IV.

BIOGRAPHICAL DATA

The patient is a 38-year-old primipara at the 12 2/7th week of gestational age. She was admitted to the hospital with vaginal bleeding and intractable nausea and vomiting. She underwent a Dilatation and curettage to evacuate the grape-like mass and had a final diagnosis of hydatidiform mole.

Name of client: Mrs. J. S. Age: 38 yrs old Sex: Female Civil Status: Married Address: Olongapo City Birthplace: Olongapo City Birth date: November 28, 1969 Occupation: House wife Weight: 96 lbs (44kg) Height: 52 (62in) Nationality: Filipino Religion: Roman Catholic Educational Attainment: High school Level # of Admission: 2 Hospital: James L. Gordon Memorial Hospital Ward: OB-Gyne Admission Date: July 29, 2009 Admission Time: 10:00 am

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V.

CHIEF COMPLAINT:

Dinudugo ako na may kasamang parang sago as verbalized by the client.

VI.

HISTORY OF PRESENT ILLNESS

8 weeks prior to admission, client experienced nausea and vomiting and considered it as normal. She had a home-based pregnancy test which revealed a positive result. No prenatal visits were made and no medications were taken. 4 weeks prior to admission, still with nausea and vomiting, client noticed her abdomen is enlarging. No consultation made and no medications taken. Two days prior to admission, client experienced hypogastric pain characterized as intermittent, mild, cramping, and non-radiating, not aggravated by physical activity and emotional stress. The patient also noted vaginal bleeding characterized as intermittent, scanty, bright red, non-foul smelling, and consuming 1-2 pads a day, moderately soaked. No medication or consultations done. Vaginal bleeding persisted until 2 hours prior to admission, patient noticed passage of grape-like tissue associated with profuse vaginal bleeding and intractable nausea and vomiting. This prompted the patient to seek consultation at James L. Gordon Memorial Hospital. The following conditions are noted: anorexia, malaise, pallor, poor skin turgor, anemia, uterus larger than gestational age, and weight loss. No fetal heart tone was noted. Diagnostic procedures were made including beta-immunoassay, ultrasound, CBC, and BUN. Dilatation and curettage, as surgical treatment, was performed. Specimen from evacuation was sent to the laboratory and had the official result of Hydatidiform mole.

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VII.

NURSING HEALTH HISTORY

PAST MEDICAL HISTORY

The client was admitted last October 2006 at James L. Gordon Memorial Hospital for her labor and delivery. This was her second time to be confined due to molar pregnancy. According to the client, she has no allergy to any food or medication. The client completed the Expanded Program for Immunization but with no vaccine for hepatitis B. The client had mumps, measles, and chickenpox as her childhood illnesses.

FAMILY HISTORY

FATHER

MOTHE R CLIEN T HUSBAND

@
CHIL D

Hypertension

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@ -

Healthy Hydatidiform mole

PERSONAL AND SOCIAL HISTORY

The client is a high school graduate and is presently a house wife. She resides at Olongapo City. She has been married for the last 8 years, a Roman Catholic and lives with her husband. She is a smoker, consuming 24 packs per year and an occasional alcoholic drinker. Her husband is 39 years old, a contractual employee in a construction agency, and is currently in good health condition with single sexual partner.

MENSTRUAL HISTORY

Her last menstrual period was on April 20, 2009. Her menarche occurred when she was 12 years old with regular interval within 3-5 days duration noted to be moderate in flow consuming 2-3 pads/day. This is usually associated with dysmenorrhea.

GYNE HISTORY

Her first sexual contact was at the age of 17, married and sexually active for 8 years, single partner, with no history of post-coital bleeding, no history of dyspareunia and no contraceptive pills were used.

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OB HISTORY

Mrs. J.S. is a 38 year old mother with an OB score of G1P1 and a TPAL of 1001. She had an NSD on the first pregnancy. The age of gestation upon admission is 12 2/7 weeks by LMP. Her LMP was April 20, 2009. Her EDC was supposed to be January 27, 2010. She was admitted in the twenty-ninth of July 2009, at 10:00 in the morning due to intractable nausea and vomiting and profuse vaginal bleeding. She has not undergone any surgical or medical sterilization.

A. B. C. D. E. F. G. H. I.

Menarche: 12 y/o Coitarche: 17 y/o Menopause: N/A EDC: January 27, 2010 AOG: 12 wks 2/7 LMP: April 20, 2009 Trimester: 1st G: 1 P: 1

TPAL: (1001)

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VIII. PHYSICAL EXAMINATION

General Appearance: Client has a medium frame body built. No obvious physical deformities. Client has an unpleasant odor. Ht: 52 (62 in) Wt: 96 lbs (44 kg) Vital Signs were taken as follows: BP: 90/60 mmHg PR: 105 bpm RR: 21 cpm Temp: 37.5 0C

Mental Status: Client is well oriented to time, place, date, and persons. Client is quite irritable and agitated. She uses only simple words in moderate tone. Client speaks tagalong during the interview.

Skin: Client has dark skin pigmentation; with obvious scarring noted on the left elbow, mole noted on the neck, slightly warm to touch and with poor skin turgor.

Nails:

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Clients nail plate shape is convex 160; (-) clubbing; capillary refill is 3 to 5 seconds noted as abnormal; client also have long and dirty nails.

Head and Face: Clients head is normocephalic and proportionate to body size; thick hair distribution; with dandruff, (-) lesions and scaling on the scalp; No tenderness noted on scalp; symmetrical facial movements.

Eyes: Dry lacrimal ducts; sclera is white; sunken eyeballs; (-) dilatation of pupils; pupils are round; bulbar is clear and palpebral is pink; Conjunctivas are pale. Client has no visual difficulties except for his past experience with feeling of blindness.

Ears: Both ears are symmetrical in positioning. Pinna recoils when folded; (-) lesions. Client is not using hearing aids.

Nose: Nasal septum is at midline; (-) secretion in both nares with cilia.

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Mouth: Clients lips are dry; oral mucosa is dry.

Neck: Lymph nodes are not palpable; no presence of lesions.

Chest and Lungs: Client has fast breathing with an RR of 21 cpm; AP to lateral ratio 1:2; symmetrical lung expansion; (-) wheezes; bronchovesicular breath sounds. PMI is at LMCL 4th and 5th intercostal space. Client has tachycardia with a PR of 105 bpm; (-) murmurs.

Abdomen: Clients abdomen is globular, positive silvery striae gravidarum, bowel sounds are heard with a rate of 13/minute, fundic height of 18 cm noted as large for age of gestation, no palpable mass, no fetal parts and no fetal heart tone noted.

Upper and Lower Extremities: The client exhibits mild to moderate weakness on both upper and lower extremities, given a motor strength of 4/5 and 3/5 on the latter.

Genitalia: Vaginal bleeding was noted with discharges of grape-like tissues.

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IX.

REVIEW OF SYSTEMS

General Appearance (-) Insomnia (+) Weight loss (-) Fever (+) Fatigue (-) Chills Skin (-) Pruritus (+) Pallor Head & Neck (-) Sweating (+)Headache (-)Syncope Eyes (-)Blurred vision *no significant findings (-)Pruritus (-)Dryness Ears (-) Hearing loss *no significant findings (-) Pain (-) Discharge Nose (-) Dryness *no significant findings (-) Discharge (-) Sneezing Mouth (-) Soreness *no significant findings (-) Pain (-) Dysphagia

noted

noted

noted

noted

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(-) Nipple discharge (-) Tenderness (-) Masses

Breast *no significant findings noted

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(-) Dyspnea (-) Orthopnea Cardio-Vascular System (-) Palpitation *no significant findings noted Gastrointestinal System (-) Constipation (+) Anorexia (-) Dysphagia (+) Nausea (+) Vomiting Renal and Urinary System (-) Dysuria *no significant findings noted (-) Hematuria (-) Nocturia (-) Polyuria (-) Retention Musculoskeletal System (-) Backache (+)Pain in hypogastric area (+)Weakness (+) Abdominal cramping Reproductive System (-) Genital sores (+)Bleeding (-) Dyspareunia (+) Vaginal discharge of grape(-) Pruritis like tissue Hematological (+) Bleeding Nervous system (+)Dizziness Psychiatric (-) Hallucination (+)Insomia

Respiratory *no significant findings noted

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X.

DIAGNOSTIC PROCEDURES

Beta-Hcg Immuno-assays - hCG levels greater than 25,700288,000 mIU/mL at 9 to 12 weeks gestation indicate exuberant trophoblastic growth and raise suspicion that a molar pregnancy should be included. A molar pregnancy may have a normal HCG level.

CBC with platelet - Anemia is a common medical complication, as is the development of a coagulopathy. It is expected in conception with Hydatidiform mole to have a decreased amount of hemoglobin, hematocrit, and platelet. BUN and creatinine studies - Positive if levels are increased. Done to measure the amount of urea nitrogen (formed when proteins
break down) in the blood.

Ultrasonography - is the criterion standard for identifying both complete and partial molar pregnancies. The classic image, using older ultrasonographic technology, is of a snowstorm pattern indicating hydropic chorionic villi. High-resolution ultrasonography shows a complex intrauterine mass containing many small cysts (usually bilateral ovarian cysts). Chest radiograph - Once a molar pregnancy is diagnosed, a baseline chest radiograph should be taken. The lungs are a primary site of metastasis for malignant trophoblastic tumors. Histological Findings:

Complete mole: Fetal tissue is absent, and severe srophoblastic proliferation, hydropic villi, and chromosomes 46XX or 46XY are present. Additionally, complete moles show over expression of several growth factors, including c-myc, epidermal growth factor, and cerb B-2, compared to normal placenta.

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Partial mole: Fetal tissue is often present as well as amnion and fetal red blood cells. Hydropic villi and trophoblastic proliferation are also observed.

XI.

LABORATORY RESULTS

SERUM:

Examination BLOOD TYPE HEMOGLOBIN

RESULT O RH(+) Low Hgb = 11.3 g/dL

REF. VALUE (F) INTERPRETATION

12-16 g/dL

Decreased hemoglobin levels due to loss of blood through the vagina and concealed hemorrhage Decreased hematocrit levels due to loss of blood through the vagina and concealed hemorrhage Normal WBC count Low levels of platelet noted due to coagulopathy

HEMATOCRIT

Low Hct = 33 %

37-47 %

WBC COUNT PLATELET

Normal WBC = 10.3 Low = 230,000 / mm3

5-10x 103/ mm3 250,000400,000/mm3

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OTHER LABORATORY FINDINGS: Examination BUN Result High BUN = 20.3 High Crea = 92 Beta hCG High b-hCG = 364,000 Ref. Value 7-20 mg/dl 53-88 umol/L 25,700-288,000mIU/ml (9-12 wks AOG)

Ultrasonograp No gestational sac; uterus enlarged; multiple anechoic hy area of varied sizes seen interspersed in the H-mole Chest Radiograph Negative pleural effusion and metastasis

Interpretation: Higher than normal levels of BUN and creatinine due to hypovolemia secondary to excessive blood loss wherein lower levels must be expected in normal pregnancy. Higher dilution of human chorionic gonadotropin in the blood is expected in conception with Hydatidiform mole because of the abnormal proliferation of trophoblastic cells that secretes hCG. Ultrasound reveals snowstorm appearance due to the distention of hydropic chorionic villi instead of a fetus. Negative metastasis indicates absence of malignancy.

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XII.

DIAGNOSIS AND DIFFERENCIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS Incomplete abortion Choriocarcinoma Degenerated Uterine Leiomyoma

FINAL DIAGNOSIS

Hydatidiform Mole

Differential Diagnosis:

INCOMPLETE ABORTION By definition, an incomplete abortion is the partial expulsion of the products of conception before the 20th week of gestation. Clinical Characteristics: (+) Vaginal bleeding (+) Abdominal cramping (+) Pregnancy test

Pathophysiology: The timing of miscarriage suggests the pathophysiology of a spontaneous abortion. Genetic anomalies (eg, trisomies); hormonal abnormalities; and infectious, immunologic, and environmental factors usually result in first-trimester pregnancy loss. Anatomic factors usually are associated with second-trimester pregnancy loss. Factor

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XIII deficiency and a complete or partial deficiency of fibrinogen are associated with recurrent spontaneous abortions. Basis for exclusion: development of fetus during conception passage of fetal parts

Diagnostic Procedure: Transabdominal ultrasound of the pelvis provides an overall view of the pelvic structures. A full bladder is required as a sonographic window. Endovaginal ultrasound gives a detailed view of the

endometrium of the uterus, ovaries, adnexa, and cul-de-sac. An empty bladder is required for optimal imaging.

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CHORIOCARCINOMA Choriocarcinoma is a quick-growing form of cancer that occurs in a woman's uterus (womb). The abnormal cells start in the tissue that would normally become the placenta, the organ that develops during pregnancy to feed the fetus. Choriocarcinoma is a type of gestational trophoblastic disease.
ETIOLOGY:

Choriocarcinoma is an uncommon, but very often curable cancer associated with pregnancy. A baby may or may not develop in these types of pregnancy. The cancer may develop after a normal pregnancy; however, it is most often associated with a complete hydatidiform mole. The abnormal tissue from the mole can continue to grow even after it is removed and can turn into cancer. About half of all women with a choriocarcinoma had a hydatidiform mole, or molar pregnancy. Choriocarcinomas may also occur after an abortion, ectopic pregnancy, or genital tumor. Clinical Characteristics:

vaginal bleeding in a woman with a recent history of hydatidiform mole, abortion, or pregnancy Irregular vaginal bleeding

Ovarian cysts Uneven swelling of the uterus Pain

BAIS FOR INCLUSION:

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Vaginal bleeding Abnormal discharge Lower abdominal pain Nausea/vomiting Absence of fetal heart tones Swelling of lower abdomen

BASIS FOR EXCLUSION:

Metastasis to other organs of the body like the lungs and the brain.

DIAGNOSTIC PROCEDURE:

Dilation of the cervical opening followed by removal of uterine contents with dilatation and curettage. Serial blood tests to determine HCG hormone levels Chemotherapy Radiation therapy

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UTERINE LEIOMYOMA(FIBROIDS) Uterine fibroids are the most common pelvic tumor. Fibroids may be seen in as many as 1 in every 5 women in their childbearing years (the time after starting menstruation for the first time and before menopause). Fibroids usually affect women over age 30. They are rare in women under 20 or in those who have gone through menopause. Etiology: The cause of uterine fibroid tumors is unknown. However, fibroid growth seems to depend on the hormone estrogen. As long as a woman with fibroids is menstruating, a fibroid will probably continue to grow, usually slowly. Fibroids can be so tiny that you need a microscope to see them. However, they can also grow very large. They may fill the entire uterus, and may weigh several pounds. Although it is possible for just one fibroid to develop, usually there is more than one. CLINICAL CHARACTERISTIC:

Abdominal fullness, gas Bleeding between periods or very prolonged bleeding with periods Increase in urinary frequency Heavy menstrual bleeding (menorrhagia), sometimes with the passage of blood clots Pelvic cramping or pain with periods Sensation of fullness or pressure in lower abdomen Sudden, severe pain due to a pedunculated fibroid

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BASIS FOR INCLUSION: Vaginal bleeding Appear in women over the age of 30 pain(in the pelvic area) pelvic pressure an enlarged abdomen which may be mistaken for pregnancy BASIS FOR EXCLUSION: Urethral obstruction Bleeding between periods Negative pregnancy test

DIAGNOSTIC PROCEDURES:

Hysteroscopic resection of fibroids: This outpatient procedure may be needed for women with fibroids growing inside the uterine cavity. In this procedure, a small camera and instruments are inserted through the cervix into the uterus to remove the fibroid tumors.

Uterine artery embolization: This procedure stops the blood supply to the fibroid, causing it to die and shrink. The long-term effects of this procedure are still unknown, and the safety of pregnancy after this procedure is a concern.

Myomectomy: This surgery removes the fibroids. It is frequently the chosen treatment for women who want to have children, because it usually can preserve fertility. Another advantage of a myomectomy is that it controls pain or excessive bleeding that
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some women with uterine fibroids have. More fibroids can develop after myomectomy. XIII. COURSE IN THE WARD

Day One The patient was admitted to the Delivery room of James L. Gordon Memorial Hospital at 10:00 am due to profuse vaginal bleeding and intractable nausea and vomiting. History of present illness and other necessary information were taken upon admission. Her vital signs were noted and recorded as follows: T: 37.5oC, P: 105 bpm, R: 21cpm, BP: 90/60 mm/Hg. Her pelvic examination revealed passage of grape-like masses, larger uterus for gestational age, and abnormally high levels of pregnancy hormone- HCG. No fetal heart tone heard through Doppler. Diagnostic procedures done before the surgical treatment includes beta-immunoassay, ultrasonography, BUN, CBC with platelet. At 11:30 am, ultrasonography result shows a snowstormlike appearance with no fetal development. Other laboratory results show high levels of hCG, decreased amount of hemoglobin, hematocrit, and platelet. The patient has oxygen inhalation at 3 L/min via nasal cannula and was infused with D5LR, 1L with 10 units oxytocin at 30gtts/min A Foley catheter was inserted to the urinary meatus to drain the bladder. The urine output was amber yellow. At 1:00 pm the patient undergo intradermal skin test, then revealed a negative result after 30 minutes. At 1:30pm the patient was assisted in a dorsal recumbent position, loading of Co-amoxiclav 1.2gm TIV with ANST(-) was given as a prophylaxis against infection and diazepam 5mg for sedation, reducing anxiety, and promoting calmness. Dilatation and curettage procedure was done. Medications given in the process of dilatation and curettage include Oxytocin to dilate the cervix, Methergine after the Dilatation and curettage to prevent hemorrhage and excessive blood loss. After the procedure, specimen was sent to the laboratory. Post-op medications prescribed by the physician were ferrous sulfate 250mg twice a day to treat the existing deficiency of iron in the red blood cells of the client, Co-amoxiclav 625mg tablet every 8 hours for seven days for prophylaxis against infection, and Mefenamic acid
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500mg tablet every 6 hours or as needed to relive the pain. Diet as tolerated.

At 2:30 pm, the patient was transferred to the recovery room. After one hour, the patient has undergone a chest x-ray and later was moved to the OB-gyne ward after 2 hours. Vital signs were noted before transferring as follows: T- 37.3 oC, P: 92 bpm, R: 19cpm, BP: 100/70 mm/Hg

Day two Patient was transferred in OB-Gyne ward. Before entering the ward, the significant others of the patient said to the nurse, kanina pa siya umiiyak at balisang-balisa, sinisisi nya ang sarili nya sa nangyare. At 6:00 a.m., the client is awake in bed stated, pakiramdam ko pagod na pagod at nanghihina ako. With an ongoing IVF of D5LR, 1L, to run for 8 hours at 40 gtts/min. Morning care was done and completed. The patient complained about pain due to abdominal cramping with the pain scale 7/10 and was provided with comfort measures such as backrub and repositioning. She was also instructed to ambulate and perform deep breathing exercise to distract the perception of the client in pain. The client then opened up for her feelings of loss and worrying about inability to conceive another baby. She had a worried facial grimace and said, Kinakabahan ako baka lumala ang sakit ko at mauwi sa kung ano. The student nurse said Naiintindihan ko po kayo. Nandito po ako at handang makinig. Therapeutic communication and client teaching was applied by the student nurse during conversation. Her vital signs were noted and recorded as follows: Temp: 37.10C, PR: 89 bpm, RR:18 cpm, BP:100/70 mm/Hg. Result from the laboratory of the specimen passed was obtained and had the Hydatidiform mole as the final diagnosis. X-ray reveals no metastasis of trophoblastic cells in the lungs and negative of choriocarcinoma.

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Day three At 6:00 a.m., the patient stated, Hindi ko alam ang gagawin ko and conveyed about actual process of her disease because of her lack of knowledge. The student nurse, in response to clients query, gave information about the disease such as its meaning, causes, and prevention for its reoccurrence. Vital signs were recorded within normal range. Due meds were given at this time. The patient was informed that she may switch to full, regular diet as tolerated. The patient was cleared for discharge at 5:00 p.m. and was given the appropriate health teachings and instructions thereafter.

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