These patients can hemorrhage severely and may require resuscitation. The patient is diagnosed with a complete abortion once all of the products of conception have passed and the cervix has closed. The patient will have a decrease in abdominal cramping and vaginal bleeding will begin to taper. The clinician should distinguish between an incomplete and complete abortion, as the former may require a dilation and curettage (D&C) if the patient is unable to spontaneously pass the remainder of the products of conception. Complete abortions can be medically managed and do not require surgical intervention. Figure 12.2 shows a spontaneous abortion in progress, with the products of conception located at the cervix.
TABLE 12.1 Risk Factors Associated with Spontaneous Abortion
There are two forms of presentation: a complete mole and a partial mole. A complete mole is the result of duplicated paternal chromosomes (both sets of chromosomes originate from the sperm), and no fetal tissue is present. The tissue that is present is entirely placental. A partial mole is the result of triploidy, with at least one set of chromosomes from maternal and paternal origin. Thus, fetal tissue is present and occasionally the fetus can be viable. Patients will typically present with vaginal bleeding mimicking an abortion, but rather than passing normal tissue, they may describe passing hydropic villi tissue, with a “grape-like” appearance. Hallmarks to making the diagnosis involve ultrasound imaging and quantitative beta human chorionic gonadotropin (β-hCG) testing. Ultrasonography will reveal enlarged cystic ovaries as a result of an abundance of theca lutein cysts and may reveal a mass within the uterine cavity that resembles a “snowstorm appearance.” This term refers to an image of frequent lucent areas scattered among many brighter areas, as shown in Figure 12.3. The patient’s β-hCG level will be much higher than expected for gestational
age, generally greater than 100,000 mIU/mL. Rarely, the presentation can be complicated by preeclampsia and hyperthyroidism. A formal diagnosis of GTD is made through histologic evaluation of the tissue after uterine evacuation. Most cases are benign, but in rare cases, a malignancy, choriocarcinoma, can develop. Malignant cases will cause β-hCG levels to remain high or continue rising after uterine evacuation. Therefore, β-hCG levels should be followed to ensure they are decreasing, in order to prevent missing persistent or metastatic disease. It may take several months for β-hCG levels to drop to an undetectable level after a molar pregnancy.