Uterine Rupture Due to Invasive Metastatic Gestational Trophoblastic Neoplasm
A 21-year-old woman presented to the ED with a 4-day history of increasing abdominal and pelvic pain associated with nausea, generalized fatigue, and orthostatic light-headedness. She denied fever, chills, emesis, syncope, dyspnea, chest pain, or vaginal bleeding, and she had no urinary symptoms. Her past medical history was significant for an evacuation of a complete hydatidiform molar pregnancy 1 month prior to presentation. The pathology report from her surgery showed gestational trophoblastic disease consistent with a 46-XX hydatidiform mole. Her initial pre-operative human chorionic gonadotropin (HCG) level had been >225,000 mIU/mL and had fallen post-operatively but had not yet reached zero by her report. She denied tobacco, alcohol, or drug use, and she had no medications or allergies.\nPhysical examination revealed an ill-appearing young woman who was anxious and uncomfortable. Her vital signs were a pulse of 126 beats per minute, temperature of 36.5 °C (97.7 °F), respiratory rate of 18 breaths per minute, blood pressure of 116/82 mmHg, and an oxygen saturation of 98% on room air. The remainder of her physical examination was unremarkable with the exception of the abdominal and pelvic examinations. Her abdomen was non-distended with bilateral inferior quadrant tenderness to palpation and mild guarding without rebound. Her pelvic examination showed scant brown fluid in the vaginal vault with diffuse and significant uterine and adnexal tenderness to palpation.\nLaboratory testing demonstrated a quantitative serum HCG level of 14,552 mIU/mL. Her complete blood count was normal with the exception of a hemoglobin of 10.9 g/ dL (reference range 11.7–16.1 g/dL). A bedside focused abdominal ultrasound was performed and demonstrated peri-cystic free fluid without evidence of free fluid elsewhere in the abdomen. Subsequently, a computed tomography (CT) with intravenous (IV) contrast of her chest, abdomen, and pelvis showed pelvic fluid consistent with blood surrounding a thickened and heterogeneous uterus. There was active peri-uterine contrast extravasation concerning for neoplastic process eroding into the uterine vasculature (), and 20 discrete pulmonary nodules were seen ().\nResuscitation with 2 liters of IV normal saline and supportive care were provided in the ED. The patient’s pulse remained tachycardic between 100–120 beats per minute, but she never became hypotensive in the ED. Large bore access was obtained bilaterally and a type and cross was sent in the ED, but the transfusion was not given until she was in the operating room. Gynecology consultation was emergently obtained, and the patient was taken directly to the operating room where she required a hysterectomy and 4 units of packed red blood cells. Her pathologic specimen demonstrated an invasive complete hydatidiform mole with foci of trophoblastic proliferation within the uterus and in the pelvis concerning for choriocarcinoma. She was started on a chemotherapy regimen post-operatively for her metastases. She did not require further surgical intervention and her choriocarcinoma went into complete remission as of follow up 6 months after chemotherapy.