Gestational Trophoblastic Disease (Green-top Guideline No. 38)

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Post category

Corresponding Author

the Royal College of Obstetricians, Gynaecologists

Publish date

09/30/2020
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Executive summary

How do molar pregnancies present to the clinician?

Clinicians should be aware of the symptoms and signs of molar pregnancy. The most common presentation is irregular vaginal bleeding, a positive pregnancy test and supporting ultrasonographic evidence.

Grade of recommendation: C

Less common presentations of molar pregnancies include hyperemesis, excessive uterine enlargement, hyperthyroidism, early-onset pre-eclampsia and abdominal distension due to theca lutein cysts. [New 2020]

Grade of recommendation: ✓

Very rarely women can present with haemoptysis or seizures due to metastatic disease affecting the lungs or brain. [New 2020]

Grade of recommendation: ✓

How are molar pregnancies diagnosed?

The definitive diagnosis of a molar pregnancy is made by histological examination.

Grade of recommendation: D

removal of a molar pregnancy

What is the best method for removal of a molar pregnancy?

Suction curettage is the method of choice for removal of complete molar pregnancies. ✓

Grade of recommendation: ✓

Suction curettage is the method of choice for removal of partial molar pregnancies except when the size of fetal parts deters the use of suction curettage and then medical removal can be used.

Grade of recommendation: ✓

Anti-D prophylaxis is recommended following removal of a molar pregnancy.

Grade of recommendation: ✓

Is it safe to prepare the cervix prior to surgical removal?

Preparation of the cervix immediately prior to uterine removal is safe.

Grade of recommendation: D

Can oxytocic infusions be used during surgical removal?

Excessive vaginal bleeding can be associated with surgical management of molar pregnancy and the involvement of an experienced clinician is advised.

Grade of recommendation: ✓

The use of oxytocic infusion prior to completion of the removal is not recommended.

Grade of recommendation: ✓

If the woman is experiencing significant haemorrhage prior to or during removal, surgical removal should be expedited and the need for oxytocin infusion weighed up against the risk of tissue embolisation.

Grade of recommendation: ✓

In what circumstances should a repeat surgical removal be indicated and what is the timing?

There is almost always a role for urgent surgical management for the woman who is experiencing heavy or persistent vaginal bleeding causing acute haemodynamic compromise, particularly in the presence of retained pregnancy tissue on ultrasound. [New 2020]

Grade of recommendation: ✓

Outside the context of acute compromise, there should be consultation with the relevant GTD referral centre before performing surgical management for the second time in the same pregnancy.

Grade of recommendation: D

Histological examination of pregnancy tissue in the diagnosis of GTD

Should pregnancy tissue from all miscarriages be examined histologically?

The histological assessment of material obtained from the medical or surgical management of all miscarriages is recommended to exclude trophoblastic neoplasia if no fetal parts are identified at any stage of the pregnancy.

Grade of recommendation: D

Women who receive care for a miscarriage should be recommended to do a urinary pregnancy test 3 weeks after miscarriage. [New 2020]

Grade of recommendation: ✓

Should pregnancy tissue be sent for examination after abortion?

There is no need to routinely send pregnancy tissue for histological examination following therapeutic abortion, provided that fetal parts have been identified at the time of surgical abortion or on prior ultrasound examination.

Grade of recommendation: D

Women who undergo medical abortion should be recommended to do a urinary pregnancy test 3 weeks after the procedure. [New 2020]

Grade of recommendation: ✓

How should women with an elevated human chorionic gonadotrophin after a possible pregnancy event be managed?

Referral to a GTD centre should be considered for all women with persistently elevated human chorionic gonadotrophin (hCG) either after an ectopic pregnancy has been excluded, or after two consecutive treatments with methotrexate for a pregnancy of unknown location. [New 2020]

Grade of recommendation: ✓

Which women should be investigated for GTN after a non-molar pregnancy?

Any woman who develops persistent vaginal bleeding after a pregnancy event is at risk of having GTN.

Grade of recommendation: D

A urine hCG test should be performed in all cases of persistent or irregular vaginal bleeding lasting more than 8 weeks after a pregnancy event.

Grade of recommendation: ✓

Symptoms from metastatic disease, such as dyspnoea and haemoptysis, or new onset of seizures or paralysis, can occur very rarely.

Grade of recommendation: D

Biopsy of secondary deposits in the vagina can cause major haemorrhage and is not recommended.

Grade of recommendation: ✓

How should suspected ectopic molar pregnancy in women be managed?

Cases of women with ectopic pregnancy suspected to be molar in nature should be managed as any other case of ectopic pregnancy. If there is a local tissue diagnosis of ectopic molar pregnancy, the tissue should be sent to a centre with appropriate expertise for pathological review. [New 2020]

Grade of recommendation: ✓

How is twin pregnancy of a viable fetus and presumptive coexistent molar pregnancy managed?

Women diagnosed with a combined molar pregnancy and viable twin, or where there is diagnostic doubt, should be referred to a regional fetal medicine centre and GTD centre.

Grade of recommendation: ✓

In the situation of a twin pregnancy where there is one viable fetus and the other pregnancy is molar, the woman should be counselled about the potential increased risk of perinatal morbidity and the outcome for GTN.

Grade of recommendation: D

Prenatal invasive testing for fetal karyotype should be considered in cases where it is unclear if the pregnancy is a complete mole with a coexisting normal twin or a possible singleton partial molar pregnancy. Prenatal invasive testing for fetal karyotype should also be considered in cases of abnormal placenta, such as suspected mesenchymal hyperplasia of the placenta.

Grade of recommendation: D

How should a placental site trophoblastic tumour or epithelioid trophoblastic tumour be managed?

All women with placental site trophoblastic tumour (PSTT) or epithelioid trophoblastic tumour (ETT) should be registered with and cared for within a GTD centre. [New 2020]

Grade of recommendation: D

How should a placental site nodule or atypical placental site nodule be managed?

Women with an atypical placental site nodule (PSN) or where the local pathology is uncertain should have their histology reviewed centrally. All women with atypical PSN will then be called up for central review to discuss the existing data, perform staging investigations and to determine further management. Women with typical PSN do not currently require further investigation or review. [New 2020]

Grade of recommendation: ✓

Which women should be registered at GTD centres?

All women diagnosed with GTD should be provided with written information about the condition and the need for referral for follow-up by a GTD centre should be explained.

Grade of recommendation: D

Clinicians should be aware that outcomes for women with GTN and GTD are better with ongoing care from GTD centres. The registration of affected women with a GTD centre represents a minimum standard of care. [New 2020]

Grade of recommendation: ✓

Women with the following diagnoses should be registered and require follow-up as determined by the screening centre:

  • complete molar pregnancy/partial molar pregnancy
  • twin pregnancy with complete or partial molar pregnancy
  • limited macroscopic or microscopic molar change suggesting possible early complete or partial molar pregnancy/choriocarcinoma
  • PSTT or ETT
  • atypical PSN. [New 2020]

Grade of recommendation: D

What is the optimum follow-up following a diagnosis of GTD?

For complete molar pregnancy, if hCG has reverted to normal within 56 days of the pregnancy event then follow-up will be for 6 months from the date of uterine removal.

Grade of recommendation: C

If hCG has not reverted to normal within 56 days of the pregnancy event then follow-up will be for 6 months from normalisation of the hCG level.

Grade of recommendation: C

Follow-up for partial molar pregnancy is concluded once the hCG has returned to normal on two samples, at least 4 weeks apart. [New 2020]

Grade of recommendation: C

Women who have not received chemotherapy no longer need to have hCG measured after any subsequent pregnancy event. [New 2020]

Grade of recommendation: C

What is the optimum treatment for GTN?

Women with GTN may be treated with single-agent or multi-agent chemotherapy.

Grade of recommendation: B

Treatment used is based on the FIGO 2000 scoring system for GTN following assessment at the treatment centre. [New 2020]

Grade of recommendation: B

PSTT and ETT are now recognised as variants of GTN. They may be treated with surgery because they are less sensitive to chemotherapy.

Grade of recommendation: D

What is the recommended interval between a complete or partial molar pregnancy and trying to conceive in the future, what is the monitoring of women following a successful pregnancy after a previous molar pregnancy and what is the outcome of subsequent pregnancies?

Women are advised not to conceive until their follow-up is complete.

Grade of recommendation: C

Women who undergo chemotherapy are advised not to conceive for 1 year after completion of treatment, as a precautionary measure.

Women who have a pregnancy following a previous molar pregnancy, which has not required treatment for GTN, do not need to send a post-pregnancy hCG sample. Histological examination of placental tissue from any normal pregnancy, after a molar pregnancy, is not indicated. [New 2020]

Grade of recommendation: D

What is the long-term outcome of women treated for GTN?

The outlook for women treated for GTN is generally excellent with an overall cure rate close to 100%. [New 2020]

Grade of recommendation: B

Further pregnancies are achieved in approximately 80% of women following
treatment for GTN with either methotrexate alone or multi-agent chemotherapy. [New 2020]

Grade of recommendation: B

There is an increased risk of premature menopause for women treated with combination agent chemotherapy. Women, especially those approaching the age of 40 years, should be warned of the potential negative impact on fertility, particularly when treated with high-dose chemotherapy.

Grade of recommendation: B

What is safe contraception following treatment of GTD and when should it be commenced?

It is important that women who have had a removal of a molar pregnancy are advised not to become pregnant until they have completed their hCG follow-up. [New 2020]

Grade of recommendation: D

Advice on contraception after a molar pregnancy can be found in the Faculty of Sexual and Reproductive Health Guideline Executive Summary Contraception After Pregnancy. [New 2020]

Grade of recommendation: D

Is the use of exogenous estrogens and other fertility drugs safe for women undergoing assisted reproductive treatment after a molar pregnancy?

The use of exogenous estrogens and other fertility drugs may be used once hCG levels have returned to normal. [New 2020]

Grade of recommendation: ✓

Is hormone replacement therapy safe for women to use after GTD?

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

Grade of recommendation: ✓

Impact of diagnosis on women and their families

GTD centres now provide individualised support to women and their families throughout their GTD journey, through dedicated GTD nurse specialists and advisors, who can be accessed either through attending a GTD centre or via phone, or both. Online support groups are available ( molarpregnancy.co.uk ) alongside regular drop hyphenate in support groups at Charing Cross Hospital, London and Weston Park Hospital, Sheffield. Further information is available from each centre. [New 2020]

Grade of recommendation: ✓

View and download the guideline

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