Sections

Treatment

Medical Care

Stabilize the patient.

Transfuse for anemia, and correct any coagulopathy.

Treat hypertension. Watch for and be prepared to treat thyroid storm, a rare complication.

Administer Rh immune globulin to nonsensitized RhD-negative women because of the possibility of a partial mole with fetal erythrocytes that express the RhD antigen. There is controversy as to whether or not RhD is expressed in human trophoblast cells.^{[43, 44]}

Consultation

A gynecologic oncologist should be consulted if the patient is believed to be at risk for or has developed malignant disease (ie, gestational trophoblastic neoplasia).

Diet and activity

No special diet is required, and patients may resume activity as tolerated.

Pelvic rest is recommended for 2-4 weeks after evacuation of the uterus, and the patient is instructed not to become pregnant for 6 months. Effective contraception is recommended during this period.^[45]

Monitor serial beta-hCG levels to identify the rare patient who develops malignant disease. If a pregnancy does occur, the elevation in beta-hCG would be confused with development of malignant disease.

Surgical Care

Evacuation of the uterus by dilation and curettage is always necessary.

Prostaglandin or oxytocin induction is not recommended because of the increased risk of bleeding and malignant sequelae.

Intravenous oxytocin should be started after dilation of the cervix at the initiation of suctioning and continued postoperatively to reduce the likelihood of hemorrhage. Consideration of using other uterotonic formulations (eg, Methergine, Hemabate) is also warranted.

Respiratory distress can occur at the time of surgery. This may be due to trophoblastic embolization, high-output congestive heart failure caused by anemia, or iatrogenic fluid overload. Distress should be aggressively treated with assisted ventilation and monitoring, as required.^[28]

Long-Term Monitoring

Serial quantitative serum beta-hCG levels should be determined. Note the following:

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.^[46]
After evacuation of a complete mole, once levels have reached the reference range for 3-4 weeks, check them monthly for 6 months.^{[47, 48, 49]} After evacuation of a partial mole, once levels have reached the reference range, obtain a confirmatory hCG level a month later. The risk of gestational trophoblastic neoplasia (GTN) after a partial mole evacuation, once the hCG level normalizes, is 1:3195.^{[50, 51]}
If the serum hCG levels plateau or rise, the patient is considered to have malignant disease (ie, GTN) 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.^[52] Evaluate all future pregnancies early with ultrasonography.

Human telomerase reverse transcriptase (hTERT) expression in the uterine contents of cases of complete mole has been suggested as a marker for persistent disease. The negative predictive value appears most significant. Absence of hTERT expression was associated with a benign course (eg, normalization of serum hCG level). All cases of persistent disease expressed hTERT; however, some cases in which hTERT was expressed regressed spontaneously.^[53]

Medication

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Media Gallery

Theca lutein cysts.
Complete mole.
Complete mole with an area of clot near cervix consistent with bleeding.
Twin gestation. Complete mole and normal twin.

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Author

Lisa E Moore, MD, MS, FACOG, RDMS Professor, Department of Obstetrics and Gynecology, Chief, Division of Maternal-Fetal Medicine, Medical Director of Labor and Delivery, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Lisa E Moore, MD, MS, FACOG, RDMS is a member of the following medical societies: American Congress of Obstetricians and Gynecologists, Central Association of Obstetricians and Gynecologists, International Society of Ultrasound in Obstetrics and Gynecology, Society for Maternal-Fetal Medicine, Society of Diagnostic Medical Sonography

Disclosure: Nothing to disclose.

Coauthor(s)

Enrique Hernandez, MD, FACOG, FACS Chairman, Department of Obstetrics and Gynecology, J Robert Willson Professor of Obstetrics, Gynecology and Reproductive Science, Professor of Pathology, Temple University Hospital, Lewis Katz School of Medicine at Temple University

Enrique Hernandez, MD, FACOG, FACS is a member of the following medical societies: Alpha Omega Alpha, American Cancer Society, American College of Obstetricians and Gynecologists, American College of Surgeons, American Gynecological and Obstetrical Society, 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, Society of Gynecologic Oncology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

A David Barnes, MD, MPH, PhD, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, CA), Pioneer Valley Hospital (Salt Lake City, UT), Warren General Hospital (Warren, PA), and Mountain West Hospital (Tooele, UT)

A David Barnes, MD, MPH, PhD, FACOG is a member of the following medical societies: American College of Forensic Examiners Institute, American College of Obstetricians and Gynecologists, Association of Military Surgeons of the US, American Medical Association, Utah Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Leslie M Randall, MD, MAS, FACS Professor and Director, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Diane Harris Wright Professor of Gynecologic Oncology Research, Massey Cancer Center, Virginia Commonwealth University School of Medicine

Leslie M Randall, MD, MAS, FACS is a member of the following medical societies: Academy for Innovation in Medical Education, American College of Surgeons, American Medical Association, American Society of Clinical Oncology, International Gynecologic Cancer Society, Society of Gynecologic Oncology

Disclosure: Nothing to disclose.

Additional Contributors

Jordan G Pritzker, MD, MBA, FACOG Adjunct Professor of Obstetrics/Gynecology, Hofstra North Shore-LIJ School of Medicine at Hofstra University; Attending Physician, Department of Obstetrics and Gynecology, Long Island Jewish Medical Center; Medical Director, Aetna, Inc; Private Practice in Gynecology

Disclosure: Nothing to disclose.

Hydatidiform Mole Treatment & Management

Medical Care

Consultation

Diet and activity

Surgical Care

Long-Term Monitoring

References

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