Gynaecology Clinical Presentation

2. Dr. Musanna Nabi Chowdhury
Intern Doctor
Gynae-Unit 3

3. A 25 years old lady, para 2, with history of evacuation
of mole 6weeks back presents with irregular per-
vaginal bleeding.

4. Particulars of the patient
Name:
Age:
Husband’s name:
Occupation:
Religion:
Address:
Date of admission:
Date of examination:
Shunara Begum
25yrs
Mofiz Ali
Housewife
Islam
Lamabazar, Sylhet
22.7.19 at 5:30 pm
22.7.19 at 5:45 pm

5. Chief Complaint
Irregular per-vaginal bleeding following suction and
evacuation of uterus 6 weeks back

6. History of present illness
According to statement of the patient, she was
amenorrhoeic for 12 weeks with exaggerated signs and
symptoms of pregnancy. It was not her planned
pregnancy and she was not on any antenatal checkup.
Since then she experienced irregular per-vaginal bleeding
which was bright red in colour,

7. moderate in amount contained a few grape-like vesicles. She
also mentioned about undue enlargement of uterus. With these
complaints she was admitted in SOMCH on 11.6.19. After
history taking and clinical examination she was advised an
ultrasonogam which was compatible with the findings of
hydatidiform mole.

8. Her initial beta-hCG level was also elevated (2575200mIU/ml).
Thus suction evacuation was done. She was discharged with
advice to do repeat USG and beta-hCG after 2 weeks. She was
again admitted to SOMCH after 2 weeks with continued per-
vaginal bleeding having beta-hCG level of 313030mIU/mL and
was treated conservatively but she could not mention the drug
name.

9. The patient had not recovered fully and her irregular per-
vaginal bleeding continued. The bleeding is now scanty in
amount, dark in colour, associated with slight lower
abdominal discomfort and not associated with vomiting. On
query, the patient denied having any breathlessness or
thyrotoxic features such as tremor or palpitation.

10. .
She gave no history of headache or other neurological
disturbance or any epigastric pain or significant weight
loss. Her bladder and bowel habit is normal. With these
complaints she is admitted to Gynae Unit 3 for further
management.

11. Menstrual History
Age at menarche: 13 years
Menstrual cycle: Regular
Menstrual flow: Average
Menstrual period: 4days
Last Menstrual Period: Could not mention

12. Obstetric History
Married for : 7years
Para : 2 (VD)
Age of last child: 2 years

13. Contraceptive History
The couple practised barrier method of contraception

14. History of past illness
The patient gave no significant past medical or surgical
history.

15. Socio-economic history
She is from a middle class family.

16. Family History
None of her family members suffered from such illness.

17. Drug history
She gave no history of prior chemotherapy. She gave no other
significant drug history or drug sensitivity.

18. Personal history
She is a non-smoker. On query she admitted having
inadequate protein intake in her diet.

19. Immunization history
She was immunized against tetanus.

20. General examination
• Appearance:
• Body built:
• Nutritional status:
• Anemia:
• Jaundice:
• Oedema:
• Dehydration:
Ill looking
Below average
Below average
Present
Absent
Absent
Absent

21. • Pulse:
• Blood pressure:
• Respiratory rate:
• Temperature:
• Heart:
• Lungs:
• Breasts:
• Thyroid gland:
• Lymph node:
88bpm
110/70mmHg
16breaths/min
98’F
Normal
Normal
Normal
Not enlarged
Not palpable

22. Abdominal examination
 Inspection
• Size and shape of abdomen: Normal
• Umbilicus: Inverted, centrally placed.
 Palpation
• Superficial: Abdomen soft and non-tender
• Deep palpation: No palpable mass or organomegaly
• Uterus- 16 weeks size
Doughy consistency
 Auscultation
• Bowel sound present

23. Per-vaginal examination
• Inspection
Vulva and perineum is apparently healthy .
• Speculum examination
Slight bleeding is seen coming through external os.
• Bimanual examination
Uterus is 16 weeks size, uniformly enlarged, mobile with
doughy consistency.
Both adnexa are normal.

24. Salient features
Mrs.Shunara Begum, 25year old housewife hailing from
Lamabazar, Sylhet was admitted to this hospital with the
complaints of irregular per-vaginal bleeding following suction
evacuation of uterus 6weeks back. She was amenorrhoeic for
12weeks,and was admitted to SOMCH 6weeks back with the
complaints of irregular per-vaginal bleeding and undue
abdominal enlargement. She was

25. diagnosed as case of molar pregnancy and suction evacuation
was done. After 2 weeks she was again admitted to SOMCH
with the same complaints and treated conservatively. But her
problem persisted and irregular per-vaginal bleeding continued,
which is scanty in amount, dark in colour and associated with
slight abdominal discomfort.

26. She previously had normal menstrual cycle, due to irregular
bleeding she could not mention her last day of menstruation.
On admission she was anaemic, her pulse was-88bpm, blood
pressure-110/70mmhg, nutritional status was below average.
On abdominal examination uterus was 16 weeks size, with
doughy consistency. On per-vaginal examination, slight
bleeding was present.

27. Provisional diagnosis
Incomplete evacuation of mole with anaemia

28. Differential diagnosis
1. Persistent gestational trophoblastic disease
2. Choriocarcinoma
3. Threatened abortion

29. Investigations
• For diagnosis
1. Ultrasonogram of whole abdomen
2. Quantitative estimation of chorionic gonadotropin(beta
hCG)
• For management
1. Full blood count, ABO and Rh typing
2. Beta-hCG
3. Chest X-ray
4. Hepatic and thyroid function tests
5. CT scan and MRI of brain.

30. Ultrasonogram: Uterus
enlarged in size;
myometrium
homogenous. Uterine
cavity contains large
soft tissue mass having
multiple cystic spaces.
No definite fetal part---
-- Suggestive of molar
pregnancy

31. .

32. .
Beta hCG level : 637810mIU/ml

33. Clinical diagnosis
Incomplete evacuation of mole with
anaemia.

34. Treatment
• Treatment on admission: 1. Inj. Ciprofloxacin
2. Inj. Metronidazole
• Definitive treatment: Suction and evacuation
• Correction of anemia: Blood transfusion

35. .
OT Note <24.7.19
11:30 am
Name of operation: Suction and evacuation
Indication of operation: Incomplete evacuation of mole
Findings : Uterus is 16 weeks size
Huge amount of molar tissue came out
Anaesthesia: Spinal

36. .
Product was sent for histopathological examination for
definitive diagnosis

37. .

38. 1.Weekly follow-up till beta-hCG level becomes negative, then
every 1 month interval upto 6 months.
2.Notice any per-vaginal bleeding, breathlessness, chest-pain,
visual disturbance or headache
3.Do not become pregnant during the follow-up period.
4.Contraceptive advice- Combined Oral Contraceptive Pill or
barrier method should be used
Advice on discharge:

39. .