By Shalynne Addison
What is a miscarriage?
Miscarriages affect approximately 1 in 4 pregnancies. Miscarriage is defined as the death of a fetus in the uterus during pregnancy. There are a variety of different reasons why miscarriages occur and even though they are incredibly common, there is still a lot unknown about them as well. Some happen because of genetic defects or chromosomal issues, while others are from infection or anatomical issues such as an irregularly shaped uterus or cervical issues. Many have an unknown reason or are just classified as “something was wrong.” There are many kinds of miscarriages – blighted ovum, chemical pregnancy, ectopic pregnancy, etc. – but for the purposes of this paper I’ll be discussing molar pregnancies.
What is a molar pregnancy?
A molar pregnancy is defined as a rare complication of pregnancy – affecting 1 in 600 pregnancies – and it is characterized by an abnormal growth of trophoblasts, the cells that normally develop into the placenta. Because of this, molar pregnancy is sometimes referred to as trophoblastic disease or Gestational Trophoblastic Disease (GTD).
There are two different types of molar pregnancies, complete and partial. Both develop cysts that typically have a “grape-like” or “Swiss cheese” looking appearance upon ultrasound observation. A complete molar pregnancy is one in which no fetus develops, and the placental tissue is abnormal, swollen, and appears to form fluid-filled cysts, or sacs. This is due to sperm cells fertilizing an egg cell that has no genetic material inside, therefore there are not enough of the right chromosomes for the baby to be able to develop. In a partial molar pregnancy, there is often normal placental tissue as well as abnormal, and may also be formation of a fetus. In this case, two sperm fertilize the egg instead of one so there is too much genetic material for the baby to be able to develop normally and it is usually miscarried early, within the first two – three months.
What is the treatment for a molar pregnancy?
In order to treat a molar pregnancy, a provider must perform a procedure called a dilation and curettage (also known as a D&C) to remove the tissue from the tumor from the uterus. A D&C is a surgery that scrapes the inside of the uterus and removes the inner layer – the endometrium. After the procedure, the provider will regularly check the patient’s HCG levels until they are back to normal, to ensure that no molar tissue has grown. This can be anywhere from several weeks to a year and many physicians advise not to get pregnant during the time period of being monitored as that can make it harder to detect if the molar tissue is persisting.
In about 20 percent of cases, some patients will experience persistent GTD, where the molar tissue grows into the muscle layer of the uterus or spreads in other ways, despite the patient having a D&C procedure. It can also develop into a form of cancer called choriocarcinoma. This generally happens after a complete molar pregnancy. Although GTD in its various forms can be persistent, it is treatable with more extensive surgery, chemotherapy, or hysterectomy. And although cancer is a horrifying diagnosis, choriocarcinoma has a cure rate of almost 100%.
How do I help my client?
Molar pregnancy can be very distressing because of the amount of stress it brings – first the client experiences a miscarriage, then the diagnosis and treatment of the molar pregnancy, and finally a potentially long period of follow-up, with further complications possible. Patients may feel fear, anxiety, grief, depression, and anger among a multitude of other emotions. If they have to go through a hysterectomy, they may feel the added burden of no longer being able to get pregnant, should they want to. Doulas, nurses, and providers should be sure that while they are attending to the client’s physical needs that they also check on their patient’s emotional state and provide resources for them – therapy, support groups, counseling, etc.
Shalynne’s personal experience with molar pregnancy.
In April 2019, I found out I was pregnant with my seventh child. I scheduled a doctor’s appointment to confirm but had been tracking my cycle and had taken a positive test. About a week before I was due to see the doctor, I started having cramping pains but brushed them off and thought I would just ask about them at my upcoming appointment. They continued to get worse until I was doubling over in pain and having difficulty doing my daily routine. I called my doctor’s office and they advised me to go to the Emergency Room. My husband drove me and upon arriving at the ER, I noticed that I was also bleeding very lightly.
I was given blood tests and an ultrasound and after waiting for several hours, the ER doctor told me that I was showing signs of miscarriage and to follow up at my doctor’s appointment that coming week. (In hindsight, I should have called the doctor then to let her know what happened and to see if I could get in sooner – that would have at least lessened the worrying a bit.)
Over the next few days, I continued to cramp, have pain, and bleed on and off, although the bleeding was much less than I’d imagined. At my doctor’s appointment the doctor was on the fence about what was going on – a tiny fetus was visible on the ultrasound to her eyes and ours, and she was concerned that the ER was too quick to jump to the conclusion of miscarriage. She said it could be a multitude of different things – subchorionic hematoma, a fluke episode of bleeding, molar pregnancy, among other things. Molar pregnancy especially stuck out to her because of what looked like very small grape clusters on the ultrasound. However, she was hesitant to diagnose. Since it was still relatively early, she advised testing my HcG levels to see if they were increasing as they should be and then coming back in a few days for another ultrasound.
We did that and came back in 4-5 days. She revealed to us that my HcG levels weren’t looking great (on the lower side) and after pulling up the ultrasound we saw that the fetus we’d observed before no longer appeared. The grape clusters were still evident though and she told us I’d need to get a D&C. This was a Friday and she scheduled it for the following Monday.
Monday afternoon we checked into the hospital. I had never had surgery before so I was quite nervous but the process of getting checked in and waiting for the doctor all took longer than the actual surgery. Getting put to sleep had been freaking me out but it wasn’t a big deal at all. Everything went quickly and smoothly. I stayed in the surgery recovery for 30-40 minutes or so and then was taken back to the room I originally started out in. I was groggy and crampy but otherwise okay. After making sure I was able to get up and around, and go to the bathroom, we were given discharge instructions and sent home. I was told to take it easy for the next few days and if I started bleeding excessively to contact the doctor.
I followed up with my doctor the following week. They tested my HcG once a week for a month to monitor whether the levels were rising or falling. Once it was back to less than 10 I was cleared to again try for a baby if I desired. My doctor did say that it might take a couple cycles before my body was back to “normal” again and not to get discouraged if fertility was delayed. I consider myself lucky as some people have much worse circumstances where the molar tissue is persistent, and they have to have repeat D&C’s or more extensive surgery/treatment. I got pregnant very quickly afterwards as well, which is another added blessing.
How Shalynne has grown as a person and a doula.
Although I recovered quickly from the miscarriage and molar pregnancy physically, mentally was a different matter. My doctor isn’t a bad person but every procedure and visit was very clinical and impersonal. The ER visit where they diagnosed my miscarriage was a horrifying experience – hours of waiting, an intense and grouchy ultrasound tech, very clinical staff who didn’t seem to care, etc. I think I honestly could have utilized the services of a doula during this time period, particularly one that specialized in miscarriage/loss, or at least had experience with it. I went through a period of intense depression and anxiety for several months afterwards. Even after getting pregnant again, I still struggled with anxiety and the added fear of something bad happening. The whole experience was terrible of course but on the positive side, it has given me a new appreciation for pregnancy and has also given me insight into miscarriage and loss that I never had before. I’ve reached out to friends and family members who’ve experienced loss and discussed their situations. I’ve also read many books dealing with those topics and enrolled in Stillbirthday University to become additionally certified later on this year, after my baby is born. I hope I never have to utilize the things I’ve learned and continue to learn but now feel more confident if I am faced with them.
The Miscarriage Association – Miscarriage: https://www.miscarriageassociation.org.uk/information/miscarriage/
The Miscarriage Association – Molar Pregnancy: https://www.miscarriageassociation.org.uk/information/molar-pregnancy/
Mayo Clinic, Molar Pregnancy: https://www.mayoclinic.org/diseases-conditions/molar-pregnancy/symptoms-causes/syc-20375175
National Cancer Institute, Gestational Trophoblastic Disease PDQ: https://www.cancer.gov/types/gestational-trophoblastic/patient/gtd-treatment-pdq
Molar Pregnancy – March of Dimes: http://www.marchofdimes.org/complications/molar-pregnancy.aspx