Case Discussion: Molar Preganancy

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Based on typical findings on US, as well as an abnormally elevated bhcg, the patient is diagnosed with gestational trophoblastic disease, likely complete hydatidiform mole.  OB/GYN consult, fluid resuscitation as indicated, and pre-op labs/NPO status for likely D&C should be initiated in the ED.

Gestational Trophoblastic Disease/Molar Pregnancy is a fertilized ovum that leads to no fetus, but instead to proliferation of abnormal tumor cells composed of placental cells (cytotrophoblast, synctiotrophoblast, intermediate trophoblast).  GTD can occur in absence of intrauterine or extrauterine pregnancy.

Spectrum of pathologic conditions: partial hyatidiform mole, complete hyatidiform mole, & gestational trophoblastic neoplasia (GTN).  GTN is a collective term that includes the conditions invasive mole, choriocarcinoma, & placental site trophoblastic tumor.

 

ED Presentation:

Vaginal bleeding in a known or newly diagnosed pregnant patient, usually occurring at 6-16 weeks

 

Importance:

  1. Complications include anemia, preeclampsia, hyperthyroidism
  2. Can lead to neoplastic disease (GTN), which can metastasize to brain and lungs
  3. High mortality rate from invasive mole secondary to hemorrhage, sepisis, embolic phenomena

 

Diagnosis:

-Abnormally elevated human chorionic gonadotropin (hCG) levels

-Ultrasound typically reveals a uterus with no fetus and a uterine mass with focal cystic spaces.  On older machines or machines with poor resolution, this led to the classically described “snow storm” appearance of the US.

-Pathologic examination for GTN

 

ED tests:

-CBC (H/H), chemistry panel (including liver function tests), thyroid function, type & screen (Rh), urinalysis, chest X-ray (for metastases)

Treatment:

-Dilation and curettage (preferred)

-Hysterectomy if childbearing no longer desired

-Chemotherapy in cases of GTN

 

Follow up:

-Serum hCG levels must be followed up until 3 consecutive tests (1-2wk apart) are within normal limits

-20% of molar pregnancies can lead to persistent trophoblastic disease even after evacuation

Please stay tuned for a video clip provided by our own Siu Fai Li, MD.  Special thanks/credit to Dr. Allen Sann for his preparation of this Case Discussion

-Dr A W Shannon

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