Gestational trophoblastic disease or Hydatidiform Mole

Nursing Care Plan to Mrs. Smith

Assessment: S> Mrs. Smith, a 35 year old,married

Chief complaint: Vaginal bleeding that varies from dark
brown spotting for 1 day duration. 3 days PTA, Mrs. Smith
experienced excessive vomiting that occurs in the morning.

O> Urinalysis test for hCG revealed positive,

UTZ revealed multiple small cystic structures, negative for
fetal parts and fetal heart beat.

Nursing Diagnosis: Fluid volume deficit r/t elevated levels of human Chorionic
Gonadotropin (hCG) from the proliferating trophoblasts

Nursing Interventions:

Independent: - Assess skin turgor and moisture of mucous membranes

 Indicators of hydration status/ degree of deficit

- Monitor Vital signs. Evaluate peripheral pulses, capillary

refill
 to have a baseline data, reflects adequacy of circulating
volume

- Monitor I&O; include all output sources (e.g., emesis,

diarrhea
 Decreasing renal output and concentration of urine
suggest developing dehydration and need for fluid
replacement.

- Weigh daily
 Sensitive measurement of fluctuations in fluid balance

- Observe for bleeding tendencies; Note the amount,

lochia/color of the vaginal discharge
 Early identification of problems (which may occur as a
result of cancer), allows for prompt intervention.

-Encourage increase fluid intake as tolerated

 To compensate with the fluid volume deficit problem

-Encourage ice chips on mouth

 For the vomiting episodes

-Encourage rest
 Prevent unnecessary energy expenditure related to
vomiting (as may trigger) and bleeding (loss of
blood/RBC)
 1. Blood Transfusion for Anemia
Dependent:  Monitor VS
 Monitor signs of allergy
 Check blood package
 Monitor IV line and regulate drops
2. Correction of Coagulopathy
 Assist
3. Hypertension Treatment
 Monitor VS
 Give meds as ordered
 Health teaching: diet and exercise
 Promote exercise
4. Dilation and Curettage for Evacuation of the Uterus
 Assist
5. Intravenous Oxytocin
 to be started with the dilation of the cervix and
continued postoperatively to reduce likelihood of
hemorrhage. Consideration of using other
uterotonic formulations such as Methergine or
Hemabate is also accepted.
 Monitor IV line and regulate drops
6. Assisted Ventilation and Monitoring for Respiratory
Distress
 during surgery, this can happen due to trophoblastic
embolization, high-output congestive heart failure
caused by anemia, or iatrogenic fluid overload.
Ventilation and monitoring should be done during such
situation.
Medication-Drug:  Assist

7. Monitor HCG for 1year

 Increased HCG results to Choriocarcinoma (malignant)

8. Drug of Choice: Methotrexate (drug analysis on last

page)

 (chemo-therapeutic drug)

9. Anitemetics

 For the vomiting episodes

o Pretest

>Urine test for hCG

 positive up to 100th day of pregnancy
 1 – 2 million IU compared with a normal pregnancy level
of 400,000 IU)

>Ultrasound
 >Laboratory test of vaginal discharge

o After mole extraction to r/o tumor

> Pelvic examination

> Chest x-ray
> Serum test for the beta subunit of hCG
 2 weeks until levels are normal, thereafter, levels are
assessed every 4 weeks for 6 – 12 months. Increased
levels after this suggest that malignant transformation
Diagnostic Procedure: has occurred.

o Nursing Responsibility

- explain the procedure to client

- ask client to void before the procedure
- label and preserve specimen

Collaborative: Dietary Department – protein, folic acid, B12-rich food

 To help patient develop new mature red blood cells to
prevent further anemia due to blood loss
OB-Gyne Department
 for further evaluation and proper treatment

Patient Health Teaching: - Encourage to have a high protein, folic acid and carotene
diet
R:

Avoid use of OTC drugs and aspirin, gastric irritants

 Affect clotting mechanism and potentiate to bleeding.

Patient Outcome: Client will display adequate fluid balance as evidenced by

stable vital signs , moist mucous membranes, skin turgor
less than 1 sec, capillary refill of less than 2 secs. and
adequate urine output

Medical Management Nursing Management

1. Patient Stabilization 1. Asses for signs and symptoms of h mole

2. Blood Transfusion for Anemia
3. Correction of Coagulopathy
4. Hypertension Treatment
5. Dilation and Curettage for Evacuation
of the Uterus
6. Intravenous Oxytocin – to be started
with the dilation of the cervix and
continued postoperatively to reduce
likelihood of hemorrhage.
Consideration of using other uterotonic
such as vaginal bleeding, nausea and
vomiting, abnormal growth in the size of
uterus for the stage of pregnancy and
symptoms of hyperthyroidism
2. Explain the importanceof adequate
nutrition in order to reduce the risk of h
mole
 formulations such as Methergine or
Hemabate is also accepted.
7. Assisted Ventilation and Monitoring for
Respiratory Distress – During surgery,
this can happen due to trophoblastic
embolization, high-output congestive
heart failure caused by anemia, or
iatrogenic fluid overload. Ventilation
and monitoring should be done during
such situation.
8. Monitor HCG x 1year= Increased HCG
results to Choriocarcinoma (malignant)
Gestational trophoblastic disease or
Hydatidiform Mole
(Reproductive System)
3. Explain the risk factors such as women
under 20 or over 40; other risk factors
include a diet low in protein folic acid and
carotene
4. Enumerate the possible potential causes
such as defect in the egg, abnormality
within the uterus, or nutritional deficiency.
5. Instruct the patient to plan the next
conception after 12 months to prevent
false result of pregnancy
6. Instruct to use a reliable contraceptive
method such as an oral contraceptive for
12 months so that a (+) pregnancy test
resulting from a new pregnancy will not be
confused with increasing levels and
devloping malignancy.
7. Explain the importance of oral
contraceptives
8. Monitor HCG levels
9. Encourage to verbalize feelings about the
loss of a possible child
 IV- B12

Aguirre, Maria Felicidad

Alabastro, Robin Niceno
Arancon, Dominique
Baula, Maria Feliza
De Leon, Adriane Jerel
Gomintong, Aura Mae
Lim, Giselle Marie
Osorio, Maria Christiana
Reyes, Ana Katrina
Simon, Stephanie Lou
Tiburcio, Maria Victoria

Methotrexate

Mechanism of Action: Inhibits dihydrofolate reductase, preventing reduction of

dihydrofolate to tetrahydrofolate, subsequently resulting to decreased synthesis of purines
and consequently DNA. Its activity is cell cycle specific.

Indication: Patients with Hydatidiform mole.

Nursing Responsibilities: Assess patient’s condition before therapy and reassess

regularly thereafter to monitor drug effectiveness. Monitor for severe allergic reaction:
rash, pruritus, urticaria, itching and flushing. Avoid contact with skin, since this drug is
very irritating. Give in the morning so drug can be eliminated at bedtime. Take
medication on an empty stomach. Encourage diligent mouth care to reduce risk for oral
infections. Avoid use of aspirin or NSAIDS, sharp objects to reduce risk for bleeding.
Instruct patient to report signs of anemia such as faintness, shortness of breathe.
Contraceptive measures may be advised. Hair may be lost during treatment. Advise
patient not to use sunblock or protective clothing to avoid burns.

Hydatidiform Mole / Molar Pregnancy (H-Mole)

 a developmental anomaly of the placenta, resulting in the proliferation &
degeneration of chorionic villi w/c develops into a grape like clusters of vesicles.
 Incidence of H-mole – most common lesion anteceding choriocarcinoma.

Diagnostics

 Ultrasound – reveals no fetal skeleton

 High HCG level in urine or blood

Risk Factors: Can predispose but not really cause

  Taiwanese & Mexicans - ↓ protein diet (noodles)
 Familial Tendency – “buntis pero di bata ang laman” , “buwa”
 ↑ incidence w/ advanced maternal age; assoc. w/ induction of ovulation by
Clomiphine Therapy (hormone) ↑ 35 & ↓ 18 yr. old
 In women w/ ↓ socio-economic status

Clinical Manifestations ADEA

 Anemia due to loss of blood

 Discharge of brownish red fluid (like prune juice) from vagina, around the 12th
wk. w/c may contain clear fluid filled grape sized vesicles.
 Exaggerated symptoms of pregnancy
Uterus too large for pregnancy
Excessive Nausea & vomiting
Early signs of PIH (before 24 weeks.)
 Absence of Fetal Heart sound

Complications DICT

 DIC – Disseminated Intravascular Coagulation

 Infection
 Choriocarcinoma is possible
 Trophoblastic embolization after evacuation of molar pregnancy can cause
Cardio-pulmonary arrest

Management

 D & C to empty the uterus

 Medical mgmt after D & C
Follow-up supervision (1 yr.) – monitor HCG level every wk., on 3-4 mos. every
other wk., then every month until 1 year is completed. If there is rising ↑ titer of
HCG, indicates pathology of choriocarcinoma.
 Drug of choice: Methotrexate (chemo-therapeutic drug)
 Pregnancy shld. be avoided for at least 1 yr. – can use contraceptives but not pills
(alters HCG levels)