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  #1  
Old 07-25-2012
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ObGyn First Trimester Vomiting!

A 23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2 C (98.9 F); orthostatic vitals are as follows: BP 136/86 mm Hg and pulse 98/min supine, and 110/70 mm Hg and 115/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable.
Which of the following is the most appropriate next step in management?
A. Upper Gl endoscopy
B. Pelvic ultrasonogram
C. CT scan of the head
D. Right upper quadrant ultrasonogram
E. Quantitative beta HCG levels

***if u choose between HCG and USG..may i know what is the reason for favoring one over another.
thanks.
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  #2  
Old 07-25-2012
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Quantitative HCG would be best....as there is no disparity between her estimated GA and Uterine size on examination (question says examination findings were normal...hence an USS may not help either)
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Old 07-25-2012
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USG :no features of molar pregnany and thyrotoxicosis associated with it .. To rule out other causes the next best step is USG
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Old 07-25-2012
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Another thing is that the question asks "next step in mgmt" although hcg may be diagnostic it's not required here yet. Stfidel you said examination findings were normal which means uterus size corresponds to GA . In molar pregnancy it shud be larger than GA so your point doesn't make sense.
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Old 07-25-2012
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Ans is HCG. :-/. More comments ?


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Old 07-25-2012
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Aman_j....what are these other causes you want to rule out with an ultrasound?...you have already mentioned H.mole....
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Old 07-26-2012
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Quote:
Originally Posted by stfidel View Post
Aman_j....what are these other causes you want to rule out with an ultrasound?...you have already mentioned H.mole....
choriocarcinoma

Last edited by gunner0101; 07-26-2012 at 03:02 PM.
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Old 07-26-2012
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Quote:
Originally Posted by gunner0101 View Post
choriocarcinoma
What in the vignette makes u think of choriocarcinoma...a highly anaplastic cancer?
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Old 07-26-2012
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Quote:
Originally Posted by stfidel View Post
What in the vignette makes u think of choriocarcinoma...a highly anaplastic cancer?
Hyperemesis gravidarum in the first trimester. Need to rule it out. BHCG good way to go.
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Personally I thought H mole is dd of hyperemesis and picked USg to look for snowstorm appearance. HCG too is pkay but it won't rule out h mole from heg.


But ans was HCG. :-/
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Old 07-26-2012
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Agree with tyagee and the question is "next step of management" that's why I picked USG . Will have to read up


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Old 07-26-2012
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Quote:
Originally Posted by tyagee View Post
Personally I thought H mole is dd of hyperemesis and picked USg to look for snowstorm appearance. HCG too is pkay but it won't rule out h mole from heg.


But ans was HCG. :-/
How much of a "snowstorm" are you expecting to see on an USG in a fetus at 9 weeks gestation ? The size of the fetus is one inch at 9 weeks equal to the size of a grape! Even if it was a twin pregnancy you won't see much ( ?two grapes).

Quote:
Molar pregnancies usually present with painless vaginal bleeding in the fourth to fifth month of pregnancy.[3] The uterus may be larger than expected, or the ovaries may be enlarged. There may also be more vomiting than would be expected (hyperemesis). Sometimes there is an increase in blood pressure along with protein in the urine. Blood tests will show very high levels of human chorionic gonadotropin (hCG).[16]
The diagnosis is strongly suggested by ultrasound (sonogram), but definitive diagnosis requires histopathological examination. On ultrasound, the mole resembles a bunch of grapes ("cluster of grapes" or "honeycombed uterus" or "snow-storm"[17]). There is increased trophoblast proliferation and enlarging of the chorionic villi.[18] Angiogenesis in the trophoblasts is impaired as well.
Besides, HEG is caused by high levels of HCG so it would be prudent to check the levels of HCG which is causing the HEG in the first place.

Last edited by Novobiocin; 07-26-2012 at 07:56 PM.
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  #13  
Old 07-26-2012
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I went with B HCG, simply due to it being easy screen tool.

High B HCG that's not appropriate for specific GA then you go for USG.

If Normal B HCG, then you can think of something else.

Although I see why people would get confused because the question asks "next step" rather than "best initial step or best dx step".
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Old 07-27-2012
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I would choose pelvic ultrasound before quantitative hCG. You would be able to differentiate between viable IUP, multiple IUP, and trophoblastic disease. "Snowstorm appearance" is a pretty outdated u/s finding (machines have higher resolution these days) that, as Novobiocin says, would appear later on. You would still see a cystic structure with no cardiac activity at 9 weeks. You can look up "9 week ultrasound" on youtube to see how clear and large the image is at that age. tyagee, where is the question from?
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