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Right Decision Service newsletter: April 2024

Welcome to the Right Decision Service (RDS) newsletter for April 2024. 

Issues with RDS and Umbraco access

Tactuum has been working hard to address the issues experienced during the last week. They have identified a series of three mitigation measures and put the first of these in place on Friday 3rd May.  If this does not resolve the problems, the second mitigation will be actioned, and then the third if necessary.

Please keep a lookout for any slowing down of the system or getting locked out. Please email myself, mbuchner@tactuum.com and onivarova@tactuum.com if you experience any problems, and also please raise an urgent support ticket via the Support Portal.

Thank you for your patience and understanding while we achieve a full resolution.

Promotion and communication resources

A rotating carousel presenting some of the key RDS tools and capabilities, and an editable slideset, are now available in the Resources for RDS providers section of the Learning and Support toolkit.

Redesign and improvements to RDS

The redesign of RDS Search and Browse is still on-track for delivery by mid-June 2024. We then plan to have a 3-week user acceptance testing phase before release to live. All editors and toolkit owners on this mailing list will be invited to participate in the UAT.

The archiving and version control functionality is also progressing well and we will advise on timescales for user acceptance testing shortly.

Tactuum is also progressing with the deep linking to individual toolkits within the mobile RDS app. There are several unknowns around the time and effort required for this work, which will only become clear as the work progresses. So we need to be careful to protect budget for this purpose.

New feature requests

These have all been compiled and effort estimated. Once the redesign work is complete, these will be prioritised in line with the remaining budget. We expect this to take place around late June.

Evaluation

Many thanks to those of you completed the value and impact survey we distributed in February. Here are some key findings from the 65 responses we received.

Figure 1: Impact of RDS on direct delivery of care

Key figures

  • 93% say that RDS has improved evidence-informed practice (high impact 62%; some impact 31%)
  • 91% report that RDS has improved consistency in practice (high impact 65%, some impact 26%)
  • 85% say that RDS has improved patient safety (high impact 59%, some impact 26%)
  • Although shared decision-making tools are only a recent addition to RDS, and only represent a small proportion of the current toolset, 85% of respondents still said that RDS had delivered impact in this area (53% high impact, 32% some impact.) 92% anticipate that RDS will deliver impact on shared decision-making in future and 85% believe it will improve delivery of personalised care in future.

Figure 2 shows RDS impact to date on delivery of health and care services

 

Key figures

These data show how RDS is already contributing to NHS reform priorities and supporting delivery of more sustainable care.

Saving time and money

  • RDS clearly has a strong impact on saving practitioner time, with 90% of respondents reporting that this is the case. 65% say it has a high impact; 25% say it has some impact on time-saving.
  • It supports devolved decision-making across the multi-professional team (85% of respondents)
  • 76% of respondents confirm that it saves money compared, for example, to investing in commercial apps (54% high impact; 22% some impact.)
  • 72% believe it has impacted already on saving money and reducing waste in the way services are delivered – e.g. reducing costs of referral management, prescribing, admissions.

Quality assurance and governance

  • RDS leads are clear that RDS has improved local governance of guidelines, with 87% confirming that this is the case. (62% high impact; 25% some impact.)

Service innovation and workforce development

  • RDS is a major driver for service innovation and improvement (83% of respondents) and has impacted significantly on workforce knowledge and skills (92% of respondents – 66% high impact; 26% some impact).

New toolkits

A few examples of toolkits published to live in the last month:

Toolkits in development

Some of the toolkits the RDS team is currently working on:

  • SARCS (Sexual Assault Response Coordination Service)
  • Staffing method framework – Care Inspectorate.
  • SIGN 171 - Diabetes in pregnancy
  • SIGN 158 – British Guideline on Management of Asthma. Selected sections will be incorporated into the RDS, and complemented by a new chronic asthma pathway being developed by SIGN, British Thoracic Society and NICE.
  • Clinical pathways from NHS Fife and NHS Lanarkshire

Please contact his.decisionsupport@nhs.scot if you would like to learn more about a toolkit. The RDS team will put you in touch with the relevant toolkit lead.

Quality audit of RDS toolkits

Thanks to all of you who have responded to the retrospective quality audit survey and to the follow up questions.  We still have some following up to do, and to work with owners of a further 23 toolkits to complete responses. An interim report is being presented to the HIS Quality and Performance Committee.

Implementation projects

Eight clinical services and two public library services are undertaking tests of change to implement the Being a partner in my care app. This app aims to support patients and the public to become active participants in Realistic Medicine. It has a strong focus on personalised, person-centred care and a library of shared decision aids, as well as simple explanations and videoclips to help the public to understand the aims of Realistic Medicine.  The tests of change will inform guidance and an implementation model around wider adoption and spread of the app.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

Gestational Trophoblastic Disease, (Molar Pregnancy) (423)

Warning

Objectives

This guideline is designed for use within the Early Pregnancy Assessment Service across GGC. The objective is to provide safe management for women with an actual or suspected diagnosis of molar pregnancy. For the purposes of this guideline Molar pregnancy in the first instance refers to pre-malignant molar pregnancies. Malignant pathology may develop later.

Please report any inaccuracies or issues with this guideline using our online form

Incidence in the UK

  • 3:1000 Partial Molar (PHM)
  • 1-3:1000 Complete Molar (CHM)
  • There is a slightly increased risk of molar pregnancy in the very young (<16 years 1.5 x higher incidence) and a significant increase with advanced maternal age (>45 20-50 x higher incidence).
  • The risk of mole is increased by 1-2% following one molar pregnancy and by 15-20% after 2.
  • The risk is not decreased by a change of partner.

Malignant (invasive mole/choriocarcinoma/placental site trophoblastic tumours)

  • The frequency of choriocarcinoma or placental-site trophoblastic tumour is less well known, since these diseases can arise after any type of pregnancy. If suspected, this would require urgent assessment and discussion with Regional Centre.

Please refer to Charing Cross Hospital, Information for Clinicians – https://hmole-chorio.org.uk/info-for-clinicians/

Signs and Symptoms

There are often no signs that a pregnancy is a molar pregnancy. In women with a positive pregnancy test some signs and symptoms in the first or second trimester that may be indicative include -

  • Irregular vaginal bleeding
  • Abdominal pain
  • Hyperemesis
  • Uterus greater than gravid date
  • Early fetal demise
  • Abnormal USS findings

Rarer presentations –

  • Anaemia
  • Excessive uterine enlargement
  • Pre-eclampsia
  • Hyperemesis
  • Hyperthyroidism
  • Respiratory distress

Molar pregnancy may only be suspected/diagnosed at ultrasound examination at 8-14
weeks or found during histological tests carried out after miscarriage.

USS Findings

  • Complete molar pregnancy may show a mass of cells, cystic/orange peel effect/snowstorm effect, without the presence of a foetus
  • Partial molar pregnancy may show an abnormal non-viable foetus and placenta
  • The lack of sonographic molar features does not exclude the possibility of either CHM or PHM.
  • Whenever possible, products of conception from non-viable pregnancies must undergo histological examination to achieve a correct diagnosis regardless of ultrasound findings

MANAGEMENT

Molar evacuation

Suction evacuation is recommended for complete and partial molar pregnancies.

  • Counsel and provide written information
  • Pre-op check FBC, U&E, LFT, TFT’s, G&S and cross match x2units.
  • Inform consultant on-call for gynaecology
  • Arrange surgical evacuation of uterus on a gynaecology list with consultant
  • If >12 weeks(CRL 65mm), discuss management with consultant
  • Molar pregnancy can be associated with excessive bleeding and a consultant should be present throughout the procedure
  • Preparation of the cervix with misoprostol prior to evacuation is thought to be safe.
  • Prolonged use of cervical preparation should be avoided to reduce the risk of embolization of trophoblastic cells.
  • Oxytocin infusion is not recommended prior to completion of the evacuation due to the potential to embolise and disseminate trophoblastic tissue into the venous system. Following completion, if there is ongoing bleeding, consider single dose oxytocin and then follow usual PPH management.
  • All Rh negative women with molar pregnancies (partial or complete) should receive Anti D after evacuation of the uterus.

Combined Molar/Viable pregnancy

Refer to fetal medicine specialist unit

Histopathology and Registration

All women who have had a molar pregnancy enter the surveillance programme.

  • Tissue must be sent to histopathology. Any suspicious tissue will be sent to the Regional Centre in Dundee for confirmation. See contact details below.
  • Request an urgent report
  • Prior to registration patient needs to be forewarned that there is a possibility that she may have a molar pregnancy. This can be done for all losses at time of obtaining SD7’s.
  • Early registration of a confirmed molar pregnancy should take place and the Named Consultant (i.e. the operating consultant) is responsible for this
  • Time taken from surgical evacuation for a definitive diagnosis may be 4 – 5 weeks, but may take longer if extra tests are required

Registration

https://hmole-chorio.org.uk/info-for-clinicians/clinicians_info_registration/

Follow up

All follow up of molar pregnancies will be determined by the Regional Molar Centre on confirmation of diagnosis.

Generally the length of time for HCG to return to normal is less than 8 weeks. However some patients have an elevated but falling hCG level for up to 6 months. Such patients do not require any additional treatment.

It is advised that a further pregnancy is deferred until the end of the follow-up period as a new pregnancy may mask evidence of relapse.

https://hmole-chorio.org.uk/patients_info/

Post-Surgical evacuation advice and Contraception

  • Advise patients that they may have vaginal bleeding for a few weeks postsurgery which should be no heavier than monthly menstruation and should gradually lessen within this time-frame
  • Provide patients with a 24 hour contact number (gynaecology) for worsening symptoms or to attend ED as an emergency if symptoms of heavy vaginal bleeding or severe pain.
  • Practical advice to reduce the chances of bleeding should be given –
    • Avoid sexual intercourse until bleeding has settled
    • Oral contraceptives containing oestrogen and/or progesterone are suitable for use after the evacuation procedure and before the urine hCG result returns to normal.
    • Do NOT use the LNG IUS hormone contraceptive coil immediately post op. However it can be used once the urine or serum hCG has normalised.

Subsequent Pregnancy

  • 1 previous molar pregnancy not requiring chemotherapy - no follow up with hcg tracking required.
  • Two or more molar pregnancies – require registration with Regional Centre, Dundee for postnatal follow up.
  • Chemotherapy treatment required for a molar pregnancy – require registration with Regional Centre, Dundee for postnatal follow up

Contacts/Further Information

Patient information, Charing Cross Hospital (CXH) Trophoblast Disease Service website

Regional Screening Centre for Scotland – Ninewells, Dundee

Hydatidiform Mole Follow-up (Scotland),

Ninewells Hospital and Medical School, Dundee, DD1 9SY.

Tel – 01382 632748
Fax – 01382 496255
Email – TAY.hmolescotland@nhs.scot

UK National Screening Centre – Charing Cross Hospital

Trophoblastic Tumour Screening and Treatment Centre
Department of Medical Oncology
Charing Cross Hospital
Fulham Palace Road
LONDON W6 8RF
UK

http://www.hmole-chorio.org.uk/index.html
Tel: 020 3311 1409
Fax: 020 3313 5577
Email: ichc.hmole@nhs.net

Editorial Information

Last reviewed: 01/01/2021

Next review date: 31/01/2026

Author(s): Jane Scott.

Approved By: Gynaecology Clinical Governance Group

Document Id: 423