EARLY DETECTION KEY TO PREVENTING COMPLICATIONS FROM MOLAR PREGNANCY

When a 46-year-old woman found herself pregnant with her sixth child, she decided not to go for any early medical check-up, thinking that she could rely on her previous pregnancy experiences.

One day, when she was in the second trimester (fourth to sixth month of pregnancy), she complained of heavy vaginal bleeding and was rushed to the hospital. An ultrasound scan revealed a “snowstorm appearance”, a classic indicator of an abnormal, and even life-threatening, pregnancy known as a molar pregnancy.

Since the woman arrived late, with an enlarged uterus and uncontrolled bleeding, the medical team had to perform a hysterectomy – the surgical removal of the uterus – as a life-saving measure.

A molar pregnancy is a rare pregnancy complication that can lead to serious consequences if not detected and treated early.

In Malaysia, the prevalence of molar pregnancy stands at 2.6 cases per 1,000 births, much higher than the 0.8 to 1.2 cases per 1,000 births recorded in the United Kingdom. According to experts, becoming pregnant at an advanced age further increases a woman’s risk of developing a molar pregnancy.

WHAT IS A MOLAR PREGNANCY?

Dr Mastura Mat Yusof, consultant obstetrician and gynaecologist at the Columbia Asia Hospital Cheras, said a molar pregnancy occurs when placental cells grow abnormally due to a genetic or chromosomal imbalance during the fertilisation of the ovum. 

There are two types of molar pregnancy – complete mole and partial mole. A complete mole occurs when an empty ovum is fertilised by a sperm, resulting in only the father’s genetic material being present, with no development of a fetus. This type carries a higher risk of developing into serious complications.

Dr Mastura Mat Yusof.

“A partial mole, on the other hand, occurs when an embryo forms with an abnormal number of chromosomes, usually because two sperms fertilise a single ovum. Although there may be some fetal tissue present, it is not viable. However, the risk of it developing into serious complications is much lower compared with a complete mole,” she told Bernama in an interview recently.

She added that one of the main dangers of a molar pregnancy is the risk of it developing into cancer known as gestational trophoblastic neoplasia (GTN).

“GTN refers to a group of cancers that occur when pregnancy tissue continues to grow abnormally and can progress into a more aggressive form of cancer, such as choriocarcinoma, which may spread to other organs such as the lungs or brain,” she explained.

GTN detected at an early stage can usually be fully cured if patients undergo chemotherapy treatment.

Dr Mastura also said that a molar pregnancy is not caused by diet or daily activities as commonly believed. Instead, it occurs randomly due to genetic abnormalities during the fertilisation of the egg.

Regarding the main symptoms of this pregnancy, she said the condition often presents with unusual pregnancy signs, including abnormal vaginal bleeding, severe nausea and vomiting due to excessively high pregnancy hormone levels, and a uterus that enlarges more rapidly than expected for the gestational age.

In some cases, excessively high levels of the hormone beta-hCG (human chorionic gonadotropin) can also affect the thyroid gland because of its structural similarity to thyroid-stimulating hormone, potentially leading to symptoms of hyperthyroidism.

This is why, she added, early pregnancy screening and follow-up monitoring are extremely important.

AGE FACTOR

On older women facing a higher risk of a molar pregnancy, Dr Mastura said as age increases, the quality of the ovum declines, so the likelihood of a molar pregnancy occurring becomes higher, adding that the risk is even greater if a woman has previously experienced a molar pregnancy. 

As for treatment, she said specialists usually perform a uterine evacuation, a special procedure to remove abnormal pregnancy tissue from the uterus.

The risk of pregnancy also increases as a woman ages. With Malaysia now moving towards an aging nation, more women are at risk of getting pregnant at a later age. Pix credit PPTX website.

She explained that unlike a typical miscarriage, molar tissue tends to bleed easily, putting patients at risk of heavier bleeding, especially if treatment is sought late.

“For most patients, uterine evacuation is sufficient as treatment. A hysterectomy is not the standard treatment for such cases or for GTN, and is only performed as a life-saving measure in certain situations, particularly for women who no longer plan to have children and those in high-risk groups,” she said.

Following the uterine evacuation procedure, patients must undergo scheduled monitoring of the beta-hCG hormone to ensure no remaining molar tissue develops into GTN, Dr Mastura explained.

“For complete mole cases, hCG levels are usually monitored weekly until they return to normal, and then monthly for up to six months. During this period, patients are not allowed to become pregnant because a new pregnancy can interfere with the interpretation of hormone readings.

“If the hCG levels fail to decline consistently or begin to rise again, the patient will be referred to a gynaecologic oncologist for further evaluation. In certain cases, treatment with single-agent chemotherapy is sufficient, with a high cure rate and without affecting the chances of future pregnancy,” she said. 

Dr Mastura also said that public awareness of molar pregnancy needs to be increased as many people are still unfamiliar with the condition.

“Therefore, every woman with a positive urine pregnancy test should undergo an early scan to confirm that the pregnancy is located inside the uterus and not outside it, as well as to assess whether the pregnancy is developing normally,” she said.

REFERRAL CENTRE, MONITORING SYSTEM

Meanwhile, Hospital Canselor Tuanku Muhriz (HCTM) consultant obstetrician and gynaecologist Prof Dr Anizah Ali stressed the need to establish dedicated referral centres for molar pregnancy cases to ensure follow-up treatment and monitoring are carried out in a more structured and coordinated manner.

“Such referral centres would enable high-risk patients to receive timely treatment while ensuring monitoring protocols are implemented consistently,” she said, adding that the strength of a referral centre lies in its comprehensive multidisciplinary facilities, including obstetrics and gynaecology, and pathology and radiology units, as well as operating theatres and blood support services.

Prof Dr Anizah Ali.

This infrastructure would also allow complications to be managed more safely and effectively. If a case progresses to GTN, or even the more severe choriocarcinoma, immediate access to oncology specialists and chemotherapy within a clearly structured referral system could accelerate intervention and improve recovery rates.

“Our concern is that the number of cases may be increasing. We cannot continue relying solely on episodic treatment. Detection and monitoring systems need to be better coordinated between public and private hospitals, especially for high-risk cases and patients who live far from specialist centres,” she said, adding that HCTM treats about seven to eight GTN patients each year.

“The number may seem small, but these are cases that have already progressed to serious complications and require specialised oncology treatment,” she said.

She also suggested that the government develop a national molar pregnancy patient registry, or at least establish one at the state level.

Such a registry would not only facilitate more systematic monitoring of follow-up treatment but also enable more efficient data collection for clinical audits and research, thereby strengthening understanding and management of the condition in the future.

She also emphasised that the real challenge is not the initial treatment but ensuring continuity of care and monitoring, as some patients fail to return for hormone level checks due to factors such as logistical constraints, travel costs or psychological trauma after losing a pregnancy.

“Without close monitoring, the risk of progression to GTN may not be detected early. In this context, an effective recall system, the use of digital records and active communication between primary care clinics and referral hospitals are crucial to ensure patients do not drop out of the monitoring process,” she said.