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After your resident scans through the entire uterus and cervix, he turns his attention to both adnexa. Satisfied with his thorough views of the pelvis, he tells the patient that he is going to order a comprehensive ultrasound via radiology to obtain a bit more information about her pregnancy. He informs them that he will come back to check on her and that he will let her know as soon as possible what her test results are.
click on images to enlarge
“I can’t believe our bad luck tonight!” your resident says, wide eyed with disbelief. “A molar pregnancy?!” You review the images with your resident outside of the room and highlight the “cluster of grapes” appearance noted on the scan. There are no theca lutein cysts in her ovaries and she has good flow on color Doppler bilaterally. Your team promptly orders a serum ß-hCG level, CBC, CMP, TSH, free T4, and a coagulation panel off of the blood that was drawn earlier. You also order a CXR to evaluate for metastases. As expected, the patient’s ß-hCG level is remarkably elevated at 310,000 mIU/mL. Fortunately, the remainder of her lab tests and CXR are unremarkable.
Your resident consults Ob/Gyn for admission and D&E, and you proudly watch your senior resident deliver the unfortunate news with sensitivity and empathy. Before you know it, the end of your shift arrives, and you and your hard-working overnight team step out into the sunshine – a new day and a fresh start.
Editor’s Note: Gestational Trophoblastic Disease, By the Numbers
- GTD occurs in about 1 per 1700 U.S. pregnancies, but is more common in other parts of the world (Japan).
- Most GTD is benign hydatidiform mole (80%), but more malignant forms of GTD include invasive mole (12-15%) and choriocarcinoma (5-8%) which can metastasize to the lung, liver, and brain -- and is very sensitive to chemotherapy GTD is often associated with a markedly elevated ß-hCG.
- The typical patient presents with nausea, vomiting, and vaginal bleeding
- Qualitative hCG testing may be negative
- Molar pregnancy can coexist with ectopic pregnancy
- Molar pregnancy related thyroid storm has been described and should be considered in any pregnancy female with suspicion for GTD and symptoms compatible with thyrotoxicosis
continue to next page for pearls and pitfalls of the pelvic ultrasound