Six Months Postpartum and Still Bleeding: Benign or Serious?
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.
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
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