A CASE OF

HYDATIDIFORM
MOLE
Argawanon, Yvonne P.
Bantugan, Dan Blyke
HISTORY
General Data:
J.U., 31 years old, G3P2(2012), Filipino, Roman Catholic,
housewife, married, born on October 15, 1996 at Sogod, Cebu.
Currently residing in Tipolo, Mandaue City, Cebu.
1st time to be admitted in Vicente Sotto Memorial Medical Center
On August 3, 2018, 10am.
HISTORY
Chief Complaint
Hypogastric pain with vaginal spotting
Menstrual History
Menarche – 14 years old
Interval – regular 28 day menstrual cycle
Duration - 4 to 5 days, used 3 pads per day, moderately soaked
Associated symptoms - dysmenorrhea
LMP - May 13, 2018
PMP - April 1st week, 2018
 HISTORY
OB history
G3P2(2012)
Place and
Outcome of
Date of Mode of Person Weight and Complications Fetal/
No. pregnancy,
pregnancy Delivery Assisting the Fetal Sex Maternal if any
Current status
Delivery
Normal Male,
Cebu City
G1 March 24, 2013 Fullterm, alive spontaneous unrecalled None
Medical Center
delivery weight
Normal Health center in Male,
G2 August 31, 2016 Fullterm, alive spontaneous Tipolo, assisted unrecalled None
delivery by midwife weight
Molar
Vicente Sotto
pregnancy, 11
G3 August 4, 2018 Suction curettage Memorial - -
5/7 weeks age
Medical Center
of gestation
HISTORY

Contraceptive History and Sexual History

Coitarche – 26 years old
Partners – 1 sexual partner
Contraception - Condom, every contact until she want to get pregnant
No history of Papsmear and STI
HISTORY
Past Medical History
Non diabetic, non-asthmatic, and non hypertensive
Measles and chicken pox
Had vaginal spotting after 2nd pregnancy (2016)
No history of surgeries and psychiatric illness.
HISTORY
Personal and Social History
Husband is 33y/o, production worker for 5 years, no illnesses
5 years married, not alcoholic, non-smoker, no history of illicit drug use
Highschool graduate
7 hours of uninterrupted sleep
Previously work was production worker for 4 years, stopped for her children
Source of income, husband’s salary and relatives
House is well ventilated, 7 individuals, 1 comfort room
HISTORY
Family History
Father, died at 76y/ due to hypertension
Mother, 67 y/o, housewife, no illnesses
Youngest out of 6
Siblings had no illnesses, with the ff. age and gender, 49, male; 40, female;
39, female; 36 male; and 33 female
Heterofamilial disease include hypertension
No family history of cancer, diabetes, or asthma. No history of twins and
congenital anomalies.
HISTORY
Nutritional History
Eats 3x/day with 2 snacks
Usually vegetables and fish
History of Present Illness
1 month PTA intermittent hypogastric pain, 5/10 pain score, nonradiating,
associated with vaginal spotting, no use of napkin
2 days PTA noted persistent hypogastric pain
Went to velez, advised to have an ultrasound
 HISTORY
History of Present Illness
Ultrasound results
requested on August 1, 2018
Impression: enlarged anteverted uterus with intraendometrial structures,
described as heterogenous structures interspersed with multiple cystic spaces
of varied size. Consider hydatidiform mole. Normal both ovaries with a corpus
luteum in the left. Tubulo-cystic structure, measuring 5.7 x 2.7 x 1.6cm.
Consider hydrosalpinx, right. Pelvic fluid, minimal free fluid in the cul de sac.

Advised for suction curettage

Due to financial constraint, referred to VSMMC
 REVIEW OF SYSTEMS
General: her usual weight is 45 kg, no recent weight change
Skin: (-) rashes, (-) lumps, (-) sores, (-) itching
HEENT Head: (-)dizziness, (-) light headedness
Eyes: clear vision, no glasses/ contact lenses, (-) pain
Ears: (-) earaches, (-) discharges
Nose: (-) colds, (-) nasal stuffiness, (-) discharge, (-) itching
Throat: (-) bleeding, (-) ulcers, (-) sores, (-) hoarseness
Neck: (-) lumps, (-) pain, (-) stiffness
Breast: (-) lumps, (-) pain or discomfort, (-) nipple discharge
Respiratory: (-) cough, (-) sputum, (-) dyspnea
 REVIEW OF SYSTEMS
Cardiovascular: (-) chest pain or discomfort, (-) palpitations
Gastrointestinal: presence of abdominal mass, (-) nausea, (-) vomiting, (-) heartburn, (-) trouble swallowing
Urinary: (-) dysuria
Genital: had vaginal spotting, (-) rashes, (-) itchiness
Peripheral vascular: (-) cramps, (-) intermittent claudications, (-) varicose veins
Musculoskeletal: (-) muscle or joint pains, (-) stiffness, (-) redness
Neurologic: (-) fainting, (-) blackouts, (-) weakness, (-) numbness
Hematologic: (-) bruises, (-) transfusion reactions
Endocrine: (-) heat/cold intolerance, (-) excessive sweating, (-) thirst or hunger
Psychiatric: had a good mood, (-) nervousness, (-) tension
PHYSICAL EXAMINATION

General Survey
Conscious, alert, responsive, cooperative
intravenous line on her right hand
Vital Signs
BP – 120/90 mmHg, left arm
PR – 62 bpm
RR – 19 cpm
Temperature: 36.8 ˚C/axilla
Weight: 45kg.
PHYSICAL EXAMINATION
Skin and nail
Skin is smooth, hair is well distributed, good skin turgor
No jaundice, lesions, masses, lumps, bruises, cyanosis
HEENT
Hair I black and well distributed
Lips, palpebral conjunctive, and gums are pinkish
No lesions, discharges, inflammation
Neck
No lesions, masses, palpitations, thyroid gland not palpable
PHYSICAL EXAMINATION
Chest and lungs
no lesions and retractions, Chest expansion and tactile fremitus are equal,
both lungs are resonant upon percussion, had clear breath sounds,
no wheezes or rales.
Breast
Pendulous, symmetric, no lesions, dimpling, and tenderness
Heart
No lesion, masses. PMI is heard at 5th intercostal space midclavicular line,
distinct S1 & S2 , regular rhythm and a heart rate of 68 bpm.
PHYSICAL EXAMINATION
Back no lesions, deformities
Abdomen flabby, active bowel sounds, no lesions and tenderness
Tympanitic except over the liver and bladder areas, dull
Had nontender hypogastric mass, movable firm with superior pole 2 finger
breadths above the symphysis pubis
Genital Introitus is parous, cervix is closed, uterus is 14 weeks size, adnexa is
negative, and discharge is minimal and whitish.
Extremities symmetric, no edema, deformities, cyanosis and tenderness
Neurologic rientated to time and place, intact long-term memory and short-
term memory and cranial nerves are intact
ADMITTING DIAGNOSIS

Hydatidiform Mole
SALIENT FEATURES
Amenorrhea for 1 month
Hypogastric pain
Vaginal spotting
nontender hypogastric mass, movable firm with superior pole 2 finger
breadths above the symphysis pubis
Uterus is 14 weeks size
AOG: 11 5/7 weeks
SALIENT FEATURES

Ultrasound dated August 1, 2018

enlarged anteverted uterus with intraendometrial structures,
described as heterogenous structures interspersed with multiple cystic
spaces of varied size. Consider hydatidiform mole. Normal both
ovaries with a corpus luteum in the left. Tubulo-cystic structure,
measuring 5.7 x 2.7 x 1.6cm. Consider hydrosalpinx, right. Pelvic
fluid, minimal free fluid in the cul de sac
SALIENT FEATURES
Laboratory examination
PT = Positive
CBC : decrease in haemoglobin, haematocrit, MCV, MCH,
Lymphocyte
increase eosinophils
Quantitative β-hCG: 55,980mlU/mL
(normal range < 1mIU/mL for nonpregnant, <7 mIU/mL
for postmenopausal)
 DIFFERENTIAL DIAGNOSIS
Salient features Threatened Inevitable Ectopic
Hydatidiform mole
abortion abortion pregnancy
Amenorrhea for 1 month
+ + + +

Hypogastric pain Abdominal

tenderness, with
+
+ adnexal +
tenderness

Vaginal spotting Spotting but may

Excessive vaginal
Bleeding in the simulate Spotting in the 1st
bleeding with
1st 20 weeks menstrual trimester
clots
bleeding
Salient features
PE: nontender hypogastric
mass, movable firm with
superior pole 2 finger
breadths above the
symphysis pubis
Ultrasound: enlarged
anteverted uterus with
intraendometrial structures,
interspersed with multiple
cystic spaces of varied size,
left ovaries with a corpus
luteum
Ectopic
Threatened abortion Inevitable abortion Hydatidiform mole
pregnancy
Hypogastric mass is Hypogastric mass is
tender, palpable Nontender
palpable just above palpable just above
adnexal mass hypogastric mass
the symphysis pubis the symphysis pubis
Fetus is seen within
the lower uterine echogenic endometrial
Live fetus with segment, sac visualization of an mass accompanying
an enlarged uterus,
subchorionic surrounded by embryo fetal pole
the so-called
hemorrhage perigestational in the adnexa “snowstorm
hemorrhage, rupture appearance”
membranes
Salient Threatened Inevitable Ectopic Hydatidiform
features abortion abortion pregnancy mole
Pregnancy test
positive + + + +

Anemia + + + +
β-hCG: 1500 to 2500 peaking at
55,980mlU/mL 5000 IU/L 5000 IU/L
mIU/mL 100,000 IU/L
Uterus sized is
bigger than smaller than a
gestational age Uterize size is normal
Correspond to
smaller than 8-week +
amenorrhea
gestational age intrauterine
gestation
SUCTION CURETTAGE DONE (AUG. 4, 2018)
Suctioned 1500 cc of vesicularity. Moderate amount of cerettings,
with biggest vesicularty approximately 1x1 cm admixed with
blood.
FINAL DIAGNOSIS: HYDATIDIFORM MOLE
A benign trophoblastic lesion, which has two types complete
hydatidiform mole and partial hydatidiform mole.
Complete hydatidiform mole completely derived from paternal
origin , having a 46,XX genotype, produced by fertilization of an
empty ovum by a single haploid (23,X) sperm; or 46,XY genotype,
produced by dispermy, in which a 23,X sperm and a 23,Y sperm
fertilize an empty ovum, which then duplicates in the ovum.
FINAL DIAGNOSIS: HYDATIDIFORM MOLE
Partial hydatidiform mole derived from paternal and maternal
chromosomes, resulting in a triploid genotype. A haploid ovum is
fertilized by two haploid spermatozoa, with 69,XXX or 69,XXY
being the most common karyotypes.
In addition, PHM may present in conjunction with a viable fetus,
showing signs of triploidy such as multiple congenital anomalies or
severe growth retardation.
 FINAL DIAGNOSIS: HYDATIDIFORM MOLE
FEATURES COMPLETE PARTIAL
MOLES MOLES
Fetal or embryonic tissue Absent Present
Hydatidiform swelling of chronic villi Diffuse Focal
Trophoblastic hyperplasia Diffuse Focal
Trophoblastic stromal inclusions Absent Present
Genetic parentage Paternal Bipaternal
Karyotype 46,XX; 46,XY 69,XXY; 69,XYY
Persistent human chorionic gonadotropin 20% of cases 0.5% of cases
EPIDEMIOLOGY
oIncidence of HM is higher in Asia than in North America or Europe
oPHM in the United Kingdom is 3/1000 pregnancies, and that of
CHM ranges from 1 to 3/1000 pregnancies (Seckl, 2010)
oEthnic groups such as Native American Indians, Inuits, Hispanics,
and African American have an increased incidence of GTD
oThe geographic risk association reflects the distribution of
different ethnic groups with a higher incidence of HM rather than
environmental or climatic factors.
COMPLETE HYDATIDIFORM MOLE
RISK FACTORS
Previous history of H. mole
Decreasing consumption of animal fat and beta-carotene
Mutation of NLRP7 gene and, more rarely, KHDC3L gene

GROSS APPEARANCE
a large volume of grapelike vesicles made up of edematous enlarged villi
COMPLETE HYDATIDIFORM MOLE
HISTOLOGIC CHARACTERISTICS
1. lack of fetal or embryonic tissues,
2. hydropic (edematous) villi
3. diffuse trophoblastic hyperplasia
4. marked atypia of trophoblasts at the implantation site
5. absence of trophoblastic stromal inclusions.
COMPLETE HYDATIDIFORM MOLE
CLINICAL FEATURES
Delayed menses Gestational hypertension before
1st trimester vaginal bleeding, 20 weeks’ gestation
with or without the passage of presence of theca lutein cysts
molar vesicles
Hyperemesis
large-for-date uterus
hyperthyroidism,
absence of fetal movement  respiratory distress from
anemia secondary to occult trophoblastic emboli to the lungs.
haemorrhage high levels of β-hCG
DIAGNOSTIC WORK UP
1. ULTRASOUND
standard imaging modality for the diagnosis of a mole
echogenic endometrial mass accompanying an enlarged uterus,
the so-called “snowstorm appearance”
Features:
absence of fetal or embryonic tissue
absence of amniotic fluid,
Enlarged placenta with multiple cysts
ovarian theca lutein cysts
DIAGNOSTIC WORK UP
2. HUMAN CHORIONIC GONADOTROPIN
At 10 weeks gestation peaking at 100,000 IU/L and then falling
thereafter
3. Biopsy
Edematous placental villi, hyperplasia of trophoblasts, and lack or
scarcity of fetal blood vessels.
 MANAGEMENT
1. SUCTION DILATATION AND CURETTAGE
 preferred method of uterine evacuation under general anesthetic

2. HYSTERECTOMY
 for whom continued fertility is not an issue, hysterectomy with preservation of the
adnexa is a treatment option.
3. PROPHYLACTIC CHEMOTHERAPY
 single-dose actinomycin D or Methothrexate
4. SERIAL β-HCG SURVEILLANCE
 to ensure a timely diagnosis of postmolar malignant GTN
5. AVOID PREGNANCY FOR 1 YEAR
6. BLOOD TRANSFUSION AND/OR LACTATED RINGER’S SOLUTION
 To treat anemia
PROGNOSIS
Outcome after treatment is excellent
Gestational Trophoblastic Neoplasia can occur after 6 months
 2-3% can develop into choriocarcinoma
 10-15% of cases, hydatidiform mole may develop into invasive moles