A 38-year-old woman, gravida 1 aborta 1, comes to the office for follow-up a week after suction curettage. The patient initially presented 7 weeks after her last menstrual period for an initial prenatal appointment. At that time, she had breast tenderness but no abdominal pain, nausea, or vaginal bleeding. During that visit, ultrasound revealed an empty gestational sac. β-hCG level was 53,256 IU/L. The patient returned a week later and repeat ultrasound confirmed a missed abortion. Suction curettage was performed and the pathological specimen from the procedure indicated a diagnosis of hydatidiform mole. Today, the patient has minimal bleeding but no pain, fevers, chills, or abnormal vaginal discharge. Blood pressure is 110/80 mm Hg and weight is 55 kg (121.3 lb). Pelvic examination shows minimal dark red blood in the vaginal vault and no active bleeding. On bimanual examination, the uterus is small and nontender. No adnexal masses are palpated. β-hCG level is 1,412 IU/L. Which of the following is the best next step in management of this patient?

Question

A 38-year-old woman, gravida 1 aborta 1, comes to the office for follow-up a week after suction curettage.  The patient initially presented 7 weeks after her last menstrual period for an initial prenatal appointment.  At that time, she had breast tenderness but no abdominal pain, nausea, or vaginal bleeding.  During that visit, ultrasound revealed an empty gestational sac.  β-hCG level was 53,256 IU/L.  The patient returned a week later and repeat ultrasound confirmed a missed abortion.  Suction curettage was performed and the pathological specimen from the procedure indicated a diagnosis of hydatidiform mole.  Today, the patient has minimal bleeding but no pain, fevers, chills, or abnormal vaginal discharge.  Blood pressure is 110/80 mm Hg and weight is 55 kg (121.3 lb).  Pelvic examination shows minimal dark red blood in the vaginal vault and no active bleeding.  On bimanual examination, the uterus is small and nontender.  No adnexal masses are palpated.  β-hCG level is 1,412 IU/L.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da36_e3c2_bc81_1d753424a943_MD0003_00 A complete hydatidiform mole is the result of abnormal fertilization of an empty ovum by either 2 sperm or 1 whose genome then duplicates. The resulting gestation contains hypertrophic and hydropic trophoblastic villi that cause a marked elevation in the β-hCG level. Hydatidiform mole is a premalignant disease that can develop into gestational trophoblastic neoplasia (GTN), such as choriocarcinoma. β-hCG is secreted by all gestational trophoblastic diseases (eg, hydatidiform mole, choriocarcinoma) and is therefore used as a marker for disease progression and/or remission. abnormal fertilization Treatment of a hydatidiform mole involves uterine evacuation via suction curettage and surveillance for the development of GTN. After suction curettage, β-hCG levels are followed weekly until undetectable; a plateau or increase in the β-hCG level is diagnostic of GTN. Once the β-hCG becomes undetectable, monthly monitoring of β-hCG levels continues for 6 months. During that time, a newly detectable β-hCG level is diagnostic for GTN. During the surveillance period, contraception is prescribed as pregnancy would make it hard to determine the significance of a rising β-hCG level and to treat GTN. GTN rarely develops >6 months after suction curettage for a hydatidiform mole. Therefore, after 6 months of undetectable β-hCG levels, patients who are interested can attempt conception. (Choices A, C, and E) It can take as long as 8 weeks after uterine evacuation for β-hCG levels to become undetectable. This patient's decreased β-hCG level is consistent with recent suction curettage. If the β-hCG levels began to increase or plateau, GTN would be diagnosed. First-line treatment for GTN includes methotrexate or hysterectomy. A repeat suction curettage is not indicated in the management of gestational trophoblastic disease (eg, HM or GTN). (Choice D) A hydatidiform mole is typically due to an abnormal fertilization, not a chromosomal abnormality, and parental karyotype is not indicated. (Choice F) CA-125 is a tumor marker for epithelial ovarian cancer and is not indicated in the management of gestational trophoblastic disease. Educational objective: Patients with hydatidiform mole are at risk for gestational trophoblastic neoplasia. Management of hydatidiform mole is by suction curettage, followed by serial β-hCG levels until levels are undetectable for at least 6 months. As pregnancy makes it difficult to determine the significance of a rising β-hCG level, contraception is required during the surveillance period. References: Current management of gestational trophoblastic diseases. (http://www.ncbi.nlm.nih.gov/pubmed/18851873)

A 38-Year-Old Woman, Gravida 1 Aborta 1, Comes to the Office