REPRODUCTIVE FUNCTION POST HYDATIDIFORM MOLE

Martaadisoebrata D, Wahyudi AP dan Ghazali MF

Obstetric and Gynecologic Department Hasan Sadikin General
Hospital/FKUP Bandung
Introduction
In general, each pregnancy will end with the birth of aterm and healthy baby. But,
during pregnancy, disruption can be found and give a failure of development, which
is called as Reproductive Failure. Failure could take the form of abortion, ectopic
pregnancy, prematurity, death in the womb, fetal growth failure or congenital
defects, depends on the stage and form of interference.
In addition to the disorders mentioned above, there is other pregnancy failure,
which the result of conception is not a fetus, but rather develops a pathological form
in clusters that resemble grapes, referred to as hydatidiform mole (HM).
If hydatidiform mole is not accompanied by the fetus, it is called as Complete
hydatidiform mole (CHM, Fig 1), whereas if it is accompanied by a fetus or part of
the fetus, it is called as Partial hydatidiform mole (PHM, Fig 2).
Most patients with HM will be recovered, after treated comprehensively, including
its main reproductive function, including menstruation, sex and pregnancy. But
approximately 15-20% will undergo malignant transformation into Malignant
Trophoblastic Tumor, which consists of Invasive Mole (Fig 3), Choriocarcinoma (Fig 4)
and Placental Site Trophoblastic Tumor (Fig 5).

1,2,3

Malignant Trophoblastic Tumor

may also occur after some condition other than HM, such as abortion, ectopic
pregnancy or normal pregnancy.
In terms of clinical epidemiology, including the number of incidence, risk factors, its
distribution and prognosis, especially for malignant type, trophoblastic disease
remains a big problem in our country.
As a condition that begins with pregnancy failure and is overshadowed by the
possibility of malignancy, in addition to give physical disorders, this disease will
provide psychological, social and spiritual impact to the patients. First, it will cause

grief and anguish. Psychologically it raises fears of a repetitive pregnancy failure.

Secondly, it will cause fear of malignancy and death. When this happens, the
psychological burden will increase, as there is also economic and social burden due
to long, expensive and uncomfortable side effects of treatment that can interferes
their social life. If malignancy can be overcome and reproductive function can be
returned to normal, the anxiety and worries will not disappeared completely,
because the fear of recurrence will still remain.
Psychosocial disorders do not only occur in PTG, but also in all cases which are
pathological. Hence, in all such cases, including patients with PTG, in addition to
medical treatment (CURE), they also need counseling and psychological support
(Care), both from doctors and her family, especially her husband.

One of the information and counseling they need is about post-HM reproductive
function, including menstruation, sex and pregnancy. The question they may ask,
including: When will I have my menstruation back? Will I get pregnant again?
Whether the pregnancy is going to be normal and deliver normal baby? Is it possible
that my pregnancy will end as HM again?
Various studies have been conducted, especially in foreign countries including
Garrett et al5, Sabire et al

and Hideo Matsui et al 7, in general, the degree and the

return of fertility of HM patients had no difference compared to normal pregnancy.

Sabire stated that the recurrence of HM was 1 to 60 compared to those who have
never experienced MH.
To date, there were no studies which specifically examine the post-MH reproductive
function, performed by teaching hospital in our country.
In the Department of Obstetrics Gynecology, Hasan Sadikin General Hospital,
Bandung, various studies concerning PTD has been done, including its reproductive
function, as it had been presented in Seoul, Korea in 1996, on WC on Gestational
trophoblastic Diseases VIII, titled "Reproductive performance in post hydatiform
mole women "8. Unfortunately, the data did not have good quality to be used for
counseling. Accordingly, we need to do more research that is more focused, so that
we will able to gather valid data to be used in providing the accurate counseling.

Subject and Procedure

Subject Research
The subjects used in this study were patients, who were treated at the Obstetrics
and Gynecology Department, Hasan Sadikin Hospital / Faculty of Medicine UNPAD, in
the period of 1995-2004, approximately 10 years old, then afterwards home visits
was conducted for two years. Source of data derived from complete medical record
which known to be qualified as subjects, added with data from the interview during
home visit.
Research design
The study was a retrospective, observational, descriptive, non-statistical study.
Inclusive criteria
All patients who did not undergo hysterectomy and they were who known to be
qualified as subjects. The patients also need to have willing to be interviewed.
Exclusive criteria
All cases which were not found during home visits (lost to follow-up).

Result
During the period, actual cases of CHM and PHM were more than that cases that
used in this study. This was because many medical records which were incomplete
or missing, and many home visits were lost to follow up. Due to the problems, only
254 cases of HM which can be presented and analyzed, consisting of 250 cases
were CHM and 4 cases were PHM.
Other evidence which indicated that the incidence of HM in RSHS was quite high,
among others, was derived from the data presented at Gestational Trophoblast
Disease One-Day Seminar, in Bandung in 1998 9, , which stated that the number of
HM patients treated at RSHS in the period 1995-1996 were 107 cases. If we use this

data as guidance, there will be more than 1000 cases in 10 years. Even if there was
a decline, the number of patients would be more than 254 cases. The data was
indicated Hospital-Based incidence, instead of Population-Based.
In 2000, Gestational Trophoblastic Disease Epidemiology Study in Bandung was
conducted by Setiorini et al

10

, and the study found the incidence of MH was 1: 500

of delivery.
Tabel 1. Distribution of cases based on age of patients at entry
Age (years old)
<20
20-24
25-29
30-34
35-39
40-44
45-49
>49
Unknown
TOTAL

Number
8
63
66
47
24
23
18
3
2
254

Percentage
3.1
24.8
26
18.5
9.4
9.1
7.1
1.2
0.8
100

In this study, age of patients with HM ranged between 17 and 56 years old, with a
mean of 29.5 years (Table 1). Reproductive age of women, at that time, was
between 15 and 45 years old. Thus, their fertile period was lasts for thirty years,
where they could become pregnant during that time. Furthermore, they would be no
longer

fertile,

due

to

menopause.

However,

in

accordance

with

current

development, there was a significant change in the reproductive period. At present,

most female began their menarche at the age of ten years old, and we were able to
get a primi gravida at the age of twelve or thirteen years old.
In addition, womens fertility period were also extending. Most of the women got
their menopause in their fifty. Thus, their fertile period grew longer to be forty years.
By extending reproductive period, there would be more possibility for mothers who
pregnant, to have molar pregnancy.
The literature and daily experience showed that those women who were pregnant at
extremes age, ie less than 20 years old and over 35 years old, often experiencing
Reproductive Failure and the failures of pregnancy could be in form of hydatidiform

mole (HM). In this study, we found a case of CHM at the age of 56 years, which was
rare to occur.
The experts mostly agreed that the risk factors of HM were including extreme age,
high number of gravidity and poor nutrition. But Mathieu

11

, said as follows:

Incidences are of didactic importance. The important factor is that any patient in
the childbearing period MIGHT harbor a mole, and therefore one must constantly
has this condition in mind.

Table 2. Distribution of CHM / PHM by the gravida at entry

Gravida
1
2-3
>3
Unknown
TOTAL

Number
49
96
84
25
254

Percentage
19.3
37.8
33.1
9.8
100

In this study, in terms of gravidity, the range was between G1 and G7 with a mean
of 3.1 (Table 2). This number did not show the actual data, because we received
referral cases of pregnant women with more than ten of gravidity.
Description of pregnant women with extreme age, grandemulti and malnutrition, is
a problem that is still common in our country. Therefore it was not surprising that
the prevalence / incidence of HM in Indonesia, was quite high compared with other
countries, especially in Western countries. Therefore, to overcome this problem, we
need to improve the family planning program, in addition to improving nutrition,
including maternal nutrition.
In addition of physical complaints such as hyperemesis, dizziness, pain and
bleeding, HM patients would be also accompanied by psychological disorders and
social form of anxiety and fear of repetition, loss of fertility and malignancy postHM, and disruption of daily social life, both in their home or public sphere (work), as
mentioned before.

Therefore, health service which provided to the HM patient must be holistic and
humanistic, as known as Biopsychosocial approach. Bio was given in the form of a
Cure for eliminating physical complaints or illness and Care to eliminate or reduce
psychosocial complaints.
Cure was not a problem, because there was a fixed protocol in hospital.
Unfortunately, Care was remained as a major problem. RSHS did not have a pattern
that can be accounted for Care, because the Care services are very closely related
to the Care Professional Ethics. In many HM patients, we did not feel assured that
they have got a good Care services, such as a sense of comfort, safety and hope.
Hopefully, at some time, we could be able to provide Cure and Care services in
balance. One of well- form Care service example is correct Informed Consent.
Research on psychosocial issues in PTG and other cancers have been done by other
researchers, such as RS Berkowitz et al

Table 3.

12

, Ngan HYS et al

13

and Wenzel LB et al

14

Distribution of CHM / PHM according to the occurrence of normal

menstruation after the evacuation.

Normal Menstruation after

Number

Percentage

evacuation
1-3 bulan (@)
4-6 bulan (&)
> 6 bulan
Unknown/Lost to follow up
TOTAL

105
85
11
53
254

41.3
33.5
4.3
20.9
100

(@): 41.3% of cases, had got a normal menstrual cycle in the first three months
after the evacuation. Thus, fertility was back to normal.
(&): Those who received normal menstrual upwards of four months after the
evacuation are those who use hormonal contraceptives, especially those who carry
out the injections or exclusive breastfeeding.

One characteristic of any type of pregnancy is the cessation of menstruation or

amenorrhea. When the baby was born, menstrual function will return again.
Unfortunately, the return of menstrual function is depends on breast feeding activity
of the mother.
The longer time that the mother give on breast feeding, the longer time of
menstrual function to be returned. This condition was called Laktasio amenorrhea.
During the time, the mother will not get pregnant. At present, the government
recommends that mothers need to breastfeed their children at least during 6
months to 2 years. This policy is known as EXCLUSIVE BREASTFEEDING (ASI
EKSKLUSIF) which is very good for the baby, because the baby will get good
nutrition and the mother will avoid unwanted pregnancy.
From Table 3, we can see that 41.3% of the cases had normal menstruation within 13 months after the evacuation of the mole. This was possible because the mother
did not breastfeed or not using long-term hormonal contraception. This means that
they were susceptible to the occurrence of a new pregnancy, unless they joined the
IUD insertion after delivery.
From the same table, there were mothers who got her menstruation period within 46 and > 6 months, respectively, 33.5% and 4.3%. They might use Long-Term
Contraception Method (LTCM) in the form of injection or implement exclusive
breastfeeding.
A total of 20.9% of cases were having unknown data or lost to follow-up. But 79.1%,
we could conclude that the degree of fertility post-HM, was back to normal. Thus,
they were able to get pregnant again.

Table 4 Distribution of the incidence of pregnancy after the evacuation CHM / PHM
Pregnancy occurrence (in

Number

Percentage

months)
1-3
4-6
7-12
>12

4
24
3
107

2.9
17.4
2.2
77.5

TOTAL

138

100

From total 254 cases of CHM / PHM, 138 (54.3%) of whom was pregnant and gave
175 deliveries. One hundred and five cases of them had delivered one time, 29
cases had delivered twice and 4 cases had delivered three times. This was
additional evidence showed that the degree of fertility post-MH had no difference to
those who had normal pregnancies.
Our PROTAP stated that it was recommended to consult of HM patients for one year
after the evacuation with the intention that if there is a change to malignancy
process, so it can be detected early. And also, during the period, it was required not
to be pregnant, due to disruption of new pregnancy in the occurrence of malignancy
post-MH, because both cases will give elevated levels of beta hCG.
Most of patients did not comply with this suggestion or requirement. For them, when
there were no more complaints, it meant that the disease has gone. This mindset
will actually harm patients because in the case of malignancy, the diagnosis will be
known in late stage.
Table 4 was an evidence of the disobedience, 12.2% of patients turned out to have
been pregnant in less than one year.
Table 5 Distribution of occurrence of pregnancy in those who become pregnant
before the one-year post CHM / PHM and type of pregnancy outcome
Pregnancy
occurrence

Pregnancy outcome

Number

Percentage

Aterm

36

87.8

Preterm

7.4

Stillbirth

IUFD

2.4

Abortion

2.4

HM

41(&)

100

before

one-year

1-12 months

TOTAL (31)
-

(&): Some of them have given birth more than once

(@): Most of them (87.8%) gave birth to aterm, even if they were pregnant before
one-year post CHM/PHM evacuation.
Table 5 showed there were 31 cases that have been pregnant within one-year after
the evacuation, with the number of deliveries were 41. This was evidence that
patients were not in obedient to the rules that made by the Hospital. In addition,
this data could be explained that the degree of fertility did not change, because
some of patients had become pregnant more than once.
From the same table, we could see that the majority (87.8%) of the results of
pregnancies was in aterm. The remaining (12.2%) had failure of pregnancy, except
for HM, although their pregnancy was less than one-year after the evacuation.
Based on this data, we are able to provide counseling that mothers who had had
HM, do not have to worry about getting pregnant, because in general they will give
birth to a normal baby in aterm. The results were in accordance with data from
other studies.
Unusual finding in the table was the number of recurrent HM which was zero,
whereas in the literature, according to Brandea J et al

15

and Yapar EG et al

16

, stated

that those who had HM, the possibility to have recurrent HM is bigger. According to
Rice LW et al

17

, after experiencing a HM pregnancy for first time, the possibility to

have recurrent MH in subsequent pregnancies was increased by 1%. according to

Sand PK et al

18

, after having 2 times of HM, the possibility to had recurrent MH was

increased to 28%. It was not rare to find cases of recurrent HM in Hasan Sadikin
Hosptal, with the most number of recurrent HM pregnancy was up to three times.
The repetition could be in a row or interspersed by normal pregnancies.
Results of this study which were associated with recurrent HM, clearly was not in
accordance to the prevailing theory. To find further explanation of this finding, more
research needs to be conducted.

Table 6 Distribution of occurrence of pregnancy in those who become pregnant after

one year post CHM / PHM and type of pregnancy outcome
Pregnancy
occurrence

Pregnancy outcome

Number

Percentage

Aterm

104

81.9

Preterm

13

10.2

Stillbirth

0.8

IUFD

2.4

Abortion

3.9

HM

Unknown

1
127(&)

0.8
100

before

one-year

>12 months

TOTAL (107)

(&): Some of them have given birth more than once.

(@): Most of them (81.9%), pregnancy outcomes was aterm
Table 6 had no substantial difference with table 5, only in the time of pregnancy.
Table 6 illustrated the group of mothers who became pregnant after one year of
post-MH. From 107 cases, 127 deliveries were recorded. As it has been described
above, from 245 cases CHM / PHM, 138 were pregnant, consisting of 105 cases had
delivery one time, 29 cases gave birth for twice and four cases gave birth for three
times. Thus, the number of deliveries reached 168. Most of them were gave birth to
aterm babies.

From tables 5 and 6, it was known that there were 16 premature pregnancy
outcomes. This result was bigger than other forms of pregnancy failure, such as
IUFD, stillbirth death or abortion. This finding could be explained because some of
the babies were born as twins or triplets.
As we know that there are three main female reproductive function, including
menstruation, sexual activity and pregnancy. These results indicated that those
three functions of post HM pregnancy patient were normal after evacuation. Those

patients, who had their menstrual period back, were able to have sex naturally, and
most of them were able to get pregnant. There were some patients who got
pregnant more than once, and they generally gave birth to aterm babies.

Table 7 Distribution of cases based on the type of delivery

Most of them (86.5%) had spontaneous labor.

In Table 7 showed that in 171 deliveries, 148 of them (86.5%) were having
spontaneous vaginal delivery. This type of labor was highly coveted by pregnant
mothers. This data was additional evidence which showed that the reproductive
function of women after a molar pregnancy has no difference with women who have
never had molar pregnancy, including their type of delivery.
Conclusion
1. Post CHM / PHM reproductive functions in form of menstruation, sexual
activity and pregnant, will becomes normal again in short period.
2. In general, the process and outcome of pregnancy in women with CHM / PHM
pregnancy has no difference with pregnancy in women who never had CHM /
PHM.
3. Therefore, mothers who have had a molar pregnancy, do not have to worry
about getting pregnant after molar pregnancy
4. In this study, due to something that can not be explained, recurrent
Hydatidiform Mole pregnancy was remained not found in the patients
5. There should be a new research with better method research, in particular to
assess Recurrent Hydatidiform Mole pregnancy
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