A 28-year-old Indian woman presents with vaginal bleeding and severe hyperemesis at 12 weeks gestation. Ultrasound shows a uterus enlarged beyond dates with a heterogeneous echo pattern ('bunch of grapes') and bilateral theca lutein cysts. β-hCG is 250,000 mIU/mL. After evacuation and histopathology confirming complete molar pregnancy, all of the following are appropriate management steps EXCEPT:

Explanation

## Management of Complete Molar Pregnancy **Key Point:** Prophylactic chemotherapy is NOT routinely given to all patients after molar evacuation. It is reserved for patients at **high risk of persistent GTN** or those with **persistent/rising β-hCG** after evacuation. ### Risk Stratification for Persistent GTN **High-Risk Features (warrant prophylactic chemotherapy):** - Age > 40 years - β-hCG > 100,000 mIU/mL - Uterine size > 16 weeks - Theca lutein cysts > 6 cm - Histologic evidence of choriocarcinoma **Low-Risk Complete Moles:** ~80% of complete moles do NOT require prophylactic chemotherapy; surveillance alone is sufficient. ### Correct Management Algorithm ```mermaid flowchart TD A[Complete Molar Pregnancy Confirmed]:::outcome --> B[Suction Evacuation]:::action B --> C{Risk Stratification}:::decision C -->|Low Risk| D[Surveillance β-hCG]:::action C -->|High Risk| E[Prophylactic Chemotherapy]:::action D --> F[Weekly β-hCG until undetectable]:::action E --> G[Weekly β-hCG until undetectable]:::action F --> H[Monthly β-hCG for 6-12 months]:::action G --> H H --> I{β-hCG Rising or Plateau?}:::decision I -->|Yes| J[Treat as Persistent GTN]:::urgent I -->|No| K[Surveillance Complete]:::outcome ``` ### Evacuation Technique **Clinical Pearl:** Suction evacuation (not sharp curettage) is the preferred method to minimize uterine perforation risk. Manual removal of products should be avoided due to high hemorrhage risk. ### Post-Evacuation Surveillance **High-Yield:** β-hCG monitoring is the cornerstone of GTD management: - **Weekly** until undetectable (usually 3–6 weeks) - **Monthly** for 6–12 months - Any rise or plateau → treat as persistent GTN - ~15–20% of complete moles develop persistent GTN ### Pregnancy Counseling **Mnemonic:** **WAIT 6–12 months** before conception to allow complete surveillance and early detection of persistent GTN. Pregnancy itself elevates hCG, confounding surveillance. ### Chemotherapy Agents (if needed) | Agent | Use | Notes | |-------|-----|-------| | Methotrexate | Low-risk persistent GTN | Single-agent, oral or IM | | Actinomycin D | High-risk or resistant disease | Preferred in pregnancy-related GTN | | Combination (EMA-CO) | High-risk choriocarcinoma | Etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine | [cite:Park 26e Ch 23]