Case presentation ob

2. Patient profile
J.Y.
17 y/o
Single
Roman Catholic
Sta Lucia Agdao,
Davao City
G1P0

3. Chief Complaint
Profuse vaginal bleeding

4. OB History
No.YearSexIndication for
C/S
Place of
Delivery
AttendingB
W
Complications
n/an/an/an/a n/a n/a n/an/a
G1P0
LMP- December 26, 2008 AOG- 18 weeks 3/7
PMP- November 26, 2008 EDC- October 2, 2009

5. Menarche: 13 y/o
Subsequent Menstrual Period:
regular, lasting for 5 days soaking 1-2 pads/day
Coitarche: 17 y/o, with 1 sexual partner
Papsmear: none
Family Planning Method: none
Gyne history

6. (+) childhood measles & chickenpox
(-) DM
(-)HPN
(-)BA
 (-)CA
Past Medical Hx

7. (+) HPN – father
(+) Ovarian Cancer – maternal
(+) Brochial Asthma – patenal side
(-) Heart disease
(-) PTB
(-) DM
Family Hx

8. Does not smoke
Slight alcoholic beverage drinker
No known food & drug allergies
Fresh graduate from HS
Personal/Social History

9. Review of Systems
HEENT: No history of head injury, good vision, good
hearing occasional mild colds, occasional canker sores
and no alarming complaints on the bucal cavity and
pharynx
Neck: no pain and difficulty in swallowing, no
complaints of tender lymph nodes
Cardio: no chest pain, no palpitations

10. Pulmo: no dyspnea, no cough
Gastrointestinal: abdominal pain on the hypogastric
region, no vomiting, claimed to have mild diarrheic
stools, no hematochezia
Urinary: no frequency, no hematuria, no dysuria
Review of Systems

11. History of Present IllnessHistory of Present Illness
4 months
PTA
(+) vaginal bleeding soaking 2 pads per
day
metrorrhagia
(+) increase in abdominal girth
no associated sings and symtoms
2 months
PTA
(+) metrorrhagia soaking 2 pads per day
(+) palpable abdominal mass between the
symphysis pubis and the umbilicus
no associated sings and symtoms

12. History of Present IllnessHistory of Present Illness
1 day PTA
Profuse vaginal bleeding
(+) nausea
(+) pallor
Palpable abdominal mass almost at the
level of the umbilicus
Admission

13. PHYSICAL
EXAMINATION

14. conscious, coherent, not in
cardiorespiratory distress
BP: 120/80
CR: 70 bpm
RR: 20 cpm
T: 36.8
o
C

15. Palms warm and dry. no rashes.
Nails without clubbing and
cyanosis.
Hair of average texture. Scalp without
lesions

16. Physical Examination
Conjunctiva pink, anicteric sclerae.
Extraocular movements intact.
Acuity good. No gross ear deformities,
no ear discharges
Nasal mucosa pink, septum midline.
No sinus tenderness

17. Physical Examination
Oral mucosa pink. Moist lips and
tongue, no tonsillar enlargement,
pharynx without exudate.
No palpable masses, No enlargement
of thyroid gland. No carotid bruit,
Trachea midline.

18. Physical Examination
 symmetrical chest expansion, no
intercostals retraction, equal tactile
fremitus, lung fields are resonant,
vesicular breath sounds w/ no added
adventitious
sounds

19. adynamic precordium, good S1 and S2, no
murmurs, regular rhythm and normal heart rate.
Symmetric, without masses,
Nipples w/out discharges and retraction.
Physical Examination

20. flat, Normoactive bowel sounds (16/min)
tympanitic no hepatomegaly or splenomegaly
Palpable abdominal mass at the level of the
umbilicus
Physical Examination

21. No edema
No varicosities, no ulcers
Physical Examination
Radial Femoral Popliteal Dorsalis
pedis
Posterior
tibial
Right +2 +2 +2 +2 +2
Left +2 +2 +2 +2 +2

22. alert and cooperative, thought coherent, oriented to
person, place and time.
(+) Nystagmus
 able to do nose pointing and rapid alternating
movements.
Intact cranial nerves
Intact pinprick, light touch, position, and vibration
sensation


Physical Examination

23. +2 +2 +2 +2

+2 +2


+2 +2


+2 +2
R L
Upper
extremities:
5/5 5/5
Lower
extremities
5/5 5/5

24. Speculum
Smooth, pinkish cervix with no lesions found
Cervix is non-dilated
Internal Examination
Corpus enlarged to ~20 wks size, fixed
No adnexal mass/tenderness
Pelvic examination

25. Metrorarrgia
Nausea
pallor
Gradually Increasing abdominal mass
4 months PTA- increase in abdominal girth
2 months PTA- palpable abdominal mass between the symphysis
pubis and the umbilicus
1 day PTA- palpable abdominal mass almost at the level of the umbilicus
No pressure signs and symptoms
Salient Features
Pelvic Examination
Corpus enlarged to ~20 wks size, fixed
Non-dilated cervix

26. Impression
Pregnancy Uteri G1P0
18 3/7 weeks AOG
Hydatidiform Mole

28. Differential Diagnosis
Submucous myoma
Ectopic pregnancy
Threatened Abortion

29. Differential Diagnosis
Features Patient Submucous
myoma
Ectopic
Pregnancy
Threatened
Abortion
Age/incidence17 years old>35 years old2% 15%*
Metrorrargia(+) (-) * (+/-) * (+)
abdominal
mass
(+) (+) * (+) * (+)
Pressure
signs and
symptoms
(-) (+)* (-) (+/-)
Nausea and
pallor
(+) (+/-) (+) (+/-)
Pain (-) (+/-) (+) * (+)
Enlarged
globular
corpus
(+)
20 weeks
AOG
(+) * (+/-) (+)
Cervical
dilatation
(+) (+) (+) (+)*

30. Differential Diagnosis
Features Patient H-mole
Age/incidence 17 years old 1 0f 1500 pregnancies
Metrorrargia (+) (+)
abdominal mass (+) (+)
Pressure signs and
symptoms
(-) (-)
Nausea and pallor (+) (+) *
Pain (-) (-)
Enlarged globular corpus(+) 20 weeks AOG (+) *
Non-dilated cervix (+) (-)

31. Management
Diagnostic studies:
Quantitative B-hCG
Transvaginal Ultrasound
Dilation and suction curettage
IV oxytocin should be administered
Follow-up for development of GTT
hCG determinations (48 hours, 3 consecutive weeks, every 6
months, and then yearly)
PE (Pelvic exam at regular intervals)
Birth control (1 year- OCP, Depo Provera)

32. Discussion
H-mole
Molar pregnancy is characterized histologically by
abnormalities of the chorionic villi that consist of
trophoblastic proliferation and edema of villous
stroma
2 forms: Complete & Partial

33. Discussion
COMPLETE
1.Hydropic degeneration and swelling
of the villous stroma
2. Absence of blood vessels in the
swollen villi.
3. Proliferation of the trophoblastic
epithelium to a varying degree

4. Absence of fetus and amnion.

35. Management
Dilatation and Suction curettage
bHCG monitoring

36. Good day