From the Guidelines
Molar pregnancy should be managed with prompt evacuation of the uterus through suction dilation and curettage (D&C), followed by close monitoring of human chorionic gonadotropin (hCG) levels to detect persistent disease. The management of molar pregnancy is crucial to prevent the development of gestational trophoblastic neoplasia (GTN), which can be invasive or malignant if left untreated. According to the most recent guidelines, women with singleton molar pregnancies should have these terminated by suction D&C 1.
Key Considerations
- Suction D&C is the preferred evacuation method, performed under ultrasound guidance to ensure complete removal while minimizing uterine perforation risk.
- Medical induction with misoprostol or oxytocin is generally avoided due to increased risk of trophoblastic embolization.
- Following evacuation, weekly hCG monitoring is essential until levels normalize, then monthly for 6-12 months.
- Reliable contraception is recommended during this monitoring period, with hormonal contraceptives being acceptable options.
- Persistent elevation or rising hCG levels may indicate GTN requiring chemotherapy, most commonly with single-agent methotrexate for low-risk disease or multi-agent regimens for high-risk cases.
Chemotherapy Regimens
- For low-risk disease, single-agent methotrexate with or without folinic acid (FA) or actinomycin D (ActD) can be used 1.
- For high-risk disease, multi-agent chemotherapy with EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine) is recommended 1.
- The FIGO scoring system should be used to determine the risk of GTN becoming resistant to single-agent chemotherapy 1.
Follow-up and Monitoring
- hCG levels should be monitored every 1-2 weeks until normalized, and then twice in 3-month intervals to ensure levels remain normal 1.
- If hCG levels remain elevated, treatment should be initiated according to the postmolar GTN algorithm 1.
- Repeat dilation and curettage or hysterectomy can be considered for persistent postmolar GTN 1.
From the Research
Molar Pregnancy Management
- The management of complete molar pregnancy involves suction curettage as the preferred method of molar evacuation, regardless of uterine size, in patients who desire to preserve fertility 2.
- Prophylactic chemotherapy may be useful in the management of high-risk molar pregnancy, especially when hormonal follow-up is either unavailable or unreliable 2.
- Patients must be followed with serial human chorionic gonadotropin levels to ensure that remission has occurred 2.
Evacuation Procedures
- Suction curettage is recommended for molar evacuation rather than sharp curettage because of its safety 3.
- Vacuum aspiration and forceps plus blunt curettage are two evacuation procedures that have been compared, with no significant difference in the incidence of gestational trophoblastic neoplasia (GTN) between the two methods 3.
- Vacuum aspiration may have the advantage of a shorter surgery period and is considered safer 3.
Chemotherapy
- Etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMA-CO) chemotherapy is effective for the treatment of high-risk gestational trophoblastic neoplasia (GTN) 4.
- The use of EMA-CO chemotherapy has minimal toxicities and allows for excellent reproductive outcomes after treatment 4.
Follow-up
- Current guidelines recommend that resolution of a complete molar pregnancy can only be confirmed once a negative β-human chorionic gonadotropin (β-hCG) has been maintained for six months following uterine surgical evacuation 5.
- However, studies have found that the risk of developing GTN once a negative β-hCG has been obtained is negligible, suggesting that a shorter follow-up may be reasonable 5.
- Increasing the human chorionic gonadotrophin cut-off to ≤1000 IU/l for starting actinomycin D in post-molar GTN developing resistance to methotrexate may spare more women multi-agent chemotherapy 6.