Serum hCG levels: within 48 hours of evacuation, weekly until undetectable, then monthly for 6 months alntrauterine devices are not suitable during surveillance.
hCG = human chorionic gonadotropin; 1M = intramuscular; PG = prostaglandin; T4 = thyroxine; TSH = thyroid-stimulating hormone.
Sims curette is performed. If bleeding continues despite uterine evacuation and oxytocin infusion, other uterotonic agents are given (see Table 20-2). In rare cases, pelvic arterial emboliza tion or hysterectomy may be necessary (Tse, 2007). Profuse management are discussed in Chapter 41 (p. 755).
Some volume of trophoblast is deported into the pelvic venous system during molar evacuation (Hankins, 1987). With large moles, the amount of tissue may be suicient to produce clinically apparent respiratory insuiciency, pulmonary edema, or even embolism. In our earlier experiences with substantial moles, these and their chest radiographic manifestations clear rapidly without specific treatment. However, fatalities have been described (Delmis, 2000). Because of deportation, there is concern that trophoblastic tissue will thrive within the lung parenchyma to cause persistent disease or even overt malignancy. Fortunately, no evidence suggests that this is a major problem.
Following curettage, anti-D immunoglobulin (Rhogam) is given to Rh D-negative women because fetal tissues with a partial mole may include red cells with D-antigen (Chap. 15, p. 305). Those with suspected complete mole are similarly treated because a deinitive diagnosis of complete versus partial mole may not be conirmed until histologicl evaluation of the evacuated products.
Following evacuation, the long-term prognosis for women with a hydatidiform mole is not improved with prophylactic chemotherapy. Moreover, chemotherapy toxicity-including death-may be significant, and thus it is not recommended routinely (Gueye, 2014; Wang, 2017).
Methods other than suction curettage can be considered for select cases. Hysterectomy with ovarian preservation may be preferable for women with complete moles who have inished childbearing. Of women aged 40 to 49 years, 30 to 50 percent will subsequently develop GTN, and hysterectomy markedly reduces this likelihood (Bandy, 1984; Elias, 2010, 2012). Theca-lutein cysts seen at the time of hysterectomy do not require removal, and they spontaneously regress following molar termination. Labor induction or hysterotomy is seldom used for molar evacuation in the United States. Both will likely increase blood loss and theoretically may increase the incidence of persistent trophoblastic disease (American College of Obstetricians and Gynecologists, 2016; Tidy, 2000).
Close biochemical surveillance for persistent gestational neoplasia follows each hydatidiform mole evacuation. This monitoring is by serial measurement of serum 3-hCG to detect persistent or renewed trophoblastic proliferation. s a glycoprotein, hCG shows structural heterogeneity and exists in diferent isoforms. Thus for surveillance, an hCG assay that can detect all forms of hCG should be used (Harvey, 2010; Ngan, 2015). hese are different from those used for routine pregnancy testing (de Medeiros, 2009). he initial 3-hCG level is obtained within 48 hours ater evacuation. This serves as the baseline, which is compared with 3-hCG quantiication done thereater every 1 to 2 weeks until levels progressively decline to become undetectable.