Thank you to Papa Hernandez for this fascinating case.

 

37F 10 weeks pregnant (by LMP), asthma presents with 1-2 weeks of SOB. Extertional, +orthopnea, + bilateral LE edema. Has yet to initiate prenatal care. Her vitals at triage:  97.7  117  230/140  28   98%.  On exam, patient is tachypneic but not in distress.  Her abdomen is non-tender (including RUQ), has bilateral pitting edema to knees.  Her urine is HCG (+) with large proteinuria. You are on the phone quickly with OB/GYN to tell them you have a patient concerning for severe preeclampsia. In response, you are kindly reminded that preeclampsia is a diagnosis made at 20 weeks. What is an important diagnostic step at this point?

 

 

 

An obstetric ultrasound. This pregnancy was presumably 10 weeks but patient had never had an ultrasound. The ED ultrasound revealed no gestational sac or fetus, but rather a “snowstorm” uterus. Yes, the patient had a molar pregnancy.

Gestational trophoblastic disease is the exception to the preeclampsia rule (for onset >20 weeks – otherwise you call it getstational hypertension). Presenting HCGs are typically > 100, 000.

TSH and HCG share a common subunit and have cross-sensitivity. Therefore, patients with GTD will often be hyperthyroid. This patient was, helping explain her high output heart failure and shortness of breath (cardiomegaly was revealed on bedside echo and cxr).

This patient received magnesium and antihypertensives in the ED, PTU for her hyperthyroidism on the floor, and a D&C by OB/GYN soon after.