One of the young Malawan doctors came to me a few days ago with an ultrasound image that he had obtained a few minutes earlier from a woman 4 months pregnant. He asked me if I agreed that it looked like a molar pregnancy. Instead of a fetus within a fluid-filled gestational (amniotic) sac, the scan showed the classic “cluster of grapes” described in books that he had remembered from medical school.
A molar pregnancy is essentially a cancer of the placenta, usually managed with a “D&C” (dilatation and curettage), a gentle suctioning of the uterine lining. This is followed by serial measurements of human chorionic gonadotropin (HCG, now of diet fad fame), which is only produced by a placenta. If there is any of the “mole” left, HCG will show up on the blood tests, prompting effective and well-tolerated chemotherapy (methotrexate). No HCG means the molar pregnancy was completely removed; no further treatment indicated
Worried that with this advanced gestational sac, the D&C might not entirely remove the molar pregnancy, I recommended hysterectomy. This was an unplanned pregnancy; she's 42; an easy decision for both of us.
Surgery went well, but follow-up will be difficult. The hospital has no HCG blood test and no readily available methotrexate. I recommended weekly urine pregnancy tests, a less sensitive measure of HCG; if repeatedly negative, she's ok, if positive, someone needs to find MTX for her.
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