A 41-year-old woman, gravida 1 para 1, comes to the office for persistent vaginal spotting and lower abdominal pain following an uncomplicated delivery 4 months ago. Since then, she has had bloody discharge of decreasing volume that has not completely resolved. For the past month, the patient has used a sanitary pad that is stained but not saturated with blood at the end of the day. The abdominal pain has been mild but constant and is minimally relieved by over-the-counter analgesics. The patient's last Pap test, during her initial prenatal visit, was normal. Human papillomavirus testing at that time was negative. She is breastfeeding her infant, who is doing well. The patient is a former smoker who has not used alcohol since prior to pregnancy and does not use illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, pulse is 68/min, and respirations are 18/min. BMI is 30 kg/m². Abdominal examination reveals mild lower abdominal tenderness to deep palpation but no masses, rebound, or guarding. Pelvic examination reveals an enlarged uterus and no adnexal masses. Speculum examination shows a dark, irregular 2-cm lesion on the posterior fornix that bleeds after contact with an applicator, with scant blood in the vaginal vault. A urine pregnancy test is positive. Which of the following is the most likely diagnosis for this patient?

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Explanation: 11ec2b69_befb_405e_8f63_2fe525a6bbb0_MD0005_00 After a term vaginal delivery, this patient has abnormal vaginal bleeding, an enlarged uterus, a vascular vaginal lesion, and a positive urine pregnancy test, a presentation consistent with gestational trophoblastic neoplasia (GTN). Choriocarcinoma is the most aggressive form of GTN, and metastasis to the lungs, vagina, central nervous system, or liver often occurs. Abnormal vaginal bleeding is common and can be from either metastatic disease (eg, vaginal lesion) or the primary tumor itself (eg, enlarged uterus). GTN is a type of neoplasm that results from malignant transformation of the chorionic villi or trophoblast. Although GTN is typically a sequela of a hydatidiform mole, it can follow any type of pregnancy, including a normal term delivery, spontaneous abortion, or ectopic pregnancy. Another risk is maternal age >40. In patients with suspected GTN, initial evaluation includes a quantitative β-hCG; thyroid, renal, and hepatic function panels; pelvic ultrasound; and chest x-ray. Treatment options include chemotherapy (typically methotrexate) and hysterectomy. After treatment, β-hCG levels are used as a marker for disease remission or progression. (Choice B) Endometrial polyps can cause abnormal vaginal bleeding; however, they typically present as intermenstrual bleeding. There is no associated abdominal pain or uterine enlargement. Endometrial polyps (Choice C) Patients with an incomplete abortion have vaginal bleeding and a positive pregnancy test. However, there is also associated cervical dilation, and products of conception are frequently visible at the cervical os, neither of which is seen in this patient. incomplete abortion (Choice D) Prolapsing leiomyomas can cause vaginal bleeding and pelvic pain; however, they typically cause heavy menses rather than persistent spotting. Prolapsing leiomyoma appear as round, smooth masses protruding through the cervix. (Choice E) Sarcoma botryoides, a type of vaginal sarcoma, typically presents in infants as a tumor with a "cluster of grapes" appearance. Educational objective: Choriocarcinoma, the most aggressive type of gestational trophoblastic neoplasia, can follow any type of pregnancy and can present with irregular vaginal bleeding. The most common locations for metastasis include the lungs and vagina. References: Gestational choriocarcinoma after term pregnancy: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/25826515) Unusual clinical presentations of choriocarcinoma: a systematic review of case reports. (http://www.ncbi.nlm.nih.gov/pubmed/28254207) Gestational trophoblastic disorders: an update in 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26556906)

A 41-Year-Old Woman, Gravida 1 Para 1, Comes to the Office