Transcript OB Case Presentation

CRUZ, MAY ANN
Clerk – San Beda College of Medicine
OB Rotation
Quirino Memorial Medical Center
General data
• E.N.
• 34 yo
• G2P1 (1001)
• Married
• Filipino
• Catholic
• Antipolo
• Admitted in QMMC for the 1st time last June 28
Chief complaint
• Vaginal bleeding
history of present illness
1 month PTC
• (+) Hypogastric pain
• (+) Vaginal bleeding (described as red droplet)
• Took Mefenamic acid 500mg/tab for pain
• Noted relief of symptoms
• No consult done
history of present illness
1 week PTC
• (+) Hypogastric pain
• (+) Vaginal bleeding (4ppd, moderately soaked)
• Consulted at a private clinic
• Ultrasound was done
• Result showed that the patient has hydatidiform mole
history of present illness
Few hours PTC
• Persistence of symptoms noted
• Sought consult
Review of systems
• General: (-) weight loss (-) easy fatigability
• CNS: (-) loss of consciousness, headache
• HEENT: (-) blurring of vision, eye pain, tinnitus, ear pain,
epistaxis, sorethroat
• RESP: (-) difficulty of breathing, (-) cough, (-) colds
• CVS: (-) chest pain, (-) palpitations
• GIT: (-) vomiting, (-) constipation
• GUT: (-) dysuria, (-) hematuria, (-) oliguria
• M/S: (-) limitation of movement, (-) joint pain
History of present pregnancy
• LMP: March 5,2011
• EDC: Dec 12, 2011
• AOG: 16 3/7 weeks AOG by LMP
• PNCU: private clinic x1
• Prenatal medications:
– MV and FeSO₄ OD
• No routine laboratory examination
Obstetric history
G₂P₁ (1001)
G1
2002
G2
Present
pregnancy
Full
Term
NSD
Home,
Assisted
by a
midwife
Female
(-)
Menstrual history
• Menarche:
• Interval:
• Duration:
• Amount:
• Symptoms:
12 yo
28 – 30 days
4 days
2 – 3 ppd, mod soaked
(-)
Sexual history
• First sexual intercourse: 23 y/o
• 1 sexual partner
• (-) History of sexually transmitted diseases
Contraceptive history
• Not practicing any type of birth control methods
Past medical history
•
•
•
•
•
•
•
•
(-) Diabetes Mellitus
(-) Hypertension
(-) Asthma
(-) Goiter
(-) Pulmonary tuberculosis
(-) Allergies
(-) Cancer
(-) History of blood transfusion, accidents or childhood
illness; surgery; hospitalizations
Family history
• (+) Hypertension (mother)
• (-) Diabetes Mellitus
• (-) Asthma
• (-) Goiter
• (-) Pulmonary tuberculosis
• (-) CVD
• (-) Renal diseases
• (-) Cancer
Personal and social history
•
•
•
•
Housewife
Non-smoker
Non-alcoholic beverage drinker
No illicit drug use
Physical examination
• General Survey
• HEENT
• Lungs
• CV
• Abdomen: FH 21cms; (-) FHT
• Extremities
• Pelvic Exam: cervix closed; uterus enlarged to 24 weeks
AOG
diagnosis
Admitting diagnosis
• G2P1 (1001) Molar pregnancy 16 3/7 weeks AOG by
LMP
• Plan:
– Suction curettage
Post-op diagnosis
• G2P1 (1011) Molar pregnancy 16 3/7 weeks AOG by
LMP, completed
Course in the wards
Day
Day 1
10:10am
7pm
9:30 pm
MD’s orders
Admit to LR/DR
NPO diet
For CBC with BT,
U/A, Blood chem
(BUN, Crea, FT4,
TSH, PT, PTT,
ALT and AST),
CXR-PA and
balloon
catheterization
Request for 2 “u”
PRBC
Shift to soft diet
Shift to DAT
For Balloon
catheterization
Labs and imaging Meds and IVF
Elevated WBC
D5LR 1L x 8 hrs
N BUN, crea, AST Ampicillin 2g TIV
Inc FT4, dec TSH
Inc BCHG
(783 931 IU/mL)
VS and Symptoms
Conscious,
coherent,
stable VS
(-) subjective
complaints
Stable VS
(+) min vaginal
bleeding
CBS, (-) DOB,
pallor
Day 3
9:45am
9:40am
DAT
NPO
For suction
curettage 6 hrs after
NPO
Transfuse 1 “u”
PRBC
Transfuse 1 “u”
PRBC
Give Paracetamol if
temp is ≥38C
For CBC
Paracetamol
500mg/tsb q 4hrs
(+) fever 38.8C
Cervix 2 cm dilated
(+) min vaginal
bleeding
Paracetamol
(+) passage of
300mg/amp, 1amp vesicular tissue
q 4hrs prn
(+) vaginal bleeding
BP 100/60
PR 112
Fever 38.2C
Day 4
S/P S/C Day 1
Transfer to ward
DAT
Start Oral meds
Start PTU
May start MTX
Day 5
S/P S/C Day 2
Cont oral meds
Cont PTU
Still for MTX
Cont MTX
Day 6
S/P S/C Day 3
Day 7
S/P S/C Day 4
Day 10
S/P S/C Day 7
For repeat BHCG
MGH
Repeat BHCG after 1
week of MTX
To follow up at OPD
CBC showed
elevated WBC
Cefuroxime 500mg
Stable VS
capsule BIDx & days
(-) subj comp
MA 500mg/tab prn for
pain
Ascorbic acid 1 tab once a
day
Ferrous sulfate 1 tab once
a day
PTU 50mg/tab,
3 tabs TID
MTX 0.9mL OD x 5days
BHCG 22 282 IU/mL
Hydatidiform mole
• Characterized by presence of avascular cystic villi
TYPES :
• Partial Mole :
– Presence of some normal villi with anucleated RBCs
• Complete Mole :
– Complete absence of normal villi
Hydatidiform mole
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
• USA : 1 per 1500 – 2000 pregnancies
• Asia : 13 per 1000 pregnancies
• Philippines : 1 – 2.3 per 120 pregnancies
7.9 per 1000 pregnancies
Risk factors
• Age:
– greatest risk >40 y/o and <20 y/o
• History of hydatidiform mole
– 20-40x increased risk
• Previous recurrent spontaneous abortion
• Lower socioeconomic status → poor nutrition
• Mexicans and Filipinos > Japanese and Chinese
a
Features
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
Clinical characteristics
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
Clinical characteristics
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 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
snowstorm or honeycomb pattern
score
0
1
2
4
pregnancy
pregnancy
Months from
index
pregnancy
<4 mos
4-6
7-12
>12
Pretreatment
HCG
<1000
1000-10,000
10,000100,000
>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
--
Single agent
2 or more
drugs
<39
>39
--FIGO-WHO
scoring
system
Antecedent
H. Mole in
Abortion in
Term
-(2002)
pregnancy
previous
previous
pregnancy
Age
Previous
-chemotherapy
• Low risk→ 0-6
Methotrexate combined w/ folinic acid
• High risk → >7
Combination of etoposide/methotrexate/
dactinomycin and cyclophosphamide/vincristine
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
Follow up
• β-HCG titers weekly until negative for 3 consecutive
determinations then q 1-3 months until 1 year
– β-HCG should decline steadily to undetectable levels within
12 – 16 weeks
• CXR every 3 months for 1 year
• Prevent pregnancy for 1 year
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 > Complete mole
• Risk of developing a 2nd molar pregnancy is 1 – 3 %