What are the risks of endometrial ablation in a patient with a history (Hx) of molar pregnancy?

Risks of Endometrial Ablation in a Patient with History of Molar Pregnancy

Endometrial ablation is contraindicated in patients with a history of molar pregnancy due to the increased risk of undetected recurrent gestational trophoblastic disease and complications if pregnancy occurs post-ablation. 1

Key Risks in Patients with History of Molar Pregnancy

• A history of molar pregnancy (gestational trophoblastic disease or GTD) represents a specific contraindication to endometrial ablation due to the risk of undetected disease recurrence that could be masked by the ablated endometrium 2
• Endometrial ablation destroys the uterine lining but does not prevent ovulation or conception, making pregnancy still possible even 20 years after a molar pregnancy 1
• Pregnancies following endometrial ablation carry serious risks including increased risk of extrauterine pregnancy, higher rates of preterm delivery, and increased risk of stillbirth 1

Specific Complications Related to Prior Molar Pregnancy

• Endometrial ablation may complicate monitoring for recurrent gestational trophoblastic disease, which requires endometrial sampling and hCG monitoring 2
• If recurrent GTD develops post-ablation, the scarred endometrium may mask symptoms and delay diagnosis 2
• The ablated endometrium makes it difficult to detect early signs of GTD recurrence on ultrasound, which typically appears as a hyperechoic area with multiple cystic spaces 2

Pregnancy-Related Complications After Endometrial Ablation

• Pregnancy after endometrial ablation can result in life-threatening complications including:
  • Uterine rupture, which has resulted in maternal death 3
  • Placenta accreta/increta requiring emergency hysterectomy 3, 4
  • Uterine synechiae leading to fetal malformations 5
  • Obstructed menses and hematometra 6

Risk Factors and Considerations

• The risk of pregnancy remains even decades after a molar pregnancy, as fertility may persist long-term 1
• Endometrial ablation is not a form of contraception and should only be performed in patients who do not desire future pregnancy 1, 7
• Patients with prior molar pregnancy require special monitoring for GTD recurrence, which is complicated by endometrial ablation 2

Alternative Treatment Options

• For patients with a history of molar pregnancy seeking treatment for abnormal uterine bleeding:
  • Levonorgestrel intrauterine device is a cost-effective alternative with higher quality of life and fewer complications 7
  • Hysterectomy should be considered as definitive treatment with higher quality of life and fewer long-term complications, particularly for patients with prior GTD 7
  • Medical management options should be exhausted before considering ablation 1

Important Clinical Considerations

• If endometrial ablation is still being considered despite these risks, concurrent tubal sterilization is strongly recommended to prevent the serious complications of post-ablation pregnancy 1, 3, 4
• Patients must be thoroughly counseled about the risks of pregnancy after ablation, including maternal death, and the importance of reliable contraception 3
• The risk of treatment failure and need for subsequent hysterectomy should be discussed, as approximately 20-25% of patients experience symptom recurrence within 5-7 years 2