Anaesthetic management of hydatidiform mole

1. Preoperative assessment and optimization

• Assess urgency: active heavy bleeding, shock, respiratory distress, severe hypertension, or thyrotoxicosis require senior multidisciplinary management.
• History/examination:
  • Gestational size, vaginal bleeding, hyperemesis
  • Symptoms/signs of hyperthyroidism: tachycardia, tremor, fever, agitation, heart failure
  • Hypertension/proteinuria and cardiopulmonary symptoms
  • Airway and aspiration risk
• Investigations:
  • CBC, blood group/cross-match, coagulation profile
  • Serum electrolytes, renal/liver function
  • Quantitative beta-hCG
  • Thyroid function tests if large mole, marked hyperemesis, or tachycardia
  • ECG; chest radiograph/echo if cardiac failure, pulmonary edema, or suspected pulmonary hypertension
• Secure at least two large-bore IV cannulas. Arrange blood products, rapid infuser, warming device, and vasopressors.
• Correct hypovolemia and anemia cautiously. Do not overload fluid because pulmonary edema can occur.
• If clinically thyrotoxic, control heart rate with a beta-blocker and involve endocrinology. In suspected thyroid storm, stabilize as far as possible, but life-threatening bleeding may necessitate evacuation with full critical-care support.

2. Choice of anaesthesia

• Short, uncomplicated first-trimester evacuation: monitored anesthesia care or total intravenous anesthesia may be suitable in selected stable patients.
• Regional anesthesia: spinal anesthesia can be used in a stable, cooperative patient with minimal bleeding and no coagulopathy. It permits early recognition of respiratory symptoms but may cause hypotension and is less suitable with major hemorrhage or anticipated prolonged surgery.
• General anesthesia with cuffed endotracheal tube: preferred if:
  • heavy bleeding/hemodynamic instability
  • large uterus or high risk of major blood loss
  • full stomach/aspiration risk
  • respiratory compromise, pulmonary edema, or agitation
  • inability to tolerate regional anesthesia
    Use rapid-sequence induction when aspiration risk is significant.

3. Intraoperative management

• Continuous ECG, pulse oximetry, capnography, NIBP. Use an arterial line in large mole, active bleeding, severe thyrotoxicosis, cardiopulmonary disease, or anticipated major transfusion.
• Position lithotomy with careful padding. Keep the patient warm.
• Ensure blood and massive hemorrhage protocol are immediately available.
• Communicate continuously with the obstetrician during cervical dilation and evacuation.
• Uterotonics: have oxytocin ready and administer in coordination with the surgeon. Textbook approaches vary on exact timing: Berek describes beginning an oxytocin infusion before induction, whereas obstetric practice may initiate it once evacuation has begun. Avoid uncoordinated bolus dosing in a hemodynamically fragile patient.
• Anticipate brisk bleeding during cervical dilatation, then a rapid decrease in uterine size after suction. Suction curettage is the preferred fertility-sparing method. Berek & Novak's Gynecology, pp. 2504-2505.
• Use balanced blood-component resuscitation if massive bleeding develops. Send serial Hb, coagulation tests, fibrinogen, blood gas, ionized calcium, and electrolytes.
• Consider tranexamic acid for significant obstetric hemorrhage according to local protocol, unless contraindicated.
• Treat uterine atony with uterotonics and surgical measures led by the obstetrician.

4. Recognize and treat key complications

5. Postoperative care

• Observe in recovery or ICU depending on blood loss, oxygenation, hemodynamics, thyroid status, and uterine size.
• Monitor for delayed hemorrhage, pulmonary edema, hypoxemia, DIC, and thyroid storm, especially during the first several hours.
• Check CBC/coagulation and electrolytes as indicated.
• Give anti-D immunoglobulin to Rh-negative, unsensitized patients.
• Ensure gynecology follow-up for serial quantitative beta-hCG surveillance, as evacuation does not eliminate the risk of persistent gestational trophoblastic neoplasia.

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