184 Gestational Trophoblastic Disease 221

Pregnancy Issues

Women with previous GTD have a 98% chance of having a normal pregnancy5. A normal dating scan at 12 weeks gestation should reassure women that their pregnancy is likely to be normal.

A rare situation occasionally arises with a twin pregnancy where one is viable and the other is molar. In this situation, pregnancy can be allowed to continue if the mother wishes as there is no increased risk of developing persistent trophoblastic disease, and the outcome after chemotherapy, if required, is unaffected. These pregnancies are high risk, with increased rates of early miscarriage, second trimester loss and pre-eclampsia. The chance of a successful pregnancy with a live baby is 40%13.

Medical Management and Care

• Most pregnancies following a molar pregnancy can be managed as low risk with community midwife based care

• If a woman conceives within 12 months of chemotherapy, joint assessment involving obstetrician, oncologist and fetal medicine specialist is required to ascertain the risk of teratogenicity

• In the case of an affected twin pregnancy, regular monitoring for signs of pre-eclampsia is essential; regular scans for growth and fetal wellbeing are indicated

Midwifery Management and Care

• If a midwife identifies a mother in early pregnancy with vaginal discharge/ bleeding, a large for dates uterus and possibly hyperemesis, then the mother should be referred to a consultant unit for assessment

• Care should be taken not to alarm the mother, as these symptoms could also be related to a multiple pregnancy

GTD presenting in pregnancy

• The management is as described on the previous page

• In the UK the mother is likely to be admitted to a gynaecological unit and be cared for by nurses; however the midwife may be involved with pre-operative preparation and psychological support

• If the mother is rhesus negative, anti-D is indicated

• In certain circumstances, midwives might be involved with aftercare, and should be alert for haemorrhage; if abnormal bleeding or a 'boggy uterus' present, re-refer to the relevant gynaecological unit

Pregnancy following a molar pregnancy

• Encourage early booking, and take a thorough case history and if necessary obtain former hospital records

• Arrange a dating scan and reassure of the low risk of recurrence

• Ensure that the screening centre where the molar pregnancy was registered is aware that the woman is pregnant to ensure appropriate postnatal follow-up

• In the case of an affected twin pregnancy, provide psychological support and be vigilant for signs of pre-eclampsia

Labour Issues

• Following a previous molar pregnancy, anticipate normal labour

• The mode of delivery for an affected twin pregnancy depends on obstetric factors such as gestation, previous obstetric history and pregnancy complications

Medical Management and Care

• No medical input is required for women with an uncomplicated pregnancy following a molar pregnancy

Midwifery Management and Care

Pregnancy following a molar pregnancy

• Normal midwifery care in labour

• Placental samples are not usually required, but it might be advisable to check with the obstetric team

Postpartum issues

The screening centre for trophoblas-tic disease where the woman is registered will request postnatal urine bHCG samples to identify recurrent disease.

In rare cases women with no history of molar pregnancy can develop gestational trophoblastic disease following a normal pregnancy. This possibility needs to be considered in women with irregular vaginal bleeding postpartum, a positive bHCG and no evidence of an intra- or extrauterine pregnancy. Prognosis tends to be worse in these women, partly due to delayed diagnosis10.

Medical Management and Care

• Liaise with appropriate trophoblastic screening centre if any suspicion of recurrent or de novo gestational trophoblastic disease

• Advise against the COCP until the bHCG level is within normal levels

Midwifery Management and Care

Pregnancy following a molar pregnancy

• Ensure arrangements have been made for follow-up care; otherwise normal postnatal care is given

• Explain that an HCG urine sample is needed in six weeks, and advise upon practical arrangements

• Be aware that whilst grief over the former pregnancy loss usually resolves by about four months, this can persist in some mothers12 and might 're-surface' postpartum

• The midwife might have to give advice on barrier methods of contraception if the combined oral contraceptive pill is contraindicated due to high HCG levels14 (see Pre-conception Care)

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