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
Questions
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Describe what you see on the ultrasound.
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.
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What is your diagnosis?
Molar pregnancy
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What is your next step in management?
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