A 41-year-old woman comes to the office after a positive home urine pregnancy test. Her last menstrual period was 12 weeks ago. For the past month, the patient has had increasing nausea. She vomits several times a day and has difficulty keeping any food down. The patient has 3 children, all born at term via cesarean section. On this visit, ultrasound demonstrates echogenic intrauterine tissue without an amniotic sac and multiple bilateral ovarian cysts. Hydropic villi are evacuated from the uterus during dilation and curettage. Which of the following should be closely monitored in this patient after the procedure?

Question

A 41-year-old woman comes to the office after a positive home urine pregnancy test.  Her last menstrual period was 12 weeks ago.  For the past month, the patient has had increasing nausea.  She vomits several times a day and has difficulty keeping any food down.  The patient has 3 children, all born at term via cesarean section.  On this visit, ultrasound demonstrates echogenic intrauterine tissue without an amniotic sac and multiple bilateral ovarian cysts.  Hydropic villi are evacuated from the uterus during dilation and curettage.  Which of the following should be closely monitored in this patient after the procedure?

Quizplus · Accepted Answer

11ec160b_3b1d_c297_9249_3f7e2ef98acb_MD0001_00 Hydatidiform moles are the most common types of gestational trophoblastic disease (GTD). A complete mole is composed of multiple cystic, edematous hydropic villi and has the macroscopic appearance of a bunch of grapes as a result of trophoblast proliferation. Microscopy would reveal large, edematous villi with decreased blood vessels, proliferation of the villous trophoblastic lining, and no fetal tissue. Ultrasound confirms lack of the fetal pole and amniotic sac, along with diffuse echogenic material in the uterus (eg, snowstorm pattern). Immunohistochemical stain p57 is negative in complete moles because of the absence of a maternal genome (the corresponding gene is paternally imprinted). Classic clinical findings of a complete mole include first-trimester vaginal bleeding and an enlarged uterine size out of proportion to gestational age. Hyperemesis gravidarum can occur from increased β-hCG secretion by the proliferating trophoblast. Excessive amounts of β-hCG also stimulate ovarian growth and can cause the formation of theca lutein cysts. Preeclampsia, anemia, and hyperthyroidism can also be present with complete moles. β-hCG levels must be monitored after uterine evacuation due to a significant risk of malignant transformation; rising or persistently elevated levels are a red flag for neoplastic conversion (eg, invasive mole, choriocarcinoma). (Choice A) An elevated alpha-fetoprotein (AFP) level in a pregnant woman may suggest a fetal neural tube defect. Other possible causes include underestimation of gestational age, twin gestation, and abdominal wall defects. AFP is also a marker of yolk sac tumors of the ovaries and testes. (Choice C) Carcinoembryonic antigen is a marker followed in patients with colorectal carcinoma and is not elevated in GTD. (Choice D) CA-125 is an ovarian tumor marker and is not used for the evaluation of GTD. This patient's ovarian cysts are likely theca lutein cysts. (Choice E) Vaginal cytology can be used to diagnose sarcoma botryoides (ie, embryonal rhabdomyosarcoma), which can occur in young girls (usually age <5 years). It has a jelly-like cystic appearance (ie, bunch of grapes) and arises from the bladder or vaginal mucosa. This patient's pathology is from the trophoblastic tissue in the uterus. Educational objective: A complete hydatidiform mole is composed of multiple cystic edematous hydropic villi resulting from trophoblast proliferation. Serial measurements of β-hCG should be performed following evacuation of a hydatidiform mole. Persistently elevated or rising levels may signify the development of an invasive mole or choriocarcinoma. __________ References: Gestational trophoblastic disorders: an update in 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26556906)

A 41-Year-Old Woman Comes to the Office After a Positive