“You’re so lucky to see this case. Believe it or not, we haven’t seen a molar pregnancy case like this in over 10 years,” I told the fifth-year medical student who came to see the patient with me. Molar pregnancy is becoming a rarer condition.
“We’re lucky, but the patient is unlucky to have this condition,” I was about to end the conversation as I was about to walk out of the operating room.
…
Molar pregnancy doesn’t happen because a woman swims and gets pregnant with a fish. It’s not like swimming breaststroke and then a fish’s sperm accidentally enters the vagina. Oh… not at all.
Instead, molar pregnancy occurs due to a severely abnormal placenta.
Normally, the placenta looks like a thick sheet of roti, and when you look at it under a microscope, you’ll see that the very small parts of the placenta resemble algae with blood vessels inside, looking like fish gills. It functions to provide nutrients to the fetus.
But in molar pregnancy, those fish gills become swollen like many small, clear tapioca pearls.
Yes, it’s abnormal, making the placenta in molar pregnancy look like a cluster of fish eggs or grapes. There are two types of molar pregnancy. The first type is where the entire uterine cavity is filled with clusters of fish eggs, with no fetus. The treatment is to suction it all out. The second type has a fetus, which is an embryo in the womb, while the placenta looks like a cluster of fish eggs.
Neither of these types can develop into a normal fetus, and they can cause many complications due to the abnormal placenta, especially severe hyperthyroidism, heart failure, pulmonary edema, hemorrhage, and even death.
Some parts can develop into choriocarcinoma after treatment. Alright, I assume we are starting to understand molar pregnancy now.
…
The story goes that Professor Ple accepted this case under our care. The patient had a molar pregnancy with a fetus, which is very rare.
I was consulted about inducing an abortion first, and then suctioning out the remaining molar tissue.
The problem is that her hyperthyroidism is very severe, which required consulting an endocrinologist to help manage it. This condition could be life-threatening for our patient.
Next is heart failure, which is a consequence of the hyperthyroidism. A cardiologist was consulted to help manage it. She was catheterized, given diuretics to expel fluid through urine, and put on high-flow oxygen to support her respiratory system.
On the morning of the day we were to perform the abortion and uterine suction, she suddenly became more fatigued. Professor Ple’s team had to rush her for a pulmonary angiogram due to high concern about possible blood clots or molar tissue embolizing to the lungs, which would be a dire situation.
As for me?
While they were all busy, I was sitting comfortably on the toilet, unaware of the chaos, as it was my rare free time in the morning that I hadn’t had in a long time.
“Paeh..” During that time, Ple called. “The patient is likely starting to miscarry. The water broke, and the ultrasound shows it’s dry.” It was a very concise case report.
“Okay, Ple, insert 2 tablets of cytotec. We’ll handle it in the operating room at 10 o’clock. I’ll hurry in.”
Well, finish up quickly then.
I rushed to handle paperwork at the office and prepared to see the patient in the delivery room, but soon the case owner called again.
“Paeh.. the baby is out. I’ll take her for uterine suction myself.”
“Calm down, Ple, wait for me.” Then I ran into the delivery room, where people were bustling around the patient’s bed, which was curtained off.
Our patient looked exhausted and fatigued. There was blood between her legs, and the umbilical cord of the aborted fetus was clamped with a cord clamp. The fetus was placed appropriately, and the blood from the vagina was not as much as expected.
“Hello, my name is Dr. Thanaphan. We’re here to take care of you.” The patient I addressed looked worried. We were about to wheel her to the operating room for uterine suction to remove the abnormal placenta. We were ready, and the operating room team signaled they were ready too.
“Oh, doctor,” the patient exclaimed, “I have abdominal pain.”
“Do you feel like pushing?” I asked, placing my hand on the top of the uterus, which felt tense.
“Yes, I want to push.”
“Then go ahead.” I signaled Professor Prin to put on gloves to assist. “Okay, push.”
The first blood clot gushed out, and the patient started pushing. I pressed the top of the uterus slightly, and the grape-like placenta began to flow out.
“Professor Prin, pull the placenta gently. I’ll press above the pubic bone.” It was like delivering a placenta in a normal pregnancy, but this was a terrifying placenta. At about 14 weeks of gestation, the abnormal placenta was larger than a hand. It was a smooth delivery of the placenta, with the uterus shrinking from the navel level to just above the pubic bone.
“How do you feel, relieved?” I asked her.
“Yes, doctor.”
“Everything will get better. We’ll take you for additional uterine suction in the operating room to make sure it’s all clear. Leaving anything behind is not good.”
“Okay.” Her face looked relieved, but the severe hyperthyroidism (thyroid storm) and heart failure still made her tired.
The male medical students helped push the bed, and I watched the scene with a female medical student.
“You’re so lucky to see a case like this, but the patient is not lucky to have this condition.”
…
“Are you the patient’s husband?” As we wheeled the stretcher from the delivery room to the operating room, a man appeared anxious, half-walking, half-running alongside.
“Yes.”
“My name is Dr. Thanaphan. I took care of the patient earlier. Everything has been aborted now, and the situation is okay. The patient is safe. We’re just going to suction out the remaining placenta, which can’t be left behind.”
“Yes, doctor.”
…
“Did you see the patient’s husband earlier?” I continued talking to the same medical student. She looked at me with curiosity.
“Sometimes we get too busy, doing this and that, and forget the important thing, which is communicating with the people around the patient, especially their partner and parents.” Yes, besides the husband, there were three others following closely, whom I could guess. I heard the husband slow down, his eyes relaxed, and he turned to the elderly group behind him and said, “It’s aborted, the doctor said it’s safe,” followed by a sigh of relief.
“They are more anxious than us. They are not doctors. Over the past few days, so much has happened to their family. Medical information has been communicated all along, which, of course, includes the dangers, and I believe death is part of that conversation. How do you think they feel?” Indeed, how do they feel? Because all they could do was wait outside the delivery room, not knowing how their wife was doing. It’s an anxiety in their hearts.
…
“Yes,” the medical student replied. I saw her turn back to look at the patient’s husband and relatives before walking into the operating room.
…
Professor Ple had been waiting in the operating room for a while. She came in to communicate with the anesthesia team, expressing concerns and communicating needs to the surgical nurses.
“We should just do uterine suction,” I informed everyone in the room because our plan was to remove the uterus if there was heavy bleeding. “And it should take no more than 15 minutes if everything goes smoothly.”
The anesthesiologist looked up, smiled, and nodded. They were about to intubate, while another group was preparing to insert an arterial line at the wrist.
“Neff will do the suction. I’ll stand by, and Professor Prin will guide the ultrasound for us,” I told the student.
“Most of the mole is in the lower uterine segment,” Professor Prin said as soon as he placed the ultrasound probe on the patient’s abdomen.
Mole refers to the molar pregnancy tissue, and the lower uterine segment is the lower part of the uterus.
Dr. Neff slowly inserted the suction tube into the uterine cavity. Professor Prin monitored for perforation by watching the ultrasound screen, while I managed the team, and Ple was the team leader.
Huh?
“Go ahead and suction,” I ordered, and then more molar pregnancy tissue flowed out with the suction.
Plop, plop, plop… imagine sucking bubble tea.
Plop, plop, plop
“240 cc, all done,” I informed everyone. “But the patient is bleeding, and the uterus isn’t firm.” Professor Ple asked for cytotec to be inserted into the patient’s rectum to help firm up the uterus.
“Please monitor the oxygen level. This medication may lower it,” I informed the anesthesia team, inserting a finger into the vagina with one hand and pressing down on the abdomen with the other to keep the uterus in hand, which helps stop the bleeding while waiting for the cytotec to take effect.
…
“You’re so lucky to see this case. Believe it or not, we haven’t seen a molar pregnancy case like this in over 10 years,” I told the fifth-year medical student who came to see the patient with me.
“We’re lucky to see the condition, but the patient is unlucky to have it. But still, I feel the patient is lucky to have us taking care of them. Look, they have three obstetricians looking after them, two more professors on standby for calls if needed, six or seven residents and interns, an anesthesiologist, and over ten nurses.” I continued to speak the same way because I felt that way.
As the uterus began to firm up and the bleeding stopped, the ICU team was ready to take over care. She would be safe under our team’s care.
…
“Paeh, do you know, we just received a call for another patient transfer, a choriocarcinoma that has spread to the vagina. There’s heavy bleeding now, and they’re packing gauze to stop the bleeding in the vagina,” I heard Professor Ple sigh after telling me about another transfer case in the same afternoon.
Well… molar pregnancy and choriocarcinoma are related, but much more aggressive.
The curse of coming in pairs remains true.
Thanaphan Chuboon, who narrated all this, hardly did anything, November 13, 67
Thanks to: Assoc. Prof. Dr. Thanaphan Chuboon
https://web.facebook.com/share/p/12F1Wa3ZYjM/