What is the standard treatment for a molar pregnancy?

From the Guidelines

The standard treatment for a molar pregnancy is surgical evacuation of the uterus through suction dilation and curettage (D&C) under ultrasound control to ensure adequate emptying of uterine contents and to avoid uterine perforation. This procedure removes the abnormal tissue from the uterus and is typically performed under general anesthesia. Following the D&C, serial monitoring of beta-human chorionic gonadotropin (β-hCG) levels is essential, usually every 1-2 weeks until undetectable for three consecutive measurements, then monthly for 6-12 months 1. This monitoring is crucial because approximately 15-20% of complete molar pregnancies and 1-5% of partial molar pregnancies can develop into gestational trophoblastic neoplasia (GTN), requiring additional treatment.

Key Considerations

• Patients should use reliable contraception during the monitoring period to avoid confusion between a new pregnancy and persistent disease.
• For patients who develop GTN or have persistent elevated β-hCG levels, chemotherapy may be necessary, with single-agent methotrexate being the first-line treatment for low-risk disease 1.
• High-risk disease may require combination chemotherapy regimens.
• The surgical approach is preferred over medical management because it allows for complete removal of abnormal tissue and provides tissue for pathological confirmation of the diagnosis.

Post-Treatment Monitoring

• Serial β-hCG monitoring is essential to detect potential development of GTN.
• Patients should be followed up regularly to monitor for signs of GTN, such as persistent elevated β-hCG levels or symptoms of metastatic disease.
• The NCCN Guidelines for Gestational Trophoblastic Neoplasia provide treatment recommendations for various types of GTD, including hydatidiform mole, persistent post-molar GTN, low-risk GTN, high-risk GTN, and intermediate trophoblastic tumor 1.

Additional Recommendations

• Histological examination of every termination is impractical, and perhaps a simple measurement of the urine or serum hCG level 3–4 weeks post-treatment to ensure return to normal is indicated 1.
• All women with a diagnosis of molar pregnancy require careful hCG monitoring to look for the recurrence of disease, suggesting malignant change indicated by a plateaued or rising hCG on three and two consecutive samples, respectively.

From the Research

Standard Treatment for Molar Pregnancy

The standard treatment for a molar pregnancy typically involves:

• Suction curettage, which is the primary treatment for molar pregnancies, especially in patients desiring to preserve fertility 2
• Hysterectomy, which is a reasonable option for patients who do not desire to preserve fertility 2
• Chemotherapy, such as methotrexate (MTX), which may be necessary for patients with persistent or invasive gestational trophoblastic disease (GTD) 3, 4

Factors Affecting Treatment

Several factors can affect the treatment of molar pregnancy, including:

• The type of molar pregnancy (complete or partial) 3
• The presence of metastasis 3
• The level of beta-human chorionic gonadotropin (beta-hCG) 3, 5
• The patient's desire to preserve fertility 2

Alternative Treatment Approaches

Alternative treatment approaches, such as:

• Direct injection of methotrexate into the tumor site 4
• Uterine artery embolization 5
• Total laparoscopic hysterectomy in combination with dilation and evacuation 2 may be considered in certain cases, but their safety and efficacy need to be further established.