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Molar Pregnancy


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Molar Pregnancy

  1. 1. Molar Pregnancy Cristal Ann Laquindanum Ateneo School of Medicine and Public Health Class of 2012
  2. 2. Objectives: <ul><li>To present a case of molar pregnancy </li></ul><ul><li>To discuss diagnostic approach in hydatidiform mole and its rationale </li></ul><ul><li>To discuss the management and surveillance protocol for hydatidiform mole </li></ul>
  3. 3. Identiying data <ul><li>Patient E.E. </li></ul><ul><li>25 years old </li></ul><ul><li>Married </li></ul><ul><li>G3P2 (2002) </li></ul><ul><li>Roman Catholic </li></ul><ul><li>housewife </li></ul>
  4. 4. Chief complaint <ul><li>Scanty brownish vaginal discharge </li></ul>
  5. 5. History of Present Illness <ul><li>Patient was regularly menstruating </li></ul><ul><ul><li>age of 14, </li></ul></ul><ul><ul><li>regular interval, </li></ul></ul><ul><ul><li>lasting for 3 days, </li></ul></ul><ul><ul><li>consumes 2 pads per day </li></ul></ul><ul><ul><li>LMP: Jan 3, 2011 </li></ul></ul>Pre-molar history
  6. 6. History of Present Illness <ul><li>12 weeks PTC, missed menses </li></ul><ul><ul><li>LMP: Jan 3 </li></ul></ul><ul><ul><li>No consult, no medications taken </li></ul></ul><ul><ul><li>Otherwise, asymptomatic </li></ul></ul><ul><li>5 weeks PTC, pregnancy test = positive </li></ul><ul><ul><li>Advised to have an ultrasound done, lost to follow up </li></ul></ul><ul><ul><li>asymptomatic </li></ul></ul>Missed menses 12 wks PT = + 5 wks
  7. 7. History of Present Illness <ul><li>3 weeks PTC, results of the TVS showed… </li></ul><ul><ul><li>Retroverted uterus (6.6 x 7.6 x 6.6) </li></ul></ul><ul><ul><li>Heterogenous mass with mixed level echoes within the uterine parenchyma (endometrial cavity) measuring 5.4 x 5.8 x 4.7 </li></ul></ul><ul><ul><li>Advised to have her B-hCG levels tested </li></ul></ul><ul><ul><ul><li>Result: 189.9 mIU/mL (NV: 0-5.0 mIU/mL) </li></ul></ul></ul><ul><ul><li>Advised to consult a tertiary hospital for further management </li></ul></ul><ul><ul><li>lost to follow up </li></ul></ul>Missed menses 12 wks PT = + 5 wks TVS result suggestive of H.mole 3 wks
  8. 8. History of Present Illness <ul><li>Few hours PTC </li></ul><ul><ul><li>Scanty brownish vaginal discharge </li></ul></ul><ul><ul><li>No vaginal bleeding </li></ul></ul><ul><ul><li>No passage of meaty material or vesicular tissue </li></ul></ul>Missed menses 12 wks PT = + 5 wks TVS result suggestive of H.mole 3 wks Scanty brownish vaginal discharge Few hrs
  9. 9. Review of Systems <ul><li>no nausea, no vomiting </li></ul><ul><li>no changes in bowel movement </li></ul><ul><li>no changes in urination </li></ul><ul><li>no easy bruisability, no past transfusions </li></ul><ul><li>no change in disposition </li></ul><ul><li>no headache, no dizziness </li></ul><ul><li>no palpitations </li></ul>
  10. 10. Ob-Gyne History <ul><li>G3P2 (2002) </li></ul><ul><li>Injectable contraceptives </li></ul><ul><ul><li>Less than 1 year in 2006 </li></ul></ul><ul><ul><li>For two more years after 1 st pregnancy (2008-2010) </li></ul></ul>G1 2005 LFT NSD male QMMC 7 lbs G2 2007 LFT NSD male OMMC 7 lbs G3 Present pregnancy
  11. 11. Menstrual History <ul><li>Menarche - 14 years old </li></ul><ul><li>Interval – regular </li></ul><ul><li>Duration – 3 days </li></ul><ul><li>Amount – 2 pads per day </li></ul><ul><li>No dysmenorrhea </li></ul><ul><li>LMP: Jan 3, 2011 </li></ul><ul><li>PMP: Dec 2010 </li></ul><ul><li>AOG: 16 weeks 6 days </li></ul>
  12. 12. Sexual history <ul><li>18 years old during 1 st coitus </li></ul><ul><li>1 sexual partner </li></ul><ul><li>No post-coital bleeding </li></ul><ul><li>No dyspareunia </li></ul>
  13. 13. Past Medical/Surgical History <ul><li>No history of diabetes, hypertension, asthma, goiter </li></ul><ul><li>No allergies to food or medication </li></ul><ul><li>No past hospitalization or surgeries </li></ul>
  14. 14. Family History <ul><li>No family history of diabetes, hypertension, cancer, thyroid disease </li></ul><ul><li>No history of molar pregnancy in the family </li></ul>
  15. 15. Personal Social History <ul><li>First-born out of 7 children </li></ul><ul><li>Finished high school </li></ul><ul><li>Housewife </li></ul><ul><li>Non-smoker, non-alcoholic drinker </li></ul>
  16. 16. Physical Examination <ul><li>General: alert, conscious, coherent, not in cardiorespiratory distress </li></ul><ul><li>Vitals: BP 120/80 HR 80 RR 20 Temp 36.9 </li></ul><ul><li>HEENT: anicteric sclerae , pink palpebral conjunctivae , no tonsillopharyngeal congestion, no cervical lymphadenopathies, neck veins are not distended. </li></ul><ul><li>Thorax and lungs: Thorax symmetric with equal chest expansion. Clear breath sounds. No wheezes or crackles. </li></ul>
  17. 17. Physical Examination <ul><li>Cardiovascular: Adynamic precordium, apex beath in 5th left intercostal space, midclavicular line. Regular rate, normal rhythm. No murmurs </li></ul><ul><li>Abdominal: Abdomen is soft, flabby, non-tender . No surgical scars. Striae gravidarum are seen below the umbilcus. The bowel sounds are normoactive. No fetal heart rate noted .   </li></ul><ul><li>Extremities: Full and equal pulses. No edema or cyanosis. </li></ul>
  18. 18. Physical Examination <ul><li>Speculum Examination: Smooth, cervix violaceous , no erosions, scanty brownish discharge from the cervical os </li></ul><ul><li>Internal Examination: Normal external genitalia, multiparous introitus, vagina admits two fingers with ease. Cervix closed, Uterus is enlarged to 3 months size. No adnexal masses or tenderness. </li></ul>
  19. 19. Salient Features <ul><li>Subjective </li></ul><ul><ul><li>25 years old </li></ul></ul><ul><ul><li>G3P2 (2002) PU 16 6/7 weeks AOG </li></ul></ul><ul><ul><li>Scanty brownish vaginal discharge </li></ul></ul><ul><ul><li>No vaginal bleeding, no passage of meaty material or vesicular tissue </li></ul></ul><ul><ul><li>No nausea, no vomiting </li></ul></ul><ul><ul><li>No headache, no dizziness </li></ul></ul><ul><ul><li>No palpitations </li></ul></ul><ul><ul><li>No comorbidities </li></ul></ul><ul><li>Objective </li></ul><ul><ul><li>Normotensive </li></ul></ul><ul><ul><li>Pink palpebral conjunctivae, clear breath sounds </li></ul></ul><ul><ul><li>Regular heart rate, normal rhythm, no fetal heart rate noted </li></ul></ul><ul><ul><li>Cervix close, enlarged uterus 3 months size </li></ul></ul><ul><ul><li>Scanty, brownish, vaginal discharge from the cervical os </li></ul></ul>
  20. 20. Salient Features <ul><li>Subjective </li></ul><ul><ul><li>Age, H.mole usually seen in less than 15 years old and more than 45 years old </li></ul></ul><ul><ul><li>Obstetric History a history of prior unsuccessful pregnancies increases the risk of gestational trophoblastic disease </li></ul></ul><ul><ul><li>Vaginal bleeding is the most common symptom seen in H.mole </li></ul></ul><ul><ul><li>Passage of vesicular tissue , presence of edema of the villous stroma </li></ul></ul><ul><ul><li>Severe nausea and vomiting , hyperemesis gravidarum in H.mole </li></ul></ul><ul><ul><li>Headache , may be a sign of gestational hypertension, also present in H.mole </li></ul></ul><ul><ul><li>Palpitations , may be a sign of thyrotoxicosis, may also be present in H.mole </li></ul></ul>
  21. 21. Salient Features <ul><li>Objective </li></ul><ul><ul><li>High blood pressure is one of the things to watch out for in H.mole because gestational hypertension or pre-eclampsia may be present </li></ul></ul><ul><ul><li>Anemia is a common finding </li></ul></ul><ul><ul><li>Lung metastasis, lungs are the first organ that choriocarcinoma may metastasize to </li></ul></ul><ul><ul><li>No fetal heart rate , beta-HCG may be high but unlike in pregnancy, no fetal heart rate can be appreciated </li></ul></ul><ul><ul><li>Uterus size is normally larger than the gestational age </li></ul></ul>
  22. 22. Impression <ul><li>G3P3 (2002) Pregnancy Uterine 16 to 17 weeks, </li></ul><ul><li>to consider Hydatidiform mole </li></ul>
  23. 23. Differential Diagnosis H.mole Ectopic Pregnancy Normal pregnancy Missed menses ✔ ✔ ✔ Enlarged uterus ✔ ✔ ✔ Vaginal spotting ✔ ✔ ✗ High B-hCG ✔ ✔ ✔ Ultrasound findings ✔ “ honeycomb” pattern = complex, echogenic intrauterine mass containing many small cystic spaces ✗ absence of a uterine pregnancy, a positive pregnancy test, fluid in the cul-de-sac, & an abnormal pelvic mass ✗ Gestational sac (4-5 weeks), heartbeat detectable (6 weeks), crown-lump length measurable (12 weeks)
  24. 24. Differential Diagnosis H.mole Ectopic Pregnancy Normal pregnancy Missed menses ✔ ✔ ✔ Enlarged uterus ✔ ✔ ✔ Vaginal spotting ✔ ✔ ✗ High B-hCG ✔ ✔ ✔ Ultrasound findings ✔ “ honeycomb” pattern = complex, echogenic intrauterine mass containing many small cystic spaces ✗ absence of a uterine pregnancy, a positive pregnancy test, fluid in the cul-de-sac, & an abnormal pelvic mass ✗ Gestational sac (4-5 weeks), heartbeat detectable (6 weeks), crown-lump length measurable (12 weeks)
  25. 25. Course in the wards <ul><li>Diagnostic labs (Day 0) </li></ul><ul><ul><li>CBC with PC, HbSAg, ABO </li></ul></ul><ul><ul><li>AST, ALT, BUN, Crea, TFTs </li></ul></ul><ul><ul><li>Transvaginal UTZ </li></ul></ul><ul><ul><li>Chest Xray </li></ul></ul><ul><ul><li>B-hCG </li></ul></ul><ul><li>Medical Management (Day 0) </li></ul><ul><ul><li>Chemoprophylaxis was started (0.6 mL OD x 5 days) </li></ul></ul><ul><li>Surgical Management (Day 5) </li></ul><ul><ul><li>Suction curettage </li></ul></ul>
  26. 26. Pathophysiology
  27. 27. Pathophysiology
  28. 29. Diagnostics Diagnostic tests Rationale Patient’s results Remarks CBC Check anemia status Check for infection Hgb: 12.9 Hct: 0.38 WBC: 12.4 Platelets: 322 Increased WBC Urinalysis with PT Check for infection and re-confirm pregnancy test Dark, yellow, hazy Sugar (-), protein (+1), RBC too numerous to count, WBC 0-2, moderate epithelial cells, few bacteria hematuria Thyroid function tests Hyperthyroidism may occur in H.mole FT4 1.53 | TSH 1.19 | T4 10.31 T uptake 1.08 | FT3 3.37 | T3 1.09 normal
  29. 30. Diagnostics Diagnostic tests Rationale Patient’s results Remarks BUN and Crea Check for renal status before methotrexate use (renal excretion) BUN 4.1 Crea 61 normal Liver enzymes Check for liver status before methotrexate use (liver metabolism) AST 15 ALT 25 ALT slightly decreased
  30. 31. Diagnostics Imaging study Rationale Patient’s results Remarks Chest xray The lungs are a primary site of metastasis for malignant trophoblastic tumors. Pulmonary nodule  Normal chest findings normal Trans-vaginal ultrasound criterion standard for identifying both complete and partial molar Uterus is retroverted. Borderline in size: 7.0 x 6.5 x 6.9. The endometrial cavity has multiple cystic structures varying in size “ honey-comb” pattern is distinct for H.mole Serum B-hCG HCG levels greater than 100,000 mIU/mL indicate exuberant trophoblastic growth 105,402.99 Increased B-hCG
  31. 32. Management <ul><li>Day 0 </li></ul><ul><ul><li>Patient was started on Methotrexate 50 mg/2mL 0.6mL OD IM to each alternating deltoid for 5 days </li></ul></ul><ul><li>METHOTREXATE </li></ul><ul><ul><li>Several studies indicate that the incidence of postmolar gestational trophoblastic disease may be decreased with prophylactic chemotherapy. </li></ul></ul><ul><ul><li>** Dactinomycin . It is added to the regimen of Methotrexate if metastasis occurs. It is an antibiotic used as an antineoplastic agent prescribed in the treatment of a variety of malignant neoplastic diseases. </li></ul></ul>
  32. 33. Methotrexate <ul><li>antimetabolite used in the treatment of certain neoplastic diseases, severe psoriasis, and adult rheumatoid arthritis </li></ul><ul><li>Since hydatidiform mole may precede choriocarcinoma, prophylactic chemotherapy with Methotrexate has been recommended. </li></ul><ul><li>administered orally or intramuscularly in doses of 15 to 30 mg daily for a five-day course </li></ul><ul><li>effectiveness of therapy is ordinarily evaluated by 24 hour quantitative analysis of urinary chorionic gonadotropin (hCG), which should return to normal or less than 50 IU/24 hr usually after the third or fourth course and usually be followed by a complete resolution of measurable lesions in 4 to 6 weeks. </li></ul>
  33. 34. Methotrexate <ul><li>Who may benefit from prophylactic chemotherapy? </li></ul><ul><ul><li>advance maternal age > 35 years </li></ul></ul><ul><ul><li>gravidity of > 4 </li></ul></ul><ul><ul><li>uterine size larger than gestation by > 6 weeks </li></ul></ul><ul><ul><li>serum B-hCG titer > 100,000 mIU/mL </li></ul></ul><ul><ul><li>theca lutein cyst(s) > 6 cm </li></ul></ul><ul><ul><li>presence of any medical complication associated with increased trophoblastic profileration: preeclampsia, thyrotoxicosis, pulmonary insufficiency and disseminated intravascular coagulopathy </li></ul></ul><ul><ul><li>poor patient compliance to follow-up </li></ul></ul>
  34. 35. Management <ul><li>Day 4 </li></ul><ul><ul><li>Patient underwent suction curettage </li></ul></ul><ul><li>Evacuation of the H.mole </li></ul><ul><ul><li>Suction evacuation is the treatment of choice for hydatidiform mole, regardless of uterine size </li></ul></ul><ul><ul><li>Suction curettage with the largest curette possible should be followed by gentle sharp curettage, and tissue from the decidua basalis should be submitted separately for pathologic study. </li></ul></ul>
  35. 36. Suction Curettage <ul><li>Suction curettage can be safely accomplished even when the uterus is the size of a 28- week gestation. </li></ul><ul><li>Blood loss usually is moderate, but precautions should be taken for the possibility of a transfusion. </li></ul><ul><li>When a large hydatidiform mole (> 12 weeks in size) is evacuated by suction curettage, a laparotomy setup should be readily available, as hysterotomy, hysterectomy, or bilateral hypogastric artery ligation may be necessary if perforation or hemorrhage occurs. </li></ul>
  36. 37. Prognosis <ul><li>More than 80% of hydatidiform moles are benign. The outcome after treatment is usually excellent. Close follow-up is essential. </li></ul><ul><li>In 2 to 3% of cases, hydatidiform moles may develop into choriocarcinoma which is a malignant, rapidly-growing, and metastatic form of cancer </li></ul>
  37. 38. Surveillance Post-Molar Pregnancy <ul><li>Monitor serum hCG levels every 2 weeks. Serial measurement of serum hCG is important to detect trophoblastic neoplasia, and even small amounts of trophoblastic tissue can be detected by the assay. These levels should progressively fall to an undetectable level </li></ul>
  38. 39. SUCTION CURETTAGE Repeat B-hCG Repeat B-hCG Every 2 weeks until normal levels ( < 5 mIU/mL) 
  39. 40. Normal B-hCG Normal B-hCG Normal B-hCG After 3 consecutive biweekly normal levels, monitoring is once every month for 6 months
  40. 41. Surveillance Post-Molar Pregnancy <ul><li>The most critical period of observation is the first 4–6 weeks postevacuation . Although the B-hCG titer usually returns to normal by 1–2 weeks after evacuation of a hydatidiform mole, it should normalize by the 8th week . Approximately 70% of patients achieve a normal B-hCG level within 8 weeks postevacuation. </li></ul>
  41. 42. Surveillance Post-Molar Pregnancy <ul><li>indications for initiating chemotherapy during the postmolar surveillance period </li></ul><ul><ul><li>(a) B-hCG levels rising for 2 successive weeks or constant for 3 successive weeks; </li></ul></ul><ul><ul><li>(b) B-hCG levels elevated at 15 weeks postevacuation; </li></ul></ul><ul><ul><li>(c) rising B-hCG titer after reaching normal levels; and </li></ul></ul><ul><ul><li>(d) postevacuation hemorrhage </li></ul></ul>
  42. 43. Patient education <ul><li>Prevent pregnancy for a minimum of 6 months to 1 year using hormonal contraception. </li></ul><ul><ul><li>If a pregnancy occurs, the elevation in beta-HCG levels cannot be differentiated from the disease process. </li></ul></ul><ul><li>Subsequent pregnancies after a molar gestation </li></ul><ul><ul><li>for every succeeding pregnancy, serum B-hCG should be monitored monthly starting 20 weeks gestation, and at 6 and 10 weeks postpartum </li></ul></ul><ul><ul><li>all placentas in subsequent pregnancies should be submitted for histopathologic examination </li></ul></ul>