Professional Documents
Culture Documents
WITH HYPERTHYROIDISM
Presented by Adam Ridha
Supervisor
dr. Pinda Hutajulu, Sp. OG (K)
OBSTETRY AND GYNECOLOGY DEPARTMENT
MEDICAL FACULTY TANJUNGPURA UNIVERSITY
RSU DOKTER SOEDARSO
INTRODUCTION
Chapter I
CASE REPORT
Chapter II
PATIENT
IDENTITY
Patient was examined on May 23th, 2014
Name : Mrs. IT
Sex
: Female
Age
: 46 years old
Address : Sui Kakap
Ethnic : Bugis
Job
: Household
Religion : Islam
No. MR : 685-775
ANAMNESIS
Chieft Complaint
lump in the abdomen since 2 months
History of Obstetric
G8
P 7A 0M 0
Keada
an
anak
1
2
3
4
5
6
7
8
Hidup
Hidup
Hidup
Hidup
Hidup
Hidup
Hidup
Rumah
Rumah
Rumah
Rumah
Rumah
Rumah
Bidan
1982
1984
1987
1990
1993
1994
2007
Spontan
Spontan
Spontan
Spontan
Spontan
Spontan
Spontan
P
L
P
P
P
L
P
Yang ini
?
?
?
?
?
?
3.800
History of Disease/Operation
Thyroid disease (+)
History of Social-Economic
The patient worked as a housewife and have BPJS
health insurance grade 3.
PHYSICAL EXAMINATION /
GENERAL STATUS
General condition: Compos Mentis, weak
Heart rate : 140x/m
Respiration rate : 26x/m
Blood pressure
: 140/80 mmHg
Eye : anemic conjungtiva (-/-), icteric sclera
(-/-)
Neck : mass (+),palpable thyroid glands, supple,
no pain, mobile, bruit (-)
OBSTETRIC STATUS
Eksternal examination
Fundal height : one finger under umbilicus
Fetal heart rate : negative
Presentation : His : negative
Estimated fetal weight : -
Internal
examination
Portio
: thick
Servical dilatation
Decend
:Amniotic
:-
: 0 cm
SUPPOTIVE EXAMINATION
Haematologic examination in 16 of may 2014
Haemoglobin
: 11,8 g/dL
Post-prandial
Ureum
: 88 mg/dL
: 38,1 mg/dL
Diagnosis
Hydatiform mole in G8 P7 A0 M0 13
weeks 4 days gestation with
hypertiroidism
THERAPHY
Prognosis
Ad vitam
: dubia ad bonam
FOLLOW UP
21 of May 2014
S : abdominal pain, abdominal lump since 2 months and
bigger, appetite (<), nausea & vommiting (-), palpable
neck mass (+)
O : HR 150 x/m, RR 20 x/m, BP 160/80 mmHg, CA (-/-),
cor and pulmo in normal condition, abdomen: palpable
mass 11 x 14 cm, vaginal bleeding (+), internist
consultation (+)
A : Hydatiform mole in G8 P7 A0 M0 13 weeks 5 days
gestation with hypertiroidism
P:
IVFD RL 20 dpm,
insertion of laminaria,
curretage,
T3/T4/TSH examination
22 of May 2014
S : vaginal bleeding (+)
O : HR 90 x/m, RR 19 x/m, BP 130/70 mmHg, fine
tremmor (+). Laboratory result: T3 4,68 nmol/L (high),
T4 297, 76 nmol/L (high), TSH 0,014 (low)
A : Hydatiform mole in G8 P7 A0 M0 13 weeks 6 days
gestation with hypertiroidism
P:
IVFD RL 20 dpm,
curretage,
Propanolol 2 x 10 mg
23 of May 2014
S : nausea (+)
O : HR 92 x/m, RR 20 x/m, BP 140/80 mmHg, fine
tremmor (+), lab. Result: WBC 6.700/mm3, RBC 3,59
M/uL, HB 9,0 g/dL, HCT 28,3 %, PLT 286 K/uL
A : Hydatiform mole in G8 P7 A0 M0 14 weeks
gestation with hypertiroidism + Anemia e.c. vaginal
bleeding
P:
IVFD RL 20 dpm,
curretage,
whole blood transfusion 350 cc,
Propanolol 2 x 10 mg
24 of May 2014
S : nausea & vomitting (+), appetite (<), vaginal
bleeding (+) decreasing
O : HR 92 x/m, RR 20 x/m, BP 150/110 mmHg, fine
tremmor (+), Fundal heigh 1 finger under umbilicus
A : Hydatiform mole in G8 P7 A0 M0 14 weeks 1 day
gestation with hypertiroidism + Anemia e.c. vaginal
bleeding
P:
IVFD RL 20 dpm,
curretage,
Propanolol 2 x 10 mg
25 of May 2014
Laboratory result: WBC 6.300/mm3, RBC 380 M/uL,
HB 9,4 g/dL, HCT 29,6 %, PLT 219 M/uL
26 of May 2014
S : feels heat
O : HR 78 x/m, RR 20 x/m, BP 130/80 mmHg, Fundal heigh
the same as umbilicus. Reconsultation to internist (+),
consultation to cardiologist (+) ECG HR 112
A : Hydatiform mole in G8 P7 A0 M0 14 weeks 3 days
gestation with hypertiroidism + Anemia e.c. vaginal
bleeding + Sinus tachycardy
P:
IVFD RL 20 dpm,
curretage,
Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
HR evaluation (60-100 x/m)
27 of May 2014
S : feels heat (-), vaginal bleeding (-)
O : HR 112 x/m, RR 26 x/m, BP 110/60 mmHg, Fundal heigh
the same as umbilicus.
A : Hydatiform mole in G8 P7 A0 M0 14 weeks 4 days
gestation with hypertiroidism + Anemia e.c. vaginal
bleeding + Sinus tachycardy
P:
IVFD RL 20 dpm,
Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
whole blood transfusion 350 cc,
HR evaluation (60-100 x/m)
Pro-Histerectomy until sign & symtomps of
thyrotoxicosis is negative
28 of May 2014
S : vaginal bleeding (+) minimal, palpitation (+)
O : HR 92 x/m, RR 20 x/m, BP 130/80 mmHg, Fundal
heigh 3 finger under umbilicus. Curettage was
perfomed, PA examination on mola fluid and blood. Lab.
Result: WBC 8.400/mm3, RBC 4,28 M/uL, HB 11,4 g/dL,
HCT 31,9 %, PLT 212 K/uL
A : Post curettage in indication of hydatiform mole
with hypertiroidism
P:
Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
Cytotex PO 2 tabs
HR evaluation (60-100 x/m)
29 of May 2014
Lab. Result : WBC 9.600/mm3, RBC 4,89 M/uL, HB
12,7g/dL, HCT 36,2 %, PLT 261 K/uL
30 of May 2014
S : complain (-)
O : HR 92 x/m, RR 20 x/m, BP 120/60 mmHg, Fundal heigh
3 finger under umbilicus.
A : Post curettage in indication of hydatiform with
hypertiroidism
P:
Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
Amoxicillin 3 x 500 mg
Mefenamic acid 3 x 500 mg
Ciprofloxacin 2 x 500 mg
Waiting PA result
Rontgent thorax PA
Out patient, klinic consultation.
LITERATURE
RIVIEW
Chapter III
INTRODUCTION
Gestational trophoblastic neoplasia (GTN) is
comprised of a spectrum of conditions, each of
which is characterised by low incidence and high
cure rates.2,4
2. Sebire N. J., Seckl M. J. Clinical review - Gestational trophoblastic disease: current management of hydatiform mole. BMJ 2008; 337. a193,
doi: 101136/bmj a193. 2008, vol 337 (453-58): BMJ
4. Phillip Savage. Clinical fatures of molar pregnancies and gestatioal trophoblastic neoplasia
HYDATIFORM
MOLE
Molar pregnancies and GTN origin from the
placental trophoblast.6
Normal trophoblast
CLINICAL
PRESENTATION
Most common abnormal vaginal bleeding at 616 weeks of gestation. 5,6
Palpable uterus larger than the gestational age
according to the last normal menstruation
period.5,6
Hyperemesis gravidarum, anemia,
hyperthyroidism, very high levels of -HCG and
pre-eclampsia before 20 weeks of gestation.
History of passing hydropic vesicles or grapelike pieces of tissue.5,6
DIAGNOSIS
Ultrasound diagnostic tool in diagnosing molar
pregnancy CHM
Shows mixed echogenic pattern, comprising
hydropic villi, an absent fetus and no amniotic fluid,
exhibiting snow storm pattern with or without
theca lutein cysts
Ultrasound appearance is non-specific, and
therefore molar pregnancies are frequently
misdiagnosed as incomplete miscarriages
Ultrasound finding in cases of PHM, includes a fetus
(sometimes growth restricted), amniotic fluid and
focal areas of anechogenic spaces in the placenta.
MANAGEMENT
Dilatation and suction evacuation is the standard
treatment of all patients presenting with a possible
diagnosis of molar pregnancy.5
Full blood count, coagulation profile, renal function
assessment, liver function test, thyroid functions,
quantitative -HCG level, and blood group
compatibility, chest X-ray and CT scan in selected
cases.
DISCUSSION
Chapter IV
Mrs. IT, 46 yo
G8 P7
Abdominal lump
since 2 months
15 February
2014
Appetite << +
N/V
Vaginal bleeding >>
Lump in the neck
since 4 months ?
Hydatiform mole in G8
P7 13 weeks gestation
Management
anemia
thyroid-function >>
trembling, sweating,
and palpitations
tachycardia
140/80 mmHg
uterus - 20-weeks gestation
Hyperthyroidism
2014
TSH (0,27 - 4,7
0,014
IU/mL)
T3 (0,92 2,33
4,68
nmol/L)
T4 (60 120
297,76
nmol/L)
Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
Dilatation and curretage
CONCLUTION
Mrs. IT, 46 years old with diagnose of hydatiform mole in G8 P7 H. 13
weeks with hyperthyroidism and anemia. The management which is given
is:
IVFD RL 20 dpm
Curretage
Propanolol 2 x 10 mg
Tyrosol 1 x 10 mg
Amoxicillin 3 x 500 mg
Mefenamic acid 3 x 500 mg
Ciprofloxacin 2 x 500 mg
Waiting PA result
Rontgent thorax PA
Out patient, klinic consultation.
REFERENCES
1. Nousheen Aziz, Sajuda Yousfani, Irfanullah Soomro, Firdous Mumtaz. Original article Gestational
trophoblastic disease. J Ayub Med Coll Abbottabad 2012; 24 (1). Downloaded from
http://www.ayubmed.edu.pk/JAMC/24-1/Nousheen.pdf
2. Sebire N. J., Seckl M. J. Clinical review - Gestational trophoblastic disease: current management of
hydatiform mole. BMJ 2008; 337. a193, doi: 101136/bmj a193. 2008, vol 337 (453-58): BMJ. Downloaded
from http://www.eottd.com/wp-content/uploads/2012/01/Lybol.pdf
3. Dave Nandini, Fernandes Sarita, Ambi Uday, Iyer Hermalata. Case Report hydatiform mole with
hypertiroidism perioperative challanges. J obstet gynecol india vol. 59, no. 4 ; july/agust 2009 pg 356-357.
Downloaded from http://medind.nic.in/jaq/t09/i4/jaqt09i4p356.pdf
4. Phillip Savage. Clinical fatures of molar pregnancies and gestatioal trophoblastic neoplasia. Downloaded
from http://www.isstd.org/isstd/chapter08_files/GTD3RDCH08.pdf
5. Deep J.P., L.B. Sedhai, J. Napit, J. Pariyar. Review article Gestational trophoblastic disease. Journal of
Chitwan Medical Collage 2013; 3(4): 4-11. Downloaded from http://www.cmc.edu.np/images/gallery/Review
%20Articles/ankVwReview%20Articles%202.pdf
6. John R. Lurain. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and
diagnosis of gestational trophoblastic disease, and management of hydatiform mole. 2010, american journal
of obstetric and gynecologis: mosby, Inc. doi:10.1016/j.ajog.2010.06.073. downloaded from
http://journalsconsultapp.elsevier-eprints.com/uploads/articles/ajog1.pdf
7. Walkington L., J Webster, B.W.Hancock, J. Everard, R.E. Coleman. Hyperthyroidism and human chorionic
gonadotrophin production in gestational trophoblastic disease. British Journal of Cancer (2011) 104, 16651669: cancer research UK. Downloaded from
http://www.nature.com/bjc/journal/v104/n11/pdf/bjc2011139a.pdf
TERIMAKA
SIH
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