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Excerpt
Between 1957 and 1990, 1397 women were treated with cytotoxic chemotherapy for invasive hydatidiform mole, choriocarcinoma, or placental site trophoblastic tumors. In 1992, 1211 of these patients were still alive (137 had died from disease or complications due to treatment) and available for follow-up and were mailed a questionnaire concerning their reproductive history after chemotherapy. The response rate to this mailing was 96 percent.
There were 728 women (72 percent) who said that they had attempted to become pregnant. Their median age at the time of diagnosis of trophoblastic disease was 26 years (range 13.7-43.7 years) and the median follow-up since treatment was 12 years. Of these, 680 women have conceived and 607 have had live births; 73 women (10 percent) have achieved pregnancy but have not had a live birth. Forty-eight patients (7 percent) wished to become pregnant but have been unable to conceive.
There was a significant difference in the age at diagnosis between the women who had a successful outcome of pregnancy (median 25 years; P = .004) and those who conceived but did not have a live birth (median 27 years) and also those who could not conceive at all (median 28 years; P = .0003). The length of follow-up has been significantly shorter for the patients who have not conceived (median 9 years) compared with the women with successful pregnancies (median 12 years, P = .0003) or those who become pregnant but not had live births (median 13 years, P = .0007).
There was no difference in pregnancy rate or outcome among women who were considered to have low-, medium-, or high-risk disease, nor did the drug regimen used (single agent methotrexate or multi-agent chemotherapy) have any measurable effect on subsequent reproductive history.
Seventeen women had a second molar pregnancy and one woman had a third. Altogether, the women reported 1313 pregnancies, with 1000 live births. The rate of still-birth among these pregnancies was significantly higher than that for the general population (P < .001). Congenital malformation occurred in 1.7 percent of the births, which is comparable with the general population. Seventeen percent of the pregnancies were delivered by cesarean and 8 percent were considered premature (before 37 weeks of gestation).
(One of the most frequently asked questions when counseling women with gestational trophoblastic disease (GTD) is, "What is the chance that this will happen again with my next pregnancy?" Because there is an increased risk of trophoblastic disease among young women, this is a particularly urgent question. In one of the largest series in the world, the group from the Charing Cross Hospital in London reports 18 repeat molar pregnancies after chemotherapy for gestational trophoblastic disease among 1313 conceptions for a rate of 1.37 percent or 1 per every 73 pregnancies. In a similar series from the New England Trophoblastic Disease Center, Berkowitz et al. reported five repeat moles among 504 women (1 percent) treated with chemotherapy for GTD (J Reprod Med 1998;43:81). Although these rates are not very high, they still represent a tremendous increase in the risk compared with the population at large-about 1 per 1000 pregnancies in the United States and Western Europe. After two episodes of gestational trophoblastic disease, the incidence of future molar pregnancy sky-rockets.
