Case 46: Bleeding in early pregnancy

 

Case 46: Bleeding in early pregnancy

CASE 46: BLEEDING IN EARLY PREGNANCY

History

A 36-year-old woman presents with vaginal bleeding at 8 weeks 3 days’ gestation. She has

never been pregnant before. Bright red ‘spotting’ commenced 7 days ago, which she thought

was normal in early pregnancy. However since then the bleeding is now almost as heavy as a

period. There are no clots. She has no abdominal pain. Systemically she has felt nausea for 3

weeks and has vomited occasionally. She had large-loop excision of the transformation zone

(LLETZ) treatment after an abnormal smear 6 years ago. Since then all smears have been

normal. There is no other significant gynaecological history. She has regular periods, bleeding for 5 days every 28 days, and has never had any known sexually transmitted infections.

In the past she used condoms for contraception.

Examination

The heart rate is 68/min and blood pressure is 108/70 mmHg. The abdomen is soft and nontender. Speculum reveals a normal closed cervix with a small amount of fresh blood coming

from the cervical canal. Bimanually the uterus feels bulky and soft, approximately 10 weeks

in size. There is no cervical excitation or adnexal tenderness.

INVESTIGATIONS

Urinary pregnancy test: positive

Figure 46.1 shows the transvaginal ultrasound findings.

Questions

• What is the likely diagnosis and differential diagnosis?

• What would one expect to see at scan in this woman if the pregnancy was normal?

• How would you manage the patient?

Figure 46.1 Transvaginal ultrasound scan showing a midsagittal view through the uterus.100 Cases in Obstetrics and Gynaecology

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ANSWER 46

The ultrasound scan shows a mixed echogenicity appearance in the uterus, typical of a complete hydatidiform mole (molar pregnancy, part of the spectrum of gestational trophoblastic

disease). There is no recognizable gestational sac or fetus.

This appearance may also be seen occasionally in pregnancies where early fetal demise has

occurred but the sac has not been expelled (delayed miscarriage) resulting in cystic degeneration of the placenta.

The incidence of hydatidiform mole (also known as gestational trophoblastic disease) is

approximately 1 in 714. It generally presents with painless vaginal bleeding though it may be

diagnosed as an incidental finding when ultrasound is performed for another indication. The

classical associations with hyperemesis, thyrotoxicosis or pre-eclampsia are rarely seen in the

developed world where diagnosis is generally made in the first trimester.

Normal findings at 8 weeks

The normal findings at 8 weeks would be a fetus of approximately 18 mm, with a positive

fetal heartbeat. The yolk sac would still be visible and the amniotic sac would also be seen.

The fetus would be beginning to develop visible arm and limb buds and fetal movement may

be seen.

Figure 46.2 shows a transvaginal image of a normal 8-week gestation sac and fetus.

Further management

The management for suspected molar pregnancy is always surgical evacuation of the uterus,

with urgent histological examination of the tissue.

Once diagnosis is confirmed by histology, any woman with a confirmed partial or complete

mole should be referred to a specialist gestational trophoblastic disease centre (in the UK in

Sheffield, Dundee and Charing Cross Hospital) for follow-up of human chorionic gonadotrophin (hCG) levels. Women with persistently raised hCG levels are offered chemotherapy

to destroy the persistent trophoblastic tissue and minimize the chance of development of

choriocarcinoma. Only 0.5 per cent of women diagnosed with a partial molar pregnancy

will require chemotherapy, compared with 10–15 per cent of women with a complete molar

pregnancy.

Figure 46.2 Transvaginal image of a normal 8-week gestation sac and fetus (amniotic sac is

seen but yolk sac is not visible in this view).Case 46: Bleeding in early pregnancy

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Most women however do not require chemotherapy as the hCG becomes negative within a

short period of time. These women should be advised:

• not to become pregnant again until the hCG is normal

• there is a 1 in 84 chance of a further molar pregnancy

• they should have hCG monitoring after any subsequent pregnancy (whether live

birth, fetal loss or termination)

• the combined oral contraceptive pill may safely be used once hCG has returned to

normal.

KEY POINTS

• Molar pregnancy may be suspected on ultrasound examination but the diagnosis

must be confirmed with histological examination of products of conception after

surgical uterine evacuation.

• Molar pregnancies must be followed up at a specialist gestational trophoblastic

disease centre.

• Development of choriocarcinoma after molar pregnancy is rare, but persistent trophoblastic disease requiring chemotherapy is more common.