Review Question - QID 108578

The most likely diagnosis for this patient is a molar pregnancy which should be treated with dilation and curettage with serial serum ß-hCG levels.

This patient is presenting with hyperemesis gravidarum, signs of hyperthyroidism, and a "snowstorm" appearance with theca-lutein cysts on ultrasound. These are key findings for complete molar pregnancy. Treatment should include timely dilation and curettage, serial ß-hCG levels for up to 6 months, and reliable contraception in the meantime to avoid confusion in interpretation of ß-hCG levels. This patient’s severe nausea early in pregnancy and significant weight loss suggest hyperemesis gravidarum, which is due to extremely high levels of beta-hCG (often > 100,000 mIU/mL) produced by the abnormal placenta in complete moles. Her other symptoms of palpitations, perspiration, and tremor may be attributed to hyperthyroidism, which is a result of cross-reactivity between TSH and ß-hCG. Many patients with complete moles also present with vaginal bleeding and large-for-dates uterus on exam. Ultrasound findings may include an enlarged uterus with cystic spaces in a “snowstorm” pattern (Figure A) and/or bilateral theca lutein cysts (Figure B), which result from high ß-hCG levels. All patients with molar pregnancies should also have a routine screening chest radiograph to look for lung metastases (Illustration A).

Figure A shows the classic “snowstorm” or “cluster of grapes” appearance of the uterus in complete molar pregnancy. There are numerous villous spaces representing the abnormal chorionic villi of the placenta, and fetal parts are absent. Figure B shows multiple large simple cysts, suggestive of theca-lutein cysts found in complete molar pregnancies.

Incorrect Answers:
Answer 1: Propylthiouracil (PTU) therapy would be the treatment of choice if hyperthyroidism is suspected in pregnancy. Although this patient does have some hyperthyroid symptoms (palpitations, perspiration, tremor), the rest of her clinical picture as well as her lab findings and ultrasound strongly suggest molar pregnancy as the main diagnosis. Separate treatment of the hyperthyroidism, which results from elevated ß-hCG levels, is unnecessary.

Answer 2: Methotrexate, a folate reductase inhibitor, is indicated if there is evidence of metastasis of the molar pregnancy. Without a chest radiograph to suggest such spread of disease, this patient should not receive methotrexate.

Answer 4: Combination mifepristone and misoprostol is an effective method for medical abortion in the first 49 days of pregnancy. However, it is not an appropriate choice for someone with an almost certain molar pregnancy, as dilation and curettage is more effective for ensuring complete removal of products of conception. Any retained products of conception may result in progression of disease to malignancy.

Answer 5: The ovarian cysts seen in this patient are most likely theca-lutein cysts due to overstimulation by high ß-hCG. These cysts are generally nonfunctional. Once the molar pregnancy is evacuated and ß-hCG levels begin to drop, the cysts will resolve on their own. There is no need to perform surgical removal.

Bullet Summary:
Complete molar pregnancies may present with vaginal bleeding, hyperemesis gravidarum, and theca-lutein cysts due to high ß-hCG levels, and ultrasound may show a “snowstorm” appearance. Treatment should include dilation and curettage, serial ß-hCG levels for up to 6 months, and reliable contraception in the meantime to avoid confusion in interpretation of ß-hCG levels (from another pregnancy).