A 28-year-old woman from rural Uttar Pradesh presents to the gynaecology clinic with a 3-month history of vaginal bleeding and lower abdominal pain. She reports that her last menstrual period was 4 months ago. On examination, the uterus is enlarged to 20 weeks size, which is disproportionate to the stated period of amenorrhoea. Serum β-hCG is markedly elevated at 850,000 mIU/mL. Transvaginal ultrasound shows a heterogeneous mass filling the uterine cavity with multiple small cystic spaces and no fetal parts. A chest X-ray is normal. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis **Key Point:** The clinical presentation—markedly elevated β-hCG (>500,000 mIU/mL), uterine size disproportionate to amenorrhoea, heterogeneous intrauterine mass with cystic spaces, and absence of fetal parts—is pathognomonic for **complete hydatidiform mole (molar pregnancy)**. ## Risk Stratification This patient has **high-risk molar pregnancy** based on: - β-hCG >100,000 mIU/mL [cite:FIGO 2015 GTD Guidelines] - Uterine size >20 weeks for dates - Absence of metastatic disease on chest imaging **High-Yield:** High-risk molar pregnancy requires chemotherapy, but ONLY after evacuation of molar tissue. Chemotherapy alone without evacuation risks perforation and haemorrhage. ## Management Algorithm ```mermaid flowchart TD A[Complete Molar Pregnancy Diagnosed]:::outcome --> B{Metastatic Disease?}:::decision B -->|Yes| C[Chemotherapy + Evacuation]:::action B -->|No| D{High-Risk Factors?}:::decision D -->|Yes| E[Evacuation First]:::action D -->|No| F[Evacuation + Observation]:::action E --> G[Chemotherapy Post-Evacuation]:::action F --> H[Serial β-hCG Monitoring]:::action G --> I[β-hCG to Undetectable]:::outcome H --> J{β-hCG Plateau/Rise?}:::decision J -->|Yes| K[Start Chemotherapy]:::action J -->|No| L[Continue Monitoring]:::action ``` ## Evacuation Method **Clinical Pearl:** Suction evacuation (vacuum aspiration) under general anaesthesia is the gold standard for molar evacuation, even in high-risk cases. It allows: - Complete removal of molar tissue - Reduced risk of uterine perforation (vs. sharp curettage) - Preservation of fertility - Monitoring for complications (haemorrhage, infection) **Warning:** Medical evacuation (misoprostol) is contraindicated in molar pregnancy due to risk of dissemination of trophoblastic cells and increased malignant transformation. ## Post-Evacuation Management After suction evacuation: 1. Pathological confirmation of molar tissue 2. Baseline β-hCG measurement 3. **Chemotherapy initiation** (methotrexate 1 mg/kg IM weekly or 5-FU regimens) because this is high-risk disease 4. Serial β-hCG monitoring until undetectable for ≥3 consecutive weeks 5. Contraception for 12 months (to avoid confusion with pregnancy-related hCG rise) **Key Point:** Hysterectomy is NOT first-line (patient is young, wishes to preserve fertility). Observation alone is inadequate for high-risk molar pregnancy (>20% risk of persistent gestational trophoblastic neoplasia).