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HYDATIFORM MOLE

WITH HYPERTHYROIDISM
Presented by Adam Ridha
Supervisor
dr. Pinda Hutajulu, Sp. OG (K)
OBSTETRY AND GYNECOLOGY DEPARTMENT
MEDICAL FACULTY TANJUNGPURA UNIVERSITY
RSU DOKTER SOEDARSO

INTRODUCTION
Chapter I

Molar pregnancy the incidence appears


to be quite high in South Asia.1,3
Gestational Throphoblastic Disease
pregnancy related group of disorders often fatal in the past.2
Hydatidiform mole affects 1-3 : 1000
pregnancies.2
10% of hydatidiform moles malignant
forms of GTD/GTN.2
Hyperthyroidism in complete molar
pregnancy 7 %, cured by evacuation
1. Nousheen Aziz, Sajuda Yousfani, Irfanullah Soomro,
of molar
tissue.3 Firdous Mumtaz. Original article Gestational trophoblastic disease. J Ayub Med Coll
Abbottabad
2012; 24 (1)
2. Sebire N. J., Seckl M. J. Clinical review - Gestational trophoblastic disease: current management of hydatiform mole. BMJ 2008; 337. a193,
doi: 101136/bmj a193. 2008, vol 337 (453-58): BMJ
3. Dave Nandini, Fernandes Sarita, Ambi Uday, Iyer Hermalata. Case Report hydatiform mole with hypertiroidism perioperative challanges. J
obstet gynecol india vol. 59, no. 4 ; july/agust 2009 pg 356-357

CASE REPORT
Chapter II

PATIENT
IDENTITY
Patient was examined on May 23th, 2014
Name : Mrs. IT
Sex
: Female
Age
: 46 years old
Address : Sui Kakap
Ethnic : Bugis
Job
: Household
Religion : Islam
No. MR : 685-775

ANAMNESIS
Chieft Complaint
lump in the abdomen since 2 months

History of Present Illnes


lump in the abdomen since 2 months and felt
getting bigger. Patient also complained of decreased
appetite accompanied by nausea and vomiting,
especially after meals. since 4 days felt blood
discharge increasing from the genitals, especially at
night which often form a blood clot. Patients
defecate once a week, urinate in the normal range.
Since 4 months felt a lump in the neck that is not
felt pain. Sometimes felt trembling, sweating, and
palpitations.

History of Obstetric
G8

P 7A 0M 0

No. Temp Tahu


Jenis
Jenis Berat (Kg)
at
n
persalin kelami
bersal
an
n
in

Keada
an
anak

1
2
3
4
5
6
7
8

Hidup
Hidup
Hidup
Hidup
Hidup
Hidup
Hidup

Rumah
Rumah
Rumah
Rumah
Rumah
Rumah
Bidan

1982
1984
1987
1990
1993
1994
2007

Spontan
Spontan
Spontan
Spontan
Spontan
Spontan
Spontan

P
L
P
P
P
L
P
Yang ini

?
?
?
?
?
?
3.800

History of Disease/Operation
Thyroid disease (+)

History of Present Pregnancy


Menarche age of 14 years with a 28-day cycle, the
duration of 7 days. Much reduced without excessive
pain. The first day of last period 15 February 2014.
Pregnancy 13 weeks 4 days.

History of Social-Economic
The patient worked as a housewife and have BPJS
health insurance grade 3.

PHYSICAL EXAMINATION /
GENERAL STATUS
General condition: Compos Mentis, weak
Heart rate : 140x/m
Respiration rate : 26x/m
Blood pressure
: 140/80 mmHg
Eye : anemic conjungtiva (-/-), icteric sclera
(-/-)
Neck : mass (+),palpable thyroid glands, supple,
no pain, mobile, bruit (-)

Heart : ictus cordis not visible and palpable


in ICS IV midclavicule sinistra, auscultation
S1/S2 single, regular, mur mur (-), gallop (-)
Lungs : auscultation basic breath sounds
vesicular, ronchi (-/-), wheezing (-/-),
percusssion sonor in both lungs, fremitus
tactile in both lung is same
Abdomen : abdominal distention (-), bowel
sounds (+), epigastric pain (-), palpable
suprapubic mass 11 x 14 cm
Ekstrimities : pitting edema (-/-), muscle tone

OBSTETRIC STATUS
Eksternal examination
Fundal height : one finger under umbilicus
Fetal heart rate : negative
Presentation : His : negative
Estimated fetal weight : -

Internal
examination

Portio
: thick
Servical dilatation
Decend
:Amniotic
:-

: 0 cm

SUPPOTIVE EXAMINATION
Haematologic examination in 16 of may 2014
Haemoglobin

: 11,8 g/dL

Red blood cells : 4,42 M/uL

Post-prandial
Ureum

: 88 mg/dL

: 38,1 mg/dL

White blood cells

: 7.200/mm3 Creatinine : 0,4 mg/dL


Plateles : 226 K/uL
ALT
: 76,0 (< 31,0 - high)
Haematocrit : 34,0 %
AST : 53,7 (< 32,0 - high)
Fasting blood glucose : 71,5
mg/dL

Albumin : 4,2 g/dL

Radiology examination in 16 of May 2014


Obg USG huge uterus with snow storm appearance
impression of mole hydatiform
Thorax PA there is no abdormalities in cor and pulmo

Diagnosis
Hydatiform mole in G8 P7 A0 M0 13
weeks 4 days gestation with
hypertiroidism

THERAPHY

General condition, vital signs, vaginal bleeding


observasion
Intra venous fluid dehydration Ringer lactate 20 dpm
Curretage
Consultation to internist

Prognosis
Ad vitam

: dubia ad bonam

Ad functionam : dubia ad malam


Ad sanactionam : dubia ad bonam

FOLLOW UP

21 of May 2014
S : abdominal pain, abdominal lump since 2 months and
bigger, appetite (<), nausea & vommiting (-), palpable
neck mass (+)
O : HR 150 x/m, RR 20 x/m, BP 160/80 mmHg, CA (-/-),
cor and pulmo in normal condition, abdomen: palpable
mass 11 x 14 cm, vaginal bleeding (+), internist
consultation (+)
A : Hydatiform mole in G8 P7 A0 M0 13 weeks 5 days
gestation with hypertiroidism
P:

IVFD RL 20 dpm,
insertion of laminaria,
curretage,
T3/T4/TSH examination

22 of May 2014
S : vaginal bleeding (+)
O : HR 90 x/m, RR 19 x/m, BP 130/70 mmHg, fine
tremmor (+). Laboratory result: T3 4,68 nmol/L (high),
T4 297, 76 nmol/L (high), TSH 0,014 (low)
A : Hydatiform mole in G8 P7 A0 M0 13 weeks 6 days
gestation with hypertiroidism
P:
IVFD RL 20 dpm,
curretage,
Propanolol 2 x 10 mg

23 of May 2014
S : nausea (+)
O : HR 92 x/m, RR 20 x/m, BP 140/80 mmHg, fine
tremmor (+), lab. Result: WBC 6.700/mm3, RBC 3,59
M/uL, HB 9,0 g/dL, HCT 28,3 %, PLT 286 K/uL
A : Hydatiform mole in G8 P7 A0 M0 14 weeks
gestation with hypertiroidism + Anemia e.c. vaginal
bleeding
P:

IVFD RL 20 dpm,
curretage,
whole blood transfusion 350 cc,
Propanolol 2 x 10 mg

24 of May 2014
S : nausea & vomitting (+), appetite (<), vaginal
bleeding (+) decreasing
O : HR 92 x/m, RR 20 x/m, BP 150/110 mmHg, fine
tremmor (+), Fundal heigh 1 finger under umbilicus
A : Hydatiform mole in G8 P7 A0 M0 14 weeks 1 day
gestation with hypertiroidism + Anemia e.c. vaginal
bleeding
P:
IVFD RL 20 dpm,
curretage,
Propanolol 2 x 10 mg

25 of May 2014
Laboratory result: WBC 6.300/mm3, RBC 380 M/uL,
HB 9,4 g/dL, HCT 29,6 %, PLT 219 M/uL

26 of May 2014
S : feels heat
O : HR 78 x/m, RR 20 x/m, BP 130/80 mmHg, Fundal heigh
the same as umbilicus. Reconsultation to internist (+),
consultation to cardiologist (+) ECG HR 112
A : Hydatiform mole in G8 P7 A0 M0 14 weeks 3 days
gestation with hypertiroidism + Anemia e.c. vaginal
bleeding + Sinus tachycardy
P:

IVFD RL 20 dpm,
curretage,
Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
HR evaluation (60-100 x/m)

27 of May 2014
S : feels heat (-), vaginal bleeding (-)
O : HR 112 x/m, RR 26 x/m, BP 110/60 mmHg, Fundal heigh
the same as umbilicus.
A : Hydatiform mole in G8 P7 A0 M0 14 weeks 4 days
gestation with hypertiroidism + Anemia e.c. vaginal
bleeding + Sinus tachycardy
P:

IVFD RL 20 dpm,
Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
whole blood transfusion 350 cc,
HR evaluation (60-100 x/m)
Pro-Histerectomy until sign & symtomps of
thyrotoxicosis is negative

28 of May 2014
S : vaginal bleeding (+) minimal, palpitation (+)
O : HR 92 x/m, RR 20 x/m, BP 130/80 mmHg, Fundal
heigh 3 finger under umbilicus. Curettage was
perfomed, PA examination on mola fluid and blood. Lab.
Result: WBC 8.400/mm3, RBC 4,28 M/uL, HB 11,4 g/dL,
HCT 31,9 %, PLT 212 K/uL
A : Post curettage in indication of hydatiform mole
with hypertiroidism
P:

Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
Cytotex PO 2 tabs
HR evaluation (60-100 x/m)

29 of May 2014
Lab. Result : WBC 9.600/mm3, RBC 4,89 M/uL, HB
12,7g/dL, HCT 36,2 %, PLT 261 K/uL

30 of May 2014
S : complain (-)
O : HR 92 x/m, RR 20 x/m, BP 120/60 mmHg, Fundal heigh
3 finger under umbilicus.
A : Post curettage in indication of hydatiform with
hypertiroidism
P:

Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
Amoxicillin 3 x 500 mg
Mefenamic acid 3 x 500 mg
Ciprofloxacin 2 x 500 mg
Waiting PA result
Rontgent thorax PA
Out patient, klinic consultation.

LITERATURE
RIVIEW
Chapter III

INTRODUCTION
Gestational trophoblastic neoplasia (GTN) is
comprised of a spectrum of conditions, each of
which is characterised by low incidence and high
cure rates.2,4

2. Sebire N. J., Seckl M. J. Clinical review - Gestational trophoblastic disease: current management of hydatiform mole. BMJ 2008; 337. a193,
doi: 101136/bmj a193. 2008, vol 337 (453-58): BMJ
4. Phillip Savage. Clinical fatures of molar pregnancies and gestatioal trophoblastic neoplasia

HYDATIFORM
MOLE
Molar pregnancies and GTN origin from the
placental trophoblast.6
Normal trophoblast

Syncytiotrophoblast invades the endometrial stroma


with implantation of the blastocyst and is the cell type
that produces human chorionic gonadotropin (hCG).
Cytotrophoblast functions to supply the syncytium with
cells in addition to forming outpouchings that become
the chorionic villi covering the chorionic sac.
Intermediate trophoblast is located in the villi, the
implantation site, and the chorionic sac.

3 types trophoblast GTD when they proliferate. 6


6. John R. Lurain. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic
disease, and management of hydatiform mole. 2010, american journal of obstetric and gynecologis: mosby, Inc. doi:10.1016/j.ajog.2010.06.073

Hydatidiform moles are abnormal conceptions with excessive


placental, and little or no fetal, development.6
Trophoblastic proliferation (cytotrophoblast &
syncytiotrophoblast) and vesicular swelling of placental villi
associated with an absent or an abnormal fetus/embryo.6
The two major typescomplete and partial (CHM and PHM).6
Affect women < 16 yo & > 50 yo, twin or multiple gestation. 6

CHM undergo early and uniform hydatid


enlargement of villi in the absence of an
ascertainable fetus or embryo, the trophoblast is
consistently hyperplastic with varying degrees of
atypia, and villous capillaries are absent. 5,6

PHM demonstrate identifiable fetal or


embryonic tissue, chorionic villi with focal
edema that vary in size and shape, scalloping and
prominent stromal trophoblastic inclusions, and a
functioning villous circulation, as well as focal
trophoblastic hyperplasia with mild atypia only.5,6

CLINICAL
PRESENTATION
Most common abnormal vaginal bleeding at 616 weeks of gestation. 5,6
Palpable uterus larger than the gestational age
according to the last normal menstruation
period.5,6
Hyperemesis gravidarum, anemia,
hyperthyroidism, very high levels of -HCG and
pre-eclampsia before 20 weeks of gestation.
History of passing hydropic vesicles or grapelike pieces of tissue.5,6

DIAGNOSIS
Ultrasound diagnostic tool in diagnosing molar
pregnancy CHM
Shows mixed echogenic pattern, comprising
hydropic villi, an absent fetus and no amniotic fluid,
exhibiting snow storm pattern with or without
theca lutein cysts
Ultrasound appearance is non-specific, and
therefore molar pregnancies are frequently
misdiagnosed as incomplete miscarriages
Ultrasound finding in cases of PHM, includes a fetus
(sometimes growth restricted), amniotic fluid and
focal areas of anechogenic spaces in the placenta.

MANAGEMENT
Dilatation and suction evacuation is the standard
treatment of all patients presenting with a possible
diagnosis of molar pregnancy.5
Full blood count, coagulation profile, renal function
assessment, liver function test, thyroid functions,
quantitative -HCG level, and blood group
compatibility, chest X-ray and CT scan in selected
cases.

HYDATIFORM MOLE WITH


HYPERTHYROIDISM
Fall in TSH suggests that it is HCG that causes
increased secretion of T3 and T4. 7
Hyperthyroidism (defined as a suppressed TSH with
raised FT3 or FT4) is more common in trophoblastic
disease than normal pregnancy. 7
HCG in GTD enhanced tyrotrophic activity.

DISCUSSION
Chapter IV

Mrs. IT, 46 yo
G8 P7
Abdominal lump
since 2 months
15 February
2014
Appetite << +
N/V
Vaginal bleeding >>
Lump in the neck
since 4 months ?

Hydatiform mole in G8
P7 13 weeks gestation

Management

anemia

thyroid-function >>

trembling, sweating,
and palpitations
tachycardia

ECG sinus tachycardia

140/80 mmHg
uterus - 20-weeks gestation

snow storm appearance

Hyperthyroidism

Trophoblastic hyperthyroidism thyroid


stimulation by hCG
The clinical features fatigue, weight loss,
muscle weakness, excessive sweating,
nervousness, heat intolerance, tachycardia
and minimal enlargement of the thyroid
gland.

Table 2. Thyroid Function Test


22 of May

2014
TSH (0,27 - 4,7
0,014
IU/mL)
T3 (0,92 2,33
4,68
nmol/L)
T4 (60 120
297,76
nmol/L)

Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
Dilatation and curretage

CONCLUTION
Mrs. IT, 46 years old with diagnose of hydatiform mole in G8 P7 H. 13
weeks with hyperthyroidism and anemia. The management which is given
is:
IVFD RL 20 dpm
Curretage
Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
Amoxicillin 3 x 500 mg
Mefenamic acid 3 x 500 mg
Ciprofloxacin 2 x 500 mg
Waiting PA result
Rontgent thorax PA
Out patient, klinic consultation.

REFERENCES
1. Nousheen Aziz, Sajuda Yousfani, Irfanullah Soomro, Firdous Mumtaz. Original article Gestational
trophoblastic disease. J Ayub Med Coll Abbottabad 2012; 24 (1). Downloaded from
http://www.ayubmed.edu.pk/JAMC/24-1/Nousheen.pdf
2. Sebire N. J., Seckl M. J. Clinical review - Gestational trophoblastic disease: current management of
hydatiform mole. BMJ 2008; 337. a193, doi: 101136/bmj a193. 2008, vol 337 (453-58): BMJ. Downloaded
from http://www.eottd.com/wp-content/uploads/2012/01/Lybol.pdf
3. Dave Nandini, Fernandes Sarita, Ambi Uday, Iyer Hermalata. Case Report hydatiform mole with
hypertiroidism perioperative challanges. J obstet gynecol india vol. 59, no. 4 ; july/agust 2009 pg 356-357.
Downloaded from http://medind.nic.in/jaq/t09/i4/jaqt09i4p356.pdf
4. Phillip Savage. Clinical fatures of molar pregnancies and gestatioal trophoblastic neoplasia. Downloaded
from http://www.isstd.org/isstd/chapter08_files/GTD3RDCH08.pdf
5. Deep J.P., L.B. Sedhai, J. Napit, J. Pariyar. Review article Gestational trophoblastic disease. Journal of
Chitwan Medical Collage 2013; 3(4): 4-11. Downloaded from http://www.cmc.edu.np/images/gallery/Review
%20Articles/ankVwReview%20Articles%202.pdf
6. John R. Lurain. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and
diagnosis of gestational trophoblastic disease, and management of hydatiform mole. 2010, american journal
of obstetric and gynecologis: mosby, Inc. doi:10.1016/j.ajog.2010.06.073. downloaded from
http://journalsconsultapp.elsevier-eprints.com/uploads/articles/ajog1.pdf
7. Walkington L., J Webster, B.W.Hancock, J. Everard, R.E. Coleman. Hyperthyroidism and human chorionic
gonadotrophin production in gestational trophoblastic disease. British Journal of Cancer (2011) 104, 16651669: cancer research UK. Downloaded from
http://www.nature.com/bjc/journal/v104/n11/pdf/bjc2011139a.pdf

TERIMAKA
SIH

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