H-Mole Chapter I-V

JMJ Marist Brothers
Notre Dame of Marbel University

Alunan Avenue, City of Koronadal
College of Arts and Sciences
NURSING DEPARTMENT
CHAPTER 1
INTRODUCTION
This chapter contains the background of the study, statement of the
problem, significance of the study, and scope and delimitation.
Background of the Study
Hydatidiform mole, also known as molar pregnancy, is a category of
gestational trophoblastic disease (GTD) that begins in the placenta and can
spread to other parts of the body. The tumor arises from gestational tissue rather
than maternal tissue, which makes it unusual. Hydatidiform mole (HM) is a
noninvasive type of gestational trophoblastic disease that can be categorized as
a complete or partial mole. (Ghassemzadeh S, Kang M. 2021). According to
Iftikhar, N. (2019), it occurs sometimes because of a genetic DNA mix-up.
Thousands of eggs are carried by most women. It is possible that some of these
would not form properly. Molar pregnancy may also happen when a sperm
fertilizes an incomplete (empty) egg or when an incomplete or multiple sperm will
fertilize a healthy egg. Amenorrhea, hyperemesis gravidarum, doughy uterus,
vaginal bleeding, uncontrolled passage of grape-like vesicles, and elevated
serum and urinary human chorionic gonadotropin (hCG) levels are all symptoms
of Hydatidiform Mole.
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According to Mulisya, O., et al. (2018), partial hydatidiform moles are
triploid conceptuses with a paternally derived extra haploid set of chromosomes.
According to Sarapuddin, S. (2016), Asia has a higher incidence of hydatidiform
mole (Taiwan has 1 case in 125 pregnancies and 2 in 1000 pregnancies in
Southeast Asia and Japan). The national prevalence rate in the Philippines is 2.4
per 1000 pregnancies. It is generally assumed that the prevalence is highest in
developing countries. The incidence is higher in women below the age of 20 and
above the age of 40. It is also higher in nulliparous women, low-income patients,
and women whose diets are deficient in protein, folic acid, and carotene.
(Mulisya, O. et al. 2018). According to Moore, L. (2020), the present mortality
rate for molar pregnancy is practically zero and gestational trophoblastic
malignancies are mostly curable.
The result of this study will be beneficial to every woman, especially the
childbearing ones, to help them understand the condition and determine what
actions need to be taken to reduce these pregnancy complications. For future
researchers, this study will serve as their guide towards making their research
study and to have a deeper understanding and background about hydatidiform
mole. Also, for nursing students, this study will answer their curiosity about why
and how a molar pregnancy occurs.
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Statement of the Problem
This study aims to understand and analyze the occurrence of G3P2 PU
Hydatidiform Mole, Partial.
Specifically, the study aims to:
1.) gather data about patient's personal information by collecting
information for demographic data, conducting past and present health
history taking and perform a complete cephalocaudal physical
assessment;
2.) review articles and journals related to the case and to make these as
references;
3.) assess patient’s activities in daily living before and during
hospitalization;
4.) interpret and refer data based on the laboratory results;
5.) conduct a drug study for each medication that were ordered by the
doctor;
6.) determine the pathophysiology of the disease, its predisposing and
precipitating factors, and medical and surgical management;
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7.) formulate a nursing care plan and determine the top 3 problems that
need to be prioritized; and
8.) provide health teachings to the patient and her family with regards to
the improvement of the patient’s well-being and effective coping strategies
emotionally, physically, and mentally.
Scope and Delimitation
This study focuses on Gravida 3 Para 2 Pregnancy Uterine Hydatidiform
Mole, Partial, an obstetrical case. The researchers aimed to understand and
analyze the occurrence of G3P2 PU Hydatidiform Mole, Partial. This study was
conducted at a Tertiary Hospital in General Santos City on April 26, 2021.
This study is limited to only one case of G3P2 PU Hydatidiform Mole,
Partial. Primary data were obtained from patient A.B. by the researchers through
an interview on April 26, 2021 during their 7:00 AM - 3:00 PM shift. The data and
information that were obtained from the doctors through an interview and the
patient’s hospital records and charts were used by the researchers as their
secondary sources.
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CHAPTER II
REVIEW OF RELATED LEARNING LITERATURE
This chapter includes review on related literature from articles, journals,
books and publications regarding the anatomy and physiology of the reproductive
system. This chapter also forms the theoretical and empirical basis upon which
the study is conducted. The chapter therefore considers the academic theories
and the various views expressed by scholars on the topic.
Reproductive System
The female reproductive system composes the internal and external sex
organs that are concerned with reproduction. In people, this system starts as an
immature system at birth and further develops to become mature during the
puberty stage. The reproductive system is responsible for menstruation,
conception, and pregnancy.
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Figure 1. Phases of Menstrual Cycle
Menstruation commonly happens during the puberty stage, which starts at
9 years old. This process starts with the first phase, the menstrual phase,
wherein development of primary follicles happens. An egg from the previous
cycle is not fertilized which causes estrogen and progesterone hormone levels
drop, since pregnancy has not taken place. What happens in this phase is that
the thickened lining of the uterus sheds through a woman’s vagina which leads to
bleeding. Second Phase is called the Follicular phase. It starts when the pituitary
gland is signaled to release follicle stimulating hormone, also known as FSH,
which would stimulate the ovaries to produce at most 20 follicles, wherein each
contains an immature egg. Among these immature eggs, only the healthiest egg
will mature, and the rest will be reabsorbed to a woman’s body. This will then set
off a surge in estrogen that causes the lining of the uterus to become thick.
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Due to the rise of estrogen levels, the release of luteinizing hormones by
the pituitary gland is triggered which then indicates the start of the third phase,
the ovulation phase. The mature egg is released by the ovary in this phase. It
then travels down to the fallopian tube toward the uterus and waits to be fertilized
by a sperm cell. Ovulation phase is only the time when a woman can get
pregnant. Finally, the luteal phase; After the follicle releases its matured egg, it
changes into corpus luteum. This structure releases progesterone and estrogen,
thus keeping the uterine lining thick and ready for a fertilized egg to implant. If a
woman gets pregnant, the body will produce the hormone that pregnancy tests
detect which is called human chorionic gonadotropin (hCG). If a woman is not
pregnant, the corpus luteum will shrink and be reabsorbed by the body leading to
decreased levels of progesterone and estrogen, which causes the onset of the
period. After this the cycle will go along and will only change when the egg is
being fertilized, that will lead to conception or pregnancy
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Figure 2. Conception
Conception only happens when a woman is fertile and if there happened
to be sexual intercourse between a man and a woman. A man can ejaculate 40-
150 million of sperm cells which start to swim and race towards the fertilized egg
that waits in the fallopian tube during the woman’s ovulation phase. For a sperm
cell to successfully fertilize an egg, it would take, most likely, 24 hours to do it. As
soon as a single sperm cell penetrates the egg, the surface of the egg cell will
immediately change that will not allow other sperm cells to enter. At this time of
fertilization, the fetus’ genetic makeup and its gender is now complete. To
continue, the fertilized egg will start to grow fast which causes it to divide into
many cells. It will then leave the fallopian tube and will now enter the uterus 3 – 4
days after fertilization. The uterus is the female reproductive organ where the
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fertilized egg is implanted, which is called the process of implantation, and will
allow the egg to grow and form a baby.
Figure 3. Parts of the Female Reproductive System
Female reproductive systems are in charge of developing gametes (also
known as eggs or ova), certain sex hormones, and retaining fertilized eggs as
they form into a mature fetus and are ready for delivery. The fertile years of a
female are between menarche (the first menstrual cycle) and menopause
(cessation of menses for 12 consecutive months). During this time, ova are
cyclically expelled from the ovary, with the ability to be fertilized by male gametes
(sperm). This cyclical egg removal is a normal part of the menstrual cycle.
(Rosner et. al., 2020)
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Ovaries
Female gonads, the ovaries are the site of gametogenesis and sex
hormone secretion. Follicular growth takes place in the outer cortex of each
ovary, while blood vessels and connective tissue are found in the inner medulla.
Gamete (egg cell, oocyte) formation takes place in the ovaries. The ovarian
follicles provide an area for the developing egg cell (or oocyte). Follicles are
made up of a variety of cell types and numbers depending on their maturation
level, which is defined by their size. A surge of luteinizing hormone (LH) secreted
by the pituitary gland triggers follicle rupture and oocyte release after oocyte
maturation is achieved. Ovulation is the process of an oocyte developing and
being released. The follicle stays active and turns into a corpus luteum, which
secretes progesterone to ready the uterus for embryo implantation. Each month,
each ovary usually takes turns releasing eggs. This alternating egg release, on
the other hand, is completely random. The other ovary will begin to release eggs
each month whether one ovary is missing or inactive. (Rosner et. al., 2020)
Fallopian Tube
The fallopian tubes allow oocytes to pass from the ovaries into the uterine
cavity. The fimbriae are finger-like projections that help move the extracted
oocyte deeper into the tube—the fimbria transfer into the ampulla, the portion of
the tube with the widest lumen. When the lumen narrows and projects into the
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uterus, the ampulla transforms into the isthmus. The tube then enters the uterus
and becomes the interstitial part. (Foti et. al., 2016)
Uterus
The uterus, commonly known as the "womb," is a hollow organ that
receives, retains, and nourishes a fertilized embryo. It is situated in the pelvis
between the urinary bladder and the rectum. It's about the size and form of peach
for people who have never been pregnant. The uterus grows enormously in size
during birth, and pregnant women can feel it just past the umbilicus in the later
stages (Marieb & Keller, 2018).
The broad ligament suspends the uterus in the pelvis and anchors it
anteriorly. Additionally, it attaches posteriorly with the round ligament, made up of
fibro-muscular connective tissue. The circular ligament begins at the cornu of the
uterus and crosses the pelvis through the deep inguinal ring, then traverses the
inguinal canal and reaches the labia majora, where its fibers merge into the mons
pubis. The uterosacral ligament is connected to the uterine cervix anteriorly.
They are bound to the sacral vertebrae from behind (Chaudhry & Chaudhry,
2020).
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The uterus performs its role as the embryo grows inside the uterus during
pregnancy. It also plays a role in sexual response since it controls blood supply
to the external genitalia and pelvis. The uterus' reproductive function involves
accepting an already fertilized ovum from the fallopian tube to travel through the
utero-tubal junction. It then undergoes implantation into the endometrium, where
it grows solely by obtaining nourishment from blood vessels. The process
continues with developing the placenta bonding to the uterus' walls where the
embryo grows before childbirth.
Physiologic Changes in the Uterus
The uterus' shape varies dramatically in response to different factors such
as estrogen intake, menstrual cycle changes, and contractions. In terms of
menstrual cycle improvements, the uterine endometrium steadily thickens during
menstruation and is thickest throughout the secretory process. The outer
myometrium's signal strength improved during the secretory process, with the
peak signal intensity found in the mid-secretory phase, likely due to the
edematous myometrium. T2WI reveals a distinct presence in people using oral
contraceptives (OCs). (Kido & Togashi, 2016)
In comparison to the thinning of the endometrium, which can be seen on
ultrasound, the junctional region thickens, while the myometrium thickens and
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shows a brighter signal on T2WI relative to standard uterine photographs.
Patients who take gonadotropin releasing hormone (GnRH) analogs have a
reduced uterus, indicating myometrial and endometrial atrophy. As the GnRH
analog is consumed, the signal amplitude of the myometrium decreases as well.
Following NACT, both the uterine and ovarian sizes, as well as the signal
strength of the myometrium, decline to levels close to those observed in post-
menopausal women.
Another form of myometrial contraction known as uterine peristalsis
occurs in a non-gravid myometrium. On the ultrasound, uterine peristalsis is
defined as rhythmic and subtle wave-like endometrial motions consistent with
inner myometrium contractions. The frequency, height, and orientation of the
peristaltic waves have been observed to change during the menstrual cycle or in
response to hormonal changes. During the mid-cycle, for example, contractions
are normally retrograde (cervix to fundus) and anterograde (cervix to fundus)
during menstruation.
Vagina
The vagina is a fibromuscular tubular structure that runs from the vulvar
vestibule to the uterine cervix and is flexible. The introitus is the distal vagina.
The anterior vagina touches the posterior bladder wall, while the anterior rectum
touches the posterior vagina. (Rosner et. al., 2020)
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Vulva
The labia majora, labia minora, clitoris, vulvar vestibule, urethral meatus,
and vaginal orifice are all parts of the external female genitalia that make up the
vulva. The mons pubis is formed by the labia majora and minora fusing anteriorly
(a layer overlying the pubic symphysis). The urethra and vaginal openings are in
the vulvar vestibule, which is situated medial to the labia minora. Bartholin’s
glands open lateral to the vaginal opening. (Rosner et. al., 2020)
Cervix
The cervix is the uterus's lower third. It forms the uterus' neck and opens
into the vaginal canal (which is also called the endocervical canal). The cervix is
about an inch long and an inch wide. It is mostly made up of muscle tissue and
plays only a small role except during pregnancy or when a medical condition
arises. The os refers to the narrow opening of the cervix. During menstruation,
the cervical os helps the flow of menstrual blood out of the vagina. Cervical
mucus is produced from the cervix. Through the menstrual period, the cervical
mucus changes consistency. The cervix develops a lot of clear mucus during the
period of greatest fertility, which aids in pregnancy. (Cornforth, T. 2020)
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Normal trophoblast cell development
Fetal trophoblast cells are important for embryo implantation into the
uterus and are major components of the placenta that maintain proper fetal
growth and development. During placental growth, the trophectoderm quickly
spreads and begins to divide into both villous cytotrophoblasts and invasive extra
villous trophoblast (EVT) and syncytiotrophoblasts. Proliferating cytotrophoblasts
produce columns to bind to the maternal decidua at the tips of anchoring villi, and
differentiating EVT cells penetrate the maternal tissues, across the decidua, and
as far as the inner third of the myometrium. As trophoblast cells differentiate from
villous to extravillous, they continue to express HLA-G inside the trophoblast cell
column.
EVT cells invade the maternal tissues through two major pathways:
interstitial and endovascular, though there is some evidence for endoglandular
invasion as well. Endovascular EVT cells infiltrate the spiral arteries, retrograde
to flow, and block the artery openings, resulting in a hypoxic condition for the
developing embryo and placenta for the first 10 weeks of gestation. Interstitial
EVT cells move into the myometrium by breaking down the extracellular matrix
and passing into the cleared spaces in a strongly controlled manner. One of the
most important roles of invading interstitial EVT cells is to remodel the uterine
spiral arteries, enabling sufficient blood flow to the maternal–placental interface.
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Interstitial EVT cells can also terminally distinguish by becoming noninvasive
multinucleated giant cells, though the process by which these cells form remains
unknown.
In addition to differentiating into EVT cells, cytotrophoblast cells combine
with the syncytiotrophoblast to replenish expended nuclei and organelles that are
shed as apoptotic bodies known as syncytial knots, though the extent with which
this happens is debatable. The syncytiotrophoblast is needed for the exchange of
gas and nutrients through the placenta to and from the developing fetus. (Ning et
al., 2019)
Role of Placenta in Pregnancy
In research from Weinberg (2021), The placenta is essential for the fetus's
health and growth, as it transports oxygen and nutrients, facilitates waste
disposal, and acts as a buffer against pathogens and other hazardous
substances in the maternal bloodstream. When these mechanisms fail to operate
normally, pregnancy complications including preeclampsia and fetal growth
restriction may occur.The placenta is the developing fetus's heart, lungs, kidneys,
and immune system, and it plays an important role in the development of the
pregnancy. The placenta guarantees that the fetus gets enough oxygen and
nutrients, eliminates waste, and modifies the maternal immune system to prevent
the fetus from being rejected. It functions as a pathogen shield and reacts to the
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maternal environment. Failure of the placenta to perform these functions results
in negative, often life-threatening consequences. Whereas the placenta is
discarded once the birth is over, the effects of placental dysfunction will be felt by
both mother and child for a long time. The placenta's primary purpose is to
ensure that a constant flow of maternal blood is carried into close proximity to the
fetal blood, allowing for effective oxygen, nutrient, and waste exchange between
the fetal and maternal circulations. The forming placenta must do three things to
accomplish this exchange: (1) implant into the uterine wall, (2) modify the
incoming maternal spiral arteries so that blood flow delivery is enhanced to
improve capacity but decrease flow rate, and (3) create specialized structures
called villous trees to increase the surface area for exchange to occur.
Furthermore, the placenta must be able to double in size during
pregnancy to meet the fetus's growing needs. The placenta acts as a buffer
between the maternal and fetal circulations, regulating the flow of circulating
molecules by transporters at the placenta-blood interface. The placenta is more
than just a passive channel for transmitting oxygen and nutrients from the mother
to the fetus and eliminating waste products; it is an active participant in
pregnancy. The placenta derives information about the maternal physiologic
state from circulating molecules in the maternal blood, as well as sending
information in the form of placental hormones and growth factors.The placenta
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also emits molecules into the maternal and fetal circulations, such as cell-free
DNA and RNA, as well as a number of vesicles containing cargo including
microRNAs which can act at a distance.
Chromosomes
Chromosomes are in the nucleus (the center) of the body's cells. In the
form of genes, they bear genetic material. Most of the cells in the body have 46
chromosomes grouped in 23 pairs. Each pair of chromosomes has one
chromosome inherited from your mother and the other chromosome inherited
from your father. Our genetic code is made up of 46 chromosomes. This code
decides our appearance, how our body works, whether we become male or
female, and whether we inherit and develop certain diseases. Reproductive cells,
such as eggs (ova) in women and sperm in males, have only 23 chromosomes.
This is so that when a sperm fertilizes an egg during natural conception, the
resulting infant has 46 chromosomes in each cell, 23 from their mother and 23
from their father. The fertilized egg (ovum) contains all the genetic material
required for reproduction. Any cells from the fertilized ovum (called trophoblast
cells) mature into the placenta and membranes that surround the developing
baby after fertilization. The embryo, from which the baby develops, is formed by
other cells. The trophoblast cells develop into and bind to the lining of the womb
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(uterus) as the placenta grows, causing the fetus to implant in the uterus.
(Harding, 2016).
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CHAPTER III
METHODOLOGY
This chapter presents the discussion on the research design of the study,
the respondents, the locale of the study, research instruments, and procedure of
data collection that were used for accurate data analysis and interpretation.
Research Design
The researchers utilized the descriptive method using a qualitative
approach to determine and analyze the respondent’s case. The researchers
opted to use a descriptive method to obtain first-hand data from the respondent
and to describe the nature of Gravida 3 Para 2 Pregnancy Uterine Hydatidiform
Mole, Partial concerning the respondent’s case. The use of the qualitative
approach is advantageous as it is flexible and involves the collection and
analysis of non-numerical data to understand concepts and formulate in-depth
insights into a problem (Bhandari, 2020).
Respondents and Locale
The respondent of the study was identified through the scope of the study
whose diagnosis falls under Gravida 3 Para 2 Pregnancy Uterine Hydatidiform
Mole, Partial. The study was conducted at a Tertiary Hospital in General Santos
City.
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Research Instruments
In gathering the primary data and information relevant to the study, the
researchers observed and interviewed the respondent using a structured
interview form and performed a complete cephalocaudal assessment to the
patient. Secondary data were obtained from the doctors through interviews, and
through the patient's hospital records and charts.
Data Collection
The researchers' nursing program coordinator and clinical instructors
facilitated the request for permission in the hospital to conduct a research study.
A consent form was given to the respondent and the doctors which served as a
document proving that they have given their permission to participate in the
study. After signing the informed consent, data collection started by taking the
past and present health history of the patient. This was followed by a
cephalocaudal assessment to obtain the patient’s signs and symptoms and to
determine the patient’s overall condition. During the patient’s stay, the
researchers conducted an interview and direct observation to obtain subjective
data and recorded the answers by note-taking.
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CHAPTER IV
DATA PRESENTATION, ANALYSIS, AND INTERPRETATION
This chapter presents, analyzes, and interprets the Initial Data Base and
Nursing Health History, which consists of the patient's past and present health
records and activities of daily living. Also, this chapter presents the patient's
Physical Assessment, Pathophysiology of the disease, and Medical and Nursing
Management that was given during the hospital stay.
Initial Database
Demographic data
Name Patient A.B.
Age 41 years old
Birthday February 21, 1980
Place of Birth General Santos City
Address Polonuling, Tupi, South Cotabato
Sex Female
Civil Status Married
Religion Roman Catholic
Occupation Government Employee
Nationality Filipino
Educational Attainment College Graduate
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Date of Admission April 25, 2021
Time of Admission 6:41AM
Chief Complaint Vaginal bleeding, nausea and vomiting,
abdominal discomfort
Admitting Diagnosis G3P2 PU Threatened Abortion vs.
Hydatidiform-Mole
Final Diagnosis Gravida 3 Para 2 Pregnancy Uterine
Hydatidiform Mole, Partial
Nursing Health History
A. Past and Present Health History
Past Health History
Patient A.B. was born on February 21, 1980, via normal spontaneous
vaginal delivery at General Santos City. She was the oldest among four siblings.
Her family was originally from Polonuling, Tupi, South Cotabato but in the year
2000, she moved and stayed in General Santos City because she went to
college there. Their family’s source of living was her father’s farm. Since their
home was close to the sea, her mother worked as a fish vendor.
According to Patient A.B., her father was on dialysis for two years and
died last 2010 due to Renal Failure. Her mother was diagnosed with Lung
Cancer after her father’s death and died last 2012. Patient A.B. claims that both
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of her parents had high blood pressure and her father had diabetes which was
the cause of his kidney stones. Also, the second-born and third-born child in their
family has diabetes and high blood pressure, respectively. She stated that there
was no one in their family member who had cancer except for her mother.
Moreover, her mother had vices. Back then, her mother was a smoker as
evidenced by her verbalization, “Mga isang pack siguro sa isang araw. Bata pa
lang ako naninigarilyo na siya. Huminto siya noong nagcollege na ako”.
Patient A.B had her first menstruation when she was in fifth grade. She
was ten years old at that time. She claimed that she did not have any other
health issues besides heavy and irregular menstruation. She changed her
sanitary napkins about three times per day during her menstruation cycle and
doubled the sanitary napkin to prevent the menses from passing through. Her
menstrual cycle was inconsistent; her menstruation was delayed for about two
weeks up to two to three months. However, she did not seek any medical
attention from an OB-Gyne and just endured the abdominal pain during her
menstrual period.
According to Patient A.B, she loved to eat vegetables. She and her family
only eat meat every weekend because it was expensive. She also liked sweets.
Whenever there are birthdays, and other events, she drinks soft drinks.
Moreover, patient A.B claimed that she had no vices as evidenced by her
verbalization, "Wala naman. Dati, before ako ikinasal, umiinom lang ako kaunti.",
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she drank a small amount of alcoholic beverages around two to three cups once
or twice a month occasionally.
Patient A.B completed her bachelor's degree in Marketing Management at
the age of 24. Right after she graduated her uncle employed her as a Local
Government Employee in Tupi. She got married in September 2014. Her
husband’s blood type is O+. Her husband originally lived in General Santos City,
but because no one else lives in their house in Polonuling, Tupi, they had
decided to stay there with their children for good. Patient A.B have two children.
On December 23, 2016, her oldest child was born, and her second child was
born on January 18, 2018, both at St. Elizabeth Hospital, Inc. Patient A.B stated
that in her first delivery she was admitted to the hospital one month prior to her
expected date of delivery (EDD) due to elevated blood pressure and she was
diagnosed with diabetes, so her doctor M.G., M.D. opted to deliver the baby via
cesarean section. According to Patient A.B., her doctor, M.G., M.D., informed her
that if she became pregnant again, it would still be through cesarean section.
Doctor M.G. then gave her an antihypertensive medication. She claimed that she
took her drug maintenance on a regular basis, which include Losartan 50mg 1
tab PO OD in the morning and Metformin 500mg 1 tab PO OD at night. Patient
A.B. had no history of allergies in dyes or shellfish and no blood reaction.
Right after her delivery, Patient A.B. stated that her menstrual cycle was
regular after her delivery than it had been in the past. However, she claimed that
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three times a year her menstruation was delayed by two to three months.
Furthermore, she said that the abdominal pain only occurred once every two
months, yet it was painful within the first two days of menstruation.
Her last menstrual period (LMP) was on March 14, 2021, which was six
weeks prior to her admission. According to her she never suspected that she was
pregnant assuming that she was only delayed given that in her younger years
she was used to having delayed menstruation. She did not also notice that her
stomach had grown as evidenced by her verbalization, “Hindi talaga, kasi akala
ko delayed lang ang menstruation ko. Hindi ko rin napansin na lumalaki ang tiyan
ko kasi mataba na ako dati pa”.
Two weeks prior to admission, Patient A.B once felt nauseated upon
waking up. A week later, it happened once every two days. She claimed that she
was unable to seek the doctor last week because she did not have time. On April
25, 2021, the patient woke up at 5:45 AM nauseated and with abdominal
discomfort. When she got in the toilet, she saw that she had been bleeding
vaginally, with “dark, circular fragments or clots” coming out with the blood,
hence admission. On April 25, 2021, at 6:30 AM, she and her husband decided
to go to a tertiary hospital in General Santos City.
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Present Health History
On April 25, 2021 at 6:30 AM, Patient A.B was admitted to a Tertiary
Hospital in General Santos City with a chief complaint of vaginal bleeding,
nausea and vomiting, and abdominal discomfort. When she was asked about the
characteristics of her vaginal discharges, patient A.B. stated that when she got in
the toilet, she saw that she had been bleeding vaginally, with “dark, circular
fragments or clots'' coming out with the blood.
She underwent laboratory and radiologic tests such as chest X-ray PA,
HBsAg (qualitative), Blood Typing/Rh Typing, B-hCG, Urinalysis, and Complete
Blood Count. At 6am, vital signs were taken every 2 hours with ongoing IVF of #4
D5LR 1L at 25gtts/min, which will be due at 7:50AM later. The doctors also
ordered routine medication of Cefuroxime 750mg IVTT qH and Ketorolac
(Dyrolac) 30mg IVTT. At 6:50am, blood samples were drawn in the ER,
underwent chest x-ray and stat ultrasound of the whole abdomen before
transferring patient A.B to Obstetrical Ward. At 7am, lochia rubra is noted as well,
with fragments and mucus. Upon palpation, the fundus is 3 inches below the
umbilicus and feels firm. Patient’s lips and mucous membranes are pinkish but
dry, blood capillary refill is less than 2 seconds. Patient verbalized, “Masakit ang
likod ko sa may bandang baba.” Pain scale was 5/10. “Sumasakit kung
gumagalaw ako pero nakakaya ko rin naman ang sakit.”
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At 9:15 am, the patient verbalized that she wanted to go to the comfort
room, but she still felt dizzy. The doctor also ordered an increased intake of liquid
to decrease her blood pressure. The doctor stated that her hCG levels still must
be checked to determine if the hCG levels are still high. If this is indeed high,
there is a possibility of malignancy. Otherwise, the physician declared a good
prognosis. If she will have her regular HCG and follow-up checkups after
discharge, malignancy, if there are any, may be detected immediately.
B. Activities of Daily Living
Date of Interview: April 26, 2021
1. Health Perception/Health Management
Before Hospitalization
The patient did not get sick but every time she felt pain due to
dysmenorrhea, she drank Buscopan to ease the pain. She could not go to the
hospital even when she was vomiting due to lack of time and she also did not
feel that she was pregnant. No one monitored her blood pressure at home, but
she still took her maintenance drugs such as Losartan 50mg 1 tab OD and
Metformin 500mg 1 tab OD.
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During Hospitalization
The patient took every medication that was given to her especially when the
nurse explains the purpose and use of these drugs.
2. Nutrition and Metabolism
Sometimes, patient A.B cannot take her breakfast when she is at work.
She was fond of eating vegetables, especially ampalaya and kangkong that she
always bought in the office canteen. They usually eat meat such as pork and
chicken for dinner. Usually, when they are busy at work, she states that she can
just finish one and a half-liter of water, and in line with this, she does not drink
any soft drinks or juices.
Patient A.B eats what she can tolerate as indicated on the doctor’s order that
the patient is on DAT.
3. Elimination
The patient does not experience pain when urinating and the urine was
usually light in color. She urinates every break time. Sometimes, she felt pain
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when eliminating waste, especially when there was pain in her abdomen, and
she only eliminates waste once every two days as verbalized by the patient.
She does not feel any pain when urinating and she is not used to wearing
a diaper. She could not go to the comfort room as she still feels dizzy, and the
doctor also ordered for bed rest.
4. Activity and Exercise
Since Patient A.B. had worked as a Local Government Employee at Tupi
and was busy during her spare time, she did not exercise at home. She was the
one who prepared food for their children in the morning and took care of
household responsibilities such as washing dishes, doing laundry, and ironing.
She did not get tired easily. After doing household chores, she would watch
movies or visit their next-door neighbor to chat.
Patient A.B. is on bed rest.
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5. Sleep and Rest
Patient A.B. slept around 10:00 or 11:00 in the evening and woke up at
4:00 in the morning, attaining approximately 6 to 7 hours of sleep during working
days. During the weekend she woke up at 5:30 in the morning, attaining
approximately 7 to 8 hours of sleep. She often slept for 1 or 2 hours after doing
household chores. Their home was humid, so she would turn on the air
conditioner to sleep comfortably.
Patient A.B was able to sleep last night due to the side effect of
anesthesia, the side effect is that she was exhausted. She is not at ease
because she had a lot of tubes hanging from her body. She only wakes up when
the nurse comes to her room. She also cannot sleep with the lights turned on.
6. Cognition
Patient A.B could see clearly without eyeglasses. She could speak and
understand Tagalog, English, Bisaya, and Ilonggo.
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Patient A.B, can talk and is focused as evidenced by her verbalization,
““Ako si A.B. Andito ako sa hospital, sa OB ward. Ang oras ngayon ay 11am.”,
“Naiintindihan ko naman ang ineexplain sa akin ng doctor at mga nurse.”
7. Self-Perception and Self-Concept
Patient A.B.’s goal in life was to provide her children a decent life. If she
suspected that her children were having issues, she spoke to them right away.
Similarly, whenever a problem arose in their household, she immediately sought
out his husband to resolve the situation. They fought sometimes, but they
eventually found a solution to resolve their family problem.
Patient A.B. is unable to decide on her own in terms of medical matters
and depends on her husband as evidenced by her verbalization, “Nahihirapan
akong gumawa ng desisyon kung medical na ang pinag-uusapan, kaya talagang
kailangan ko munang kausapin ang asawa ko”.
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8. Roles and Relationship
Patient A.B. had a lot of friends, and she was close to her office staff and
even her children. If her colleagues, coworkers, or children had an issue or
problem, she was the one they run to. She had a successful relationship with
both her children and husband because whenever there was an issue or problem
that may arose in their family, they resolved it immediately. She was a serious
individual who also knew how to socialize with her friends, office staff, and she
was familiar with most of the residents in Polonuling, Tupi because she grew up
there. Moreover, whenever she had the time, she went to her neighborhood
which is her college best friend to chat.
Patient A.B. claimed that before she entered the OR her neighbor and co-
office staff visited her. Her children were unable to visit her in the hospital
because they were not allowed yet, after her operation, they were able to talk via
videocall. Only her husband was watching over her.
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9. Sexuality
Patient A.B. did not use any forms of contraception. She assumed that
she is in the menopausal stage since her last menstrual period (LMP) was on
March 14, 2021, which was six weeks prior to her admission.
Patient A. B’s husband is present at her bedside to watch over her and
leaves only when it is necessary such as to buy their food or medications.
10. Coping and Stress Tolerance
According to Patient A.B, despite having a lot of office workload, she
claimed that she still finds a way to finish their papers in the office within the day
because cramming would trigger her stress. She was stressed at home because
she was always the one who does the household chores. She tends to raise her
voice to her children at times, but she eventually understands them because she
knows they have their own needs that she needs to sustain.
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Patient A.B gives her full trust in the doctors and nurses, and she still
imagines her family by her side.
11. Values and Beliefs
Patient A.B. was a Roman Catholic. They went to church in their barrio
every Sunday with her husband and children. She prayed every night and asked
God to bless her family. She constantly asks her children to pray first before
eating.
Patient A.B prayed hard to God before she was brought to the hospital.
Even now she still thanks God that nothing bad happened to her. While waiting
for the pending laboratory results, she believes that God will not leave her, and
everything will be okay.
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Physical Assessment
A. General Survey
Date: April 26, 2021
1. Appearance
Received lying on bed in semi-Fowler's position, awake, conscious, and
coherent. With an IVF of #4 D5LR 1L at 25 gtts/min hooked at the left metacarpal
vein, patent, and intact. IVF level of 90cc is noted. With Oxygen inhalation of
2L/min via nasal cannula. Lochia rubra is noted as well, with fragments and
mucus. Upon palpation, the fundus feels firm and is located 3 inches below the
umbilicus. Patient’s lips and mucous membranes are pinkish but dry, blood
capillary refill is less than 2 seconds. Patient verbalized, “Masakit ang likod ko sa
may bandang baba.” Pain scale was 5/10. “Sumasakit kung gumagalaw ako pero
nakakaya ko rin naman ang sakit.” Fingernails are clean and well-trimmed, but
the toenails are dirty and untrimmed. Skin is warm to touch and has good skin
turgor.
2. Mental Status
Patient A.B. had a Glasgow Coma Scale score of 15. A score of 15 is
interpreted as in mild condition wherein the patient opens her eyes
spontaneously, scored as 4; when asked, she correctly stated her name, place,
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and date as a verbal response, scored as 5; and obeys command as a motor
response, scored as 6.
3. Vital Signs upon Admission Date: April 25, 2021
Patient’s Vital Signs Results Normal Range
Temperature 37.2 °C 36.5°C-37.5°C
Pulse rate 113 bpm 60-100 bpm
Respiratory rate 23 cpm 12-20 cpm
Blood Pressure 130/90 mmHg Systolic: 84 - 120
Diastolic: 54 - 80
Oxygen Saturation 97% 96%-100%
4. Vital Signs upon Assessment Date: April 26, 2021
Patient’s Vital Signs Results Normal Range
Temperature 36.5 °C 36.5°C-37.5°C
Pulse rate 91 bpm 60-100 bpm
Respiratory rate 20 cpm 12-20 cpm
Blood Pressure 120/90 mmHg Systolic: 84 - 120
Diastolic: 54 - 80
Oxygen Saturation 99% 96%-100%
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B. Cephalocaudal Assessment
Date: April 26, 2021
1. Skin
The patient’s skin is uniform in color, without the presence of any foul
odor. Skin returns to normal after pinching and no swelling found. Skin is warm to
touch. There is loose skin at the abdominal area and scar from caesarean
section found in the hypogastric region.
2. Hair and Scalp
The hair of the patient is black, thick, oily, and silky. Hair is evenly
distributed and there are no signs of infection and infestation observed.
3. Nails
Fingernails are clean and well-trimmed, but the toenails are dirty and
untrimmed. It is hard, firm, and smooth. Nail plates are firmly attached to nail
beds. Capillary refills in less than 2 seconds and skin returns to normal after
pinching. No lesions, bleeding, and pain was noted.
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4. Head and Neck
The head of the patient is round; normocephalic and symmetrical. There
are no nodules or depressions and masses upon palpation. Her face is round,
smooth, and symmetrical. Temporal artery is nontender and elastic. Neck is
symmetric with centered head position without the presence of bulging masses
and lesions. Has a full range of motion of the neck, smooth, controlled, and with
no discomfort. Can resist when force is applied. Trachea is in the central midline
of the neck.
5. Eyes
The patient’s external eye assessment shows eyeballs are symmetrical in
size and position, eyeballs are in the same plane as eyebrow and maxilla, each
upper lid covers upper portion of cornea when patient is looking straight, eye
lashes span outwards, the edge of the lids are in apposition to eyeballs, small
lachrymal gland is recognizable, and hair distribution in eyebrows is in its entire
length. On PERRLA’s test, the patient’s eyes when light is flashed to the right
eye, the right eye constricted and when light is flashed to the left eye, the left eye
constricted.
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6. Ears
Ears are equal in size bilaterally with no swelling and thickening upon
inspection. Skin is intact, smooth with no lumps, lesions, and nodules. The pinna
and tragus are firm, no pain felt, and when palpating the mastoid process is
painless. Auricles are symmetrical, aligned with the corner of each eye, and have
the same color with facial skin. No discharge, swelling, and redness.
7. Nose
Nose appears symmetric, smooth, straight, and uniform in color with the
facial skin, and proportion to the other facial features. There was no presence of
discharge and no nasal flaring is noted.
8. Mouth
Patient’s lips are pinkish but dry. The buccal mucosa of the patient
appeared as uniformly pale pink; moist, soft, and without exudates. Gums are
pink without swelling or redness. No retraction of gums. There are 32 yellowish
teeth present and the dental cavity was noted at the upper first molar. The
tongue is centrally positioned midline with no tremors. It is pink in color, moist
and smooth. Equal bilateral strength in tongue. The smooth palates are smooth
and pink in color while the hard palate has a more irregular texture. The uvula of
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the client is positioned in the midline of the soft palate. Tonsillar pillars are pink
and symmetric.
9. Neck
Neck is symmetric with centered head position without the presence of
bulging masses and lesions. Has a full range of motion of the neck, smooth,
controlled with no discomfort and can resist when force is applied. Trachea is in
the central midline of the neck. Thyroid glands are not visible but palpable when
swallowing. Lymph nodes are nonpalpable. No enlargement and inflammation
noted.
10. Chest and Lungs
The patient had no history of smoking, anterior and posterior chest have
intact skin and equal chest expansion. Resonance is percussed and auscultated
in the posterior and anterior thorax. Lesions, masses, and abnormal inspiratory
retraction of the interspaces are not observed as the thorax is inspected. Chest
excursion is noted to be symmetrical without lag and no adventitious sounds
noted. Skin color is the same with upper limbs and neck and sternum is midline.
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11. Axillae
No inflamed lymph nodes, lumps or masses noted upon palpation.
12. Peripheral Vascular System
Patient’s peripheral pulses are all present and strong. No masses, no
tenderness, heart sounds are clear and strong. There were no reports of
shortness of breathing and chest pain. Veins are visible in the feet and varicose
veins are noted at the interior part of the calf.
13. Abdomen
Scar from caesarean section is noted in her hypogastric region and loose
skin from her previous pregnancy. Upon palpation, fundus is halfway the
symphysis pubis and umbilicus.
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A molar pregnancy, otherwise called a Hydatidiform mole — is an
uncommon complication of pregnancy described by the unusual development of
trophoblasts, the cells that usually develop into the placenta. As the cells
degenerate, they are filled with liquid and show up as clear liquid-filled, grape-
sized vesicles. With this condition, the embryo fails to create a primitive start.
Such structures should be recognized because they are related to
choriocarcinoma, a rapidly metastasizing malignancy (Molar Pregnancy -
Symptoms and Causes, 2017). The rate of gestational trophoblastic sickness is
roughly 1 in every 1,500 pregnancies (Bruce & Sorosky, 2020).
In Patient A.B.'s case, one of the predisposing factors is her gestational
age, wherein women older than 35-year-old are at risk for this condition.
Furthermore, Patient A.B. is a 41-year-old woman, which makes her susceptible
to this disease. The patient also has an Asian heritage (Filipino). Although molar
pregnancy has no racial or ethnic preference, some studies show that Asian
countries have a 15 times higher rate of developing molar pregnancy than the
U.S. (Bruce & Sorosky, 2020). Furthermore, the patient experienced low protein
intake during her younger years because she only ate vegetables during
weekdays since meat is expensive. She also mentioned that her menstruation is
usually irregular. According to a research by Johnson (2019), irregular cycles can
lead to infertility if not checked by a physician or healthcare provider since this
might mean that a woman is not ovulating. Patients can be susceptible to
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diseases that lead to health complications, including molar pregnancy. Although
molar pregnancy is a rare condition, there is still a possibility that a pregnant
woman can acquire this. Pregnancy is considered a precipitating factor because
hydatidiform moles cannot form without sperm cells penetrating the egg cell
through fertilization. Also, the patient's blood type is A. Some researchers state
that women with blood type A are more likely at risk for developing gestational
trophoblastic diseases, but the reason is still unknown (Gestational Trophoblastic
Disease - Risk Factors, 2021).
Fertilization has four stages, and the first is sperm preparation. During
this stage, the penetration of sperm into the egg occurs. Next is the sperm-egg
recognition binding. As the sperm penetrates the egg, it notices that the eggs are
empty, which makes it nonviable, leading to the entrance of multiple sperms. In
natural sperm-egg recognition binding, an egg needs only one sperm that should
bind to it. After that, a sperm-egg fusion and fusion of sperm and egg pronuclei
and activation of the zygote happens. In this stage, the two sperms fertilize the
egg. Typically, each sperm and egg cell contributes 23 (DNA pieces that hold our
genes) to produce a cell with 46 chromosomes (Gundersen & Shapiro, 2018).
When two sperm cells simultaneously fertilize an egg cell, the result is a partial
hydatidiform mole.
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Instead of the typical two sets of chromosomes, the fertilized egg has three
groups (69 chromosomes). An embryo with three sets of chromosomes cannot
develop naturally into a baby. Apart from that, a malformed fetus is born, along
with some typical placental tissue and a partial hydatidiform mole. Then,
trophoblastic development happens wherein excess trophoblast tissue grows into
abnormal masses that are usually benign but can sometimes become cancerous.
In the case of Patient A.B., she was diagnosed with partial hydatidiform
mole wherein the fertilized egg contains the normal maternal DNA but double the
number of paternal DNA. This is because the embryo only partially develops and
does not become a viable fetus. In partial hydatidiform mole, some chorionic villi
are formed. Because this is a partial molar pregnancy, there is a fetal tissue
development, unlike with the complete hydatidiform mole where fetal tissue is
absent. In this condition, there is no infant development because it is miscarried
early in the pregnancy. With Patient A.B.'s case, the fetus did not survive
because of incomplete implantation and a high hCG level of 240,516 mIU/ mL.
Typically, the hCG level in her status should only range from 1,080-56,500
mIU/ml.
Before admission, the patient experienced some signs and symptoms of
Partial Hydatidiform Mole. These are pelvic pain, vaginal bleeding, elevated
blood pressure caused by vaginal bleeding, and nausea and vomiting due to an
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abnormal rise in hCG levels. Her bleeding also led to anemia and its signs and
symptoms. On the other hand, her red blood cells count in the laboratory test are
within the normal range. That is why it cannot be a call for concern. During the
initial assessment, the patient rated her pelvic pain with a pain scale of 5/10, and
her blood pressure was 130/80 mmHg. Because of early diagnosis and proper
treatment, Partial Hydatidiform Mole (Molar Pregnancy) can be curable and has a
lesser chance of developing into malignancies.
With the rare chance of developing into malignancy or death, non-
pharmacologic and pharmacologic measures are administered to the patient to
attain an excellent prognosis. Partial Hydatidiform Mole is managed through non-
pharmacological interventions: Chest X-ray, HBsAg test, blood typing, Beta-hCG
test, Complete Blood Count, Urinalysis, Antigen swab, Pelvic ultrasound,
Pregnancy test (serum), Activated Partial Thromboplastin Time (aPTT), Partial
Thromboplastin Time (PTT) with INR, Biopsy, Direct Anti-globulin Test, and
Dilatation and Curettage.
For the Pharmacologic Interventions: Cefuroxime 750mg IVTT, Ketorolac
30mg IVTT, Losartan, Metphormine 500 mg/tab, FeSO4, Nalbuphine,
Diphenhydramine, Paracetamol, Methylergonovine Maleate were administered
as ordered by the physician. Since the patient was feeling good and there were
no complications during and after the medical procedures, the physician noted
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that the patient’s prognosis was good. Also, because it was detected earlier and
interventions were administered on time, partial hydatidiform mole can be easily
treated.
If it is not appropriately cured and discovered late in pregnancy,
Gestational Trophoblastic Neoplasia can transpire where there is a constant
growth of abnormal placental tissue. Also, it can turn into an invasive mole where
molar cells spread to other organs. Lastly, it can be cancerous and turn into
Gestational Choriocarcinoma, leading to the patient's death if complications
arise.
Medical Nursing Management
A. Medical Management
The patient arrived via wheelchair from Tupi, South Cotabato to a tertiary
hospital at General Santos City. She was admitted at the Obstetric Ward with an
initial diagnosis of G3P2 PU Threatened Abortion vs. Hydatidiform mole.
Chest X-Ray
The posteroanterior (PA) chest view examines the organs, tissues, and
bony structures of the thoracic cavity. It is used to diagnose conditions relating to
organs of the thoracic cavity. Also, it is used to detect pneumoperitoneum or
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intraperitoneal gas in patients with acute abdominal pain as it serves as the most
sensitive plain radiograph (Er, A. et al., 2020).
HbsAg (Qualitative) Test
HbsAg qualitative test detects the presence of hepatitis B surface antigen
in human serum or plasma. HbsAg is present on the surface of a causative agent
(hepatitis B virus) of hepatitis B. HbsAg test is done to patients who undergo
blood transfusion as they are at risk of hepatitis B infection. It is also done to
patients who will undergo surgery (Abbott Laboratories, 2010).
Blood Typing/Rh Typing
Blood typing is a method which determines a person's type of blood and is
grouped according to the ABO blood typing system. Rh typing is done to identify
if the surface of RBCs contains Rh factor. These are done to ensure that the
person can safely donate a blood or receive a blood transfusion (Bethesda,
2021).
Beta Human Chorionic Gonadotropin (Beta-HCG) Test
Beta-Human Chorionic Gonadotropin (Beta-HCG) Test measures the level
of beta HCG present in the blood. Beta HCG is normally produced by the cells of
the developing placenta during pregnancy however high levels of beta HCG can
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also be seen in certain tumors. This is done for the diagnosis of gestational
trophoblastic disease (Betz & Fane, 2020).
Complete Blood Count
Complete blood count evaluates the level of blood components such as
red blood cell, white blood cell, platelets, hematocrit, and hemoglobin. Abnormal
increase or decrease in level may indicate underlying medical conditions such as
anemia and infection (Complete blood count (CBC), 2020).
Urinalysis
Urinalysis is a diagnostic test that detects the presence of diseases.
Urinalysis includes inspection of the color, clarity, specific gravity, and pH of the
urine and presence of glucose and albumin in the urine (Urinalysis, 2019).
Antigen Swab Test
Antigen swab test is a diagnostic test for viral infection. It is an
immunoassay which detects the presence or absence of viral proteins (Centers
for Disease Control and Prevention [CDC], 2020).
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Pregnancy Test (Serum)
Serum pregnancy tests measure human chorionic gonadotropin (hCG)
which is produced after implantation by placental synctiotrophoblasts. Positive
result indicates that the woman is pregnant however there are cases of false-
positive result which may indicate a woman has hCG-producing tumor (Betz, D.
& Fane, K., 2020).
Pelvic Ultrasound
Pelvic ultrasound is a noninvasive procedure which assesses the
structures and organs within the female pelvis. It produces images which allows
visualization of uterus, ovary, and other pelvic organs and structures (John
Hopkins Medicine, N/A).
Activated Partial Thromboplastin Time (aPTT)
Activated Partial Thromboplastin Time is a screening test that determines
the number of seconds a clot is formed in a sample of blood after an activator
(reagents) are added which speeds up the clotting time and results in a narrow
reference range. It is also used to determine the patient’s response to heparin
therapy (Prothrombin Time and International Normalized Ratio (PT/INR), 2019).
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Partial Thromboplastin Time with International Normalized Ratio
The partial thromboplastin time is a test that evaluates a person’s ability to
appropriately form blood clots. The PTT assesses the amount and the function of
certain proteins in the blood called coagulation or clotting factors that are an
important part of blood clot formation. It may be ordered along with an
international normalized ratio to monitor individuals who are being treated with
the blood-thinning medication (anticoagulant) warfarin (Prothrombin Time and
International Normalized Ratio (PT/INR), 2019).
Biopsy
Biopsy is a procedure where cells or tissues are removed from the body to
be analyzed in the laboratory to check for damage or disease (Bethesda, 2017).
Direct antiglobulin test
The direct antiglobulin test is used primarily to determine if the antibodies
attached to RBCs are the cause of hemolytic anemia and to investigate a blood
transfusion reaction (Karp, J., et al., 2020).
Dilatation and Curettage
Dilation and curettage is a medical procedure wherein the cervix is dilated
and endometrial lining is scraped to diagnose and treat abnormal or excessive
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uterine bleeding (Todd, 2020).
B. Laboratory Results
1. RADIOLOGIC REPORT – 4/25/21- 7:00 AM
Chest PA
The patient is free from any problems in the lungs and heart. No other
significant findings.
Impression:
• Essentially negative chest radiograph
2. MICROBIOLOGY RESULT- 4/25/21
I. HbSAg (qualitative)- 4/25/21- 6:50 AM
Result: Nonreactive
No hepatitis B surface antigen was found.
II. Blood Typing/ Rh Typing- 4/25/21 6:50AM
ABO: A
Rh Type: POSITIVE
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III. B-HCG (stat)- 4/25/21- 6:50AM
Result: 240,516 mIU/ mL
The B-HCG result of the patient is higher compared to the normal result in
her case which is 1,080-56,500 mIU/ml. This is also one of the bases why the
patient is diagnosed with H-mole because high B-HCG means that there is a
molar pregnancy.
IV. Complete Blood Count
Table 1
Complete blood count upon admission on April 25, 2021 (6:50AM)
TEST NAME RESULT NORMAL INTERPRETATION
RANGE
Hemoglobin 11 g/dl 11.6 – Low hemoglobin count indicates
15.8 that the body's tissues have an
(g/dL) insufficient oxygen supply.
Hematocrit 35.2% 36% - The hematocrit level of the patient
48% is slightly below the normal range.
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Erythrocytes 4.0 4.5 – 5.5 Low RBC count may trigger a
vitamin B6, B12, or folate
deficiency. Internal bleeding, renal
failure, or malnutrition (when a
person's food lacks adequate
foods to satisfy their body's needs)
signify low RBC count.
RBC Indices
MCV 82 fL 78 – 90 fL MCV is within the normal range
MCH 29.3 pg 27 – 32 The MCH is within the normal
pg range
MCHC 32.7 g/dL 30 – 38 The patient’s MCHC is within the
g/dL normal range
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Leukocytes 9.78×103/uL 3.6 - 9.0 The leukocytes of the patient are
(WBC) (×103/uL) higher than the normal range and
increased White blood cells
indicate an infection or due to the
physiologic stress induced by the
pregnant state.
Differential
Count
Segmented 0.80 2.0 – 7.0 The neutrophils of the patient are
Neutrophils x109 low and low neutrophils can
indicate the presence of an
infection.
Lymphocytes 0.07 1.0 – 3.0 The lymphocytes of the
x109 patient are low. Low lymphocyte
levels indicate that the body has a
problem in fighting off infection.
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Monocytes 0.11 0.2 – 1.0 The monocytes of the patient are
x109 within the normal range.
Eosinophil 0.01 0.02 – 0.5 The patient's eosinophil count is
x109 low, and this can indicate that an
illness or infection is not
adequately isolated or controlled.
Basophil 0.02 – 0.1
x109
Platelet 297.00(×109/uL 120 – 400 The patient’s platelet count is
Count (×109/uL) within the normal range.
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V. Complete Blood Count
Table 2
Complete blood count on April 25, 2021 (11:40PM), Post-BT
TEST NAME RESULT NORMAL INTERPRETATION
RANGE
Hemoglobin 11.8 g/dl 11.6 – The patient’s hemoglobin count is
15.8 within normal limits. This indicates
(g/dL) that her body has enough oxygen.
Hematocrit 35.7% 36% - A hematocrit that is lower than
48% normal can signify a lack of healthy
red blood cells (anemia)
Erythrocytes 4.2 4.5 – 5.5 Low RBC count may trigger a
vitamin B6, B12, or folate
deficiency. Internal bleeding, renal
failure, or malnutrition (when a
person's food lacks adequate foods
to satisfy their body's needs)
signify low RBC count.
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RBC Indices
MCV 83 fL 78 – 90 fL MCV fluctuates in proportion to
the total size of red blood cells.
MCH 28.4 pg 27 – 32 The patient’s MCH result is within
pg normal range.
MCHC 33.5 g/dL 30 – 38 The patient’s MCHC is within
g/dL normal limits.
Leukocytes 10.21×103/uL 3.6 - 9.0 Increased White blood cells
(WBC) (×103/uL) indicate an infection or due to the
physiologic stress induced by the
pregnant state.
Differential
Count
Segmented 0.81 2.0 – 7.0 Low neutrophils can indicate the
Neutrophils x109 presence of an infection.
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Lymphocytes 0.08 1.0 – 3.0 Low lymphocyte levels indicate that
x109 the body has a problem in fighting
off infection.
Monocytes 0.11 0.2 – 1.0 Low monocytes show that the body
x109 has a decreased overall white
blood cell count.
Eosinophil 0.01 0.02 – 0.5 Eosinophils fight diseases linked
x109 with allergens and infectious
microorganisms. Low eosinophil
count can indicate that an illness or
infection is not adequately isolated
or controlled.
Basophil 0.02 – 0.1
x109
Platelet 263.00(×109/uL 120 – 400 Platelet count is within normal
Count (×109/uL) range.
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VII. URINALYSIS
Table 3
Urinalysis result on April 25, 2021 (7:02AM)
TEST RESULT NORMAL Interpretation
NAME RANGE
Urine Amber Yellowish The urine color is within the normal range
Color yellow to amber
Urine Clear Clear The urine clarity is within the normal range.
Clarity
Glucose Negative Negative There is no glucose noted in the urine of the
patient which is a normal finding
Albumin Negative Negative No albumin was noted which means that the
patient’s kidney is healthy.
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Mucus Few Few The mucus threads are within the normal
Threads range.
Sq. Rare Rare There is a rare squamous epithelial cell seen
Epithelial in the urine which means that the result is
Cells normal.
Red 2-5/HPF 4 HPF There are 2-5 HPF RBC noted in the
Blood patient’s urine which means that there is a
Cells possible infection l,m[because RBC
shouldn’t be seen the urine except only if the
patient is having menstruation and in the
case of our patient, she is experiencing
vaginal bleeding which means that RBC in
the urine is a normal finding.
White 2-5/HPF 2-5/HPF The WBC of the patient is in the normal
Blood range.
Cells
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pH 5.5 4.5-8 The result shows a slight increase in the
amount of time that the blood can clot e pH
level of the patient’s urine is within the range
which is 5.5 in which the normal range can
vary from 4.5-8.
Specific 1.005 1.005 The patient’s specific gravity is within the
Gravity normal range.
VII. Antigen Swab- 4/25/21- 6:50AM
Result: Negative
The patient is negative from SARS-CoV-2 virus.
VIII. Pelvic ultrasound (stat) - 4/25/21- 7:00AM
Impression:
• Fetal demise (crowd rump length: 7mm) with placental hydropic change
and fetal hydropic regeneration.
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• Greatly enlarged placenta relative with the size of the uterine cavity.
IX. Pregnancy Test (serum) - 4/25/21- 6:50AM
Result: POSITIVE
X. ACTIVATED PARTIAL THROMBOPLASTIN TIME
Table 4
Activated Partial Thromboplastin Time result on April 25, 2021 (9:15AM)
Examination Result Interpretation
Control time 30.2 This is the reference range of the patient’s APTT
seconds
Patient time 31.1 The result shows that there is a delay in the clotting
seconds factor of the patient’s blood
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XI. PARTIAL THROMBOPLASTIN TIME WITH INR
Table 5
Partial Thromboplastin Time with INR result on April 25, 2021 (9:15AM)
Examination Result Interpretation
Control time 11.3 This is the reference range or baseline data of the
seconds patient’s PTT with INR
Patient time 11.4 The result shows a slight increase in the amount of
seconds time that the blood can clot
95.9% The % activity of the patient is within the normal
range which is 85%-100%.

% Activity
INR 0.98 The result for INR is within normal limits with a
normal range of 0.8-1.1.
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XII. B-HCG – 4/25/21- 9:25AM
RESULT: 96,463 mIU/m
The B-HCG decreased in the second test at 9:25. Although it is not yet in
the normal range, it still decreased.
XIII. Biopsy- 4/25/21- 1:40 PM
Specimen: uterine tissue
Gross Examination:
• Fetal/embryonic tissue: Present
• Hydropic swelling of villi: Focal
• Trophoblastic hyperplasia: Focal
• Implantation-site trophoblast: mild atypia
• Karyotype: Triploid
Interpretation:
This is a case of a partial hydatidiform mole as it has a karyotype of
triploid genotypes derived from a haploid ovum which is fertilized by two sperm,
mild trophoblastic atypia and focal trophoblastic hyperplasia, focal chorionic
swelling, with the presence of embryonic tissue is also noted.
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C. Drug Studies
Date Doctor’s Order
April 25, 2021 Cefuroxime 750mg IVTT now then q8H ANST
April 25, 2021 Ketorolac (Dyrolac) 30mg IVTT q8H (1st dose given) x
3 doses then PRN for pain
April 25, 2021 Diphenhydramine 50mg IVTT pre-BT
April 25, 2021 Paracetamol (Naprex) 300mg IVTT pre-BT
April 26, 2021 Losartan 50mg/tab 1 tab PO OD qAM
April 26, 2021 Metformin 500mg/tab 1 tab PO OD qPM
April 26, 2021 FeSO4 1 tab OD now then OD ac AM
April 26, 2021 Nalbuphine (Nubain) 2mg SIVP q8 PRN for
breakthrough pain >7/10 or itchiness
April 26, 2021 Methylergonovine maleate (Methergine) 1 tab
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1. Cefuroxime
Table 6
Drug study on Cefuroxime
Date ordered April 25, 2021 (9:10AM)
Doctor’s order Cefuroxime 750mg IVTT now then q8H ANST
Generic name Cefuroxime
Trade name Ceftin, Zinacef
Classifications
Therapeutic: Anti-infectives
Pharmacologic: Second Generation Cephalosporins, Pregnancy
Category B
Actions Cefuroxime, like the penicillins, is a beta-lactam
antibiotic. By binding to specific penicillin-binding
proteins (PBPs) located inside the bacterial cell
wall, it inhibits the third and last stage of bacterial
cell wall synthesis. Cell lysis is then mediated by
bacterial cell wall autolytic enzymes such as
autolysins; it is possible that cefuroxime interferes
with an autolysin inhibitor.
Indications For the treatment of many different types of
bacterial infections such as bronchitis, sinusitis,
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tonsillitis, ear infections, skin infections, gonorrhea,
and urinary tract infections.
Contraindications Contraindicated with allergy cephalosporin or
penicillin. Use cautiously with renal failure, lactation,
pregnancy.
Interactions Tab: Lower bioavailability of drugs that reduce
gastric acidity. Lower estrogen reabsorption &
reduced efficacy of OCs.
Adverse effects CNS: seizures (high doses).
GI: Pseudomembranous colitis, diarrhea,
cramps, nausea, vomiting.
Derm: rashes, urticaria.
Hemat agranulocytosis, bleeding (increase with
cefotetan and cefoxitin), eosinophilia, hemolytic
anemia, neutropenia, thrombocytopenia.
Local: pain at IM site, phlebitis at IV site.
Misc: allergic reactions including anaphylaxis and
serum sickness, superinfection.
Nursing responsibilities 1. Before initiating therapy, perform skin
testing and obtain a history to determine
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previous use of and reactions to penicillin or
cephalosporins.
2. Administer every 8hrs to maintain serum
levels and to prevent drug resistance.
3. Have vitamin K available in case
hypoprothrombinemia occurs.
4. Discontinue if hypersensitivity reaction
occurs
5. Instruct the patient to report signs of
hypersensitivity.
Rationale Cefuroxime is given since the patient will undergo
dilation and curettage procedure and the patient is
at risk of infection. This medication is used to treat
or prevent bacterial infections.
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2. Ketorolac (Dyrolac)
Table 7
Drug study on Ketorolac
Date ordered April 25, 2021
Doctor’s order Ketorolac (Dyrolac) 30mg IVTT q8H (1st dose
given) x 3 doses then PRN for pain
Generic name Ketorolac
Trade name Dyrolac
Classifications
Therapeutic: Nonsteroidal anti-inflammatory drugs (NSAIDs)
Pharmacologic: Pyrrolizine carboxyclic acid
Actions Anti-inflammatory and analgesic activity; inhibits
prostaglandins and leukotriene synthesis.
Indications Short-term management of pain of moderate to
severe acute post-op pain following the surgical
procedures associated with low risk of hemorrhage.
Contraindications Hypersensitivity to ketorolac, aspirin or other
NSAIDs. History of stroke (CVA), heart attack (MI),
CHF NYHA class II-IV, CABG, uncontrolled HTN.
Previous or active peptic ulceration. As prophylactic
analgesia before surgery & for intraoperative use;
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post-op with high risk of hemorrhage.
Interactions Not be given in patients receiving anticoagulants or
requiring prophylactic anticoagulant therapy
including low-dose heparin. Increased risk of
ketorolac associated bleeding with other NSAIDs,
aspirin & oxypentifylline. Increased t1/2 & plasma
concentration with probenecid.
Adverse effects CNS: headache,dizziness, somnolence,
insomnia, fatigue, dizziness tinnitus,
ophthalmologic effects
Respiratory: rhinitis, hemoptysis, dyspnea.
GI: GI pain, diarrhea, vomiting, nausea
CNS: dizziness, fatigue, insomnia, headache
Hematologic: neutropenia, leukopenia,
decreased Hgb or Hct, bone marrow depression.
Dermatologic: sweating, dry mucous membrane,
pruritus.
Nursing responsibilities 1. Administer every 8 hours to maintain serum
levels and control pain.
2. Keep emergency equipment readily available
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at time of initial dose, in case of severe
hypersensitivity reaction.
3. Before administering the drug first assess the
patient history (e.g., allergies, renal impairment,
etc.) and physical condition of the patient.
4. Monitor signs of GI bleeding, including
abdominal pain, vomiting blood, blood in stools,
or black, tarry stools. Report these signs to the
physician immediately.
5. Assess dizziness and drowsiness that might
affect gait, balance, and other functional activities.
Report balance problems and functional limitations
to the physician and caution the patient and
family/caregivers to guard against falls and trauma.
Rationale Ketorolac is given to manage moderate to severe
acute post-op pain since the patient undergoes
dilation and curettage procedure. This medication is
used to reduce pain and control swelling and
inflammation.
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3. Diphenhydramine
Table 8
Drug study on Diphenhydramine
Doctor’s order Pre BT med: Diphenhydramine 50mg IVTT
Generic name Diphenhydramine Hydrochloride
Trade name
Benadryl
Classifications
Therapeutic: Antihistamines
Pharmacologic: Histamine H1 antagonist
Actions Diphenhydramine acts as an inverse agonist at the
H1 receptor, thereby reversing effects of histamine
on capillaries, reducing allergic reaction symptoms.
Lastly, diphenhydramine acts as an intracellular
sodium channel blocker, resulting in local anesthetic
properties. Has atropine-like, antipruritic, and
sedative effects.
Indications Relief symptoms associated with perennial and
seasonal allergic rhinitis; vasomotor rhinitis; mild,
uncomplicated urticaria and angioedema; allergic
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reactions to blood or plasma; adjunctive therapy in
anaphylactic reactions.
Contraindications Contraindicated if patient is allergic to
antihistamines, third trimester of pregnancy and if
patient is lactating.
Interactions
Drug-drug: Possible increased and prolonged
anticholinergic effects with MAOIs. Risk for
increased sedation with alcohol, CNS
depressants; avoid this combination.
Drug-food: Increased risk of hepatotoxicity with
alcohol.
Adverse effects
CNS: Drowsiness, sedation, dizziness, disturbed
coordination, fatigue, confusion, restlessness,
excitation, nervousness, tremor, headache,
blurred vision, diplopia
CV: Hypotension, palpitations, bradycardia,
tachycardia, extrasystoles
GI: Epigastric distress, anorexia, increased
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appetite and weight gain, nausea, vomiting,
diarrhea or constipation
GU: Urinary frequency, dysuria, urinary retention,
early menses, decreased libido, impotence
Hematologic: Hemolytic anemia, hypoplastic
anemia, thrombocytopenia, leukopenia,
agranulocytosis, pancytopenia
Respiratory: Thickening of the bronchial
secretions, chest tightness, wheezing, nasal
stuffiness, dry mouth, dry nose, dry throat, sore
throat
Others: Urticaria, rash, anaphylactic shock,
photosensitivity, excessive perspiration.
Nursing responsibilities 1. Monitor patient response, and arrange for
adjustment of dosage to lowest possible
effective dose
2. Instruct patient to report if there is DOB,
hallucinations, tremors, loss of coordination,
bleeding or bruising, visual disturbances, and
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cardiac arrhythmias.
3. Educate patient that if drowsiness, dizziness,
constipation, stomach upset or blurred vision
may occur or worsen, report it right away to
the NOD or to the physician
Rationale Diphenhydramine is administered in the majority of
blood transfusions as a prophylaxis against fever.
This can also reduce the occurrence of FNHTR
(Febrile non-hemolytic transfusion reaction) to the
patient.
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4. Paracetamol (Naprex)
Table 9
Drug study on Paracetamol
Doctor’s order Pre BT med: Naprex 300mg IVTT
Generic name Paracetamol
Trade name Naprex
Classifications
Therapeutic: Analgesics and Antipyretics
Pharmacologic: Non-opioid analgesics and antipyretics
Actions Paracetamol exhibits analgesic action by peripheral
blockage of pain impulse generation. Reduces fever
because it produces antipyresis by inhibiting the
hypothalamic heat-regulating center. Its weak anti-
inflammatory activity is related to inhibition of
prostaglandin synthesis in the CNS.
Indications
Analgesic-antipyretic in patients with aspirin
allergy, hemostatic disturbances, bleeding
diathesis, upper GI disease, gouty arthritis
Arthritis and rheumatic disorders involving
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musculoskeletal pain (but lacks clinically
significant antirheumatic and anti-inflammatory
effects)
Common cold, flu, other viral and bacterial
infections with pain and fever.
Unlabeled use: prophylactic for children receiving
DTP vaccination to reduce incidence of fever and
pain.
Contraindications Contraindicated if the patient is allergic to its
components and ingredients. Severe hepatic
impairment or active liver disease (IV).
Interactions
Drug-drug: Decreased absorption with
cholestyramine. Decreased serum
concentrations with rifampicin and some
anticonvulsants (e.g., phenytoin, phenobarbital,
carbamazepine, primidone). Enhances the
anticoagulant effect of warfarin and other
coumarins with prolonged use. Increased
absorption with metoclopramide and
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domperidone. Increased serum concentration
with probenecid. May increase serum
concentration of chloramphenicol.
Drug-food: Increased risk of hepatotoxicity with
alcohol. Decreased serum concentration with St
John’s wort.
Adverse effects
CNS: Headache
CV: Chest pain, dyspnea, myocardial damage
when doses of 5-8g/day are ingested daily for
several weeks or when doses of 4g/day are
ingested for 1 year
GI: Hepatic toxicity and failure, jaundice
GU: Acute renal failure, renal tubular necrosis
Hematologic: Methemoglobinemia-cyanosis;
hemolytic anemia-hematuria, anuria;
neutropenia, leukopenia, pancytopenia,
thrombocytopenia, hypoglycemia
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Hypersensitivity: Rash, fever.
Nursing responsibilities 1. Discontinue drug if hypersensitivity reaction
occurs.
2. Instruct patient to report rash, unusual
bleeding, or bruising, yellowing of the skin or
eyes, changes in voiding patterns.
3. Evaluate patient response to drug.
4. Patient should be cautioned not to take any
other products containing paracetamol
5. Instruct patient to report paleness,
weakness, and heartbeat skips.
6. instruct patient to report abdominal pain,
jaundice, dark urine, itchiness, or clay-
colored stools.
7. instruct patient to report pain that persists for
more than 3-5 days.
8. Instruct patient to report N&V. cyanosis,
shortness of breath and abdominal pain as
these are signs of toxicity.
Rationale The most common approach to reducing the
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occurrence of FNHTR (Febrile non-hemolytic
transfusion reaction) and allergic reactions to blood
products is premedication with acetaminophen
which is also known as paracetamol.
5. Losartan
Table 10
Drug study on Losartan
Doctor’s order Losartan 50mg/tab 1 tab PO OD qAM
Generic name Losartan
Trade name Cozaar
Classifications
Therapeutic: Angiotensin II receptor antagonist
Pharmacologic: Antihypertensive
Actions It blocks vasoconstrictor, aldosterone-secreting
effects of angiotensin II, inhibiting binding of
angiotensin II to AT1 receptors.
Indications Losartan is widely used to treat hypertension and
heart failure, and to protect your kidneys if you have
both kidney disease and diabetes. It helps to
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prevent strokes, heart attacks and kidney problems.
Contraindications Hypersensitivity to losartan, hypotension, mild to
moderate kidney impairment, hypovolemia,
hyperkalemia, pregnancy, renal failure.
Interactions 1. Taking losartan with other drugs that work in
the same way may increase your chance of
hypotension, hyperkalemia, and kidney
damage.
2. Using losartan with NSAIDs raises your risk
of kidney damage. NSAIDs may also reduce
the blood pressure-lowering effects of
losartan.
3. Taking losartan with drugs that contain
potassium, potassium supplements, or salt
substitutes with potassium, can increase
your risk of hyperkalemia.
4. Risk of hypotension is increased if you take
diuretics.
Adverse effects Hypotension, tachycardia, diarrhea, stomach pain,
muscle cramps, dizziness, headache, sore throat,
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fever, cough.
Nursing responsibilities 1. Monitor blood pressure, renal function (BUN
and serum creatinine [SCr]), and potassium
levels
2. Monitor CBC, electrolytes, liver & kidney
function with long-term therapy.
3. Monitor daily patterns of bowel activity, stool
consistency.
Rationale Losartan was given for its vasodilator effect which
causes a decrease in systemic vascular resistance
(SVR) and an increase in blood flow, resulting in a
reduction of blood pressure.
6. Metformin
Table 11
Drug study on Metformin
Doctor’s order Metformin 500mg/tab 1 tab PO OD qPM
Generic name Metformin
Trade name Apo-Metformin, Fortamet, Glucophage, Glucophage
XR, Glumetza, Glycan, Riomet
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Classifications
Therapeutic: Biguanide antihyperglycemic
Pharmacologic: Antidiabetic agent
Actions Decreases hepatic production of glucose;
Decreases intestinal absorption of glucose,
improves insulin sensitivity.
Indications Metformin lowers blood sugar levels by improving
the way the body handles insulin. It's usually
prescribed for diabetes when diet and exercise
alone have not been enough to control blood sugar
levels.
Contraindications Hypersensitivity to metformin, chronic heart failure,
metabolic acidosis, diabetic ketoacidosis, severe
renal disease, abnormal creatinine clearance
resulting from shock, myocardial infarction,
lactation.
Interactions 1. Cationic medications (e.g., Digoxin,
Morphine, Quinine, Ranitidine, Vancomycin)
may increase concentration/effects.
2. Furosemide may increase concentration.
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Adverse effects Nausea, vomiting, abdominal pain, diarrhea,
constipation, anorexia.
Nursing responsibilities 1. Monitor urine or serum glucose levels
frequently to determine effectiveness of drug
and dosage.
2. Assess for adverse reactions during therapy.
3. Assess for signs of hypoglycemia (tremors,
dizziness, anxiety, headache, tachycardia,
numbness).
Rationale Metformin was given since the patient has a history
of diabetes. Metformin lowers blood sugar levels by
improving the way the body handles insulin.
7. FeSO4
Table 12
Drug study on Ferrous Sulfate
Doctor’s order FeSO4 1 tab OD now then OD ac AM
Generic name Ferrous Sulfate
Trade name Slow FE, Fer-In-Sol, Feratab, Iron, Mol-Iron, Feosol
Classifications
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Therapeutic: Antianemics
Pharmacologic: Oral Iron Bivalent
Actions Ferrous sulfate facilitates oxygen transport via
Hemoglobin concentration (Hb). It is used as an iron
source as it replaces iron found in Hb, myoglobin
and other enzymes.
Indications This medication is an iron supplement used to treat
or prevent low blood levels of iron (such as those
caused by anemia or pregnancy).
Contraindications Haemochromatosis, other iron overload syndromes.
Blood disorders (e.g., paroxysmal nocturnal
hemoglobinuria, hemolytic anemia, hemosiderosis,
other anemias); active peptic ulcer, regional
enteritis, and ulcerative colitis. Patient receiving
frequent blood transfusions. Concomitant parenteral
iron therapy.
Interactions 1. May decrease the absorption of
tetracyclines, fluoroquinolones (e.g.,
ciprofloxacin, norfloxacin, ofloxacin),
bisphosphonates, levodopa, methyldopa,
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penicillamine, entacapone and levothyroxine.
2. Reduced absorption with antacids, products
containing zinc, magnesium, calcium,
phosphorus, and trientine. Cholestyramine
binds iron to the gastrointestinal tract thus
preventing its absorption.
3. Delayed plasma clearance with
chloramphenicol.
4. Decreased absorption with tea, coffee, milk,
eggs, and whole grains.
Adverse effects Gastrointestinal disorders: Gastrointestinal irritation,
nausea, vomiting, epigastric pain, diarrhea,
constipation, blackening of stool, tooth
discoloration, abdominal discomfort.
Immune system disorders: Hypersensitivity
Nursing responsibilities 1. Give on an empty stomach if possible
because oral iron preparations are best
absorbed then (i.e., between meals).
Minimize gastric distress if needed by giving
with or immediately after meals with
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adequate liquid.
2. Monitor Hb and hematocrit during therapy.
3. Monitor bowel movements as constipation is
a common adverse effect.
4. Inform patient of the side effects such as iron
preparations cause dark green or black
stools and may cause constipation.
Rationale FeSO4 is given to the patient to raise erythrocytes
level since the RBC lab results revealed to be 4.2
which are still low even after the PRBC
administration.
8. Nalbuphine (Nubain)
Table 13
Drug study on Nalbuphine
Doctor’s order Nalbuphine (Nubain) 2mg SIVP q8 PRN for
breakthrough pain >7/10 or itchiness
Generic name Nalbuphine
Trade name Nubain
Classifications
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Therapeutic: Opioid Analgesic
Pharmacologic: Morphinan derivative opioids
Actions The exact mechanism of action is unknown but is
believed to interact with an opiate receptor site in
the CNS (probably in or associated with the limbic
system). The opiate antagonistic effect may result
from competitive inhibition at the opiate receptor but
may also be a result of other mechanisms.
Indications Nalbuphine is indicated for the relief of moderate to
severe pain.
Contraindications 1. Significant respiratory depression
2. Severe or active bronchial asthma
3. Known or suspected gastrointestinal
obstruction including ileus
4. Hypersensitivity to nalbuphine or any other
ingredients in the injection.
Interactions 1. Do not drink Alcohol
2. Benzodiazepines and Other Central Nervous
System (CNS) Depressants evidence shows
that in nondependent patients it will not
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antagonize an opioid analgesic administered
just before, concurrently, or just after an
injection of nubain.
3. Serotonergic Drugs may result in serotonin
syndrome.
4. Muscle Relaxants may enhance
the neuromuscular blocking action of skeletal
muscle relaxants and produce an increased
degree of respiratory depression.
5. Diuretics can reduce the efficacy of diuretics
by inducing the release of antidiuretic
hormone.
6. Anticholinergic Drugs may increase risk of
urinary retention and/or severe constipation,
which may lead to paralytic ileus.
7. Monoamine Oxidase Inhibitors (MAOIs) may
manifest as serotonin syndrome or opioid
toxicity (e.g., respiratory depression, coma).
Adverse effects Central nervous system: Nervousness, depression,
restlessness, crying, euphoria, floating, hostility,
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unusual dreams, confusion, faintness,
hallucinations, dysphoria, a feeling of heaviness,
numbness, tingling, or unreality.
Cardiovascular: hypertension, hypotension,
bradycardia, or tachycardia.
Gastrointestinal: cramps, dyspepsia, or bitter taste.
Respiratory: depression, dyspnea, or asthma.
Dermatologic: itching, burning, or urticaria.
Allergic Reactions: anaphylactic, anaphylactoid, or
severe hypersensitivity reactions have been
reported with nalbuphine use, and care should be
given providing immediate supportive medical
treatment should they occur.
Nursing responsibilities 1. Assess respiratory rate before drug
administration.
2. Monitor ambulatory patients; nalbuphine may
produce drowsiness.
3. Monitor patients closely for respiratory
depression, especially within the first 24 to
72 hours of initiating therapy with and
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following dosage increases of nubain.
4. Avoid abrupt termination of nalbuphine
following prolonged use, which may result in
symptoms similar to narcotic withdrawal:
nausea, vomiting, abdominal cramps,
lacrimation, nasal congestion, piloerection,
fever, restlessness, anxiety.
Rationale Nalbuphine (Nubain) is given to manage moderate
to severe pain. Also serves as preoperative
sedation analgesia and as a supplement to surgical
anesthesia.
9. Methylergonovine maleate (Methergine)
Table 14
Drug study on Mathylergonovine
Doctor’s order
Methylergonovine maleate (Methergine) 1 tab PO
TID
Generic name methylergonovine maleate
Trade name Methergine
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Classifications
Therapeutic: Ergot alkaloids
Pharmacologic: Ergolines
Actions Methergine (methylergonovine) is
an ergot alkaloid that affects the smooth muscle of
a woman's uterus, improving the muscle tone as
well as the strength and timing of uterine
contractions.
Indications Following delivery of placenta, for routine
management of uterine atony, hemorrhage and
subinvolution of the uterus. For control of uterine
hemorrhage in the second stage of labor following
delivery of the anterior shoulder.
Contraindications Hypertension; toxemia; pregnancy; hypersensitivity
to the drug, threatened spontaneous abortion,
prolonged use, and uterine sepsis.
Interactions
CYP3A4 Inducers -Drugs (e.g., nevirapine,
rifampicin) that are strong inducers of CYP3A4 are
likely to decrease the pharmacological action of
Methergine.
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Beta-blockers - caution should be exercised when
Methergine is used concurrently with beta-
blockers. Concomitant administration with beta-
blockers may enhance the vasoconstrictive action
of ergot alkaloids.
Anesthetics- Anesthetics like halothan and
methoxyfluran may reduce the oxytocic potency of
Methergine.
Glyceryltrinitrate And Other Antianginal Drugs -
Methylergonovine maleate produces
vasoconstriction and can be expected to reduce
the effect of glyceryl trinitrate and other antianginal
drugs.
Caution should be exercised when Methergine
(methylergonovine maleate) is used concurrently
with other vasoconstrictors, ergot alkaloids, or
prostaglandins.
Adverse effects GI: Nausea, vomiting (especially with IV doses).
CV: Severe hypertensive episodes, bradycardia.
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Body as a Whole: Allergic phenomena
including shock, ergotism.
Nursing responsibilities 1. Monitor vital signs (particularly BP) and uterine
response during and after parenteral
administration of methylergonovine until partum
period is stabilized (about 1–2 h).
2. Assess calcium levels because drug
effectiveness may decrease with hypocalcemia.
3. Assess extremities for color, warmth, movement,
pain. Report chest pain promptly. Provide
support with ambulation if dizziness occurs.
4. Notify physician if BP suddenly increases or if
there are frequent periods of uterine relaxation.
5. Instruct the patient to report severe cramping for
increased bleeding.
Rationale Methylergonovine belongs to ergot alkaloids. It
works by increasing the rate and strength of
contractions and the stiffness of the uterus muscles.
Since the patient suffers from vaginal bleeding,
these effects help to decrease bleeding.
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D. Problem List
1. Acute pain related to abnormal proliferation of trophoblastic cells.
2. Impaired mobility related to pain as evidenced by limited range of motion,

slowed movement and the pain scale of 5/10.
3. Risk for Injury r/t elevated blood pressure.
4. Disturbed body image related to physiologic changes of the uterus

associated with false pregnancy.
5. Readiness for enhanced health management related to understanding of

health teachings.
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CHAPTER V
SUMMARY, CONCLUSION, AND RECOMMENDATION
This chapter presents the summary, conclusion and recommendations of
the prognosis and discharge plan.
DISCHARGE PLAN
Hydatidiform Mole is a growth of an abnormal fertilized egg or an
overgrowth of tissue from the placenta. Women appeared to be pregnant, but the
uterus enlarged much more rapidly than in normal pregnancy. The patient was
diagnosed with Gravida 3 Para 2 Pregnancy Uterine Hydatidiform Mole, partial,
and underwent operations such as Dilatation and Curettage. The patient had her
laboratory tests and radiologic tests, and she also had a pelvic examination.
During the clinical encounter on April 26, 2021, they conducted a physical
examination as well as an interview regarding the past and present health history
of the patient and her activities of daily living before and during hospitalization.
Pain interventions are also given during the encounter before discharge. The
patient was admitted last April 25, 2021 and was discharged last April 27, 2021.
Molar pregnancy is common in tertiary health institutions. It has also
remained as the cause of maternal morbidity and mortality. In general, after the
patient underwent operations such as Dilatation and Curettage, the health and
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state of the patient was in good state. Complete blood count and b-HCG is
needed for the patient’s follow-up check up to ensure that the patient is
recovering and in good state.
Based on the study that was conducted by the researchers, here are
some recommendations that can be implemented; to have urine tests and blood
tests 4 weeks later to check the level of HCG.To follow certain home medication
and instructions that the physician ordered such as FeSO4 1 tab PO OD ac am,
Methergine 1 tab PO TID x 7 days, and Cefurex 500mg/tab 1 tab x 5 days. The
physician also advised the patient to have perineal care since the patient is still
experiencing spotting.
PROGNOSIS
Partial or Complete Hydatidiform Mole is a rare case among pregnant
women, which happens when the tissues assigned to form the placenta for the
baby grow abnormally that could, anytime, build a tumor that spreads around the
mother’s uterus. Based on the case presented, the patient is diagnosed with
G3P2 PU Hydatidiform Mole, Partial, wherein she underwent biopsy, dilatation,
and curettage to determine the extent of her condition and for the purpose of
giving interventions.
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According to the patient’s physician, the patient’s prognosis was good.
The patient was feeling good during the doctor’s rounds. There were also no
complications during and after the medical procedures but feels slight pain in her
lower back and fundus because of the procedures. Furthermore, biopsy and
repeat b-HCG results were ensured and relayed to the physician, since it will tell
if the HCG levels are high which may mean that there is a malignancy.
Fortunately, the HCG levels were at a normal level. Before allowing the patient to
be discharged, the doctor has reminded her to be in touch with regards to her
HCG and follow-up checkups in order to detect any malignancy. It can be
concluded that H-Mole is a condition that is easily treated as long as it is
detected earlier and that the patient is responsible enough to follow the doctor’s
orders.
In general, as soon as a patient with Hydatidiform Mole, either partial or
complete, undergoes procedures or operations, such as dilatation and curettage,
the prognosis is good. All treated H-mole cases end well, including the tendency
of recurrency. It should just be ensured that the patient will have her follow-up
checkups in order to immediately detect arising or recurrent conditions for urgent
intervening.
Based on the case study conducted by the researchers, here are some
recommendations that can be suggested: The nurses should strictly remind the
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patient to attend her follow-up checkups since these are vital to know whether
she experiences recurrency of the condition. Recurrent Hydatidiform Mole
happens because of the gene mutations that resulted from the production of
proteins with impaired functions. When this happens, oocytes will not develop
normally which results in an undeveloped pregnancy. Addition to this, the
researchers should also ensure that the patient is still allowed to get pregnant
without experiencing this condition again. Since the mother has experienced
such a condition, it can be suggested that as soon as she experiences early
signs, immediately go to the doctor for verification and interventions. For the
future researchers, a case study about complete hydatidiform mole is advised to
have knowledge about the realistic difference between a partial and complete
hydatidiform mole condition.
109

H-Mole Chapter I-V

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JMJ Marist Brothers

Notre Dame of Marbel University

This chapter contains the background of the study, statement of the

problem, significance of the study, and scope and delimitation.

Background of the Study

Hydatidiform mole, also known as molar pregnancy, is a category of

than maternal tissue, which makes it unusual. Hydatidiform mole (HM) is a

noninvasive type of gestational trophoblastic disease that can be categorized as

a complete or partial mole. (Ghassemzadeh S, Kang M. 2021). According to

Iftikhar, N. (2019), it occurs sometimes because of a genetic DNA mix-up.

fertilizes an incomplete (empty) egg or when an incomplete or multiple sperm will

fertilize a healthy egg. Amenorrhea, hyperemesis gravidarum, doughy uterus,

vaginal bleeding, uncontrolled passage of grape-like vesicles, and elevated

According to Mulisya, O., et al. (2018), partial hydatidiform moles are

triploid conceptuses with a paternally derived extra haploid set of chromosomes.

According to Sarapuddin, S. (2016), Asia has a higher incidence of hydatidiform

mole (Taiwan has 1 case in 125 pregnancies and 2 in 1000 pregnancies in

per 1000 pregnancies. It is generally assumed that the prevalence is highest in

(Mulisya, O. et al. 2018). According to Moore, L. (2020), the present mortality

rate for molar pregnancy is practically zero and gestational trophoblastic

malignancies are mostly curable.

actions need to be taken to reduce these pregnancy complications. For future

study and to have a deeper understanding and background about hydatidiform

and how a molar pregnancy occurs.

Statement of the Problem

This study aims to understand and analyze the occurrence of G3P2 PU

Hydatidiform Mole, Partial.

Specifically, the study aims to:

1.) gather data about patient's personal information by collecting

information for demographic data, conducting past and present health

history taking and perform a complete cephalocaudal physical

3.) assess patient’s activities in daily living before and during

4.) interpret and refer data based on the laboratory results;

6.) determine the pathophysiology of the disease, its predisposing and

precipitating factors, and medical and surgical management;

need to be prioritized; and

the improvement of the patient’s well-being and effective coping strategies

emotionally, physically, and mentally.

Scope and Delimitation

This study focuses on Gravida 3 Para 2 Pregnancy Uterine Hydatidiform

Mole, Partial, an obstetrical case. The researchers aimed to understand and

conducted at a Tertiary Hospital in General Santos City on April 26, 2021.

This study is limited to only one case of G3P2 PU Hydatidiform Mole,

REVIEW OF RELATED LEARNING LITERATURE

This chapter includes review on related literature from articles, journals,

and the various views expressed by scholars on the topic.

puberty stage. The reproductive system is responsible for menstruation,

conception, and pregnancy.

Figure 1. Phases of Menstrual Cycle

Menstruation commonly happens during the puberty stage, which starts at

wherein development of primary follicles happens. An egg from the previous

gland is signaled to release follicle stimulating hormone, also known as FSH,

Due to the rise of estrogen levels, the release of luteinizing hormones by

detect which is called human chorionic gonadotropin (hCG). If a woman is not

being fertilized, that will lead to conception or pregnancy

Conception only happens when a woman is fertile and if there happened

allow the egg to grow and form a baby.

Figure 3. Parts of the Female Reproductive System

Female reproductive systems are in charge of developing gametes (also

(Rosner et. al., 2020)

made up of a variety of cell types and numbers depending on their maturation

maturation is achieved. Ovulation is the process of an oocyte developing and