Transcript OB Case Presentation

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.
Obstetric history
G 3P2 (2012)
Year
birth
of Place
Method of Complicat
delivery ion
1st
2006
pregnancy
QMMC
NSD
None
2nd
2007
pregnancy
House
NSD
None
3rd
2011
pregnancy
QMMC
Suction
none
and
curettage
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 2040x
 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
Diffuse
swelling of embryonic
villi
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
Hypogastric pain
Amenorrhea
Enlargement of Abdomen
Others:
86
14.2
8.5
3.9
%
No FHT by Doppler after 12 weeks
Hyperemesis gravidarum
Sxs of preeclampsia
Sxs of hyperthyroidism
Lung , 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 HONEYCOMB
PATTERN
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
FIGO-WHO scoring system (2002)
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
TREATMENT
Termination of Molar Pregnancy
 Evacuation by Suction Curettage
IV oxytocin given
Low incidence of uterine perforation
and embolization
Fertility 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 0-6
methotrexate combined w/ folinic acid
 High risk → score of >7
combination 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 days
CBC,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 Prognosis
duration < 4 months
pre-evacuation β-HCG titers < 100,000 Iu/L
β-HCG undetectable in 4 weeks
Histologic type :
Partial mole is better than Complete mole
Risk of developing a 2nd molar pregnancy is 1 – 3
%
Thank you