Six months postpartum and still bleeding: benign or serious

Six Months Postpartum and Still Bleeding: Benign or Serious?

Clinical Presentation
A 39-year-old, gravida 2, para 2 woman presents to the clinic for a routine gynecologic examination. She has no significant medical history and smokes a pack of cigarettes per day. Six months ago, she had an uncomplicated vaginal delivery of a term infant. Today, the patient complains of persistent vaginal bleeding over the past month, mild vague abdominal pain that she relates to gas, and a cough that recently started. Her bleeding requires at least 1 pad every day.

Physical Examination
Vital signs: all within normal limits
Lungs: clear to auscultation bilaterally; no wheezes, rales, or rhonchi
External genitalia: appearance is normal, perineum intact
Pelvic exam: a small, friable mass is discovered 2 cm from the cervix on the anterior vaginal wall
Cervix: appears parous and slightly dilated, with blood-tinged discharge present at the external os
Bimanual exam: bilateral adnexal fullness and a 14-week size uterus
Diagnostic Studies
A urine pregnancy test is positive. An ultrasound is performed, which shows bilateral 9-cm multicystic adnexal masses and debris in the uterine cavity.

What is the next best step in the diagnostic process for this patient?

Biopsy of the adnexal mass
Suction and curettage
Quantitative beta-hCG

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Six months postpartum and still bleeding: benign or serious