Case presentation ob
Download as PPT, PDF•10 likes•17,390 views
This document describes the case of a 17-year-old female patient who presented with profuse vaginal bleeding. Her physical examination revealed an enlarged uterus consistent with 18 weeks gestation and a non-dilated cervix. She was diagnosed with a hydatidiform mole based on her symptoms of metrorrhagia and abdominal mass without pressure signs, as well as ultrasound findings. She underwent dilation and suction curettage for management of the molar pregnancy, and will require follow-up hCG monitoring to check for any persistent gestational trophoblastic disease.
Case presentation ob
- 2. Patient profile J.Y. 17 y/o Single Roman Catholic Sta Lucia Agdao, Davao City G1P0
- 3. Chief Complaint Profuse vaginal bleeding
- 4. OB History No. Year Sex Indication for C/S Place of Delivery Attending B W Complications n/a n/a n/a n/a n/a n/a n/a n/a G1P0 LMP- December 26, 2008 AOG- 18 weeks 3/7 PMP- November 26, 2008 EDC- October 2, 2009
- 5. Menarche: 13 y/o Subsequent Menstrual Period: regular, lasting for 5 days soaking 1-2 pads/day Coitarche: 17 y/o, with 1 sexual partner Papsmear: none Family Planning Method: none Gyne history
- 6. (+) childhood measles & chickenpox (-) DM (-)HPN (-)BA (-)CA Past Medical Hx
- 7. (+) HPN – father (+) Ovarian Cancer – maternal (+) Brochial Asthma – patenal side (-) Heart disease (-) PTB (-) DM Family Hx
- 8. Does not smoke Slight alcoholic beverage drinker No known food & drug allergies Fresh graduate from HS Personal/Social History
- 9. Review of Systems HEENT: No history of head injury, good vision, good hearing occasional mild colds, occasional canker sores and no alarming complaints on the bucal cavity and pharynx Neck: no pain and difficulty in swallowing, no complaints of tender lymph nodes Cardio: no chest pain, no palpitations
- 10. Pulmo: no dyspnea, no cough Gastrointestinal: abdominal pain on the hypogastric region, no vomiting, claimed to have mild diarrheic stools, no hematochezia Urinary: no frequency, no hematuria, no dysuria Review of Systems
- 11. History of Present IllnessHistory of Present Illness 4 months PTA (+) vaginal bleeding soaking 2 pads per day metrorrhagia (+) increase in abdominal girth no associated sings and symtoms 2 months PTA (+) metrorrhagia soaking 2 pads per day (+) palpable abdominal mass between the symphysis pubis and the umbilicus no associated sings and symtoms
- 12. History of Present IllnessHistory of Present Illness 1 day PTA Profuse vaginal bleeding (+) nausea (+) pallor Palpable abdominal mass almost at the level of the umbilicus Admission
- 14. conscious, coherent, not in cardiorespiratory distress BP: 120/80 CR: 70 bpm RR: 20 cpm T: 36.8 o C
- 15. Palms warm and dry. no rashes. Nails without clubbing and cyanosis. Hair of average texture. Scalp without lesions
- 16. Physical Examination Conjunctiva pink, anicteric sclerae. Extraocular movements intact. Acuity good. No gross ear deformities, no ear discharges Nasal mucosa pink, septum midline. No sinus tenderness
- 17. Physical Examination Oral mucosa pink. Moist lips and tongue, no tonsillar enlargement, pharynx without exudate. No palpable masses, No enlargement of thyroid gland. No carotid bruit, Trachea midline.
- 18. Physical Examination symmetrical chest expansion, no intercostals retraction, equal tactile fremitus, lung fields are resonant, vesicular breath sounds w/ no added adventitious sounds
- 19. adynamic precordium, good S1 and S2, no murmurs, regular rhythm and normal heart rate. Symmetric, without masses, Nipples w/out discharges and retraction. Physical Examination
- 20. flat, Normoactive bowel sounds (16/min) tympanitic no hepatomegaly or splenomegaly Palpable abdominal mass at the level of the umbilicus Physical Examination
- 21. No edema No varicosities, no ulcers Physical Examination Radial Femoral Popliteal Dorsalis pedis Posterior tibial Right +2 +2 +2 +2 +2 Left +2 +2 +2 +2 +2
- 22. alert and cooperative, thought coherent, oriented to person, place and time. (+) Nystagmus able to do nose pointing and rapid alternating movements. Intact cranial nerves Intact pinprick, light touch, position, and vibration sensation Physical Examination
- 23. +2 +2 +2 +2 +2 +2 +2 +2 +2 +2 R L Upper extremities: 5/5 5/5 Lower extremities 5/5 5/5
- 24. Speculum Smooth, pinkish cervix with no lesions found Cervix is non-dilated Internal Examination Corpus enlarged to ~20 wks size, fixed No adnexal mass/tenderness Pelvic examination
- 25. Metrorarrgia Nausea pallor Gradually Increasing abdominal mass 4 months PTA- increase in abdominal girth 2 months PTA- palpable abdominal mass between the symphysis pubis and the umbilicus 1 day PTA- palpable abdominal mass almost at the level of the umbilicus No pressure signs and symptoms Salient Features Pelvic Examination Corpus enlarged to ~20 wks size, fixed Non-dilated cervix
- 26. Impression Pregnancy Uteri G1P0 18 3/7 weeks AOG Hydatidiform Mole
- 28. Differential Diagnosis Submucous myoma Ectopic pregnancy Threatened Abortion
- 29. Differential DiagnosisFeatures Patient Submucous myoma Ectopic Pregnancy Threatened Abortion Age/incidence 17 years old >35 years old 2% 15%* Metrorrargia (+) (-) * (+/-) * (+) abdominal mass (+) (+) * (+) * (+) Pressure signs and symptoms (-) (+)* (-) (+/-) Nausea and pallor (+) (+/-) (+) (+/-) Pain (-) (+/-) (+) * (+) Enlarged globular corpus (+) 20 weeks AOG (+) * (+/-) (+) Cervical dilatation (+) (+) (+) (+)*
- 30. Differential Diagnosis Features Patient H-mole Age/incidence 17 years old 1 0f 1500 pregnancies Metrorrargia (+) (+) abdominal mass (+) (+) Pressure signs and symptoms (-) (-) Nausea and pallor (+) (+) * Pain (-) (-) Enlarged globular corpus (+) 20 weeks AOG (+) * Non-dilated cervix (+) (-)
- 31. Management Diagnostic studies: Quantitative B-hCG Transvaginal Ultrasound Dilation and suction curettage IV oxytocin should be administered Follow-up for development of GTT hCG determinations (48 hours, 3 consecutive weeks, every 6 months, and then yearly) PE (Pelvic exam at regular intervals) Birth control (1 year- OCP, Depo Provera)
- 32. Discussion H-mole Molar pregnancy is characterized histologically by abnormalities of the chorionic villi that consist of trophoblastic proliferation and edema of villous stroma 2 forms: Complete & Partial
- 33. Discussion COMPLETE 1. Hydropic degeneration and swelling of the villous stroma 2. Absence of blood vessels in the swollen villi. 3. Proliferation of the trophoblastic epithelium to a varying degree 4. Absence of fetus and amnion.
- 35. Management Dilatation and Suction curettage bHCG monitoring
- 36. Good day