Ob Jc Case Of Hydatidiform Mole

A CASE OF HYDATIDIFORM MOLE Argawanon, Yvonne P. Bantugan, Dan Blyke

HISTORY General Data: J.U., 31 years old, G3P2(2012), Filipino, Roman Catholic,

housewife, married, born on October 15, 1996 at Sogod, Cebu. Currently residing in Tipolo, Mandaue City, Cebu. 1st time to be admitted in Vicente Sotto Memorial Medical Center

On August 3, 2018, 10am.

HISTORY Chief Complaint Hypogastric pain with vaginal spotting Menstrual History Menarche – 14 years old Interval – regular 28 day menstrual cycle Duration - 4 to 5 days, used 3 pads per day, moderately soaked Associated symptoms - dysmenorrhea LMP - May 13, 2018

PMP - April 1st week, 2018

HISTORY OB history

G3P2(2012) No.

G1

G2

G3

Date of pregnancy

March 24, 2013

Outcome of pregnancy, Current status Fullterm, alive

August 31, 2016

Fullterm, alive

August 4, 2018

Molar pregnancy, 11 5/7 weeks age of gestation

Mode of Delivery Normal spontaneous delivery Normal spontaneous delivery

Place and Person Assisting the Delivery Cebu City Medical Center Health center in Tipolo, assisted by midwife

Vicente Sotto Suction curettage Memorial Medical Center

Weight and Fetal Sex Male, unrecalled weight Male, unrecalled weight -

Complications Fetal/ Maternal if any

None

None

-

HISTORY Contraceptive History and Sexual History Coitarche – 26 years old Partners – 1 sexual partner Contraception - Condom, every contact until she want to get pregnant No history of Papsmear and STI

HISTORY Past Medical History Non diabetic, non-asthmatic, and non hypertensive

Measles and chicken pox Had vaginal spotting after 2nd pregnancy (2016) No history of surgeries and psychiatric illness.

HISTORY Personal and Social History Husband is 33y/o, production worker for 5 years, no illnesses

5 years married, not alcoholic, non-smoker, no history of illicit drug use Highschool graduate 7 hours of uninterrupted sleep

Previously work was production worker for 4 years, stopped for her children Source of income, husband’s salary and relatives House is well ventilated, 7 individuals, 1 comfort room

HISTORY Family History Father, died at 76y/ due to hypertension

Mother, 67 y/o, housewife, no illnesses Youngest out of 6 Siblings had no illnesses, with the ff. age and gender, 49, male; 40, female; 39, female; 36 male; and 33 female Heterofamilial disease include hypertension No family history of cancer, diabetes, or asthma. No history of twins and congenital anomalies.

HISTORY Nutritional History Eats 3x/day with 2 snacks

Usually vegetables and fish History of Present Illness 1 month PTA intermittent hypogastric pain, 5/10 pain score, nonradiating, associated with vaginal spotting, no use of napkin 2 days PTA noted persistent hypogastric pain Went to velez, advised to have an ultrasound

HISTORY History of Present Illness Ultrasound results requested on August 1, 2018 Impression: enlarged anteverted uterus with intraendometrial structures, described as heterogenous structures interspersed with multiple cystic spaces of varied size. Consider hydatidiform mole. Normal both ovaries with a corpus luteum in the left. Tubulo-cystic structure, measuring 5.7 x 2.7 x 1.6cm. Consider hydrosalpinx, right. Pelvic fluid, minimal free fluid in the cul de sac. Advised for suction curettage

Due to financial constraint, referred to VSMMC

REVIEW OF SYSTEMS General: her usual weight is 45 kg, no recent weight change

Skin: (-) rashes, (-) lumps, (-) sores, (-) itching HEENT Head: (-)dizziness, (-) light headedness Eyes: clear vision, no glasses/ contact lenses, (-) pain

Ears: (-) earaches, (-) discharges Nose: (-) colds, (-) nasal stuffiness, (-) discharge, (-) itching Throat: (-) bleeding, (-) ulcers, (-) sores, (-) hoarseness

Neck: (-) lumps, (-) pain, (-) stiffness Breast: (-) lumps, (-) pain or discomfort, (-) nipple discharge Respiratory: (-) cough, (-) sputum, (-) dyspnea

REVIEW OF SYSTEMS Cardiovascular: (-) chest pain or discomfort, (-) palpitations Gastrointestinal: presence of abdominal mass, (-) nausea, (-) vomiting, (-) heartburn, (-) trouble swallowing Urinary: (-) dysuria

Genital: had vaginal spotting, (-) rashes, (-) itchiness Peripheral vascular: (-) cramps, (-) intermittent claudications, (-) varicose veins Musculoskeletal: (-) muscle or joint pains, (-) stiffness, (-) redness

Neurologic: (-) fainting, (-) blackouts, (-) weakness, (-) numbness Hematologic: (-) bruises, (-) transfusion reactions Endocrine: (-) heat/cold intolerance, (-) excessive sweating, (-) thirst or hunger Psychiatric: had a good mood, (-) nervousness, (-) tension

PHYSICAL EXAMINATION General Survey Conscious, alert, responsive, cooperative

intravenous line on her right hand Vital Signs BP – 120/90 mmHg, left arm

PR – 62 bpm RR – 19 cpm Temperature: 36.8 ˚C/axilla Weight: 45kg.

PHYSICAL EXAMINATION Skin and nail Skin is smooth, hair is well distributed, good skin turgor

No jaundice, lesions, masses, lumps, bruises, cyanosis HEENT Hair I black and well distributed

Lips, palpebral conjunctive, and gums are pinkish No lesions, discharges, inflammation Neck No lesions, masses, palpitations, thyroid gland not palpable

PHYSICAL EXAMINATION Chest and lungs no lesions and retractions, Chest expansion and tactile fremitus are equal, both lungs are resonant upon percussion, had clear breath sounds, no wheezes or rales. Breast Pendulous, symmetric, no lesions, dimpling, and tenderness

Heart No lesion, masses. PMI is heard at 5th intercostal space midclavicular line, distinct S1 & S2 , regular rhythm and a heart rate of 68 bpm.

PHYSICAL EXAMINATION Back no lesions, deformities Abdomen flabby, active bowel sounds, no lesions and tenderness

Tympanitic except over the liver and bladder areas, dull Had nontender hypogastric mass, movable firm with superior pole 2 finger breadths above the symphysis pubis Genital Introitus is parous, cervix is closed, uterus is 14 weeks size, adnexa is negative, and discharge is minimal and whitish. Extremities symmetric, no edema, deformities, cyanosis and tenderness Neurologic rientated to time and place, intact long-term memory and shortterm memory and cranial nerves are intact

ADMITTING DIAGNOSIS Hydatidiform Mole

SALIENT FEATURES Amenorrhea for 1 month Hypogastric pain

Vaginal spotting nontender hypogastric mass, movable firm with superior pole 2 finger breadths above the symphysis pubis

Uterus is 14 weeks size AOG: 11 5/7 weeks

SALIENT FEATURES Ultrasound dated August 1, 2018

enlarged anteverted uterus with intraendometrial structures, described as heterogenous structures interspersed with multiple cystic spaces of varied size. Consider hydatidiform mole. Normal both ovaries with a corpus luteum in the left. Tubulo-cystic structure, measuring 5.7 x 2.7 x 1.6cm. Consider hydrosalpinx, right. Pelvic fluid, minimal free fluid in the cul de sac

SALIENT FEATURES Laboratory examination PT = Positive

CBC : decrease in haemoglobin, haematocrit, MCV, MCH, Lymphocyte

increase eosinophils Quantitative β-hCG: 55,980mlU/mL (normal range < 1mIU/mL for nonpregnant, <7 mIU/mL for postmenopausal)

DIFFERENTIAL DIAGNOSIS Salient features Amenorrhea for 1 month

Threatened abortion

Inevitable abortion

Ectopic pregnancy

Hydatidiform mole

+

+

+

+

Hypogastric pain +

Vaginal spotting Bleeding in the 1st 20 weeks

+

Abdominal tenderness, with adnexal tenderness

Spotting but may Excessive vaginal simulate bleeding with menstrual clots bleeding

+

Spotting in the 1st trimester

Salient features

PE: nontender hypogastric mass, movable firm with superior pole 2 finger breadths above the symphysis pubis

Ultrasound: enlarged anteverted uterus with intraendometrial structures, interspersed with multiple cystic spaces of varied size, left ovaries with a corpus luteum

Threatened abortion

Inevitable abortion

Ectopic pregnancy

Hydatidiform mole

Hypogastric mass is palpable just above the symphysis pubis

Hypogastric mass is palpable just above the symphysis pubis

tender, palpable adnexal mass

Nontender hypogastric mass

Live fetus with subchorionic hemorrhage

Fetus is seen within echogenic endometrial the lower uterine segment, sac visualization of an mass accompanying an enlarged uterus, surrounded by embryo fetal pole the so-called perigestational in the adnexa “snowstorm hemorrhage, rupture appearance” membranes

Salient features

Threatened abortion

Inevitable abortion

Ectopic pregnancy

Hydatidiform mole

Pregnancy test positive

+

+

+

+

Anemia

+

+

+

+

5000 IU/L

5000 IU/L

1500 to 2500 mIU/mL

peaking at 100,000 IU/L

β-hCG: 55,980mlU/mL

Uterus sized is bigger than gestational age

Correspond to amenorrhea

Uterize size is smaller than gestational age

smaller than a normal 8-week intrauterine gestation

+

SUCTION CURETTAGE DONE (AUG. 4, 2018) Suctioned 1500 cc of vesicularity. Moderate amount of cerettings, with biggest vesicularty approximately 1x1 cm admixed with blood.

FINAL DIAGNOSIS: HYDATIDIFORM MOLE A benign trophoblastic lesion, which has two types complete hydatidiform mole and partial hydatidiform mole.

Complete hydatidiform mole completely derived from paternal origin , having a 46,XX genotype, produced by fertilization of an empty ovum by a single haploid (23,X) sperm; or 46,XY genotype, produced by dispermy, in which a 23,X sperm and a 23,Y sperm fertilize an empty ovum, which then duplicates in the ovum.

FINAL DIAGNOSIS: HYDATIDIFORM MOLE Partial hydatidiform mole derived from paternal and maternal chromosomes, resulting in a triploid genotype. A haploid ovum is fertilized by two haploid spermatozoa, with 69,XXX or 69,XXY being the most common karyotypes. In addition, PHM may present in conjunction with a viable fetus, showing signs of triploidy such as multiple congenital anomalies or severe growth retardation.

FINAL DIAGNOSIS: HYDATIDIFORM MOLE FEATURES Fetal or embryonic tissue Hydatidiform swelling of chronic villi

COMPLETE MOLES Absent Diffuse

PARTIAL MOLES Present Focal

Trophoblastic hyperplasia

Diffuse

Focal

Trophoblastic stromal inclusions

Absent

Present

Genetic parentage Karyotype Persistent human chorionic gonadotropin

Paternal 46,XX; 46,XY 20% of cases

Bipaternal 69,XXY; 69,XYY 0.5% of cases

EPIDEMIOLOGY oIncidence of HM is higher in Asia than in North America or Europe oPHM in the United Kingdom is 3/1000 pregnancies, and that of CHM ranges from 1 to 3/1000 pregnancies (Seckl, 2010) oEthnic groups such as Native American Indians, Inuits, Hispanics, and African American have an increased incidence of GTD

oThe geographic risk association reflects the distribution of different ethnic groups with a higher incidence of HM rather than environmental or climatic factors.

COMPLETE HYDATIDIFORM MOLE RISK FACTORS Previous history of H. mole Decreasing consumption of animal fat and beta-carotene Mutation of NLRP7 gene and, more rarely, KHDC3L gene GROSS APPEARANCE a large volume of grapelike vesicles made up of edematous enlarged villi

COMPLETE HYDATIDIFORM MOLE HISTOLOGIC CHARACTERISTICS 1. lack of fetal or embryonic tissues, 2. hydropic (edematous) villi 3. diffuse trophoblastic hyperplasia 4. marked atypia of trophoblasts at the implantation site 5. absence of trophoblastic stromal inclusions.

COMPLETE HYDATIDIFORM MOLE CLINICAL FEATURES Delayed menses

Gestational hypertension before 1st trimester vaginal bleeding, 20 weeks’ gestation with or without the passage of presence of theca lutein cysts molar vesicles Hyperemesis large-for-date uterus hyperthyroidism, absence of fetal movement  respiratory distress from anemia secondary to occult haemorrhage

trophoblastic emboli to the lungs. high levels of β-hCG

DIAGNOSTIC WORK UP 1. ULTRASOUND standard imaging modality for the diagnosis of a mole echogenic endometrial mass accompanying an enlarged uterus, the so-called “snowstorm appearance” Features: absence of fetal or embryonic tissue absence of amniotic fluid, Enlarged placenta with multiple cysts ovarian theca lutein cysts

DIAGNOSTIC WORK UP 2. HUMAN CHORIONIC GONADOTROPIN At 10 weeks gestation peaking at 100,000 IU/L and then falling thereafter 3. Biopsy Edematous placental villi, hyperplasia of trophoblasts, and lack or scarcity of fetal blood vessels.

MANAGEMENT 1. SUCTION DILATATION AND CURETTAGE 

preferred method of uterine evacuation under general anesthetic

2. HYSTERECTOMY  for whom continued fertility is not an issue, hysterectomy with preservation of the adnexa is a treatment option. 3. PROPHYLACTIC CHEMOTHERAPY  single-dose actinomycin D or Methothrexate 4. SERIAL β-HCG SURVEILLANCE  to ensure a timely diagnosis of postmolar malignant GTN 5. AVOID PREGNANCY FOR 1 YEAR 6. BLOOD TRANSFUSION AND/OR LACTATED RINGER’S SOLUTION  To treat anemia

PROGNOSIS Outcome after treatment is excellent Gestational Trophoblastic Neoplasia can occur after 6 months  2-3% can develop into choriocarcinoma  10-15% of cases, hydatidiform mole may develop into invasive moles