CASE REPORT

HYDATIDIFORMMOLE

Supervised by:
dr. Mutawakkil JP, Sp.OG

Presented by:
Meryana (2014-061-010)

Department of Obstetrics and Gynecology

Medical Faculty of Atma Jaya Catholic University
RSUD R. Syamsudin, S.H., Sukabumi
2016

INTRODUCTION
Post-term pregnancies is a pregnancy that has reached or surpassed 42 weeks (249
of gestation). Some studies said that about 11% of all pregnancy remain undelivered after
42 weeks. The most common cause of prolonged pregnancy is wrong calculation in the
estimation of gestational age. Pregnant women may be at risk for low amniotic fluid level
bacause of decreasing of amniotic fluid level by half on 42 weeks or more of gestational
age, this state is called oligohydramnios.
Pregnancies presenting with oligohydramnios are of concern as they may be
associated with obstetrical problems and shown to have a high incidence of poor fetal
outcome. Oligohydramnios can cause complications in about 12% of pregnancies that go
beyond 41 weeks. About 8% of pregnant women can have low levels of amniotic fluid, 4%
being diagnosed with oligohydramnios.
Oligohydramnios can occur at any time during pregnancy. The earlier in pregnancy
that oligohydramnios occurs, the poorer the prognosis. Fetal mortality rates as high as 8090% have been reported with oligohydramnios diagnosed in the second trimester. Most of
this mortality is a result of major congenital malformations and pulmonary hypoplasia
secondary to PROM before 22 weeks' gestation.
Considering the complications of this problem, we better acknowledge about this
case in depth. Therefore, authors conduct an analysis and discussion related to
oligohydrmanios cases of Ms Y who is diagnosed as oligohydrmanios in 41-42 weeks of
gestations.

Case Report
I.

II.

Identity
Name
: Mrs. T
Age
: 32 years old
Ethnic
: Sundanese
Religion
: Moslem
Education
: Senior High School
Job
: Employee
Date of Admission : March 24rd 2016 at 1.03 p.m.
Anamnesis
Chief Complain
Vaginal bleeding since one month ago

History Of Present Illness

One month before admission, the patient felt bleeding from the vaginal
(patchy hemorrhage) everyday. Patients admitted there is abdominal pain and
nausea. Patients admitted there is vomiting. patients admitted to vomiting of food
Patients were also admitted to dizziness and weakness. During pregnancy, the
patient never felt fetal movement.

History of Past Illness:

History of hypertension

: Denied

History of diabetes mellitus

: Denied

History of allergy

: Denied

History of epilepsy

: Denied

History of hematologic disease

: Denied

History of urinary tract/kidney disease : Denied

History of trauma
History of surgery

: Denied
: Denied

Family History
Patient denied any similar complain in her family.

Menstrual cycle:
o Menarche

: 14 years old

o Menstrual cycle

: 28 days, regular

Duration

: 7 days

Dysmenorrhea

:-

o First day of last menstrual cycle : January, 2016

Marital History
Married once, has lasted 12 years with current husband.

N
o
1

Contraception History : Patient using contraception kb suntik 2 tahun lalu

Obstetric History
Date

2005
2

2008

Gestationa

Labor

l Age

History
Spontaneou

9 months

s Vaginal
Birth
Spontaneou

9 months

Femal
e
Femal
e

Birth
This Pregnancy

III.

s Vaginal

Sex

Physical examination
Vital Signs
General Condition

: well condition

Birth

Breast

Weight

Feeding

3000 g

3000 g

Therapy

Level of Consciousness : compos mentis

Blood Pressure
: 110/80 mmHg
Heart Rate
: 80 beats per minute
Respiratory Rate
: 20 times per minute
Temperature
: 377 C
Body Weight
: 50 kilograms
Body Height
: 147 cm
BMI
: 23,1 kg/m2
General Examination
Eyes
: Anemic conjungtiva -/-, anicteric sclera, pupil 3mm/3mm, Iight
reflex +/+
Thorax :
Cardiac: Regular first and second heart sound, murmur -, gallop
Pulmo : Vesicular +/+, rhonchi -/-, wheezing -/ Mammae : Areola hyperpigmentation +/+, retraction -/-, breast milk -/ Abdomen :
Inspection: flat
Palpation: supple, tenderness (-)
Percussion : tympanic
Auscultation: bowel sound (+) 6 times per minute
Extremities : Edema : -/- , Physiologic reflex: +/+/+/+, Pathologic reflex: -/-

Gynecologic Examination
Inspeculo

Not performed

Vaginal toucher

Vulva and vagina : normal

Portio : soft, no dilatation

Uterine Corpus : normal

Parametrium and cavum douglasi : normal

Recto vaginal toucher : not performed

IV.

Laboratory Examination

Hematology

April 26th 2016

Hb
Ht

10.7 g/dL
33%
11900/L

Leukocyte
Eritrocyte

4 million/L
82fL
28pg
34g/dL
287.000/L

MCV
MCH
MCHC
Trombocyte

V.

Working Diagnosis
G3P2A0, 36 years old, 14 weeks of gestation with hydatidiform mole

VI.

VII.

VIII.

Planning
Check B-HCg
USG
Post Partum Instruction
IVFD RL + 20 IU oxytocin
Mefenamic Acid 3 x 500 mg PO
Cefadroxil 2 x 500 mg PO
Final Diagnosis
Mother:
P2A1, 32 years old, post partus matures per vaginam with preineum sutures, with
history of oligohydramnios

IX.

Follow Up
April 25th 2016
S
O

Headache
General condition : well
Consciousness : CM

BP : 110/80 mmHg
HR : 80 BPM
RR : 20 x/m
T : 36,5OC
Abdomen
Inspection: flat
Palpation: supple, tenderness (-)
Percussion : tympanic
Auscultation: bowel sound (+) 6 times per minute
A
P

G3P2A0, 36 years old, 14 weeks of gestation with hydatidiform mole

Observe general condition and vital sign
Observe fetal wellness and uterine contraction
Observe birth improvement
Pro termination with misoprostol per fornix tab (25mg)

April 26th 2016.

S

Headache

General condition : well

Consciousness : CM
BP : 110/70 mmHg
HR : 78 BPM
RR : 20 x/m
T : 36OC
Abdomen
Inspection: flat
Palpation: supple, tenderness (-)
Percussion : tympanic
Auscultation: bowel sound (+) 6 times per minute

A
P

G3P2A0, 36 years old, 14 weeks of gestation with hydatidiform mole

Observe general condition and vital sign

Observe fetal wellness and uterine contraction
Observe birth improvement

RL + oxytocin drip 5 IU 20 dpm

March 27th 2016, 9 p.m.
S
O

Dull abdominal discomfort

General condition : well
Consciousness : CM
BP : 120/70 mmHg
HR : 84 BPM
RR : 20 x/m
T : 36,4OC
Abdomen
Inspection: flat
Palpation: supple, tenderness (-)
Percussion : tympanic

Auscultation: bowel sound (+) 6 times per minute

G3P1A1, 32 years old, 40-41 weeks of gestation, in labor, with

olygohydramnios, with single living fetus intrauterine, head presentation

Observe general condition and vital sign
Observe fetal wellness and uterine contraction
Observe birth improvement

March 28th 2016, 6.30 a.m.

S
O

Dull abdominal discomfort

General condition : well
Consciousness : CM
BP : 120/70 mmHg
HR : 92 BPM
RR : 20 x/m
T : 36OC
Uterine contraction (+)
FHR : 146 BPM
VT : v/v normal, 10 cm dilatation portio, head presentation, hodge III, amnion

fluid (-)
G3P1A1, 32 years old, 40-41 weeks of gestation, labor, with
olygohydramnios, with single living fetus intrauterine, head presentation

Observe general condition and vital sign

Observe fetal wellness and uterine contraction
Observe birth improvement

March 28th 2016

6.50 a.m.
Female baby

7 a.m.
Complete placentae

Weight : 3280 g
Height : 50 cm
APGAR 5/7
7.30 a.m.
S
Dull abdominal discomfort and pain on perineum site
O
General condition : well
Consciousness : CM
BP : 120/70 mmHg
HR : 82 BPM
RR : 20 x/m
T : 36OC
Fundal height : 2 fingers below umbilicus
Uterine contraction : good
A

Hb post partus : 11,3 g/dl

P2A1, 32 years old, post partus maturus per vaginam with oxytocin

augmentation, perineum repair, and history of oligohydramnios

IVFD RL + 20 IU oxytocin drip
Cefadroxil 2x1 PO
Mefenamic Acid 3x1 PO
Observe general condition and vital sign
Observe post partum condition

March 29th 2016

S
O

Improvement on dull abdominal discomfort and pain on perineum site

General condition : well
Consciousness : CM
BP : 110/70 mmHg
HR : 80 BPM

RR : 22 x/m
T : 36,3OC
Fundal height : 2 fingers below umbilicus
Uterine contraction : good
A

Lochia : rubra, minimal

P2A1, 32 years old, post partus maturus per vaginam with oxytocin

augmentation, perineum repair, and history of oligohydramnios

Cefadroxil 2x1 PO
Mefenamic Acid 3x1 PO
Observe general condition and vital sign
Observe post partum condition

I.

Prognosis
Quo ad vitam
: bonam
Quo ad functionam : bonam
Quo ad sanationam : bonam

DISCUSSION
Problems :
1. What are the etiologies in this case?
2. What are the clinical manifestations in this case?
3. What are the complications in this case?
4. How to treat this patient?
Etiology
Case
Theory
This patient had some conditions like post ETIOLOGY:Thecauseisnotdefinitely
maturity, because over 40 weeks of gestation known,butitappearstoberelatedtothe
ovulardefectasitsometimesaffectsone
there would be decreasing about 8% of ovumofatwinpregnancy.However,the
followingfactorsandhypotheseshavebeen
amniotic fluid.
forwarded:

Itsprevalenceis
highestinteenagepregnanciesandin
thosewomenover35yearsofage.

Theprevalence
appearstovarywithraceandethnic
origin.

Faultynutrition

causedbyinadequateintakeof
protein,animalfatcouldpartly
explainitsprevalenceintheOriental
Countries.Lowdietaryintakeof
caroteneisassociatedwithincreased
risk.

Disturbedmaternal
immunemechanismssuggestedby
(a)Riseingammaglobulinlevelin
absenceofhepaticdisease(b)
IncreasedassociationwithABblood
groupwhichpossessesnoABO
antibody.

Cytogenetic
abnormalityIngeneral,complete
moleshavea46,XXkaryotype
(85%),themolarchromosomesare
derivedentirelyfromthefather.
Theovumnucleusmaybeeither
absent(emptyovum)orinactivated
whichhasbeenfertilizedbyahaploid
sperm.Itthenduplicatesitsown
chromosomesaftermeiosis.This
phenomenonisknownas
androgenesis.Infrequently,the
chromosomalpatternmaybe46,XY
or45,X.

Thehigherthe
ratioofpaternal:maternal
chromosomes,thegreateristhe
molarchange.Completemolesshow
2:0paternal/maternalratiowhereas
partialmoleshows2:1ratio.

Historyofprior
hydatidiformmoleincreasesthe
chanceofrecurrence(1to4%).

The strongest risk factors are age and a

history of prior hydatidiform mole. Women

at both extremes of reproductive age are
most vulnerable. Specifically, adolescents
and women aged 36 to 40 years have a
twofold risk, but those older than 40 have an
almost tenfold risk (Altman, 2008; Sebire,
2002a). For those with a prior complete
mole, the risk of another mole
is 1.5 percent. With a previous partial mole,
the rate is 2.7 percent (Garrett, 2008). After
two prior molar pregnancies, Berkowitz and
associates (1998) reported that 23 percent of
women had a third mole.

Clinical Manifestations
Case
Theory
In this case, the evidences were uterine size 1 to 2 months of amenorrhea before
was smaller than the gestational age

discovery. In 41 women with a complete

mole diagnosed at a mean of 10 weeks,
Gemer and colleagues (2000) reported
that 41 percent were asymptomatic and
58

percent

had

vaginal

bleeding.

Moreover, only 2 percent had anemia or

hyperemesis,

and

none

had

other

manifestations that in the past were

common in these women.

As gestation advances,

symptoms

generally tend to be more pronounced

with complete compared with partial
moles

(Niemann,

2007a).

Untreated

molar pregnancies will almost always

cause uterine bleeding that varies from
spotting to profuse hemorrhage. Bleeding
may presage spontaneous molar abortion,
but more often, it follows an intermittent
course for weeks to months. In more
advanced

moles

with

considerable

concealed uterine hemorrhage, moderate

iron-deficiency anemia develops.

Many women have uterine growth that is

more rapid than expected. The enlarged
uterus has a soft consistency, but typically
no fetal heart motion is detected. Nausea
and vomiting may become significant.
The ovaries contain multiple theca-lutein
cysts in 25 to 60 percent of women with a
complete mole (Fig. 20-3). These likely
result from overstimulation of lutein
elements by sometimes massive amounts
of hCG. Because theca-lutein cysts
regress following pregnancy evacuation,
expectant management is preferred.

Occasionally a larger cyst may undergo

torsion,

infarction,

and

hemorrhage.

However, oophorectomy is not performed

unless there is extensive infarction that
persists after untwisting.

Complications
Case
Theres no complication as described in this Immediate:
case

Theory

(1)HemorrhageandshockThecauses
ofhemorrhageare:(a)Separationofthe
vesiclesfromitsattachmenttothedecidua.
Thehemorrhagemaybeconcealedor
revealed.(b)Massiveintraperitoneal
hemorrhagewhichmaybethefirstfeatureof
aperforatingmole.(c)Duringevacuationof
themoledueto(i)atonicuterusor(ii)
uterineinjury.
(2)Sepsis:Theincreasedriskofsepsisis
dueto:(a)Astherearenoprotective
membranes,thevaginalorganismscancreep
upintotheuterinecavity.(b)Presenceof
degeneratedvesicles,sloughingdeciduaand
oldbloodfavorsnidationofbacterialgrowth.
(c)Increasedoperativeinterference.
(3)Perforationoftheuterus:Theuterus
maybeinjureddueto:(a)Perforatingmole
whichmayproducemassive
intraperitonealhemorrhage(b)During
vaginalevacuationspeciallybyconventional
(D&E)methodorduringcurettage
followingsuctionevacuation.
(4)Preeclampsiawithconvulsiononrare
occasion.
(5)Acutepulmonaryinsufficiencydueto
pulmonaryembolizationofthetrophoblastic
cellswithorwithoutvillistroma.Symptoms
usuallybeginswithin46hoursfollowing
evacuation.
(6)Coagulationfailureduetopulmonary
embolizationoftrophoblasticcellsasthey
causefibrinandplateletsdepositionwithin
thevasculartree(seep.626).

Late:Thedevelopmentofchoriocarcinoma
followinghydatidiformmoleranges
between2and10%.Theknownrisk
factorsarerecordedintheboxabove
whicharemorelikelytobeassociatedwith
themalignantchange.

Treatment
Case
Theory
This patient was 41 weeks of gestation and Withtheuseofultrasonographyandsensitive
hCGtesting,diagnosisismadeearlyin
was inducted with misoprostol and oxytocin.
majorityofthecases.
Along with evaluation for fetal growth and
Theprinciplesinthemanagementare:
wellness until in labor, along with
Suctionevacuation(SE)oftheuterus
rehydration for the mother.
as
earlyasthediagnosisismade.
Supportivetherapy:Correctionof

anemiaandinfection,ifthereisany.
Counselingforregularfollowup(p.196).

Thepatientsaregroupedintotwo:
GroupA:Themoleisinprocessof

expulsion(Fig.15.17)lesscommon.
GroupB:Theuterusremainsinert

(earlydiagnosiswithultrasonography).

Criteria for labor induction :

Pregnancy > 41 weeks

Bishop score < 6
USG resulting oligohydramnios
NST resulting deceleration variable

References
1. Low amniotic fluid levels: oligohydrmanios. American Pregnancy Association. 2015.
Available from: http://americanpregnancy.org/pregnancy-complications/oligohydramnios/
2. Barbara L. Hoffman M, John O. Schorge M, Joseph I, Schaffer M, Lisa M. Halvorson M,
Karen D, Bradshaw M, F. Gary Cunningham M. Williams Gynecology. Newyork:
McGraw-Hill;2012
3. D.C Dutta. Oligohydrmanios. In: DC Dutta, eds. D.C. Duttas Text book of Gynecology,
6th ed. New Delhi:Jaypee Brothers Medical Publisher;2013
4. Sally Collins, Sabaratnam Arulkumaran, Kevin Hayes, Simon Jackson, Lawrence Impey.
Oxford handbook of obstetrics and gynaecology. 3rd ed. UK: Oxford University Press.
2013.
5. Krisnadi SR, et al. Pedoman diagnosis dan terapi obstetri dan ginekologi. Rumah Sakit
Hasan Sadikin. Bandung: Bagian Obsgyn FKUP; 2005.