What is the criterion standard for identifying both complete and partial molar pregnancies?
Correct Answer A:
A molar pregnancy is a mass of abnormal tissue (hydatidiform mole) that comes from the placenta inside the uterus, which triggers symptoms of pregnancy. About 1 out of 1,000 women with early pregnancy symptoms has a molar pregnancy.
There are two types of molar pregnancy: complete and partial.
If there are symptoms that suggest a molar pregnancy, one should do a pelvic exam, an hCG level, and a pelvic ultrasound, which can confirm a molar pregnancy. Molar pregnancy may also be found during a routine ultrasound in early pregnancy.
Ultrasonography is the criterion standard for identifying both complete and partial molar pregnancies. The classic image, using older ultrasonographic technology, is of a snowstorm pattern representing the hydropic chorionic villi. High-resolution ultrasonography shows a complex intrauterine mass containing many small cysts.
A 34-year-old woman presents to her doctor because she thinks she is pregnant, but is frightened because she has had a lot of bleeding yesterday with clumps that looked like ‘grapes’. She is very worried and upset.
Which of the following did she likely have?
Correct Answer D:
A hydatidiform mole is growth of an abnormal fertilized egg or an overgrowth of tissue from the placenta. Most often, a hydatidiform mole is an abnormal fertilized egg. The abnormal egg develops into a hydatidiform mole rather than a fetus (a condition called molar pregnancy). However, a hydatidiform mole can develop from cells that remain in the uterus after a miscarriage or a full-term pregnancy.
Women who have a hydatidiform mole feel as if they are pregnant. But because hydatidiform moles grow much faster than a fetus, the abdomen becomes larger much faster than it does in a normal pregnancy. Severe nausea and vomiting are common, and vaginal bleeding may occur. These symptoms indicate the need for prompt evaluation by a doctor.
Often, doctors can diagnose a hydatidiform mole shortly after conception. No fetal movement and no fetal heartbeat are detected. As parts of the mole decay, small amounts of tissue that resemble a bunch of grapes may pass through the vagina. After examining this tissue under a microscope, a pathologist can confirm the diagnosis.
A 27-year-old nulligravida presents in the office complaining of bilateral painful breasts. Clinical examination reveals that both breasts are tender and contain multiple tender, shotty nodules that are immovable.
The most likely diagnosis is:
Correct Answer C:
Fibrocystic changes refer to mastalgia, breast cysts, and nondescript lumpiness, which may occur in isolation or together; breasts have a nodular and dense texture and are frequently tender when palpated. Fibrocystic changes cause the most commonly reported breast symptoms and have many causes.
Most causes are not associated with increased risk of cancer; they include adenosis, ductal ectasia, simple fibroadenoma, fibrosis, mastitis, mild hyperplasia, cysts, and apocrine or squamous metaplasia. Other causes, particularly if fibrocystic changes require biopsy, may slightly increase risk of breast cancer. Fibrocystic changes is a common condition affecting 30% to 60% of child bearing age women (between 20 and 45 years of age).
→ Carcinoma of breast (choice A) is more common in women > 40, common cancers have painless nodules;few present with pain especially the rare inflammatory breast cancer presents with pain; however, it doesn't fit the description of this patient's condition and its likelihood is very low.
→ Galactocele (choice B) is a benign lesion that commonly occurs in lactating women. This patient is nulligravida.
→ Intraductal papilloma (choice D) is incorrect. Intraductal papillomas can be central, large and solitary near the nipple, which is not seen in this patient. They can also be multiple and peripheral, but they are also associated with nipple discharge, which is not present in this patient.
→ Fibroadenomas (choice E) also are common in women of childbearing age, but they are usually non-tender and they are highly movable on palpation.
A 32-year-old woman presents to the outpatient clinic with a 7-month-history of amenorrhea and hot flushes. She denies any symptoms of pregnancy and the uterus is of normal size.
The most appropriate test to support a diagnosis of premature ovarian failure is:
Premature menopause (premature ovarian failure - POF) is the permanent end of menstrual periods before age 40 because the ovaries become unable to produce hormones because ovulation stops. You should suspect premature menopause when women younger than 40 have menopausal symptoms.
Studies to establish the diagnosis of POF are as follows:
A 23-year-old asymptomatic woman is seen for routine examination. You are able to palpate a 4 cm diameter right sided cystic adnexal mass.
The appropriate management is:
Adnexal masses are frequently found in both symptomatic and asymptomatic women. In premenopausal women, physiologic follicular cysts and corpus luteum cysts are the most common adnexal masses, but the possibility of ectopic pregnancy must always be considered. Other masses in this age group include endometriomas, polycystic ovaries, tuboovarian abscesses and benign neoplasms.
Malignant neoplasms are uncommon in younger women but become more frequent with increasing age. In postmenopausal women with adnexal masses, both primary and secondary neoplasms must be considered, along with leiomyomas, ovarian fibromas and other lesions such as diverticular abscesses.
Information from the history, physical examination, ultrasound evaluation and selected laboratory tests will enable you to find the most likely cause of an adnexal mass. An ultrasound examination (choice C) is the most valuable diagnostic study in the evaluation of an adnexal or pelvic mass. Ultrasound can also indicate whether a mass is cystic or solid, whether its contour is smooth or contains excrescences, and whether it contains any internal septa or papillae. It is best to obtain both transvaginal and transabdominal sonograms to evaluate a pelvic or adnexal mass. Transvaginal ultrasonography has several advantages in that it provides improved resolution of pelvic structures with less artifact and does not require a distended bladder for visualization.
→ All adnexal masses that are symptomatic or have characteristics of a malignancy should be considered for surgical evaluation (choice A). This is not the case with this patient.
→ Transvaginal aspiration of ovarian cysts (choice B) has been advocated as a viable alternative to surgery in patients who are high-risk surgical candidates. Given this patient's history and presentation, we can safely conclude that she does not need this procedure done.
→ Several studies have shown that monophasic oral contraceptives (choice D) are associated with suppression of functional cysts. Pre-menopausal patients are often given a monophasic contraceptive preparation and then reexamined in four to six weeks.
→ Premenopausal patients with an asymptomatic cystic mass smaller than 10 cm can be followed (choice E), because 70 percent of these masses will resolve. However, its characteristics need to be confirmed by ultrasound first.
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