What is the recommended initial management and follow‑up for a woman of reproductive age diagnosed with a hydatidiform mole?

Management of Hydatidiform Mole

Initial Treatment: Immediate Uterine Evacuation

Suction dilation and curettage under ultrasound guidance is the definitive initial treatment for all women with hydatidiform mole who wish to preserve fertility. 1, 2

• Perform suction aspiration followed by gentle sharp curettage, with ultrasound guidance to minimize uterine perforation risk 1, 3
• Ensure blood products are immediately available before starting the procedure due to substantial hemorrhage risk 3
• Administer uterotonic agents (oxytocin, methylergonovine, and/or prostaglandins) during the procedure and continue for several hours postoperatively to prevent bleeding 1, 3
• Give Rho(D) immunoglobulin at the time of evacuation to all Rh-negative patients 1, 3, 2
• Confirm complete evacuation with post-procedure ultrasound or hysteroscopy 3, 2
• Send all tissue for histopathologic examination to confirm diagnosis 3

For women over 40 years old or those who have completed childbearing, hysterectomy is an acceptable alternative that reduces (but does not eliminate) the need for subsequent monitoring. 1

Pre-Evacuation Workup

Before proceeding with evacuation, obtain the following studies 1, 2:

• Quantitative serum β-hCG level
• Complete blood count with platelets
• Comprehensive metabolic panel including liver function tests
• Thyroid function tests (TSH, free T4, free T3) - critical because hCG cross-reacts with TSH receptors causing hyperthyroidism when levels exceed 100,000 mIU/mL 3, 2
• Renal function tests
• Blood type and screen
• Chest X-ray to evaluate for metastatic disease 1, 2
• Pelvic ultrasound (already performed for diagnosis)

Post-Evacuation hCG Surveillance Protocol

All women require strict hCG monitoring to detect malignant transformation, which occurs in 15-20% of complete moles and 1-5% of partial moles. 4, 2

For Complete Hydatidiform Mole:

• Measure serum β-hCG weekly until undetectable 2
• Once undetectable, continue monthly measurements for 6 months 1, 2
• If hCG normalizes after 56 days post-evacuation, extend monthly monitoring for 6 months after normalization 2

For Partial Hydatidiform Mole:

• Measure serum β-hCG every 2 weeks until undetectable 1
• Once undetectable, monthly monitoring is generally sufficient 2

Contraception Requirements

Prescribe reliable hormonal contraception immediately after evacuation and maintain throughout the entire surveillance period. 5, 6

• Pregnancy during surveillance makes hCG monitoring impossible and delays detection of malignancy
• Contraception should continue until completion of the full monitoring protocol

Indications for Chemotherapy (Gestational Trophoblastic Neoplasia)

Initiate chemotherapy immediately if any of the following criteria are met 1, 2:

• hCG levels plateau (less than 10% decline) over three consecutive weekly measurements 2
• hCG levels rise over two consecutive weekly measurements 2
• hCG remains detectable beyond 6 months post-evacuation 2
• Evidence of metastatic disease on imaging 2
• Histologic evidence of choriocarcinoma 2
• Heavy vaginal bleeding requiring transfusion 2
• Evidence of gastrointestinal or intraperitoneal hemorrhage 2

Prophylactic Chemotherapy Consideration

Prophylactic methotrexate or dactinomycin may be considered for high-risk patients, though this remains controversial. 1

High-risk criteria include:

• Age >40 years 1
• hCG levels exceeding 100,000 mIU/mL 1
• Excessive uterine enlargement beyond expected gestational size 1
• Theca lutein cysts larger than 6 cm 1

The evidence suggests prophylactic chemotherapy may reduce progression risk by 3-8%, but routine administration is not standard practice 1. This decision should be made in consultation with a gestational trophoblastic disease specialist center.

Prognosis and Long-Term Outcomes

The cure rate for gestational trophoblastic neoplasia approaches 100% when treated appropriately, with fertility generally preserved. 4, 2

• Recurrent elevation of hCG after normalization occurs in less than 1% of patients 1
• Women with recurrent molar pregnancies can still achieve normal live births in subsequent pregnancies 4
• Approximately 2-3% of all hydatidiform moles progress to choriocarcinoma 2

Critical Management Pitfalls to Avoid

• Never use medications that induce uterine contractions (prostaglandins, misoprostol) before evacuation - this increases hemorrhage and embolization risk 6
• Do not allow pregnancy during surveillance - this makes malignancy detection impossible 5
• Ensure hCG assay detects all forms (intact molecule, hyperglycosylated, free β-subunit, core fragment) to avoid false-negative results 6
• Do not discharge patients from surveillance early even if hCG normalizes quickly - complete the full 6-month protocol 1, 2