eMedicine Specialties > Obstetrics and Gynecology > Gynecologic Oncology

Hydatidiform Mole: Follow-up

Author: Lisa E Moore, MD, FACOG, Assistant Professor, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of New Mexico Health Sciences Center
Coauthor(s): Enrique Hernandez, MD, FACOG, FACS, Chairman, Department of Obstetrics and Gynecology, Director of Gynecologic Oncology, Abraham Roth Professor of Obstetrics, Gynecology and Reproductive Science, Professor of Pathology, Temple University Hospital, Temple University School of Medicine
Contributor Information and Disclosures

Updated: Sep 24, 2008

Follow-up

Further Outpatient Care

  • Serial quantitative serum beta-hCG levels should be determined.
    • Serum hCG levels are obtained weekly until the levels are within reference range for 3-4 weeks.
    • Levels should consistently drop and should never increase. Normal levels are usually reached within 8-12 weeks after evacuation of the hydatidiform mole. As long as the hCG levels are falling intervention is not needed.
    • Once levels have reached the reference range for 3-4 weeks, check them monthly for 6 months.31,32,33
    • If the serum hCG levels plateau or rise, the patient is considered to have malignant disease (ie, gestational trophoblastic neoplasia) and metastatic disease needs to be excluded.
  • Effective contraception is recommended during the period of follow-up. To avoid uterine perforation and bleeding, if an intrauterine contraceptive device (IUD) is selected, insertion should await involution of the uterus and normalization of serum hCG levels.
  • After a hydatidiform mole, the risk of developing a second mole is 1.2-1.4%. The risk increases to 20% after 2 moles.34 Evaluate all future pregnancies early with ultrasonography.

Complications

  • Perforation of the uterus during suction curettage sometimes occurs because the uterus is large and boggy. If perforation is noted, the procedure should be completed under laparoscopic guidance.
  • Hemorrhage is a frequent complication during the evacuation of a molar pregnancy. For this reason, intravenous oxytocin should be started at the initiation of the suctioning. Methergine and/or Hemabate should also be available. Blood for possible transfusion should be readily available.
  • Malignant trophoblastic disease develops in 20% of molar pregnancies. For this reason, quantitative hCG should be serially monitored as described above.
  • Factors released by the molar tissue could trigger the coagulation cascade. Patients should be monitored for disseminated intravascular coagulopathy (DIC).
  • Trophoblastic embolism could cause acute respiratory insufficiency.29 The greatest risk factor for this complication is a uterus larger than that expected for a gestational age of 16 weeks. The condition may be fatal.

Prognosis

  • Because of early diagnosis and appropriate treatment, the current mortality rate from hydatidiform mole is essentially zero. Approximately 20% of women with a complete mole develop a trophoblastic malignancy. Gestational trophoblastic malignancies (ie, gestational trophoblastic neoplasia) are almost 100% curable.
  • Clinical factors that have been associated with risk of malignant disease are advanced maternal age, high levels of hCG (>100,000 mIU/mL), eclampsia, hyperthyroidism, and bilateral theca lutein cysts.25 Most of these factors appear to reflect the amount of trophoblastic proliferation. Predicting who will develop gestational trophoblastic disease remains difficult, and treatment decisions should not be based on the presence of any or all of these risk factors.

Patient Education

  • Because of the small but real potential for development of malignant disease and because these malignancies are absolutely curable, the importance of consistent follow-up care must be emphasized.
  • To avoid any confusion about the development of malignant disease, the patient must avoid pregnancy during the period of follow-up described above. Effective contraception should be used. If a pregnancy occurs, the elevation in beta-hCG levels cannot be differentiated from the disease process.
  • Future pregnancies should undergo early sonographic evaluation because of the increased risk of recurrence of a molar gestation.
  • The risk of recurrence is 1-2%. After 2 or more molar pregnancies, the risk of recurrence has been reported as 1 in 6.5 to 1 in 17.5.35
  • For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Birth Control Overview and Birth Control FAQs.

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider the diagnosis in a patient who presents with hyperemesis: Many patients with molar gestations develop intractable nausea and vomiting because of the high levels of circulating hCG.
  • Failure to explain the importance of close follow-up care after evacuation of the mole: Approximately 20% of patients with molar gestations develop trophoblastic malignancy.
  • Failure to recognize the significance of plateauing or rising serum beta-hCG levels: If the serum beta-hCG levels plateau or rise, the patient is considered to have developed a malignant change and metastasis need to be excluded. Staging and therapy is instituted as described in the Gestational Trophoblastic Neoplasia article.
  • Failure to consider the diagnosis in a patient who presents with preeclampsia before 24 weeks' gestation: 1% of patients with a complete mole develop preeclampsia.20
  • Failure to recognize a molar gestation with a coexistent normal fetus: Twinning and higher order multiples with molar gestations have been described. The risk for malignant disease with metastasis is high, as is the risk of maternal morbidity from bleeding, eclampsia, or other complications of the molar gestation.
 


More on Hydatidiform Mole

Overview: Hydatidiform Mole
Differential Diagnoses & Workup: Hydatidiform Mole
Treatment & Medication: Hydatidiform Mole
Follow-up: Hydatidiform Mole
Multimedia: Hydatidiform Mole
References
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References

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Further Reading

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Keywords

gestational trophoblastic disease, placental site trophoblastic tumor, molar pregnancy, complete mole, partial mole, cystic mole, hydatidiform mole, choriocarcinoma, invasive mole, trophoblastic hyperplasia, nonmetastatic trophoblastic disease, theca lutein cysts, diet deficient in animal fat, diet deficient in carotene, hyperemesis, trophoblastic malignancy, vaginal bleeding, hyperthyroidism, absence of fetal heart tones, preeclampsia, toxemia, proteinuria, edema with hyperreflexia

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Contributor Information and Disclosures

Author

Lisa E Moore, MD, FACOG, Assistant Professor, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of New Mexico Health Sciences Center
Lisa E Moore, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, and Society for Maternal-Fetal Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Enrique Hernandez, MD, FACOG, FACS, Chairman, Department of Obstetrics and Gynecology, Director of Gynecologic Oncology, Abraham Roth Professor of Obstetrics, Gynecology and Reproductive Science, Professor of Pathology, Temple University Hospital, Temple University School of Medicine
Enrique Hernandez, MD, FACOG, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, American College of Surgeons, American Medical Association, American Society for Colposcopy and Cervical Pathology, Association of Professors of Gynecology and Obstetrics, Johns Hopkins Medical and Surgical Association, Pennsylvania Medical Society, Philadelphia County Medical Society, and Society of Gynecologist Oncologists
Disclosure: Nothing to disclose.

Medical Editor

Jordan G Pritzker, MD, Assistant Professor of Obstetrics, Gynecology, and Women's Health, Women's Comprehensive Health Center, Albert Einstein College of Medicine; Physician-In-Charge, Dept of Obstetrics and Gynecology, Long Island Jewish Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

A David Barnes, MD, PhD, MPH, FACOG, Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital, Mammoth Lakes, California, Pioneer Valley Hospital, Salt Lake City, Utah, Warren General Hospital, Warren, Pennsylvania and Mountain West Hospital, Tooele, Utah
A David Barnes, MD, PhD, MPH, FACOG is a member of the following medical societies: American College of Forensic Examiners, American College of Obstetricians and Gynecologists, American Medical Association, Association of Military Surgeons of the US, and Utah Medical Association
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

David Chelmow, MD, Professor of Obstetrics and Gynecology, Tufts University School of Medicine; Program Director, Tufts University Affiliated Hospitals OB/GYN Residency Program; Chair, Tufts University Health Sciences Campus Institutional Review Board
David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making
Disclosure: Nothing to disclose.

 
 
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