Wednesday, March 2, 2011

Hydatidiform Mole~

Awen came for a prenatal yesterday morning, saying she’d been bleeding non-stop for 9 days. She was pale and worried and scared -- she had a right to be.

As I measured her belly and reviewed her vitals, the best conclusion I could come up with was a missed abortion and/or intrauterine fetal demise (IUFD).

For those who don’t know, a missed abortion is when a child dies in utero before 20 weeks gestation, (whereas a IUFD is after the 20 week mark), and the child is not expelled.

She had no idea when she got pregnant, but I thought she might be more than 20 weeks since her fundal height was 20 cm and she reported fetal movements before the bleeding began. If so, she had an intrauterine fetal demise (IUFD) which wasn’t being expelled.

The abdominal mass was alternately soft and mushy, then hard and rigid. There were no heart tones and no clots passed, and the bleeding was strange-- slightly foul smelling, and thin.

I conferred with Dennis and he agreed that the best course of action would be to induce her, lest the pregnancy become septic. I asked her if she had family to help her through this, but she didn’t. She spoke, however, of a sister in town who could help her with food, and she’d send word for her husband to come.

Once, the prenatals were through, I started her on an oxytocin drip. I titrated the dosage, bumping it up regularly to help the contractions take off. A few hours into it, I did a vaginal exam. She was completely closed, so I bumped it up some more.

Four hours later, she was still only 1 1/2 cm dilated, 50% effaced. I wasn’t sure if this was normal as I’ve never done it before. The books never said how long such things would take. But Dennis had done this numerous times before, so he was my reference.

However, several hours later, she started passing large clots. I called Dennis in because clots in ‘labor’ don’t make sense. He assured me it wasn’t normal and suggested we were wrong about the gestation age.

I agreed. Perhaps we were dealing with an early pregnancy (missed abortion) after all, and/or incarcerated clots. We were guessing, but they were our best guesses.

Dennis decided to do a manual vacuum aspiration (MVA) to remove the missed abortion and clots and I happily handed her case over. Margaret was taking over the shift, so I left them to it.

About an hour later, I was called to help them again; Tom was called as well. When we arrived, the room was full of IV fluids, bowls of blood and a pile of clots mixed with strange looking tissue that Dennis had removed during the procedure.

He had called us because she wouldn’t stop bleeding. He had completed the MVA and removed as much  tissue as he could get, but he couldn’t get the bleeding to stop. He also wanted us to weigh in on the tissues extracted.

The white, vesicled tissue was distinct and immediately apparent; what he removed was not a fetus but a hydatidiform mole. (For those who don’t know, a H. Mole is a rare mass or growth that forms in the uterus. It develops early in pregnancy, as a tissue that is suppose to become the placenta, goes rogue. What develops is a grape-like vesicle tissue that is NOT a baby but still produces pregnancy hormones.)

We discussed how to manage her case as she lay there bleeding. What should we do to stop the bleeding? To look at the amount of blood lost and the amount that kept pouring out, I was shocked Awen was even conscious! Afterward, we conservatively estimated her to have lost 3000cc. That’s about half a person's blood volume!

She was going into shock despite massive fluid replacement, but was still coherent. A miracle!

After discussing her case, I suggested I do an internal manual extraction of clots, since the MVA was not getting it out. Frankly, there was too much blood to even see the cervix. How Dennis was able to do it at all was/is a mystery.

An internal manual exploration is not something you normally do for miscarriages, but if you recall I did it on a incomplete abortion last year and it worked. I explained my reasoning to Dennis and he agreed.

So, I donned gloves and explained what and why to Awen; she agreed, and I reached in to extract what I could. It was painful-- there is no doubt. But once the clots were removed from her vaginal vault, I was able to extract a large piece of vesicles and tissue trapped in her cervix.

Instantly, her bleeding stopped as her uterus clamped down, and the room heaved a collective sigh of relief.

Wow.

Of the four of us in the room, only Dennis had ever seen a hydatidiform mole before -- just once. What a miracle we were able to get it out, keep her alive and stop the bleeding! What excellent team work!

She has been resting all day and is still dizzy for all the blood loss, but that is to be expected.
Pray for a full recovery and that this mole wouldn’t reoccur her next pregnancy. Thanks!