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Boggy, tender uterus
25%
98/387
Chronic pelvic pain
14%
53/387
Friable cervix
10%
37/387
Nodular pelvic exam
15%
57/387
Vomiting
34%
133/387
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This patient with vaginal bleeding, heterogeneous appearance on ultrasound, and a large uterine size likely has a complete mole, which is also associated with severe vomiting. A complete mole, also known as a hydatidiform mole, develops when an empty egg is fertilized by 2 sperm. As a result, the mole develops with 46 paternal chromosomes and no fetal parts. The complete mole is characterized by elevated beta-hCG, a uterine size larger than expected for the gestational age, and a heterogenous “snow-storm” or “cluster of grapes” appearance of the uterine contents on ultrasound. These patients tend to present with hyperemesis gravidarum along with painless vaginal bleeding. Hyperemesis gravidarum is characterized by severe nausea and vomiting that starts early in the pregnancy. An incomplete mole consists of 23 maternal chromosomes and 46 paternal chromosomes, and will also demonstrate fetal parts. The uterine size is typically normal for an incomplete mole. A complete mole may progress to choriocarcinoma if untreated. As a result, after removal of the mole, the patient should have routine follow-up with serial beta-hCG measurements along with contraception to ensure that treatment has been successful and to monitor for persistent or malignant gestational trophoblastic disease. Incorrect Answers: Answer 1: A boggy, tender uterus is seen in adenomyosis, endometrial glands invade the uterine myometrium, which can result in dysmenorrhea. Hydatidiform moles present with painless vaginal bleeding. Answer 2: Chronic pelvic pain can be seen in a variety of gynecologic conditions, including conditions causing dysmenorrhea such as endometriosis. Hydatidiform moles generally present with painless vaginal bleeding. Answer 3: A friable cervix suggests cervicitis or other infectious etiologies. This can be seen in pelvic inflammatory disease. Hydatidiform moles are not infectious in nature and infections are not predisposing factors. Answer 4: A nodular pelvic exam can suggest leiomyomas, which can be asymptomatic or cause abnormal bleeding. This patient has an ultrasound consistent with a molar pregnancy and not uterine leiomyomas. Bullet Summary: Hydatidiform moles present with vaginal bleeding, snowstorm appearance on ultrasound, and vomiting due to hyperemesis gravidarum.
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