(31) Complex Care in an Adolescent: Management of Molar Pregnancy, Malignancy, Maternal Complications, and Malformations

Background: We present a case of an adolescent without known medical problems who presented to care for abnormal vaginal bleeding and was diagnosed and treated for complex medical conditions with consequences for her long-term health and fertility. This case highlights complexities adolescents face when accessing gynecologic and obstetric healthcare, the importance of early diagnosis and treatment of uterine anomalies, and challenges in appropriate long term counseling and medical follow-up as adolescents transition to adulthood.

Case: The patient presented at age 19 with vaginal bleeding and abnormal Beta human chorionic gonadotropin (HCG) levels. Transvaginal ultrasounds were notable for two separate uterine horns with an abnormal gestational sac in the right horn. HCG levels were abnormal and she underwent dilation and curettage with pathology concerning for molar pregnancy. She presented with bleeding and uptrending HCG; ultrasounds notable for a new abnormal vascularity in the right horn suspicious for molar pregnancy or uterine arteriovenous malformation (AVM). She was treated with methotrexate and actinomycin. Abnormal vascularities persisted on imaging and she was diagnosed with an AVM and subsequently treated with bilateral uterine artery embolization (UAE) at age 20. Overall symptoms improved.

She sought preconception counseling, but out of concerns her family would find out, she did not complete counseling and conceived at age 21. Her pregnancy was complicated by fetal growth restriction with reversed end diastolic flow and she was delivered by classical cesarean section at 27 weeks for fetal bradycardia; surgery confirmed the uterine didelphys with the pregnancy in the left uterine horn. 9 months after her delivery, she presented again for vaginal bleeding and was found to have an AVM in the same distribution as prior. She was treated with a second bilateral UAE at age 23; she has had no issues since; she continues to decline contraception.

Comments: This case highlights complexities adolescents face with limited healthcare access outside of medical emergencies and patient concerns about privacy. More information is needed about fertility after UAE to know if it is a viable option for adolescents who desire future fertility. AVM development and recurrence in an adolescent population is not well studied or understood.