed to complete treatment, as it varies between individuals. On average treatment lasts 5-6 months, our aim is to return hCG levels to normal. For all treatments (low-risk, high risk and recurrent disease)  chemotherapy is continued for a further three cycles (six weeks) of maintenance treatment after hCG levels have returned to normal. The importance of the extra treatment is to kill off any remaining cells that may still be present, although the blood test shows normal values.

Once treatment has been completed you will be reviewed in an out-patient clinic and followed up with regular blood tests to detect any chance of it recurring.

During treatment blood serum samples will be monitored regularly until normal. Following this you will have blood tests taken fortnightly for 6 months and then monthly for 6 months until monitoring has shown one year of normal hCG results.

Before you leave the hospital, you will be provided with instructions for your follow-up schedule. Information will be given relevant to your care on discharge. You will be given a contact number of a team member if there any concerns or worries.

It is important to avoid sun exposure as your skin may be more sensitive than usual. A sun factor (30 or above) is necessary and should be applied daily until treatment has finished.

Chemotherapy used to treatment molar pregnancy is unlikely to have a major effect on fertility other than to bring the menopause forward by a year or two. However, it is strongly recommended that you do not become pregnant for one year after the end of treatment. For some women, this can seem a very long time to wait. For others, pregnancy is the last thing on their minds. It is worth noting that how you feel now may well change. Our advice to wait is due to the small risk of relapse (3% overall), most of which occur within the first year. This is because we will not be able to tell whether the rise in hCG is due to the previous molar pregnancy or a new pregnancy. Sexual intercourse is not discouraged during treatment once the necessary precautions are being used. Barrier contraceptive methods such as condoms and/or the oral contraceptive pill are recommended until your hormone levels have normalised. Most women will find that chemotherapy will stop your periods for a few months, but generally they usually restart 2-6 months after finishing treatment. Once your treatment is finished, you can use any method of contraception you wish, but you should wait at least six weeks before an IUD (coil) is fitted as the size of your cervix may have changed.

The risk of having a another molar pregnancy is less than 1%.

Please do not hesitate to contact one of the clinical nurse specialists in the national GTD office and/or visit the national GTD website

Other sources of information:

NCCP : The National Cancer Control Programme : Cancer prevention, diagnosis and treatment, is a major healthcare challenge. The National Cancer Control Programme aims to prevent cancer, cure cancer, and increase survival and quality of life for those who develop cancer, by converting the knowledge gained through research, surveillance and outcome evaluation into strategies and actions.

ISSTD
The ISSTD is the International Society for the Study of Trophoblastic Diseases, the official medical agency for physicians treating hydatidiform mole, PSTT, and choriocarcinoma.

CancerBackup
Europe’s leading cancer information service, providing accurate, up-to-date and authorative cancer information, resources and support for people affected by cancer.

My Molar Pregnancy
Information, personal stories, and support for women with molar pregnancy. This site is for women with molar pregnancy or who want to know more about it, without the medical jargon. Here you’ll find the help and support you need.

Molar Pregnancy Support and Information
Molar Pregnancy Support Website – Offering Support and Information to those who have concerns or questions about a molar pregnancy.

Miscarriage Association
The Miscarriage Association – support and information for anyone affected by miscarriage, ectopic pregnancy or molar pregnancy.

Rare forms of Trophoblastic Disease

Choriocarcinoma

A choriocarcinoma is referred to as a malignancy developing within the placenta during an otherwise normal pregnancy. A choriocarcinoma most often follows a molar pregnancy but can follow a normal pregnancy, ectopic pregnancy or abortion and should always be considered when a patient has continued vaginal bleeding after the end of a pregnancy. The illness can take a while to diagnose, however the elevated hCG level in a woman who is not pregnant is highly supportive of the diagnosis. If you develop persistant or irregular bleeding after a pregnancy, you may have a choriocarcinoma. You should have a pregnancy test to exclude this and an ultrasound scan is advisable. Further investigations will be necessary where a choriocarcinoma is suspected.

The treatment for choriocarcinoma will be carried out as an inpatient and generally with EMA-CO chemotherapy .Although this treatment is intense , fortunately choriocarcinoma is highly sensitive to it and there is a very high expectation of cure once diagnosed.

Placental Site Trophoblastic Tumour (PSTT)and Epithelioid Trophoblastic Tumour (ETT)

These tumours are extremely rare in Ireland. All patients with PSTT or ETT will be assessed by us to discuss an individualised treatment plan with you.