A 29-year-old woman comes to the emergency department with chest pain and dyspnea for 10 days. The chest pain is bilateral, dull, persistent, and not worsened by exertion. The patient's medical history is significant for a normal spontaneous vaginal delivery 3 months ago, after which she has had frequent episodes of dark, bloody vaginal discharge. The most recent bleeding episode was 6 days ago. The patient has no fever, chills, hemoptysis, orthopnea, or leg pain. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37.5 C (99.5 F), blood pressure is 110/68 mm Hg, pulse is 80/min, and respirations are 16/min. BMI is 26.2 kg/m². Physical examination reveals bilaterally clear lungs. The extremities are warm and well perfused. There is no peripheral edema. Pelvic examination reveals an enlarged uterus, a closed cervix, and minimal dark blood in the vagina. Complete blood count and serum electrolytes are within normal limits. Chest x-rays reveal multiple bilateral infiltrates of various shapes. Which of the following would be most helpful in establishing this patient's diagnosis?

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11ec25c8_d9c1_b3fd_bc81_8bf27ebd9026_MD0003_00 Choriocarcinoma is a form of gestational trophoblastic neoplasia, a malignancy that arises from placental trophoblastic tissue and secretes β-hCG. Although it most commonly follows a hydatidiform mole, choriocarcinoma can occur after a normal gestation or spontaneous abortion. Choriocarcinoma typically presents <6 months after a pregnancy. Presenting symptoms include irregular vaginal bleeding, an enlarged uterus, and pelvic pain. Choriocarcinoma is an aggressive type of gestational trophoblastic neoplasia; the most common site of metastatic spread is to the lungs. Symptoms of pulmonary metastasis include chest pain, hemoptysis, and dyspnea. When choriocarcinoma is suspected, obtaining a quantitative β-hCG level helps to confirm the diagnosis. (Choice A) The staging system for choriocarcinoma relies on chest x-ray, rather than chest CT scan, findings. Therefore, in this patient with known pulmonary metastases on chest x-ray, a chest CT scan is not indicated and would not change management. Even among patients with choriocarcinoma who have a negative chest x-ray, the detection of metastasis on chest CT scan is not associated with worsened outcomes and does not alter management. (Choices B, C, and E) A ventilation perfusion scan is best at identifying pulmonary embolism. Echocardiogram can show evidence of myocardial infarction and heart failure, and pulmonary function tests can identify obstructive and restrictive lung diseases. Although pulmonary embolism, myocardial infarction, and obstructive/restrictive lung diseases could all explain this patient's dyspnea and chest pain, none of them explain her irregular vaginal bleeding or enlarged uterus. Furthermore, her chest x-ray findings are most consistent with metastasis. Educational objective: Choriocarcinoma is a metastatic form of gestational trophoblastic neoplasia that may occur after a hydatidiform mole, normal pregnancy, or spontaneous abortion. The lungs are the most frequent site of metastasis. Choriocarcinoma should be suspected in postpartum women with an enlarged uterus, irregular vaginal bleeding, pulmonary symptoms, and multiple infiltrates on chest x-ray. Diagnosis is confirmed by an elevated β-hCG level. References: Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. (http://www.ncbi.nlm.nih.gov/pubmed/20728069)

A 29-Year-Old Woman Comes to the Emergency Department with Chest