SUMMARY STATEMENTS (GRADE ratings in parentheses)
- 1If symptoms of pregnancy persist 4 to 6 weeks after termination of pregnancy, evacuation of a nonviable pregnancy, or spontaneous abortion, measurement of serum or urine human chorionic gonadotropin may allow for earlier diagnosis of gestational trophoblastic disease if products of conception are not sent routinely for pathology (moderate).
- 2The differentiation of complete hydatidiform mole, partial hydatidiform mole, and malignant trophoblastic disease by a gynaecologic pathologist allows for tailored follow-up and management of gestational trophoblastic neoplasia (low).
- 3The treatment of hydatidiform mole consists of surgical evacuation by suction dilatation and curettage or hysterectomy followed by human chorionic gonadotropin surveillance (moderate).
- 4Prophylactic chemotherapy is considered only for high-risk patients who are unlikely to return for regular follow-up (very low).
- 5Post-molar follow-up consists primarily of serial human chorionic gonadotropin monitoring (high).
- 6Hormonal contraception can be safely prescribed and intrauterine contraceptive devices can be inserted after normalization of human chorionic gonadotropin levels (low).
- 7Referral for genetic counseling and testing should be arranged for women with recurrent gestational trophoblastic disease as this is a rare scenario that may be associated with a familial gene mutation (moderate).
- 8The finding of a persistent low-level human chorionic gonadotropin may be benign (e.g., false-positive human chorionic gonadotropin or pituitary production of human chorionic gonadotropin), premalignant (e.g., quiescent gestational trophoblastic disease), or malignant (e.g., placental site trophoblastic tumour or epithelioid trophoblastic tumour) (moderate).
- 9Long-term follow-up may eventually reveal a diagnosis of gestational trophoblastic neoplasia for patients with a true positive human chorionic gonadotropin result but no immediate evidence of disease at the time of testing (low).
RECOMMENDATIONS (GRADE ratings in parentheses)
- 1Women of reproductive age presenting with abnormal uterine bleeding, bleeding >6 weeks following pregnancy, or evidence of metastatic disease should have serum human chorionic gonadotropin levels tested in order to promptly diagnose and manage gestational trophoblastic disease (strong, low).
- 2Any products of conception that appear abnormal at the time of dilatation and curettage should undergo histologic examination to rule out gestational trophoblastic disease (strong, very low).
- 3Initial workup for post-molar gestational trophoblastic neoplasia requires a chest X-ray to look for lung metastases and a pelvic ultrasound scan to assess extent of disease in the pelvis (strong, moderate).
- 4Initial workup for suspected choriocarcinoma, gestational trophoblastic neoplasia after a non-molar pregnancy, and/or post-molar gestational trophoblastic neoplasia with lung metastases on chest X-ray requires pelvic ultrasound scan, computed tomography scan of the chest and abdomen (with arterial phase through the liver), and magnetic resonance imaging of the brain (strong, moderate).
- 5Women with suspected hydatidiform mole should be offered either suction evacuation of the uterus or hysterectomy for initial management (strong, moderate).
- 6All Rh-negative women should be offered anti-D immune globulin after uterine evacuation to prevent alloimmunization (strong, high).
- 7For all patients after evacuation of a molar pregnancy, weekly monitoring of serum quantitative human chorionic gonadotropin should begin 2 weeks post-procedure and continue until levels remain undetectable for 3 consecutive weeks. For complete hydatidiform mole, human chorionic gonadotropin should continue to be monitored monthly for 6 months. For partial hydatidiform mole, human chorionic gonadotropin should be measured 1 month after the first undetectable result to confirm resolution (strong, high).
- 8Women undergoing follow-up after molar pregnancy should receive reliable contraception throughout the entire duration of follow-up (strong, moderate).
- 9For women with previous gestational trophoblastic neoplasia or recurrent molar pregnancy, follow-up in a subsequent pregnancy should include early ultrasound scan, close examination of the placenta, and histologic examination of any nonviable pregnancy (strong, high).
- 10Women diagnosed with gestational trophoblastic neoplasia should be promptly referred to a specialist in gynaecologic oncology for staging, risk scoring, and treatment (strong, high).
- 11Women with low-risk gestational trophoblastic neoplasia should undergo treatment with single-agent chemotherapy, although hysterectomy is an option for select patients (strong, high).
- 12Women with high-risk gestational trophoblastic neoplasia should undergo treatment with multi-agent chemotherapy at a centre with expertise in managing this disease (strong, high).
- 13Ultrahigh-risk gestational trophoblastic neoplasia with liver or brain metastasis or a modified World Health Organization score as adapted by the International Federation of Gynecology and Obstetrics (FIGO),56of ≥13 should undergo low-dose induction chemotherapy with etoposide and cisplatin weekly for 1 to 3 weeks to avoid complications of uncontrolled hemorrhage followed by multi-agent chemotherapy at a centre with expertise in managing this disease, preferably at a reference centre (strong, high).
- 14Women who become pregnant during follow-up for gestational trophoblastic disease or gestational trophoblastic neoplasia should be referred to gynaecologic oncology and maternal–fetal medicine for assessment and management (strong, very low).
- 15The care of patients with gestational trophoblastic disease should be managed in specialized centres and their data recorded in centralized (regional and/or national) registries, where possible (strong, high).
Abbreviations:GTD (Gestational trophoblastic disease), GTN (Gestational trophoblastic neoplasia), hCG (Human chorionic gonadotropin), hCG-H (Hyperglycosylated human chorionic gonadotropin)
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