Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

singleton molar pregnancy: desiring fertility

1st line – suction evacuation

Back
ACUTE
|
singleton molar pregnancy: desiring fertility
1st line – 

suction evacuation

General anesthesia is achieved, and beta-blockade given, if the woman is clinically hyperthyroid.[48]​ 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.[50]​​

Plus – supportive care

Back
ACUTE
|
singleton molar pregnancy: desiring fertility
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Women with unevacuated hydatidiform moles generally require stabilization of associated comorbidities (e.g., respiratory distress, preeclampsia/eclampsia, hyperthyroidism, or severe anemia) before definitive treatment.

Using a large-bore intravenous catheter is appropriate in women with uterine enlargement >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 labor 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 hose, as a single modality, is considered adequate for venous thromboembolism prophylaxis.

High-output cardiac failure may be secondary to hyperthyroidism or thyroid storm, severe preeclampsia, gestational hypertension, pulmonary edema, and, less commonly, anemia.[47] 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 minimize barotrauma, and central hemodynamic monitoring.

Plus – contraception

Back
ACUTE
|
singleton molar pregnancy: desiring fertility
Plus – 

contraception

Treatment recommended for ALL patients in selected patient group

During the period of follow-up after evacuation of the mole, strict adherence to contraception should be advised.[3][34][51]

Unless contraindicated for separate medical conditions, women should commence a reliable method of hormonal birth control, such as an oral contraceptive, immediately after molar evacuation.[52][53]

However, intrauterine devices (medicated or not) are contraindicated in women with active, invasive tumors or persistently elevated hCG levels because of the risk of uterine perforation.[51]​ (see Patient discussions)

Consider – Rho(D) immune globulin

Back
ACUTE
|
singleton molar pregnancy: desiring fertility
Consider – 

Rho(D) immune globulin

Treatment recommended for SOME patients in selected patient group

Women who are Rho (D)-negative should receive Rho(D) immune globulin.[49]

Primary options

Rho(D) immune globulin: consult specialist for guidance on dose

More

Plus – fluid replacement plus antiemetic and/or H2 antagonist

Back
ACUTE
|
singleton molar pregnancy: desiring fertility
|
with hyperemesis gravidarum
Plus – 

fluid replacement plus antiemetic and/or H2 antagonist

Treatment recommended for ALL patients in selected patient group

The objectives of managing a woman with molar pregnancy complicated by hyperemesis revolve around symptomatic control of emesis with an antiemetic and/or an H2 antagonist and intravenous hydration with electrolyte replacement, while moving toward 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]​​​

Primary options

metoclopramide: 5-10 mg intravenously/intramuscularly every 8 hours when required

OR

prochlorperazine rectal: 25 mg twice daily when required

Secondary options

ondansetron: 4 mg intravenously/orally every 8 hours when required

OR

famotidine: 20 mg intravenously every 12 hours

Plus – blood products and cessation of blood loss

Back
ACUTE
|
singleton molar pregnancy: desiring fertility
|
with active bleeding
Plus – 

blood products and cessation of blood loss

Treatment recommended for ALL patients in selected patient group

Women with severe anemia or hemodynamic instability require transfusion before treatment.

If acute hemorrhage occurs before or during surgical management, the procedure should be completed promptly and the benefit of oxytocic infusion considered against the risk of embolization and dissemination of trophoblastic tissue through the venous system.[34]​ The use of oxytocic agents or methylergonovine will control bleeding after surgical management in most women.[34]​ Prostaglandins can be considered, if acute bleeding during or after evacuation is encountered. 

Rarely, women will require a second suction evacuation to control symptomatic hemorrhage after the initial molar evacuation.[34]

In women with an established diagnosis of postmolar GTN, chemotherapy will usually control bleeding.

Very rarely, women with normal hCG levels develop delayed bleeding after molar evacuation.

Pelvic-transvaginal Doppler ultrasound or contrast magnetic resonance imaging studies of the uterus may be helpful to exclude postmolar uterine arteriovenous malformation.

Depot medroxyprogesterone and tranexamic acid, selective embolization, myometrial wedge resection and repair, or hysterectomy may be required.[55]

Primary options

oxytocin: 10 units intramuscularly as a single dose; or 10-40 units by intravenous infusion at a rate to control uterine atony

Secondary options

methylergonovine: 0.2 mg orally three to four times daily for up to 7 days; or 0.2 mg intramuscularly every 2-4 hours as required

Plus – beta-blocker ± methimazole

Back
ACUTE
|
singleton molar pregnancy: desiring fertility
|
with thyrotoxicity
Plus – 

beta-blocker ± methimazole

Treatment recommended for ALL patients in selected patient group

Thyrotoxicosis in molar pregnancy is typically self-limited and best treated with supportive care.

Beta-blockers should be given with the induction of anesthesia at the time of surgical management, if the woman is clinically hyperthyroid. Methimazole can be added, if a faster clinical response is needed or there is a thyrotoxic storm.[48]

Primary options

propranolol hydrochloride: 60-80 mg orally (immediate-release) every 4-6 hours

OR

propranolol hydrochloride: 60-80 mg orally (immediate-release) every 4-6 hours

and

methimazole: 5-20 mg orally every 8 hours initially until patient becomes euthyroid, followed by 5-15 mg once daily

Plus – antihypertensives

Back
ACUTE
|
singleton molar pregnancy: desiring fertility
|
with preeclampsia
Plus – 

antihypertensives

Treatment recommended for ALL patients in selected patient group

Antihypertensive 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).[56][57]

Primary options

labetalol: 100 mg orally twice daily initially, increase gradually according to response, usual dose 100-400 mg twice daily, maximum 2400 mg/day

OR

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90-120 mg/day (depending on brand)

OR

methyldopa: 250 mg orally two to three times daily initially, increase gradually according to response, usual dose 250-1000 mg/day given in 2-4 divided doses, maximum 3000 mg/day

Consider – magnesium sulfate

Back
ACUTE
|
singleton molar pregnancy: desiring fertility
|
with preeclampsia
Consider – 

magnesium sulfate

Treatment recommended for SOME patients in selected patient group

In the US, magnesium sulfate is recommended for all women with severe preeclampsia.[56]​ 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).[57] Seizures reflect progression to eclampsia, and are both treated and prevented with magnesium sulfate. The Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (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, hypercalcemia, and hypermagnesemia in the neonate.[58][59] Despite the recommendation, magnesium sulfate is usually only used for 24-48 hours in clinical practice.

Primary options

magnesium sulfate: consult specialist for guidance on dose

More

Plus – management of cyst

Back
ACUTE
|
singleton molar pregnancy: desiring fertility
|
with theca lutein cyst
Plus – 

management of cyst

Treatment recommended for ALL patients in selected patient group

Theca lutein cysts result from hCG stimulation of the ovaries and may present with pelvic or abdominal masses, pain, or ovarian torsion. 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.[47]

singleton molar pregnancy: not desiring fertility

1st line – hysterectomy

Back
ACUTE
|
singleton molar pregnancy: not desiring fertility
1st line – 

hysterectomy

Hysterectomy may be more desirable for the management of molar pregnancy than suction evacuation in women who have completed childbearing.[54] It is associated with an increased risk of postoperative complications compared with suction evacuation, but a decreased risk of postoperative GTN.​[54] Women undergoing hysterectomy for the management of molar pregnancy should also be monitored postoperatively with the measurement of serial hCG levels.

Plus – supportive care

Back
ACUTE
|
singleton molar pregnancy: not desiring fertility
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Women with unevacuated hydatidiform moles generally require stabilization of associated comorbidities (e.g., respiratory distress, preeclampsia/eclampsia, hyperthyroidism, or severe anemia) before definitive treatment.

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

Sequential compression hose, as a single modality, is considered adequate for venous thromboembolism prophylaxis.

High-output cardiac failure may be secondary to hyperthyroidism or thyroid storm, severe preeclampsia, gestational hypertension, pulmonary edema, and, less commonly, anemia.[47]​ 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 minimize barotrauma, and central hemodynamic monitoring.

Plus – fluid replacement plus antiemetic and/or H2 antagonist

Back
ACUTE
|
singleton molar pregnancy: not desiring fertility
|
with hyperemesis gravidarum
Plus – 

fluid replacement plus antiemetic and/or H2 antagonist

Treatment recommended for ALL patients in selected patient group

The objectives of managing a woman with molar pregnancy complicated by hyperemesis revolve around symptomatic control of emesis with an antiemetic and/or an H2 antagonist and intravenous hydration with electrolyte replacement, while moving toward prompt removal of the hydatidiform mole. Hyperemesis associated with a MP 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]

Primary options

metoclopramide: 5-10 mg intravenously/intramuscularly every 8 hours when required

OR

prochlorperazine rectal: 25 mg twice daily when required

Secondary options

ondansetron: 4 mg intravenously/orally every 8 hours when required

OR

famotidine: 20 mg intravenously every 12 hours

Plus – blood products and cessation of blood loss

Back
ACUTE
|
singleton molar pregnancy: not desiring fertility
|
with active bleeding
Plus – 

blood products and cessation of blood loss

Treatment recommended for ALL patients in selected patient group

Women with severe anemia or hemodynamic instability require transfusion before treatment.

If acute hemorrhage occurs before or during surgical management, the procedure should be completed promptly and the benefit of oxytocic infusion considered against the risk of embolization and dissemination of trophoblastic tissue through the venous system.[34]​ The use of oxytocic agents or methylergonovine will control bleeding after surgical management in most women.[34]

Primary options

oxytocin: 10 units intramuscularly as a single dose; or 10-40 units by intravenous infusion at a rate to control uterine atony

Secondary options

methylergonovine: 0.2 mg orally three to four times daily for up to 7 days; or 0.2 mg intramuscularly every 2-4 hours as required

Plus – beta-blocker ± methimazole

Back
ACUTE
|
singleton molar pregnancy: not desiring fertility
|
with thyrotoxicity
Plus – 

beta-blocker ± methimazole

Treatment recommended for ALL patients in selected patient group

Thyrotoxicosis in molar pregnancy is typically self-limited and best treated with supportive care.

Beta-blockers should be given with the induction of anesthesia at the time of surgerical management, if the woman is clinically hyperthyroid. Methimazole can be added, if a faster clinical response is needed or there is a thyrotoxic storm.[48]

Primary options

propranolol hydrochloride: 60-80 mg orally (immediate-release) every 4-6 hours

OR

propranolol hydrochloride: 60-80 mg orally (immediate-release) every 4-6 hours

and

methimazole: 5-20 mg orally every 8 hours initially until patient becomes euthyroid, followed by 5-15 mg once daily

Plus – antihypertensives

Back
ACUTE
|
singleton molar pregnancy: not desiring fertility
|
with preeclampsia
Plus – 

antihypertensives

Treatment recommended for ALL patients in selected patient group

Antihypertensive 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).[56][57]

Primary options

labetalol: 100 mg orally twice daily initially, increase gradually according to response, usual dose 100-400 mg twice daily, maximum 2400 mg/day

OR

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90-120 mg/day (depending on brand)

OR

methyldopa: 250 mg orally two to three times daily initially, increase gradually according to response, usual dose 250-1000 mg/day given in 2-4 divided doses, maximum 3000 mg/day

Consider – magnesium sulfate

Back
ACUTE
|
singleton molar pregnancy: not desiring fertility
|
with preeclampsia
Consider – 

magnesium sulfate

Treatment recommended for SOME patients in selected patient group

In the US, magnesium sulfate is recommended for all women with severe preeclampsia.[56]​ 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).[57] Seizures reflect progression to eclampsia, and are both treated and prevented with magnesium sulfate. The Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (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, hypercalcemia, and hypermagnesemia in the neonate.[58][59] Despite the recommendation, magnesium sulfate is usually only used for 24-48 hours in clinical practice.

Primary options

magnesium sulfate: consult specialist for guidance on dose

More

Plus – management of cyst

Back
ACUTE
|
singleton molar pregnancy: not desiring fertility
|
with theca lutein cyst
Plus – 

management of cyst

Treatment recommended for ALL patients in selected patient group

Theca lutein cysts result from hCG stimulation of the ovaries and may present with pelvic or abdominal masses, pain, or ovarian torsion. 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.[47]

viable twin fetus: elective termination not desired

1st line – expectant management

Back
ACUTE
|
viable twin fetus: elective termination not desired
1st line – 

expectant management

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 preeclampsia, hyperthyroidism, or acute respiratory distress), or term.[34] Conservative management is not recommended in the presence of choriocarcinoma or fetal aneuploidy.[4]​ Postpartum, the placenta should be sent for evaluation by a pathologist experienced in the evaluation of GTD, and routine postmolar surveillance should be initiated.[34] Importantly with careful medical monitoring about 60% achieve viable live births.[60] 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.[60]

Plus – fluid replacement plus antiemetic and/or H2 antagonist

Back
ACUTE
|
viable twin fetus: elective termination not desired
|
with hyperemesis gravidarum
Plus – 

fluid replacement plus antiemetic and/or H2 antagonist

Treatment recommended for ALL patients in selected patient group

The objectives of managing a woman with molar pregnancy complicated by hyperemesis revolve around symptomatic control of emesis with an antiemetic and/or an H2 antagonist and intravenous hydration with electrolyte replacement, while moving toward 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]

The UK Teratology Information Service recommends that ondansetron should be reserved as a second-line agent when first-line agents have failed. This is due to the small increased risk of orofacial clefts noted in one study when ondansetron was taken during the first trimester.​​​​​[62][63]​ The UK Medicines and Healthcare products Regulatory Agency also issued a drug safety update for ondansetron that provides similar advice.​[64]

Primary options

metoclopramide: 5-10 mg intravenously/intramuscularly every 8 hours when required

OR

prochlorperazine rectal: 25 mg twice daily when required

Secondary options

ondansetron: 4 mg intravenously/orally every 8 hours when required

OR

famotidine: 20 mg intravenously every 12 hours

Plus – blood products and cessation of bleeding

Back
ACUTE
|
viable twin fetus: elective termination not desired
|
with active bleeding
Plus – 

blood products and cessation of bleeding

Treatment recommended for ALL patients in selected patient group

Women with severe anemia or hemodynamic instability require transfusion before treatment.

If acute hemorrhage occurs before or during surgical management, the procedure should be completed promptly and the benefit of oxytocic infusion considered against the risk of embolization and dissemination of trophoblastic tissue through the venous system.[34] The use of oxytocic agents or methylergonovine will control bleeding after surgical management in most women.[34] Prostaglandins can be considered, if acute bleeding during or after evacuation is encountered.

Rarely, women will require a second suction evacuation to control symptomatic hemorrhage after initial molar evacuation.[34]

In women with an established diagnosis of postmolar GTN, chemotherapy will usually control bleeding. Very rarely, women with normal hCG levels develop delayed bleeding after molar evacuation. Pelvic-transvaginal Doppler ultrasound or contrast magnetic resonance imaging studies of the uterus may be helpful to exclude postmolar uterine arteriovenous malformation.

Depot medroxyprogesterone and tranexamic acid, selective embolization, myometrial wedge resection and repair, or hysterectomy may be required.[55]

Primary options

oxytocin: 10 units intramuscularly as a single dose; or 10-40 units by intravenous infusion at a rate to control uterine atony

Secondary options

methylergonovine: 0.2 mg orally three to four times daily for up to 7 days; or 0.2 mg intramuscularly every 2-4 hours as required

Plus – beta-blocker ± methimazole

Back
ACUTE
|
viable twin fetus: elective termination not desired
|
with thyrotoxicity
Plus – 

beta-blocker ± methimazole

Treatment recommended for ALL patients in selected patient group

Thyrotoxicosis in molar pregnancy is typically self-limited and best treated with supportive care.

Beta-blockers should be given with the induction of anesthesia at the time of surgical management, if the woman is clinically hyperthyroid. Methimazole can be added, if a faster clinical response is needed or there is a thyrotoxic storm.[48]

Primary options

propranolol hydrochloride: 60-80 mg orally (immediate-release) every 4-6 hours

OR

propranolol hydrochloride: 60-80 mg orally (immediate-release) every 4-6 hours

and

methimazole: 5-20 mg orally every 8 hours initially until patient becomes euthyroid, followed by 5-15 mg once daily

Plus – antihypertensives

Back
ACUTE
|
viable twin fetus: elective termination not desired
|
with preeclampsia
Plus – 

antihypertensives

Treatment recommended for ALL patients in selected patient group

Antihypertensive 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).[56][57]

Primary options

labetalol: 100 mg orally twice daily initially, increase gradually according to response, usual dose 100-400 mg twice daily, maximum 2400 mg/day

OR

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90-120 mg/day (depending on brand)

OR

methyldopa: 250 mg orally two to three times daily initially, increase gradually according to response, usual dose 250-1000 mg/day given in 2-4 divided doses, maximum 3000 mg/day

Consider – magnesium sulfate

Back
ACUTE
|
viable twin fetus: elective termination not desired
|
with preeclampsia
Consider – 

magnesium sulfate

Treatment recommended for SOME patients in selected patient group

In the US, magnesium sulfate is recommended for all women with severe preeclampsia.[56] 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).[57] Seizures reflect progression to eclampsia, and are both treated and prevented with magnesium sulfate. The Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (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, hypercalcemia, and hypermagnesemia in the neonate.[58][59] Despite the recommendation, magnesium sulfate is usually only used for 24-48 hours in clinical practice.

Primary options

magnesium sulfate: consult specialist for guidance on dose

More

Plus – management of cyst

Back
ACUTE
|
viable twin fetus: elective termination not desired
|
with theca lutein cyst
Plus – 

management of cyst

Treatment recommended for ALL patients in selected patient group

Theca lutein cysts result from hCG stimulation of the ovaries and may present with pelvic or abdominal masses, pain, or ovarian torsion. 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.[47]

viable twin fetus: elective termination

1st line – suction evacuation

Back
ACUTE
|
viable twin fetus: elective termination
1st line – 

suction evacuation

General anesthesia is achieved, and beta-blockade given, if the woman is clinically hyperthyroid.[48] 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.[50]

Plus – supportive care

Back
ACUTE
|
viable twin fetus: elective termination
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Women with unevacuated hydatidiform moles generally require stabilization of associated comorbidities (e.g., respiratory distress, preeclampsia/eclampsia, hyperthyroidism, or severe anemia) before definitive treatment.

Using a large-bore intravenous catheter is appropriate in women with uterine enlargement >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 labor 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 hose, as a single modality, is considered adequate for venous thromboembolism prophylaxis.

High-output cardiac failure may be secondary to hyperthyroidism or thyroid storm, severe preeclampsia, gestational hypertension, pulmonary edema, and, less commonly, anemia.[47]​ 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 minimize barotrauma, and central hemodynamic monitoring.

Plus – fluid replacement plus antiemetic and/or H2 antagonist

Back
ACUTE
|
viable twin fetus: elective termination
|
with hyperemesis gravidarum
Plus – 

fluid replacement plus antiemetic and/or H2 antagonist

Treatment recommended for ALL patients in selected patient group

The objectives of managing a woman with molar pregnancy complicated by hyperemesis revolve around symptomatic control of emesis with an antiemetic and/or an H2 antagonist and intravenous hydration with electrolyte replacement, while moving toward 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]

Primary options

metoclopramide: 5-10 mg intravenously/intramuscularly every 8 hours when required

OR

prochlorperazine rectal: 25 mg twice daily when required

Secondary options

ondansetron: 4 mg intravenously/orally every 8 hours when required

OR

famotidine: 20 mg intravenously every 12 hours

Plus – blood products and cessation of bleeding

Back
ACUTE
|
viable twin fetus: elective termination
|
with active bleeding
Plus – 

blood products and cessation of bleeding

Treatment recommended for ALL patients in selected patient group

Women with severe anemia or hemodynamic instability require transfusion before treatment.

If acute hemorrhage occurs before or during surgical management, the procedure should be completed promptly and the benefit of oxytocic infusion considered against the risk of embolization and dissemination of trophoblastic tissue through the venous system.[34]​ The use of oxytocic agents or methylergonovine will control bleeding after surgical management in most women.[34]​ Prostaglandins can be considered, if acute bleeding during or after evacuation is encountered.

Rarely, women will require a second suction evacuation to control symptomatic hemorrhage after the initial molar evacuation.[34]

In women with an established diagnosis of postmolar GTN, chemotherapy will usually control bleeding.

Very rarely, women with normal hCG levels develop delayed bleeding after molar evacuation.

Pelvic-transvaginal Doppler ultrasound or contrast magnetic resonance imaging studies of the uterus may be helpful to exclude postmolar uterine arteriovenous malformation.

Depot medroxyprogesterone and tranexamic acid, selective embolization, myometrial wedge resection and repair, or hysterectomy may be required.[55]

Primary options

oxytocin: 10 units intramuscularly as a single dose; or 10-40 units by intravenous infusion at a rate to control uterine atony

Secondary options

methylergonovine: 0.2 mg orally three to four times daily for up to 7 days; or 0.2 mg intramuscularly every 2-4 hours as required

Plus – beta-blocker ± methimazole

Back
ACUTE
|
viable twin fetus: elective termination
|
with thyrotoxicity
Plus – 

beta-blocker ± methimazole

Treatment recommended for ALL patients in selected patient group

Thyrotoxicosis in molar pregnancy is typically self-limited and best treated with supportive care.

Beta-blockers should be given with the induction of anesthesia at the time of surgical management, if the woman is clinically hyperthyroid. Methimazole can be added, if a faster clinical response is needed or there is a thyrotoxic storm.[48]

Primary options

propranolol hydrochloride: 60-80 mg orally (immediate-release) every 4-6 hours

OR

propranolol hydrochloride: 60-80 mg orally (immediate-release) every 4-6 hours

and

methimazole: 5-20 mg orally every 8 hours initially until patient becomes euthyroid, followed by 5-15 mg once daily

Plus – antihypertensives

Back
ACUTE
|
viable twin fetus: elective termination
|
with preeclampsia
Plus – 

antihypertensives

Treatment recommended for ALL patients in selected patient group

Antihypertensive 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).[56][57]

Primary options

labetalol: 100 mg orally twice daily initially, increase gradually according to response, usual dose 100-400 mg twice daily, maximum 2400 mg/day

OR

nifedipine: 30-60 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 90-120 mg/day (depending on brand)

OR

methyldopa: 250 mg orally two to three times daily initially, increase gradually according to response, usual dose 250-1000 mg/day given in 2-4 divided doses, maximum 3000 mg/day

Consider – magnesium sulfate

Back
ACUTE
|
viable twin fetus: elective termination
|
with preeclampsia
Consider – 

magnesium sulfate

Treatment recommended for SOME patients in selected patient group

In the US, magnesium sulfate is recommended for all women with severe preeclampsia.[56] 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).[57]​ Seizures reflect progression to eclampsia, and are both treated and prevented with magnesium sulfate. The Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (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, hypercalcemia, and hypermagnesemia in the neonate.[58][59]​ Despite the recommendation, magnesium sulfate is usually only used for 24-48 hours in clinical practice.

Primary options

magnesium sulfate: consult specialist for guidance on dose

More

Plus – management of cyst

Back
ACUTE
|
viable twin fetus: elective termination
|
with theca lutein cyst
Plus – 

management of cyst

Treatment recommended for ALL patients in selected patient group

Theca lutein cysts result from hCG stimulation of the ovaries and may present with pelvic or abdominal masses, pain, or ovarian torsion. 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.[47]

ONGOING

following initial management: high risk of gestational trophoblastic neoplasia with completed follow up unlikely

1st line – prophylactic chemotherapy

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ONGOING
|
following initial management: high risk of gestational trophoblastic neoplasia with completed follow up unlikely
1st line – 

prophylactic chemotherapy

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 postmolar 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][61]​​

Primary options

methotrexate: consult local specialist protocol for dosing guidelines

OR

dactinomycin: consult local specialist protocol for dosing guidelines

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