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Case History

image A 26-year-old woman,15 weeks pregnant, is admitted to hospital with vaginal bleeding. She is very anxious and complains of palpitations. Her vital signs are blood pressure 190/110 mmHg, pulse rate 112 beats per minute and respiration rate 22 per minute. On physical examination, her uterus is large for dates. The laboratory findings are haemoglobin 9 g/100 ml, white cell count 8000 × 106 cells/l, platelets 160 000 × 106 cells/l, free T3 (triiodothyronine) highly elevated, free T4 (thyroxine) highly elevated, thyroid-stimulating hormone (TSH) <0.01 mU/l, and serum human chorionic gonadotrophin (hCG) 250 000 mIU/ml.

How do you investigate?

How do you manage this patient?

What is the proper follow-up after hydatidiform mole evacuation?

What is the impact of a hydatidiform mole on subsequent pregnancies?

What if the serum hCG level does not normalize after molar evacuation?


How do you investigate?

image Abnormally elevated serum hCG levels, vaginal bleeding and an excessively enlarged uterus point to the diagnosis of hydatidiform mole. However, an hCG value in the normal range does not exclude it. The work-up should include a complete blood count and coagu lation profile, renal- and liver-function tests and thyroid function tests. An ultrasound scan is performed to confirm diagnosis and in most cases identifies a hydatidiform mole as a complex intrauterine mass with multiple anechoic areas of varying size (snowstorm appearance; Figure 28.1). An ultrasound scan may also find a twin pregnancy where there is one viable fetus and the other pregnancy is molar. In the latter case, the pregnancy can be allowed to proceed if the mother wishes, following appropriate counselling.1 A chest X-ray should be taken once the diagnosis of a hydatidiform mole has been made.

Figure 28.1

Transabdominal ultrasonography of a molar pregnancy: the uterus is bulky and the endometrial cavity is filled with an echogenic structure containing multiple small cysts.

How do you manage this patient?

Patients with molar pregnancies may suffer from various medical complications including hyperthyroidism, hyperemesis gravidarum, pre-eclampsia, trophoblastic embolization and theca lutein ovarian cysts (Table 28.1). Consequently, symptoms can vary and include hypertension, proteinuria, hyper-reflexia indicating pre-eclampsia, palpitations, weight loss and tremor caused by hyperthyroidism, abdominal pain from theca lutein ovarian cysts which can tort or rupture (leading to an acute abdomen), and respiratory distress due to trophoblastic embolization. Some complications are potentially life-threatening and consideration should be given to treat a mole in a facility with an intensive care unit.

Table 28.1Symptoms and complications of a hydatidiform mole

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