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