OG9.5 | Gestational Trophoblastic Neoplasia — Summary & Reflection

KEY TAKEAWAYS

Gestational trophoblastic neoplasia begins with the clinical presentation of a molar pregnancy — most often a complete mole presenting with vaginal bleeding, a uterus large for dates, very high β-hCG (often >100,000 mIU/mL), the snowstorm ultrasound pattern, bilateral theca-lutein cysts, hyperemesis, and early-onset hypertension. Complete moles arise from androgenetic diploidy (empty ovum + single sperm that duplicates); partial moles from triploidy. The excess β-hCG drives hyperemesis, theca-lutein cysts, early PET, and subclinical hyperthyroidism.

Management begins with pre-operative assessment including CXR (pulmonary metastases), TFTs (thyroid storm risk), and blood cross-match, followed by suction curettage under anaesthesia with oxytocin started after cervical dilatation. All tissue is sent for histopathology; anti-D is given to Rh-negative women.

Post-evacuation weekly β-hCG surveillance is the critical bridge. Normal β-hCG reaches undetectable levels by 8–12 weeks. A β-hCG plateau (±10% over three weekly assays) or rise (>10% over two consecutive assays) is diagnostic of GTN and mandates referral to a trophoblastic disease centre. OCP contraception during surveillance prevents interpretive confusion. Oncologic staging (FIGO 2002), WHO prognostic scoring, and chemotherapy (methotrexate, actinomycin-D, EMA/CO) are covered in OG34.3.

REFLECT

Consider a woman in a district hospital setting who had a suction evacuation six weeks ago for a molar pregnancy. She returns with persistent light spotting, and her β-hCG is 6,500 mIU/mL — it was 12,000 mIU/mL three weeks ago and 9,000 mIU/mL two weeks ago. Using Kolb's cycle: What did you observe in this encounter? What conceptual framework tells you whether this is a normal or abnormal trajectory? What does the available evidence tell you about the next action? And looking ahead: What generalisation about the β-hCG surveillance window would you carry into your next clinical posting? Reflect on the interplay between your role as the first-contact clinician (safe evacuation, surveillance initiation) and the oncologist's role (staging, chemotherapy) — what does the handoff at the referral trigger require of each?