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Hydatidiformmole:Management
OfficialreprintfromUpToDate
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Hydatidiformmole:Management
Authors
RossSBerkowitz,MD
DonaldPeterGoldstein,MD
NeilSHorowitz,MD

SectionEditors
RobertLBarbieri,MD
BarbaraGoff,MD

DeputyEditors
SandyJFalk,MD,FACOG
SadhnaRVora,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Jul2016.|Thistopiclastupdated:Dec11,2015.
INTRODUCTIONHydatidiformmole(HM)ispartofagroupofdiseasesclassifiedasgestationaltrophoblasticdisease
(GTD),whichoriginateintheplacentaandhavethepotentialtolocallyinvadetheuterusandmetastasize.The
pathogenesisofGTDisuniquebecausethematernaltumorarisesfromgestationalratherthanmaternaltissue[1].
HMismadeupoftwodistinctentities,completehydatidiformmoleandpartialhydatidiformmole.Thesedifferonthebasis
ofchromosomalpattern,grossandmicroscopichistopathology,andclinicalpresentationandoutcome[24].Molar
pregnancies,althoughbenign,areconsideredtobepremalignantbecausetheyhavethecapabilityofdevelopingintoa
malignancy.Malignantdiseaseisreferredtoasgestationaltrophoblasticneoplasia(GTN)thehistologicentitiesincluded
inthisgroupare:

Invasivemole
Choriocarcinoma
Placentalsitetrophoblastictumor
Epithelioidtrophoblastictumor

ThemanagementofHMwillbereviewedhere.ThepathologyofGTD,epidemiologyanddiagnosisofHM,andtopics
regardingGTNarediscussedseparately:
(See"Gestationaltrophoblasticdisease:Pathology".)
(See"Hydatidiformmole:Epidemiology,clinicalfeatures,anddiagnosis".)
(See"Gestationaltrophoblasticneoplasia:Epidemiology,clinicalfeatures,diagnosis,staging,andriskstratification",
sectionon'Differentialdiagnosis'.)
(See"Initialmanagementoflowriskgestationaltrophoblasticneoplasia".)
(See"Initialmanagementofhighriskgestationaltrophoblasticneoplasia".)
(See"Managementofresistantorrecurrentgestationaltrophoblasticneoplasia".)
MANAGEMENTSurgicaluterineevacuation(alsoreferredtoasdilationandevacuationordilationandcurettage)isthe
mainstayofmanagementforhydatidiformmole(HM),eithercompleteorpartialmole.Hysterectomyisanoptioninwomen
whohavecompletedchildbearing.
UterineevacuationSuctioncurettageisthepreferredtechniqueforuterineevacuation,regardlessofuterinesize[5].
ForwomenwithHM,wesuggestuterineevacuationwithsuctioncurettageratherthanmedicationonlymethods.Useof
medicationonlymethodsforuterineevacuation(misoprostol,mifepristone,oxytocin)iscontroversial,andfewstudies
haveevaluatedtheefficacyorsafetyofthisapproach[5].Concernhasbeenraisedthatinducinguterinecontractionswith
uterotonics(oxytocin,prostaglandins)willincreasetheriskoftrophoblasticembolizationtothelungsorofmetastatic
disease.Inaddition,obtainingaspecimenforpathologyevaluationiscrucialforconfirmingthediagnosisofHMand
identifyingcompleteversuspartialmole.Itismoredifficulttoobtainacompletespecimenwithmedicationonly
evacuation.
TheonlystudythatevaluatedmedicationonlyevacuationforHM(n=4257)reportedthatamongwomenwhounderwent
medicationonlyevacuation(mainlywithprostaglandins),20of77(26percent)subsequentlyrequireduterinecurettage,

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andsevenweretreatedwithchemotherapy(9percentcomparedwith4to6percentafteruterinecurettage)[6].Further
studyofthisissueisneeded.
Duringsuctionevacuation,wedonotuseprostaglandinsforcervicalripening,baseduponthestudycitedabove[6].
Startingatthetimeofanesthesiainduction,wedoadministeranoxytocininfusion(10unitsin1LRingerlactatesolution
at50drops/min)toincreasemyometrialtoneandfacilitatecontraction,andthusdecreasebloodloss.
Theprocedureforsuctionevacuationconsistsofmechanicaldilationofthecervix,followedbysuctionevacuationand
thencurettage.Thetechniqueisthesameasforspontaneousorinducedabortion.(See"Spontaneousabortion:
Management",sectionon'Surgicalevacuation'and"Surgicalterminationofpregnancy:Firsttrimester",sectionon
'Curettage'.)
Mechanicaldilationofthecervixshouldbeperformedgraduallytoaccommodateacannuladiameterappropriateforthe
uterinesize.Somecliniciansadvocatetheuseoflaminariainsertedonthepreviousdayinnulliparatofacilitatedilation.
Duringdilatation,briskbleedingmaybeencounteredduetopassageofcopiousamountsofbloodretainedinthe
endometrialcavity.Evacuationoftheuterinecontentsinarapid,yetinathoroughandsafefashion,reducesoverallblood
loss.Aftertheinitiationofsuctionevacuation,theuterusgenerallyshrinksrapidly,andbleedingiswellcontrolled.Ifthe
uterusislargerthan14weekssize,thesurgeonmayusefundalmassageviatheabdomentofacilitateuterinecontraction.
Whensuctionevacuationisthoughttobecomplete,agentlesharpcuretteshouldbeusedtoremoveanyresidual
chorionictissue.Somesurgeonsprefertouseintraoperativesonographytomonitortheproceduretodeterminewhen
evacuationiscomplete.Whereasconfirmationofthediagnosisofcompletemoleisusuallypossibleongrossinspectionof
thecurettings,theappearanceofpartialmoleisfrequentlynonspecific.Bleedingfromamolarevacuationmaybe
substantiallymorethanfromaspontaneous,missed,orincompleteabortion.Completemolartissuewillusuallyhave
markedlydilatedvillithatappearlikegrapeclusters.Thechangesinpartialmoleareusuallymoresubtle,andpartialmole
mayonlybesuspectedordiagnosedbaseduponthemicroscopicfindings.
PatientsathighriskforGTNPatientsatahighriskofgestationaltrophoblasticneoplasia(GTN)maybenefitfrom
hysterectomyorprophylacticchemotherapy.Highriskfeaturesarediscussedbelow.(See'Gestationaltrophoblastic
neoplasia'below.)
HysterectomyWesuggesthysterectomyforwomenwithHMwhoare40yearsandhavecompletedchildbearing.
GTNismorelikelyinthisagegroup.Comparedwithuterineevacuation,hysterectomyappearstodecrease,butnot
eliminate,theriskofGTN.(See'Gestationaltrophoblasticneoplasia'below.)
Thebenefitofhysterectomyinthisagegroupwasillustratedinaseriesof82womenaged40to49withcompletemole
GTNdevelopedin37of68(54percent)womentreatedwithdilationandevacuationaloneandinnoneofthesixpatients
treatedwithhysterectomyalone[7].Markedlyelevatedhumanchorionicgonadotropin(hCG)levels>175,000mIU/mL
appearedtoconstitutean"ultrahighrisk"groupforwhomprophylacticchemotherapyorhysterectomyshouldbe
especiallyconsidered.Eleven(85percent)ofthirteenpatientswithpreevacuationhCGlevels>175,000mIU/mL
developedGTN.Similarly,anotherstudythatincluded22womenaged50orolderwithcompletemolefoundthatGTN
developedin9of15patients(60percent)treatedwithdilationandevacuationaloneandinnoneofthesevenpatientswho
underwentprimaryhysterectomy[8].
Whencounselingpatientsabouttreatmentoptions,itisimportanttoinformthepatientthathysterectomyeliminateslocal
invasionandreducesthechanceofdevelopingpersistenttrophoblasticdisease,butitdoesnotpreventallcasesof
metastaticdiseaseduetooccultmetastases[9].Womentreatedwithhysterectomystillrequiremonitoring,including
serialhCGlevels[5].MetastaticGTNdevelopsin4percentofpatientsafteruterineevacuationofacompletehydatidiform
mole[1].(See'Followup'below.)
Attimeofhysterectomy,theovariesmaybepreservedsinceovarianmetastasesarerarelyencountered.Ifprominent
ovarianthecaluteincystsarepresent,theycanbeaspiratedtoreducethevolumeandpatientdiscomfort.Duetothe
highlyvascularnatureofthegraviduterus,supracervicalhysterectomyisfrequentlyperformedtoreducebloodlossand
avoidureteralinjury.
Hysterectomymayalsobeperformedfortheemergencymanagementofacutehemorrhageatthetimeofmolar
evacuation,althoughtheuseofuterinearteryembolizationhasbeenshowntobesuccessfulinmanagingthis
complication[10].
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ProphylacticchemotherapyAtourinstitution,weofferchemotherapyfollowingevacuationofacomplete
hydatidiformmoletohighriskwomen(see'Gestationaltrophoblasticneoplasia'below),butnottoothers.Italsomaybe
particularlyusefulinpatientswithhighriskcompletemolewhenhormonalfollowupiseitherunavailableorunreliable,as
maybethecasewithadolescentsorincertainresourcepoorregions,suchassomepartsofAsiaandAfrica[5].
Importantly,chemoprophylaxisdoesnotappeartoimpactfuturefertilitypotential[11,12].Bothmethotrexateand
actinomycinDhavebeenusedinthissetting,andtherearenodatatosuggestwhetheroneshouldbethepreferredagent.
Atourcenter,wegenerallyadministeractinomycinDtohighriskpatients.
Thispractice(otherwiseknownasprophylacticchemotherapyorchemoprophylaxis)issupportedbydatathatconsistently
showthatchemotherapycanreducetheriskofsubsequentprogressionorthediagnosisofGTNinthesepatients[1217].
Forwomenatlowrisk,wedonotproceedwithprophylacticchemotherapy,butratherinitiatefollowup.(See'Followup'
below.)
Theadministrationofprophylacticchemotherapyissupportedbya2012metaanalysisthatincludedthreerandomized
trials(n=613patients,alldiagnosedwithcompletemole)[13].Theuseofprophylacticchemotherapywasassociated
witha63percentreductionintheriskofGTN(relativerisk[RR]0.37,95%CI0.240.57).Despitethisfinding,issues
relatedtothemethodologicalqualityofthetrials,includingthesmallsizeofthestudypopulationsincluded,limitthewider
acceptanceofthisrecommendation.Inaddition,asnotedinthismetaanalysis,thebenefitofprophylacticchemotherapy
isnotentirelyclearbecauseotherdatasuggestthatpatientswhounderwentprophylacticchemotherapyandwere
subsequentlydiagnosedwithGTNexperiencedadelayinsubsequentdiagnosisandrequiredmorecoursestoachieve
remission[13].
AttheNewEnglandTrophoblasticCenter,wehavetreated93patientsinthisfashion,andonly10(11percent)developed
persistentdisease[12].Ofnote,noneofthesepatientshadmetastaticdiseaseatthetimepersistentdiseasewas
detected.Sixpatientsweretreatedwithmethotrexateforpersistenttumor,andofthese,fiverequiredonlyonecourseof
methotrexatetoattainremission.
Rh(D)immuneglobulinPatientswhoareRh(D)negativeshouldreceiveantiDimmuneglobulinatthetimeof
treatmentbecausetheRh(D)factorisexpressedontrophoblast.(See"PreventionofRh(D)alloimmunizationin
pregnancy".)
MANAGEMENTOFCOMPLICATIONS
HyperthyroidismMolarpregnancyassociatedhyperthyroidismwillresolvewithtreatmentofthegestational
trophoblasticdisease(GTD).SomepatientswillrequireantithyroidtherapyuntilGTDtreatmentiscomplete.Beta
adrenergicblockingagentsmayberequiredbeforetheinductionofanesthesiatopreventorrapidlyreversemanyofthe
metabolicandcardiovascularcomplicationsofathyroidstorm[18].
Thecriteriafortreatmentandapproachtotherapyarethesameasforotherhumanchorionicgonadotropin(hCG)mediated
hyperthyroidism.(See"Hyperthyroidismduringpregnancy:Treatment".)
OvarianthecaluteincystsThecaluteincystsusuallyregressslowlyovertwotofourmonthsfollowingevacuation
withdeclininghCGlevels.Iftheyaresymptomatic,theycanbeaspiratedtransabdominallyunderultrasoundguidance.
Thecaluteincystsmaycauseadnexaltorsionor,rarely,theyrupturespontaneously.Insuchcases,theycanbemanaged
laparoscopically[19].(See"Ovarianandfallopiantubetorsion"and"Evaluationandmanagementofrupturedovarian
cyst".)
PreeclampsiaPreeclampsiaassociatedwithcompletemolarpregnancyresolvespromptlyaftermolarevacuationand
usuallydoesnotrequiremedicalmanagement.
CardiopulmonarysymptomsInwomentreatedinthefirsttrimester,cardiopulmonarysymptomsarerare[20].After
uterineevacuationforcompletehydatidiformmoleinthesecondtrimester,approximately2percentofpatientsusedto
developcardiopulmonarysymptoms,includingchestpain,dyspnea,tachypnea,andtachycardia.Auscultationofthechest
usuallyrevealsdiffuserales,andthechestradiographoftendemonstratesbilateralpulmonaryinfiltrates.Thesignsand
symptomsusuallyresolvewithin72hoursafterevacuationwithcardiopulmonarysupport.
Respiratorydistressisusuallyattributedtotrophoblasticembolization,butcanalsobeduetothecardiopulmonary
complicationsofthyroidstorm,toxemia,andmassivefluidreplacement.Thepresenceofpulmonaryinfiltratescan
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sometimesbemisinterpretedasmetastases,forwhichchemotherapyisinappropriatelyadministered.Inmostcases,the
infiltrateswillresolveover48to72hoursasthehCGleveldecreases[21].
FOLLOWUPFollowupoftreatmentofhydatidiformmole(HM)consistsofmeasurementofserialserumhuman
chorionicgonadotropin(hCG)levels,untilanundetectablelevelisreachedandismaintainedforseveralmonths(algorithm
1).
Poorcompliancewithpostmolarsurveillanceandtreatmentprotocolsisassociatedwithpooreroutcomesdueto
advanceddisease.IntheUnitedStates,indigentwomentreatedaturban,publichospitalsarethegroupmostlikelytofail
tocomplywithstandardprotocolsforanumberofreasons,includingcost,transportationissues,andchildcare
requirements[22].Patienteducationiscrucialtohelppatientstounderstandandcomplywithsurveillanceprotocols.
SerialhCGAllpatientswithHMshouldbemonitoredwithserialserumhCGtestingvaluesafterevacuationtoevaluate
forpostmolargestationaltrophoblasticneoplasia(GTN).
SurveillanceprotocolGuidelinesfromtheAmericanCollegeofObstetriciansandGynecologistsadvisethe
followingprotocol[23]:
Everyweekuntilnondetectableforthreeweeks,then
EverymonthforsixmonthsIfthehCGremainsundetectableforsixmonths,thenthepatientmayresumetryingto
becomepregnant,ifshewishes.
ShorterdurationofmonitoringManypatientsfindthesixmonthperiodoffollowupdifficulttocomplete.
Womenmaywishtobeginattemptinganotherpregnancysooner,particularlythoseoverage35.Furthermore,weeklyor
monthlyhCGtestingisanxietyprovokingformanywomen,expensive,andinconvenient,makingnoncompliance
common.
AshorterperiodofhCGmonitoringappearstobesafe[2431].TheriskofGTNis<1percentafteranundetectablehCG
levelisattained,basedupondatafromseveralthousandwomenfrommultipleinstitutions,includingtheCharingCross
Hospital,UniversityofTexasSouthwestern,NewEnglandTrophoblasticDiseaseCenter(NETDC),andcentersin
Hungary,Australia,andtheNetherlands[2531].Thiswasillustratedinalargeseriesofwomenwithmolarpregnancy(n=
22,053)fromCharingCrossHospitalinEnglandamongwomeninwhomthehCGnormalized,only1in760developed
GTN[32].IfthehCGnormalizedwithin56daysafterevacuation,theriskofGTNwas1in1536comparedwith1in464
whenhCGnormalizedingreaterthan56days.ThemeantimetofirstraisedhCGlevelafternormalizationwas449and
462daysinthe<56and>56daygroups,respectively.DuetothelongintervaltothehCGriseafternormalization,itis
possiblethatsomeofthesecaseswerenewmolarconceptions.Similarly[25],inaseriesof1029patientswithcomplete
moletreatedwithevacuation,nopatientdevelopedGTNafterthehCGlevelbecameundetectableusinganassay
sensitiveto<5mIU/mL.
PatientswithpartialmolemaybeparticularlysuitableforshorteneddurationofhCGsurveillancebecauseoftheirlowrisk
ofpersistence[29].Asanexample[31],inaprospectivecohortstudy(n=2008)ofpatientsregisteredattheFrench
TrophoblasticDiseaseCentre,theriskofpostmolarGTNafterhCGnormalizationwas0.34percentaftercompletemole,0
percentafterpartialmole,and0.36percentafteramultiplepregnancywithcoexistingmole.Similarly,inastudyinvolving
284womenwithpartialmole,noneofthepatientsdevelopedGTNfollowingspontaneousdeclineandnormalizationofthe
hCGlevel[27].
Onthebasisofthesedata,itmaybereasonabletoabbreviatehCGfollowupforwomenwithbothcompletemoleand
partialmolewithoutappreciablyincreasingtheriskofdelayeddiagnosisofGTN.Itisthecurrentpolicyatourcenter,the
NETDC,toallowpatientsfollowingeitheracompleteorpartialmoletobecomepregnantafterachievingthreeconsecutive
weeklyfollowedbythreeconsecutivemonthlyundetectablehCGlevels.
ItispossibletoutilizehCGregressioncurvestopredictapatientsriskofdevelopingGTNaftermolarevacuation[3335].
Inonestudy,anhCGlevelof>199mIU/mLinthethirdthrougheighthweekfollowingpartialmoleevacuationwas
associatedwithatleasta35percentriskofGTN[36].Similarly,anotherstudyreportedthatwomenafteracompletemole
whosehCGlevelswere<200mIU/mLinthefourthweekafterevacuationor<100mIU/mLinthesixthweekafter
evacuationhadariskofpersistencebelow9percent.AnhCGlevel>2000mIU/mLinthefourthweekafterevacuation
wasassociatedwitha63.8percentriskofdevelopingpersistentdisease[26].
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DiagnosisofGTNFollowingevacuationofacompleteorpartialmolarpregnancy,ifhCGlevelsriseorremain
elevatedoverseveralweeks,thepatientisclassifiedashavingGTN.ThediagnosisofpostmolarGTNisbaseduponthe
followingInternationalFederationofGynecologyandObstetrics(FIGO)criteria[3739]:
hCGlevelsplateau(remainwithin10percentofthepreviousresult)acrossfourmeasurementsoverathreeweek
period(eg,days1,7,14,and21)
hCGlevelincreases>10percentacrossthreevaluesoveratwoweekduration(eg,measurementsondays1,7,and
14,increaseis>10percentfromday1today14)
PersistenceofdetectableserumhCGformorethansixmonthsaftermolarevacuation
ThereareinternationallyacceptedcriteriatomakethediagnosisofGTNforwomenwhohadapriormolarpregnancy.
However,FIGOalsoacceptsthediagnosisofGTNbasedonahistologicdiagnosisofchoriocarcinomaorinvasivemole
(eg,madebyexaminationofuterinecurettings)and/ortheidentificationofclinicalorradiologicalevidenceofmetastases.
TheevaluationanddiagnosisofGTNisdiscussedindetailseparately.(See"Gestationaltrophoblasticneoplasia:
Epidemiology,clinicalfeatures,diagnosis,staging,andriskstratification",sectionon'Diagnosticevaluation'and
"Gestationaltrophoblasticneoplasia:Epidemiology,clinicalfeatures,diagnosis,staging,andriskstratification",sectionon
'Diagnosis'.)
PersistentlowhCG(quiescentGTN)Onrareoccasionsfollowingmolarevacuation,thehCGlevelwillfailto
normalizeandremainelevatedatlowlevels(<200mIU/mL).Onecauseofpersistent(presentforatleastthreemonths)
lowlevelhCGisquiescentGTN,alsoreferredtoasinactiveGTN.
QuiescentGTNisapersistentlylowlevelofhCGintheabsenceofanyclinicalorradiologicalevidenceofGTN.While
quiescentGTNmostcommonlyoccursafteracompletemole,itmaydevelopafterpartialmole,invasivemole,or
choriocarcinoma.Thisconditionisthoughttobeduetothepresenceofasmallfocusofhighlydifferentiated,noninvasive
syncytiotrophoblastcellsthatproducesmallstableamountsofhCGandusuallydonotprogresstoinvasivediseaseas
longascytotrophoblastorintermediatecellsareabsent[40].
QuiescentGTNischaracterizedbythefollowing:(1)fociofdiseasearenotreadilyidentifiableclinically,and(2)hCGlevel
isunresponsivetotherapy,presumablybecausethegrowthcycleofthesecellsislongandcomparabletonormalcells.
PatientswithquiescentGTNshouldnotbetreatedwithchemotherapy,butclosefollowupisindicatedbecause6to10
percentwilleventuallydevelopactiveGTN,requiringtreatment[4143].
AlthoughFIGOguidelinesrecommendtreatmentinpatientswithpersistenthCGlevelssixmonthsaftermolarpregnancy,
agroupfromCharingCrossHospitalreportedon76patientsfromacohortof13,960withHMswhohadpersistently
elevatedbutdeclininghCGlevelssixmonthsafterevacuation.Inthisstudy,66(87percent)patientsweretreated
expectantly,andonly13percentrequiredchemotherapytreatment[44].
ThemeasurementofhyperglycosylatedhCG(hCGH)hasbeenproposedforsurveillanceinpatientswithquiescentGTN
[42,45].hCGHisaglycoproteinproducedbycytotrophoblastcellsandisassociatedwithtrophoblastinvasion,growthof
cytotrophoblastcells,andoverallpromotionofplacentalimplantation.Itisthoughttobeapromoterofchoriocarcinoma
growthandtumorigenesis,andisthemainformofhCGproducedinactiveGTN.
ThepresenceoflowlevelsofhCGHindicatesthepresenceofquiescentGTN.IncreasinglevelsofhCGHindicatethe
developmentofactiveGTNthatrequirestreatment[40,41].
PatientswithquiescentGTNshouldbemonitoredwithmonthlyhCGtestingandadvisedtoavoidpregnancy[46].Active
GTNshouldbediagnosed,andtreatedappropriately,ifhCGHrisestogreaterthan20percentoftotalhCGoriftotalhCG
hastwodoublings[45,47,48].(See"Initialmanagementoflowriskgestationaltrophoblasticneoplasia".)
ThereareseveralotheretiologiesofapersistentlowlevelhCG,includingpituitaryglandhCGproductionparticularlyin
perimenopausalwomen.ThedifferentialdiagnosisofpersistentlowhCGisdiscussedindetailseparately.(See"Human
chorionicgonadotropin:Testinginpregnancyandgestationaltrophoblasticdiseaseandcausesoflowpersistentlevels",
sectionon'CausesandevaluationofpersistentlowlevelsofhCG'.)
ContraceptionWomenwithmolarpregnancymustbeadvisedtousereliablecontraceptionduringtheentireintervalof
hCGmonitoring.AnewpregnancyduringthisperiodwouldmakeitdifficultorimpossibletointerprethCGresultsand
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wouldcomplicatemanagement.Optionsincludehormonalcontraceptionorbarriermethods.Depotmedroxyprogesteroneis
anoptionforwomenwhohavedifficultycomplyingwithcontraceptiveuse[22].Anintrauterinedeviceshouldnotbeused
beforethehCGnormalizesbecauseoftheriskofuterineperforationduetosubinvolutionoftheuterusorinvasivemole.
Historically,womenwereadvisedtouseonlybarriercontraceptionbaseduponaconcernthathormonalcontraceptives
mayincreasetheriskofGTN[49].Somedatasuggestthatthisincreasedriskwasassociatedwithestrogendosesof50
mcgorhigherinolderoralcontraceptives[50].However,thesafetyofpostmolaruseoforalcontraceptiveshasbeen
demonstratedinthreereports,includingtworandomizedtrials[5153].ThelargestwasaGynecologicOncologyGroup
randomizedtrial(n=266)thatassignedpatientstooralcontraceptivesorbarriercontraceptionafterevacuationofanHM
[52].Nosignificantdifferenceintherateofpostmolartrophoblasticdiseasewasfoundbetweenthegroupsinfact,the
oralcontraceptivegrouphadalowerrate(23versus33percent).Themediantimetospontaneousregressionintheoral
contraceptivesgroupwasnineweeks,whereasthemediantimetoregressioninthebarriergroupwas10weeks.Twice
asmanypatientsinthebarriergroupbecamepregnantintheimmediatefollowupperiod.Inaddition,asystematicreview
ofsevenstudiesincluding1533womenreportedthatallbutonestudyfoundnoincreasedriskofGTNwithpostmolaruse
oforalcontraceptives[54].
OUTCOME
GestationaltrophoblasticneoplasiaHydatidiformmole(HM)iswellrecognizedtohaveariskofdevelopinginvasive
disease,referredtoasgestationaltrophoblasticneoplasia(GTN).
ThereportedincidenceofGTNaftereachtypeofmolarpregnancyis[9,5558]:
Completemole(15to20percent)
Partialmole(1to5percent)
ThewiderangeofthereportedincidenceofpostmolarGTNresultsfromdifferencesindiagnosticcriteriaandthesizeof
thepopulationstudied.Amongwomenwithmolarpregnancy,theriskfactorsfordevelopingGTNinclude:(1)complete
molewithsignsoftrophoblasticproliferation(uterinesizegreaterthangestationalage,serumhumanchorionic
gonadotropin[hCG]levels>100,000mIU/mL)(2)ovarianthecaluteincysts>6cmindiameterand(3)age>35to40
years.
Theincreasedriskincompletemolewithsignsofmarkedtrophoblasticproliferationwasillustratedbydatafromour
center,theNewEnglandTrophoblasticDiseaseCenter(NETDC),from858womenwithcompletemole[5].Thepresence
versusabsenceoftrophoblasticproliferativesigns(uterinesizegreaterthangestationalage,serumhCGlevels>100,000
mIU/mL,andovarianthecaluteincysts>6cmindiameter)wasassociatedwithsignificantlyhigherratesofuterine
invasion(31.0versus3.4percent)andmetastases(8.8versus0.6percent).Sincecompletemolesarecurrentlyusually
diagnosedinthefirsttrimester,theclassicalsignsoflatemolarpregnancyarenotcommonlyencountered.Despiteearly
diagnosis,however,theincidenceofpostmolarGTNisunchanged.Firsttrimestercompletemolesstillfrequentlypresent
withhighhCGvalues,andhighhCGvaluesinfirsttrimestercompletemolesarestillassociatedwiththedevelopmentof
GTN.
Olderpatientswithcompletemolearealsoatincreasedriskofdevelopingapostmolartumor.Studieshavefoundthat33
to60percentofwomenoverage40withcompletemoledeveloppersistentdisease[7,59,60].Otherstudieshavereported
that53to56percentofwomenover50withcompletemolesdevelopedpostmolartumor[8,61].
Completemolesaremorecommonlyaneuploidinolderwomen,andaneuploidymaybeariskfactorforGTN[62].One
studyreportedthat10of13(77percent)aneuploidcompletemolesdevelopedpersistenttumor[63].
Incontrasttopatientswithadvancedage,adolescents(<age20)donotappeartohaveahigherriskofdeveloping
postmolardisease.Asanexample,onestudyoftheclinicalpresentationandoutcomein220adolescentpatientswith
completemolenotedasignificantlydecreasedriskofdevelopingGTN[64].
Forpartialmole,noriskfactorsfordevelopingGTNhavebeenidentified[65].Afterpartialmole,persistenttumoris
generallynonmetastatic[5].Asanexample,11studiesincluding7579patientswithpartialmoleshowthatonly76(1.0
percent)womendevelopedpersistenttumorandonlynine(0.1percent)hadmetastases[2,3,6573].
Patientswithrepeatmolarpregnancyareatanincreasedriskofdevelopingpersistenttumor.Onestudyreporteda
threefoldincreasedriskofpostmolartumorinpatientswitharepeatmolarpregnancy[74].Among39patientswithtwo
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molarpregnanciesmanagedattheNETDCfrom1965to2013,persistenttumordevelopedfollowingthefirstmolein4of
20(20percent)completemolesandfollowingthesecondmole,in8of20(40percent)completemoles,andin2of17
(11.7percent)partialmoles[75].
SubsequentpregnancyIngeneral,patientswithbothcompletemoleandpartialmolecananticipatenormalfuture
reproductiveoutcomes.
AttheNETDCbetween1965and2013,obstetricoutcomesincluded[75]:
Patientswithcompletemolehad1388subsequentpregnancies:949(68.4percent)termlivebirths,103(7.4percent)
prematuredeliveries,seven(0.5percent)stillbirths,256(18.4percent)spontaneousabortions,and11(0.8percent)
ectopicpregnancies.Majorandminorcongenitalanomaliesweredetectedin40(3.8percent)infants.
Patientswithpartialmolehad357subsequentpregnancies:260(72.8percent)termlivebirths,eight(2.2percent)
prematuredeliveries,one(0.3percent)stillbirth,64(17.9percent)spontaneousabortions,andtwo(0.6percent)
ectopicpregnancies.Majorandminorcongenitalanomalieswerediagnosedinonlyfour(1.5percent)infants.
Theseratesaresimilartootherinstitutions[76,77].
RepeatmolarpregnancyWomenwithapriorHMareatincreasedriskofdevelopingsubsequentHMcompared
withthegeneralpopulation[78].
EstimatesoftheriskofsubsequentHMare:
Afteronemolarpregnancy(1to1.9percent)[76,77,79]
Aftertwomolarpregnancies(15to17.5percent)[75,76]
Asingleinstitutionseriesreportedthatamong2578womenwithcompletemole,thesubsequentpregnancywasmolarin
27(1.9percent),including22(81percent)completemolesandfive(19percent)partialmoles[77].Among2627patients
withapartialmole,thesubsequentpregnancywasmolarin25(1.7percent),including17(68percent)partialmolesand
eight(32percent)completemoles.Theoverallriskofmolarpregnancywas1.8percent,whichrepresenteda20fold
increasecomparedwiththegeneralpopulation.Among27caseswithrepeatcompletemole,threehadlatermolar
pregnancies,indicatingarecurrencerateaftertwopreviouscompletemolesof11percent.
AttheNETDCbetween1965and2013,followingtwomolarpregnancies,25patientshad40subsequentpregnancies:
seven(17.5percent)molarpregnancies(sixcomplete,onepartial),25(62.5percent)termlivebirths,oneintrauterinefetal
demise(2.5percent),threespontaneousabortions(7.5percent),threeinducedabortions(7.5percent),andoneectopic
pregnancy(2.5percent)[75].
ObstetricmanagementDuetotheriskofrecurrentHM,inourpractice,weadvisepatientswithapriorHMtohave
afirsttrimesterultrasoundtoconfirmnormalgestationaldevelopmentinsubsequentpregnancies.Additionally,we
measureaserumhCGatsixweeksafterthecompletionofanytypeoffuturepregnancy(eg,termdelivery,spontaneous
abortion,inducedabortion)toexcludechoriocarcinoma.Afterpretermortermdeliveriesinpatientswithpriormolar
pregnancyorGTN,theplacentashouldbecarefullyexaminedandsenttopathologyifanyabnormalitiesarepresent.
Additionally,allproductsofconceptionfrommiscarriagesorabortionsshouldbeexaminedpathologically.
SUMMARYANDRECOMMENDATIONS
Hydatidiformmole(HM)ispartofagroupofdiseasesclassifiedasgestationaltrophoblasticdisease(GTD),which
originateintheplacentaandhavethepotentialtolocallyinvadetheuterusandmetastasize.(See'Introduction'
above.)
UterineevacuationisthemainstayoftreatmentforHM.ForwomenwithHM,wesuggestuterineevacuationwith
suctioncurettageratherthanmedicationonlymethods(Grade2C).(See'Uterineevacuation'above.)
ForwomenwithHMwhoareage40yearsandhavecompletedchildbearing,wesuggesthysterectomyratherthan
uterineevacuation(Grade2C).(See'Hysterectomy'above.)
FollowupoftreatmentofHMconsistsofmeasurementofserialweeklyserumquantitativehumanchorionic
gonadotropin(hCG),untilanundetectablelevelisreached(algorithm1).(See'Surveillanceprotocol'above.)
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Followingevacuationofacompleteorpartialmolarpregnancy,ifhCGlevelsriseorremainelevatedoverseveral
weeks,thepatientisclassifiedashavinggestationaltrophoblasticneoplasia(GTN).Thediagnosisofpostmolar
GTNisbasedupontheInternationalFederationofGynecologyandObstetrics(FIGO)criteria.(See'Diagnosisof
GTN'above.)
WomenwithmolarpregnancymustbeadvisedtousereliablecontraceptionduringtheentireintervalofhCG
monitoring.AnewpregnancyduringthisperiodwouldmakeitdifficultorimpossibletointerprethCGresultsand
wouldcomplicatemanagement.Optionsincludehormonalcontraceptionorbarriermethods.(See'Contraception'
above.)
EstimatesoftheriskofrecurrentHMare:afteronemolarpregnancy(1to1.9percent),andaftertwomolar
pregnancies(15to17.5percent).(See'Repeatmolarpregnancy'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1.BerkowitzRS,GoldsteinDP.Currentadvancesinthemanagementofgestationaltrophoblasticdisease.Gynecol
Oncol2013128:3.
2.VassilakosP,RiottonG,KajiiT.Hydatidiformmole:twoentities.Amorphologicandcytogeneticstudywithsome
clinicalconsideration.AmJObstetGynecol1977127:167.
3.SzulmanAE,SurtiU.Theclinicopathologicprofileofthepartialhydatidiformmole.ObstetGynecol198259:597.
4.SzulmanAE,SurtiU.Thesyndromesofhydatidiformmole.I.Cytogeneticandmorphologiccorrelations.AmJ
ObstetGynecol1978131:665.
5.BerkowitzRS,GoldsteinDP.Clinicalpractice.Molarpregnancy.NEnglJMed2009360:1639.
6.TidyJA,GillespieAM,BrightN,etal.Gestationaltrophoblasticdisease:astudyofmodeofevacuationand
subsequentneedfortreatmentwithchemotherapy.GynecolOncol200078:309.
7.EliasKM,ShoniM,BernsteinM,etal.Completehydatidiformmoleinwomenaged40to49years.JReprodMed
201257:254.
8.EliasKM,GoldsteinDP,BerkowitzRS.Completehydatidiformmoleinwomenolderthanage50.JReprodMed
201055:208.
9.LurainJR,BrewerJI,TorokEE,HalpernB.Naturalhistoryofhydatidiformmoleafterprimaryevacuation.AmJ
ObstetGynecol1983145:591.
10.TseKY,ChanKK,TamKF,NganHY.20yearexperienceofmanagingprofusebleedingingestationaltrophoblastic
disease.JReprodMed200752:397.
11.KashimuraY,KashimuraM,SugimoriH,etal.Prophylacticchemotherapyforhydatidiformmole.Fiveto15years
followup.Cancer198658:624.
12.BerkowitzRS,GoldsteinDP,DuBeshterB,BernsteinMR.Managementofcompletemolarpregnancy.JReprod
Med198732:634.
13.FuJ,FangF,XieL,etal.Prophylacticchemotherapyforhydatidiformmoletopreventgestationaltrophoblastic
neoplasia.CochraneDatabaseSystRev201210:CD007289.
14.KimDS,MoonH,KimKT,etal.Effectsofprophylacticchemotherapyforpersistenttrophoblasticdiseasein
patientswithcompletehydatidiformmole.ObstetGynecol198667:690.
15.UbertiEM,FajardoMdoC,daCunhaAG,etal.Preventionofpostmolargestationaltrophoblasticneoplasiausing
prophylacticsinglebolusdoseofactinomycinDinhighriskhydatidiformmole:asimple,effective,secureandlow
costapproachwithoutadverseeffectsoncompliancetogeneralfollowuporsubsequenttreatment.GynecolOncol
2009114:299.
16.GoldsteinDP,BerkowitzRS.Prophylacticchemotherapyofcompletemolarpregnancy.SeminOncol199522:157.
17.LimpongsanurakS.ProphylacticactinomycinDforhighriskcompletehydatidiformmole.JReprodMed2001
46:110.
18.NagatakiS,MizunoM,SakamotoS,etal.Thyroidfunctioninmolarpregnancy.JClinEndocrinolMetab1977
44:254.
19.BerkowitzRS,GoldsteinDP,BernsteinMR.Laparoscopyinthemanagementofgestationaltrophoblastic
neoplasms.JReprodMed198024:261.
http://www.uptodate.com/contents/hydatidiformmolemanagement?topicKey=ONC%2F3194&elapsedTimeMs=6&source=search_result&searchTerm=mana

8/13

8/27/2016

Hydatidiformmole:Management

20.SotoWrightV,BernsteinM,GoldsteinDP,BerkowitzRS.Thechangingclinicalpresentationofcompletemolar
pregnancy.ObstetGynecol199586:775.
21.TwiggsLB,MorrowCP,SchlaerthJB.Acutepulmonarycomplicationsofmolarpregnancy.AmJObstetGynecol
1979135:189.
22.MassadLS,AbuRustumNR,LeeSS,RentaV.Poorcompliancewithpostmolarsurveillanceandtreatment
protocolsbyindigentwomen.ObstetGynecol200096:940.
23.CommitteeonPracticeBulletinsGynecology,AmericanCollegeofObstetriciansandGynecologists.ACOG
PracticeBulletin#53.Diagnosisandtreatmentofgestationaltrophoblasticdisease.ObstetGynecol2004103:1365.
24.TuncerZS,BernsteinMR,GoldsteinDP,etal.Outcomeofpregnanciesoccurringwithin1yearofhydatidiformmole.
ObstetGynecol199994:588.
25.WolfbergAJ,FeltmateC,GoldsteinDP,etal.LowriskofrelapseafterachievingundetectableHCGlevelsin
womenwithcompletemolarpregnancy.ObstetGynecol2004104:551.
26.WolfbergAJ,BerkowitzRS,GoldsteinDP,etal.PostevacuationhCGlevelsandriskofgestationaltrophoblastic
neoplasiainwomenwithcompletemolarpregnancy.ObstetGynecol2005106:548.
27.WolfbergAJ,GrowdonWB,FeltmateCM,etal.LowriskofrelapseafterachievingundetectableHCGlevelsin
womenwithpartialmolarpregnancy.ObstetGynecol2006108:393.
28.KerkmeijerLG,WielsmaS,MassugerLF,etal.RecurrentgestationaltrophoblasticdiseaseafterhCGnormalization
followinghydatidiformmoleinTheNetherlands.GynecolOncol2007106:142.
29.LavieI,RaoGG,CastrillonDH,etal.Durationofhumanchorionicgonadotropinsurveillanceforpartialhydatidiform
moles.AmJObstetGynecol2005192:1362.
30.SebireNJ,FoskettM,ShortD,etal.Shorteneddurationofhumanchorionicgonadotrophinsurveillancefollowing
completeorpartialhydatidiformmole:evidenceforrevisedprotocolofaUKregionaltrophoblasticdiseaseunit.
BJOG2007114:760.
31.SchmittC,DoretM,MassardierJ,etal.RiskofgestationaltrophoblasticneoplasiaafterhCGnormalisation
accordingtohydatidiformmoletype.GynecolOncol2013130:86.
32.CoyleC,ShortD,DayalL,etal.TimetohCGnormalizationinpatientswithhydatidiformmolarpregnancyandrisk
ofpersistentgestationaltrophoblasticdisease.XVIIWorldCongressonGestationalTrophoblasticDisease,2013,
p.60(abstract).
33.LybolC,SweepFC,OttevangerPB,etal.Linearregressionofpostevacuationserumhumanchorionicgonadotropin
concentrationspredictspostmolargestationaltrophoblasticneoplasia.IntJGynecolCancer201323:1150.
34.vanCromvoirtSM,ThomasCM,QuinnMA,etal.Identificationofpatientswithpersistenttrophoblasticdisease
aftercompletehydatidiformmolebyusinganormal24hoururinehCGregressioncurve.GynecolOncol2014
133:542.
35.KimBW,ChoH,KimH,etal.Humanchorionicgonadotrophinregressionrateasapredictivefactorofpostmolar
gestationaltrophoblasticneoplasminhighriskhydatidiformmole:acasecontrolstudy.EurJObstetGynecol
ReprodBiol2012160:100.
36.GrowdonWB,WolfbergAJ,FeltmateCM,etal.PostevacuationhCGlevelsandriskofgestationaltrophoblastic
neoplasiaamongwomenwithpartialmolarpregnancies.JReprodMed200651:871.
37.KohornEI.ThenewFIGO2000stagingandriskfactorscoringsystemforgestationaltrophoblasticdisease:
descriptionandcriticalassessment.IntJGynecolCancer200111:73.
38.FIGOCommitteeonGynecologicOncology.CurrentFIGOstagingforcancerofthevagina,fallopiantube,ovary,
andgestationaltrophoblasticneoplasia.IntJGynaecolObstet2009105:3.
39.NganHY,BenderH,BenedetJL,etal.Gestationaltrophoblasticneoplasia,FIGO2000stagingandclassification.
IntJGynaecolObstet200383Suppl1:175.
40.ColeLA.HyperglycosylatedhCG,areview.Placenta201031:653.
41.KohornEI.WhatweknowaboutlowlevelhCG:definition,classificationandmanagement.JReprodMed2004
49:433.
42.NguSF,ChanKK.ManagementofChemoresistantandQuiescentGestationalTrophoblasticDisease.CurrObstet
GynecolRep20143:84.
43.ColeLA,KhanlianSA.InappropriatemanagementofwomenwithpersistentlowhCGresults.JReprodMed2004
49:423.
44.AgarwalR,TeohS,ShortD,etal.Chemotherapyandhumanchorionicgonadotropinconcentrations6monthsafter
uterineevacuationofmolarpregnancy:aretrospectivecohortstudy.Lancet2012379:130.
45.ColeLA,MullerCY.HyperglycosylatedhCGinthemanagementofquiescentandchemorefractorygestational
trophoblasticdiseases.GynecolOncol2010116:3.
http://www.uptodate.com/contents/hydatidiformmolemanagement?topicKey=ONC%2F3194&elapsedTimeMs=6&source=search_result&searchTerm=mana

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8/27/2016

Hydatidiformmole:Management

46.HancockBW.hCGmeasurementingestationaltrophoblasticneoplasia:acriticalappraisal.JReprodMed2006
51:859.
47.HwangD,HancockBW.Managementofpersistent,unexplained,lowlevelhumanchorionicgonadotropinelevation:
areportof5cases.JReprodMed200449:559.
48.KhanlianSA,ColeLA.Managementofgestationaltrophoblasticdiseaseandothercaseswithlowserumlevelsof
humanchorionicgonadotropin.JReprodMed200651:812.
49.StoneM,BagshaweKD.Ananalysisoftheinfluencesofmaternalage,gestationalage,contraceptivemethod,and
themodeofprimarytreatmentofpatientswithhydatidiformmolesontheincidenceofsubsequentchemotherapy.Br
JObstetGynaecol197986:782.
50.HoYuenB,BurchP.Relationshipoforalcontraceptivesandtheintrauterinecontraceptivedevicestotheregression
ofconcentrationsofthebetasubunitofhumanchorionicgonadotropinandinvasivecomplicationsaftermolar
pregnancy.AmJObstetGynecol1983145:214.
51.BerkowitzRS,GoldsteinDP,MareanAR,BernsteinM.Oralcontraceptivesandpostmolartrophoblasticdisease.
ObstetGynecol198158:474.
52.CurrySL,SchlaerthJB,KohornEI,etal.Hormonalcontraceptionandtrophoblasticsequelaeafterhydatidiformmole
(aGynecologicOncologyGroupStudy).AmJObstetGynecol1989160:805.
53.AdewoleIF,OladokunA,FawoleAO,etal.Fertilityregulatorymethodsanddevelopmentofcomplicationsafter
evacuationofcompletehydatidiformmole.JObstetGynaecol200020:68.
54.CostaHL,DoyleP.Influenceoforalcontraceptivesinthedevelopmentofpostmolartrophoblasticneoplasiaa
systematicreview.GynecolOncol2006100:579.
55.GoldsteinDP,BerkowitzRS.Thediagnosisandmanagementofmolarpregnancy.In:GestationalTrophoblastic
Neoplasms:ClinicalPrinciplesofDiagnosisandManagement,Saunders,Philadelphia1982.p.143.
56.CurrySL,HammondCB,TyreyL,etal.Hydatidiformmole:diagnosis,management,andlongtermfollowupof347
patients.ObstetGynecol197545:1.
57.GestationalTrophoblasticDisease,3rdedition,HancockBW,SecklMJ,BerkowitzRS,ColeLA(Eds),International
SocietyfortheStudyofTrophoblasticDisease,www.isstd.org2009.p.1502.
58.BagshaweKD.Trophoblasticneoplasia.In:CancerMedicine,3,HollandJF,FreiFIII,BastRJr.,etal.(Eds),
Williams&Wilkins,Baltimore1993.p.1691.
59.TowWS.Theinfluenceoftheprimarytreatmentofhydatidiformmoleonitssubsequentcourse.JObstetGynaecol
BrCommonw196673:544.
60.XiaZF,SongHZ,TangMY.Riskofmalignancyandprognosisusingaprovisionalscoringsysteminhydatidiform
mole.ChinMedJ(Engl)198093:605.
61.TsukamotoN,IwasakaT,KashimuraY,etal.Gestationaltrophoblasticdiseaseinwomenaged50ormore.Gynecol
Oncol198520:53.
62.TsujiK,YagiS,NakanoR.Increasedriskofmalignanttransformationofhydatidiformmolesinoldergravidas:a
cytogeneticstudy.ObstetGynecol198158:351.
63.MartinDA,SuttonGP,UlbrightTM,etal.DNAcontentasaprognosticindexingestationaltrophoblasticneoplasia.
GynecolOncol198934:383.
64.BragaA,GrowdonWB,BernsteinM,etal.Molarpregnancyinadolescents.JReprodMed201257:225.
65.FeltmateCM,GrowdonWB,WolfbergAJ,etal.Clinicalcharacteristicsofpersistentgestationaltrophoblastic
neoplasiaafterpartialhydatidiformmolarpregnancy.JReprodMed200651:902.
66.CzernobilskyB,BarashA,LancetM.Partialmoles:aclinicopathologicstudyof25cases.ObstetGynecol1982
59:75.
67.WielsmaS,KerkmeijerL,BekkersR,etal.Persistenttrophoblastdiseasefollowingpartialmolarpregnancy.AustN
ZJObstetGynaecol200646:119.
68.WongLC,MaHK.Thesyndromeofpartialmole.ArchGynecol1984234:161.
69.OhamaK,UedaK,OkamotoE,etal.Cytogeneticandclinicopathologicstudiesofpartialmoles.ObstetGynecol
198668:259.
70.BolisG,BelloniC,BonazziC,etal.Analysisof309casesafterhydatidiformmole:differentfollowupprogram
accordingtobiologicbehavior.Tumori198874:93.
71.SecklMJ,FisherRA,SalernoG,etal.Choriocarcinomaandpartialhydatidiformmoles.Lancet2000356:36.
72.GotoS,YamadaA,IshizukaT,TomodaY.Developmentofpostmolartrophoblasticdiseaseafterpartialmolar
pregnancy.GynecolOncol199348:165.
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73.HancockBW,NazirK,EverardJE.Persistentgestationaltrophoblasticneoplasiaafterpartialhydatidiformmole
incidenceandoutcome.JReprodMed200651:764.
74.ParazziniF,MangiliG,BelloniC,etal.Theproblemofidentificationofprognosticfactorsforpersistenttrophoblastic
disease.GynecolOncol198830:57.
75.VargasR,BarroilhetLM,EsselenK,etal.Subsequentpregnancyoutcomesaftercompleteandpartialmolar
pregnancy,recurrentmolarpregnancy,andgestationaltrophoblasticneoplasia:anupdatefromtheNewEngland
TrophoblasticDiseaseCenter.JReprodMed201459:188.
76.BagshaweKD,DentJ,WebbJ.HydatidiformmoleinEnglandandWales197383.Lancet19862:673.
77.SebireNJ,FisherRA,FoskettM,etal.Riskofrecurrenthydatidiformmoleandsubsequentpregnancyoutcome
followingcompleteorpartialhydatidiformmolarpregnancy.BJOG2003110:22.
78.BRANDESJ,PERETZA.RECURRENTHYDATIDIFORMMOLEREPORTOFACASE.ObstetGynecol1965
25:398.
79.RiceLW,LageJM,BerkowitzRS,etal.Repetitivecompleteandpartialhydatidiformmole.ObstetGynecol1989
74:217.
Topic3194Version14.0

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GRAPHICS
Molarpregnancymanagementalgorithm

*Betahumanchorionicgonadotropin.
Patientsshouldusecontraceptionuntilfollowupiscomplete.
AdecreasinghCGisdefinedasalevelthatdecreases>10percentcomparedwiththeprevious
result,andcontinuestomeetthiscriterionacrossfourvaluesduringathreeweekperiod.
AnincreasinghCGisdefinedasalevelthatincreases>10percentcomparedwiththeprevious
result,andcontinuestomeetthiscriterionacrossthreevaluesduringatwoweekperiod.
AnunchangedhCGisdefinedasalevelthatremainswith+/10percentcomparedwiththe
previousresult,andcontinuestomeetthiscriterionacrossfourvaluesduringathreeweekperiod.
AfterachievingoneundetectablehCGvalue(<5mIU/mL),theriskofdevelopinggestational
trophoblasticneoplasiais<1percent.AmericanCollegeofObstetricianandGynecologyguidelines
advisethatafterthehCGisundetectable,tocontinuetomeasurehCGmonthlyforsixmonths.
BasedontheextremelylowriskofariseinhCGafteritbecomesundetectable,inourpractice,we
continuemonthlyhCGfollowupforthreemonthsandthenfollowupiscomplete.
Graphic105721Version1.0

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ContributorDisclosures
RossSBerkowitz,MDNothingtodisclose.DonaldPeterGoldstein,MDNothingtodisclose.NeilSHorowitz,MD
Nothingtodisclose.RobertLBarbieri,MDNothingtodisclose.BarbaraGoff,MDConsultant/AdvisoryBoards:Roche
Diagnostics[Biomarkersforovariancancer(HE4)].Employment(Spouse):Lilly[Generaloncology(Gemcitabine,
pemetrexed)].SandyJFalk,MD,FACOGNothingtodisclose.SadhnaRVora,MDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedby
vettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.
AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

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