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Gestational trophoblastic disease

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of gestational trophoblastic disease are prepared by our editorial team based on guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG 2021), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2021), the American College of Radiology (ACR 2019), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists ...
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Screening and diagnosis

Clinical presentation
As per RCOG 2021 guidelines:
Recognize the clinical presentation of molar pregnancy:
Situation
Guidance
Most commonly
Irregular vaginal bleeding
Positive pregnancy test
Supporting ultrasound evidence
B
Less common
Hyperemesis
Excessive uterine enlargement
Hyperthyroidism
Early-onset preeclampsia
Abdominal distension due to theca lutein cysts
E
Very rare
Dyspnea and hemoptysis due to pulmonary metastasis
New-onset seizures or paralysis due to brain metastasis
B
Recognize that any patient developing persistent vaginal bleeding after a pregnancy is at risk of having GTD.
B
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Classification and risk stratification

Prognosis
As per RCOG 2021 guidelines:
Recognize that:
the outlook for patients treated for gestational trophoblastic neoplasia is generally excellent with an overall cure rate close to 100%
further pregnancies are achieved in approximately 80% of patients following treatment for gestational trophoblastic neoplasia with either methotrexate alone or multi-agent chemotherapy
there is an increased risk of premature menopause in patients treated with combination agent chemotherapy
B
Warn patients, especially if approaching the age of 40 years, of the potential negative impact of combination agent chemotherapy on fertility, particularly with high-dose chemotherapy.
B

Diagnostic investigations

Pregnancy testing
As per RCOG 2021 guidelines:
Advise patients to do a urinary pregnancy test 3 weeks after a miscarriage or medical abortion.
E
Obtain urine hCG in all patients with persistent or irregular vaginal bleeding lasting > 8 weeks after pregnancy.
E

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  • Serum hCG levels

  • Diagnostic imaging

Diagnostic procedures

Histopathology: as per RCOG 2021 guidelines, perform histological examination for definitive diagnosis of molar pregnancy.
B
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  • Prenatal karyotyping

Medical management

Setting of care: as per RCOG 2021 guidelines, consider referring all patients with persistently elevated human chorionic gonadotrophin either after an ectopic pregnancy has been excluded, or after two consecutive treatments with methotrexate for a pregnancy of unknown location to a GTD center.
E
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  • Chemotherapy

  • Anti-D immunoglobulin

Surgical interventions

Uterine curettage and hysterectomy, indications: as per RCOG 2021 guidelines, consider performing suction curettage as the method of choice for removal of complete molar pregnancies.
E
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More topics in this section

  • Uterine curettage and hysterectomy (technical considerations)

  • Repeated surgery

Specific circumstances

Patients with ectopic pregnancy
As per RCOG 2021 guidelines:
Manage patients with ectopic pregnancy suspected to be molar in nature as any other case of ectopic pregnancy.
E
Send a tissue specimen to a center with appropriate expertise for pathological review, if there is a local tissue diagnosis of ectopic molar pregnancy.
E

Patient education

General counseling
As per RCOG 2021 guidelines:
Counsel patients with a twin pregnancy where there is one viable fetus and the other pregnancy is molar about the potential increased risk of perinatal morbidity and the outcome for gestational trophoblastic neoplasia.
B
Warn patients, especially if approaching the age of 40 years, of the potential negative impact of combination agent chemotherapy on fertility, particularly with high-dose chemotherapy.
B

Follow-up and surveillance

Serial hCG monitoring: as per RCOG 2021 guidelines, follow-up patients with complete molar pregnancy for 6 months from the date of uterine removal, if hCG has reverted to normal within 56 days of the pregnancy.
B
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More topics in this section

  • Contraception

  • Post-treatment hormone therapy

  • Subsequent pregnancy