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  7. Gestational Trophoblastic Disease, (Molar Pregnancy) (423)
Important: please update your RDS app to version 4.7.3

Welcome to the March 2025 update from the RDS team

1.     RDS issues - resolutions

1.1 Stability issues - Tactuum implemented a fix on 24th March which we believe has finally addressed the stability issues experienced over recent weeks.  The issue seems to have been related to the new “Tool export” function making repeated calls for content when new toolkit nodes were opened in Umbraco. No outages have been reported since then, and no performance issues in the logs, so fingers crossed this is now resolved.

1.2 Toolkit URL redirects failing– these were restored manually for the antimicrobial calculators on the 13th March when the issue occurred, and by 15th March for the remainder. The root cause was traced to adding a new hostname for an app migrated from another health board and made live that day. This led to the content management system automatically creating internal duplicate redirects, reaching the maximum number of permitted redirects and most redirects therefore ceasing to function.

This issue should not happen again because:

  • All old apps are now fully migrated to RDS. The large number of migrations has contributed to the high number of automated redirects.
  • If there is any need to change hostnames in future, Tactuum will immediately check for duplicates.

1.3 Gentamicin calculators – Incidents have been reported incidents of people accessing the wrong gentamicin calculator for their health board.  This occurs when clinicians are searching for the gentamicin calculator via an online search engine - e.g. Google - rather than via the health board directed policy route. When accessed via an external search engine, the calculator results are not listed by health board, and the start page for the calculator does not make it clearly visible which health board calculator has been selected.

The Scottish Antimicrobial Prescribing Group has asked health boards to provide targeted communication and education to ensure that clinicians know how to access their health board antimicrobial calculators via the RDS, local Intranet or other local policy route. In terms of RDS amendments, it is not currently possible to change the internet search output, so the following changes are now in progress:

  • The health board name will now be displayed within the calculator and it will be made clear which boards are using the ‘Hartford’ (7mg/kg) higher dose calculator
  • Warning text will be added to the calculator to advise that more than one calculator is in use in NHS Scotland and that clinicians should ensure they access the correct one for their health board. A link to the Right Decision Service list of health board antimicrobial prescribing toolkits will be included with the warning text. Users can then access the correct calculator for their Board via the appropriate toolkit.

We would encourage all editors and users to use the Help and Support standard operating procedure and the Editors’ Teams channel to highlight issues, even if you think they may be temporary or already noted. This helps the RDS team to get a full picture of concerns and issues across the service.

 

2.     New RDS presentation – RDS supporting the patient journey

A new presentation illustrating how RDS supports all partners in the patient journey – multiple disciplines across secondary, primary, community and social care settings – as well as patients and carers through self-management and shared decision-making tools – is now available. You will find it in the Promotion and presentation resources for editors section of the Learning and support toolkit.

3.     User guides

A new user guide is now available in the Guidance and tips section of Resources for providers within the Learning and Support area, explaining how to embed content from Google Calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream and Jotforms into RDS pages. A webinar for editors on using this new functionality is scheduled for 1 May 3-4 pm (booking information below.)

A new checklist to support editors in making all the checks required before making a new toolkit live is now available at the foot of the “Request a new toolkit” standard operating procedure. Completing this checklist is not a mandatory part of the governance process, but we would encourage you to use it to make sure all the critical issues are covered at point of launch – including organisational tags, use of Alias URLs and editorial information.

4.Training sessions for RDS editors

Introductory webinars for RDS editors will take place on:

  • Tuesday 29th April 4-5 pm
  • Thursday 1st May 4-5 pm

Special webinar for RDS editors – 1 May 3-4 pm

This webinar will cover:

  1. a) Use of the new left hand navigation option for RDS toolkits.
  2. b) Integration into RDS pages of content from external sources, including Google Calendar, Google Maps and simple Jotforms calculators.

Running usage statistics reports using Google analytics

  • Wednesday 23rd April 2pm-3pm
  • Thursday 22nd May 2pm-3pm

To book a place on any of these webinars, please contact Olivia.graham@nhs.scot providing your name, role, organisation, title and date of the webinar you wish to attend.

5.New RDS toolkits

The following toolkits were launched during March 2025:

SIGN guideline - Prevention and remission of type 2 diabetes

Valproate – easy read version for people with learning disabilities (Scottish Government Medicines Division)

Obstetrics and gynaecology induction toolkit (NHS Lothian) – password-protected, in pilot stage.

Oral care for care home and care at home services (Public Health Scotland)

Postural care in care homes (NHS Lothian)

Quit Your Way Pregnancy Service (NHS GGC)

 

6.New RDS developments

Release of the redesign of RDS search and browse, archiving and version control functionality, and editing capability for shared content, is now provisionally scheduled for early June.

The Scottish Government Realistic Medicine Policy team is leading development of a national approach to implementation of Patient-Reported Outcome Measures (PROMs) as a key objective within the Value Based Health and Care Action Plan. The Right Decision Service has been commissioned to deliver an initial version of a platform for issuing PROMs questionnaires to patients, making the PROMs reports available from patient record systems, and providing an analytics dashboard to compare outcomes across services.  This work is now underway and we will keep you updated on progress.

The RDS team has supported Scottish Government Effective Prescribing and Therapeutics Division, in partnership with Northern Ireland and Republic of Ireland, in a successful bid for EU funding to test develop, implement and assess new integrated care pathways for polypharmacy, including pharmacogenomics. As part of this project, the RDS will be working with NHS Tayside to test extending the current polypharmacy RDS decision support in the Vision primary care electronic health record system to include pharmacogenomics decision support.

7. Implementation projects

We have just completed a series of three workshops consulting on proposed improvements to the Being a partner in my care: Realistic Medicine together app, following piloting on 10 sites in late 2024. This app has been commissioned by Scottish Government Realistic Medicine to support patients and citizens to become active partners in shared decision-making and encouraging personalised care based on outcomes that matter to the person. We are keen to gather more feedback on this app. Please forward any feedback to ann.wales3@nhs.scot

 

 

Gestational Trophoblastic Disease, (Molar Pregnancy) (423)

Objectives

This guideline is designed for use within the Early Pregnancy Assessment Service across GGC. The objective is to provide safe management for women with an actual or suspected diagnosis of molar pregnancy. For the purposes of this guideline Molar pregnancy in the first instance refers to pre-malignant molar pregnancies. Malignant pathology may develop later.

Please report any inaccuracies or issues with this guideline using our online form

  • 3:1000 Partial Molar (PHM)
  • 1-3:1000 Complete Molar (CHM)
  • There is a slightly increased risk of molar pregnancy in the very young (<16 years 1.5 x higher incidence) and a significant increase with advanced maternal age (>45 20-50 x higher incidence).
  • The risk of mole is increased by 1-2% following one molar pregnancy and by 15-20% after 2.
  • The risk is not decreased by a change of partner.

Malignant (invasive mole/choriocarcinoma/placental site trophoblastic tumours)

  • The frequency of choriocarcinoma or placental-site trophoblastic tumour is less well known, since these diseases can arise after any type of pregnancy. If suspected, this would require urgent assessment and discussion with Regional Centre.

Please refer to Charing Cross Hospital, Information for Clinicians – https://hmole-chorio.org.uk/info-for-clinicians/

There are often no signs that a pregnancy is a molar pregnancy. In women with a positive pregnancy test some signs and symptoms in the first or second trimester that may be indicative include -

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

Rarer presentations –

  • 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.

  • Complete molar pregnancy may show a mass of cells, cystic/orange peel effect/snowstorm effect, without the presence of a foetus
  • Partial molar pregnancy may show an abnormal non-viable foetus and placenta
  • The lack of sonographic molar features does not exclude the possibility of either CHM or PHM.
  • Whenever possible, products of conception from non-viable pregnancies must undergo histological examination to achieve a correct diagnosis regardless of ultrasound findings

Molar evacuation

Suction evacuation is recommended for complete and partial molar pregnancies.

  • Counsel and provide written information
  • Pre-op check FBC, U&E, LFT, TFT’s, G&S and cross match x2units.
  • Inform consultant on-call for gynaecology
  • Arrange surgical evacuation of uterus on a gynaecology list with consultant
  • If >12 weeks(CRL 65mm), discuss management with consultant
  • Molar pregnancy can be associated with excessive bleeding and a consultant should be present throughout the procedure
  • Preparation of the cervix with misoprostol prior to evacuation is thought to be safe.
  • Prolonged use of cervical preparation should be avoided to reduce the risk of embolization of trophoblastic cells.
  • Oxytocin infusion is not recommended prior to completion of the evacuation due to the potential to embolise and disseminate trophoblastic tissue into the venous system. Following completion, if there is ongoing bleeding, consider single dose oxytocin and then follow usual PPH management.
  • All Rh negative women with molar pregnancies (partial or complete) should receive Anti D after evacuation of the uterus.

Combined Molar/Viable pregnancy

Refer to fetal medicine specialist unit

All women who have had a molar pregnancy enter the surveillance programme.

  • Tissue must be sent to histopathology. Any suspicious tissue will be sent to the Regional Centre in Dundee for confirmation. See contact details below.
  • Request an urgent report
  • Prior to registration patient needs to be forewarned that there is a possibility that she may have a molar pregnancy. This can be done for all losses at time of obtaining SD7’s.
  • Early registration of a confirmed molar pregnancy should take place and the Named Consultant (i.e. the operating consultant) is responsible for this
  • Time taken from surgical evacuation for a definitive diagnosis may be 4 – 5 weeks, but may take longer if extra tests are required

Registration

https://hmole-chorio.org.uk/info-for-clinicians/clinicians_info_registration/

All follow up of molar pregnancies will be determined by the Regional Molar Centre on confirmation of diagnosis.

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.

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.

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

  • Advise patients that they may have vaginal bleeding for a few weeks postsurgery which should be no heavier than monthly menstruation and should gradually lessen within this time-frame
  • Provide patients with a 24 hour contact number (gynaecology) for worsening symptoms or to attend ED as an emergency if symptoms of heavy vaginal bleeding or severe pain.
  • Practical advice to reduce the chances of bleeding should be given –
    • Avoid sexual intercourse until bleeding has settled
    • Oral contraceptives containing oestrogen and/or progesterone 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 post op. However it can be used once the urine or serum hCG has normalised.

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

Patient information, Charing Cross Hospital (CXH) Trophoblast Disease Service website

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

Editorial Information

Last reviewed: 01/01/2021

Next review date: 31/01/2026

Author(s): Jane Scott.

Approved By: Gynaecology Clinical Governance Group

Document Id: 423