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Clinical Case

Discussion
Shamenee Banduringgu
131303168
Case History
MrsA, a 31 year old para 2, is
referred to the assessment unit at the
maternity hospital by her GP, in view
of her persistent vomiting and pain in
the right lower quadrant of
abdomen. She is 12 weeks pregnant
by date and has been unable to
take any food or drinks for the past 3
days. 10 vomiting episode She feels
exhausted and unable to do her
daily routine.
The abdominal pain is sudden in onset,
colicky in nature, lasted for 2 hours.
The pain score was 8/10, she unable to
continue working
There is no radiation of the pain.
Not associated with PV bleeding or
discharge, dysuria, hematuria, trauma
or fever with chills and rigor.
Not relieved by analgesics.
Menstrual history:

She attained menarche at the age of 13


years old. Her cycles were regular with flow
of 6 days in each cycles of 28 days and
the amount is moderate. It was associated
with dysmenorrhea.
No history of OCP used
No pap smear test done before
Past medical & surgical history:
NIL
Family history:
Her father had HT, DM and controlled
under medication.
Her mother is healthy.
No history of malignancy in the family.
No similar symptom in the family
Personal history:

Lossof appetite and loss of weight due to excessive


vomiting
Decrease bowel and bladder habit
She does not smoke and consume alcohol
General examination:
Patient is alert, cooperative and is sitting
comfortably on the bed. She is moderately
built and nourished.
Height is 160 cm, weight 55 kg, BMI of 21.5
BP: 130/84 mmHg.
Pulse : 94 bpm regular rhythm, normal
volume and character.
She appeared pale, seen on the lower
palpebral conjunctiva
Pulse : 94 bpm regular rhythm, adequate
volume and normal character.
There is present of bilateral pitting edema
Abdominal examination:
Inspection:
The abdomen is uniformly distended with the flanks
not full
The umbilicus is centrally placed and flat.
There are no visible scars or dilated veins appreciated.
Palpation:
Abdomen was soft and tender.
Symphysiofundal height correspond to 20 weeks of
gestation
Has doughy feels
Systemic examination:
Respiratory:
Vesicularbreath sounds were heard on both the
sides with no abnormal added sound heard.

Cardiovascular:
Thereis no visible jugular venous pulsation on the
neck. The S1 & S2 were normal with no murmur
Investigation

Full Blood Count:


Hb 8.6 g/ dL ( decrease)
Platelets 300x 10^9/ L (normal )
TWBC 9000 x 10^9/ L (normal )
Neutrophils (75.5%) (normal)
Lymphocytes (25.1%) (normal )
Eosinophils (4.3%) ( normal)
Serial B-HCG level
1305 IU/L ( 8/9/2017)
3000 IU/L (10/9/2017)
5000 IU/L (12/9/2017)
6000 IU/L ( 14/9/2017)

Abdominal Ultrasound
Intrauterine
mass containing multiple cystic areas
Snowstorm appearance
Patient had successfully undergone Suction
Curettage on 15/9/2017 and mass
succesfully removed. Minimal product of
conception like material evacuated with
minimal blood loss.

Her current B-HCG levels reading is 7012


IU/L. She currently admitted in the ward for
observation.
Gestational
Trophoblastic
Disease
Classification Gestational trophoblastic disease

WHO classification Hydatidiform Mole


*Complete
*Incomplete
Invasive
Choriocarcinoma
Placental site tumor
Trophoblastic lesions
Histological classification Complete mole
Partial mole
Invasive mole
Metastatic mole
Choriocarcinoma
Placental site trophoblastic tumor
Epitheloid trophoblastic tumor
Incidence :
Molar pregnancies 1-1.5 in 1000 live
births

Choriocarcinoma 1 in 50,000 live births

Recurrent risk of molar pregnancy 1 in 55


after one affected pregnancy , and 1 in 7
birth after two previous molar
pregnancies
HYDATIFORM
MOLE
Risk factors

1) 5-10 fold increase in those >40 years


2) >30% GTD in pregnancies >50 years
3) Higher incidence in <16 years
4) History of prev molar pregnancy
5) Recurrent molar pregnancy (NLRP7 Gene
mutation)
Clinical features
Symptoms:
Classically Irregular vaginal bleeding in a women
with signs of pregnancy
History of passage of grape like vesicles
Hyperemesis gravidarum
Absence of fetal movements
Lower abdominal pain
Anaemia
Hyperthyroidism (not common)
Weight loss

Signs:
Large for dates uterus
Sign of early onset preeclampsia <20 weeks
Theca-lutein ovarian cyst >6 cm
Respiratory distress
Differential
diagnosis
Vaginal bleeding :
ectopic pregnancy,
miscarriage,
cervical ectropion,
cervical neoplasm,
genital tract infection
Adenomyosis
Endometrial can
Degeneration of leiomyoma

Excessive vomiting :
UTI,
gastro-intestinal disease,
metabolic disease,
hyperemesis gravidarum
Physical examination
1. Evaluate general condition/
Haemodynamic status
2. Vital signs
3. Sign of anaemia
4. Abdominal examination
Uterine size large for dates
Tenderness (large theca lutein cysts),
rebound ternderness and guarding (present
in hemoperitoneum)
Speculum examination
Quantify blood loss,
presence of clots,
product of conception in vagina or cervix
(grape like vesicles),
state of cervix and cervical os (open or
closed)
Bimanual examination
Uterine size and consistency (large for
dates with doughy consistency),
Uterine tenderness, adnexal mass and
tenderness
Ultrasonography:

Indication;
Early trimester bleeding
Uterus larger than gestational age
Absence f fetal movement or
fetal parts on examination after
20 weeks
Investigation
1. FBC, Blood grouping and typing
2. Trans-vaginal USG:
1. Image in 1st trimester: May resemble
missed/incomplete miscarriage, hence diagnosis
needs to be confirmed with HPE
2. Typical snowstorm appearance seen in 2nd
trimester as heterogenous mass with no fetal
development
3. Quantitative assessment of beta-HCG
4. Liver function test
5. Renal function test
6. Thyroid function test
7. Ultrasonography
8. Imaging studies
Immediate Management
Initial assessment and stabilization of patient
Correction of fluid and electrolytes
Correction of anemia
Preoperative assessment (cardiorespiratory)
Surgical suction curettage under anesthesia
Anti D Ig for the negative mothers
Role of hysterectomy and chemoprophylaxis
Treatment
Complete molar pregnancy:
Post treatment surveillance
6 months (RCOG) after evacuation of
uterus where B-hCG normalizes after 56
days (in uncomplicated case)
In other cases follow-up is continued till B-
hCG falls to normal values. In Malaysia 2
years is advised
Serum B-hCG is determined
Done weekly for 4 weeks after evacuation
Fortnightly for 3 months
Monthly follow up for 6-24 months
Follow up for life at 6 monthly intervals.
1. History , examination and investigation
Return of menstruation
Type of contraception
Any abnormal vaginal bleeding
Presence of anemia and chest pelvic
examination
Pap semar if it is due
Serum beta hCG
USG of uterus.
contraceptive advices
Most commonly used drugs is methotrexate (MTX)
with folinic acid (Leucovorin) .
Single drug regime with low risk should suffice
Commonly employed is MTX alternating with folinic
acid for 8 days.
serum beta hCG is used to monitor progress.
3. Placenta site trophoblastic
tumour (PSTT)
Uncommon and arise from placenta insertion
Occur in women of median age 31
Minimal hCG, & human placental lactogen (monitored
during follow-up)
Syncytiothrophoblast cells generally absent, instead
sheets of intermediate trophoblastic cells predominate
Not very responsive to chemotherapy, thus
hysterectomy preferred
Malignant trophoblastic
disease
1. Invasive mole:
Invade myometrium
Can lead to perforation and intraperitoneal
bleeding
Presents as elevated hCG after evacuation of
mole, abnormal vaginal bleeding or abdominal
pain
Risk increase:
Long time (>4 months) between LMP and
treatment
Uterus has become very large
Woman is > 40 years old
References
National Cancer Institute. PDQ gestational
trophoblastic disease treatment. Updated February
25, 2015.
www.cancer.gov/cancertopics/pdq/treatment/gest
ationaltrophoblastic/HealthProfessional. Accessed
June 30, 2016.
https://www.rcog.org.uk>gtg38
Gynaecology Today first edition 2012, pg 568-585