What is the best next step in managing a 38-year-old woman with a history of hydatidiform mole, now presenting with minimal bleeding and a beta-human chorionic gonadotropin (β-hCG) level of 1,412 IU/L one week after suction curettage?

From the Guidelines

The best next step in managing this patient is to monitor her β-hCG levels weekly until they become undetectable, then monthly for 6-12 months, as recommended by the NCCN guidelines 1. After the diagnosis of hydatidiform mole (molar pregnancy) and successful evacuation by suction curettage, close surveillance of β-hCG levels is essential to detect persistent trophoblastic disease or choriocarcinoma. The patient's current β-hCG level of 1,412 IU/L indicates a need for continued monitoring, as the guidelines suggest that hCG levels should be monitored until they become undetectable, and then monthly for an additional 6 months 1. During this follow-up period, the patient should be advised to use reliable contraception to avoid pregnancy, as a new pregnancy would make it impossible to distinguish between normal pregnancy-related β-hCG and persistent trophoblastic disease. Additionally, a chest X-ray and baseline liver and thyroid function tests should be obtained to rule out metastatic disease, as recommended by the guidelines 1. If β-hCG levels plateau or rise during monitoring, further evaluation for gestational trophoblastic neoplasia would be warranted, potentially requiring chemotherapy, with options including methotrexate, dactinomycin, etoposide, and fluorouracil 1. This careful surveillance approach is necessary because approximately 15-20% of complete molar pregnancies can progress to persistent gestational trophoblastic disease. Some key points to consider in the management of this patient include:

• The importance of close surveillance of β-hCG levels to detect persistent trophoblastic disease or choriocarcinoma
• The need for reliable contraception to avoid pregnancy during the follow-up period
• The potential need for chemotherapy if β-hCG levels plateau or rise during monitoring
• The importance of ruling out metastatic disease with a chest X-ray and baseline liver and thyroid function tests.

From the Research

Management of Hydatidiform Mole

The patient in question has a history of hydatidiform mole and is now presenting with minimal bleeding and a beta-human chorionic gonadotropin (β-hCG) level of 1,412 IU/L one week after suction curettage. The following steps can be considered in managing this patient:

• Measurement of serum β-hCG levels weekly until the value is undetectable (< 1 or < 2) 2
• If serum β-hCG is undetectable within 56 days after evacuation, the patient can be discharged from follow-up after an additional four monthly measurements 2
• If serum β-hCG is first normalized after 56 days, the patient is followed up with monthly serum β-hCG measurement for six months 2
• The patient should use safe contraception during the follow-up period 2

Monitoring for Persistent Trophoblastic Disease

It is essential to monitor the patient for signs of persistent trophoblastic disease (PTD), which can be indicated by:

• Stagnation of β-hCG levels (less than 10% fall over three measurements) 2
• Increase in β-hCG levels 2
• Presence of β-hCG for longer than 6 months 2
• If PTD is suspected, a chest X-ray and gynecologic ultrasound scanning should be performed, and the patient should be referred to oncologic treatment 2

Importance of β-hCG Monitoring

Serial β-hCG serum level evaluation is crucial in preventing late diagnosis and potential development of metastasis 3. The rate of decrease of β-hCG level at two weeks after surgical evacuation is a reliable predictive factor for the progression of molar pregnancies to persistent GTN 4.

Treatment Options

If the patient is diagnosed with PTD, the primary treatment is methotrexate (MTX), either orally every third week or IV every week 2. In MTX-resistant PTD, IV actinomycin D is added or replaces MTX 2. Third-line chemotherapy options include BEP or EP, alternatively EMA-CO 2.