Approach

Care of women with molar pregnancy generally requires the expertise of a consultant. Women who desire preservation of fertility should undergo suction evacuation (electrical or manual), usually under ultrasound guidance.[3][4][34]​​ Hysterectomy may be considered in women who do not want to preserve fertility.[3][4][34][42]

Supportive care

Women with unevacuated hydatidiform moles generally require stabilisation of associated comorbidities (e.g., respiratory distress, pre-eclampsia/eclampsia, hyperthyroidism, or severe anaemia) before definitive treatment. Using a large-bore intravenous catheter is appropriate in women with uterine enlargement greater than 14 weeks' gestational size, in anticipation of the need to rapidly administer intravenous fluids and blood products at the time of evacuation.

Oxytocics or other means of inducing labour should not be given before cervical dilation intraoperatively.

Prophylactic antibiotics are not considered mandatory, and are reserved for clinical concerns of infected products of conception.

Sequential compression stockings, as a single modality, is considered adequate for venous thrombo-embolism prophylaxis.

High-output cardiac failure may be secondary to hyperthyroidism or thyroid storm, severe pre-eclampsia, gestational hypertension, pulmonary oedema, and, less commonly, anaemia.[50]​ This condition is usually self-limiting, and resolves over time after complete removal of the molar pregnancy. It is best treated with supportive care, including mechanical ventilation tailored to minimise barotrauma, and central haemodynamic monitoring.

Women desiring future pregnancy

Suction evacuation (electrical or manual) is the preferred management option for women with molar pregnancies who desire preservation of fertility.[3][4][34]​​​​​​​​

Technique

  • General anaesthesia is achieved, and beta-blockade given if the women is clinically hyperthyroid.[51]​​​​ Women who are Rho (D)-negative should receive anti-D immunoglobulin.[52] After the cervix is gently mechanically dilated with tapered Pratt dilators, intravenous oxytocin may be given to facilitate involution of the uterus. A suction cannula is advanced gently to the uterine fundus, and rotated while mechanical suction is applied. Sharp uterine curettage is not recommended because of the risk of uterine perforation, and equivalent outcomes with the suction method.[53]​​

In the absence of histopathology, post-treatment measurement of human chorionic gonadotrophin (hCG) levels should be performed weekly until normalisation of hCG levels or diagnosis of gestational trophoblastic neoplasia (GTN). The duration of monitoring varies by country.[3] ​(see Monitoring)

During the period of follow-up after evacuation of the mole, strict adherence to contraception should be advised.[3][34]​​​[54] ​Unless contraindicated for separate medical conditions, women should commence a reliable method of hormonal birth control, such as an oral contraceptive, immediately after uterine evacuation.[55][56]​​ However, intrauterine devices (medicated or not) are contraindicated in women with active, invasive tumours or persistently elevated hCG levels because of the risk of uterine perforation.[54] (see Patient discussions)

Women not desiring future pregnancy

Hysterectomy may be more desirable for the management of molar pregnancy than suction evacuation in women who have completed childbearing.[57]​ It is associated with an increased risk of postoperative complications compared with suction evacuation, but a decreased risk of postoperative GTN.[57]​ Women undergoing hysterectomy for the management of molar pregnancy should also be monitored postoperatively with the measurement of serial hCG levels.

With hyperemesis gravidarum

The objectives of managing a woman with molar pregnancy complicated by hyperemesis revolve around symptomatic control of emesis with an anti-emetic and/or an H2 antagonist and intravenous hydration with electrolyte replacement, while moving towards prompt removal of the hydatidiform mole. Hyperemesis associated with a molar gestation resolves promptly after removal, roughly in parallel with the decline in hCG levels. Complete hydatidiform mole, because it is accompanied by significantly higher levels of hCG, is more likely to be associated with these symptoms than partial hydatidiform mole.[23]​​[24][25][26]

With active bleeding

Bleeding can complicate hydatidiform mole, as acute haemorrhage before treatment, surgical management, or as delayed haemorrhage during follow-up of a patient after evacuation of a molar pregnancy. It is important to establish the baseline haemogram in women with molar pregnancy before treatment. Women who are Rho (D)-negative should receive anti-D immunoglobulin.[52]​ Women with severe anaemia or haemodynamic instability require transfusion before treatment. 

If acute haemorrhage occurs before or during surgical management, the procedure should be completed promptly and the benefit of oxytocic infusion considered against the risk of embolisation and dissemination of trophoblastic tissue through the venous system.[34]​ The use of oxytocic agents or methylergometrine will control bleeding after surgical management in most women.[34] Prostaglandins can be considered, if acute bleeding during or after evacuation is encountered. Bleeding around the time of uterine evacuation rarely requires uterine artery embolisation or hysterectomy. Delayed haemorrhage after uterine evacuation (while hCG levels are still elevated) is often a sign of trophoblastic proliferation. Rarely, a woman will require a second suction evacuation to control symptomatic haemorrhage after the initial molar evacuation.[34]

In women with an established diagnosis of post-molar GTN, chemotherapy will usually control bleeding.

Very rarely, women with normal hCG levels develop delayed bleeding after molar evacuation. These women will often have a history of heavy menstrual bleeding preceding the episodes of spontaneous bleeding. Pelvic-transvaginal Doppler ultrasound or contrast magnetic resonance imaging studies of the uterus may be helpful to exclude post-molar uterine arteriovenous malformation. Depot medroxyprogesterone and tranexamic acid, selective embolisation, myometrial wedge resection and repair, or hysterectomy may be required to treat these lesions.[58]

With thyrotoxicity

Thyrotoxicosis in molar pregnancy is typically self-limited and best treated with supportive care. Beta-blockers should be given with the induction of anaesthesia at the time of surgical management, if the woman is clinically hyperthyroid. Carbimazole can be added, if a faster clinical response is needed or there is a thyrotoxic storm.[51]

With pre-eclampsia

Anti-hypertensive therapy should be started if systolic BP is persistently between 140 and 159 mmHg and/or diastolic BP is persistently between 90 and 109 mmHg, or if there is severe hypertension (systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg).[59][60] ​​

In the US, magnesium sulfate is recommended for all women with severe pre-eclampsia.[59] In other countries, including the UK, a more targeted approach is recommended, allowing the physician to exercise individual judgment based on the woman's specific risk factors (e.g., presence of uncontrolled hypertension or deteriorating maternal condition).[60] Seizures reflect progression to eclampsia, and are both treated and prevented with magnesium sulfate. The Food and Drug Administration (FDA) and MHRA recommend that maternal administration of magnesium sulfate should not last longer than 5-7 days during pregnancy due to the risk of skeletal adverse effects, hypercalcaemia, and hypermagnesemia in the neonate.[61][62]​​​​ Despite the recommendation, magnesium sulfate is usually only used for 24-48 hours in clinical practice.

Management of molar pregnancy with a viable twin generally entails close observation for pre-eclampsia as the pregnancy is carried to either voluntary termination, forced delivery, or term. Definitive treatment of pre-eclampsia consists of delivery. The decision about when and how to deliver should only be made after a thorough assessment of the risk and benefits to the mother and co-existing twin.

With theca lutein cyst

Theca lutein cysts result from hCG stimulation of the ovaries and may present with pelvic or abdominal masses, pain, or ovarian torsion. Their incidence is 7% to 9% among women with complete hydatidiform moles.[24][25]​ The presence of theca lutein cysts does not necessarily mandate ovarian removal because these cysts are a response to ovarian exposure to elevated hCG levels or hypersensitivity of the ovaries to hCG. They usually involute over time after surgical management of molar pregnancy, and can be drained or, exceptionally, removed, if ovarian torsion with necrosis is confirmed.[50]

With viable twin fetus

Management of molar pregnancy with a viable twin generally entails close observation as the pregnancy is carried to either voluntary termination, forced delivery due to medical complications (e.g., bleeding, severe pre-eclampsia, hyperthyroidism, or acute respiratory distress) or term.[34] Conservative management is not recommended in the presence of choriocarcinoma or fetal aneuploidy.[4] Postnatal, the placenta should be sent for evaluation by a pathologist experienced in the evaluation of GTD, and routine post-molar surveillance should be initiated.[34]​ Importantly, with careful medical monitoring, about 60% achieve viable live births.[63] Twin pregnancies comprising a viable fetus and a coexisting hydatidiform mole have an increased risk of GTN, with a higher proportion of these women developing metastatic disease or requiring chemotherapy.[63]

With risk of post-molar GTN and non-compliance with follow-up

Chemoprophylaxis is given only after evacuation of a hydatidiform mole and assessment of clinical and social risk factors. A clinical risk assessment is used to identify women at low risk or high risk of developing post-molar GTN.[4] In women who are at high risk of developing GTN (e.g., maternal age >40 years, women with complete hydatidiform moles or hCG levels >100,000 mIU/mL) and in whom hCG monitoring is either unavailable or unlikely to be followed, it may be possible to reduce the risk of GTN by administering chemoprophylaxis with methotrexate or dactinomycin.[4][64]​​​

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