Gestational Trophoblastic Disease, (Molar Pregnancy) (423)

There are often no clinical signs of a molar pregnancy. In women with a positive pregnancy test some signs and symptoms in the first or second trimester include:

• Irregular vaginal bleeding
• Abdominal pain
• Hyperemesis
• Uterus greater than gravid date
• Early fetal demise
• Abnormal USS findings

Rarer presentations of GTD include:

• Anaemia
• Excessive uterine enlargement
• Pre-eclampsia
• Hyperemesis
• Hyperthyroidism
• Respiratory distress

Molar pregnancy may only be suspected/diagnosed at ultrasound examination at 8-14 weeks or found during histological tests carried out after miscarriage.

USS Findings

• Complete molar pregnancy (CHM) may show a mass of cells, cystic/orange peel effect/snowstorm effect, without the presence of a fetus
• Partial molar pregnancy (PHM) may show an abnormal non-viable fetus and placenta
• The lack of sonographic molar features does not exclude the possibility of either CHM or PHM.

Histology

• Whenever possible, products of conception from non-continuing pregnancies must undergo histological examination to achieve a correct diagnosis regardless of ultrasound findings

Inpatient suction evacuation is recommended for complete and partial molar pregnancies.  The consultant on-call for gynaecology should be informed if a molar pregnancy is suspected due to the risk of bleeding.

Pre op counselling and paperwork

• Counsel and provide written information (see patient information section)
• Ensure copies of Form 2 are complete (Form 2: Authorisation for burial or cremation following pregnancy loss up to 23 weeks and 6 days gestation | Right Decisions (scot.nhs.uk))
• Complete standardised GG&C consent form, Surgical management of miscarriage or retained products of conception. (353955_5_0-sevac-smm-consent-form_s.pdf (SECURED) (scot.nhs.uk))
• All patients undergoing surgical evacuation for non-continuing pregnancy should be counselled on the risks of possible molar pregnancy and the need for further follow up
• Pre-operatively check FBC, U&E, LFT, TFT’s, G&S and cross match x2units packed red cells
• Arrange inpatient surgical evacuation of uterus on a gynaecology list with consultant on call via CEPOD theatre co-ordinator and anaesthetist
• If >12 weeks(CRL 65mm), discuss management options with consultant

Intraoperative considerations

• Molar pregnancy can be associated with excessive bleeding and a consultant should be present throughout the procedure in theatre.
• Consider the use of intra-operative ultrasound during the procedure.
• Preparation of the cervix with either sublingual or vaginal misoprostol immediately prior to evacuation is thought to be safe. (Misoprostol for cervical priming prior to surgical management of 1st trimester miscarriage up to and including 13+0 weeks gestation (1011) | Right Decisions (scot.nhs.uk))
• If bleeding following misoprostol priming occurs, surgical evacuation of the uterus should be expedited.
• Following completion of the procedure, if there is ongoing bleeding, consider administration of Tranexamic Acid 1g IV +/- oxytocin 5iu IV as one single dose.
• Oxytocin infusion is not recommended prior to completion of the evacuation due to the potential for trophoblastic tissue to embolise and disseminate into the venous system.
• There is concern regarding the use of ergometrine and prostaglandins in the management of bleeding following GTD or suspected GTD due to the risk of tissue embolisation, and these should be avoided [1].
• PPH management with non-uterotonic methods e.g. intrauterine balloons, interventional radiology can be considered.

Postoperative considerations and Histology request

• All Rhesus negative women with molar pregnancies (partial or complete) should receive anti-D prophylaxis within 72 hours after evacuation of the uterus. Anti-D Immunoglobulin Administration Following Potentially Sensitising Events in D Negative Women (559) | Right Decisions
• All tissue from non-continuing pregnancies must be sent to histopathology for confirmation of products of conception and examination to assess for molar tissue. Where tissue is suspected to be from a molar pregnancy, this should be sent as an urgent specimen.
• Please ensure the correct Named Consultant (i.e the consultant on call) is used on Trackcare when requesting the test.

Combined Molar/Viable pregnancy

Refer to fetal medicine specialist unit for ongoing management.

All women who have had a molar pregnancy enter the surveillance programme (see link below)

• If the local histology lab deem the tissue to be suspicious of a molar pregnancy, they will alert Named Consultant via TrakCare results and tissue will be sent to the Regional Centre in Dundee for confirmation
• If the provisional local histopathology report is suspicious of molar pregnancy, the patient must be informed and registered with the Regional Centre in Dundee as soon as possible before final confirmation of pathology. This is to ensure patients get an early HCG sample collection within 56 days of surgical evacuation.
• The Named Consultant (i.e. consultant on call) is responsible for chasing these results via TrakCare results.
• Time taken from surgical evacuation for a definitive diagnosis may be 4 – 5 weeks, but may take longer if extra tests are required. Registration should not be delayed to allow for an early HCG sample collection within 56 days of surgical evacuation.

Please complete online registration form using the following link:

Registration – Charing Cross Gestational Trophoblast Disease Service

Or

complete this form EmailMoleRegFormJan2024Contrast.doc and email to: TAY.hmolescotland@nhs.scot

All follow up of molar pregnancies will be determined by the Dundee Regional Molar Centre on confirmation of diagnosis. All women should be registered as soon as possible so blood testing packs and information can be sent to the patient.

Generally the length of time for HCG to return to normal is less than 8 weeks. However some patients have an elevated but falling hCG level for up to 6 months. Such patients do not require any additional treatment.

If the hCG level normalises within 56 days from the date of evacuation, with a follow up confirmatory normal blood hCG 4 weeks later, the rate of persistent gestational trophoblastic disease is extremely low. Therefore, for women diagnosed with a complete mole with hCG normalisation within 56 days of the date of the evacuation, hCG monitoring for a 6 month period is no longer required. These women can be discharged from central follow up once their blood and a confirmatory hCG level is normal and try for a new pregnancy should they wish.

If this 56 day window is missed, the standard 6 month complete mole follow up period will have to be applied.

• Advise patients that they may have vaginal bleeding for a few weeks post-surgery which should be no heavier than monthly menstruation and should gradually lessen within this time-frame
• Provide patients with a 24 hour contact number (local gynaecology ward) for worsening symptoms or to attend local Accident and Emergency department if they experience symptoms of heavy vaginal bleeding or severe pain.
• Avoid sexual intercourse until bleeding has settled
• It is advised that a further pregnancy is deferred until the end of the follow-up period as a new pregnancy may mask evidence of relapse.

Contraceptive advice

Current advice can be found in the Faculty of sexual and reproductive health Guideline, ‘contraception after pregnancy’ contraception-after-pregnancy-guideline-oct2020.pdf (fsrh.org).  Discussion should be documented in patient notes.  Most methods of contraception are safe to use after treatment for GTD, with the exception of intrauterine contraception.

UKMEC recommendations for patient specific characteristics should also be considered.

• Progestogen only, combined hormonal contraception and barrier methods are suitable for use after the evacuation procedure and before the urine hCG result returns to normal.
• Do NOT use the LNG IUS hormone contraceptive coil immediately following evacuation. However it can be used once the urine or serum hCG has normalised.

HRT advice

Hormone replacement therapy may be used once hCG levels have returned to normal. (1)

In a subsequent pregnancy following a molar pregnancy, advice for management and testing is outlined below.  The risk of a further molar pregnancy is low (1%).

• 1 previous molar pregnancy not requiring chemotherapy - no follow up or hCG tracking required.
• Two or more previous molar pregnancies – require registration with Regional Centre, Ninewells Hospital Dundee for postnatal follow up.
• Chemotherapy treatment required for a previous molar pregnancy – require registration with Regional Centre, Ninewells Hospital Dundee for postnatal follow up

Charing Cross Hospital (CXH) Trophoblast Disease Service website

https://hmole-chorio.org.uk/patients_info/

Dundee Patient information leaflet

PROD_369484.pdf (scot.nhs.uk)

Miscarriage Association

Molar pregnancy - The Miscarriage Association

Regional Screening Centre for Scotland – Ninewells, Dundee

Hydatidiform Mole Follow-up (Scotland),
Ninewells Hospital and Medical School, Dundee, DD1 9SY.

Tel – 01382 632748
Fax – 01382 496255
Email – TAY.hmolescotland@nhs.scot

UK National Screening Centre – Charing Cross Hospital

Trophoblastic Tumour Screening and Treatment Centre
Department of Medical Oncology
Charing Cross Hospital
Fulham Palace Road
LONDON W6 8RF
UK

http://www.hmole-chorio.org.uk/index.html
Tel: 020 3311 1409
Fax: 020 3313 5577
Email: ichc.hmole@nhs.net