CASE 6 - HYDATIDIFORM MOLE

Nehemiah Roland C. Francisco

 GENERAL DATA
 J.L., 38 years old, G1P0, Single, Filipino, Roman
Catholic, currently resides in Imus, Cavite,
consulted the DLSUMC-ER on February 10, 2021
at 4:30 pm.
 Chief Complaint

 Vaginal bleeding
 PAST MEDICAL/SURGICAL HISTORY
 Patient had history of allergies to seafood
and Ibuprofen.
 No history of asthma, diabetes mellitus,
hypertension, heart disease, seizure
disorders, thyroid disorders nor sexually
transmitted disease.
 FAMILY HISTORY


Hypertension - ♀

Diabetes - ♂
 PERSONAL AND SOCIAL HISTORY
 College graduate
 Works as a bank employee
 She is a non-smoker and non- alcoholic
beverage drinker.
 MENSTRUAL HISTORY
 Menarche at 11 years old
 Regular, lasts for 5-7 days
 2-3 fully soaked pads a day with noted
dysmenorrhea
 LNMP = November 25-30, 2020
 PMP = October 2020
 GYNECOLOGICAL HISTORY
 Pap smear, last 2020 – Unremarkable
 SEXUAL HISTORY
 First sexual contact at 27 years of age
 Two (2) lifetime sexual partner.
 Patient had last sexual contact last December 2020.

 Contraceptive History
 None
 HISTORY OF PRESENT PREGNANCY

5wks PTC 4 weeks PTC 3 weeks PTC 4 days PTC Day of consult

• (-) regular • (+) • (+) vaginal • UTZ- • (+) vaginal

menstrual pregnancy spotting, hydatidifor spotting
period test hypogastric m mole
pain, low • ref to
back pain specialist
• UTZ-
pregnancy
of unknown
viability
 REVIEW OF SYSTEMS
 Unremarkable
PHYSICAL EXAMINATION
 GENERAL SURVEY
 Patient is well developed, well nourished, conscious,
coherent, oriented to place, person and time, in no
cardiorespiratory distress, appears her chronological age of 38
and ambulant without assistive devices.
 VITAL SIGNS
 BP = 120/70mmHg
 HR = 80bpm
 RR = 19cpm
 Temp = 36.3°C

 Chest & Lungs – Unremarkable

 Heart – Regular rate & rhythm with no murmur
 Abdomen – soft & non tender
 PHYSICAL EXAMINATION
 GENITALIA/CLINICAL PELVIMETRY
 External genitalia grossly normal. Vagina is nulliparous, cervix is
closed, corpus is enlarged to 12 weeks, no cervical motion
tenderness nor adnexal mass tenderness

 Laboratory
 Serum beta – hCG: 120,000 mIU/mL
GYNECOLOGY ULTRASOUND REPORT(TVS)
GYNECOLOGY ULTRASOUND REPORT(TVS)
 GYNECOLOGY ULTRASOUND REPORT(TVS)
 Diagnosis:
 Normal sized anteverted uterus
 Consider H. mole complete
 Myoma uteri
 Consider theca lutein cyst, right
 Normal left ovary with corpus luteum
FINAL DIAGNOSIS
 38 yo, G1P0, Myoma Uteri FIGO 5, Theca Lutein Cyst R, Complete
Hydatidiform
5wks PTC 4 weeks PTC 3 weeks PTC 4 days PTC Day of consult

• (-) regular • (+) pregnancy • (+) vaginal • UTZ- • (+) vaginal

menstrual test spotting, hydatidiform spotting
period hypogastric mole
pain, low • ref to
back pain specialist
• UTZ-
pregnancy of
unknown
viability

 Well circumscribed hypoechoic mass at the left posterolateral near cervico-

corporeal junction, subserous measuring 4.40 x 4.31 x 3.85 cm (FIGO 5)
 Within the endometrium an echogenic material with cystic spaces measuring 7.10
x 5.35 x 4.50 cm (Volume = 88.9 mL)
 Within the right ovary a thin walled, biloculated, anechoic cystic structure
measuring 1.78 x 1.95 x 1.15 cm.
 DIFFERENTIAL DIAGNOSES
More Likely Less Likely

Ectopic Pregnancy (+) pregnancy test (+) beta-hCG 120,000

(+) vaginal bleeding mIU/mL
(+) adnexal mass (+) thin walled
(+) hypogastric pain biloculated anechoic cyst

Threatened Miscarriage (+) vaginal bleeding (+) TVS unknown viability

(+) pregnancy test (+) beta-hCG 120,000
(+) hypogastric pain mIU/mL
 Case discussion
 Hydatidiform moles are abnormal pregnancies characterized
histologically by aberrant changes within the placenta. Classically, the
chorionic villi in these placenta show varying degrees of trophoblastic
proliferation and edema of the villous stroma
 Pathogenesis
 85-90% 46,XX
 Paternal in origin
 Androgenesis
 ovum is fertilized by a haploid
sperm
Pathogenesis
• Microscopically
• Enlarged, edematous villi
• Abnormal
trophoblastic
proliferation

• Macroscopically
• transform the chorionic
villi into clusters of
vesicles
MANAGEMENT
 DIAGNOSTIC PROCEDURES
 Covid 19 RT- PCR
 CBC – to assess if blood transfusion is needed due to vaginal
bleeding
 Blood typing & cross matching – transfusion PRN
 Serum beta-hCG – elevated in pregnancy, highly elevated in H.
moles
 DIAGNOSTIC PROCEDURES
 Transvaginal ultrasound
 Normal size anteverted uterus, with a well circumscribed
hypoechoic mass at the left posterolateral near cervico-
corporeal junction, subserous measuring 4.40 x 4.31 x 3.85 cm.
 Within the endometrium an echogenic material with cystic
spaces measuring 7.10 x 5.35 x 4.50 cm (Volume = 88.9 mL)
 Within the right ovary a thin-walled, biloculated, anechoic cystic
structure measuring 1.78 x 1.95 x 1.15 cm.
 DEFINITIVE TREATMENT
 Uterine Evacuation
 Suction curettage is the preferred method of evacuation regardless
of the uterine size in patients who wish to remain fertile
 Hysterectomy is rarely recommended unless the patient wishes
surgical sterilization or is approaching menopause
 DEFINITIVE TREATMENT
 Hysterectomy
 May be done if patient is not desirous of pregnancy
 Definitive and most common surgical treatment for leiomyomas
 Eliminates risk of locally invasive disease and the risk of persistent
trophoblastic disease by up to 50% but does not prevent metastases
 POST OP MONITORING
 Beta-hCG monitoring
 Used to confirm if treatment was successful
 Goal: progressive decrease in hCG by at least 10% across 4
values during a 3-week period (days 1, 7, 14, and 21) until
hCG is undetectable (< 5 mIU/mL)
 Monitoring until 6 months because there is increased
incidence of Hydatidiform Mole into Gestational
Trophoblastic Neoplasia.
 Theca Lutein Cyst
 resolve spontaneously following removal of the stimulating hormone
source (H mole, beta-hCG)
Thank You!
 References
 1) Cunningham, G. F., Lenovo, K. J., & Bloom, S. L. (2018). Williams
Obstetrics (25th ed.). New York: McGraw-Hill Education.
 2) Lobo, RA, Gershenson DM, Lentz GM, Valea FA. Comprehensive
Gynecology 7th, edition. 2017