ULTRASOUND CASE REVIEWS
Partial Hydatidiform Mole and Coexisting Viable Twin Pregnancy Ee Tein Tay, MD examination of the tissue confirmed the presence of fetal parts and focal trophoblastic proliferation, consistent with a partial mole with a coexisting fetal pregnancy. The patient was discharged on hospital day 2 and was advised to follow-up for repeat laboratory test for serial A-hCG levels given the risk of metastatic trophoblastic disease.
Abstract: Twin partial hydatidiform molar pregnancy with a viable fetus is an uncommon occurrence. Presentations of molar pregnancies include vaginal bleeding, unusually elevated A-human chorionic gonadotropin level, and preeclampsia. Previous descriptions of twin molar and fetus pregnancies in the literature have been described in the outpatient obstetric setting. We present a case of partial molar pregnancy with a viable fetus detected with emergency ultrasound in a pediatric emergency department.
ULTRASOUND FINDINGS/TECHNIQUE
A 21-year-old primigravida at 11 weeks gestation presented to the pediatric emergency department (ED) with 2 days of vaginal bleeding and abdominal pain. She reported passing gushes of blood with clots but no tissue, which had increased before ED arrival. The abdominal pain was described as crampy, located bilaterally in the lower abdomen, and radiating to the back. The patient denied fever, chills, vomiting, dysuria, dizziness, chest pain, or shortness of breath. She reported no past medical or surgical histories, had received prior prenatal care, and took only prenatal vitamins and iron supplements. On examination, the patient was alert and afebrile with normal vital signs. Abdominal examination revealed a soft, nondistended, and nontender abdomen without any costovertebral tenderness. Pelvic examination with a speculum showed dark red blood in the vaginal canal without active bleeding from the closed cervical os. There was no cervical or bilateral adnexal motion tenderness, and no masses were palpated. The remaining physical examination finding was unremarkable. Laboratory test showed normal urinalysis, complete blood count, and thyroid function test results. Quantitative A-human chorionic gonadotropin (A-hCG) level was 1 191 079 mIU/mL. An emergency ultrasound was performed to evaluate for an intrauterine pregnancy. Based on emergency ultrasound findings, a molar pregnancy with a viable fetus was suspected. An obstetric physician was consulted, who confirmed the diagnosis of a coexisting molar and viable fetal twin pregnancy via a repeat ultrasound. The patient was admitted for observation and continued having increased vaginal bleeding during her hospital stay. Because of the risk of hemorrhage, dilatation and curettage was performed the following day. Surgical pathologic
A bedside transabdominal ultrasound was performed in the ED and showed an intrauterine pregnancy with a fetal heart rate of 176 beats per minute and an adjacent cystic heterogeneous tissue with a ‘‘snowstorm’’ appearance suggestive of a molar pregnancy (Fig. 1). Multiple cysts were seen on the left ovary. The right ovary was normal. A molar pregnancy is suspected if the ultrasound shows a heterogeneous solid mass with multiple cystic echogenic tissue within the placenta appearing as a snowstorm or a ‘‘cluster of grapes’’1Y6 (Fig. 2). These cysts have irregular contours and thin walls, unlike normal gestational sacs with smooth contours and thick echogenic rims.4 Transabdominal ultrasound of the uterus and ovaries is best performed using a curvilinear or a phased array probe. The probe should be placed above the pubic symphysis, and images should be done in both longitudinal and transverse planes.7 In transabdominal imaging, a full bladder is important to provide a window for evaluating the ovaries and to displace overlying bowel.7 The probe is moved side to side in the longitudinal plane and up and down in the transverse plane to visualize the uterus and surrounding structures. The endometrial stripe is identified as an echogenic line in the middle of the uterus (Fig. 3). A gestational sac with a fetal pole or yolk sac visualized in the center of the uterus suggests an intrauterine pregnancy (Fig. 4). For early pregnancies, the gestational sac can be visualized by transvaginal ultrasound as early as 4.5 weeks after last menstruation and after 5 weeks by transabominal ultrasound.8 Structures are best visualized via a transvaginal ultrasound using an intracavitary probe in the first trimester. For this examination, an empty bladder is preferred to reduce uterine distortion from a full bladder.7 The uterus and adnexal structures should be scanned in the sagittal plane by inserting the probe into the vagina and moving the probe from side to side (Fig. 5). By turning the probe counterclockwise 90 degrees and moving it up and down, one can image the transverse plane. Gentle compression of the right and left lower quadrants of the abdomen may bring the ovaries into view.
From the Department of Emergency Medicine, Pediatric Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. Disclosure: The author declares no conflict of interest. Reprints: Ee Tein Tay, MD, Department of Emergency Medicine, Pediatric Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Pl, Box 1149, New York, NY 10026 (e
Partial Hydatidiform Mole and Coexisting Viable Twin Pregnancy Ee Tein Tay, MD examination of the tissue confirmed the presence of fetal parts and focal trophoblastic proliferation, consistent with a partial mole with a coexisting fetal pregnancy. The patient was discharged on hospital day 2 and was advised to follow-up for repeat laboratory test for serial A-hCG levels given the risk of metastatic trophoblastic disease.
Abstract: Twin partial hydatidiform molar pregnancy with a viable fetus is an uncommon occurrence. Presentations of molar pregnancies include vaginal bleeding, unusually elevated A-human chorionic gonadotropin level, and preeclampsia. Previous descriptions of twin molar and fetus pregnancies in the literature have been described in the outpatient obstetric setting. We present a case of partial molar pregnancy with a viable fetus detected with emergency ultrasound in a pediatric emergency department.
ULTRASOUND FINDINGS/TECHNIQUE
A 21-year-old primigravida at 11 weeks gestation presented to the pediatric emergency department (ED) with 2 days of vaginal bleeding and abdominal pain. She reported passing gushes of blood with clots but no tissue, which had increased before ED arrival. The abdominal pain was described as crampy, located bilaterally in the lower abdomen, and radiating to the back. The patient denied fever, chills, vomiting, dysuria, dizziness, chest pain, or shortness of breath. She reported no past medical or surgical histories, had received prior prenatal care, and took only prenatal vitamins and iron supplements. On examination, the patient was alert and afebrile with normal vital signs. Abdominal examination revealed a soft, nondistended, and nontender abdomen without any costovertebral tenderness. Pelvic examination with a speculum showed dark red blood in the vaginal canal without active bleeding from the closed cervical os. There was no cervical or bilateral adnexal motion tenderness, and no masses were palpated. The remaining physical examination finding was unremarkable. Laboratory test showed normal urinalysis, complete blood count, and thyroid function test results. Quantitative A-human chorionic gonadotropin (A-hCG) level was 1 191 079 mIU/mL. An emergency ultrasound was performed to evaluate for an intrauterine pregnancy. Based on emergency ultrasound findings, a molar pregnancy with a viable fetus was suspected. An obstetric physician was consulted, who confirmed the diagnosis of a coexisting molar and viable fetal twin pregnancy via a repeat ultrasound. The patient was admitted for observation and continued having increased vaginal bleeding during her hospital stay. Because of the risk of hemorrhage, dilatation and curettage was performed the following day. Surgical pathologic
A bedside transabdominal ultrasound was performed in the ED and showed an intrauterine pregnancy with a fetal heart rate of 176 beats per minute and an adjacent cystic heterogeneous tissue with a ‘‘snowstorm’’ appearance suggestive of a molar pregnancy (Fig. 1). Multiple cysts were seen on the left ovary. The right ovary was normal. A molar pregnancy is suspected if the ultrasound shows a heterogeneous solid mass with multiple cystic echogenic tissue within the placenta appearing as a snowstorm or a ‘‘cluster of grapes’’1Y6 (Fig. 2). These cysts have irregular contours and thin walls, unlike normal gestational sacs with smooth contours and thick echogenic rims.4 Transabdominal ultrasound of the uterus and ovaries is best performed using a curvilinear or a phased array probe. The probe should be placed above the pubic symphysis, and images should be done in both longitudinal and transverse planes.7 In transabdominal imaging, a full bladder is important to provide a window for evaluating the ovaries and to displace overlying bowel.7 The probe is moved side to side in the longitudinal plane and up and down in the transverse plane to visualize the uterus and surrounding structures. The endometrial stripe is identified as an echogenic line in the middle of the uterus (Fig. 3). A gestational sac with a fetal pole or yolk sac visualized in the center of the uterus suggests an intrauterine pregnancy (Fig. 4). For early pregnancies, the gestational sac can be visualized by transvaginal ultrasound as early as 4.5 weeks after last menstruation and after 5 weeks by transabominal ultrasound.8 Structures are best visualized via a transvaginal ultrasound using an intracavitary probe in the first trimester. For this examination, an empty bladder is preferred to reduce uterine distortion from a full bladder.7 The uterus and adnexal structures should be scanned in the sagittal plane by inserting the probe into the vagina and moving the probe from side to side (Fig. 5). By turning the probe counterclockwise 90 degrees and moving it up and down, one can image the transverse plane. Gentle compression of the right and left lower quadrants of the abdomen may bring the ovaries into view.
From the Department of Emergency Medicine, Pediatric Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. Disclosure: The author declares no conflict of interest. Reprints: Ee Tein Tay, MD, Department of Emergency Medicine, Pediatric Emergency Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Pl, Box 1149, New York, NY 10026 (e
