How should I take a comprehensive history for a patient presenting with abdominal distension, vaginal bleeding and possible molar pregnancy?

History Taking for Suspected Molar Pregnancy with Abdominal Distension and Vaginal Bleeding

When evaluating a patient with abdominal distension, vaginal bleeding, and possible molar pregnancy, immediately obtain a comprehensive gynecologic and obstetric history focusing on specific high-risk features, current symptom severity, and life-threatening complications that require urgent intervention. 1

Critical Initial Questions

Pregnancy History and Dating

• Establish the date of the last menstrual period to determine gestational age, as complete moles typically present between 6-16 weeks gestation 2, 3
• Ask about previous pregnancies, specifically any history of prior molar pregnancy, which increases recurrence risk to 1-2% in subsequent pregnancies 4
• Document any history of infertility or assisted reproductive technology, as these may alter risk profiles 2

Current Symptom Characterization

Vaginal Bleeding Pattern:

• Quantify bleeding severity (number of pads per hour, presence of clots or tissue passage) to assess hemorrhage risk 1
• Determine onset timing and progression, as vaginal bleeding is the most common presenting symptom in complete moles 2, 3
• Ask about passage of grape-like vesicular tissue, which is pathognomonic for molar pregnancy 2

Abdominal Distension and Pain:

• Assess whether uterine size exceeds expected gestational age, as approximately 50% of complete moles show exuberant trophoblastic growth with marked uterine enlargement 3
• Evaluate for acute abdominal pain or peritoneal signs that could indicate uterine perforation or hemorrhage requiring emergency intervention 1

Life-Threatening Complications Assessment

Respiratory Symptoms:

• Ask about dyspnea, chest pain, or hemoptysis, as 15% of invasive moles metastasize to the lungs and can cause acute respiratory distress syndrome 2, 1
• Document any sudden onset of respiratory symptoms post-evacuation, as rapid progression to pulmonary metastases can occur within days 5

Hyperemesis and Thyroid Storm:

• Quantify severity of nausea and vomiting, as severe hyperemesis occurs in 40-50% of patients with markedly elevated hCG levels 6
• Screen for hyperthyroidism symptoms (palpitations, tremor, heat intolerance, anxiety) since hCG cross-reactivity with TSH receptors can trigger thyroid storm when hCG exceeds 100,000 mIU/mL 6, 3

Preeclampsia Features:

• Ask about severe headaches, visual changes, or right upper quadrant pain, as preeclampsia can develop before 20 weeks in molar pregnancy 3

Gynecologic History Specifics

Menstrual and Sexual History

• Document menstrual cycle regularity and contraception use, as hormonal contraception will be mandatory during the entire hCG monitoring period 1
• Obtain sexual history including number of partners and consistency of condom use to assess STD risk factors 2

Previous Gynecologic Conditions

• Ask about history of pelvic inflammatory disease, prior ectopic pregnancy, or IUD use, as these increase ectopic pregnancy risk in the differential diagnosis 2
• Document any prior abnormal Pap tests, uterine fibroids, endometriosis, or gynecologic surgeries 2
• Inquire about previous STDs or genital tract infections 2

Risk Factor Assessment

Maternal Age

• Document exact age, as maternal age extremes (very young or >40 years) are the main risk factors for molar pregnancy 4

Geographic and Ethnic Background

• Note geographic origin, as molar pregnancy incidence varies globally (1:1,000-1,500 pregnancies in developed countries) 4

Current Medications and Exposures

• List all current medications, particularly anticoagulants that could exacerbate bleeding 1
• Document any recent exposure to chemotherapy or radiation 2
• Ask about substance use (tobacco, alcohol, illicit drugs) as part of comprehensive assessment 2

Review of Systems for Complications

Hematologic:

• Ask about easy bruising or bleeding from other sites to assess for coagulopathy 6
• Document symptoms of anemia (fatigue, dizziness, syncope) from chronic vaginal bleeding 6

Cardiovascular:

• Screen for chest pain, palpitations, or syncope that could indicate hemodynamic instability or thyroid storm 1, 6

Neurologic:

• Ask about severe headaches, visual changes, or seizures suggesting preeclampsia or cerebral metastases 3

Psychosocial Assessment

• Evaluate patient's understanding of the diagnosis and its implications for future fertility 4
• Screen for anxiety or depression, as molar pregnancy has considerable psychosocial repercussions requiring multidisciplinary support 4
• Assess social support system and ability to comply with mandatory long-term hCG monitoring 1

Red Flags Requiring Immediate Escalation

Hemodynamic Instability:

• Document vital signs abnormalities (tachycardia, hypotension, tachypnea) indicating active hemorrhage or shock 1

Severe Respiratory Distress:

• Any dyspnea, oxygen desaturation, or hemoptysis requires immediate chest imaging and potential ICU admission 1, 5

Neurologic Changes:

• Altered mental status, severe headache, or visual changes mandate urgent evaluation for preeclampsia or metastatic disease 3

Documentation Priorities

• Record exact gestational age by dates and any discrepancy with uterine size 2
• Document baseline symptom severity to track progression during monitoring 1
• Note all risk factors for postmolar gestational trophoblastic neoplasia (GTN), as 15-20% of complete moles progress to malignancy requiring chemotherapy 1, 4