© Cambridge University Press 2015. History of present illness: A 38-year-old gravida 4, para 3–0–1–3 woman presents to the emergency department complaining of heavy vaginal bleeding for the past 2 days. Six months prior to presentation she had undergone a dilation and curettage (D&C) for a complete molar pregnancy. She reports that she has not kept any of her follow-up appointments since surgery. Over the past few months, she has developed irregular, heavy menses, and now reports that her bleeding is so heavy it often soaks through her clothing. She also reports nausea and mild lower abdominal cramping. She recently developed a persistent cough with blood-streaked sputum, which seems to be worsening. She otherwise denies fever, chills, dizziness, palpitations, chest pain, or shortness of breath. She has no other medical problems and has never had abdominal surgery. She is on no medication and her husband plans a vasectomy for contraception. She is a stay-at-home mother who doesn’t smoke and reports having one glass of wine each evening. Physical examination General appearance: Well-nourished woman in no acute distress Vital signs: Temperature: 36.9°C Pulse: 102 beats/min Blood pressure: 118/76 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 97% on room air HEENT: Unremarkable Cardiovascular: Regular rhythm, mild tachycardia; no rubs, murmurs, or gallops Lungs: Mild diffuse crackles bilaterally Abdomen: Soft, nontender, nondistended, active bowel sounds present. Firm uterine fundus palpated 3–4 cm below umbilicus Rectal: Normal tone, no masses; brown stool noted; hemoccult negative Pelvic: Active bleeding from the cervical os, with blood pooling in vaginal vault; cervix closed; uterus mobile and enlarged, approximately 16-weeks’ size; enlarged adnexa bilaterally. No cervical motion or adnexal tenderness Extremities: No clubbing, cyanosis, or edema Neurologic: Alert and oriented × 4. No focal deficits Laboratory studies: Urine pregnancy test: Positive Quantitative beta-hCG: 376 524 mIU/mL (normal nonpregnant <5 mIU/mL) Ht: 21% (normal 34.9–44.5%) Blood type: B positive Hepatic function panel, thyroid function tests, and metabolic panel were all within normal limits.