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R11) Vaginal bleeding after attempted IUD insertion
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a female patient with vaginal bleeding after IUD insertion.
- Review the DDx considerations for vaginal bleeding.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating female patients of reproductive age with vaginal bleeding.
History
A 37-year-old woman (G0P0) with no significant medical history arrived at the triage following vaginal bleeding that occurred after attempting to insert an intrauterine device (IUD) at a clinic. She reports a five-month period of amenorrhea and two months of nausea and vomiting in the morning. Recently, she noticed a small amount of vaginal bleeding accompanied by the passage of grape-like clusters of vesicles. She is sexually active and occasionally uses condoms, but she does not believe she could be pregnant. She has tried to conceive several times in the past few years but has been unsuccessful.
Physical Exam
Vital signs: Blood pressure (BP): 120/75 mmHg, Heart rate (HR): 88 beats per minute, Respiratory rate (RR): 14 breaths per minute, Temperature: 98.7°F, Oxygen saturation: 99%.
Abdominal examination: There is mild tenderness upon palpation around the uterine fundus.
Pelvic examination findings: The cervix appears normal and closed. The adnexa are mobile and non-tender. However, the uterus is enlarged, mobile, and mildly tender. The fundal height corresponds to approximately 10 weeks of gestation.
Fetal Doppler: No fetal heart tones.
Labs
Beta-HCG: 100,000 IU/L.
Hemoglobin (Hgb): 14 g/dL (12-16 g/dL).
Sodium (Na+): 135 mmol/L (Reference range: 135-145 mmol/L),
Chloride (Cl-): 90 mmol/L (Reference range: 96-106 mmol/L),
Potassium (K+): 2.8 mmol/L (Reference range: 3.5-5.0 mmol/L),
Bicarbonate (HCO3-): 28 mmol/L (Reference range: 22-28 mmol/L).
Provisional Diagnosis
Select the Dx you believe is most appropriate
Based on the history of vaginal bleeding, passage of tissue, hyperemesis gravidarum with hypokalemic hypochloremic metabolic alkalosis, absence of fetal cardiac activity, markedly elevated beta HCG levels, advanced maternal age, and history of infertility, the most likely provisional diagnosis for this 37-year-old female is a hydatidiform mole.
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Potential Acuity
What is your assessment of the likely acuity for this patient?
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This patient requires routine, but expedited workup.
First Imaging Study
What is the first imaging study you will order?
Transvaginal ultrasound is the preferred initial imaging study for suspected gestational trophoblastic disease (GTD) due to its accuracy and cost-effectiveness in confirming the presence of a hydatidiform mole and distinguishing between partial and complete moles. Pelvic MRI and CT are more expensive and time-consuming and are not necessary for the initial workup.
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Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
Transvaginal Ultrasound
What best describes the findings on the transvaginal ultrasound?
The transvaginal ultrasound demonstrates the “snowstorm sign,” or “bunch of grapes” appearance, characterized by irregular cystic spaces made up of innumerable hydropic villi. The extensive trophoblastic proliferation and absence of identifiable fetal tissue suggests that this is a complete, and not a partial molar pregnancy.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
Transvaginal ultrasound (TVUS) along with laboratory studies, such as beta-hCG, is sufficient to confirm the diagnosis of a molar pregnancy. However, a chest x-ray is recommended as the next imaging study since the lungs are a common site of metastasis for malignant trophoblastic disease. The chest X-ray also serves as a baseline to compare with future chest imaging studies in case the beta-hcG remains persistently elevated.
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What is your Diagnosis now that you have seen the imaging results?
The most likely diagnosis based on the history, lab, and imaging findings is a complete hydatidiform mole. Partial moles can be differentiated from complete moles by the presence of fetal parts and a smaller, more regular gestational sac. Complete moles result from the fertilization of an empty ovum, leading to chromosomal makeup of 46, XX or XY. In contrast, partial moles occur when an egg is fertilized by two sperm, resulting in 69, XXY chromosomal makeup. Partial moles typically have lower levels of beta-HCG compared to complete moles. Since there is no evidence of invasion or metastasis, and considering the gestational age, this is unlikely to be choriocarcinoma.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient requires routine, but expedited workup.
Assessment and Plan
Please provide your assessment and plan for this patient
This 37-year-old female presents with symptoms and findings consistent with a complete hydatidiform mole: vaginal bleeding following a failed IUD insertion, a uterus enlarged to approximately 10 weeks gestational size, absent fetal heart tones, and a significantly elevated beta-HCG level. The was confirmed by a transvaginal ultrasound that revealed the characteristic "snowstorm sign". The management plan should involve referral to a specialist for a dilation and curettage (D&C) procedure to evacuate the molar pregnancy. Post-procedure, close monitoring of beta-HCG levels is imperative to confirm complete removal of the mole. Given the risk of malignant transformation, a chest x-ray should be obtained to exclude pulmonary metastases. Finally, the patient should be counseled to avoid pregnancy for a minimum of 6-12 months while under follow-up care.
Lessons Learned:
- A complete hydatidiform mole is a benign type of gestational trophoblastic disease (GTD). It results fertilization of an empty ovum, leading to a diploid chromosomal pattern of 46,XX or 46,XY.
- Risk factors for molar pregnancy include advanced maternal age, history of infertility, and prior history of molar pregnancy or other GTD.
- Key features of a complete hydatidiform mole include an enlarged uterus out of proportion to gestational age, bHCG greater than 100,000 IU/L or markedly elevated for gestational age, intrauterine mass with cystic spaces without any evidence of fetal parts, nausea/vomiting secondary to with elevated bHCG, vaginal bleeding, and bilateral theca lutein cysts.
- Radiologists are instrumental in diagnosing molar pregnancies through the analysis of transvaginal ultrasound images and assessing the disease extent in cases of suspected gestational trophoblastic neoplasia or malignancy with persistent elevated bHCG.
- Management of a complete hydatidiform mole involves surgical evacuation using suction curettage, followed by regular monitoring of bHCG levels until they become undetectable, and advocating for at least 6 months of contraception post-procedure.
- Although not an obstetric emergency, prompt treatment is required to minimize the risk of evolving into persistent gestational trophoblastic disease or malignancy.
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