Gestational trophoblastic disease — structured oral station (12 minutes)

Opening prompt — "She is asking if she can still have children. Answer her."

Model response — the prognosis is the reassurance: ^[1][2]

• Set up and listen. Sit at her level, acknowledge the distress, and confirm she has heard the word molar pregnancy before asking what she understands.
• Name the diagnosis plainly: "This is a molar pregnancy — an abnormal fertilisation where the placenta grows into cysts instead of supporting a baby. There is no viable pregnancy here, and that is not your fault."
• Give the prognosis she asked for: "This is one of the most curable conditions we treat. Most women need only the evacuation and follow-up blood tests, and your fertility afterwards is usually normal."
• Then the honesty: "A small proportion go on to need chemotherapy, and even then the cure rate is extremely high. I will follow your pregnancy hormone closely afterwards so that if anything more is needed we catch it early."^[1][2]

Examiner is listening for: the diagnosis in plain language, absolution, the prognostic honesty without doom, and an explicit commitment to follow-up. ^[2]

Probe 1 — "Talk me through the evacuation."

• "Suction evacuation under ultrasound guidance, by an experienced operator, with a large cannula. It is the preferred method regardless of uterine size."^[1][5]
• "I would not give oxytocin until the evacuation is under way — oxytocics before suction can push trophoblast into the circulation and cause lung problems. I would not use medical induction or hysterotomy, because both spread the trophoblast."^[1][6]
• "She is Rh D negative if relevant, so she needs anti-D. And I send all the tissue for histology, because sometimes the diagnosis is only made afterwards — that is how the surveillance gets triggered."^[5][6]

Probe 2 — "What happens after the evacuation?"

• "Serial serum hCG, weekly until it is normal, then at decreasing intervals. I register her with the trophoblast centre so the follow-up does not get lost, and the evidence supports around six months of follow-up after the hCG spontaneously normalises — 98 per cent of persistent disease shows up within six months of evacuation."^[2][3]
• "Contraception throughout. A new pregnancy would reset the hormone clock and we would not be able to tell a pregnancy from recurrent disease."^[2]
• "I would tell her that if her hCG plateaus over four values across three weeks, or rises over three consecutive weekly values, or if choriocarcinoma is found on histology, that meets the FIGO criterion to start chemotherapy."^[2]

Probe 3 — "Her hCG rises over three weekly values. How do you decide the treatment?"

• "I stage and score her. Pelvic ultrasound and a chest radiograph are the basic imaging; a chest CT counts only lung lesions 1 cm or larger. If there is lung disease or suspicion of choriocarcinoma I add brain MRI and full-body imaging."^[2]
• "The FIGO anatomical stage is I for uterus only, II for genital structures, III for lung, IV for elsewhere. The WHO prognostic score has eight variables — age, antecedent pregnancy, interval, pre-treatment hCG, largest tumour size, site and number of metastases, and previous failed chemotherapy — eight in FIGO 2000, seven since the 2026 revision removed the chemotherapy row."^[2][7]
• "Score 6 or below is low risk — single-agent methotrexate with folinic acid or actinomycin-D. Score 7 or above is high risk — EMA-CO. The two are written together, for example Stage I:4."^[2][4]

Probe 4 — "She asks what happens to her fertility with chemotherapy."

• "Single-agent methotrexate does not impair fertility, and most women resume normal cycles. EMA-CO carries a small risk of earlier menopause because of the etoposide, but fertility is generally preserved and subsequent pregnancies are encouraged."^[2]
• "In the next pregnancy she has an early ultrasound, and an hCG six weeks after the end of any pregnancy, whatever its outcome, because the recurrence risk is around 1 per cent."^[5][6][8]

Probe 5 — "What if the hCG stays positive but her urine test is negative?"

• "That is phantom hCG — heterophile antibodies holding the hormone in the serum but not the urine. I confirm with a urine pregnancy test and serial serum dilution before I ever give chemotherapy, because treating a false positive is an avoidable harm."^[2][5]