GESTATIONAL TROPHOBLASTIC DISEASE

a.k.a

Hydatidiform Mole Molar Pregnancy

Submitted by: Anna Dominique B. Santos BSN IV A2 Submitted to: Maam Frailan Venus Datic September 2013 LUMC Delivery Room

I.

Definition

Gestational Trophoblastic Disease is an abnormal proliferation and then degeneration of the trophoblastic villi. Molar pregnancy, also known as hydatidiform mole, occurs when what would normally become the placenta transforms into a growing mass of cysts. As the cells degenerate, they become filled with fluid and appear as clear, fluid-filled, grape-sized vesicles. The embryo fails to develop beyond a primitive start. Abnormal trophoblast cells are associated with choriocarcinoma which is a quick-growing form of cancer that occurs in a womans uterus. The incidence of gestational trophoblastic disease occurs approximately in 1 out of 1500 pregnancies. Risk factors include low protein intake, 35 years of age and above, Asian, and blood group A women who marry blood group O men. There are two types of molar growth according to chromosome analysis: 1. Complete Mole In a complete mole, all of the trophoblastic villi swell and become cyctic. If an embryo forms, it dies early at only 1 to 2 mm in size, with no fetal blood present in the villi. On chromosomal analysis, although the karyotype is a normal 46XX or 46XY, the chromosome component was contributed only by the father or an empty ovum was fertilized and the chromosome material was duplicated. 2. Partial Mole In a partial mole, some of the villi form normally. The syncytiotrophoblastic layer of villi, however, is swollen ans misshapen. A macerated embryo of approximately 9 weeks gestation may be present and fetal blood may be present in the villi. A partial mole has 69 chromosomes (a triploid formation in which there are 3 chromosomes instead of 2 in every pair,

one set supplied by an ovum that apparently was fertilized by 2 sperm ot an ovum fertilized by 1 sperm in which meiosis or reduction division did not occur). This could also occur if one set of 23 chromosomes was supplied by one sperm and an ovum did not undergo reduction division supplied 46. Compared to complete moles, partial moles rarely lead to choriocarcinoma. Although still above average, hCG titers are lower in partial than in complete moles; titers also return to normal faster after mole evacuation.

II.

Pathophysiology

Symptoms: o Abnormal growth of the womb (uterus) Excessive growth in about half of cases Smaller-than-expected growth in about a third of cases o Nausea and vomiting that may be severe enough to require a hospital stay due to extremely high levels of hCG. o Vaginal bleeding with spotting of brown blood to a profuse fresh flow at approximately week 16 of pregnancy. The bleeding progresses and will soon be accompanied by discharge of clear, fluid-filled vesicles. o Symptoms similar to preeclampsia that occur in the 1st trimester or early 2nd trimester -- this is almost always a sign of a hydatidiform mole, because preeclampsia is extremely rare this early in a normal pregnancy (20 weeks AOG) High blood pressure Swelling in feet, ankles, legs Proteinuria

Diagnostics: o A pelvic examination may show signs similar to a normal pregnancy, but the size of the womb may reach its landmarks (just over the symphysis brim at 12 weeks, at the umbilicus at 20 to 24 weeks) before the usual time because trophoblast cells proliferate rapidly due to this condition. The baby's heart sounds are absent because there is no viable fetus o A uterine ultrasound will show a dense growth (snowflake pattern) but no fetal growth o HCG blood test results to strongly positive (1 to 2 million IU compared to the normal pregnancy level of 400,000 IU) because trophoblast cells that produce hCG are overgrowing.

III.

Nursing Interventions A. Diagnostic Assess characteristics of pain. Observe for non verbal cues of pain. Assess for bleeding, amount, and characterictics. Assess for emotional distress. Assess for nausea and vomiting. Assess ability to work.

B. Therapeutic Assist in performing deep breathing exercises. Assist in diversional activities such as guided imagery.

Assist to a comfortable position. Allow privacy to grieve Provide physical care such as a back rub or nourishment as needed. Prepare client for surgery as ordered. Administer analgesics as ordered. Provide emotional support such as therapeutic communication.

C. Educative Instruct to do relaxational activities such as deep breathing exercises when in pain. Instruct to do diversional activities such as watching TV, and listening to music when in pain. Encourage question and verbalization or expression of feelings. Educate client on why she should delay next pregnancy for another year. Instruct client to eat foods rich in protein. Educate about the importance of the follow-up assessment in order to detect early a gestational disease when it is almost 100 % curable. Teach that any effective contraceptive method may be used except an intrauterine device (IUD) because of bleeding irregularities associated with the IUD. Oral contraceptives are the preferred method since they are highly effective. Explain the treatment program if a gestational trophoblastic disease develops.

IV.

Medical/Surgical Interventions Suction Curettage Abortion

Hysterectomy

Prostaglandins are the most commonly used agents owing to their ability to induce contractions and thus expel the products of conception. o Mifepristone primes the uterus by allowing local production of prostaglandins. o Misoprostol help uterus expel products of conception that are not adherent to the uterine walls such as blood clots. o Oxytocin keeps the uterus contracted to prevent bleeding. o Methotrexate reduce hCG levels following treatment for hydatidiform mole.