TEALE FENNING

Abik

You have this result in clinic and are about to see Miss MT, aho is 19 yrs old and had an ERPC for suspected molar pregnancy last week by your SpR colleague. Histology confirms complete mole.
Discuss your management of her.

(Marks will be awarded for being faster than the last question!!!!!) Wink

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

Can I call you for the answer? I'm really slow typing and it is these spelling mistakes I make that you might need an ophthalmologist by the end of this exam...

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

Wolverine; Hey, that's not fair-- what about all of us-- we shall miss the benefits if you just call Abik!!!

Maybe, just the main points to be typed please

Abik · Posted: Sun May 06, 2007 1:29 pm Post subject:

Why dont you try cpeedahsa?

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

=Registration of any molar pregnancy should be done.

= Routine repeat evacuation after the diagnosis of a molar pregnancy is not manditary.

=should undergo serial follow up by pregnancy test to exclude persistent GTN

= Patient should be adviced to avoid conception for 1 year, COC can be used when HCG return back to normal. IUCD is not contraindicated.

= In cases where there are persisting symptoms, such as vaginal bleeding, after initial evacuation, consultation with the screening centre should be sought before any further surgical intervention.

=acute respiratory or neurological symptoms can reflect persistant GTD

= Criteria for the use of chemotherapy:
*elevating level of HCG
* any level after 4-6 months
*appearance of secondaries......forget the rest..may be persistant V. bleeding..?!

Abik · Posted: Mon May 07, 2007 9:50 am Post subject:

Good points and all the information you need, BUT.....

Management = history, examination, investigations, treatment!!!!!!!

This is an OSCE. I know it's difficult on the computer to imagine a structured viva or role play and I know some people (not mentioning any names!) have difficulty with their typing but I don't think you learn anything by writing down a few bullet points. (maybe my own style of learning?)

So....

history
how is she? any ongoing bleeding? what has she been told so far?
LMP how many weeks. history of presentation
past obs hx
contraceptive history
risk of STI's?
cycle details
other symptoms? - SOB, haemoptysis, neurology?
PMH/PSH/DH allergies?

examination
If still bleeding. endometritis? RPOC?

Investigations
any HCGs done? USS if RPOC
Hb if bleeding

Treatment
counselling - we looked at the pregnancy tissue under the microscope which we do routinely and found that there was abnormal tissue which we sometimes see. It appears that all this tissue has been removed and now we just need to monitor the level of pregnancy hormone in your blood to make sure it returns to normal. The tissue was unfortunealty never going to be a normal pregnancy - I'm sorry. There is a special centre in London that monitors the blood levels for us and I will contact them and they will arrange for your blood tests down here. The vast majority of people have a few tests over the next couple of months and everything goes back to normal. It is very rare but occasionally you may need some further treatment to ensure all the tissue is gone.
Until the level is back to normal it is very important that you do not get pregnant and also do not use hormones for contraception. I will give you some information on effective use of barrier mathods and also the IUCD so that you can decide with your partner which will be best for you.
any questions?

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

Thanks Abi
I know you are an active girl
My bullet is for easy memorising of notes.
I need clarification: in such cases which the Histopathological exam confirm the diagnosis, do we have to return back to start from the history, POHx, GA,....can you justify the points you mention please ??
I like your patient conselling.
Thanks.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

emak,

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

Good job guys, thank you for saving me from writting... Cool

Is IUCD a good idea after evacuation for molar? I can't remember and I don't want to get trapped with it, like I got with Stacey and start mumbling staff like IUS is not contraindicated bla bla...

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

cpeedahsa · Century Club Joined: 21 Apr 2007 Posts: 921

I would just add when counselling--

I am sorry you are going through this situation.

We need to discuss this . Would you like to tell me what you know about molar pregancy; and we can take it from there?

This is a condition known as molar pregnancy and is rare . Molar pregnancy is an abnormal pregnancy, so all women who become pregnant are at a slight degree of risk. In the UK, about 1 in 1000 women who become pregnant (0.1%) will develop a molar pregnancy. In Asian women, molar pregnancies are 3 times more common.

If you have a ‘complete mole’ no parts of a baby (foetal tissue) ever form.

We would need to register your pregnancy at a treatment centre. This is because there is a small (3 in every 20 women (15%) risk of you needing some medication and we need to know this. However, what I would like to let you know is most molar pregnancies are not nasty/cancerous (they are benign). Even though they can spread beyond the womb, they are completely curable.

It is recommended that you do not become pregnant until hCG level has been normal for six months

Blood and/or urine tests would be done.

More than 98% of women who become pregnant following a molar pregnancy will not have a further mole or be at increased risk of obstetric complications. That would mean , you have about a 1 in 100 chance (1%) of having another one.

*************************************************************

(I am not entirely sure if I would mention specific statistics about risk of malignancy in complete mole- 5-32%) What do you all suggest?

wolverine · Century Club Joined: 16 Jan 2007 Posts: 394

I wouldn't mention statistics as well but I would stress the need for follow up.

Molar pregnancy is an abnormal pregnancy: Whay do you mean by abnormal pregnancy doc?
I'm a bit obsessed trying to find a way to describe molar pregnancy in lay terms. I would say that It's a pregnancy that is not developing normally. It's more (if partial) or entirely (if complete) the trophoblast (that is the cells that are forming the afterbirths) that is growing.

EMAK · Century Club Joined: 26 Nov 2006 Posts: 572

Thanks Raj fopr your clarification....
Actually I have a new one
Cpeedasha give a good patient conselling , but this type of conselling I think will be helpful for the OSCES because for answering such question
( management), we don't have time and space for such details about counselling, only for small short information, what do you think ??!