A 37-year-old woman, gravida 2 para 1, comes to the office to establish prenatal care. Her last menstrual period was 10 weeks ago. The patient has had some brown vaginal discharge and pelvic pressure over the past several days, but no frank blood or abdominal pain. She also reports mild nausea but no vomiting. The patient was undergoing infertility treatment and had several failed in vitro fertilization cycles before this spontaneous pregnancy. She takes a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs. Blood pressure is 130/80 mm Hg and pulse is 92/min. Speculum examination shows thick brown discharge in the vaginal vault, but no active bleeding. A 12-week-size uterus and bilateral adnexal masses are palpated on bimanual examination. Bedside pelvic ultrasound reveals bilaterally enlarged ovaries and an enlarged uterus filled with a heterogeneous mass composed of cystic structures. A urine pregnancy test is positive. Which of the following is the best next step in management of this patient?

Question

A 37-year-old woman, gravida 2 para 1, comes to the office to establish prenatal care.  Her last menstrual period was 10 weeks ago.  The patient has had some brown vaginal discharge and pelvic pressure over the past several days, but no frank blood or abdominal pain.  She also reports mild nausea but no vomiting.  The patient was undergoing infertility treatment and had several failed in vitro fertilization cycles before this spontaneous pregnancy.  She takes a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 130/80 mm Hg and pulse is 92/min.  Speculum examination shows thick brown discharge in the vaginal vault, but no active bleeding.  A 12-week-size uterus and bilateral adnexal masses are palpated on bimanual examination.  Bedside pelvic ultrasound reveals bilaterally enlarged ovaries and an enlarged uterus filled with a heterogeneous mass composed of cystic structures.  A urine pregnancy test is positive.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da35_370f_bc81_b73443585f90_MD0003_00 This patient's presentation of pelvic pressure, uterine size larger than expected for gestational age, and bilateral adnexal masses is concerning for a hydatidiform mole. Ultrasound findings of a hydatidiform mole include an enlarged uterus filled with a heterogeneous mass of cystic structures, often referred to as a "Swiss cheese" or "snowstorm" pattern. Ovarian theca lutein cysts, as seen in this patient, are common with hydatidiform mole and develop due to ovarian hyperstimulation from markedly elevated β-hCG levels. Risk factors for hydatidiform mole include infertility and extremes of maternal age (≤15 and >35). "snowstorm" pattern Gestational trophoblastic neoplasia (GTN) can arise from a hydatidiform mole, and uterine evacuation via suction curettage is indicated to remove all of the premalignant tissue. Hysterectomy is an alternate management option for patients who have completed childbearing. After uterine evacuation (or hysterectomy), patients are followed with serial β-hCG levels (Choice C). Decreasing β-hCG levels indicate resolution of the hydatidiform mole; plateauing or increasing levels indicate the development of GTN. (Choice A) Misoprostol is contraindicated in the management of hydatidiform mole due to the high risk of incomplete uterine evacuation. (Choice B) Laparoscopy is indicated for large and/or symptomatic ovarian cysts. This patient has no symptoms, and the theca lutein cysts will resolve after treatment of the hydatidiform mole when the β-hCG level decreases. (Choice D) CA-125 is a tumor marker for epithelial ovarian carcinoma and is used to monitor disease progression. Ovarian theca lutein cysts do not express CA-125. (Choice E) Because hydatidiform mole is a premalignant condition, conservative management via repeat ultrasound in 1 week is contraindicated due to increased risk for persistent GTN and/or complications of hydatidiform mole (eg, hyperemesis gravidarum, preeclampsia). Educational objective: A complete hydatidiform mole can present with pelvic pressure, uterine size larger than expected for gestational age, and an ultrasound showing bilateral theca lutein ovarian cysts and an enlarged uterus with a heterogeneous mass composed of cystic spaces. Management includes uterine evacuation with suction curettage. References: Gestational trophoblastic disorders: an update in 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26556906)

A 37-Year-Old Woman, Gravida 2 Para 1, Comes to the Office