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HYDATIDIFORM
MOLE
Argawanon, Yvonne P.
Bantugan, Dan Blyke
HISTORY
General Data:
J.U., 31 years old, G3P2(2012), Filipino, Roman Catholic,
housewife, married, born on October 15, 1996 at Sogod, Cebu.
Currently residing in Tipolo, Mandaue City, Cebu.
1st time to be admitted in Vicente Sotto Memorial Medical Center
On August 3, 2018, 10am.
HISTORY
Chief Complaint
Hypogastric pain with vaginal spotting
Menstrual History
Menarche – 14 years old
Interval – regular 28 day menstrual cycle
Duration - 4 to 5 days, used 3 pads per day, moderately soaked
Associated symptoms - dysmenorrhea
LMP - May 13, 2018
PMP - April 1st week, 2018
HISTORY
OB history
G3P2(2012)
Place and
Outcome of
Date of Mode of Person Weight and Complications Fetal/
No. pregnancy,
pregnancy Delivery Assisting the Fetal Sex Maternal if any
Current status
Delivery
Normal Male,
Cebu City
G1 March 24, 2013 Fullterm, alive spontaneous unrecalled None
Medical Center
delivery weight
Normal Health center in Male,
G2 August 31, 2016 Fullterm, alive spontaneous Tipolo, assisted unrecalled None
delivery by midwife weight
Molar
Vicente Sotto
pregnancy, 11
G3 August 4, 2018 Suction curettage Memorial - -
5/7 weeks age
Medical Center
of gestation
HISTORY
General Survey
Conscious, alert, responsive, cooperative
intravenous line on her right hand
Vital Signs
BP – 120/90 mmHg, left arm
PR – 62 bpm
RR – 19 cpm
Temperature: 36.8 ˚C/axilla
Weight: 45kg.
PHYSICAL EXAMINATION
Skin and nail
Skin is smooth, hair is well distributed, good skin turgor
No jaundice, lesions, masses, lumps, bruises, cyanosis
HEENT
Hair I black and well distributed
Lips, palpebral conjunctive, and gums are pinkish
No lesions, discharges, inflammation
Neck
No lesions, masses, palpitations, thyroid gland not palpable
PHYSICAL EXAMINATION
Chest and lungs
no lesions and retractions, Chest expansion and tactile fremitus are equal,
both lungs are resonant upon percussion, had clear breath sounds,
no wheezes or rales.
Breast
Pendulous, symmetric, no lesions, dimpling, and tenderness
Heart
No lesion, masses. PMI is heard at 5th intercostal space midclavicular line,
distinct S1 & S2 , regular rhythm and a heart rate of 68 bpm.
PHYSICAL EXAMINATION
Back no lesions, deformities
Abdomen flabby, active bowel sounds, no lesions and tenderness
Tympanitic except over the liver and bladder areas, dull
Had nontender hypogastric mass, movable firm with superior pole 2 finger
breadths above the symphysis pubis
Genital Introitus is parous, cervix is closed, uterus is 14 weeks size, adnexa is
negative, and discharge is minimal and whitish.
Extremities symmetric, no edema, deformities, cyanosis and tenderness
Neurologic rientated to time and place, intact long-term memory and short-
term memory and cranial nerves are intact
ADMITTING DIAGNOSIS
Hydatidiform Mole
SALIENT FEATURES
Amenorrhea for 1 month
Hypogastric pain
Vaginal spotting
nontender hypogastric mass, movable firm with superior pole 2 finger
breadths above the symphysis pubis
Uterus is 14 weeks size
AOG: 11 5/7 weeks
SALIENT FEATURES
Ultrasound: enlarged
anteverted uterus with
intraendometrial structures, Fetus is seen within
the lower uterine echogenic endometrial
interspersed with multiple
cystic spaces of varied size, Live fetus with segment, sac visualization of an mass accompanying
an enlarged uterus,
left ovaries with a corpus subchorionic surrounded by embryo fetal pole
the so-called
luteum hemorrhage perigestational in the adnexa “snowstorm
hemorrhage, rupture appearance”
membranes
Salient Threatened Inevitable Ectopic Hydatidiform
features abortion abortion pregnancy mole
Pregnancy test
positive + + + +
Anemia + + + +
β-hCG: 1500 to 2500 peaking at
55,980mlU/mL 5000 IU/L 5000 IU/L
mIU/mL 100,000 IU/L
Uterus sized is
bigger than smaller than a
gestational age Uterize size is normal
Correspond to
smaller than 8-week +
amenorrhea
gestational age intrauterine
gestation
SUCTION CURETTAGE DONE (AUG. 4, 2018)
Suctioned 1500 cc of vesicularity. Moderate amount of cerettings,
with biggest vesicularty approximately 1x1 cm admixed with
blood.
FINAL DIAGNOSIS: HYDATIDIFORM MOLE
A benign trophoblastic lesion, which has two types complete
hydatidiform mole and partial hydatidiform mole.
Complete hydatidiform mole completely derived from paternal
origin , having a 46,XX genotype, produced by fertilization of an
empty ovum by a single haploid (23,X) sperm; or 46,XY genotype,
produced by dispermy, in which a 23,X sperm and a 23,Y sperm
fertilize an empty ovum, which then duplicates in the ovum.
FINAL DIAGNOSIS: HYDATIDIFORM MOLE
Partial hydatidiform mole derived from paternal and maternal
chromosomes, resulting in a triploid genotype. A haploid ovum is
fertilized by two haploid spermatozoa, with 69,XXX or 69,XXY
being the most common karyotypes.
In addition, PHM may present in conjunction with a viable fetus,
showing signs of triploidy such as multiple congenital anomalies or
severe growth retardation.
FINAL DIAGNOSIS: HYDATIDIFORM MOLE
FEATURES COMPLETE PARTIAL
MOLES MOLES
Fetal or embryonic tissue Absent Present
Hydatidiform swelling of chronic villi Diffuse Focal
Trophoblastic hyperplasia Diffuse Focal
Trophoblastic stromal inclusions Absent Present
Genetic parentage Paternal Bipaternal
Karyotype 46,XX; 46,XY 69,XXY; 69,XYY
Persistent human chorionic gonadotropin 20% of cases 0.5% of cases
EPIDEMIOLOGY
oIncidence of HM is higher in Asia than in North America or Europe
oPHM in the United Kingdom is 3/1000 pregnancies, and that of
CHM ranges from 1 to 3/1000 pregnancies (Seckl, 2010)
oEthnic groups such as Native American Indians, Inuits, Hispanics,
and African American have an increased incidence of GTD
oThe geographic risk association reflects the distribution of
different ethnic groups with a higher incidence of HM rather than
environmental or climatic factors.
COMPLETE HYDATIDIFORM MOLE
RISK FACTORS
Previous history of H. mole
Decreasing consumption of animal fat and beta-carotene
Mutation of NLRP7 gene and, more rarely, KHDC3L gene
GROSS APPEARANCE
a large volume of grapelike vesicles made up of edematous enlarged villi
COMPLETE HYDATIDIFORM MOLE
HISTOLOGIC CHARACTERISTICS
1. lack of fetal or embryonic tissues,
2. hydropic (edematous) villi
3. diffuse trophoblastic hyperplasia
4. marked atypia of trophoblasts at the implantation site
5. absence of trophoblastic stromal inclusions.
COMPLETE HYDATIDIFORM MOLE
CLINICAL FEATURES
Delayed menses Gestational hypertension before
1st trimester vaginal bleeding, 20 weeks’ gestation
with or without the passage of presence of theca lutein cysts
molar vesicles
Hyperemesis
large-for-date uterus
hyperthyroidism,
absence of fetal movement respiratory distress from
anemia secondary to occult trophoblastic emboli to the lungs.
haemorrhage high levels of β-hCG
DIAGNOSTIC WORK UP
1. ULTRASOUND
standard imaging modality for the diagnosis of a mole
echogenic endometrial mass accompanying an enlarged uterus,
the so-called “snowstorm appearance”
Features:
absence of fetal or embryonic tissue
absence of amniotic fluid,
Enlarged placenta with multiple cysts
ovarian theca lutein cysts
DIAGNOSTIC WORK UP
2. HUMAN CHORIONIC GONADOTROPIN
At 10 weeks gestation peaking at 100,000 IU/L and then falling
thereafter
3. Biopsy
Edematous placental villi, hyperplasia of trophoblasts, and lack or
scarcity of fetal blood vessels.
MANAGEMENT
1. SUCTION DILATATION AND CURETTAGE
preferred method of uterine evacuation under general anesthetic
2. HYSTERECTOMY
for whom continued fertility is not an issue, hysterectomy with preservation of the
adnexa is a treatment option.
3. PROPHYLACTIC CHEMOTHERAPY
single-dose actinomycin D or Methothrexate
4. SERIAL β-HCG SURVEILLANCE
to ensure a timely diagnosis of postmolar malignant GTN
5. AVOID PREGNANCY FOR 1 YEAR
6. BLOOD TRANSFUSION AND/OR LACTATED RINGER’S SOLUTION
To treat anemia
PROGNOSIS
Outcome after treatment is excellent
Gestational Trophoblastic Neoplasia can occur after 6 months
2-3% can develop into choriocarcinoma
10-15% of cases, hydatidiform mole may develop into invasive moles