Your Treatment

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.

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 will usually need to remain in hospital during your initial treatment as there is 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 ?

The side effects are generally 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. You will be advised to use Corsodyl mouthwash after every meal and before you go to bed.

Sore eyes

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

Nausea

It is possible that you may feel sick. We can prescribe 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.

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).

Week 1-EMA:

• Actinomycin D is given via a fast running infusion of normal saline (water and salts solution). This takes approximately 5 to 10 minutes.
• Etoposide is given via a 500 ml bag of normal saline infusion. This takes one hour.
• Methotrexate is given via a one-litre bag of normal saline infusion. This takes approximately 12 hours. We will give you a short course of folinic acid tablets to take 24 hours from the start of the methotrexate.

You will be required to stay overnight during this treatment programme.

Week 2-C0:

• Vincristine is given in the same way as the Actinomycin D- via a fast-running infusion of normal saline. This takes about 10 minutes.
• Cyclophosphamide is given via a 500ml bag of normal saline infusion. This takes one hour.

The EMA and CO chemotherapy regime alternate at weekly intervals. One week you will have the EMA treatment and the next you will have the CO treatment. Please note that your blood count will be checked before the start of each treatment and chemotherapy will only be given if your blood count is normal.

Are there any side effects associated with high risk treatment?

It is important to realise that side effects vary with each individual.

• Hair Loss (Temporary)
• Nausea and vomiting
• Myelosuppression (drop in blood count)
• Fatique (extreme tiredness)
• Mouth ulcers
• Loss of appetite

All of the side effects will be explained in detail by your oncology specialist nurse. A chemotherapy booklet will also be available with all the relevant information for your treatment.

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 give a precise time in completing treatment, as it varies between individuals. However, 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 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. For high risk patients, treatment usually takes four months to complete.

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 samples will be monitored twice a week until normal. Following this you will have blood tests taken fortnightly for six months, and monthly for another six months until monitoring has shown one year of normal hCG results.

A molar pregnancy can sometimes recur after a subsequent healthy pregnancy, therefore a further post-natal hCG blood test is recommended at 6 and 10 weeks after every pregnancy regardless of the outcome.

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 for the clinical nurse specialist with any concerns or queries.

Having a molar pregnancy does not affect your chance of having another baby. However, it is strongly recommended that you do not become pregnant for one year after the end of treatment. 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 2-6months 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 another molar pregnancy is less than 1%.

Please do not hesitate to contact the clinical nurse specialist at the following details.

National Gestational Trophoblastic Disease Registry, Monitoring and Advisory Centre

Cork University Maternity Hospital, Wilton, Cork.

Phone: (021) 492 0526 Fax: (021) 492 0566

Other sources of information

NCCP (http://www.hse.ie/eng/services/list/5/cancer/profinfo/guidelines/gtd/ )

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 (www.isst-d.org)

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

Cancer Backup (www.macmillan.org.uk)

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(www.mymolarpregnancy.com)

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 (www.molarpregnancy.co.uk/)

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

Miscarriage Association (www.miscarriage.ie)

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