Recommended Contraception After Molar Pregnancy
Oral contraceptive pills (OCPs) are the most appropriate contraceptive choice for this patient, as they are safe, effective, and do not increase the risk of postmolar gestational trophoblastic disease. 1
Evidence Supporting OCP Use After Molar Pregnancy
The most relevant evidence comes from a randomized study of 100 patients managed for molar pregnancy, which found:
- No increased risk of postmolar trophoblastic disease with OCPs: 18.9% of OCP users developed postmolar disease compared to 14.3% of barrier method users (not statistically significant, P > 0.10) 1
- No delay in hCG regression: Mean hCG regression time was 7.0 weeks with OCPs versus 7.2 weeks with barrier methods 1
- OCPs can be safely prescribed during the entire interval of gonadotropin monitoring after molar evacuation 1
Why Not IUD?
IUDs should be avoided in this clinical scenario for several important reasons:
- The patient is in the immediate postabortion period following suction D&C 2
- While IUDs can technically be inserted within the first 7 days post-first-trimester abortion (U.S. MEC 1), this requires the IUD to be placed at the time of surgical abortion for immediate contraceptive effect 2
- If not placed at the time of D&C, the patient would need 7 days of backup contraception 2
- Most critically, this patient requires close hCG monitoring for postmolar gestational trophoblastic disease, and any intrauterine intervention could complicate surveillance or be mistaken for retained molar tissue on ultrasound 3
Why Not Vaginal Ring?
The vaginal ring is a combined hormonal contraceptive that could be used, but:
- It offers no advantage over OCPs in this clinical context 2
- OCPs have specific evidence supporting their safety after molar pregnancy 1
- The ring would require the same timing considerations as OCPs (can be started immediately if reasonably certain not pregnant) 2
Why Not Tubal Ligation?
Tubal ligation is inappropriate for this 29-year-old primigravida because:
- She is young and has never had a live birth 2
- Sterilization is intended to be irreversible and should only be offered after appropriate counseling about permanency 2
- This patient needs effective contraception during hCG monitoring (typically several months), not permanent sterilization 3
- Reversible methods like OCPs are equally effective for preventing pregnancy during the surveillance period 1
Practical Implementation
Start OCPs immediately if reasonably certain the patient is not pregnant (which she is not, having just undergone suction D&C) 2:
- No additional contraceptive protection needed if started within 5 days of the procedure 2
- If started >5 days after D&C, use backup contraception for 7 days 2
- Continue OCPs throughout the entire hCG monitoring period 1
- OCPs do not interfere with hCG regression or increase malignant transformation risk 1
Critical Monitoring Considerations
After molar pregnancy evacuation:
- Close surveillance with serial hCG monitoring is essential to diagnose gestational trophoblastic neoplasia 3
- Most patients have few symptoms at diagnosis in the modern era due to earlier detection 3
- The risk of postmolar GTN has not changed despite earlier diagnosis 3
- Cure rates for postmolar low-risk GTN approach 100% 3