A case presentation on Molar pregnancy

Molar pregnancy

1. A case presentation Presented by : Dr. Md. Tanvir elahi Dr. Md. Ismail hosen

2. Mrs. Yesmin akter 24 years old muslim female house wife hailing from gafargaon, Mymensingh came to this hospital with the complaints of: H/o Amenorrhea for 21 + weeks H/O per vaginal bleeding for two days H/O passage of grape like substances for one day Lower abdominal pain for 15 days

3. History of present illness According to the statement of the patient she was a regularly menstruating woman with normal flow and duration. Then she developed amenorrhea for 21+ weeks. She confirmed her pregnancy by urinary strip test. She was not a booked case and was not on her regular ANC. Her pregnancy was uneventful untill she developed per vaginal bleeding for 01 month which was irregular and scanty in amount but for last two days it was moderate in amount. She also complaints lower abdominal pain for 15 days which was mild in nature initially then became moderate for last 2 days. She also complaints of passage of grape like substances for one day. She also complaints of excessive vomiting during pregnancy period. With all these complaints she was admitted to this hospital for better management.

4. History of past illness: Patient is non diabetic, normotensive, non asthmatic and has no h/o any other diseases

5. Obstetric History Married for : 06 years Para : 2 c/s + 0 ab gravida : 3 rd Number of living chid : 2 Age of last child : 1.5 years Menstrual History MC : R(28 + 2 days) MP : 3-5 days LMP : May 27, 2019 EDD : May 14, 2020 Contraceptive history : OCP

6. Family history: Nothing significant Socio economic history : Nothing significant Drug history : Nothing significant Immunization history : She was immunized as per EPI schedule Surgical history: she has a h/o previous two c/s

7. General Examination Appearance : Ill Looking Body built : Average Co-Operation Co operative Decubitus : supine Anaemia : + Jaundice : Absent Oedema : absent Pulse : 80 beats/min BP : 110/70 Respiratory rate : 20 breaths/min Temp. : 98 F

8. Per abdomina examination: On inspection: The lower abdomen is enlarged. There is presence of transverse scar mark in the lower abdomen. On palpation: Height of the uterus : 24 weeks Feel of the uterus : Doughy feel Fetal parts , fetal movement : Absent On auscultation: Fetal heart sound : Absent All other systemic examination revealed normal

9. Per vaginal examination On inspection: Vulva and vagina was normal. Mild per vaginal bleeding was present. On digital examination: Cervical os was closed.

10. Probable diagnosis On the basis of history taking and clinical examination our porobable diagnosis is Molar pregnancy

11. Differential diagnosis Threatend abortion Missed abortion Fibroid uterus with pregnancy

12. Investigations Ivestigations to establish diagnosis Serum Beta hCG Uktra sonogr X ray chest P/A view Bleeding time clotting time Routine investigations for ANC Complete blood count Urine R/M/E Blood grouping and cross matching Seeological examination TSH FBS & 2 hours after 75gm glucose intake USG of pregnancy profile HBsAg, Anti HIV 1&2, VDRL

13. Confirmatory Diagnosis Our confirmatory diagnosis is Molar pregnancy

14. Treatment given Order on admission: Bed rest Diet: Normal Inj. Cephradin(1gm)-------- 1 vial I/V stat and Q6H Inf. Metronidazole(500mg/100mL)--------1 bottle I/V Stat and TDS Inj. Esomeprazole(40mg) ------- 1 vial I/V stat and BD Inj. Tiemonium methylsulphate(5mg)----- 1 amp. I/V stat and TDS

15. After establishment of diagnosis patient was given following pre operative order Bed rest Diet: NPO --------------TFO Inf. Harmann’s solution(1L) I/V running---------stat Inj. Cephradin(1gm)------ Ivial I/V Stat and Q6H Inf. Metronidazole(500mg/100mL)------1 Bottle I/V Stat and TDS Inj vitamin C----- iamp. I/V Stat Inj. Vit B complex------1 amp. I/V Stat

16. Definitive treatment- Suction and evacuation Prior surgical procedure cross match was done and two units of blood were kept preserved. Patient counselling was done Informed written conscent was taken from legal guardian Then patient was sent to OT

17. Operation Notes Time: 7.20 PM Date : Nov 01, 2019 Name of operation : Suction and Evacuation Indication of operation: Molar pregnancy Procedure : With all aseptic precaution suction and evacuation has been done under G/A. No complications occurred during the procedure. ** Height of the uterus : 24 weeks ** amount of product : Huge ** Amount of bleedong : Huge ** Specimen was sent for histopathology Surgeon: Dr. Jinnat Sultana Assistants: Dr. Redowana Rehana Parvin Dr. Nisa Shifa Anaesthesia: General anaesthesia Anaesthetist : Dr. Sharif

18. Post op. order Bed rest Diet: NPO for 6 hours Inf. Hartsol(1L)+ 5% DA(1L)+5% DNS (1L) + 4 amp ocin Inj. Avlosef(1gm) Inf Metryl ( 500mg) Inj. Maxpro(40 mg) Inj. Torax (30mg) Tab Napa (500mg) Tab ceevit (250mg) Clofenac supp

19. Post operative period As intra operative bleeding was huge and patient was not stable patient was transferred to HDU. After improvement she was transferred to gyane ward. Prior discharge she was transfused with two units of blood. Patient has been counselled for proper follow up She left our hosoital on Nov 4, 2019( On 3 rd pod)

20. Advice on discharge Please do serum beta hCG weekly untill 3 consecutive serum beta hCG becomes negative. then do monthly serum beta hCG for 6 months and two monthly for next 6 months Please avoid any pregnancy for at least 1 year. Better for her not to conceive. Use oral contraceptive pill or barrier method. Take medicines regularly Come to gynae OPD after one week with the report of serum beta hCG and Histopathology If any other complications arise withis this period of time please contact immediately with hospital.

21. Case discussion

22. Gestational Trophoblastic Diseases Definition: It encompasses a spectrum of proliferative abnormalities of trophoblast associated with pregnancy. Gestational trophoblastic neoplasia: Persistent GTD (ersistently raised beta hCG) is referred as gestational trophoblastic neoplasia(GTN)

23. Classification of gestational trophoblastic diseases Hydatidiform Mole : a) Complete Mole b) Partial Mole Invasive Mole Placental site trophoblastic tumor Choriocarcinoma : a) Nonmetastatic ( Confined to the uterus) b) Metastatic

24. Low Risk ( Good Prognosis) Disease is present in less than 4 months duration Initial serum hCG level less than 40000 mIU/mL Metastasis limited to lung and vagina No prior chemotherapy No preceding term delivery High Risk ( Poor Prognosis) Long duration of disease Initial serum hCG more than 40000mIU/mL Brain or liver metastasis Failure of prior chemotherapy Following term pregnancy WHO score more than 7

25. Hydatidiform mole(Syn: Vesicular mole) Definition : It is an abnormal condition of the placenta where there are partly degenerative and partly proliferative changes in the young chorionic villi It is best regarded as benign neoplasia of the chorion with malignant potential As there is formation of clusters of small cysts of varying size which supeeficially resembles to hydatid cyst it is named as hydatidiform mole Types: 1) Complete Mole 2) Incomplete Mole(Partial) However unless specified molar pregnancy relates one with complete mole

26. Etiology Definite cause is not known. However following hypotheses and factors are the thought to be responsible: 1) Age group: Teen Age and over 35 years of age 2) Race and Ethnicity: Common in oriental countries, Central and latin america and africa 3) Nutrion: Inadequate intake of protein, animal fat, Low dietary intake of carotene 4) Distubed maternal immune mechanism: a) Rise of gamma globulin level in the absence of hepatic disease b) Increased association with AB blood group which possesses no ABO antibody

27. Cytogenetic abnormality: In general complete mole hase a chromosome karyotype of 46 XX in 85% of cases and the molar chromisome is derived entirely from father. The ovum nucleas may be absent or become inactivated. It the duplicates its own chromosome after meiosis. This phenomenon is known as androgenesis. Infrequently the chromosomal pattern may be 46 XY or or 45X0 Previous history of hydatidiform mole(1-4%)

28. Pathogenesis of Hydatidiform Mole The secretion from hyperplastic cells transferred substances from maternal blood Accumulate in the stroma of the villi which are devoid of blood vessels Distension of the villi to form small vesicles ** Vesicle fluid is interstitial fluid and is almost similar to ascitic fluid but rich in hCG

29. Naked eye appearance: the mass filling the uterus is made up of multiple clusters of cysts of varying size. There is no trace of embryo or amniotic sac Hemorrhage if occurs takes place in the decidual spaces Microscopic appearance: There is maeked proliferation of the syncitial and cytotrophoblastic epithelium Marked thinning of the stromal tissue due to hydropic degeneration

30. Clinical features A) Patient Profile : Age group and parity: teenaged and erderly patient over 35 years with high parity has high prevalance B) Symptoms: Patient gives a history of amenorrhea for 8-12 weeks with initial featues suggestive of normal pregnancy like morning sickness etc Per vaginal bleeding: it is the most common oresentation. Present in 90% cases It may confuse with threatened or incomplete abortion But in this case blood may be mixed with gelatinous fluid from ruptired cysts giving the appearance : White currant in red currant juice

31. Varying degree of lower abdominal pain may be due to Overstretching of the uterus Concealed hemorrhage Uterine contraction to expel out the contents Infection Rarely oerforation of the uterus( In case of invasive mole)

32. Constitutional Symptoms : a) the patient becomes sick without any apparent reason Vomiting of pregnancy becomes excessive. It may be due to excess chorionic gonadotropin C) Breathlessness: due to pulmonary embolization of the trophoblastic cells D) thyrotoxic fearures : Tremors or tachycardia are present ocassionally Probably due to increased chorionic thyrotropin E) Expulsion of grape like vesicles per vagina is diagnostic of vesicular mole. F) No history of quickening

33. Signs: Features suggestive of early moths of pregnancy are evident The patient looks more ill than can be accounted for. Pallor is present and may be unusually out of proportion to the visible blood loss. These may be due to concealed hemorrhage. It is mostly due iron deficiency but may be megaloblastic due to folic acid deficiency Features of preclamsia: Hypertension, edema, and/or proteinurea( In 50% cases) Rarely convulsion may occur

34. On per abdominal examination: On Inspection On Palpation: Size of the uterus is more than that expected for the period of amenorrhea in 70%, corresponds with the period in 20%, and smaller than the period of amenorrhea in 10% The frequent finding of undue enlargement of the uterus due to exuberant growth of the vesicles and concealed hemorrhage. Uterus is firm, elastic(Doughy): Due to absence of amniotic fluid sac Fetal parts not felt nor any fetal movement External ballotment can not be elicited

35. On auscultation: Fetal heart sound absent which cannot be detected even by the doppler effect cardioscope Per vaginal examination: Internal ballotment cannot be elicited Unilateral or bikateral enlargement of the ovary( Theca lutein cyst) in 25 to 50% cases Enlarged ovary may not be palpable due to enlarged uterus Finding of vesicles in vaginal discharge is oathognomonic of hydatidiform mole If the cervical os is open instead of the membranes blood clot or vesicles may be felt

36. Differential diagnosis of molar pregnancy Threatend abortion Points in favor: 1. h/o amenorrhoa for 8-12 weeks 2. Aymptoms of early pregnancy 3.Per vaginal bleeding Points against: 1.Expulsion of Grape like vesicles per vagina. 2.Blood is mixed with gelatinous fluid in case of molar pregnancy. But in threatened abortion blood is dark colored Fibroid or ovarian tumor with pregnancy Points in favor: 1. Disproportionate enlargement of the uterus Points against: no Expulsion Of grape like substance Multiple pregnancy Points in favor: 1. Presence Of preeclampsia in early months 2. Disproportionate enlargement of the uterus and unusually high hCG titer in urine Points against: Fetal heart sound present. External ballotment internal ballotment positive Fetal movement present No expulsion of grape like substance

37. Investigations for diagnosis Full blood count ABO and Rh grouping Hepatic, renal and thyroid function tests are carried out Ultrasonography of lowwe abdomen : Snow storm appearance Estimation of chorionic gonadotropin: High hCG titer in urine(Positive pregnancy test) diluted upto 1 in 200 to 1 in 500 beyond 100days of gestation is very much suggestive. Rapidly increasing value of serum hCG ( hCG is greater than 100,000mIU/mL) is usual with molar pregnancy. Normal pregnancy value reaches a peak at about 10 to14 wekks and rarely more than 100,000 mIU/mL

38. Plain xray of abdomen: uterine size more than 16 weeks a negative fetal shadow may be of help. Straight xray of the chest should be carried out as a routine for the evidence of pulmonary embolization even in benign mole Ct scan and MRI: Routinelt not done Histological examination of product of conception : Definitive diagnosis

39. Complications of Molar pregnancy Immediately: 1. Hemorrhage and shock: Due to A) separation of the vesicles from its attachments from the decidua may be concealed or revealed. B)Mintrae intra peritoneal hemorrhage which may be the rfirst feature of perforating mole C) during evacuation of the mole due to atonic uterus and uterine injury 2. Sepsis: due to as there are no protective Membranes the vaginal organisms can creep up into uterine cavity. B) presence of degenerated vesicles, sloughing decidua and old blood favors nidation of bacterial growth. C) Due to increased operative Interference 2. Perforation of the uterus: due to perforating mole which may produce massive intra peritoneal hemorrhage b) during vaginal evacuation specially by conventional method ( d &e) or during curattege following suction and evacuation

40. Preclampsia with convulsion or rare occasion Acute pulmonary insufficiency due to pulmonary embolization of trophoblastic cells Coagulation failure due to pulmonary embolization of trophoblastic cells as they cayse fibrin and platelet deposition within the vascular tree

41. Late complications: malignant change: the development of choriocarcinoma following hydatidiform mole occur in 2 to 10% cases.

42. Prognosis Risk of hemorrhage and shock is markedly diminished if there is early diagnosis and blood transfusiin and treatment 15-20% cases progress to persistent GTD cgaracterized by re elevation of hCG 5% cases metastatic disease develops 1-4% cases recurrence of hydatidiform mole in future pregnancy To get good prognosis the following factors to be monitored: Recognition of high risk factors related to choriocarcinoma Careful followup of serum beta hCG Use of cytotoxic drug at optimum time and in the right case

43. Management With the use of ultrasonography and hCG tesring diagnosis is made early in majority cases. The principles of management are: Suction evacuation of the uterus as early as diagnosis is made Correction of anaemia and infection if any Counselling for regular follow up

44. Supportive therapy The patient usually presents with variable amount of bleeding with associated anaemia and infection. So supportive treatment is necessary: I/V infusion with ringers lactate solution Blodd transfusion is given if patient is anaemic Parenteral antiobiotic is given Blood is kept reserved during operative procedure as there ic chance of hemorrhage

45. Definitive therapy Suction and evacuation: Can be done under diazepam sedation or general anaesthesia A negative pressure is applied upto 200-250 mm Hg Alternatively dilatation and evacuation can also be done During evacuation procedure : Senior surgeon should be present Monitoring the oatient with oukse oxymeter 500ml ringers lactate solution iv infusion is set up Use of oxytocin helps the expulsion of mole and reduces blood loss but its routine use is not recommended as it may increase the risk of embolization After evacuation IM Methergine 0.2 mg is given Following evacuation antiD Ig should be given to Rh negative woman

46. Complicarion of vaginal evacuation Injury to the uterus leading to hemorrhage and shock Acute pulmonary insufficiency(Rare but Fatal) Thyroid storm(Rare but fatal) Acute pulmonary insufficiency occur due to pulmonary embolism of trophoblastic cells. C/F are: chest pain, tachycardia, tachypniea, dyspnoea occuring within 4 to 6 hrs of evacuation. Medical induction by oxytocin drip ma increase the risk of embolisation. Management: ICU support, monitoring the arterial PO2, ventilatory assistance Thyroid storm: If evacuation is done under the hyperthoid state of patient then the acute features of hyperthyroidism like hyperthermia, delirium, covulsions, coma, even cardiovascular collapse may develop. So if patient is also suffering from hyperthyroidism she should be given proper treatment to make her euthyroid. Then operative procedure should be performed.

47. Hysterectomy in case of molar pregnancy Though hysterectomy reduces the risk of persistent GTD by five fold it should bedone only in following cases: Patients with age over 35 years Family completed irrespective of age Uncontrolled hemorrhage or perforation during surgical evacuation Perforating mole The uterus following hysterectomy should be sent to histopathology

48. The enlarged overies (Theca lutein cyst) found during operation should be left undisturbed as they will regress following removal of mole But if complications arises like rupture, torsion or infarction it should be removed.

49. Follow up Even after hysterectomy following molar pregnancy there may be persistant GTD in 305% cases. So, Routine followup is mandatory for all cases.