What is the recommended treatment for a molar pregnancy, specifically regarding suction evacuation?

Management of Molar Pregnancy: Suction Evacuation as First-Line Treatment

Suction dilation and curettage (D&C) performed under ultrasound guidance is the recommended first-line treatment for molar pregnancy in women who wish to preserve fertility. 1, 2

Diagnosis and Initial Assessment

• Molar pregnancy is typically diagnosed based on a combination of ultrasound findings, clinical symptoms, and elevated hCG levels 1, 2
• Characteristic ultrasound findings for complete molar pregnancy include a heterogeneous mass ("snowstorm" appearance), absence of fetal development, and possible theca-lutein ovarian cysts 1, 2
• Partial molar pregnancies may present with focal cystic spaces within placenta, abnormal gestational sac, and possible fetal anomalies 1, 2
• Complete workup should include:
  • History and physical examination 2
  • Quantitative hCG assay 1, 2
  • Complete blood count with platelets 1, 2
  • Liver, renal, and thyroid function tests 1, 2
  • Blood type and screen 1, 2
  • Chest X-ray 1, 2

Treatment Procedure

• Suction D&C under ultrasound guidance is the safest method to ensure adequate emptying of uterine contents and avoid uterine perforation 1, 2
• Ultrasound guidance during the procedure is essential to reduce the risk of uterine perforation 1, 2
• Uterotonic agents (e.g., methylergonovine, prostaglandins) should be administered during the procedure and continued for several hours postoperatively to reduce the risk of heavy bleeding 1, 2
• Rho(D) immunoglobulin should be administered at evacuation to patients with Rh-negative blood types 1, 2
• For women who are older or do not wish to preserve fertility, hysterectomy can be considered as an alternative 1

Post-Evacuation Management

• All women with molar pregnancy require careful hCG monitoring to detect potential development of gestational trophoblastic neoplasia (GTN) 1, 2
• hCG monitoring should be done every 1-2 weeks until levels normalize (defined as 3 consecutive normal assays) 1, 2
• After normalization, hCG should be measured twice in 3-month intervals 1, 2
• Reliable contraception should be used during the entire follow-up period 2, 3
• Second D&C for recurrence does not usually prevent the subsequent need for chemotherapy and should only be attempted after discussion with a GTD reference center 1

Criteria for Post-Molar GTN

Post-molar GTN is diagnosed when meeting any of the following FIGO criteria:

• hCG levels plateau for 4 consecutive values over 3 weeks 2
• hCG levels rise >10% for 3 values over 2 weeks 2
• hCG persistence 6 months or more after molar evacuation 2, 3

Special Considerations

• Prophylactic chemotherapy at the time of evacuation is controversial and generally not recommended as standard practice 1, 2
• It may be considered for high-risk patients with risk factors including:
  • Age >40 years 1, 2
  • hCG levels >100,000 mIU/mL 1, 2
  • Excessive uterine enlargement 1, 2
  • Theca lutein cysts >6 cm 1, 2
• Vacuum aspiration has been shown to have a shorter surgery time compared to forceps and blunt curettage, with no difference in GTN incidence 4

Potential Complications

• Re-biopsy to confirm malignant change is not advised due to risk of triggering life-threatening hemorrhage 1, 2
• Complete evacuation of the uterus may not be achieved at the first attempt in up to 25% of cases 5
• Medical evacuation (using medications rather than surgical evacuation) should not be used for molar pregnancy 3

Follow-up After Treatment

• After normalization of hCG, patients who had a complete molar pregnancy should be followed for at least 6 months 3
• In all future pregnancies, early ultrasound scanning (around 8 weeks gestation) is recommended 3
• Eight weeks after termination of all future pregnancies, serum hCG should be measured 3