Hydatiform Mole With Hyperthyroid

8/9/2019 Hydatiform Mole With Hyperthyroid

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HYDATIFORM MOLEWITH HYPERTHYROIDISM

Presented by Adam Ridha

OBSTETRY AND GYNECOLOGY DEPARTMENT

MEDICAL FACULTY TANJUNGPURA UNIVERSITY

RSU DOKTER SOEDARSO

Supervisor

dr Pi!d" #u$"%u&u' Sp OG (K)


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INTRODUCTIONChapter I


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Molar pregnancy the incidence appearsto be quite high in South Asia.1,3

Gestational hrophoblastic !isease pregnancy related group o" disorders #o"ten fatal in the ast.$

%ydatidi"orm mole a&ects 1#3 ' 1(((pregnancies.$

1() o" hydatidi"orm moles !alignantfo"!s o" G!*G+.$H#e"th#"oi$is!in complete molarpregnancy ), cured by e-acuationo" molar tissue.31. Nousheen Aziz, Sajuda Yousfani, Irfanullah Soomro, Firdous Mumtaz. Original article estational tro!ho"lastic disease. # A$u" Med %ollA""otta"ad &'1&( &) *1+

&. Se"ire N. #., Secl M. #. %linical re-ie / estational tro!ho"lastic disease0 current management of h$datiform mole. M# &''2( 334. a153,

doi0 1'11367"mj a153. &''2, -ol 334 *)83/82+0 M#

3. 9a-e Nandini, Fernandes Sarita, Am"i :da$, I$er ;ermalata. %ase


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CASE REPORTChapter II


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PATIENT

IDENTITYPatient as e/amined on May $3th, $(10+ame ' Mrs. I

e/ ' 2emaleAge ' 0 years oldAddress ' ui 4a5ap6thnic ' 7ugis8ob ' %ouseholdReligion ' Islam+o. MR ' 9:#:


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ANAMNESISChieft Co!laint lump in the abdomen since $ months

Histo"# of P"esent Illnes lump in the abdomen since $ months and "elt

getting bigger. Patient also complained o" decreasedappetite accompanied by nausea and -omiting,

especially a"ter meals. since 0 days "elt blooddischarge increasing "rom the genitals, especially atnight hich o"ten "orm a blood clot. Patientsde"ecate once a ee5, urinate in the normal range.ince 0 months "elt a lump in the nec5 that is not"elt pain. ometimes "elt trembling, seating, andpalpitations.


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Histo"# of O%stet"i&

G 9 P A (M (

No' Te!

at

%e"sal

in

Tahu

n

(enis

e"salin

an

(enis

)ela!i

n

*e"at +,g- ,ea$a

an

ana)

. Rumah 1;9$ pontan P < %idup

/ Rumah 1;90 pontan = < %idup

0 Rumah 1;9 pontan P < %idup

1 Rumah 1;;( pontan P < %idup

2 Rumah 1;;3 pontan P < %idup

3 Rumah 1;;0 pontan = < %idup

4 7idan $(( pontan P 3.9(( %idup

5 >ang ini


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Histo"# of Disease6Oe"ationhyroid disease ?@

Histo"# of P"esent P"egnan

Menarche age o" 10 years ith a $9#day cycle, theduration o" days. Much reduced ithout e/cessi-epain. he Brst day o" last period 1: 2ebruary $(10.Pregnancy 13 ee5s 0 days.

Histo"# of So&ial7E&ono!i&

he patient or5ed as a housei"e and ha-e 7P8health insurance grade 3.


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General condition' Compos Mentis, ea5

%eart rate ' 10(/*m

Respiration rate ' $/*m

7lood pressure ' 10(*9( mm%g

6ye ' anemic conungti-a ?#*#, icteric sclera?#*#

+ec5 ' mass ?@,palpable thyroid glands, supple,no pain, mobile, bruit ?#

PHYSICAL E8AMINATION 6

9ENERAL STATUS


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%eart ' ictus cordis not -isible and palpablein IC ID midcla-icule sinistra, auscultation1*$ single, regular, mur mur ?#, gallop ?#

=ungs ' auscultation basic breath sounds-esicular, ronchi ?#*#, heeEing ?#*#,percusssion sonor in both lungs, "remitustactile in both lung is same

Abdomen ' abdominal distention ?#, boelsounds ?@, epigastric pain ?#, palpablesuprapubic mass 11 / 10 cm

65strimities ' pitting edema ?#*#, muscle tone


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O*STETRIC STATUS

E)ste"nal e:a!ination 2undal height ' one Bnger under umbilicus

2etal heart rate ' negati-e

Presentation ' # %is ' negati-e

6stimated "etal eight ' #

Inte"nale:a!ination Portio ' thic5 er-ical dilatation ' ( cm !ecend ' #

Amniotic ' #


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%aemoglobin ' 11,9 g*d=

Red blood cells ' 0,0$ M*u=

hite blood cells ' .$((*mm3

Plateles ' $$ 4*u=

%aematocrit ' 30,( )

2asting blood glucose ' 1,:mg*d=

SUPPOTI;E E8AMINATION%aematologic e/amination in 1 o" may $(10

Post#prandial ' 99 mg*d=

Hreum ' 39,1 mg*d=

Creatinine ' (,0 mg*d= A= ' ,( ? 31,( # high

A ' :3, ? 3$,( # high

Albumin ' 0,$ g*d=


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Ra$iolog# e:a!inationin 1 o" May $(10

O%g US9huge uterus ith snow stormappearance i!"ession of !ole h#$atifo"!

Tho"a: PAthere is no abdormalities in cor and pulmo


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Diagnosis

%ydati"orm mole in G9 P A( M( 13ee5s 0 days gestation ithhypertiroidism


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THERAPHYGeneral condition, -ital signs, -aginal bleeding

obser-asionIntra -enous Fuid dehydration Ringer lactate $( dpmCurretageConsultation to internist


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P"ognosis

Ad -itam ' dubia ad bonam Ad "unctionam ' dubia ad malam

Ad sanactionam' dubia ad bonam


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FOLLOW UP


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21 of May 2014

' abdominal pain, abdominal lump since $ months andbigger, appetite ?, nausea J -ommiting ?#, ala%lene&) !ass +


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23 of May 2014 ' nausea ?@

K ' %R ;$ /*m, RR $( /*m, 7P 10(*9( mm%g, Bnetremmor ?@, lab. Result' 7C .((*mm3, R7C 3,:;M*u=, H* ?= g6$L, HCT /5?0 , P= $9 4*u=

A ' %ydati"orm mole in G9 P A( M( 10 ee5sgestation ith hypertiroidism @ Ane!ia e'&' @aginal%lee$ing

P '

ID2! R= $( dpm, curretage,

Bhole %loo$ t"ansfusion 02= &&?

Propanolol $ / 1( mg


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24 of May 2014 ' nausea J -omitting ?@, appetite ?, -aginal

bleeding ?@ decreasing

K ' %R ;$ /*m, RR $( /*m, 7P 1:(*11( mm%g, Bnetremmor ?@, 2undal heigh 1 Bnger under umbilicus

A ' %ydati"orm mole in G9 P A( M( 10 ee5s 1 daygestation ith hypertiroidism @ Anemia e.c. -aginalbleeding

P ' ID2! R= $( dpm,

curretage,



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25 of May 2014

=aboratory result' 7C .3((*mm3, R7C 39( M*u=,H* ?1 g6$L, %C $;, ), P= $1; M*u=


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26 of May 2014

' "eels heat K ' %R 9 /*m, RR $( /*m, 7P 13(*9( mm%g, 2undal heigh

the same as umbilicus. Re&onsultation to inte"nist +


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27 of May 2014

' "eels heat ?#, -aginal bleeding ?# K ' %R 11$ /*m, RR $ /*m, 7P 11(*( mm%g, 2undal heigh

the same as umbilicus.

A ' %ydati"orm mole in G9 P A( M( 10 ee5s 0 daysgestation ith hypertiroidism @ Anemia e.c. -aginal

bleeding @ inus tachycardy

P ' ID2! R= $( dpm,


yrosol 1 / 1( mg Bhole %loo$ t"ansfusion 02= &&,

%R e-aluation ?(#1(( /*m

P"o7Histe"e&to!# until sign s#!to!s ofth#"oto:i&osis is negati@e


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28 of May 2014 ' -aginal bleeding ?@ minimal, palpitation ?@ K ' %R ;$ /*m, RR $( /*m, 7P 13(*9( mm%g, 2undal

heigh 3 Bnger under umbilicus. Curettage asper"omed, PA e/amination on mola Fuid and blood. =ab.Result' 7C 9.0((*mm3, R7C 0,$9 M*u=, H* ..?1 g6$L,%C 31,; ), P= $1$ 4*u=

A ' Post &u"ettagein indication o" hydati"orm moleith hypertiroidism

P ' Propanolol $ / 1( mgyrosol 1 / 1( mg

C#tote: PO / ta%s

%R e-aluation ?(#1(( /*m


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29 of May 2014 =ab. Result ' W*C '3==6!!0, R7C 0,9; M*u=, H*

./?4g6$L, %C 3,$ ), P= $1 4*u=


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30 of May 2014 ' complain ?#

K ' %R ;$ /*m, RR $( /*m, 7P 1$(*( mm%g, 2undal heigh3 Bnger under umbilicus.

A ' Post curettage in indication o" hydati"orm ithhypertiroidism

P ' Propanolol $ / 1( mg

yrosol 1 / 1( mg

A!o:i&illin 0 : 2== !g

Mefena!i& a&i$ 0 : 2== !g

Ci"oo:a&in / : 2== !g

Waiting PA "esult

Rontgent tho"a: PA

Out atient? )lini& &onsultation.


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LITERATURERI;IEW

Chapter III


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INTRODUCTION Gestational trophoblastic neoplasia ?G+ is

comprised o" a spectrum o" conditions, each o"hich is characterised by lo incidence and highcure rates.$,0

&. Se"ire N. #., Secl M. #. %linical re-ie / estational tro!ho"lastic disease0 current management of h$datiform mole. M# &''2( 334. a153,

doi0 1'11367"mj a153. &''2, -ol 334 *)83/82+0 M#

). Phillip a-age. Clinical "atures o" molar pregnancies and gestatioal trophoblastic neoplasia


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HYDATIFORM

MOLE Molar pregnancies and G+ origin "rom the

placental trophoblast.

+ormal trophoblast yncytiotrophoblast in-ades the endometrial stroma

ith implantation o" the blastocyst and is the cell typethat produces human chorionic gonadotropin ?hCG.

Cytotrophoblast "unctions to supply the syncytium ithcells in addition to "orming outpouchings that become

the chorionic -illi co-ering the chorionic sac. Intermediate trophoblast is located in the -illi, the

implantation site, and the chorionic sac.

3 types trophoblast G! hen they proli"erate.

6. #ohn


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%ydatidi"orm moles are abnormal conceptions ith e/cessi-eplacental, and little or no "etal, de-elopment.

rophoblastic proli"eration ?cytotrophoblast J

syncytiotrophoblast and -esicular selling o" placental -illiassociated ith an absent or an abnormal "etus*embryo.

he to maor typesLcomplete and partial ?C%M and P%M.

A&ect omen 1 yo J :( yo, tin or multiple gestation.


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C%M undergo early and uni"orm hydatidenlargement o" -illi in the a%sen&eo" anascertainable fetus o" e!%"#o, the trophoblast isconsistently hyperplastic ith -arying degrees o"atypia, and -illous capillaries are absent.:,

P%M demonstratei$entia%le fetal o"e!%"#oni& tissue, chorionic -illi ith "ocaledema that -ary in siEe and shape, scalloping and

prominent stromal trophoblastic inclusions, and a"unctioning -illous circulation, as ell as "ocaltrophoblastic hyperplasia ith mild atypia only.:,


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CLINICAL

PRESENTATION Most common abnormal -aginal bleeding at #1 ee5s o" gestation.:,3

Palpable uterus larger than the gestational ageaccording to the last normal menstruationperiod.:,3

%yperemesis gra-idarum, anemia,hyperthyroidism, -ery high le-els o" N#%CG and

pre#eclampsia be"ore $( ee5s o" gestation. %istory o" passing hydropic -esicles or grape#li5e pieces o" tissue.:,3


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DIA9NOSIS Hltrasounddiagnostic tool in diagnosing molar

pregnancy O C%M

hos mi/ed echogenic pattern, comprising

hydropic -illi, an absent "etus and no amniotic Fuid,e/hibiting sno storm patternQ ith or ithouttheca lutein cysts

Hltrasound appearance is non#speciBc, andthere"ore molar pregnancies are "requentlymisdiagnosed as incomplete miscarriages

Hltrasound Bnding in cases o" P%M, includes a "etus?sometimes groth restricted, amniotic Fuid and"ocal areas o" anechogenic spaces in the placenta.


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MANA9EMENT !ilatation and suction e-acuation is the standard

treatment o" all patients presenting ith a possiblediagnosis o" molar pregnancy.:

2ull blood count, coagulation proBle, renal "unctionassessment, li-er "unction test, thyroid "unctions,quantitati-e N#%CG le-el, and blood groupcompatibility, chest #ray and C scan in selectedcases.


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HYDATIFORM MOLE WITHHYPERTHYROIDISM

2all in % suggests that it is %CG that causesincreased secretion o" 3 and 0.

%yperthyroidism ?deBned as a suppressed % ith

raised 23 or 20 is more common in trophoblasticdisease than normal pregnancy.

%CG in G! enhanced tyrotrophic acti-ity.


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DISCUSSIONChapter ID


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Mrs. I>, )6 $o

2 ?4

A"dominal lum!since & months

1: 2ebruary$(10A!!etite @@

N7B

Baginal "leeding CC

=um! in the nec

since ) months D

trem"ling, seating,

and !al!itations

tach$cardia

1)'72' mm;g

uterus / &'/ees gestation

;$datiform mole in 2?4 13 ees gestation

E% sinus tach$cardia

sno storm a!!earance

th$roid/function CC

;$!erth$roidism

anemia

M"!"*e+e!$


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rophoblastic hyperthyroidism thyroidstimulation by hCG

he clinical "eatures

fatigue, eight loss,muscle ea5ness, e:&essi@e sBeating,ner-ousness, heat intole"an&e, ta&h#&a"$iaand minimal enla"ge!ent of the th#"oi$glan$.


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Ta%le /' Th#"oi$ Fun&tion Test

$$ o" May

$(10

TSH +=?/4 7 1?4

IU6!L-=?=.1

T0 +=?/ /?00

n!ol6L-1?35

T1 +3= ./=

n!ol6L-/4?43


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yrosol 1 / 1( mg !ilatation and curretage


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CONCLUTION Mrs. I, 0 years old ith diagnose o" hydati"orm mole in G9 P %. 13

ee5s ith hyperthyroidism and anemia. he management hich is gi-enis'

ID2! R= $( dpm

Curretage


yrosol 1 / 1( mg

Amo/icillin 3 / :(( mg

Me"enamic acid 3 / :(( mg

CiproFo/acin $ / :(( mg

aiting PA result

Rontgent thora/ PA

Kut patient, 5linic consultation.


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REFERENCES1. +ousheen AEiE, auda >ous"ani, Ir"anullah oomro, 2irdous MumtaE. Kriginal article O Gestational

trophoblastic disease. 8 Ayub Med Coll Abbottabad $(1$S $0 ?1. !onloaded "romhttp'**.ayubmed.edu.p5*8AMC*$0#1*+ousheen.pd"

$. ebire +. 8., ec5l M. 8. Clinical re-ie # Gestational trophoblastic disease' current management o"hydati"orm mole. 7M8 $((9S 33. a1;3, doi' 1(113*bm a1;3. $((9, -ol 33 ?0:3#:9' 7M8. !onloaded"rom http'**.eottd.com*p#content*uploads*$(1$*(1*=ybol.pd"

3. !a-e +andini, 2ernandes arita, Ambi Hday, Iyer %ermalata. Case Report O hydati"orm mole ithhypertiroidism O perioperati-e challanges. 8 obstet gynecol india -ol. :;, no. 0 S uly*agust $((; pg 3:#3:.!onloaded "rom http'**medind.nic.in*aq*t(;*i0*aqt(;i0p3:.pd"

0. Phillip a-age. Clinical "atures o" molar pregnancies and gestatioal trophoblastic neoplasia. !onloaded"rom http'**.isstd.org*isstd*chapter(9TBles*G!3R!C%(9.pd"

:. !eep 8.P., =.7. edhai, 8. +apit, 8. Pariyar. Re-ie article O Gestational trophoblastic disease. 8ournal o"Chitan Medical Collage $(13S 3?0' 0#11. !onloaded "rom http'**.cmc.edu.np*images*gallery*Re-ie)$(Articles*an5DRe-ie)$(Articles)$($.pd"

. 8ohn R. =urain. Gestational trophoblastic disease I' epidemiology, pathology, clinical presentation anddiagnosis o" gestational trophoblastic disease, and management o" hydati"orm mole. $(1(, american ournalo" obstetric and gynecologis' mosby, Inc. doi'1(.1(1*.aog.$(1(.(.(3. donloaded "romhttp'**ournalsconsultapp.else-ier#eprints.com*uploads*articles*aog1.pd"

. al5ington =., 8 ebster, 7..%ancoc5, 8. 6-erard, R.6. Coleman. %yperthyroidism and human chorionicgonadotrophin production in gestational trophoblastic disease. 7ritish 8ournal o" Cancer ?$(11 1(0, 1:#1;' cancer research H4. !onloaded "romhttp'**.nature.com*bc*ournal*-1(0*n11*pd"*bc$(1113;a.pd"


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Hydatiform Mole With Hyperthyroid