The Case

CC

Positive home pregnancy test

HPI

31F G2P1 presents with positive home urine pregnancy test. She states that she is 5 days late on her period. Reports vaginal spotting and abdominal cramps two days ago which have now resolved.  Has had no prenatal care. Now completely asymptomatic.

Physical Exam

VS: BP 99/54, HR 55, RR 18, O2 100% RA, afebrile
NAD, AAOx3
CTAB, RRR no r/g/m
Abdomen soft, non-tender, non-distended
No ext edema
Pelvic: no CMT/adnexal fullness/tenderness. Os closed. No blood or discharge
See bedside TVUS movie clip

Labs

Beta – 36246
CBC – 5.6>12.4/37.2<262
BMP – 138/3.5/105/22/13/0.6<86
T&S – O+
UA – small 1+ LE, 2-5 WBC, 1-10 epithelial cells, few bacteria

Media


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Questions

  1. Describe what you see on the ultrasound.

    Show Answer

    Endometrial cavity with IUP and gestational sac, but abnormal tissue consistent with “cluster of grapes” appearance adjacent to the IUP. Multiple sub-centimeter cystic structures. No free fluid.

  2. What is your diagnosis?

    Show Answer

    Molar pregnancy

  3. What is your next step in management?

    Show Answer

    Order preoperative labs and consult GYN

More Info

GYN consult TVUS also revealed findings consistent with a likely partial molar pregnancy. As the patient was deemed hemodynamically stable, she was given close outpatient clinic follow up in a few days in order to schedule an outpatient diagnostic and therapeutic D&C. Two weeks later the patient had a successful D&C without any complications. Pathology confirmed the diagnosis of partial molar pregnancy.

 

Facts of Molar Pregnancy

  • Hydatidiform mole (HM) is a type of gestational trophoblastic (GTD) that has the potential to locally invade the uterus or metastasize. It is a maternal tumor that arises from gestational tissue.
  • Partial moles can coexist with an IUP however there is a high rate of intrauterine death. It is commonly misdiagnosed as an incomplete or missed abortion until pathology is performed.
  • Risk factors for partial molar pregnancy include prior molar pregnancy and extreme maternal ages (<15 and >35 years)
  • Serum hCG in women with HM are usually higher than IUP or ectopics, however partial moles have lower hCGs than complete moles
  • A TVUS of a partial mole typically shows an IUP, placenta with enlarged cystic spaces. A complete molar pregnancy classically looks like a heterogenous mass with numerous discrete anechoic spaces (“snowstorm / swiss cheese pattern”).
  • Uterine evacuation is the mainstay of treatment. Follow up weekly serum hCGs are measured until it is undetectable. A rise in hCG after evacuation may represent recurrence