STUDENT NAME: MAH WEN YI (P1170051)

CLERKING DATE: 10th September 2020

INTRODUCTION
Madam C is a 35-year-old Chinese housewife, Gravida 2 Para 1. Her last
normal menstrual period was 2nd March 2020 and she claims to have
regular menstrual cycles. Her last childbirth was 2 years ago.
PRESENTING COMPLAINT
She is currently admitted for her 3rd cycle of chemotherapy for persistent
trophoblastic disease.
HISTORY OF PRESENTING COMPLAINT
She first had a positive urine pregnancy test on the 02/04/2020 when she
missed her menses. This was associated with morning sickness, but no
vomiting was reported. No booking was done at the time.
On 20/4/2020, she presented with per vaginal bleeding. She had 2 episodes
of such bleeding, each described to be “streaks of blood mixed in with
mucous”. It was associated with lower abdominal pain which was
described to be crampy and rated 2 out of 10 on the pain scale. The pain
came on gradually, does not radiate anywhere and there were no known
relieving or exacerbating factors.
No passing of clots or products of conception was reported. There was no
known trauma prior to the bleeding.
She denied anaemic symptoms such as shortness of breath, palpitations
and dizziness.
She attended Kulim Hospital at 7 weeks + 4 days of period of
amenorrhoea (20/4/2020) and had an ultrasound scan done. However, the
ultrasound findings revealed an empty uterus with no fetal heartbeat and
she was informed to return in two weeks for follow-up.
However, due to worsening bleeding, she attended Adventist hospital on
26/4/2020 at 8 weeks + 3 days of period of amenorrhoea. Initial B-hCG
level was at 1956IU/L. Ultrasound scan confirmed molar pregnancy.
She had suction and curettage done on 28/4/2020. The tissues were sent
for histopathological examination (HPE) which confirmed hydatidiform
molar pregnancy.
She returned for follow-ups on B-HCG levels post-S&C and the results
were as follows:
DATE Serum B-HCG (IU/L)
4/5/2020 1863
4/6/2020 260
18/6/2020 551
26/6/2020 782

Due to persistently high B-HCG levels, she had a repeat dilatation and
curettage on 27/6/2020. Tissues sent for HPE showed early secretory
phase endometrial tissue admixed with fragments of mucus and no
evidence of residual hydatidiform molar pregnancy.
After her second attempt at ERPOC, her B-HCG level was as follows:
DATE B-HCG (IU/L)
9/7/2020 869

She was referred to Penang General Hospital after the repeat D&C. She
had a CECT TAP done on 9/7/2020, which revealed a solidarity right
lung nodule at midzone and posterior to the sternum measuring 1cm
in size. No other abnormalities were noted. She denies haemoptysis, cough
or dyspnoea.
She was scored 3 on the WHO Prognostic Scoring System and
therefore was deemed at low risk. She was treated with single-agent IV
methotrexate (50mg in 500mL NS over 2 hours) with IM folinic acid
(15mg 30 hours after each MTX dose) for a total of 10 days followed by 6
resting days. She started her first cycle of methotrexate on 29/7/2020. She
completed her first cycle on 7/8/2020 and was discharged. The first and
second cycles were uneventful.
DATE B-HCG (IU/L) / Action Plan
22/7/2020 947
31/7/2020 -Completed 1st cycle Day 3 MTX-
2/8/2020 -Completed 1st cycle Day 5 MTX-
4/8/2020 -Completed 1st cycle Day 7 MTX-
6/8/2020 -Completed 1st cycle Day 9 MTX-
17/8/2020 1.4
19/8/2020 -Completed 2nd cycle Day 3 MTX-
21/8/2020 -Completed 2nd cycle Day 5 MTX-
23/8/2020 -Completed 2nd cycle Day 7 MTX-
25/8/2020 -Completed 2nd cycle Day 9 MTX-
2/9/2020 <0.3
5/9/2020 -Completed 3rd cycle Day 3 MTX-
7/9/2020 -Completed 3rd cycle Day 5 MTX-
9/9/2020 -Completed 3rd cycle Day 7 MTX-

As of clerking date, she was on 3rd cycle Day 8. She is due for pre-chemo
blood tests on 17/9/2020 and 4th cycle Day 1 MTX on 21/9/2020.
She currently complains of palpitations, oral ulcers and epigastric
discomfort. An ECG was done which revealed sinus tachycardia. Oral aid
gel, T. neurobion and T. omeprazole were prescribed for alleviation of her
current symptoms.
Otherwise, she has no fever, anaemic, URTI or UTI symptoms.
GYNAECOLOGICAL HISTORY
She claims to have regular menstrual cycles. She attained menarche at the
age of 11 with 5 days of flow and 25-28 days per cycle. She denies
dysmenorrhoea, menorrhagia and intermenstrual bleed. She has never had
a pap smear done.
SEXUAL HISTORY
She was married 3 years ago and has only ever had a single sexual partner
throughout her life, which is her current husband. Her first coitus was 3
years ago with her current husband. She is sexually active with him and
has sexual intercourse about once every two weeks. She denies
dyspareunia and post-coital bleeding. She was not sexually active
throughout this pregnancy.
She does not take any form of oral contraceptive pills. However, her
husband currently practices barrier contraceptive methods with her.
OBSTETRICS HISTORY
2 years ago, she had an uneventful spontaneous vaginal delivery. She
delivered a healthy baby girl weighing 2.8kg at birth.
PAST MEDICAL HISTORY
She has no known medical illness.
PAST SURGICAL HISTORY
Other than the recent suction and curettage and dilatation and curettage,
she has never undergone any surgical procedures.
DRUGS HISTORY
She was not previously on any regular medications. She denies any history
of traditional medications consumption. She is currently on:
- T. Neurobion 1/1 OD
- T. Omeprazole 40mg OD
- Oral aid gel TDS
- Chemotherapy regime: IV methotrexate (50mg in 500mL NS over 2
hours) with IM folinic acid (15mg 30 hours after each MTX dose)
for 10 days, with 7 resting days between each cycle
ALLERGIES
No known food and drug allergies.
FAMILY HISTORY
Her mother has a history of stroke. She has two maternal aunts with
known malignancy – one has breast cancer, one has endometrial cancer.
Her father is healthy and well.
SOCIAL HISTORY
She is originally from Kulim, Kedah. She used to be an office lady but
stopped working 1 year ago to take care of her child. She currently lives
with her husband and daughter. Her husband is an administrative executive
in Kulim. She lives in a landed property and does not need to use stairs.
She does not smoke or drink. Her husband also does not smoke or drink.
There are no financial problems. She has no known diet restrictions and no
transportation problems.
Due to her current need for prolonged hospital stays, her child is being
taken care of by her mother-in-law in Kulim. Once discharged, she plans
on staying with a relative in Georgetown to avoid the known COVID-19
cluster back in Kedah.
SYSTEMIC REVIEW
As mentioned in history of presenting complaint. She denies fever, thyroid
symptoms, bleeding tendency, loss of weight and loss of appetite.
SUMMARY
Madam C is a 35-year-old Chinese housewife, Gravida 2 Para 1, with
regular menstrual cycles and family history of gynaecological malignancy.
She initially presented with per vaginal bleeding with mild lower
abdominal pain secondary to molar pregnancy. She had one S&C and one
repeat D&C done in Adventist hospital due to persistently raised B-HCG
level. CT scan later revealed right lung nodule. She is currently on day 8
of her 3rd cycle of methotrexate/folinic acid therapy.
GENERAL EXAMINATION
Madam C is lying on the bed and appears well-built, alert, conscious, not
tachypnoeic, not cyanotic. She is not attached to any medical devices.
A. VITAL SIGNS
Pulse rate: 76/min
Respiratory rate: 12/min
Temperature: 37.1oC
Blood pressure: 110/68mmHg
SpO2: 98%
B. HANDS
Noted 3 punch marks on dorsal aspect of left hand. Patient claims IV
cannula was removed due to pain. No thrombophlebitis noted.
C. FACE AND NECK EXAMINATION
Multiple small oral ulcers noted on the buccal mucosa.
D. BREAST EXAMINATION
No significant finding.
E. CARDIOVASCULAR EXAMINATION
No significant finding.
F. RESPIRATORY EXAMINATION
No significant finding.
ABDOMINAL EXAMINATION
Inspection
The patient’s abdomen moves with inspiration. There is no visible scar,
abdominal distension or dilated veins. The umbilicus is central and
inverted.
Palpation
No tenderness elicited. No mass palpable. No organomegaly appreciated.
Percussion was resonant throughout, so shifting dullness test was not done.
Auscultation
Normal bowel sounds are heard.
VAGINAL EXAMINATION
No vaginal examination was conducted.
DIAGNOSIS
Persistent Trophoblastic Disease (Stage III, Score 4)

INVESTIGATIONS (before diagnosis)

INVESTIGATIO JUSTIFICATION RESULT
N
Urine pregnancy To confirm or rule out Positive
test (UPT) pregnancy Student’s comment:
This is the appropriate
initial investigation for
any woman in
reproductive age group
presenting with PV
bleeding.
Full blood count To evaluate severity of Hb: 13.7g/dL
(FBC) blood loss, coagulation WCC: 7.54
problems, infection Plt: 320
Student’s comment: All
within normal range.
Iron supplementation
and transfusions are not
necessary.
Blood typing To evaluate need for BG: O+
anti-D immunoglobulin Student’s comment: No
 should curettage be anti-D prophylaxis is
ordered. required. It is usually
given for partial mole
but not complete mole.
Serum B-hCG To diagnose GTD Initial B-hCG: 1956IU/L
Student’s comment: B-
hCG is not diagnostic
but raises suspicion of
GTD. Our patient has
considerably low initial
level of B-hCG. This is
important for
prognostic scoring later
on.
Transabdominal To diagnose GTD Molar pregnancy noted.
ultrasound Student’s comment:
Ultrasound diagnosis is
complex. The typical
“snowstorm
appearance” can be
encountered rarely. It is
not diagnostic but
greatly raises suspicion
of GTD. Theca lutein
cyst, which is absent in
this case, can also
suggest GTD. An S&C
is indicated at this
point.
Histopathological To confirm diagnosis of Confirmed hydatidiform
examination GTD molar pregnancy.
(HPE) post-S&C Student’s comment:
The only diagnostic
method for GTD, but
HPE results did not
specify complete or
partial in this case.

INVESTIGATIONS (after diagnosis)

INVESTIGATION JUSTIFICATIO RESULTS
N
Histopathological To check for Early secretory phase
examination (HPE) residual endometrial tissue
post-D&C hydatidiform admixed with fragments of
molar pregnancy mucus. No evidence of
residual hydatidiform
molar pregnancy.
Student’s comment:
repeat D&C is important
to rule out residual
tissues and malignancies
such as choriocarcinoma.
Serial B-hCG To monitor for Persistently raised B-hCG
persistent GTD but each <1000IU/L
Student’s comment: This
raises suspicion for
persistent trophoblastic
disease and requires
further imaging.
CXR To check for Lungs are clear. No
metastases abnormalities detected.
Student’s comment:
CXR is routine but small
abnormalities may not be
visible.
CECT-TAP To stage disease Right lung nodule 1cm in
by checking for diameter. No involvement
metastases of other sites.
Student’s comment: This
is important for staging
and prognostic scoring.
Pre-chemo blood tests To ensure latest Hb: 13.7g/dL
blood profiles are TW: 7.54 x 109/L
satisfactory before Plt: 320 x 109 /L
starting ANC: 4.69 x 109 /L
chemotherapy. Urea: 4.9mmol/L
Creatinine: 54mmol/L
K+: 3.9mmol/L
Na+: 138mmol/L
 Mg2+: 0.8mmol/L
Ca2+: 2.3mmol/L
S. Bil: 3mcmol/L
B-HCG: <0.3IU/L
Student’s comment: All
parameters within
normal range.
Chemotherapy can
proceed.

MANAGEMENT
ISSUES INTERVENTIONS DONE
Molar pregnancy noted on Suction and curettage
ultrasound - Informed consent obtained
- General anaesthesia
- Oxytocin 40U in 1 pint D5%
- Suction curettage under
ultrasound guidance
- All tissues sent for HPE to
confirm hydatidiform molar
pregnancy
- Post-evacuation serial B-
hCG measurements done
Student’s comment: Use of
oxytocin is unnecessary if the
patient is not bleeding
excessively. In fact, use of
inappropriate oxytocin can
increase risk of embolization and
metastasis of trophoblastic
tissues. In our case, this may
have been the cause of the lung
metastasis.
Persistently raised B-hCG Repeat dilatation and curettage
- All tissues sent for HPE.
- Confirmed no residual
hydatidiform molar
pregnancy
Advised on contraception

CECT-TAP revealed right lung
nodule
Side effects of chemotherapy
(palpitations, oral ulcers, epigastric palpitations
discomfort)
Student’s comment: A scan
should have been done prior to
repeat D&C to rule out other
metastasis sites.
Staging and prognostic scoring
were done
- Stage III, Score 4
- Low Risk
Started on single agent
chemotherapy
- IV methotrexate (50mg in
500mL NS over 2 hours)
with IM folinic acid (15mg
30 hours after each MTX
dose) for 10 days, with 7
resting days between each
cycle
Student’s comment: Prognostic
scoring should guide
chemotherapy regime. This is
appropriate.
ECG was done to evaluate the
- Sinus tachycardia
Medications were given for
symptomatic treatment
- T. Neurobion 1/1 OD
- T. Omeprazole 40mg OD
- Oral aid gel TDS
Student’s comment: CTX side
effects can be debilitating and
should be managed accordingly
such as in this case.

DISCUSSIONS
1. Gestational Trophoblastic Neoplasia
- In our case, it was not clear in the HPE report whether the
hydatidiform mole was complete or partial. However, with the
 picture of a persistent trophoblastic disease in our case, it is safe to
say that our patient most likely has a complete hydatidiform mole.
- In this case, the repeat dilatation and curettage was unnecessary.
The use of oxytocin may have introduced trophoblastic tissues
into the venous system and therefore the development of the
right lung nodule. This was most likely the cause of the
persistently raised B-HCG level. The patient could have started on
chemotherapy earlier had a CT scan been done earlier for evaluation.
CXR was procedural but often may not reveal small nodules such as
the one in our case.

2. Staging and prognostic scoring

- For staging, our patient is Stage III as GTN has spread to lungs
without involvement of the genitourinary system.
- For FIGO scoring, our patient scored 4 for the following:
o Age - 0
o Antecedent pregnancy (term) - 2
o Interval from end of pregnancy to chemo (<4 months) – 0
o Pretreatment serum hCG (1956IU/L) – 1
o Largest tumour size (<3cm) – 0
o Site of metastases (lungs) – 0
o Number of metastases (one) – 1
o Previous failed chemotherapy (zero) – 0
- Patient is low risk (score 0-6), therefore a methotrexate/folinic
acid regime is appropriate for her.

3. Advice for patient

- Women who undergo chemotherapy should be advised to be on
contraception until 1 year after completion of treatment.
- Barrier contraceptives initially until hCG levels revert to normal.
- Combined oral contraceptive pills after hCG levels revert to normal.
- If patient was on OCP prior to diagnosis, may continue but advise on
low risk of developing gestational trophoblastic neoplasia.

4. Chemotherapy monitoring
- Methotrexate can have significant multi-organ effects, such as
hepatotoxicity and nephrotoxicity.
- It is very important to do pre-chemo blood tests to ensure that the
patient is not suffering from chemotherapy side effects.
- In our case, pre-chemo blood tests were done prior to the
commencement of each cycle and they were normal.