Case no

HYDATIDIFORM MOLE
Identity Patient Spouse
Name Mrs. H Mr. A
Age 30 Years Old 32 Years Old
MR. No. 01.02.59.02
Address Sungai Penuh Sungai Penuh
Education Senior High School Senior High School
Occupation Housewife Trader
Admission Date September 18th, 2018
Anamnesis
Chief Complain
A 30 years old female patient was admitted gynaecology
ward of dr. M. Djamil central general hospital on September,
18th 2018 at 11.15 pm referred from Polyclinic Gynecology
diagnosed with Hydatidiform mole
Present Illness History

• Previously, patient felt groin tenderness since 1 week ago and

performed examination in Sungai Penuh General Hospital and
diagnosed with Hydatidiform mole. Patient got oral medication and
after reexamination, the patient was told that the mole has already
disappear, but she still felt groin tenderness and decided to control
back to hospital and then she was referred to Gynecology Polyclinic
dr. M Djamil General Hospital Padang
• Tissue like air bubble which came out from vagina was (-)
• Tissue like meat which came out from vagina was (-)
• Amenorrhea since 4 month ago
• First date of last menstrual period was June, 2018
• Menstruation history: menarche at 13 years old, regular cycle, which
last for 5 to 7 days each cycle with the amount of 2-3 times pad
change/day without menstrual pain
• Nausea (+), vomiting (-)
• No complain of micturition and defecation
Previous illness history
• No previous history of heart, lung, liver, kidney, DM, and hypertension
• Allergic history was denied
Family illness history
• No history of contagious, congenital and psychological illness among her family
 Occupation, Socioeconomics, Psychiatry,
and Habitual History:

Marriage history: once in 2004

History of pregnancy/abortion/delivery: 4/1/2
1. 2005, male, 3300 grams, term pregnancy, spontaneous,
midwives, alive
2. 2007, abortion, curretage
3. 2009, female, 1300 grams, preterm pregnancy, CS,
doctor, alive
4. Present
History of family planning : (-)
History of immunization : (-)
History of education : senior high school
History of habitual : smoking (-), drugs (-), alcohol (-)
Physical Examination:

GA Cons BP HR RR T BH BW BMI
Mdt CMC 120/80 85 21 36,8 150 cm 62kg 20

 Eyes : Conjunctiva was anemic, Sclera wasn’t icteric

 Neck : JVP 5-2 cmH2O, thyroid gland no enlargement

 Chest : Heart and Lung normal

 Extremity : Edema -/-, Physiological Reflex +/+, Pathological

Reflex -/-
Gynecology Record
Abdomen
Inspection : Abdomen little enlarged
Palpation : uterine fundal was palpated at half of umbilical symphysis
pubic
Percussion : Tympanic
Auscultation: bowel sound was normal, FHS (-)

Genitalia
Inspection : vulva and urethra were normal, Vaginal Bleeding (-)
Inspeculo :
vagina : Tumor (-), Laceration (-), Fluxus (-)
Portio : MP, a size of an adult toe, Tumor (-), Laceration (-), Fluxus (-),
OUE opened
VT Bimanual :
• Vagina : tumor(-)
• Portio : MP, tumor(-), OUE Opened 1 cm
• CUT : AF, size as big as an adult fist
• AP : hard to accesed
• CD : not protrude
Ultrasonoghraphy
USG

• Uterus RF, size 7,93 x 4,28 x 4,73 cm

• There’s hyperechoic and hypoechoic mass size 5,89 x 3,86 with
honey comb appearance intrauterine cavity
• Right ovarian size 1,71 x 1,11 cm
• Left ovarian size 1,81 x 0,74 cm
• Impression : Susp. Hydatidiform mole
Laboratory Finding :

Parameter Results Normal Range Unit

Hemoglobin 12,6 12-16 g/dl
Leukosit 9.590 5.9-16.9 103/mm3
Trombosit 378.000 150.00-400.00 103/mm3
Hematokrit 39 31-41 %
PT 11,1 10,5 – 13.7 “
APTT 40,8 34,5 – 44.7 “
Albumin 3,7 3.8 – 5.0 g/dL
Globulin 3,1 2.3 – 2.8 g/dL
SGOT 16 3-30 u/L
SGPT 11 3-33 u/L
Ureum 12 2.0 – 4.2 mg/dl
Creatinin 0.6 0.4 – 0.7 Mg/dl
LDH 337 240-480 u/L
RBG 118 <200 mg/dL
Calcium 8,1 8,1-10,3 mg/dL
Kalium 3,7 3,5-5,1 mmol/L
Sodium 141 139-145 mmol/L
Chlorida 109 97-111 mmol/L
HbsAg Non-reactive Non-reactive Non-reactive
Anti HIV Non-reactive Non-reactive Non-reactive
B-Hcg 410,3 0,00-1,00 mIU/ml
T3 0,93 0,58-1,59 mg/mL
T4 83,85 60-120 Nmol/L
Diagnose

• Hydatidiform mole

Action:

• Control GA, VS
• Consult to Internist
• Consult to Cardiologist
• Report to operating theatre and consult to anesthesiologist
• Informed consent
• Antibiotics Inj. Ceftriaxone 1g IV 30 minute before
procedure (skin test)

Plan

• Curretage
Cardiology Department
• D/ Hydatidiform Mole
• Risk of Cardiovascular complication : 1%

Internist department
D/ Hydatidiform mole
- Currently there’s no sign of hyperthyroid in this patient
- Risk of cardiovascular : mild
- Risk of pulmonary : mild
- Risk of Metabolic : mild
- Thyroid function : stable
09/09/2018 10.15 am : curettage was performed

Tissue like bubble came out about 5 grams

Bleeding while curettage was about 10 cc

Diagnose
Post Curettage oi hydatidiform mole
Plan:
• Control GA, VS, vaginal bleeding
• IVFD RL drip metergin 2 amp 20 dpm
• Cefixime 2x200 mg
• SF 1x180 mg
• Vit C 3x50 mg
• Check Routine Laboratory post curettage
Laboratory Post Operation
Parameter Results Normal Range Unit
Hemoglobin 12,2 12-16 g/dl
Leukosit 9.860 5.9-16.9 103/mm3
Trombosit 342.000 150.00-400.00 103/mm3
Hematokrit 37 31-41 %
Thank You