OB Case Presentation

1. OB Case Presentation Tan, Irene Carmelle S.

2. 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

3. History of present pregnancy • LMP: January 9,2011 • EDC: October 16, 2011 • AOG: 14 2/7 weeks AOG by UTZ

4. History 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. Obstetric history G 3P2 (2012)

8. 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

9. Family history • Father: (-) hypertension, diabetes mellitus, cardiovascular disease, asthma, stroke • Mother: (+) hypertension, (-) diabetes mellitus, cardiovascular disease, asthma, stroke

10. 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.

11. Sexual 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. Contraceptive 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. 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

17. The patient was tranfused one unit of packed RBC

18. 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

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. 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.

23. Complete mole • No fetus or normal villi present • Trophoblastic proliferation • Marked villous hydrops • Absence of blood vessels in villi • Bunch of grapes appearance

24. Partial mole • Fetus and some normal villi are present • Focal villous hydrops • Blood vessels and RBCs present • Gross fetal parts present

25. 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

26. 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

27. 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

28. 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

29. UTZ : snowstorm or honeycombpattern

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. 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. 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

35. 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

36. 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

37. 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

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 2nd molar pregnancy is 1 – 3 %

39. Thank you