A 28-year-old woman, gravida 2 para 0 aborta 2, comes to the office for follow-up after a suction curettage 2 weeks ago for an empty gestational sac. The patient has had light vaginal spotting since the procedure, but no heavy vaginal bleeding or passage of clots. She has had no fever, abdominal pain, or abnormal vaginal discharge. The patient has no chronic medical conditions and has had no previous surgeries. A year ago, she had a left-sided ectopic pregnancy that was treated with methotrexate. She has no history of sexually transmitted infections. Family history is noncontributory. The patient does not use tobacco, alcohol, or illicit drugs. She has no drug allergies. Temperature is 36.7 C (98 F) and blood pressure is 120/60 mm Hg. BMI is 24 kg/m². Pelvic examination shows a nontender, 6-week-sized uterus and no adnexal masses or tenderness. Speculum examination reveals scant dark blood in the vaginal vault but no active bleeding or abnormal discharge. The pathology report indicates hyperplastic and hydropic trophoblastic villi but no fetal tissue, consistent with a hydatidiform mole. In addition to starting contraception, which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_bf5c_e7e3_8f63_d99a73745e1d_MD0005_00 This patient has a hydatidiform mole (HM), the result of abnormal fertilization of an empty ovum by either 2 sperm or 1 sperm whose genome then duplicates. The resulting gestation contains hypertrophic and hydropic trophoblastic villi that cause a marked elevation in the β-hCG level (>100,000 IU/L). HM is a premalignant disease that can develop into gestational trophoblastic neoplasia (GTN) (eg, choriocarcinoma). abnormal fertilization Treatment of HM involves uterine evacuation via suction curettage (or hysterectomy if childbearing is completed) and surveillance for the development of GTN. β-hCG is secreted by all gestational trophoblastic diseases (eg, HM, choriocarcinoma) and is therefore used as a marker for disease progression and/or remission. After treatment, serial quantitative β-hCG levels are followed weekly until undetectable; a plateau or increase in the β-hCG level diagnoses 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 concerning 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 treatment for HM. Therefore, after 6 months of undetectable β-hCG levels, patients can attempt conception if desired. (Choices A, C, and E) A rising or plateauing β-hCG level after suction curettage is concerning for GTN and requires further evaluation. This evaluation includes a pelvic ultrasound to assess for a pelvic mass and uterine enlargement. In addition, a chest x-ray is performed as the lungs are the most common site of metastasis. Methotrexate is the first-line treatment for GTN. (Choice B) Conservative management with no further testing increases the risk for undiagnosed GTN. Educational objective: Patients with hydatidiform mole are at risk for gestational trophoblastic neoplasia. Management of hydatidiform mole is by suction curettage, after which serial β-hCG levels are followed until they are undetectable for 6 months. Because 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 28-Year-Old Woman, Gravida 2 Para 0 Aborta 2, Comes