University of Perpetual Help System DALTA

Brgy.Paciano, Rizal Calamba City, Laguna

GESTATIONAL TROPHOBLASTIC
DISEASE
(HYDATIDIFORM MOLE)

Submitted by: Cassie G. Paragas BSN 3a3 group 4

Submitted to: Mr.Edmund Zuasola

DEFINITION

Gestational Trophoblastic Disease is abnormal proliferation and degeneration of the

trophoblastic villi. As the cells degenerate, they become filled with fluid and appear as clear
fluid-filled, grape-sized vesicles. With this condition, the embryo fails to develop beyond a
primitive start. Such structures must be identified because they are associated with
choriocarcinoma, a rapidly metastasizing malignancy.

The incidence of gestational trophoblastic disease is approximately 1 in every 1,500

pregnancies. The condition tends to occur most often in women who have a low protein intake,
in women older than age 35 years, and in women of Asian heritage.

Two types of molar growth can be identified by chromosome analysis. With a complete
mole, all trophoblastic villi swell and become cystic. 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
karyo-type is a normal 46XX or 46XY, this chromosome component was contributed only by the
father or an “empty ovum” was fertilized and the chromosome material was duplicated.

With a partial mole, some of the villi form normally. The syncytiotrophoblastic layer of
villi, however, is swollen and misshapen. A macerated embryo of approximately 9 weeks
gestation may be present and fetal blood may be present in the villi. A partial mode has 69
chromosomes (a triploid formations in which there are three chromosomes instead of two for
every pair, one set supplied by an ovum that apparently was fertilized by two sperm or an ovum
fertilized by one 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 that did not
undergo reduction division supplied 46.

In contrast in 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.
ASSESSMENT

Because proliferation of the trophoblast cells occurs so rapidly with this condition, the uterus
tends to expand faster than normally. This causes the uterus to reach its landmarks (just over the
symphysis brim at 12 weeks, at the umbilicus at 20 to 24 weeks) before the usual time. This
rapid development is also diagnostic of multiple pregnancy or a miscalculated due date,
however, so this finding must be evaluated carefully. No fetal heart sounds are heard because
there is no viable fetus. Because hCG is produced by the trophoblast cells that are overgrowing, a
serum or urine test of hCG for pregnancy will be strongly positive (1 to 2 million IU compared
with a normal pregnancy level of 400,000 IU).

Results continue to be strongly positive after day 100 of pregnancy, when the level of hCG
normally would begin to decline. This fact must be evaluated carefully also, however, because
highly positive test results can be characteristics of multiple pregnancies with more than one
placenta. The nausea and vomiting of early pregnancy is usually marked, probably due to the
high hCG level present. Symptoms of pregnancy-induced hypertension (i.e., hypertension,
edema, and proteinuria) are ordinarily not present before week 20 of pregnancy. With gestational
trophoblastic disease, they may appear before this time. A sonogram will show dense growth
(typically a snowflake pattern) but no fetal growth in the uterus.

At approximately week 16 of pregnancy, if the structure was not identified earlier by

sonogram, it will identify itself with vaginal bleeding. This may begin as vaginal spotting of
dark-brown blood or as a profuse fresh flow. As the bleeding progresses, it is accompanied by
discharge of the clear fluid-filled vesicles. This is why it is important for any woman who begins
to miscarry at home to bring any clots or tissue passed to the hospital with her. The presence of
clear fluid-filled cysts changes the diagnosis from miscarriage to gestational trophoblastic
disease.
NURSING INTERVENTION

Therapy for gestational trophoblastic disease is suction curettage to evacuate the mole. After
surgery, hCG levels remain high. Half of women still have a positive reading in 3 weeks; one
fourth still have a positive result at 40 days.

Following mole extraction, women should have a baseline pelvic examination, a chest x-ray,
and a serum test for the beta subunit of hCG. The hCG is then analyzed every 2 weeks until
levels are again normal. Thereafter, serum hCG levels are assessed every 4 weeks for 6 to 12
months. Gradually declining hCG titers suggest no complication. Levels that plateau for three
times or increase suggest that malignant transformation has occurred. A woman should be
instructed to use a reliable contraceptive method such as an oral contraceptive agent for 12
months so that a positive pregnancy tests (the presence of hCG) resulting from a new pregnancy
will not be confused with increasing levels and a developing malignancy. After 6 months, if hCG
levels are still negative, a woman is theoretically free of the risk of a malignancy developing. By
12 months, she could plan a second pregnancy. Although the development of gestational
trophoblastic disease means that a pregnancy never materialized and that a fetus never formed, a
woman may experience the same feeling of loss after its evacuation that she would have
experience after the loss of a true pregnancy: she did, after all, believe she was pregnant. In
addition, she is faced with the possibility that a malignancy may develop. She also must delay
her childbearing plans for a year. If she had already put of having a child for some time, this may
seem to be an unbearably long time.

MEDICAL TREATMENT

Some physicians give women who have had gestational trophoblastic disease a prophylactic
course of methotrexate, the drug of choice for choriocarcinoma. However, because the job
interferes with white blood cells formation (leucopenia), prophylactic use must be weighed
carefully. If malignancy should occur, it can be treated effectively in most instances with
methotrexate at that time. Dactinomycin is added to the regimen if metastasis occurs.

Women need the opportunity to express their anger and sense of unfairness at this type of
event. They may feel inadequate because something went wrong with the pregnancy. They may
wonder whether it will happen again, or whether they will ever be able to have children.
Unfortunately, women who have one incidence of gestational trophoblastic disease have an
increased risk of a second molar pregnancy. They need early screening with ultrasound during a
second pregnancy to be certain this is not happening again.

Reference: Maternal & Child Health Nursing 5th ed.; Adele Pillitteri