Wednesday, 7 September 2011

The pregnancy which was not

The pregnancy which was not

6/9/11: Today we had the rare opportunity to observe treatment of a molar pregnancy. This is where there is abnormal placenta formation due to an ovum (egg) being incorrectly fertilised - usually by the genetic material from just 2 sperm (so no maternal material - the egg is empty) but sometimes from maternal material as well (so has 50% extra chromosomes). As a result of the abnormal genetics the placenta invades tissue beyond its normal site and the embryo is incompatible with life, but the pregnancy hormones are still produced and so amenorrhoea and the sensation of pregnancy continues without a fetus. 3% of complete moles (those moles just produced by paternal DNA) develop in a malignant disease - choriocarcinoma (cancer originating from the chorion, the outer layer surrounding the embryo prior to its death).

Ironically in molar pregnancies the symptoms of pregnancy are exaggerated and the patient is likely to suffer from extreme morning sickness and have a uterus which is large for dates.

The treatment of moles in the UK would follow the following steps:

1. Removal of the mole by gentle suction.
2. Weekly hCG (the hormone produced in pregnancy) checks until the level returns to normal. A rise in hCG would indicate possible relapse or invasive mole.
3. Avoid pregnancy for at least 1 year
4. Increased risk future pregnancy will also be molar - ultrasound to confirm is normal
5. Chemotherapy may be required if invasion mole or choriocarcinoma.

In Tanzania however molar pregnancies are removed using D and C (dilatation and curettage - the cervix is dilated and then the lining of the uterus scraped off using a curette), patients are advised to attend follow up in a year but the doctor told us they don't tend to turn up and very few hospitals can offer chemotherapy if it is needed due to expense.

Molar pregnancies are quite rare in the UK (oxford handbooks quotes a rate of 1.54 in every 1000 pregnancies) and are only treated in I think 2 specialist centres - everywhere else refers patients to these. Therefore most medical students or even doctors do not get to observe the treatment of molar pregnancies being carried out. So I guess from the point of view of my training it is pretty lucky to get to see this treatment happening. But from the patients point of view it must have been a horrible diagnosis, going from being 6 months pregnant to not being pregnant at all and instead having material in her uterus which might turn into cancer. When I say I was lucky to be able to observe this operation I don't mean I am pleased the condition had occurred; obviously I would very happily swap this learning opportunity for her to instead have a successful normal pregnancy.

The actual operation was pretty gruesome with lots of large lumpy bits being removed and the patient lost perhaps a litre of blood. Molar pregnancies are supposed to look like frog spawn on removal... Well I wouldn't say that but was quite unusual in appearance.

D and C looked seriously harsh way of treating the condition (think I prefer the sound of the gentle suction recommended in England!). At least this patient was under general anesthetic though - we saw a D and C on a woman who had heavy periods (so ?endometriosis) immediately before this surgery where the woman didn't even have local anaesthetic. Although that procedure didn't last anywhere near as long and involved less curettage, the woman still looked in considerable amounts of pain. The molar pregnancy patient had the same anaethatist as the other day (bowel obstruction patient) - still wasn't impressed with him, he seemed fascinated by the operation which is good but as a result spent a lot of time watching the D and C and very little time observing the patient or her vital signs. Yet again we had to alert him of worrying vital signs or movements from the patient. To quote AJ, he was "about as useful as a chocolate fireguard".

The rest of the day was pretty quiet, no women in labour and OPD was very empty. Aj and I were asked to review a patient on maternity by one of the midwives who thought she looked ill. She did look pretty ill and was tachycardic and tachypnoic (fast heart rate and respiratory rate). We couldn't hear the fetal heart sounds to start with but fortunately this turned out to just be our lack of experience/ ability rather than a genuine problem! The patient had been suffering from abdominal pain for 5 days and the pain was especially on the right hand side, she also had been recorded as having a swinging (temperature up, normal, up, normal etc) fever throughout her time in hospital. Right hand side pain tends to ring alarm bells of appendicitis but I think maybe this patient would be even sicker if it was appendicitis untreated for 5 days and the doctors seemed to have considered it and then discounted it. The doctors had already treated for malaria and now thought the pain was due to myositis which is basically just inflammation of the muscle and can be caused by anything from lupus (which would be Houses working diagnosis no doubt!) to bacterial infection. So a pretty vague diagnosis really and the patient was being given several antibiotics to try and treat the possible infection.

When we took the patients history with the help of a midwife as translator we discovered she had not passed stool or flatus (wind) for the last 5 days either. No one knew this yet because no one had asked. Pretty shocking question to miss out on an abdominal pain history - in England if a patient has abdo pain you always always always ask about bowel movements. Whether or not these symptoms are causing the pain (she could have bowel obstruction, the lack of even flatus in particular is a bit worrying) or the pain has caused the symptoms (if a patient is not mobilising due to pain, their bowel can become more dormant and so they get constipated) is difficult to tell. We asked a doctor to review the patient and as a result he prescribed her some laxatives. Hopefully these might help relieve at least some of her pain.

So much more responsibility here as a medical student than in UK (we see patients in England too but they will always be seen by a doctor afterwards regardless of what we say, here if we don't ask for a senior review then the patient will not get one), great practice for when we qualify though!

Halfadoc x

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