This 16 year old patient presents to the Emergency Department you have just started at in Menominee Michigan.   All of today’s patients have been on their way home this last day of hunting season.  You suspect this patient will be more interesting, as she is wearing a PETA shirt and not a shred of orange or leather.  Although her chief complaint was nausea and vomiting, her urine pregnancy test was positive, prompting the ultrasound evaluation which revealed this image:


What is your diagnosis and what is the next step for this patient?

The image obtained reveals the complex cystic intrauterine mass of gestational trophoblastic disease.  On a older, lower resolution machine the image might have the classically described “snowstorm” pattern.

In addition to this image your beta hCG level of 198,000 convince the obstetrician who was about to take a well deserved nap to come down to the ED for one last patient.

While you are waiting for his arrival, you obtain a chest x-ray, knowing that 20% of patients develop gestational trophoblastic neoplasia which can metastasize to the lungs.   You order preop labs and a TSH.  Although these patients are at risk for thyroid storm due to thyrotropin stimulation by supranormal hCG levels, your patient shows no signs of hyperthyroidism.