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Case Study H MOLE
Case Study H MOLE
(GTD)
Or
HYDATIDIFORM MOLE (H Mole)
Nursingcasestudy.blogspot.com
I. PATIENT’S PROFILE
Name: Mrs. M. T.
Address: Asocong Gusaran, Kabayan, Benguet
Civil Status: Married
Birth date: 23-May-1978
Age: 29 y/o
Nationality: Filipino
Religion: Roman Catholic
Admission:
Date: 09-Nov-2007
Time: 11:20 AM
Admitting Clerk: F. C. Forosan
Attending Physician: Dr. Paggao, Dr. Cariaga
Admitting Diagnosis: G2P1(1001) Gestational Trophoblastic Disease
Chief Complaint:
H mole.
Gestational Trophoblastic Disease, existing in many terms like Hydatidiform Mole, is a condition
associated with second-trimester bleeding. It is an abnormal proliferation and degeneration of the
trophoblastic villi. As the cells degenerate, they become filled with fluid and appear as clear fluid-filled,
grape-sized vesicles. With this condition, the embryo fails to develop beyond a primitive start. Such
structures must be identified because they are associated with choriocarcinoma, a rapidly metastasizing
malignancy. The incidence of gestational trophoblastic disease is approximately 1 in every 1,500
pregnancies.
Sperm Ovum
2 4
3 + + Duplication = 6
Partial Mole: With a partial mole, some of the villi form normally. The syncytiotrophoblastic layer of the
villi, however, is swollen and misshapen. A macerated embryo of approximately 9 weeks; gestation may
be present in the villi. A partial mole has 69 chromosomes (a triploid formation in which there is three
chromosomes instead of two for every pair, one set supplied by an ovum that apparently was fertilized by
two sperm or an ovum fertilized by one sperm in which meiosis or reduction division did not occur). This
could also occur if one set of 23 chromosomes was supplied by one sperm and an ovum did not undergo
reduction division supplied 46 (see Fig. 2). In contrast to complete moles, partial moles rarely lead to
choriocarcinoma.
Sperm Ovum
4 2 6
6 + 3 = 9
or
2
3
2 6
+ + 3 = 9
2
3
hyperplasia
• Karyotype Paternal 46XX (97%) or 46XY Paternal and maternal 69XXY or
(47%) 69XYY
5-10% Rare
• Malignant changes
A. Symptoms:
1. amenorrhea
2. exaggerated symptoms of pregnancy especially vomiting
3. symptoms of preeclampsia that may be present as headache and edema
4. vaginal bleeding as the main complaint; due to the separation of vesicles from the uterine wall
and there may be blood-stained, watery discharge (the watery part is from the ruptured vesicles)
• Prune juice-like discharge may occur brownish because it is retained for sometime inside
the uterine cavity.
B. Signs:
1. preeclampsia develops in 20 – 30 % cases, usually before 20 weeks’ AOG
2. pallor indicating anemia may be present
3. hyperthyroidism develops in 3-10% of cases manifested by enlarged thyroid gland and
tachycardia (due to chorionic thyrotropin secreted by the trophoblast and hCG also has a thyroid-
stimulating effect)
V. PATHOPHYSIOLOGY
Low intake of proteins and vitamin A, Asian heritage, Women older than 35 years
Partial mole
or
Complete mole
Uterus
expands Abdominal
Trophoblastic proliferation faster than pain
normal
Ovarian
pain
Pallor Preeclampsia
Note: Those inside the boxes end up as the signs & symptoms of H mole.
Medical Care:
Surgical Care:
• Evacuation of the uterus by dilation and curettage is always necessary. Suction curettage: a
method of curettage in which a specimen of the endometrium or the products of conception are
removed by aspiration. The procedure is done through general anesthesia, but not which relaxes
the uterus as it may induce severe bleeding. A cannula is connected to a suction pump adjusted
at negative pressure of 300-500 mmHg but depends according to the duration of the pregnancy.
• Prostaglandin or oxytocin induction is not recommended because of the increased risk of
bleeding and malignant sequelae.
• Intravenous oxytocin should be started with the dilation of the cervix and continued
postoperatively to reduce the likelihood of hemorrhage. Consideration of using other uterotonic
formulations (eg, Methergine, Hemabate) is also warranted.
• Respiratory distress is often observed at the time of surgery. This may be due to trophoblastic
embolization, high-output congestive heart failure caused by anemia, or iatrogenic fluid overload.
Distress should be aggressively treated with assisted ventilation and monitoring, as required.
B. Nursing Management:
Nursing Considerations:
• A gynecologic oncologist should be consulted if the patient is believed to be at risk for or has
developed malignant disease.
• No special diet is required.
• Patients may resume activity as tolerated.
• Pelvic rest is recommended for 4-6 weeks after evacuation of the uterus, and the patient is
instructed not to become pregnant for 12 months. Adequate contraception is recommended
during this period.
• Monitor serial beta-HCG values to identify the rare patient who develops malignant disease. If a
pregnancy does occur, the elevation in beta-HCG would be confused with development of
malignant disease.
Patient Education:
• Because of the small but real potential for development of malignant disease and because these
malignancies are absolutely curable, the importance of consistent follow-up care must be
emphasized.
• The patient must avoid pregnancy for 1 year to avoid any confusion about the development of
malignant disease. Effective contraception should be used. If a pregnancy occurs, the elevation in
beta-HCG levels cannot be differentiated from the disease process.
• Future pregnancies should undergo early sonographic evaluation because of the increased risk of
recurrence of a molar gestation.
• The risk of recurrence is 1-2%. After 2 or more molar pregnancies, the risk of recurrence has
been reported as 1 in 6.5 to 1 in 17.5.
Reference:
Brunner & Suddarth’s Textbook of Medical-Surgical Nursing-11th edition by Suzanne C. Smeltzer (et. al.)