Management of Rising β-hCG After Molar Pregnancy Evacuation
When quantitative β-hCG levels are rising after dilation and curettage for molar pregnancy, initiate chemotherapy according to the postmolar gestational trophoblastic neoplasia (GTN) algorithm, as rising hCG >10% for 3 consecutive values over 2 weeks meets FIGO diagnostic criteria for postmolar GTN. 1, 2
Diagnostic Criteria for Postmolar GTN
The NCCN, ACOG, and SOGC all use the FIGO staging criteria to diagnose postmolar GTN when one or more of the following patterns occur after molar evacuation: 1, 2
- hCG levels rise >10% for 3 consecutive values over 2 weeks (this is your scenario) 1, 2
- hCG levels plateau for 4 consecutive values over 3 weeks 1, 2
- hCG persistence 6 months or more after molar evacuation 1, 2
Immediate Workup Before Treatment
Once rising hCG establishes the diagnosis of postmolar GTN, complete the following assessment: 1, 2
- History and physical examination focusing on symptoms of metastatic disease 1
- Doppler pelvic ultrasound to evaluate for uterine masses and assess vasculature 1, 2
- Chest X-ray to screen for pulmonary metastases 1, 2
- Complete blood count with platelets 1
- Liver, renal, and thyroid function tests 1
- Blood type and screen 1
Treatment Selection Algorithm
Single-agent versus multiagent chemotherapy depends on FIGO prognostic scoring and clinical staging: 3
- Low-risk GTN (FIGO score ≤6): Initiate single-agent methotrexate or dactinomycin 1, 3
- High-risk GTN (FIGO score ≥7): Initiate multiagent chemotherapy (EMA-CO or similar regimens) 4, 3
Risk factors that increase FIGO score include: 1
- Age >40 years
- Initial hCG levels >100,000 mIU/mL
- Interval from index pregnancy >12 months
- Presence of metastases
- Prior failed chemotherapy
Role of Repeat Curettage
Repeat dilation and curettage can be considered for persistent postmolar GTN before initiating chemotherapy, with 68% of patients having no further evidence of disease or chemotherapy requirements after this procedure. 2 However, this approach carries perforation risk and is generally not recommended as standard practice, with chemotherapy being the primary treatment. 4
Critical Pitfalls to Avoid
- Do not wait for hCG to plateau or persist for 6 months when levels are already rising >10% over 2 weeks—this pattern alone meets diagnostic criteria and requires immediate treatment 1, 2
- Do not initiate chemotherapy based on a single elevated hCG value—follow the established FIGO criteria requiring serial measurements 2
- Do not use medical uterine evacuation for molar pregnancy—suction dilation and curettage is the standard 4
- Be aware that qualitative urine hCG assays may be falsely negative in the presence of markedly elevated hCG levels found in molar pregnancy, so always use quantitative serum hCG for monitoring 5
Monitoring During Treatment
Continue measuring serum hCG every 1-2 weeks during chemotherapy until normalization (3 consecutive normal assays), then measure twice at 3-month intervals to ensure levels remain normal. 1, 2 The cure rate for postmolar low-risk GTN approaches 100% with appropriate chemotherapy. 3