What is the recommended management for termination of a molar pregnancy?

Management of Molar Pregnancy Termination

Women with singleton molar pregnancies should have these terminated by suction dilation and curettage (D&C) under ultrasound guidance, as this is the treatment of choice for patients who wish to preserve fertility. 1

Pre-Evacuation Workup

Before proceeding with evacuation, obtain the following essential laboratory tests:

• Quantitative serum β-hCG to establish baseline values (often >100,000 mIU/mL in complete moles) 2
• Complete blood count with platelets to assess for anemia and ensure adequate platelet count before surgery 2
• Comprehensive metabolic panel including liver and renal function tests to detect electrolyte imbalances and liver enzyme elevations 2
• Thyroid function tests (TSH and free T4) to identify hyperthyroidism from hCG cross-reactivity with TSH receptors 2
• Blood type and screen to prepare for potential hemorrhage and determine Rho(D) immunoglobulin needs 2
• Chest X-ray to screen for pulmonary metastases 2

Surgical Evacuation Technique

Suction D&C under ultrasound guidance is the safest method to ensure adequate emptying of uterine contents and avoid uterine perforation. 3

Key technical considerations during the procedure:

• Perform the evacuation under direct ultrasound visualization to control the resection and minimize perforation risk 3
• Administer uterotonic agents (methylergonovine or prostaglandins) during and after the procedure to reduce heavy bleeding 3
• Administer Rho(D) immunoglobulin at evacuation to patients with Rh-negative blood types 1, 3

Important Caveat About Second Curettage

Second D&C for recurrence does not usually prevent the subsequent need for chemotherapy and should only be attempted after discussion with a GTD reference centre. 1 This is a critical pitfall to avoid, as re-biopsy to confirm malignant change carries risk of triggering life-threatening hemorrhage 3

Alternative to Hysterectomy

For patients who have completed childbearing, hysterectomy is an option that reduces the risk of developing nonmetastatic gestational trophoblastic tumor (GTT), though this is not the standard approach for fertility preservation 4

Post-Evacuation hCG Monitoring Protocol

All women with molar pregnancy require careful hCG monitoring to detect potential development of gestational trophoblastic neoplasia (GTN). 3

Monitoring Schedule

• Every 1-2 weeks until levels normalize (defined as 3 consecutive normal assays) 3
• After normalization:
  • For complete hydatidiform mole: Monthly hCG monitoring for 6 months 3, 5
  • For partial hydatidiform mole: One additional normal hCG value is required before discharge from monitoring 5

Critical Technical Point

Serial quantitative serum β-hCG measurements must be performed using the same laboratory and assay for the entire monitoring period to avoid inter-assay variability that could mislead clinical decisions 3

If serum β-hCG results are inconsistent with the clinical picture, repeat the test with an alternative assay and corroborate with a urine β-hCG measurement to exclude false-positive serum values 3

Contraception During Follow-Up

Reliable contraception should be used during the entire follow-up period. 3 Any form of contraception may be used including the oral contraceptive pill, as long as there are no other contraindications 1

Criteria Triggering Chemotherapy (Post-Molar GTN)

Post-molar GTN is diagnosed when meeting any of the following FIGO criteria:

• hCG levels plateau for 4 consecutive values over 3 weeks 3
• hCG levels rise >10% for 3 values over 2 weeks 3
• hCG persistence 6 months or more after molar evacuation 3

Additional indications for chemotherapy include:

• Heavy vaginal bleeding 3
• Histological evidence of choriocarcinoma 3
• Evidence of metastases 3
• Serum hCG ≥20,000 IU/L >4 weeks after evacuation 3

Risk Factors for Post-Molar GTN

Be particularly vigilant in patients with:

• Age >40 years 3
• hCG levels >100,000 mIU/mL 3
• Excessive uterine enlargement 3
• Theca lutein cysts >6 cm 3

Chemotherapy Regimens if GTN Develops

If GTN is diagnosed, additional staging workup includes Doppler pelvic ultrasound and chest X-ray (if positive, proceed with MRI brain and CT body) 3

Treatment is based on FIGO scoring:

• Low-risk (score 0-6): Single-agent chemotherapy with methotrexate with folinic acid (MTX/FA) preferred in most European centres because it is less toxic than MTX alone or single-agent actinomycin D 1
• High-risk (score ≥7): Multi-agent chemotherapy with EMA/CO (etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine) 1

Chemotherapy for low-risk disease should be continued for 6 weeks of maintenance treatment after hCG normalisation 1

Long-Term Reproductive Outlook

After successful treatment of a molar pregnancy, the risk of a recurrent molar pregnancy in subsequent conceptions is approximately 1% 3

Fertility is not otherwise affected with 83% of women becoming pregnant after either MTX/FA or EMA/CO chemotherapy 1 There is no obvious increase in the incidence of congenital malformations 1

When a patient does become pregnant, confirm by ultrasound that the pregnancy is normal, then discontinue follow-up but recheck hCG at 6 and 10 weeks after the pregnancy to ensure no recurrence or new disease 1