Obstetric Formula Documentation for Patient with History of Molar Pregnancies
For a patient with 3 prior abortions (2 molar, 1 non-molar) who is now pregnant for the 4th time, document the obstetric history as: G4P0A3 (or G4P0030 in the expanded GTPAL format), with a detailed notation specifying "2 molar pregnancies" in the clinical record.
Understanding the Obstetric Formula Components
The standard obstetric notation follows the GTPAL system where:
- G (Gravidity) = Total number of pregnancies, including the current one = 4 1
- T (Term births) = Deliveries ≥37 weeks = 0
- P (Preterm births) = Deliveries between 20-36 weeks = 0
- A (Abortions) = Pregnancy losses <20 weeks = 3 1, 2
- L (Living children) = Current living children = 0
Critical Documentation Requirements
Molar pregnancies are classified as abortions in the obstetric formula because they represent pregnancy losses before viability, but require explicit specification in the medical record 3. The distinction between molar and non-molar abortions carries significant clinical implications for:
- Risk stratification: Women with recurrent molar pregnancies have a 15-20% risk of developing post-molar gestational trophoblastic neoplasia (GTN) after complete moles 1, 2
- Genetic counseling: Patients with 2 or more molar pregnancies may have familial recurrent hydatidiform mole (FRHM), an autosomal recessive condition associated with NLRP7 and KHDC3L gene mutations 1, 4
- Surveillance planning: This patient requires intensive hCG monitoring throughout the current pregnancy and postpartum period 1, 2
Proper Clinical Documentation Format
Document as follows in the medical record:
"G4P0A3 (2 complete/partial molar pregnancies, 1 spontaneous abortion)"
Or using expanded notation:
"G4P0030 with history of 2 molar pregnancies"
Essential Clinical Considerations for Current Pregnancy
This patient requires high-risk obstetric management with specific attention to:
- Baseline hCG measurement at first prenatal visit to establish normal pregnancy progression 2, 5
- Early ultrasound confirmation (6-8 weeks) to exclude recurrent molar pregnancy, looking for characteristic "snowstorm" appearance or cystic placental changes 1, 2
- Serial hCG monitoring if any clinical suspicion of recurrent molar disease, with levels that should double every 48-72 hours in early normal pregnancy 5
- Thyroid function testing if hyperemesis develops, as molar pregnancies can cause hyperthyroidism through hCG-TSH receptor cross-reactivity 5
Risk Assessment for Recurrent Molar Pregnancy
The risk of a third molar pregnancy in this patient is substantially elevated 6, 4, 7:
- Women with 2 prior molar pregnancies have a 32-fold increased risk compared to the general population 7
- Familial recurrent hydatidiform mole should be strongly suspected with 2 consecutive molar pregnancies 1, 4
- Genetic testing for NLRP7 and KHDC3L mutations should be offered, as women with FRHM are unlikely to achieve normal pregnancy except through ovum donation 1
Post-Delivery Surveillance Protocol
If this pregnancy results in a normal delivery, the patient still requires hCG monitoring 1, 2:
- Obtain baseline hCG at 6 weeks postpartum to ensure return to non-pregnant levels (<5 mIU/mL) 2, 5
- Any plateaued or rising hCG warrants immediate evaluation for GTN with pelvic Doppler ultrasound and chest X-ray 2
- Reliable contraception should be used during any surveillance period 2
Common Documentation Pitfalls to Avoid
Never document molar pregnancies separately from the abortion count, as this creates confusion in the obstetric formula and may lead to inadequate risk assessment 1. The numerical formula remains standard (G4P0A3), but the clinical narrative must specify the molar nature of 2 of these losses 3.
Do not assume all 3 abortions were molar - the question specifically states only 2 were molar, so one was a standard spontaneous abortion, which has different implications for recurrence risk 7.