Expulsion of all fetal and placental tissue from the uterine cavity at 10 weeks’ gestation.
Match the description with the correct type of abortion.
Bleeding occurs in about 30% to 40% of pregnancies before 20 weeks’ gestation, with about half of these pregnancies ending in spontaneous abortion. A threatened abortion describes uterine bleeding that occurs without any cervical dilation or effacement. Inevitable abortion occurs when there is bleeding and cervical dilation, with or without rupture of membranes. Incomplete abortion is when only a portion of the products of conception have been expelled, and the cervix remains dilated. In cases where all fetal and placental tissue have been expelled, the cervix is closed, bleeding is minimal, and uterine cramps have ceased, a diagnosis of complete abortion may be made. A missed abortion is one in which fetal death occurs before 20 weeks’ gestation without expulsion of any fetal or maternal tissue for at least 8 weeks thereafter. When a fetus is retained in the uterus beyond 5 weeks after fetal death, consumptive coagulability with hypofibrogenemia may occur. This is uncommon, however, in gestations of less than 14 weeks in duration.
A 19-year-old P0 presents for her first prenatal visit. She is 12 weeks’ pregnant by sure last menstrual period. She reports vaginal bleeding, and on physical examination, you appreciate a 16-week size uterus. You are unable to detect fetal heart tone with a Doppler. The ultrasound shown is obtained.
Which of the following best describes the patient’s diagnosis?
The history, clinical picture, and ultrasound of the woman in the question are characteristic of hydatidiform mole, which are usually diagnosed during the first trimester. The most common symptom is vaginal bleeding, often accompanied by an enlarged-for-dates uterus. Other signs and symptoms include absent fetal heart tones, cystic enlargement of the ovaries, hyperemesis gravidarum, hypertension, and abnormally high levels of hCG for gestational age. Ultrasound, such as this one, typically shows a diffuse mixed echogenic pattern, classically referred to a “snowstorm” pattern. The most common chromosomal makeup for partial mole is 69, XXX, or 69, XXY, and for complete mole is 46, XX. Hydatidiform mole is 10 times as common in the Far East as in North America, and it occurs more frequently in women older than 45 years of age. Grossly, these lesions appear as small, clear clusters of grapelike vesicles, the passage of which confirms the diagnosis. Hysterectomy may be considered as primary therapy for molar pregnancy in women who have completed childbearing.
The patient undergoes suction dilation and curettage (D&C) for management of the suspected molar pregnancy. The pathology report reveals trophoblastic proliferation and hydropic degeneration with the absence of vasculature; no fetal tissue is identified. A chest x-ray is negative for any evidence of metastatic disease.
Which of the following is the best next step in her management?
Molar pregnancies without evidence of metastatic disease should be followed routinely by hCG titers after uterine evacuation. ACOG guidelines suggest weekly hCG values until nondetectable for 3 weeks, followed by monthly titers for 6 months. After 6 months, the patient may resume trying to get pregnant if she wishes. During this followup period, it is very important that the patient be on reliable contraception, because an elevated hCG may indicate a new pregnancy versus postmolar gestational trophoblastic neoplasia. Most authorities agree that prophylactic chemotherapy should not be routinely employed, because 85% and 90% of affected patients will require no further treatment. For a young woman in whom preservation of reproductive function is important, hysterectomy is not routinely indicated.
Which of the following would be an indication to start single-agent chemotherapy?
Single-agent chemotherapy is usually instituted if postmolar gestational trophoblastic neoplasia is diagnosed. Recently, the International Federation of Gynecologists and Obstetricians (FIGO) standardized criteria for the diagnosis of postmolar gestational trophoblastic neoplasia—1- an hCG level plateau of 4 values +/- 10% over 3 weeks; 2- an hCG level increase of greater than 10% of three values over 2 weeks, 3- persistence of detectable hCG for more than 6 months after molar evacuation. New intrauterine pregnancy should always be ruled out. Single-agent chemotherapy (usually with methotrexate or actinomycin-D) should be instituted, provided that the trophoblastic disease has not metastasized to the liver or brain. The presence of such metastases usually requires initiation of multiagent chemotherapy.
A 32-year-old woman presents to the emergency department with abdominal pain and vaginal bleeding. Her last menstrual period (LMP) was 8 weeks ago, and her pregnancy test is positive. Her blood pressure is 85/65 mm Hg and her pulse is 110 beats per minute. On examination, her abdomen is distended and tender. A bedside abdominal ultrasound shows free fluid within the abdominal cavity. The decision is made to take the patient to the operating room for emergency exploratory laparotomy.
Which of the following is the most likely diagnosis?
The most likely diagnosis is ruptured ectopic pregnancy. Molar pregnancy, incomplete abortion, and missed abortion can also be associated with abdominal pain and vaginal bleeding, but would not be associated with free fluid (blood) within the abdominal cavity, hypotension, and tachycardia. A torsed ovarian cyst would present with intermittent abdominal pain. The ultrasound would show a pelvic mass with no doppler flow to the ovary, not free fluid.