Month: August 2016

When having a baby can kill you

~ quinlivanj ~ Leave a comment

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Pregnancy is usually a happy time with the outcome being a healthy baby. However, some complications in pregnancy can be serious. Over the years I have cared for many couples with molar pregnancy (technically known as gestational trophoblast disease). This terrible complication of pregnancy not only results in grief from the “lost baby”, but can also have lasting physical, social and psychological consequences for both the mother and father (1,2,3,4). Untreated, molar pregnancy can cause death of the mother (1,2).

Of note, our research into molar pregnancy revealed that many fathers experienced lasting social and psychological symptoms following molar pregnancy (4). One reason for this is due to the origins of the disease.

Origins of molar pregnancy

There are two types of molar pregnancy, a complete mole and a partial mole. In both cases, the male sperm plays a key role.

In a complete molar pregnancy, sperm (one or two) fertilize an egg that has lost its female genetic material (DNA). Therefore all the genetic material in the fertilized egg arises from the male and none from the female.

In a partial molar pregnancy, a single egg is fertilized by two sperm causing an excess of male genetic material within the fertilised egg.

The incidence of molar pregnancy varies around the globe, from 1 in 200 to 1 in 2000 pregnancies (1,2).

Impact on pregnancy

Sadly, molar pregnancy never results in a normal baby except for the extraordinarily rare cases of twinning where one twin is a molar pregnancy and the other a normal pregnancy. Instead, the usual situation is that the uterus becomes full of abnormal placental tissue and no baby is present (complete mole) or some fetal development occurs, but the fetus  is  malformed and not viable (partial mole).

The abnormal placental tissue causes bleeding and can metastasis around to body to other organs such as the lungs, in the same way an untreated cancer may spread around the body.

Impact on women

Most molar pregnancies present with abnormal vaginal bleeding between 8 and 16 weeks of pregnancy. Initially most women are concerned about miscarriage.

The diagnosis may be strongly suspected following an ultrasound, where a characteristic pattern called a “snowstorm” may be seen within the uterus. However, the condition is not definitively diagnosed until a sample of the tissue within the uterus is sent for analysis (histopathology) and tissue that looks like a cluster of grapes (abnormal chorionic villi) are seen under the microscope.

Some women may present with signs of thyroid disease, as the abnormal placental tissue can produce thyroid-like hormones. Women may also present with excessive nausea and vomiting of pregnancy (hyperemesis) and rarely may present with abnormally high blood pressure readings under 20 weeks of pregnancy.

Management of molar pregnancy

Once a molar pregnancy is confirmed, management involves surgery, follow up surveillance and possibly chemotherapy.

The initial management is uterine suction curettage. This surgical procedure is necessary to confirm the diagnosis and exclude an even rarer form of gestational trophoblastic disease called choriocarcinoma. The surgery carries more risk than a usual suction curettage, as the abnormal placental tissue is very vascular, and therefore the risk of heavy bleeding is higher. This means that the attending gynaecologist will often cross match blood and organise an anaesthetic consultation to plan the safest time to perform surgery. Medication may be required following surgery to help contract the uterus and reduce post operative bleeding.

Following surgery, women receive a “risk rating” that is determined on a number of factors such as their levels of pregnancy hormone, blood group, the presence of metastatic disease and the histopathology of the molar pregnancy.

Based on the “risk rating” results, women enter a follow up surveillance program that involves monitoring with serial blood or urine pregnancy hormone levels.

If a women had a high initial risk score, or her pregnancy hormone levels rose or failed to fall during her surveillance period, then she will require chemotherapy. This is usually Methotrexate, but in some case will be combined chemotherapy.

The impact of molar pregnancy on women is often profound. This is particularly true as the risk of molar pregnancy increases as women become older. Some women may have been trying to conceive for many years and then discover their pregnancy is a molar pregnancy. Not only do they not have the baby they desire, they face surgery, prolonged surveillance during which pregnancy is contraindicated, and possible chemotherapy. They must defer trying to have a child until they have been cleared (3,4).

Impact on partners

Partners of affected women can also suffer due to delayed childbearing, prolonged stress and a feeling of guilt related to the male role in the origins of molar pregnancy (4,5,6).

In our research, we contacted 158 former patients in our service with molar pregnancy and through these women, interviewed  41 partners. We found many partners were as emotionally fragile as the woman. For full results click here.

In a thematic analysis we found several themes related to anxiety and fear, sadness and depression, and guilt.

Anxiety

Anxiety was the dominant theme, rather than depression. Anxiety arose in male partners from a sense of frustration consequent to experiencing loss of control over their fertility, particularly their anxiety that they, as a couple, may never have a child.

‘Wouldn’t have occurred to us before when we were just worried about possible health of a baby’

‘Words cannot describe how emotionally stressful it was… I witnessed my partner being torn apart emotionally.’

‘Almost given up hope/plans of having a child at our age (maybe still some fear that another pregnancycould go awry).’

‘My world came crashing down.’

Guilt and blame

Partners felt guilty or blamed themselves for the occurrence of the molar pregnancy. Factors such as the male contribution in conception and individual genetic structures impacted on male participant’s view of cause and effect.

‘I somehow feel responsible in a way that it may have been my fault that it had something to do with my (works) my body that wasn’t right that caused this unusual pregnancy.’

Medical care

Themes relating to medical care centred around the actual treatment of molar pregnancy and the constant reminder of the diagnosis during the prolonged follow up perios that meant couples relived the experience. This delayed emotional recovery. The lack of clear information added to confusion and uncertainty.

‘…we are constantly reminded of our ‘failure’ through monthly urine samples, etc.’

‘I didn’t know as a individual at the time what was going on with my partner because we didn’t have enough information.’

Male partners’ displacement of feelings

Male partners felt a sense of indirect involvement in the management of the molar pregnancy. A new unfamiliar distancing occurred in a small percentage of couple relationships because of withdrawal from communication with partners during this time. This left partners feeling hopeless, unable to initiate appropriate actions to help their partner cope with trauma resulting from the diagnosis.

Partners felt they had to manage other financial and social matters additionally during this period of time. The male partner viewed himself largely as a supporter and made a distinction from being the patient.

‘I still cannot imagine what it would be like for my partner as she was the one carrying the pregnancy.’

‘It is hard for the husband to feel the same sense of loss as the wife because he has not had any physical contact with the “baby”.’

‘I felt very detached from it because it wasn’t my body going through the miscarry.’

Sexual function

Some men reported disparity in sexual functioning with their partner and described sexual tensions in their relationship.

‘My partner seems a little numb now, compared with before, and that makes it harder to feel good about sex and being close. I’m still keen but she seems less so…’

‘With all this happening inside her, she now seems less interested in sex, maybe that’s normal, but when I try she looks almost scared.’

‘…reduced desire by wife/apprehension re. sexual, even sensual contact…’

Positive role of children

The protective effect of children came through in our research. Subsequent delivery of a healthy child overcame the sense of loss.  This was reported both as an actual experience and as a hypothetically positive experience.

‘The scars only really started healing once we were given the gift of a beautiful baby boy nearly 2 years later.’

Summary

Most of the time pregnancy is a happy event, but occasionally things go wrong. It is important to remember that both mother and father may be deeply impacted and to provide support and follow up when things don’t go to plan.

Ultimately, providing support to ensure the couple are able to help each other through a sad and frightening experience is as important as getting the actual medicine right.

 References

  1. Berkowitz RS, Goldstein DP. Gestational trophoblastic diseases. In Principles and Practice of Gynecologic Oncology, Hoskins WJ, Perez CA, Young RC (eds.), Lippincott Williams & Wilkins: Philadelphia, PA, 2000; pp 1117–1137.
  2. Feltman CM, Growden WB, Wolfberg AJ et al. Clinical characteristics of persistent gestational trophoblastic disease after partial hydatidiform molar pregnancy. J Reprod Med 2006;51:902–906.
  3. Berkowitz RS, Marean AR, Hamilton N et al. Psychological and social impact of gestational trophoblastic neoplasia. J Reprod Med 1980;25:14–16.
  4. Quinlivan JA, Ung KA, Petersen RW. The impact of molar pregnancy on the male partner.Psychooncology. 2012 Sep;21(9):970-6. doi: 10.1002/pon.1992. Epub 2011 May 24.
  5. Wenzel L, Berkowitz RS, Robinson S, Bernstein M, Goldstein D. The psychological, social, and sexual consequences of gestational trophoblastic disease. Gynecol Oncol 1992;46:74–81.
  6. Wenzel L, Berkowitz RS, Robinson S, Goldstein DP, Bernstein MR. Psychological, social and sexual effects of gestational trophoblastic disease on patients and their partners. J Reprod Med 1994;39(3):163–167.

Pokemon Go, exercise and gestational diabetes mellitus

~ quinlivanj ~ 4 Comments

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The recent Pokemon Go craze could have an unintentional benefit for women with pregnancy complicated by Gestational Diabetes Mellitus (GDM). The exercise involved in walking  around parks trying to capture Pokemon helps manage blood sugar levels and can lead to a reduced need for medication and diabetic complications.

The benefits of exercise in pregnancy

Regular exercise, particularly walking, is beneficial in pregnancy. Not only can regular exercise limit excessive gestational weight gain to international standards, it can also help prevent or manage GDM (1,2).

However, encouraging women to participate in regular exercise during pregnancy has proven challenging (3). Several randomised trials of exercise interventions in pregnancy have failed to demonstrate an effect on preventing excessive gestational weight gain or on the incidence or management of GDM, mainly due to poor compliance and low levels of participation by pregnant women in exercise programs (3,4,5).

So how might Pokemon Go help?

Women diagnosed with GDM are often asked to monitor their blood sugar level each morning (fasting blood sugar level) and again  2 hours after every meal (post prandial 2 hour blood sugar level). If the morning fasting blood sugar level, or the post prandial 2 hour blood sugar levels are higher than recommended targets (2,5), then medication may be necessary in order to reduce the risk of pregnancy complications such as abnormal fetal growth (macrosomia), excessive amniotic fluid (polyhydramnios), placental damage or fetal death in utero.

Regular exercise, even a 30 minute walk performed three times a week, can be helpful in regulating gestational weight gain and blood sugar levels.

This is where Pokemon Go might help.

By combining a regular walk with a game, it might encourage pregnant women to walk.

Maybe the manufacturers could invent pregnant Pokemon for our pregnant women to capture and provide an extra incentive!

Over to you game makers.

What else is new in gestational diabetes research?

Our research team recently published a paper on managing gestational diabetes (6). In this research study we explored whether it was possible to safely streamline the number of women who have to undergo antenatal investigations.

The particular focus of our recent study was on the value of fetal cardiotocography (CTGs) in managing GDM (6).

Different levels of risk in GDM?

The prevalence of GDM is rising due to increases in maternal obesity and a rise in sedentary lifestyles (6,7,8). If increasing numbers of pregnant women need increasing numbers of tests, our maternity systems will explode and costs of care will rise.

GDM pregnancies do have an increased risk of maternal and fetal complications such as gestational hypertension, pre-eclampsia, caesarean delivery, development of type 2 diabetes postpartum, fetal macrosomia, birth trauma and shoulder dystocia (6,7,8). The risk of maternal and fetal complications is particularly high in GDM pregnancies with poor blood sugar control (6,7,8).

Medications that reduce blood sugar levels in women with GDM include Insulin and Metformin. Medication is only prescribed when women cannot achieve ideal blood fasting and 2-hour post prandial blood sugar levels despite eating a diabetic diet and undertaking regular exercise.

Women who need medication to manage their blood sugar level are therefore  at higher risk of potential pregnancy complications compared to women who are able to manage their blood sugar levels with  diet and exercise.

Fortunately, 70% of women can manage their blood sugar levels with diet and exercise. This means only 30% of women diagnosed with GDM require medication.

Antenatal monitoring in GDM

Antenatal fetal monitoring is routinely performed in pregnancies complicated by GDM.

The two most common tests undertaken to monitor the wellbeing of the fetus are cardiotocographs (CTG) and ultrasound (9,10).

CTG can detect some pregnancies at risk of stillbirth, allowing for prompt further intervention (9,10).

How do CTGs work?

The heart rate of a fetus is determined by a balance between two different types of neurotransmitters (sympathetic and parasympathetic) that  act on the sinoatrial node in the heart (11).

This balance is mediated through a number of factors including catecholamines (11). If fetal pathology is present, and the fetus is unwell, this balance can be affected, and changes in fetal heart rate patterns can be observed on a heart rate trace – the CTG (11,12). 

A number of conditions are associated with abnormal CTG tracings. Specific CTG findings that suggest fetal hypoxia and acidosis include reduced variation in the baseline fetal heart rate and loss of rises in heart rate (accelerations) or development of drops in fetal heart rate after uterine contractions (late decelerations) (13).

Using CTGs in pregnancy complicated with GDM

As high levels of blood sugar can damage the placenta and lead to fetal pathology that makes the fetus at risk of low oxygen or death, CTGs have been used to monitor GDM pregnancies.

However, there is a lack of consensus on the frequency and commencement gestation of CTG monitoring in GDM pregnancies (14,15,16).

Results from our research

In our recent research publication, published in the Australian and New Zealand Journal of Obstetrics and Gynaecology, we evaluated the role of CTGs in managing pregnancy complicated by GDM (6). Click here to read to full paper.

We audited 1404 consecutive antenatal CTGs in women diagnosed with GDM to determine how often they resulted in a change in management.

Overall, we found that in women requiring medication in order to manage their blood sugar levels, 43 CTGs were required to change management.

In women who did not require medication to manage their blood sugar levels, but who had another factor complicating their pregnancy, 161 CTGs were required to change management.

However, in women who did not require medication to manage their blood sugar levels and who had no other pregnancy complication, CTGs did not change management.

Therefore, if pregnant women with GDM can achieve good blood sugar control with changes to their diet and exercise, they do not require CTG monitoring.

This further emphasises the need to promote a diabetic diet and regular exercise in women with GDM.

If Pokemon Go is a potential solution to help encourage pregnant women walk and exercise on a regular basis, then it might result in a cost saving to our health system through improved pregnancy outcomes, less need for prescribed medication in GDM pregnancy and less need for antenatal monitoring with CTGs.

Maybe we should run a trial?

References

  1. Quinlivan J. The Challenge to deliver cost effective care for patients with Gestational Diabetes Mellitus. Repro Syst Sexual Dis 2014; 2014(3):4. DOI: 10.4172/2161-038X.1000144
  2. International Association of Diabetes and Pregnancy Study Groups Recommendations on the Diagnosis and Classification of Hyperglycemia in pregnancy. Diabetes Care 2010;33:676-682.
  3. Quinlivan J Dietary component of lifestyle interventions helps obese pregnant women. Evidence Based Medicine 06/2012; 18:e4 doi:10.1136/eb-2012-100794.
  4. Quinlivan J, Juliania S, Lam L. Antenatal dietary interventions in obese pregnant women to restrict gestational weight gain to institute of medicine recommendations: a meta-analysis. Obstetrics and Gynecology 2011: 118(6): 1395-401.
  5. Nankervis A, McIntyre HD, Moses R, Ross GP, Callaway L, Porter C, et al. Consensus guidelines for the testing and diagnosis of gestational diabetes mellitus in Australia. Australasian Diabetes in Pregnancy Society; 2014.
  6. Jeffery T, Petersen RW, Quinlivan JA. Does cardiotocography have a role in the antenatal management of pregnancy complicated by gestational diabetes mellitus? ANZJOG 2016; DOI: 10.1111/ajo.12487.
  7. Landon MB, Mele L, Spong CY, Ramin SM, Casey B, Wapner RJ, et al. The relationship between maternal glycemia and perinatal outcome. Obstet Gynecol. 2011 Feb;117(2):218-24.
  8. HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008;358:1991-2002.
  9. Graves CR. Antepartum fetal surveillance and timing of delivery in the pregnancy complicated by diabetes mellitus. Clin Obstet Gynecol. 2007;50(4): 1007-1013.
  10. Kjos SL, Leung A, Henry OA, Victor MR, Paul RH, Medearis AL. Antepartum surveillance in diabetic pregnancies: predictors of fetal distress in labor. Am J Obstet Gynecol. 1995 Nov;173(5):1532-1539.
  11. McDonnell S, Chandraharan E. The Pathophysiology of CTGs and Types of Intrapartum Hypoxia. Current Women’s Health Reviews. 2013;9(3): 158-68.
  12. McDonnell S, Chandraharan E. Fetal Heart Rate Interpretation in the Second Stage of Labour: Pearls and Pitfalls. Br J Med Med Res. 2015;7(12): 957-70.
  13. Devoe LD, Jones CR. Nonstress test: evidence-based use in high-risk pregnancy. Clin Obstet Gynecol. 2002 Dec;45(4):986-992.
  14. Metzger BE, Buchanan TA, Coustan DR, de Leiva A, Dunger DB, Hadden DR, et al. Summary and Recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care. 2007 Jul;30(S2) :S251-60.
  15. Landon MB, Vickers S. Fetal surveillance in pregnancy complicated by diabetes mellitus: is it necessary?. J Matern Fetal Neonatal Med. 2002 Dec; 12(6):413-416.
  16. Loomis L, Lee J, Tweed E, Fashner J. What is appropriate fetal surveillance for women with diet-controlled gestational diabetes?. J Fam Pract. 2006 Mar;55(3):238-240.