29. Diagnostics Diagnostic tests Rationale Patient’s results Remarks CBC Check anemia status Check for infection Hgb: 12.9 Hct: 0.38 WBC: 12.4 Platelets: 322 Increased WBC Urinalysis with PT Check for infection and re-confirm pregnancy test Dark, yellow, hazy Sugar (-), protein (+1), RBC too numerous to count, WBC 0-2, moderate epithelial cells, few bacteria hematuria Thyroid function tests Hyperthyroidism may occur in H.mole FT4 1.53 | TSH 1.19 | T4 10.31 T uptake 1.08 | FT3 3.37 | T3 1.09 normal
30. Diagnostics Diagnostic tests Rationale Patient’s results Remarks BUN and Crea Check for renal status before methotrexate use (renal excretion) BUN 4.1 Crea 61 normal Liver enzymes Check for liver status before methotrexate use (liver metabolism) AST 15 ALT 25 ALT slightly decreased
31. Diagnostics Imaging study Rationale Patient’s results Remarks Chest xray The lungs are a primary site of metastasis for malignant trophoblastic tumors. Pulmonary nodule Normal chest findings normal Trans-vaginal ultrasound criterion standard for identifying both complete and partial molar Uterus is retroverted. Borderline in size: 7.0 x 6.5 x 6.9. The endometrial cavity has multiple cystic structures varying in size “ honey-comb” pattern is distinct for H.mole Serum B-hCG HCG levels greater than 100,000 mIU/mL indicate exuberant trophoblastic growth 105,402.99 Increased B-hCG
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39. SUCTION CURETTAGE Repeat B-hCG Repeat B-hCG Every 2 weeks until normal levels ( < 5 mIU/mL)
40. Normal B-hCG Normal B-hCG Normal B-hCG After 3 consecutive biweekly normal levels, monitoring is once every month for 6 months
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Notes de l'éditeur
Patient was regularly menstruating since age of 14, regular interval, lasting for 3 days, consumes 2 pads per day. The patient is apparently well until 3 months prior to consult, when she missed her menses. Pregnancy test was done at home and then at the health center, result was positive. She was advised at the health center to have an ultrasound done. [The result of the ultrasound showed enlarged uterus with an endo/myometrial mass. She was then advised to have her B-hCG levels tested then advised to consult to a tertiary hospital for further management.
Patient was regularly menstruating since age of 14, regular interval, lasting for 3 days, consumes 2 pads per day. The patient is apparently well until 3 months prior to consult, when she missed her menses. Pregnancy test was done at home and then at the health center, result was positive. She was advised at the health center to have an ultrasound done. [The result of the ultrasound showed enlarged uterus with an endo/myometrial mass. She was then advised to have her B-hCG levels tested then advised to consult to a tertiary hospital for further management.
Patient was regularly menstruating since age of 14, regular interval, lasting for 3 days, consumes 2 pads per day. The patient is apparently well until 3 months prior to consult, when she missed her menses. Pregnancy test was done at home and then at the health center, result was positive. She was advised at the health center to have an ultrasound done. [The result of the ultrasound showed enlarged uterus with an endo/myometrial mass. She was then advised to have her B-hCG levels tested then advised to consult to a tertiary hospital for further management.
Patient was regularly menstruating since age of 14, regular interval, lasting for 3 days, consumes 2 pads per day. The patient is apparently well until 3 months prior to consult, when she missed her menses. Pregnancy test was done at home and then at the health center, result was positive. She was advised at the health center to have an ultrasound done. [The result of the ultrasound showed enlarged uterus with an endo/myometrial mass. She was then advised to have her B-hCG levels tested then advised to consult to a tertiary hospital for further management.
exaggerated symptoms of pregnancy especially vomiting symptoms of preeclampsia that may be present as headache and edema hyperthyroidism develops in 3-10% of cases manifested by enlarged thyroid gland and tachycardia (due to chorionic thyrotropin secreted by the trophoblast and hCG also has a thyroid-stimulating effect)
Stopped because she noticed abdominal enlargement and tenderness (?) abdominal pain: may be dull-aching due to rapid distension of uterine by mole or by concealed hemorrhage; colicky due to start of expulsion ovarian pain due to stretching of ovarian capsule or complication in the cystic ovary as torsion
The fetal heart can first be heard in most women between 16 and 19 weeks when carefully auscultated with a DeLee fetal stethoscope.
Fetal movement 16 weeks
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Risk factors: The role of gravidity, estrogen status, oral contraceptives, and dietary factors in the risk of gestational trophoblastic disease is unclea AGE aged 15 years or younger, and those aged 45years or older. PREVIOUS MOLE . It is an abnormal proliferation and degeneration of the trophoblastic villi. As the cells degenerate, they become filled with fluid and appear as clear fluid-filled, grape-sized vesicles. With this condition, the embryo fails to develop beyond a primitive start
Hyperthyroidism from stimulation of thyrotropin receptors by hCG occurs in up to 10% of patients with hydatidiform mole. The disease is usually subclinical and most patients remain asymptomatic. Treatment
Hyperthyroidism from stimulation of thyrotropin receptors by hCG occurs in up to 10% of patients with hydatidiform mole. The disease is usually subclinical and most patients remain asymptomatic. Treatment
Hyperthyroidism from stimulation of thyrotropin receptors by hCG occurs in up to 10% of patients with hydatidiform mole. The disease is usually subclinical and most patients remain asymptomatic. Treatment
Hyperthyroidism from stimulation of thyrotropin receptors by hCG occurs in up to 10% of patients with hydatidiform mole. The disease is usually subclinical and most patients remain asymptomatic. Treatment .3 mg/kg
http://www.drugs.com/pro/methotrexate.html Choriocarcinoma and similar trophoblastic diseases: Methotrexate is administered orally or intramuscularly in doses of 15 to 30 mg daily for a five-day course. Such courses are usually repeated for 3 to 5 times as required, with rest periods of one or more weeks interposed between courses, until any manifesting toxic symptoms subside. The effectiveness of therapy is ordinarily evaluated by 24 hour quantitative analysis of urinary chorionic gonadotropin (hCG), which should return to normal or less than 50 IU/24 hr usually after the third or fourth course and usually be followed by a complete resolution of measurable lesions in 4 to 6 weeks. One to two courses of Methotrexate after normalization of hCG is usually recommended. Before each course of the drug careful clinical assessment is essential. Cyclic combination therapy of Methotrexate with other antitumor drugs has been reported as being useful. Since hydatidiform mole may precede choriocarcinoma, prophylactic chemotherapy with Methotrexate has been recommended.
http://www.drugs.com/pro/methotrexate.html Choriocarcinoma and similar trophoblastic diseases: Methotrexate is administered orally or intramuscularly in doses of 15 to 30 mg daily for a five-day course. Such courses are usually repeated for 3 to 5 times as required, with rest periods of one or more weeks interposed between courses, until any manifesting toxic symptoms subside. The effectiveness of therapy is ordinarily evaluated by 24 hour quantitative analysis of urinary chorionic gonadotropin (hCG), which should return to normal or less than 50 IU/24 hr usually after the third or fourth course and usually be followed by a complete resolution of measurable lesions in 4 to 6 weeks. One to two courses of Methotrexate after normalization of hCG is usually recommended. Before each course of the drug careful clinical assessment is essential. Cyclic combination therapy of Methotrexate with other antitumor drugs has been reported as being useful. Since hydatidiform mole may precede choriocarcinoma, prophylactic chemotherapy with Methotrexate has been recommended.
Subsequently, the patient is tested monthly for six months and then at two monthly intervals for a further six months to insure that the hCG levels remain unde- tectable.
WILLIAMS: Monitor serum hCG levels every 2 weeks. Serial measurement of serum hCG is important to detect trophoblastic neoplasia, and even small amounts of trophoblastic tissue can be detected by the assay. These levels should progressively fall to an undetectable level . Once the hCG level falls to a normal level, test the patient monthly for 6 months; then follow-up is discontinued and pregnancy allowed. PHIL CPG: serum B-hCG level is measured 1 week after molar evacuation, then every 2 weeks thereafter until the level becomes normal ( < 5 mIU/mL). After 3 consecutive biweekly normal levels, the frequency of tumor marker monitoring is once every month for 6 months for young patients with intact uteri, pregnancy maybe allowed after 6 months of normal serum B-hCG level. A low-dose combined oral contraceptive pill is the preferred method of artificial contraception.
WILLIAMS: Monitor serum hCG levels every 2 weeks. Serial measurement of serum hCG is important to detect trophoblastic neoplasia, and even small amounts of trophoblastic tissue can be detected by the assay. These levels should progressively fall to an undetectable level . Once the hCG level falls to a normal level, test the patient monthly for 6 months; then follow-up is discontinued and pregnancy allowed. PHIL CPG: serum B-hCG level is measured 1 week after molar evacuation, then every 2 weeks thereafter until the level becomes normal ( < 5 mIU/mL). After 3 consecutive biweekly normal levels, the frequency of tumor marker monitoring is once every month for 6 months for young patients with intact uteri, pregnancy maybe allowed after 6 months of normal serum B-hCG level. A low-dose combined oral contraceptive pill is the preferred method of artificial contraception.
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