UNIVERSITY OF PERPETUAL HELP – DR. JOSE G.

TAMAYO MEDICAL UNIVERSITY

Along Old National Hi – Way, Sto. Nino, City of Binan, Laguna
COLLEGE OF MEDICINE
DEPARTMENT OF OBSTETRICS and GYNECOLOGY

Case Protocol

Manimtim, Kim Adarem Joy Laroza March 29, 2019

Junior Intern

OBJECTIVES:
1. To be able to present a case of molar pregnancy
2. To discuss the definition, risk factors, classification and diagnostics of molar pregnancy
3. To be able to discuss the treatment and management of molar pregnancy

General Data:
This is a case of E.F., 19-year-old, G1P0, single, Filipino, Catholic, currently residing at Bi ñan, Laguna and was
admitted for the first time in our institution on March 22, 2019.

Chief Complaints: Vaginal bleeding

Past Medical History:

(-) Hospitalization/Surgical Procedure
(-) Blood Transfusion
(-) Hypertension
(-) Diabetes Mellitus
(-) Asthma
(-) Cancer
(-) Others

Family History:
(+) Hypertension - Paternal
(-) Heart Disease
(-) Diabetes Mellitus
(-) Asthma
(-) Cancer
(-) Others:

Personal/Social History:
Patient is currently unemployed, single, living with a 21 year old meat vendor for 1 month. Patient is non-
smoker and occasional alcoholic beverage drinker with no known allergy to food and drugs.

Menstrual History:
Patient had her menarche at 12 years old lasting for 7 days. Subsequent menstrual period followed with
intervals of 28-30 days, 4-5 days duration, consuming 2-3 fully soaked regular pads per day. Patient does experience
dysmenorrhea.

LMP:October 18, 2019 PMP: September 2018 LNMP: October 18, 2018

Sexual History
Patient had her first coitus at the age of 18 years old with a single sexual partner. Patient note post coital
bleeding but denies dyspareunia.

Contraceptive History:
Patient has no history of contraceptive use.

Gynecologic History:
Patient has no history of leukorrhea, vaginal pruritus, and cervicovaginitis. No PAP smear was done.
 UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY
Along Old National Hi – Way, Sto. Nino, City of Binan, Laguna
COLLEGE OF MEDICINE
DEPARTMENT OF OBSTETRICS and GYNECOLOGY
Obstetric History:
G1P0

Gravida Year Gender Term Indication for Place of Birth weight Complications
CS Delivery
G1 PRESENT PREGNANCY

Prenatal History:
At 5 weeks amenorrhea, patient suspected pregnancy and had pregnancy test done which revealed positive.
Patient denies exposure to radiation and intake of teratogenic agents. No consult was done.
At 17 weeks age of gestation, patient had her first prenatal check-up at a health center. Patient was
prescribed multivitamins tab, 1 tab once a day, folic acid tab, 1 tab once a day, and ferrous sulfate tab, 1 tablet once
a day. No laboratory was requested.

History of Present Illness:

23 days prior to admission, patient noted vaginal bleeding consuming 2-3 moderately soaked regular pads,
associated with nausea, vomiting and difficulty of breathing. No medications taken. No consult done.
During the interim, symptoms persisted on and off until 19 days prior to admission, patient had passage of
meaty material accompanied with bloody vaginal discharge. No medication taken. No consult was done.
17 days prior to admission, patient sought consult at a clinic where ultrasound was done which revealed
vesicular echoic pattern and an impression of missed abortion VS hydatidiform mole. No medication taken.
4 days prior to admission, patient consulted at our institution due to vaginal bleeding, consuming 2-3
moderately soaked regular pads. Patient was advised admission but refused due to financial constraints. Patient was
advised to return to Jonelta OPD for further evaluation and management.
Few hours prior to admission, persistence of symptoms prompted consult to our institution and was
subsequently admitted.

Review of System:
CNS: (-) loss of consciousness, (-) seizure, (-) headache
CVS: (-) palpitations, (-) cyanosis, (-) chest pain
Respiratory: (-) difficulty of breathing, (-) cyanosis
GIT: (-) vomiting, (-) diarrhea, (-) constipation
GUT: (-) anuria, (-) dysuria, (-) hematuria
Musculoskeletal: (-) limitation of movements
Hematology: (-) bleeding tendencies

Pertinent Physical Examination:

General: conscious, coherent, not in cardiorespiratory distress
Signs: BP: 110/80 mmHg CR: 80 bpm RR: 18 cpm T: 36.0˚C
Skin: no active dermatoses, warm to touch, good skin turgor,
Head and Neck: anicteric sclera, pink palpebral conjunctivae, no cervicolymphadenopathy, no nasoaural
discharge, no tonsillopharyngeal congestion
Chest and Lungs: symmetrical chest expansion, no retractions, clear breath sounds
CVS: adynamic precordium, normal rate, regular rhythm, no murmur
Abdominal: flabby, normoactive bowel sounds, soft
Pelvic Exam: IE: cervix closed, uterus small, scanty vaginal bleeding
Extremities: grossly normal, no edema, full and equal pulses

Neurologic Exam:
Cerebrum: oriented to three spheres
Cerebrum: no nystagmus

CN I – not tested
CN II – pupils 2-3mm, equally reactive to light
CN III, IV, VI – intact extraocular muscles
CN V – can clench teeth
CN VII – no facial asymmetry
CN VIII – can hear
CN IX, X – can swallow
CN XI – can shrug shoulders
 UNIVERSITY OF PERPETUAL HELP – DR. JOSE G. TAMAYO MEDICAL UNIVERSITY
Along Old National Hi – Way, Sto. Nino, City of Binan, Laguna
COLLEGE OF MEDICINE
DEPARTMENT OF OBSTETRICS and GYNECOLOGY
CN XII – tongue at midline

Admitting Diagnosis: G1P0 TO CONSIDER MOLAR PREGNANCY 21 6/7 WEEKS AGE OF GESTATION BY LAST
NORMAL MENSTRUAL PERIOD

Plan:
Diet: Diet as tolerated
IVF: D5LR 1L to run for 8 hours
Labs: Repeat CBC with PC 6 hours post blood transfusion, Blood typing with Rh typing, HbsAg, Urinalysis,
BUN, Crea, ALT, AST, Chest X ray
Meds: Cefoxitin (Monowel) 1 gm IV as loading dose
For Suction curettage under spinal anesthesia
Encourage voiding freely
Increase oral fluid intake
Daily perineal hygiene
Monitor VS Q4

Course in the Ward:

Upon admission, patient was placed on NPO diet. Venoclysis was started with D5LR 1L to run for 8 hours.
Laboratory exams requested and done were CBC with PC which revealed leukocytosis (11.7), Blood typing with Rh
typing which revealed “A” positive, HbsAg screening which revealed non-reactive, Urinalysis which revealed glucosuria
(1+), BUN which revealed low blood levels (4.56), and Creatinine, ALT, AST, and Chest x-ray which revealed normal
results. Medications given were Cefoxitin (Monowel) 1gm IV as loading dose. Patient then underwent suction
curettage under spinal anesthesia with intraoperative findings of: SE: cervix violaceous, smooth with minimal bleeding
per os, IE: cervix admits tip, uterus enlarged to 18 weeks size, no bilateral adnexal mass; Obtained 300cc of vesicular
tissues admixed with blood, non foul-smelling. Estimated blood loss: 1,300cc. Patient tolerated procedure well and
was transferred to recovery room. Patient was transferred to room when patient was fully awake. Vital signs were
monitored every hour. Patient was to be transfused with 3 units PRBC.

3 hours post curettage, patient had stable vital signs, not yet voiding freely, had soft abdomen, had no
hypogastric pain, cervix closed, uterus small, and had scanty vaginal bleeding. Patient was placed on diet as tolerated
once fully awake. IVF was continued with D5LR 1L + 10u oxytocin to run for 8 hours, followed by D5LR 1L to run for 8
hours. BT line was PNSS 1L to KVO. Medications started were Cefuroxime 500mg/tab, 1 tab 2x a day and Ibuprofen
cap, 1 cap every 8 hours as needed for pain on full stomach. Patient was advised to lie flat on bed until 4am then may
have 1 pillow thereafter. Patient was encouraged to do deep breathing exercises. Daily perineal hygiene was advised.
1st unit of PRBC has already been transfused and 2 nd unit of PRBC was already being transfused for 4-6 hours to be
followed by 3rd unit of PRBC for 4-6 hours. Patient was for repeat CBC with PC 6 hours after blood transfusion of 3 rd
unit of PRBC. Patient was encouraged to void freely. Vital signs were monitored every hour while on blood transfusion
and every 4 hours otherwise.

Post curettage day 1, patient had stable vital signs, voiding freely, had soft abdomen, and no hypogastric
pain. Upon IE: cervix closed, uterus slightly enlarged, and with scanty vaginal bleeding. Patient was placed on diet as
tolerated. IVF mainline was shift to heplock. BT line was removed. Repeat CBC with PC 6 hours after blood transfusion
was done which revealed leukocytosis (15.3) with predominance of neutrophils (0.71). Oral medication was continued.
Daily perineal hygiene was continued. Patient was advised to increase oral fluid intake. Vital signs were monitored
every 4hours.

Post curettage day 2, patient had a BP range of 120-130/80-90mmHg, stable cardiac rate, respiratory rate,
temperature, voiding freely, had soft abdomen, no hypogastric pain and with scanty vaginal bleeding. Patient was
discharged with the following home medications: Cefuroxime 500mg/tab, 1 tab 2x a day and Ibuprofen cap, 1 cap
every 8 hours as needed for pain on full stomach. Patient was advised to have serum BHCG done on March 29, 2019.
Patient was advised to do daily perineal care. Patient was advised to follow-up after 1 week with her Obstetrician with
the results of her serum BHCG and other labs done as in-patient. Patient was sent home stable.

Final Diagnosis: G1P0(0010) TO CONSIDER MOLAR PREGNANCY 21 6/7 WEEKS AGE OF GESTATION BY
LAST NORMAL MENSTRUAL PERIOD, SUCTION CURETTAGE UNDER SPINAL ANESTHESIA, S/P BLOOD
TRANSFUSION 3 UNITS PACKED RED BLOOD CELLS FOR ANEMIA SECONDARY TO ACUTE BLOOD LOSS,
AWAITS HISTOPATH RESULT