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OB C ASE P RESENTATION Tan, Irene Carmelle S.. G ENERAL DATA M.A. is a 32 year old, G3P2 (2012), married, Filipino, Catholic, currently residing in Antipolo.

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Presentation on theme: "OB C ASE P RESENTATION Tan, Irene Carmelle S.. G ENERAL DATA M.A. is a 32 year old, G3P2 (2012), married, Filipino, Catholic, currently residing in Antipolo."— Presentation transcript:

1 OB C ASE P RESENTATION Tan, Irene Carmelle S.

2 G ENERAL 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

3 H ISTORY OF PRESENT PREGNANCY LMP: January 9,2011 EDC: October 16, 2011 AOG: 14 2/7 weeks AOG by UTZ

4 H ISTORY OF PRESENT PREGNANCY 2months PTC the patient did not have her menstrual period No pregnancy test was done.

5 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.

6 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.

7 Year of birth Place Method of delivery Complicat ion 1 st pregnancy 2006QMMCNSDNone 2 nd pregnancy 2007HouseNSDNone 3 rd pregnancy 2011QMMCSuction and curettage none Obstetric history G 3P2 (2012)

8 P AST 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

9 F AMILY HISTORY Father: (-) hypertension, diabetes mellitus, cardiovascular disease, asthma, stroke Mother: (+) hypertension, (-) diabetes mellitus, cardiovascular disease, asthma, stroke

10 P ERSONAL 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.

11 S EXUAL HISTORY First sexual intercourse →18 y/o. The patient and her current partner are monogamous. She has no history of sexually transmitted diseases.

12 Unremrkable ROS and PE

13 C ONTRACEPTIVE HISTORY used intrauterine device from 2008-2010 stopped using intrauterine device because she wanted to get pregnant again

14 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

15 C OURSE 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

16 Blood chemistryUrinalysis RBC2.94 x10 /L ↓ColorYellow Hemoglobin84 g/L ↓TransparencySlightly hazy Hematocrit0.26 % ↓Reaction6.5 MCV87.1/ LSpecific gravity1.020 MCH28.6 pgWBC0-1 MCHC32.9 %RBC15-20 PlateletadequateEpithelial cellsfew WBC25.6 x10 /L ↑BacteriaFew Neutrophil0.837 ↑Mucus threadsmoderate AlbuminNegative Prothrombin time 10.8 sec SugarNegative PT INR 0.90 KetonesNegative APTT 39.2 sec BUN2.71 mmol/L Creatinine57.87 umol/L ↓ AST22 U/L ↑ ALT32 U/L Sodium133 ↓ Potassium3.5 Chloride101 TSH0.026 ↓ FT416.55 B HCG361,601 ↑

17 The patient was tranfused one unit of packed RBC

18 H YDATIDIFORM 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

19 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

20 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.

21 R ISK 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.

22 featureComplete moleIncomplete mole Fetal or embryonic tissue AbsentPresent Hydatidiform swelling of embryonic villi DiffuseFocal Trophoblastic hyperplasia DiffuseFocal Trophoblastic stromal inclusions AbsentPresent Genetic percentagePaternalBipaternal Karyotype46XX; 46XY69XXY; 69XYY Persistent human chorionic gonadotropin 20% of cases0.5% of cases

23 C OMPLETE MOLE No fetus or normal villi present Trophoblastic proliferation Marked villous hydrops Absence of blood vessels in villi Bunch of grapes appearance

24 P ARTIAL MOLE Fetus and some normal villi are present Focal villous hydrops Blood vessels and RBCs present Gross fetal parts present

25 C OMPLETE MOLE Clinical Presentation : 1 st or early 2 nd 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

26 P ARTIAL MOLE Clinical Presentation : 2 nd 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

27 S IGNS AND SYMPTOMS Vaginal bleeding86 Hypogastric pain14.2 Amenorrhea8.5 Enlargement of Abdomen3.9% Others: No FHT by Doppler after 12 weeks Hyperemesis gravidarum Sxs of preeclampsia Sxs of hyperthyroidism Lung, liver, brain involvement

28 DIAGNOSIS Clinical Symptoms UTZ : “ snow-storm appearance”/ honeycomb pattern β - HCG titers : >100,000 IU/l on 100 th day from LMP * Normal Pregnancy  HCG goes down on the 60 th -70 th day from LMP


30 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

31 score0124 Age<39>39-- Antecedent pregnancy H. MoleAbortionTerm-- Months from index pregnancy <4 mos4-67-12>12 Pretreatment HCG <10001000-10,00010,000-100,000>100,000 Largest tumor size <3cm3-5cm>5cm-- Site of metastasis --Spleen, kidneyGIBrain, liver Number of metastasis 01-45-6>8 Previous chemotherapy -- Single agent2 or more drugs FIGO-WHO scoring system (2002)

32 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

33 Low risk→score of 0-6 methotrexate combined w/ folinic acid High risk → score of >7 combination of etoposide/methotrexate/dactinomycin and cyclophosphamide/vincristine

34 I NDICATIONS 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

35 F OLLOW 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

36 METHOTREXATE Pulse MTX : 40 mg/m ² 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

37 A CTINOMYCIN 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/m ² q 2 weeks

38 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 2 nd molar pregnancy is 1 – 3 %

39 Thank you

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