Small Group

Discussion
DIVINE WORD HOSPITAL – DEPT OF OBGYN
Consultant In-Charge: Dr Canson
Opening Prayer
General Objectives

to understand the concepts and principles of the diagnosis and management of

gestational trophoblastic disease;

know the possible complications and preventive measures for patients who are at
risk for another molar pregnancy.
Specifically,
• To identify the pertinent history and physical examination findings given in the case;

• To extract and elicit other additional information in the patient’s history and physical
examination not mentioned in the protocol to help narrow down the diagnosis;

• To interpret the results in the ancillary tests and correlate them with their
corresponding indications;

• To provide a primary diagnosis and discuss the basis for consideration;

• To give at least 3 differential diagnoses and discuss the  grounds in considering each;
Specifically,

• To discuss the appropriate plan and management for this case;

• To know how to do postevacuation surveillance in patients with hydatidiform mole.

• To have basic knowledge on the pathophysiology of gestational trophoblastic disease

• To know the clinical presentation of patients with molar pregnancy;

• To differentiate between a partial and a complete hydatidiform mole; and

• To identify the risk factors as well as preventive measures for patients who have had
molar pregnancies.
 1
Vaginal Bleeding
Chief complaint
Date of consult: March 22, 2021

AB a 32-year-old G2P1 (1001) was brought to the ER for

vaginal bleeding. She has regular monthly menses lasting 3-4
days, fully soaking 2-3 pads per day, with no dysmenorrhea. Her
LMP was December 10-12, 2020. She had a pregnancy test done
a month prior which showed a positive result, however, she did
not seek prenatal consult nor had an ultrasound done. She came
in now with a 1-week history of vaginal bleeding which started as
spotting now progressing to bleeding fully soaking 1 baby diaper.
 She has no known comorbidities and has an
unremarkable family history. Her previous pregnancy in
2018 was delivered vaginally, term, with no associated
feto-maternal complications. She is a housewife,
nonsmoker, and nonalcoholic drinker. She has had only
1 sexual partner who is her husband 20 years her
senior. They use only withdrawal methods as
contraception. Review of systems is unremarkable.
 Vital Signs:
BP: 160/100 mmHg PHYSICAL EXAMINATION
HR: 105 bpm
RR: 20 cpm
T: 36.5 Awake, conscious, coherent, ambulatory

Anthropometrics
HEENT: slightly pale conjunctiva
Lungs: clear breath sounds
Wt: 44kg
Heart: dynamic precordium, tachycardic, regular rhythm,
Ht: 157 cm
(-) murmur
BMI: 17.8
Abdomen: soft abdomen, no fetal heart tones appreciated

Pelvic Exam
• Normal external genitalia, smooth vagina, cervix admits tip,
• corpus 22 weeks size boggy,
• (+) right adnexal mass 8 x 6 cm cystic with slight pain on
deep palpation, (+) left adnexal mass 6 x 6 cm cystic;
Speculum Exam: 
Rectovaginal Exam vaginal walls pink
• good sphincter tone, intact rectal vault, bilateral  and smooth
parametria smooth and pliable, inferior pole of
masses palpable at the cul de sac  blood clots per os
 Laboratory Exam

Pregnancy Test Serum bHcg

positive 115,000 mIU/mL

Transabdominal Ultrasound

● Complex intrauterine echogenic

mass  containing multiple
discrete cystic spaces 

● Bilateral adnexal masses

probably ovarian in origin
 What are the pertinent
information in the patient’s
history?
● 32-year-old G2P1 (1001) 

● 1-week history of vaginal bleeding

o started as spotting then progressing to bleeding
fully soaking 1 baby diaper

● GI- NSVD 2018 with no associated feto-maternal

complications. 

● LMP :December 10-12, 2020

● Pregnancy test - positive (done a month prior)

● Regular monthly menses lasting 3-4 days, fully
soaking 2-3 pads per day, with no dysmenorrhea.

● No prenatal consult , no previous ultrasound. 

● No known comorbidity

● She is a housewife, nonsmoker, and nonalcoholic

drinker.
● 1 sexual partner her husband (20 years her senior)

● Contraception: withdrawal method.

What other information would you like
to extract from the patient to narrow
down your diagnosis?
● Was there passage of meaty tissue or grape like mass?

● Does the patient have any history of intake of possible

abortifacient drugs or chemotherapeutic drugs?

● Does the patient have any history of sexual abuse or

was there any immediate trauma to the perineal area?

● Was there any history of dysuria, frequency, fever?

● Does the patient drink more than 5 cups coffee a day?

● History of STD?
● Is there history of infertility or ART?

● History of contraceptive use?

● Was there any hx of abdominal pain?

● Were there any episodes of vertigo or syncope? 

● Was there history of prior hmole?

● Hx of difficulty sleeping, sudden weight loss, heat

intolerance?

● Hx of headache or visual distubances? Pre

eclampsia
What are pertinent findings in the
patient’s physical examination
and their corresponding
interpretation?
● Vital signs: 
○ BP- 160/100mmHg  (hypertensive) 
○ PR- 105 beats/minute   (Tachycardic)
   
● Anthropometrics:
○ Wt: 44kg, Ht: 157 cm BMI 17.8
(Underweight)
●
HEENT: slightly pale conjunctivae

● Heart: dynamic precordium, tachycardic

● Abdomen: soft abdomen, no fetal heart tones
appreciated 

● Pelvic (Internal and Rectovaginal Exam): 

○ corpus 22 weeks size boggy, (+) right
adnexal mass 8 x 6 cm cystic with slight
pain on deep palpation, (+) left adnexal
mass 6 x 6 cm cystic
 What other physical
examination findings would
you like to elicit in the patient?
● Delay in capillary refill >3 seconds, pale oral
mucosa, cool clammy skin

● Loss of skin elasticity, decrease in urine

output

● Tachycardia is already present, assess for

Presence of neck mass/goiter, mild
tremors, sweating, warm skin

● Cervical motion tenderness

● Presence of uterine contents in the
vaginal canal

● Abdominal tenderness, pain, or

guarding

● Abdominal mass

● note of headache and swelling in

extremities
What are your considered differential
diagnoses and corresponding reasons
for ruling them in?
 Considerations Rule In Rule Out
Hydatidiform mole Amenorrhea Cannot totally rule
(complete) Vaginal spotting/bleeding out
Soft abdomen
Large for date uterus
No fetal heart sounds
appreciated

Ectopic pregnancy Amenorrhea Cannot totally rule

Vaginal spotting/bleeding out
Bilateral adnexal masses
Enlarged uterus
No fetal heart sounds
appreciated
 Considerations Rule In Rule Out
Missed abortion Amenorrhea Cannot totally rule
Vaginal spotting out
No fetal heart sounds
appreciated
Increased paternal age

Incomplete Amenorrhea No passage of meaty

abortion Vaginal spotting/bleeding tissue
Open cervix
Increased paternal age
Complete abortion Amenorrhea No passage of meaty
Vaginal spotting/bleeding tissue
Increased paternal age Closed cervix
 Considerations Rule In Rule Out
Threatened Amenorrhea No fetal heart tones
abortion Vaginal spotting/bleeding appreciated
Increased paternal age Closed cervix

Normal pregnancy Amenorrhea No fetal heart tones

Vaginal spotting/bleeding appreciated
Enlarged uterus
 What laboratory and ancillary
procedures should be requested
and why?
 Complete blood count with
Urine pregnancy test blood typing

Quantitative serum B- Urinalysis

hCG measurement
Ultrasound TSH and FT4

AST and ALT

 How would you interpret the
laboratory and ultrasound
findings?
● Pregnancy test is positive meaning the
patient is pregnant.

● Serum β-hCG is high at 115,000 mIU/mL, way

beyond normal pregnancy level, which is
indicative of hydatidiform mole specifically a
complete mole.
● Transabdominal ultrasound
○ showed complex intrauterine echogenic mass
containing multiple discrete cystic spaces or
“snow storm” appearance without any fetus or
fetal tissues or placenta which is highly
suggestive of complete mole.

○ Also in the ultrasound, it showed bilateral

adnexal masses probably ovarian in origin. It is
highly suggestive of theca lutein cysts which are
commonly seen in or associated with complete
mole.

○ Theca lutein cysts develop with prolonged

exposure to LH.
 With the history, physical findings
and laboratory results, what is your
preoperative diagnosis?
G2P1 (1001) 14 4/7 weeks AOG by
LMP; Hydatidiform Mole; Anemia,
Secondary; T/C Hyperthyroidism
 Basis

● Amenorrhea of 3 months

● 1-week history of vaginal bleeding

● Pregnancy test – positive

● Abdominal PE- no fetal heart tone appreciated

● Speculum Exam:  blood clots per os 

 Basis

Pelvic Exam: 
○ Corpus 22 weeks size boggy (large for date uterus) because in H. mole uterine
growth is more rapid than expected

○ (+) right adnexal mass 8 x 6 cm cystic with slight pain on deep palpation

○  (+) left adnexal mass 6 x 6 cm cystic

● Serum bhcg: 115,000 mIU/mL

 Basis
Transabdominal ultrasound:
● Complex intrauterine echogenic mass containing multiple
discrete cystic spaces
● Bilateral adnexal masses probably ovarian in origin

● BP- 160/100mmHg

● Pale conjunctiva

● Tachycardia and dynamic precordium

How will you manage
this patient?
● The treatment of choice for patients with molar pregnancy is suction
evacuation and curettage under ultrasound guidance if fertility is to be
maintained.  The cervix is serially dilated (at around 8-10cm) then a large
suction curette is advanced just past the endocervix into the endometrial
canal.

● While ongoing surgical procedure is performed, intravenous oxytocin infusion

(20 units/L) is started to enhance uterine contractility and is continued post-op
to reduce bleeding. But according to the RCOG, use of oxytocin infusion prior
to completion of the evacuation is not recommended because of the risk of
embolization of trophoblastic tissue in the venous system.
● If childbearing is complete, hysterectomy with preservation of the adnexa is an
alternative approach. 
● If the uterus is large (>16 weeks in gestational size), typed and crossmatched
blood for transfusion should also be available since risk of bleeding increases
with uterine size.
● If the mother is Rh-negative, we give Rh immunoglobulin (Rhogam) to prevent
sensitization (RhD factor is expressed on the trophoblast).
● Prophylactic use of Methotrexate or Actinomycin D chemotherapy is given in
situations where risk of postmolar GTN is much greater than normal or where
adequate HCG follow up is not possible. However, its routine use is not
recommended due to the morbidity associated with even a single dose of
chemotherapy.
 Management
Laboratories/ Rationale
Complication Diagnostics
Hyperthyroidism FT4 and TSH HCG has a thyrotropin-like effect and can
cause hyperthyroidism as a complication
in women with molar pregnancies.

Expected results:
Increased FT4, Decreased TSH 
Electrolyte imbalance from Serum electrolytes Excessive vomiting from hyperemesis
hyperemesis (Na, K, Cl, Mg) gravidarum secondary to elevated levels
of HCG as a complication of molar
pregnancy warrants identification of any
ongoing electrolyte imbalance. 

**Preop clearance din

Anemia CBC To confirm presence of anemia as it can

 Management
Laboratories/ Rationale
Complication Diagnostics
Anemia CBC To confirm presence of anemia as it can
be a complication from concealed uterine
hemorrhage especially with advanced
molar pregnancy. As for our patient,
although she has slightly pale palpebral
conjunctiva, it is best to confirm this with
a CBC.

Expected results:
Decreased hemoglobin and hematocrit
*Initial hemoglobin of <10 mg/dl
warrant a preoperative blood
transfusion.
DIC PT (extrinsic), PTT Expected results:
(intrinsic) Prolonged PT and PTT - since
 Management
Laboratories/ Rationale
Complication Diagnostics
DIC PT (extrinsic), PTT Expected results:
(intrinsic) Prolonged PT and PTT - since
coagulation factors are consumed.

*Preop din
Preeclampsia Platelet count Platelet count: <100,000/uL
(Thrombocytopenia)

AST, ALT AST, ALT twice the upper limit of normal

Urinalysis Urinalysis for presence of protein in the

urine (≥300mg/24hr)

Creatinine as an adjunct to calculate

 Management
Laboratories/ Rationale
Complication Diagnostics
Preeclampsia Creatinine Creatinine as an adjunct to calculate
protein:creatinine ratio together with
protein urinalysis (value of ≥0.3 is
indicative of preeclampsia). Also a value
of >1.1 dL or 2x baseline indicates renal
insufficiency.
Pulmonary insufficiency Chest X-Ray To rule out metastasis of trophoblastic
tissue, pulmonary hemorrhage,
congestion and infection (for
methotrexate)

Preoperative BT and For ongoing surgery since suction

 Management
Laboratories/ Rationale
Complication Diagnostics
Preoperative BT and For ongoing surgery since suction
Crossmatching curettage entails increased blood loss

12L ECG 12L ECG to detect presence of cardiac

anomalies that can affect surgical
procedure and lead to hemodynami
instability
 Medications
BASIS MANAGEMENT
PROBLEMS
Pre-eclampsia BP: 160/100 BP control by
administration of either of
the following drugs:

Nifedipine (CCB): 
MOA: Inhibits flow of
calcium across slow
channels of cellular
membranes. It reduces BP
without compromise to
placental blood flow. Has
a quicker onset of action
(compared to hydralazine).
 Medications
BASIS MANAGEMENT
PROBLEMS
Pre-eclampsia BP: 160/100 Dose: 10-20mg PO every
30 minutes for a maximum
doseof 50mg. 
SE: Tachycardia,
headache, palpitations
DDI: Magnesium sulfate
(Marked hypotension)
Alternative: Nicardipine
5mg/hour with increments
of 2.5mg/hr every 5 minutes
to a max dose of 10mg/hr
or until MAP is reduced
by15%.
 Medications
BASIS MANAGEMENT
PROBLEMS
Pre-eclampsia BP: 160/100 Labetalol (BB):
MOA: Reduction of
peripheral vascular
resistance without
compromising blood flow to
the brain and peripheral,
coronary or renal systems.
Dose: 20mg slow IV
infusion every 2 minutes for
a maximum dose of 300mg.
CI: Moderate-to-severe
asthma, bradycardia, or
congestive heart failure
 Medications
BASIS MANAGEMENT
PROBLEMS
Pre-eclampsia BP: 160/100 Hydralazine (vasodilator):
MOA: Arteriolar vasodilator
with onset of action at 10-
20 minutes after
administration.
Dose: 5-10mg IV or IM
every 15 minutes for a
maximum dose of 20mg IV
or 30mg IM.
 Medications
BASIS MANAGEMENT
PROBLEMS
Anemia Slightly pale conjunctiva Prepare typed and
Tachycardia (HR: 105bpm) crossmatched whole blood
as well as blood component
for transfusion if Hgb
<10g/dL

Rhogam for mothers who

are Rh negative with either
Rh positive or Rh unknown
father.
● For dilatation of cervix preoperatively using laminaria or mechanically
by balloon of Foley catheter or intraoperatively by hegars.
● For emergency suction evacuation and curettage with ultrasound
guidance after cervical dilation. With simultaneous infusion of
crystalloids and oxytocin (20 units/L) intraoperatively and
postoperatively.
● Save placental tissues for histopathologic diagnosis post-curettage
● Collect serum B-HCG within 48 hours post-op as baseline
measurement for postcurettage surveillance.
 How do we perform post
evacuation  surveillance in
patients with molar pregnancy?
● serum b hcg should be determined
○ 48 hrs after evacuation then

○ weekly until the serum b hcg is already undetectable (<5

mIU/ml) 
○ monitor again once a month for 6 months.
●
However, since this is not cost efficient, according to our local
guidelines.
● use reliable contraception (combined oral contraceptives:
recommended)
○ Perfect use failure rate of 0.3%
○ Typical use failure rate of 7%

● This also suppresses the release of LH to prevent cross reactivity during

ovulation wherein there is LH surge.
What is molar pregnancy? Give
an overview of its
pathophysiology.
 Hyatidiform Mole

• is a chromosomal anomalous growth of trophoblastic tissue

categorized as complete or partial.
 What are the two types of
hydatidiform moles? Can you please
differentiate the two. What is the
importance in differentiating the 2
forms?
 What are the risk factors in
developing molar pregnancy? Can
you identify some of the factors for
this patient?
 Risk Factors
● Ethnic predisposition

● Extremes of maternal age

● Extremes of maternal age

● Prior history of H mole

● Vitamin A deficiency and low dietary intake of carotene

● Genetics
What will you advise
this patient?
● Women who have successfully completed GTN chemother­apy are
advised to delay pregnancy for 12 months.

● This is because, patients are at greatest risk of relapse during this

time and the rising hCG of pregnancy can prevent early detection and
diagnosis of disease recurrence.

● We advise the patient that women with prior hydatidiform mole

generally do not have impaired fertility, and their pregnancy
outcomes are usually normal
● Fertility and pregnancy outcomes are typically normal, and
congenital anom­aly rates are not increased

● One exception is an unexplained higher stillbirth rate of 1.5 percent

compared with a background rate of 0.8 percent

● Sonographic evaluation is recommended in early pregnancy, and

subsequently if indicated.

● One concern though is the 2-percent risk for developing

trophoblastic dis­ease in a subsequent pregnancy

● Beta hcg measured 6 weeks oost partum

● After hydatidiform mole or GTN treatment, in subsequent
pregnancy, the placenta or products of conception are sent for
pathological evaluation at delivery
● unexplained higher stillbirth rate of 1.5 percent compared with a
backgroundrate of 0.8 percent

● After hydatidiform mole or GTN treatment, in subsequent pregnancy,

the placenta or products of conception are sent for pathological
evaluation at delivery

● A serum 3-hCG level is measured 6 weeks postpartum

THAN
KS!