Management of Molar Pregnancy
The primary treatment for molar pregnancy is surgical evacuation by suction dilation and curettage (D&C) under ultrasound guidance, which is the safest method to ensure adequate emptying of uterine contents and avoid uterine perforation. 1
Diagnosis and Initial Assessment
- Molar pregnancy is typically diagnosed based on ultrasound findings, clinical symptoms (most commonly vaginal bleeding between 6-16 weeks), and elevated hCG levels 1, 2
- Complete molar pregnancy shows characteristic ultrasound findings including a heterogeneous "snowstorm" appearance and absence of fetal development 1, 2
- Partial molar pregnancy shows focal cystic spaces within placenta, abnormal gestational sac, and possible fetal anomalies 1, 3
- Initial workup should include:
- Quantitative hCG assay (typically elevated beyond expected level for gestational age) 1, 2
- Complete blood count with platelets 1
- Liver, renal, and thyroid function tests 1, 2
- Blood type and screen (for potential anti-D immunization in Rh-negative women) 1, 2
- Chest X-ray (as baseline or if clinical suspicion of metastases exists) 1, 2
Surgical Management
- Suction D&C under ultrasound guidance is the treatment of choice for molar pregnancy in women who wish to preserve fertility 1
- Blood should be available pre-operatively due to risk of significant hemorrhage 2
- Uterotonic agents (e.g., methylergonovine, prostaglandins) should be used during and after the procedure to reduce risk of heavy bleeding 1
- Administer Rho(D) immunoglobulin at evacuation to patients with Rh-negative blood types 1
- Re-biopsy to confirm malignant change is not advised due to risk of triggering life-threatening hemorrhage 4, 1
- Post-evacuation assessment should include ultrasound or hysteroscopy to ensure complete evacuation 2
Post-Evacuation Monitoring
- 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:
- Reliable contraception should be used during the entire follow-up period 1, 5
Diagnosis and Management of Post-Molar GTN
Post-molar GTN is diagnosed using FIGO criteria when meeting one or more of the following:
If GTN is diagnosed, additional staging workup includes:
Treatment of GTN is based on FIGO risk scoring system:
- Low-risk GTN (score 0-6): single-agent chemotherapy with methotrexate or actinomycin D 4, 1
- High-risk GTN (score ≥7): multi-agent chemotherapy 1
- For nonmetastatic and low-risk metastatic disease: actinomycin D 12 mcg/kg intravenously daily for five days as a single agent 6
- For high-risk metastatic disease: actinomycin D 500 mcg intravenously on Days 1 and 2 every 2 weeks for up to 8 weeks, as part of a multi-agent combination chemotherapy regimen 6
Special Considerations
- Risk factors for post-molar GTN include age >40 years, hCG levels >100,000 mIU/mL, excessive uterine enlargement, and theca lutein cysts >6 cm 1
- Endometrial ablation is contraindicated in patients with a history of molar pregnancy due to the increased risk of undetected recurrent gestational trophoblastic disease 7
- Twin pregnancies with a coexistent normal twin and complete mole result in healthy babies in approximately 40% of cases, without obvious increase in risk of malignant change 2
- The reproductive outcomes after molar pregnancy are generally comparable with those of the general population, except for a higher occurrence of recurrent molar pregnancy (1.0-2.0% of subsequent pregnancies) 5