MOLAR PREGNANCY: FOLLOW-UP BEYOND ONE UNDETECTABLE SERUM β-hCG, IS IT
NECESSARY?
Nirmala CK, Harry SR, Nor Azlin MI, Lim PS, Shafiee MN, Nur Azurah AG, Shamsul AS, Omar MH, Hatta MD
Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur.
Malaysia.
INTRODUCTION
Gestational trophoblastic disease is a
common gynaecological problem in Asia
with incidence of 1 to 3 in 1000
pregnancies 2-7.
In Malaysia, the estimated incidence of
molar pregnancy was 2.8 in 1000 deliveries
in 19981.
METHODOLOGY AND RESULTS
Between January 2005 and December
2010, 102 patients were diagnosed to
have molar pregnancy.
The incidence of hydatidiform mole
was 2.6 per 1000 deliveries in our
centre.
GTD is considered highly curable, but
accurate initial management is essential.
GTD produces serum β-hCG level (human
chorionic gonadotropin), which can be
measured in either urine or serum and will
be extremely high in molar pregnancy.
After molar evacuation, patients should be
followed with serum β-hCG level
monitoring and are considered to have
achieved remission when serum β-hCG
level decline to undetectable level within
six months.
In view of possible theoretical risk of
relapse
or
developing
persistent
gestational trophoblastic disease (pGTD),
the patients are recommended for
continued follow-up with serum β-hCG
level for a period of two years.
Women often defaulted follow-up and do
not complete the recommended long
protocol. The long protocol has caused
significant practical and emotional
complications to the woman and her
family.
OBJECTIVES
To determine the need to continue follow-up
for uncomplicated molar pregnancy beyond
attaining one undetectable serum β-hCG
level.
The number of defaulters and the number of
patient who relapsed after achieving one
undetectable serum β-hCG level were
determined.
This study will help to evaluate our hospital
protocol for follow-up of patients with molar
pregnancy with an aim to change our future
surveillance policy to ensure an optimal care.
RESULTS
Histology diagnosis
n=102 (%)
Complete hydatidiform mole
47 (46.1)
Partial hydatidiform mole
57 (53.9)
Mean pre-evacuation serum β-hCG level (mIU/ml) p=0.47
 Complete hydatidiform mole 491328.18±806110.13
 Partial hydatidiform mole
210707.10±373543.58
Mean post-evacuation serum β-hCG level (mIU/ml) p=0.45
 Complete hydatidiform mole 58380.10±132812.97
The mean age of patients with molar
pregnancy were 31.98±7.86 years
with minimum age 17 years old and
maximum age 55 years old.
DISTRIBUTION OF AGE GROUP IN
PATIENTS WITH MOLAR PREGNANCY
4%
16%
80%
LESS THAN 20
20-40
 Partial hydatidiform mole
27058.66±78113.26
The number of patients who developed persistent
trophoblastic disease before attaining one undetectable
serum β-hCG level was 4 (3.9%).
The number of patient with uncomplicated molar
pregnancy was 98 out of 102 patients (96.07%).
28 out of 102 (27.5%) of the patients defaulted follow-up
before completion of protocol.
15 out of 28 (53.5 %) had get pregnant before completed
follow up and the rest 13 out of 28 (46.4%) were loss
follow up.
40 AND BEYOND There was no patient who appeared to have relapsed
Majority of the patient were multiparous
(69.6 %)
following one undetectable serum β-hCG level in
uncomplicated molar pregnancy.
DISCUSSION
Mean gestational weeks at presentation was
10.71±3.43 weeks. The most advanced
gestational week at the time of diagnosis was
at 24 weeks.
This study recommended that patient with uncomplicated
molar pregnancy to have a shorter duration of follow up
not exceeding six months after one undetectable serum βhCG level.
60 patients (58.8%) had normal antecedent
pregnancy. Only one patient had a previous
complete hydatidiform molar pregnancy.
This provided minimal additional benefit while increasing
financial and emotional burden to patient and maybe one
of the contributing factors for defaulting follow-up.
Presenting clinical features
Vaginal bleeding
Hyperemesis
Symptom of thyrotoxicosis
Clinical diagnosis miscarriage
Hypertension
n=102
(%)
97 (95.1)
4 (3.9)
1 (1)
31 (30.4)
4 (3.9)
Sign of thyrotoxicosis
Uterus larger than dates
1 (1.0)
18 (17.6)
Ultrasound ‘snow-storm’ feature
48 (47.1)
Presenting initial diagnosis
Molar pregnancy
70 (68.6)
Miscarriage
32 (31.4)
The limitation of this study was being a retrospective
study, thus, all measurement and the result reflect the
situation in UKMMC at that particular time.
A prospective study need to be done in our centre with a
revised protocol and an audit to determine whether any
patient relapse following one undetectable serum β-hCG
level.
REFERENCES
Sivanesaratnam V. The management of gestational trophoblastic disease in developing countries such as Malaysia. International
Journal of Gynaecology & Obstetrics 1998. 60(1): 105-109.
Ross SB, Donald PG. Current management of gestational trophoblastic diseases. Gynecologic Oncology. 2009; 112: 654 – 662.
Mungan T, Kuscu E, Dabakoglu T et al. Hydatidiform mole: clinical analysis of 310 patients. Int J Gynecol Obstet. 1996; 52: 233-236.
Dalya A, Tommaso B, George C et al. Recognising gestational trophoblastic disease. Best Practice & Research Clinical Obstetrics and
Gynaecology. 2009; 23: 565-573.
Soper JT, Mutch DG, Schink JC. American College of Obstetrician and Gynecologists. Diagnosis and treatment of gestational
trophoblastic disease: ACOG Practice Bulletin No.53. Gynecol Oncol. 2004; 93(3): 575-585.
Altieri A, Franceshi S, Ferlay et al. Epidemiology and aetiology of gestational trophoblastic diseases. Lancet Oncol. 2003; 4(11): 670678.
Audu BM, Takai IU, Chama CM et al. Hydatidiform mole as seen in a university teaching hospital: a 10-year review. J Obstet gynaecol.
2009; 29(4): 322-325.
Hou JL, Wan XR, Xiang Y et al. Changes of clinical features in hydatidiform mole: analysis of 113 cases. J Reprod Med. 2008; 53(8):
629-633.