Case Presentation OB

Patient profileJ.Y.17 y/o SingleRoman Catholic Sta Lucia Agdao,Davao City

G1P0

Chief Complaint

Profuse vaginal bleeding

OB HistoryNo. Yea

rSex

Indication for C/S

Place of Delivery

Attending

BW

Complications

n/a n/a n/a n/a n/a n/a n/a

n/a

G1P0 LMP- December 26, 2008 AOG- 18 weeks

3/7PMP- November 26, 2008 EDC- October 2,

2009

Menarche: 13 y/oSubsequent Menstrual Period:

regular, lasting for 5 days soaking 1-2 pads/day

Coitarche: 17 y/o, with 1 sexual partner

Papsmear: none

Family Planning Method: none

Gyne history

(+) childhood measles & chickenpox(-) DM (-)HPN (-)BA (-)CA

Past Medical Hx

(+) HPN – father(+) Ovarian Cancer – maternal (+) Brochial Asthma – patenal side(-) Heart disease(-) PTB(-) DM

Family Hx

Does not smokeSlight alcoholic beverage drinker No known food & drug allergiesFresh graduate from HS

Personal/Social History

Review of SystemsHEENT: No history of head injury, good vision,

good hearing occasional mild colds, occasional canker sores and no alarming complaints on the bucal cavity and pharynx

Neck: no pain and difficulty in swallowing, no complaints of tender lymph nodes

Cardio: no chest pain, no palpitations

Pulmo: no dyspnea, no cough

Gastrointestinal: abdominal pain on the hypogastric region, no vomiting, claimed to have mild diarrheic stools, no hematochezia

Urinary: no frequency, no hematuria, no dysuria

Review of Systems

History of Present IllnessHistory of Present Illness4 months

PTA(+) vaginal bleeding soaking 2 pads per day

metrorrhagia

(+) increase in abdominal girth

no associated sings and symtoms

2 months PTA

(+) metrorrhagia soaking 2 pads per day

(+) palpable abdominal mass between the symphysis pubis and the umbilicus

no associated sings and symtoms

History of Present IllnessHistory of Present Illness1 day PTA

Profuse vaginal bleeding

(+) nausea

(+) pallor

Palpable abdominal mass almost at the level of the umbilicus

Admission

PHYSICAL EXAMINATION

conscious, coherent, not in cardiorespiratory distress

BP: 120/80CR: 70 bpmRR: 20 cpmT: 36.8oC

Palms warm and dry. no rashes.

Nails without clubbing and cyanosis.

Hair of average texture. Scalp without lesions

Physical ExaminationConjunctiva pink, anicteric sclerae. Extraocular movements intact.

Acuity good. No gross ear deformities, no ear discharges

Nasal mucosa pink, septum midline. No sinus tenderness

Physical ExaminationOral mucosa pink. Moist lips and tongue, no tonsillar enlargement, pharynx without exudate.

No palpable masses, No enlargement of thyroid gland. No carotid bruit, Trachea midline.

Physical Examination symmetrical chest expansion, no intercostals retraction, equal tactile fremitus, lung fields are resonant, vesicular breath sounds w/ no added adventitioussounds

adynamic precordium, good S1 and S2, no murmurs, regular rhythm and normal heart rate.

Symmetric, without masses,Nipples w/out discharges and retraction.

Physical Examination

flat, Normoactive bowel sounds (16/min) tympanitic no hepatomegaly or

splenomegaly

Palpable abdominal mass at the level of the umbilicus

Physical Examination

No edemaNo varicosities, no ulcers

Physical Examination

Radial Femoral Popliteal

Dorsalis pedis

Posterior tibial

Right +2 +2 +2 +2 +2

Left +2 +2 +2 +2 +2

alert and cooperative, thought coherent, oriented to person, place and time.

(+) Nystagmus

able to do nose pointing and rapid alternating movements.

Intact cranial nerves

Intact pinprick, light touch, position, and vibration sensation

Physical Examination

+2 +2 +2

+2 +2 +2

+2 +2

+2 +2

R LUpper

extremities: 5/5 5/5

Lower extremities

5/5 5/5

SpeculumSmooth, pinkish cervix with no lesions

foundCervix is non-dilated

Internal ExaminationCorpus enlarged to ~20 wks size, fixedNo adnexal mass/tenderness

Pelvic examination

MetrorarrgiaNausea pallorGradually Increasing abdominal mass

4 months PTA- increase in abdominal girth2 months PTA- palpable abdominal mass between the

symphysis pubis and the umbilicus1 day PTA- palpable abdominal mass almost at the level of

the umbilicus

No pressure signs and symptoms

Salient Features

Pelvic ExaminationCorpus enlarged to ~20 wks size, fixedNon-dilated cervix

Impression

Pregnancy Uteri G1P0 18 3/7 weeks AOGHydatidiform Mole

Differential Diagnosis

Submucous myomaEctopic pregnancyThreatened Abortion

Differential DiagnosisFeatures Patient Submucou

s myomaEctopic Pregnancy

Threatened Abortion

Age/incidence

17 years old

>35 years old

2% 15%*

Metrorrargia

(+) (-) * (+/-) * (+)

abdominal mass

(+) (+) * (+) * (+)

Pressure signs and symptoms

(-) (+)* (-) (+/-)

Nausea and pallor

(+) (+/-) (+) (+/-)

Pain (-) (+/-) (+) * (+)Enlarged globular corpus

(+) 20 weeks AOG

(+) * (+/-) (+)

Cervical dilatation

(+) (+) (+) (+)*

Differential DiagnosisFeatures Patient H-moleAge/incidence 17 years old 1 0f 1500

pregnanciesMetrorrargia (+) (+)abdominal mass (+) (+)Pressure signs and symptoms

(-) (-)

Nausea and pallor (+) (+) *Pain (-) (-)Enlarged globular corpus

(+) 20 weeks AOG (+) *

Non-dilated cervix (+) (-)

Management Diagnostic studies:

Quantitative B-hCGTransvaginal Ultrasound

Dilation and suction curettageIV oxytocin should be administered

Follow-up for development of GTThCG determinations (48 hours, 3 consecutive

weeks, every 6 months, and then yearly)PE (Pelvic exam at regular intervals)Birth control (1 year- OCP, Depo Provera)

DiscussionH-mole

Molar pregnancy is characterized histologically by abnormalities of the chorionic villi that consist of trophoblastic proliferation and edema of villous stroma

2 forms: Complete & Partial

DiscussionCOMPLETE

1. Hydropic degeneration and swelling of the villous stroma

2. Absence of blood vessels in the swollen villi.3. Proliferation of the

trophoblastic epithelium to a varying degree

4. Absence of fetus and amnion.

ManagementDilatation and Suction curettagebHCG monitoring

Good day