RH Case 9 "Sometimes you should make a mountain out of a molehill"

DAY 1
1. Implantation occurs on day 6 as a blastocyst, syncytiotrophoblast invades int
o endometrium via chorionic villi, decidua basalis makes the maternal
component of the placenta, capsularis covers the conceptus, parietalis l
ines the uterus. [Google anatomy of placenta]
2. hCG is Human Chorionic Gonadotropin (peptide hormone), it has the same alpha
subunit as LH, FSH, and TSH. hCG tells corpus luteum to produce progesterone
to maintain pregnancy until the end of the first trimester. hCG is also
given as a gonadotropin to patients deficient in LH.
3+4. Rh sensitization: mother is Rh negative, if baby is Rh positive, mother wil
l become sensitized and make anti-Rh antibodies. This is dangerous to the mother
's
next pregnancy (she'll attack the next baby). Blood type compatibility i
s essential, if not-->Type II Hypersensitivity.
5. Indirect Coomb's test: test mom's blood to see if she has anti-Rh antibodies
already (to see if sensitization has already happenned)
6. The drug Rhogam is given the mom to stop her from making antibodies against t
he baby (preventative measure).
7. Naegele's Rule is a standard way of calculating the due date for a pregnancy.
The rule estimates the expected date of delivery (EDD) by adding one year,
subtracting three months, and adding seven days to the first day of a w
oman's last menstrual period (LMP). The result is approximately 280 days (40 wee
ks)
from the LMP.
8. a- Spontaneous/Complete abortion: products of conception are expelled natural
ly
b- Incomplete abortion: some fetal tissue is expelled and some is retained
c- Threatened abortion: loss of blood, but fetal heart rate is detected
d- Missed abortion: dead fetus remains in uterus, not discovered until ultras
ound (asymptomatic)
e- Septic abortion: tissue from left over abortion causes infection in mother
f- Synthetic prostaglandins, mifepristol, ru486, mifepristone
9. Aneuploidy is the largest cause of 1st trimester abortions, prior tubal damag
e/surgery, teratogens, maternal age, infections, trauma
10. Risk factors for Gestational Trophoblastic Neoplasia: Age (women less than 2
0 and greater than 40, if >50 then 1/3 result in molar pregnancy) ,
prior molar pregnancy (1-2% increase in risk), prior miscarriage, blood type (A
and AB are at higher risk), birth control pills, diet, family history.
11. Complete mole- chorionic villi are enlarged (edematous epithelium), like gra
pes, no fetus; with proliferation of chorionic epithelium.
Partial mole- some fetal parts are present, less trophoblastic proliferation
.
12. Increase in uterine size in the complete mole, and really high levels of bet
a hCG. Vaginal bleeding in both complete and partial. Nausea and vomiting, signs
of
hyperthyroidism, vaginal discharge of tissue that is like grapes. Absenc
e of fetal heart tones in partial mole.

DAY 2
1. Invasive mole is rarely metastatic, lesions characterized by trophoblastic in
vasion of myometrium. 2.5% of invasive moles go on to become choriocarcinoma.
Choriocarcinoma is a malignant tumor of the trophoblastic epithelium, he
matogenous spread occurs easily.
Placental site trophoblastic tumor (PSTT) is a rarer gestational trophob
last neoplasia, derived from more differentiated trophoblasic cells, they
infiltrate the myometrium.
2. Since she had an invasive mole, she should be monitored for a year, and have
her Beta-hCG levels checked regularly to make sure there are no remnants of the
mole.
Needs 3 steady weeks of undetectable levels, and then once a month check
s for a year.
3. To make sure the remnants of the mole do not grow back.
4. At least a year needs to pass before she reattempts conceiving pregnancy. We
would recommend birth control and safe sex.
5. Lungs (50%), vagina (30%-40%), and then brain, liver, and kidney. [Sites of m
etastasis]
6. Age, family history