By: PGI Kathleen Kaye A. Luceñara

Molar Pregnancy: “A sour and grapy encounter…”

IMPART

ARRIVEPRESENT

IDENTIFY DISCUSS

EXAMINE

Present a complete history and physical examination of the case

Arrive at a sound admitting impression and final diagnosis

Identify relevant differential diagnoses

Discuss the case comprehensively

Examine the management of the case

Impart updates and insights relevant to the case

General Information

• EV• 25 years old• Single• Filipino• Catholic• Office Worker• From Sto Tomas• Admitted: 1/21/15

Chief Complaint

Amenorrhea

7 w

ks P

TA

Amenorrhea Mild nausea and vomiting Vaginal spotting• Pregnancy Test - POSITIVE• No consult done at this time

4 d

ays

PTA

FIRST PRENATAL check up • USD done revealed:

ULTRASOUND RESULT

Cervix 2.7 x 2.4 cm Normal

Uterus 6.0 x 4.9 x 5 x 4cm

Normal size anteverted with no myometrial lesions

Endometrium 3.14 cmThickened and Hyperechoic with

multiple cystic spaces suggestive of molar gestation. No evidence of

gestational sac development

Right OvaryLeft Ovary

1.6 x 1.3 cm2.3 x 1.5 cm Normal in size and echotexture

Adnexae No lesions

Others (-) Free fluid in the cul-de-sac

Final Impression:Normal anteverted uterusThickened endometriumNormal ovariesT/C Molar Pregnancy

2 da

ys P

TA

Sought second opinion, USD was repeated with the following results:

ULTRASOUND RESULT

Cervix 3.41 x 2.53 x 2.33cm Normal

Uterus 7.27 x 6.13 x 5.48 Normal size anteverted

Right OvaryLeft Ovary

2.54 x 1.13 x 1.022.49 x 1.80 x 1.76

NormalNormal w/ corpus luteum

OthersWithin endometrial cavity are multiple cystic

structures of varying sizes. No fetus noted in this scan

Final Impression:Molar PregnancyNormal Ovaries BilateralWith corpus luteum, left ovary

ADMITTED• Scheduled for suction

curettage

OBSTETRIC HISTORYPRIMIGRAVID (G1P0)

LMP: Nov. 5, 2014 x 3-4 days x 2PPDPMP: Oct. 2, 2014 x 3-4 days x 2PPDEDC: Sept. 12, 2014AOG: 11 weeksMenarche: 14 years old Subsequently: 28-30-day cycles x 3-4 days

x 2 PPD; (+) Dysmenorrhea

No known allergies to food or drugs

Non – Diabetic Non-Asthmatic Non-Hypertensive

PAST MEDICAL HISTORY

PERSONAL-SOCIAL HISTORY

Office worker

Smoker

Alcoholic-beverage drinkerc

FAMILY HISTORY

Unremarkable

REVIEW OF SYSTEMS

GENERAL SKIN EENT RESPIR CARDIO

Weight Loss Rashes Dysphagia Cough

Colds

Palpitations

URINARY GYNECOLOGIC MUSCULO- HEMA- GASTRO

Dysuria

Hematuria

Discharges Joint Pains Bleeding Gums

Epistaxis

Abdominal Pain

Changes in BM

Unremarkable

PHYSICAL EXAMINATION

General

Awake Conscious and responsive Not in respiratory distress

Vital SignsT :36.9°CRR :19 cpm CR :79 bpmBP :120/70 mmHgWeight :56.5 KgHeight : 5’4”BMI : 21.26 (Normal)

Skin

I: • No pallor • No mottling• No discolorations or rashes

P: Good skin turgor, warm to touch

Head

I: • Round with smooth skull

contour

P: No nodules noted

Eye

I: • Anicteric Sclera• Pink palpebral conjunctiva

Ears

I: • Symmetrical, aligned with the

outer canthus of the eye

P: Elastic with good recoil

Nose

I: • Symmetrical and straight• No nasal flaring noted• Nasal septum is in midline

Mouth and Throat

I: • Lips are pink and moist• Oral mucosa is moist• Tongue moist and in midline • Tonsillopharyngeal area is not

hyperemic with no exudates

Neck

I: • Neck is midline• Non-distended veins• No anterior neck masses

P: Lymph nodes are not palpable and not tender

ChestI: With symmetrical chest expansion and no retractions noted

P: Lung fields are resonant upon percussion

P: With symmetrical chest expansion

A: No crackles on both mid-lower lung fields

Cardiovascular

I: With adynamic precordium

A:• Regular cardiac rate and rhythm• PMI at 5th ICS 7cm from the

midsternum• No murmurs• With full pulsation of peripheral

pulses

Abdomen

• Flabby• Soft and undistended• No tenderness • Uterus palpated at the level of

the symphysis pubis

Internal Examination

I: inserts two fingers with ease

C: soft but closed

U: slightly enlarged

A: not enlarged, no tenderness

D: no discharge

Extremities

I: • Grossly normal muscle size and tone • No gross deformities or contractures

P: • CRT < 3s • Pulses are strong and not easily

obliterated by pressure

Neuro

General• No cranial nerve deficits• No sensory or motor deficits

125

SALIENT FEATURES (HISTORY)

2Primigravid

3Amenorrhea for 11 weeks

4

5USD: Endometrium is hyperechoic,

thickened w/ cystic spaces

6USD: No gestational sac

7No vaginal Spotting

9Unremarkable Family Hx

5 10

Unremarkable ROS

Minimal Nausea & Vomiting

Positive PT

1Uterus palpable at the level of

the symphisis pubis

SALIENT FEATURES (PE)

2IE: slightly enlarged uterus

3IE: no tenderness

4

5

IE: unremarkable adnexae

IE: no discharge

IMPRESSION

Hydatidiform Mole, G1P0

DIFFERENTIALS

Amenorrhea and (+) PT

Pregnancy Gestational Trophoblastic DiseasePregnancy

DIFFERENTIALS

Pregnancy

Ectopic Pregnancy

Normal Pregnancy

ECTOPIC PREGNANCYImplantation of the blastocyst anywhere outside the uterus, 96% of the time in the

FALLOPIAN TUBE

RULE-IN RULE- OUT Amenorrhea for 11 weeks No abdominal pain or tenderness

Positive pregnancy test No vaginal bleeding or spotting

Absence of gestational sac the uterus

No adnexal abnormalities via USD

Mild nausea and vomiting No adnexal or cervical motion tenderness noted on IE

DIFFERENTIALS

Pregnancy

Ectopic Pregnancy

Normal Pregnancy

NORMAL PREGNANCYRULE-IN RULE- OUT

Amenorrhea for 11 weeks No gestational sac or fetus noted

via USD Positive pregnancy test

Mild nausea and vomiting

DIFFERENTIALS

Amenorrhea and (+) PT

Pregnancy MolarGestational Trophoblastic Disease

Gestational Trophoblastic Disease

Gestational Trophoblastic Disease

RULE-IN RULE- OUT Amenorrhea for 11 weeks

Cannot be ruled out

Positive pregnancy test

Absence of gestational sac the uterus with thickened and hyerechoic endometrium with cystic spaces.

Mild nausea and vomiting

Abnormal trophoblast proliferation: hydatidiform moles and non-molar

trophoblastic neoplasms

DAY

0 Admitted to ROOM OF CHOICE Placed on diet as tolerated then

placed on Nothing per orem after midnight

Vital signs monitored Scheduled for suction curettage Evening Primrose 2 soft gels

inserted per vagina every 6 hours Misoprostol one tab inserted per

vagina 3 hours prior to OR

DAY

0 LABS:

• Complete Blood Count• Blood typing• Pregnancy Test•Beta HcG (Quanitative)

COMPLETE BLOOD COUNTHemoglobin 124

RBC 4.13

Leukocytes 9.9

Neutrophil 0.81

Lymphocytes 0.15

Monocyte 0.04

Hematocrit 0.40

Thrombocytes 314

BLOOD TYPE O +

Pregnancy TestPositive

Serum HcG (Quanti)>1,500 mIU/mL

(Normal: 75,300mIU/mL)

DAY

1 OPERATIVE TECHNIQUE:1. Induction via spinal anesthesia2. Placed on dorsal lithotomy 3. Asepsis/antisepsis was done4. Sterile Drapes applied at lower

extremities5. Bladder was emptied6. Pelvic Examination was done7. Sims vaginal retractor was

applied at posterior vaginal wall

DAY

1 OPERATIVE TECHNIQUE:8. Anterior lip of cervix was grasped

with tenaculum9. Suction cannula was introduced

through the cervix all the way to the fundus

10. Approx. 100cc of vesicular tissues admixed with blood were suctioned

11. Sharp curette was applied after suctioning

DAY

1 OPERATIVE TECHNIQUE:

12. Perineal Washing done13. Specimen was sent for histopath14. End of procedure

OPERATIVE FINDINGS

Cervix is pink and smooth. Uterus was slightly enlarged. Vesicular Tissues admixed

with blood approximately 100 mL were suctioned

Day 1 (Immediately Post-Op)KEY EVENTS PROBLEM MANAGEMENT

(+) minimal vaginal bleeding

No complains of pain

Stable Vital Signs

Molar Pregnancy, G1P0, S/P Suction

and Sharp Curettage

Monitored at the PACU

Meds:1. Cefalexin

500mg/tab three times daily

2.Methergin 1 tab every 4 hours x 6 doses

3.Mefenamic acid 500mg every 6 hours x 1 day

T :36.0 to 36.4RR :19 to 20PR :80s to 90sBP :100-110/60-80

Day 2 (1st Post-Op Day)KEY EVENTS PROBLEM MANAGEMENT

(+) minimal vaginal bleeding

No complains of pain

Stable Vital Signs Repeat Serum Beta

HcG

Molar Pregnancy, G1P0, S/P Suction

and Sharp Curettage

Cleared for discharge with Take-home

Meds:1. Cefalexin

500mg/tab three times daily x 6 days

2. Methergin 1 tab TID x 3 days

3.MVT 1 cap OD x 1 monthT :36.0 to 36.4

RR :19 to 20PR :80s to 90sBP :100-110/60-80

Serum HcG (Quanti)106,155 mIU/mL

FINAL DIAGNOSIS

Hydatidiform Mole, G1P0 (0010)

Hydatidiform MoleExcessively edematous immature

placentas, which include the following:

1. Complete H. Mole2. Partial H. Mole3. Invasive Mole

MALIGNANT: marked penetration, destruction

of myometrium and ability to metastasize

Epidemiology and Risk Factors

• 13 in every 1000 pregnancy • Ethnicity: Asians, Hispanics and American

Indiants• Age: adolescents and women (36 – 40y.o.) women (older than 40) • History of a previous mole: previous complete mole – 1.5% risk previous partial mole – 2.7 % two molar pregnancies – 23%

Pathology

Partial vs Complete

Beta-HcG

• Hormone produced by the syncytiotrophoblast of the placenta

• Homologues: LH, TSH and FSH• Doubling Time: 48 - 72 hours• Half life: 24 – 36 hours normal

after 5 to 7 days• Associated with morning sickness

Beta-HcG

• First detected: 11 days after conception and about 12 – 14 days after conception by a urine test

• Peak: 8 to 11 weeks of pregnancy

• Nadir: 16 weeks of pregnancy

Clinical Manifestations• Amenorrhea• Irregular bleeding• Uterus large for gestational age• Significant nausea and vomiting • Theca lutein cysts, Elevated FT4 and

decreased TSH• Severe pre-eclampsia and eclampsia

Clinical ManifestationsIn the advent of sonography, majority of molar

pregnancies today are recognized EARLY

• Diagnosis after 1 to 2 months of amenorrhea• Diagnosed at a mean AOG of 10 weeks• 41% of women with molar pregnancy are

asymptomatic

DIAGNOSISSonographyMainstay of diagnosisCOMPLETE MOLE:Echogenic uterine mass

with anechoic cystic spaces without a fetus or amniotic sac

“SNOWSTORM” appearance

DIAGNOSISSonography

PARTIAL MOLE:Thickened multicystic

placenta with fetus

The overall sensitivity and positive predictive value for the ultrasound diagnosis of hydatidiform mole was 44% and 48% (Kirk et al., 2007)

DIAGNOSISSerum HcG

commonly elevated above expected for

gestational age

MANAGEMENT• Screen for complications• Termination of molar pregnancy• Recommended: Suction curettage• Preoperative cervical dilatation with an osmotic

agent is recommended if the cervix is minimally dilated

Post-evacuation Surveillance

POST-EVACUATION SURVEILLANCE

Reliable contraceptionReview pathology reportSerial serum beta HcG measurements

UNDETECTABLE: 7 weeks (partial); 9 weeks (Complete)

Plateauing or Increasing levels: suspect GTN 15 – 20% risk for complete moles1% – 5% risk for partial moles

UPDATE

GOAL: To systematically review the evidence for the effectiveness and safety of P-Chem to prevent GTN in women with a molar pregnancy.

OUTCOME: The time to diagnosis was longer in the P-Chem group than the control group (2 studies, 33 participants; mean difference (MD) 28.72; 95% CI 13.19 to 44.24; P = 0.0003) and the P-Chem group required more courses to cure subsequent GTN (1 poor-quality study, 14 participants; MD 1.10; 95% CI 0.52 to 1.68; P = 0.0002).

Fu et al. (2012)

UPDATE

CONCLUSION: P-Chem may reduce the risk of progression to GTN in women with CMs who are at a high risk of malignant transformation; however, current evidence in favour of P-Chem is limited by the poor methodological quality and small size of the included studies. As P-Chem may increase drug resistance, delay treatment of GTN and expose women unnecessarily to toxic side effects, this practice cannot currently be recommended.

Kumar et al. (2015)

Thank you!