OB CASE PRESENTATION
Tan, Irene Carmelle S.
GENERAL DATA
M.A. is a 32 year old, G3P2 (2012), married, Filipino, Catholic, currently residing in Antipolo was admitted in QMMC
Chief complaint vaginal bleeding
HISTORY OF PRESENT PREGNANCY
LMP: January 9,2011 EDC: October 16, 2011 AOG: 14 2/7 weeks AOG by UTZ
HISTORY OF PRESENT PREGNANCY
2months PTC the patient did not have her menstrual period No pregnancy test was done.
1 month PTC having hypogastric pain which was described
as squeezing and rated as 7/10 severity pain lasted for 10-30mins took Mefenamic acid once pain was accompanied by vaginal bleeding
which was described as red droplet She went to the center and consulted. Pregnancy test was done and the result was
positive. No intervention was done.
Few weeks PTC hypogastric pain and bleeding persisted and
the volume of blood expelled was greater than before
She now consulted a lying in and ultrasound was done.
Result showed that the patient has hydatidiform mole which prompted the patient to be admitted in QMMC.
Year of birth
Place Method of delivery
Complication
1st pregnancy
2006 QMMC NSD None
2nd pregnancy
2007 House NSD None
3rd pregnancy
2011 QMMC Suction and curettage
none
Obstetric historyG 3P2 (2012)
PAST MEDICAL HISTORY
denied of having Diabetes Mellitus, hypertension, asthma, pulmonary tuberculosis, allergies, renal diseases, goiter, cancer and other illness
patient did not undergo any surgeries no history of blood transfusion, accidents or
childhood illness
FAMILY HISTORY
Father: (-) hypertension, diabetes mellitus, cardiovascular disease, asthma, stroke
Mother: (+) hypertension, (-) diabetes mellitus, cardiovascular disease, asthma, stroke
PERSONAL AND SOCIAL HISTORY
Works as a masseuse Non-smoker and an occasional alcoholic
beverage drinker No illicit drug use Her husband is a cigarette vendor They have been together for 3 years.
SEXUAL HISTORY
First sexual intercourse →18 y/o. The patient and her current partner are
monogamous. She has no history of sexually transmitted
diseases.
Unremrkable ROS and PE
CONTRACEPTIVE HISTORY
used intrauterine device from 2008-2010 stopped using intrauterine device because
she wanted to get pregnant again
DIAGNOSIS
Admitting diagnosis G3P2 (2002) Molar pregnancy 14 2/7 weeks
AOG by UTZ
Post-op diagnosis G3P2 (2012) Molar pregnancy 14 2/7 weeks
AOG by UTZ
COURSE IN THE WARD
Medications given: Ampicillin 1g TIV every 6 hrs Hyoscine N-Butyl Bromide 1 amp every 4 hrs Ranitidine 50mg IV Cefalexin 500mg every 8hrs x 7 days Methergin 1 tab 3x/day for 3 days Oxytocin 10% Ascorbic acid 1 tab once a day Ferrous sulfate 1 tab once a day Mefenamic acid 500mg 1 tab per needed
Blood chemistry Urinalysis
RBC 2.94 x10 /L ↓ Color Yellow
Hemoglobin 84 g/L ↓ Transparency Slightly hazy
Hematocrit 0.26 % ↓ Reaction 6.5
MCV 87.1/ L Specific gravity 1.020
MCH 28.6 pg WBC 0-1
MCHC 32.9 % RBC 15-20
Platelet adequate Epithelial cells few
WBC 25.6 x10 /L ↑ Bacteria Few
Neutrophil 0.837 ↑ Mucus threads moderate
Albumin Negative
Prothrombin time 10.8 sec Sugar Negative
PT INR 0.90 Ketones Negative
APTT 39.2 sec
BUN 2.71 mmol/L
Creatinine 57.87 umol/L ↓
AST 22 U/L ↑
ALT 32 U/L
Sodium 133 ↓
Potassium 3.5
Chloride 101
TSH 0.026 ↓
FT4 16.55
B HCG 361,601 ↑
The patient was tranfused one unit of packed RBC
HYDATIDIFORM MOLE Characterized by presence of avascular
cystic villi 89.6 % of all trophoblastic disease
TYPES : Partial Mole : presence of some normal villi
with anucleated RBCs
Complete Mole : complete absence of normal villi
has three morphologic characteristics: (1) a mass of vesicles (distended villi) that
appear as large, grapelike dilations (2) a loss of fetal blood vessels, which are
either diminished or absent from the villi (3) hyperplasia of the syncytiotrophoblast
and cytotrophoblast
EPIDEMIOLOGY
United States→the rate is estimated to be approximately one in 1500 to 2000 pregnancies and in one in 600 therapeutic abortions (Berkowitz and associates and Eifel and associates )
rates from Southeast Asia are 5 to 15 times higher with much larger variations, and rates up to 13 per 1000 have been reported by Altieri and colleagues.
RISK FACTORS
Risk increases with age, greatest risk >40 y/o Increase risk in <20 y/o History of hydatidiform mole →increases risk
20-40x Previous recurrent spontaneous abortion Lower socioeconomic status as well as in
underdeveloped areas → poor nutrition Mexicans and Filipinos appear to have
elevated rates compared with Japanese and Chinese.
feature Complete mole Incomplete mole
Fetal or embryonic tissue
Absent Present
Hydatidiform swelling of embryonic villi
Diffuse Focal
Trophoblastic hyperplasia
Diffuse Focal
Trophoblastic stromal inclusions
Absent Present
Genetic percentage Paternal Bipaternal
Karyotype 46XX; 46XY 69XXY; 69XYY
Persistent human chorionic gonadotropin
20% of cases 0.5% of cases
COMPLETE MOLE
No fetus or normal villi present
Trophoblastic proliferation
Marked villous hydrops
Absence of blood vessels in villi
Bunch of grapes appearance
PARTIAL MOLE
Fetus and some normal villi are present
Focal villous hydrops Blood vessels and
RBCs present Gross fetal parts
present
COMPLETE MOLE
Clinical Presentation : 1st or early 2nd trimester
Large for date uterus (50 % of cases) Contents expelled earlier (~10-16 weeks) Early onset of Preeclampsia β-HCG titer is higher than partial mole UTZ : no fetal parts ↑ risk of Choriocarcinoma
PARTIAL MOLE
Clinical Presentation : 2nd trimester Normal or Small for date uterus Contents are expelled later (~10-26 weeks) Normal symptoms of pregnancy β-HCG titer is lower than complete mole UTZ : (+) fetal components Lower risk of Choriocarcinoma
SIGNS AND SYMPTOMS Vaginal bleeding 86 Hypogastric pain 14.2 Amenorrhea 8.5 Enlargement of Abdomen 3.9 % Others:
No FHT by Doppler after 12 weeks
Hyperemesis gravidarumSxs of preeclampsiaSxs of hyperthyroidismLung , liver , brain involvement
DIAGNOSIS
Clinical Symptoms UTZ : “ snow-storm appearance”/
honeycomb pattern β - HCG titers :
>100,000 IU/l on 100th day from LMP* Normal Pregnancy HCG goes down
on the 60th-70th day from LMP
UTZ : SNOWSTORM OR HONEYCOMBPATTERN
Metastasis Common sites: lungs, liver, brain
Other tests to request: CXR : Rule out lung metastasis; “canon-ball”
exudates SGPT/SGOT : rule out liver metastasis
Baseline liver function prior to chemotherapy
BUN/Creatinine : Baseline kidney function prior to chemotherapy
CBC
score 0 1 2 4
Age <39 >39 -- --
Antecedent pregnancy
H. Mole Abortion Term --
Months from index pregnancy
<4 mos 4-6 7-12 >12
Pretreatment HCG
<1000 1000-10,000 10,000-100,000
>100,000
Largest tumor size
<3cm 3-5cm >5cm --
Site of metastasis
-- Spleen, kidney
GI Brain, liver
Number of metastasis
0 1-4 5-6 >8
Previous chemotherapy
-- -- Single agent 2 or more drugs
FIGO-WHO scoring system (2002)
TREATMENTTermination of Molar Pregnancy Evacuation by Suction Curettage
IV oxytocin givenLow incidence of uterine perforation and embolizationFertility is preserved
Replacement of blood loss Treatment of infection Prophylactic chemotherapy
Can be given before or after evacuation or hysterectomy*Methotrexate *Actinomycin
Low risk→score of 0-6methotrexate combined w/ folinic acid
High risk → score of >7combination of etoposide/methotrexate/dactinomycin and cyclophosphamide/vincristine
INDICATIONS FOR INITIATING CHEMOTHERAPY FOLLOWING MOLAR PREGNANCY
Brain, liver, GI or lung mets >2cm on chest X-ray
Histological evidence of choriocarcinoma Heavy vaginal bleeding or GI intraperitoneal
bleeding Pulmonary, vulvar or vaginal metastases
unless the HCG level is falling Rising HCG in 2 consecutive serum samples HCG > 20,000 iu/l > 4weeks after evacuation HCG plateau in 3 consecutive serum samples Raised HCG level 6 months after evacuation
FOLLOW UP
β-HCG titers q weekly until negative (less than 5 mIu/ml) for 3 consecutive determinations then q 1-3 months until 1 year
CXR q 3 months x 1 year* for early detection of lung mets
Prevent pregnancy for 1 year * combination OCPs
METHOTREXATE
Pulse MTX : 40 mg/m² IM weekly MTX with Folinic Acid Rescue
Day 1 , 3 , 5 , 7 :MTX 1.0 mg/kg/day IM or IV
Day 2 , 4 , 6 , 8 :Folinic Acid 0.1 mg/kg/day
ACTINOMYCIN D
5 Day Actinomycin D :12 μg/kg IV daily x 5 daysCBC,platelet count,SGOT daily(+) response : retreat at the same dose(-) response : add 2 μg/kg to the initial
dose or switch to MTX
Pulse Actinomycin D : 1.25 mg/m² q 2 weeks
PROGNOSIS
Good Prognosisduration < 4 monthspre-evacuation β-HCG titers < 100,000
Iu/Lβ-HCG undetectable in 4 weeksHistologic type : Partial mole is better than Complete mole
Risk of developing a 2nd molar pregnancy is 1 – 3 %
Thank you