Bleeding 2 Molar Pregnancy

Dear all future doctors, welcome to Taylor's Early Pregnancy Asssessment Unit. Sit back, relax and click [[here|start]] to kickstart the game. <img src="/Bleeding2/TU.jpg"/>

Mrs. Brenda, a 40-year-old G5P4 at 10 weeks Period of gestation is referred from Klinik Kesihatan complaining of mild vaginal bleeding and passage of grape-like vesicles for the past 4 days. This is associated with a dull ache felt in the lower abdomen for the past 1 week. What further history should you elicit from this patient? Choose the BEST answer. [[1. Detailed history regarding bleeding such as amount, fresh/old blood, associated features, any passage of product of conception]] [[2. Detailed history regarding her lower abdominal pain such as site of pain, radiation, nature of pain, aggravating factors, relieving factors, shoulder tip pain]] [[3. Detailed past obstetric history such as year of delivery, gender, birthweight, any complications, mode of delivery, period of gestation at delivery, current status of the child (Alive?/Well?)]] [[4. All of the above]]

Ohh nooo You are asked to choose the BEST answer. You are right that it is necessary to obtain a detailed history regarding her bleeding such as amount, fresh/old blood, associated features, any passage of product of conception. But, you also need to obtain: <li>A detailed history regarding her lower abdominal pain such as site of pain, radiation, nature of pain, aggravating factors, relieving factors, shoulder tip pain.</li> <li>A detailed past obstetric history such as year of delivery, gender, birthweight, any complications, mode of delivery, period of gestation at delivery, current status of the child (Alive?/Well?)</li> Go back and try again. (track: 'oh no', 'play') (track: 'oh no', 'volume', 0.2)

Ohh nooo You were asked to choose the BEST answer. You are right that it is necessary to obtain a detailed history regarding her lower abdominal pain such as site of pain, radiation, nature of pain, aggravating factors, relieving factors, shoulder tip pain. But, you also need to obtain: <li>A detailed history regarding the bleeding such as amount, fresh/old blood, associated features, any passage of products of conception.</li> <li>A detailed past obstetric history such as year of delivery, gender, birthweight, any complications, mode of delivery, period of gestation at delivery, current status of the child (Alive?/Well?)</li> Go back and try again. (track: 'oh no', 'play') (track: 'oh no', 'volume', 0.2)

Ohh nooo You were asked to choose the BEST answer. You are right that it is necessary to obtain a detailed past obstetric history such as year of delivery, gender, birthweight, any complications, mode of delivery, period of gestation at delivery, current status of the child (Alive?/Well?). But, you also need to obtain: <li>A detailed history regarding the bleeding such as amount, fresh/old blood, associated features, any passage of products of conception.</li> <li>A detailed history regarding her lower abdominal pain such as site of pain, radiation, nature of pain, aggravating factors, relieving factors, shoulder tip pain.</li> Go back and try again. (track: 'oh no', 'play') (track: 'oh no', 'volume', 0.2)

Yayyyyy.... That is right. You need to obtain the following: <li>Detailed past obstetric history such as year of delivery, gender, birthweight, any complications, mode of delivery, period of gestation at delivery, current status of the child (Alive?/Well?)</li> <li>Detailed history regarding bleeding such as amount, fresh/old blood, associated features, any passage of product of conception.</li> <li>Detailed history regarding lower abdominal pain such as site of pain, radiation, nature of pain, aggravating factors, relieving factors, shoulder tip pain.</li> <li>Exaggerated pregnancy symptoms:   &nbsp • hyperemesis (10%)   &nbsp • hyperthyroidism (5%)   &nbsp • early pre-eclampsia (5%)</li> <li>Risk factors for hyatidiform mole:   &nbsp • Age: extremes of reproductive life (>40 yrs and <15 yrs of age) in complete moles, not partial moles.   &nbsp • Ethnicity: x2 higher in east Asia, particularly Korea and Japan.   &nbsp • Previous molar pregnancy: x10 higher risk of developing future molar pregnancy.</li> Now you can proceed to the next stage. Click [[here|exam]] (track: 'cheer', 'play') (track: 'cheer', 'volume', 0.2)

No, no. Passage of grape-like vesicles is not a typical presentation of ectopic pregnancy, but you need to exclude it too, from further history-taking. Never mind, try again (track: 'witch', 'play') (track: 'witch', 'volume', 0.5)

Yes, passage of grape-like vesicles is typical for molar pregnancy. <img src="/Bleeding2/grapes.jpg"/> <img src="/Bleeding2/molar.jpg"/> Image source: Victoria L. Parker, John A. Tidy. Current management of gestational trophoblastic disease. Obstetrics, Gynaecology & Reproductive Medicine, Volume 31, Issue 1, 2021, Pages 21-29, ISSN 1751-7214. https://doi.org/10.1016/j.ogrm.2020.11.006. Click [[here|story]] (track: 'happykids', 'play') (track: 'happykids', 'volume', 0.5)

No, no. Passage of grape-like vesicles is not a typical presentation of miscarriage but you need to exclude it too, from further history-taking. Never mind, try again (track: 'witch', 'play') (track: 'witch', 'volume', 0.5)

Mrs. Brenda, a 40-year-old G5P4 at 10 weeks Period of gestation is referred from Klinik Kesihatan complaining of mild vaginal bleeding and passage of grape-like vesicles for the past 4 days. This is associated with a dull ache felt in the lower abdomen for the past 1 week. On further questioning, Mrs Brenda denies any shoulder tip pain, but she complains of excessive nausea and vomiting. Below are physical examination and expected findings. Choose the correct pair. [[1. General examination: Polycythemia, hypotension, tachycardia]] [[2. Abdominal examination: Soft, Uterus 16 weeks size palpable]] [[3. Pelvic exmination: Os open, passage of grape-like vesicles, cervical excitation positive]]

No, dear. General examination needs to done, but you would expect to see pallor, NOT polycythemia. Since she is bleeding, you may notice tachycardia with or without hypotension. Try again. (track: 'no dear', 'play') (track: 'no dear', 'volume', 0.2)

Hooray.... That's correct! In a molar pregnancy, you can expect to find that the uterus is larger than date. In addition to the abdominal examination, you need to perform a general examination to look for pallor and her vital signs. A pelvic examination should follow to check whether the cervical os is open or closed, any active bleeding, passage of any grape-like vesicle, any product of conceptions suggestive of miscarriage, and the presence of cervical excitation (which is positive in ectopic pregnancy) Now let's move on to the next [[challenge|Other causes]]. (track: 'yess', 'play') (track: 'yess', 'volume', 0.2)

No, dear. Pelvic examination needs to done and you would expect to find an open cervical Os and passage of grape-like vesicles. However, cervical excitation will be negative as it is a molar pregnancy. Cervical excitation is positive only in ectopic pregnancy or tubo-ovarian abscess. Try again. (track: 'no dear', 'play') (track: 'no dear', 'volume', 0.2)

Sorry. Wrong date is NOT the correct choice. Wrong date IS one of the reasons for uterus larger than date. Read the question carefully again: Other causes of uterus larger-than-date-includes the following EXCEPT ;-) It's OK, try again. You will get it right this time. (track: 'smirk', 'play') (track: 'smirk', 'volume', 0.2)

Sorry. Multiple pregnancy is NOT the correct choice. Multiple pregnancy IS one of the reasons for uterus larger than date. Read the question carefully again: Other causes of uterus-larger-than-date includes the following EXCEPT ;-) It's OK, try again. You will get it right this time. (track: 'smirk', 'play') (track: 'smirk', 'volume', 0.2)

That is right!! Oligohydramnios causes the uterus to be smaller-than-date. Only polyhydramnios causes the uterus to be larger-than-date. Thr other causes of uterus larger-than-date are: 1. Wrong dates. 2. Constitutionally large fetus. 3. Multiple pregnancy. 4. Fetal macrosomia. 5. Polyhydramnios. 6. Uterine fibroids in pregnancy. 7. Ovarian cysts in pregnancy 8. Molar pregnancy. Click [[here|inv]]. (track: 'clapping', 'play') (track: 'clapping', 'volume', 0.2)

Sorry. Uterine fibroid in pregnancy is NOT the correct choice. Uterine fibroid in pregnancy IS one of the reasons for uterus larger than date. Read the question carefully again: Other causes of uterus larger-than-date includes the following EXCEPT ;-) It's OK, try again. You will get it right this time. (track: 'smirk', 'play') (track: 'smirk', 'volume', 0.2)

An exciting journey is awaits you.....Click on the picture to proceed. [[<img src="/Bleeding2/ship.jpg" >->invx]]

Which of the following investigations would you like to request for Mrs Brenda at this stage? [[1. Serum CA125]] [[2. Serum progesterone]] [[3. Serum beta hCG]] [[4. Serum CEA]]

Uhhh oh Serum CA125 is a tumour marker which increases in certain types of ovarian tumors, NOT in molar pregnancy. Never mind, try again. (track: 'uh oh', 'play') (track: 'uh oh', 'volume', 0.7)

Uhhh oh Serum progesterone is a critical hormone in early pregnancy. A low level of serum progesterone is associated with threatened miscarriage, but NOT in molar pregnancy. Never mind, try again. (track: 'uh oh', 'play') (track: 'uh oh', 'volume', 0.7)

Uhhh oh Serum CEA is a tumour marker which increases in certain gastrointestinal tumors, but not in molar pregnancy. Never mind, try again. (track: 'uh oh', 'play') (track: 'uh oh', 'volume', 0.7)

Correct! You are good. Abnormally high levels of serum beta hCG is suggestive of molar pregnancy. <img src="/Bleeding2/bhcg.jpg"/> Mrs Brenda's serum beta hCG is measured. A pelvic ultrasound is performed. What do you expect to see on her pelvic ultrasound? [[1. Whorl-like appearance]] [[2. Grape-like appearace]] [[3. Funnelling]] [[4. Snow-storm appearance]] (track: 'music box', 'play') (track: 'music box', 'volume', 0.2)

No, dear. Whorl-like appearance is the pathognomonic ultrasound feature of uterine fibroid, not molar pregnancy. Try again. <img src="/Bleeding2/USwhorl.png"/> Image source: Gavrilova-Jordan, L., Rose, C., Traynor, K. et al. Successful term pregnancy following MR-guided focused ultrasound treatment of uterine leiomyoma. J Perinatol 27, 59–61 (2007). https://doi.org/10.1038/sj.jp.7211624 (track: 'no', 'play') (track: 'no', 'volume', 0.2)

Ohh noooooo... Grape-like appearance refers to the gross appearance of molar pregnancy. You are asked for the ultrasonograhphic appearance. That's OK. Try again <img src="/Bleeding2/vesicles.jpg"/> Image source: http://panduankehamilanibu.blogspot.com/2015/12/kenali-ciri-ciri-hamil-anggur-dan.html (track: 'no', 'play') (track: 'no', 'volume', 0.2)

No, dear. Cervical funnelling is a sign of cervical incompetence and represents the dilatation of the internal part of the cervical canal and shortening of the cervical length. It is NOT associated with molar pregnancy. Try again. <img src="/Bleeding2/USfunnel.png"/> Image source: https://es.slideshare.net/slideshow/incompetencia-itsmico-cervical-81626511/81626511 (track: 'no', 'play') (track: 'no', 'volume', 0.2)

Yes! Snow-storm appearance is the pathognomonic ultrasound feature of molar pregnancy. Molar changes can now be detected from the second month of pregnancy by ultrasound, which typically reveals a uterine cavity filled with multiple sonolucent areas of varying size and shape ('snow-storm appearance') without associated embryonic or fetal structures. Well done! Have a look at the following snow-storm appearance and click on the picture to move forwards. [[<img src="/Bleeding2/USsnowstorm.jpg" >-> otherinvx]] Image source: https://alamhamilblog.com/2014/05/18/kandungan-molar-atau-anggur/ (track: 'one cheer', 'play') (track: 'one cheer', 'volume', 0.2)

In addition to serum beta hCG and pelvic ultrasound, you need to do the following tests: 1. Full blood count to check haemoglobin level 2. Blood grouping and cross match in case Mrs Brenda requires a blood transfusion 3. Chest X-ray to exclude lung metastasis from a Molar pregnancy 4. Thyroid fuction test to exclude thyrotoxicosis&#42 &#42hCG is structurally similiar to thyroid stimulating hormone (TSH) molecules. Therefore, when there is a significant rise in hCG levels with gestational trophoblastic disease, hyperthyroidism may be induced. Fortunately, thyroid function tests return to normal after treatment of the molar pregnancy and normalization of hCG levels. Alright. You have come a long way in managing Mrs Brenda. Let's keep [[going|treatment]].

You are almost there, hang on.....Click on the picture to escape the snow storm. [[<img src="/Bleeding2/snow.jpg" >->s&c]]

Mrs Brenda is properly assessed and relevant investigations are done. She has marked pallor, her SpO2 is 97% on air, BP is 100/68 mmHg, pulse rate is 100/min. Her abdomen is soft, non-tender, and the uterus is 16 weeks in size. Her pelvic examination reveals the passage of grapes-like vesicles. Her ultrasound shows snow-storm appearance. Other investigation findings: •Haemoglobin 7.2g% •Blood group O positive •Thyroid function test normal •CXR normal •Serum beta hCG 180000 IU/L Mrs Brenda is resuscitated. Her airway and breathing are assessed and she is given some Oxygen. Two large bore IV lines are inserted and fluid resuscitation by crystalloids is commenced, followed by a blood transfusion. After resuscitation, how would you manage Mrs Brenda? [[1. Methotrexate]] [[2. Suction and curettage]] [[3. Salpingectomy]]

Hooray! Suction curettage is the method of choice of evacuation for complete molar pregnancies. Suction curettage is the method of choice of evacuation for partial molar pregnancies except when the size of the fetal parts deters the use of suction curettage and then medical evacuation can be used. <img src="/Bleeding2/abortion.jpg" /> Image source: https://office.prolifeproducts.org/suction-and-curettage-abortion-diagram Click [[here|POC]] to face more challenges (track: 'Bingo', 'play') (track: 'Bingo', 'volume', 0.2)

No, dear. That is not the correct choice as a first-line treatment for gestational trophoblastic disease. Try again. <img src="/Bleeding2/boxer.jpg"/> (track: 'Punch 2', 'play') (track: 'Punch 2', 'volume', 0.2)

No, dear. Salpingectomy is the recommended treatment for tubal ecopic pregancy, NOT for molar pregnancy. That's ok, try again. <img src="/Bleeding2/angry.jpg" /> (track: 'Punch 2', 'play') (track: 'Punch 2', 'volume', 0.2)

Hyatidiform mole can be subdivided into complete and partial mole based on genetic and histological features. <img src="/Bleeding2/molardiag.jpg" /> Image source: Savage, P. (2008), Molar pregnancy. The Obstetrician & Gynaecologist, 10: 3-8. https://doi.org/10.1576/toag.10.1.003.27370 Complete mole • Consists of diffuse hydropic villi with trophoblastic hyperplasia. • This is diploid, derived from sperm duplicating its own chromosome following fertilization of an ‘empty’ ovum. This is mostly 46XX with no evidence of fetal tissue. Partial mole • Consists of hydropic and normal villi. • This is triploid (69XXX, XXY, XYY) with one maternal and two paternal haploid sets. Most cases occur following two sperms fertilizing an ovum, and a fetus may be present. Well done! Following suction and currettage on Mrs Brenda, you have sent the products of conception for histopathological examination. Click [[here|counselling]] to go to the post-operative management.

You are humane and thoughtful. But that is not the right choice. The products of conception need to be sent to the laboratory for histopathological examination to determine the type of molar pregnancy. It's OK, try again. <img src="/Bleeding2/angel.jpg" /> (track: 'sad', 'play') (track: 'sad', 'volume', 0.2)

You are smart. Tell your lecturer about it ;-) The products of conception need to be sent to the laboratory for histopathological examination to determine the type of molar pregnancy. Click [[here|types]] to learn more about the types of Molar pregnancy. (track: 'lightapplause', 'play') (track: 'lightapplause', 'volume', 0.2)

Madam Brenda recovered well after suction and currettage. Before she is discharged, what important steps should you take? [[1. Start oral contraception to prevent future pregnancies]] [[2. Counsel that follow-up duration should be 3 months from now]] [[3. Check haemoglobin level and repeat the beta hCG level]]

Wrong answer. If Oral contraception is started before serum beta hCG levels return to normal, there is a potential (albeit low) risk of developing Gestational Trophoblastic NEOPLASIA. That's fine. You can try again. <img src="/Bleeding2/sad.jpg" /> (track: 'Game over', 'play') (track: 'Game over', 'volume', 0.2)

Wrong answer. Follow-up duration should be at least 6 months from now. If hCG has reverted to normal within 56 days of the pregnancy event, then the duration of follow-up should be 6 months from the date of uterine evacuation. If hCG has not reverted to normal within 56 days of the pregnancy event, then the duration of follow-up should be for 6 months from normalisation of the hCG level. It is ok, now you know ;-) Try again. <img src="/Bleeding2/sad.jpg" /> (track: 'Game over', 'play') (track: 'Game over', 'volume', 0.2)

That is right. Before Mrs Brenda is discharged, you need to check her post-op haemoglobin level and her serum beta hCG level again to see how much it has fallen from her baseline pre-operative level. She should then be followed-up with forthnightly beta hCG until it normalises (< 4 IU/L) If hCG has reverted to normal within 56 days of the pregnancy event, then the duration of follow-up should be 6 months from the date of uterine evacuation. If hCG has not reverted to normal within 56 days of the pregnancy event, then the duration of follow-up should be for 6 months from normalisation of the hCG level. <img src="/Bleeding2/graph.png"/> Image source: Katke, Rajshree. (2016). Gestational Trophoblastic Disease And Its Complications:Review Of Patient Profiles And Management At A Tertiary Care Centre. The Southeast Asian Journal of Case Report and Review. 5. 2276-2281. Click [[here|contraception]] to read more about counselling her for family planning. (track: 'short success', 'play') (track: 'short success', 'volume', 0.2)

Contraception advice: <li>Women with Gestational trophoblastic disease (GTD) should be advised to use barrier methods of contraception until hCG levels revert to normal. Once hCG level have normalised, the combined oral contraceptive pill may be used.</li> <li>If oral contraception has been started before the diagnosis of GTD was made, the woman can be advised to remain on oral contraception but she should be advised that there is a potential but low increased risk of developing Gestational trophoblastic Neoplasm.</li> <li>Intrauterine contraceptive devices should NOT be used until hCG levels are normal to reduce the risk of uterine perforation.</li> <img src="/Bleeding2/condom.jpg"/> Click [[here|final]] to finish. (track: 'Baby Giggle 1', 'play') (track: 'Baby Giggle 1', 'volume', 0.2)

<h3>Congratulations!</h3> You have successfully managed Mrs Brenda's molar pregnancy. Her serum beta hCG level returns to normal after 4 months and you followed her up for a total of 6 months. The good news is, since they already have 4 children and Mrs Brenda has gone through a lot lately, her husband Mr Oscar decides to undergo a vasectomy. So, hey! Boys..... can you do the same for your future wife if needed? Girls...... ask your boyfriend if they would have a vasectomy for you if neccessary. That's your homework. PS: Whatever the answer is, rule no. 1 is DO NOT FIGHT :D <img src="/Bleeding2/vasec.jpg"/> Reading list: 1. <a href="/Bleeding2/Gestational trophoblastic diseases RCOG.pdf" target="_blank">Gestational trophoblastic diseases (RCOG)</a> 2. <a href="/Bleeding2/Molar pregnancy Gynaecology by 10 Teachers 18th Ed.pdf" target="_blank">Molar pregancy, Gynaecology by Ten Teachers, 18th edition</a> 3. <a href="/Bleeding2/Molar pregancy Oxford Handbook of Obstretics & Gyneacology 3rd Ed [PDF].pdf" target="_blank">Molar Pregnancy, Handbook of Obstetrics & Gynaecology, 3rd edition</a> (link: "Restart Game")[(reload:)] Artwork for this website were generated by the author using AI tools (Ideogram 2.0 and DALL-E) (track: 'football', 'play') (track: 'football', 'volume', 0.2)

You have performed a suction and currettage procedure on Mrs Brenda under ultrasound guidance. What are you going to do with products of conception? [[1. To give the products of conception to Mrs Brenda to bury/discard according to her tradition]] [[2. To send for histological examination]]

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Other causes of uterus larger than date includes the following EXCEPT for: [[1. Wrong date]] [[2. Multiple pregnancy]] [[3. Oligohydramnios]] [[4. Uterine fibroid in pregnancy]]