Evolution of a Teenage and Young Adult Service, in Sheffield, U.K., for Patients with Gestational Trophoblastic Neoplasia.

OBJECTIVE: To describe the evolution of a teenage and young adult (TYA) service for patients with gestational trophoblastic neoplasia (GTN). BACKGROUND: Since its opening in 2002 the TYA unit has demonstrated its effectiveness and ability to care for GTN patients, offering additional emotional assessment and meeting the specific needs that many young GTN patients have. Patients using the TYA unit were identified from the Centre's databases, and individual records were scrutinized for demographics, clinical presentation, barriers to care, compliance, and specific needs. RESULTS: Of the 121 GTN patients who have utilized the facilities, there were 94 complete moles, 11 choriocarcinomas, 3 placental site trophoblastic tumors, 1 twin molar pregnancy, and 4 with persistent unexplained hCG elevation. Presenting with a complicated social background was identified as a barrier to care in 8 patients. In addition to patients, 40 relatives and 12 infants have also utilized the facilities. A total of 33% of patients and carers had social work input and/or refer-ral to psychology services. CONCLUSION: The bespoke service and care offered to TYA patients is appropriate and should be considered the gold standard for young patients, enabling them to cope with their unique challenges during diagnosis and treatment.

[Gestational Trophoblastic Disease: psychological impact and the role of defence mechanisms during illness and follow-up]. / Tumori del trofoblasto di origine gestazionale: impatto psicologico e ruolo dei meccanismi di difesa nel percorso di malattia.

UNLABELLED: Gestational Trophoblastic Disease (GTD) is a group of disorders that derive from the placenta and arise after a rare gestational event. They can be divided into pre-malignant forms (partial and complete hydatidiform mole) and malignant forms called Gestational Trophoblastic Neoplasia (GTN). Despite a favourable prognosis, the nature of this group of disorders can be a source of stress for patients who are affected by this disease. METHODS: Thirty-one patients diagnosed with GTD completed a battery of self-administered questionnaires aimed at analysing the psychological adaptation of the patients to the disease. The variables analysed were the following: defense mechanisms, anxiety, depression and infertility-related stress. RESULTS: Patients with GTN use mature defense mechanisms significantly more than patients with hydatidiform mole. Regression analyses highlight that, considering demographic and clinical variables, immature defense mechanisms are significantly related to state anxiety. Immature defence mechanisms also significantly predict infertility-related global stress. CONCLUSIONS: The results show the importance of taking into consideration defense mechanisms used by patients, as they are involved in the modulation of psychological adaptation to GTD.

Gestational trophoblastic disease: an overview.

This article reviews the different disease entities that fall under the classification of gestational trophoblastic disease (GTD). The conditions included range from molar pregnancy to the malignant forms of gestational trophoblastic neoplasm (GTN). These disorders all arise from abnormal placental trophoblastic development. The different types of GTD, symptomatology, and diagnostic modalities are examined. The various methods of treatment are reviewed. Although the management of GTD and GTN falls outside the scope of midwifery practice, midwives need to be aware of the incidence, risk factors, and symptoms for specific types of GTD in order to be able to diagnose and refer for treatment in a timely manner. Psychosocial aspects that affect the woman who has not only had a pregnancy loss but also may be faced with a life-threatening illness are examined. The role of the midwife in the management, counseling, and follow-up of GTD and GTN is discussed.

The impact of molar pregnancy on the male partner.

BACKGROUND: Molar pregnancy is a complication of 1 in 200-2000 pregnancies whereby abnormal placental tissue proliferates in the absence of a fetus and may lead to metastases. The disease origin lies in dispermy or dual fertilisation of the egg. The aim of this study was to explore the impact of molar pregnancy upon the male partner. METHODS: Institutional ethics committee approval and individual consent were obtained. All women listed on the state molar pregnancy database who were receiving active follow-up (n = 102) and a random sample of women who had been registered in the previous 30 years (n = 56) were sent a postal survey outlining the purpose of the study and an invitation for their partner to participate. Sixty-six women gave permission for their partner to participate in the study. Questionnaires included the Hospital Anxiety and Depression Scale, Satisfaction with Life Scale and Sexual History Form 12. Responding partners were also invited to make comments about any aspect of particular concern. A reminder mail out was issued after 6 weeks. RESULTS: The response rate was 62% (N = 41). The key findings were that 32.5% and 12.5% of men met the case criteria for anxiety and depressive disorder, respectively. These figures represent a doubling of usual community rates for anxiety disorder. However, overall quality of life and sexual functioning outcomes were consistent with community samples. The presence of children played a protective role and was associated with significantly better psychological function and quality of life in univariate and multivariate analysis. Qualitative results complemented the quantitative data, with anxiety as the dominant emotional theme. CONCLUSION: There are high persisting levels of anxiety in male partners of women with molar pregnancy. Partners may benefit from therapy where anxiety disorders are detected.

Grieving after early pregnancy loss--a common reality.

A miscarriage can be very traumatic for a couple and their immediate family. The aim of this study was to assess, using the Perinatal Grief Scale (PGS), whether the type of early pregnancy loss influences the severity of grief and whether the presence of living children influences the severity of grief. Over a period of 6 months in 2008, seventy five patients were recruited for the study, of which 7 (9.3%) had molar pregnancies, 20 (26.7%) had ectopic pregnancies, 43 (573%) had a miscarriage and 5 (6.7%) had recurrent miscarriages. In this study there was no significant difference in severity of grief, between women that had a miscarriage and ectopic pregnancy (p = 0.14) or, between women that had a miscarriage and a molar pregnancy (p = 0.85). Women who had experienced a ectopic pregnancy did not have a higher grief intensity than the women that had a molar pregnancy (p = 0.75). However, for women with a child, the grief intensity significantly increases with the number of miscarriages (p = 0.015). Women with no children with an ectopic pregnancy grieve significantly more than those with a child (p = 0.019). An appointment for the 'Miscarriage Clinic' should be offered to all of these women but special attention should be paid to those in the categories most at risk

Long-term psychological morbidity, sexual functioning, and relationship outcomes in women with gestational trophoblastic disease.

OBJECTIVE: Clinical observation suggests a protracted psychosocial recovery after gestational trophoblastic disease (GTD), although this has not been well studied. We describe long-term psychological morbidity, sexual functioning, and relationship outcomes after GTD. MATERIALS AND METHODS: Cross-sectional analysis was made of 176 Australian women previously diagnosed with GTD recruited from a statewide registry. Participants comprised 149 women (85%) who did not require chemotherapy and 27 women (15%) who required chemotherapy for malignant or persistent GTD/molar disease (gestational trophoblastic tumor [GTT]). Data were collected from medical records and via validated self-report questionnaires. RESULTS: The participants were 94 women (53%) with partial mole, 75 women (43%) with complete mole, 4 women (2%) with choriocarcinoma, and 3 women (2%) with hydatidiform mole not otherwise specified. The mean (SD) age at diagnosis and time since diagnosis were 32.1 (6.3) and 4.7 (3.3) years, respectively. Elevated levels of depression and anxiety were reported by 22% and 26% of the women, respectively. One fifth to half of the women experienced some GTD-related avoidant and intrusive phenomena, the latter being more prominent among women who had not had chemotherapy. Sexual dysfunction was reported by 52% of the women. Most women (81%) felt well supported by their partners during the illness, 19% thought the relationship had changed, and 26% perceived that GTD had negatively affected sex life. This perception was stronger in those who received chemotherapy, although objective measures of sexual morbidity showed no group differences. Socially disadvantaged women and those who did not conceive subsequent to the diagnosis had poorer psychosocial outcomes. CONCLUSIONS: Notwithstanding limitations, this study is the largest of its type to date. Psychological morbidity rates exceeded community norms, but sexual dysfunction rates, although high, are likely consistent with local norms. These findings highlight the long-term burden of GTD and the importance of a supportive care component in management, even among those who do not require chemotherapy. Socially disadvantaged women and those who do not conceive subsequent to GTD diagnosis require greater psychosocial support.

Assessment of quality of life and psychologic aspects in patients with gestational trophoblastic disease.

OBJECTIVE: To assess quality of life (QoL) and psychological aspects in patients with gestational trophoblastic disease (GTD). METHODS: This cross-sectional self-report study was conducted among 54 women. Validated question-naires assessed QoL (WHO-QOL-bref), symptoms of depression (Beck Depression Inventory [BDI]) and anxiety (State-Trait Anxiety Inventory [STAI]). RESULTS: Most patients rated overall QoL as good (44.44%) and were satisfied with their health status (42.59%). Mean QoL domain score was lowest for psychologic health (53.86 +/- 21.46) and highest for social relationships (65.74 +/- 22.41). BDI mean was 15.81 +/- 11.15, indicating dysphoria. STAI means were 46 +/- 6.46 for trait-anxiety and 43.72 +/- 4.23 for state-anxiety, both evidencing medium-high anxiety. Among employed patients, environment domain mean was the highest (p = 0.024). Presence of children resulted in lowest means for physical health (p = 0.041) and environment (p= 0.045). Patients desiring children showed significantly higher means for physical health (p = 0.004), psychological health (p = 0.021) and environment (p = 0.003). Chemotherapy had no significant influence on QoL (p > 0.05). CONCLUSION: This study evidenced psychological impact on GTD patients, suggesting specialized care centers should provide psychological interventions during treatment and follow-up of GTD patients, highlighting the importance of a multidisciplinary approach.

The impact of molar pregnancy on psychological symptomatology, sexual function, and quality of life.

BACKGROUND: Molar pregnancy is an unusual complication of pregnancy whereby abnormal placental tissue proliferates in the absence of a fetus. There is usually a protracted follow-up period where pregnancy is contra-indicated. Whilst the medical outcomes of the disease have been well explored, limited data have evaluated the impact on psychological symptomatology, sexual function, and quality of life. METHODS: Institutional ethics approval and individual consent were obtained. All women listed on the hospital molar pregnancy register receiving active follow-up (n = 102) and a random sample of women who had been registered in the previous 30 years (n = 56) were sent a postal survey outlining the purpose of the study and an invitation to participate. Questionnaires included the Hospital Anxiety and Depression Scale (HADS), Satisfaction with Life Scale (SWLS), and Sexual History Form 12 (SHF-12). RESULTS: The response rate was 54%. The key findings were that 60%, 55%, and 18% of women scored > or =10 on the total HADS, > or =8 on HADS-A, and >8 on HADS-D, respectively. The presence of children played a protective role and was associated with significantly better psychological function and quality of life. SWLS were in the lower end of ranges reported for community controls (mean of 23.9). Chemotherapy had an adverse impact on quality of life ratings (SWLS for chemotherapy yes = 21.7, no = 25). Sexual dysfunction was similar to community samples and was independent of age, time since diagnosis, chemotherapy requirement, and presence of children. Qualitative results complemented the quantitative data with similar emotional themes identified as well as issues related to the medical condition, care, and support networks. CONCLUSION: Women with a molar pregnancy may benefit from a multidisciplinary approach to management that addresses their psychological and sexual needs in addition to medical aspects of care.

Psychosocial and reproductive outcomes of gestational trophoblastic diseases.

Current therapy for molar pregnancy and gestational trophoblastic neoplasias (GTNs) has resulted in high cure rates with preservation of fertility, even in the setting of chemotherapy for widespread metastatic disease. Data from the New England Trophoblastic Disease Center on later pregnancies following complete and partial mole, as well as persistent GTN show that patients can, in general, anticipate normal subsequent pregnancy outcome. Nevertheless, patients and their partners often express anxiety and fear related to the risk of disease recurrence and the outcome of subsequent pregnancies after treatment for gestational trophoblastic disease. These psychosocial sequelae may persist for years in both patients and their partners.

Pregnancy after EMA/CO for gestational trophoblastic disease: a report from The Netherlands.

OBJECTIVE: To investigate whether a desire for pregnancy changed after etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine (EMA/CO) treatment for gestational trophoblastic disease and whether the incidence of infertility and adverse pregnancy outcome differed from the general population. DESIGN: A cohort study was performed. Data were collected from hospital records and questionnaires. SETTING: The study was carried out in referral hospitals in The Netherlands. POPULATION: All women registered by the Dutch Working Party on Trophoblastic Disease and treated with EMA/CO were included. METHODS: A questionnaire was sent to all surviving patients treated with EMA/CO from 1986 until 1997. Women who underwent a hysterectomy were excluded from the study. MAIN OUTCOME MEASURE: Pregnancy outcome and pregnancy wish after chemotherapy. RESULTS: Fifty patients were treated with EMA/CO. In 86%, a complete remission was achieved. A questionnaire was sent to 33 patients. Response rate was 82% (27/33). After EMA/CO, 18 of the patients experienced a regular menstrual cycle. Three patients had an amenorrhoea. Fourteen patients had a pregnancy wish. Twelve patients conceived; 21 pregnancies occurred. Sixteen pregnancies were term deliveries. Two pregnancies ended in a miscarriage and two congenitally abnormal children were delivered prematurely. CONCLUSION: After EMA/CO, 86% of women with a pregnancy wish achieved pregnancy. However, women can be so anxious about a new pregnancy that they refrain from it. A causative relation between the two congenitally abnormal children and EMA/CO cannot be determined because of the small sample. The rate of miscarriages is not higher than in the general population. We can reassure patients that pregnancy after EMA/CO has a high probability of success and a favourable outcome. To diminish the fear of getting pregnant in some patients, psychosocial care should be considered in addition to medical care.

Midwifery management of first trimester bleeding and early pregnancy loss.

As many as 25% of women experience bleeding in the first and early second trimester of pregnancy; about half of these will have a miscarriage or, more rarely, ectopic or molar pregnancy loss. This can be a difficult time for women because of the uncertainty of the outcome, lack of preventative measures, and emotional significance of early pregnancy loss. The qualities that characterize midwifery care, including providing complete information, encouraging self-determination, and being sensitive to the emotional state, are particularly important at this time. This article reviews the epidemiology; physiologic process; signs and symptoms of first trimester bleeding; miscarriage and other early pregnancy losses; and methods of clinical, biochemical, and sonographic evaluation. A framework to guide midwifery evaluation and management, based on confirmation of an intrauterine pregnancy followed by the determination of viability, is presented. Surgical, medical, and expectant management of nonviable pregnancy, management of viable pregnancy when bleeding persists, and follow-up care, including screening for psychological sequelae, are discussed. Case studies and specific clinical guidelines for midwifery care, consultation, collaboration, and referral are included. Understanding the emotional significance of first trimester bleeding and loss as a basis for sensitive care throughout the management process is addressed.

Psychosocial impact of persistent trophoblastic disease.

The female identity of women who suffer from hydatidiform mole developing into persistent trophoblastic disease is threatened in two ways. The reproductive failure is shortly followed by a disease originating in the uterus requiring chemotherapy. Although somatic treatment results are excellent, the psychological effects may be severe and protracted. We conducted a study of 22 women who were between 6 months and 5 years after the end of successful treatment. It appeared that 19 women suffered from psychological sequelae. The three oldest women of the study group, 50 years or older, belonged to the group of women demonstrating signs of prolonged psychological effects.

Psychosis following hydatidiform mole in a patient with recurrent puerperal psychosis.

The association of a puerperal psychosis with the removal of a trophoblastic tumour supports the hormonal hypothesis for the aetiology of puerperal psychosis and suggests new lines of investigation into this disorder.