From the Guidelines
The most helpful test to establish this patient's diagnosis would be a serum beta-human chorionic gonadotropin (β-hCG) level. This patient's presentation strongly suggests gestational trophoblastic disease, specifically choriocarcinoma with pulmonary metastases. The combination of persistent vaginal bleeding after delivery, an enlarged uterus, and multiple bilateral pulmonary infiltrates in a young woman who recently gave birth points to this diagnosis. Choriocarcinoma is a malignant form of gestational trophoblastic disease that can develop after any type of pregnancy, including normal delivery. It produces excessive β-hCG and has a tendency to metastasize early, particularly to the lungs, which explains the patient's chest pain, dyspnea, and pulmonary infiltrates. The persistent vaginal bleeding despite being three months postpartum is highly suspicious.
Some may consider the possibility of pulmonary embolism (PE) given the patient's symptoms of chest pain and dyspnea. However, the patient's presentation, including the type of chest pain and the absence of other typical PE symptoms such as hemoptysis or leg pain, makes this less likely. Furthermore, the guidelines for diagnosing PE in pregnancy, as outlined in the study by 1, recommend against the use of certain diagnostic tests due to radiation exposure concerns.
Once the β-hCG level is confirmed to be elevated, additional workup would include:
- Pelvic ultrasound to assess the uterus and rule out other causes of vaginal bleeding
- Chest CT to evaluate the extent of pulmonary involvement
- Brain MRI to assess for metastatic disease
- Liver function tests to evaluate for any potential liver involvement
Early diagnosis is critical as gestational trophoblastic disease, even when metastatic, has an excellent prognosis with appropriate chemotherapy. The management of such cases requires a multidisciplinary approach, including obstetricians, oncologists, and radiologists, to ensure the best possible outcomes for the patient. The recent guidelines, such as those published in 1, emphasize the importance of minimizing radiation exposure during pregnancy, which supports the initial choice of a serum β-hCG level as the most helpful diagnostic test in this scenario.
From the Research
Diagnostic Approach
To establish a diagnosis for the patient, the following options can be considered:
- Computed Tomography Pulmonary Angiography (CTPA) as the imaging test of first choice 2
- Ventilation-perfusion scan as an alternative for patients with concomitant symptomatic deep vein thrombosis or a stringent contraindication for CTPA 2, 3
Imaging Tests
The patient's symptoms and medical history suggest the need for imaging tests to rule out pulmonary embolism. The options include:
- CTPA, which has a high sensitivity and specificity for the diagnosis of pulmonary embolism 2, 4
- Ventilation-perfusion scan, which has a high specificity but a quite low sensitivity in the diagnosis of pulmonary embolism 3
- Ventilation/perfusion SPECT lung scintigraphy, which can detect pulmonary embolism in patients with intermediate or high clinical probability 5
Clinical Considerations
The patient's clinical presentation, including chest pain and dyspnea, suggests the need for a thorough diagnostic evaluation. The following factors should be considered:
- The patient's medical history, including recent childbirth and episodes of dark, bloody vaginal discharge
- The patient's physical examination results, including clear lungs and an enlarged uterus
- The patient's laboratory results, including complete blood count and serum electrolytes within normal limits
- The patient's chest x-ray results, which reveal multiple bilateral infiltrates of various shapes 6