Trophoblastic Disease

 

Neoplasms of trophoblastic origin that can follow intra- or extrauterine pregnancy.

 

A hydatidiform mole is the end stage of a degenerating pregnancy in which the villi have become hydropic and the trophoblastic elements have proliferated.

Persistent trophoblastic disease (PTD, chorioadenoma destruens, or invasive mole) is a local invasion of the myometrium by the villi of the hydatidiform mole. In contrast, metastatic trophoblastic disease (MTD, choriocarcinoma, or chorioepithelioma) is an invasive–usually widely metastatic–tumor composed of syncytiotrophoblastic and cytotrophoblastic elements only.

 

A mole is more common in older patients. Molar pregnancies occur in about 1/2000 gestations in the USA; however, for unknown reasons, the incidence in Asiatic countries approaches 1/200. Over 80% of hydatidiform moles are benign.

However, 15% lead to local invasion characteristic of PTD; 2 to 3% are followed by MTD.

The locally invasive variant may cause uterine perforation, hemorrhage, and sepsis.

Symptoms, Signs, and Diagnosis

 

Hydatidiform mole often manifests itself shortly after conception by

¨1a rapid increase in the size of the uterus, often causing it to be larger than it should be by dates.

¨2Vaginal bleeding, lack of fetal movement, lack of fetal heart tones at the appropriate time (12 wk with Doppler ultrasonography), and severe nausea and vomiting should arouse clinical suspicion.

¨3Passage of typical grapelike molar tissue suggests the diagnosis, and histologic examination confirms it.

¨4Without such proof, the diagnosis may be difficult to differentiate from other pregnancy complications involving a possibly normal fetus.

¨5Ultrasonography, the diagnostic modality of choice, is not infallible but usually demonstrates absence of an amniotic sac with a fetus in it.

 

Human chorionic gonadotropin (HCG) is produced by the proliferating trophoblastic tissue, and high levels of HCG found on radioimmunoassay are valuable in evaluating treatment.

Serum and urinary HCG levels are elevated during the first 100 days of gestation (even more so with multiple pregnancy); therefore, the value of the test early in pregnancy is diminished. Radioimmunoassay for the b subunit of HCG is used for diagnosis and management of trophoblastic disease.

 

Complications of a mole include intrauterine infection and septicemia,

¨6hemorrhage, toxemia of pregnancy (the only condition in which true toxemia is seen in the first half of pregnancy), and

¨7development of MTD. PTD, because it is intramural, tends to cause bleeding; it may infiltrate adjacent tissue and occasionally metastasize to distant sites.

¨8MTD metastasizes early and widely via the venous and lymphatic systems and is highly malignant.

 

Treatment

 

Evacuation of hydatidiform mole is essential. The treatment of choice is suction curettage, followed by oxytocin stimulation and curettage of the uterus.

Hysterotomy is no longer used for evacuation. Hysterectomy may be selected, based on the age, parity, and future pregnancy plans of the patient. After evacuation, serial chest x-rays should be taken and serum b-HCG titers should be determined.

The titer should progressively fall to a normal level in 8 wk. If it fails to fall or if it rises after once falling, studies for malignant progression should be performed.

The patient should use contraception for a year, since detection of malignant change is compromised by pregnancy.

Patients with persistent or rising HCG levels may have either PTD (invasive mole) or MTD and should receive chemotherapy with methotrexate, dactinomycin, or a combination of drugs, depending on the organs involved, b-HCG titers, and postevacuation duration.

 

Chemotherapy has largely replaced hysterectomy in both conditions; results are good, reproductive capacity is preserved, and major surgery is avoided.

However, hysterectomy may be considered in patients > 40 yr or those desiring sterilization and may be required for those with infection, uncontrolled bleeding, or invasion of disease through the uterine wall. For patients with trophoblastic malignancy, the overall remission rate is 75 to 85%.

 

 

 

Nursing Process

 

Prevention

 

Because the cause of hydatidiform mole is unknown, there is no known prevention. However, malnutrition or stress might play a part in influencing its development; therefore instructions should be given to all patients planning a pregnancy regarding the importance of stress management and a balanced diet high in protein and vitamin A.

 

Assessment

 

Hydatidiform mole: to detect a hydatidiform mole early, the nurse should observe for signs of a mole at each prenatal visit during the first 20 weeks of gestation.

Such signs as uterine bleeding, uterine size small or large for dates, hyperemesis gravidarum, signs of preeclampsia before 24 weeks of gestation, passage of grapelike vesicles, or inability to detect FHR with Doppler FHR device after 10 to 12 weeks of gestation should be brought to the attention of the obstetrician or healthcare provider immediately.

 

Gestational Trophoblastic Neoplasia: Because a gestational trophoblastic neoplasia may develop following a normal delivery or an abortion, all patients should be taught the importance of reporting any unusual bleeding following any reproductive event. In these cases, hCG levels should be determined in order to detect early a gestational trophoblastic neoplasia.

 

Nursing Diagnosis/Collaborative Problems and Interventions

 

¨     Potential Complication: Hemorrhage related to trophoblastic invasion or uterine rupture.

 

Desired Outcomes:

 

The signs and symptoms of hemorrhage will be minimized/managed as measured by distal pulses; stable vital signs; orientation to person, place, and time; urinary output greater than 30 ml/hr, an no signs of bleeding

 

Interventions

 

1.     Monitor for evidence of hemorrhage such as vital signs, abdominal pain, uterine status, and vaginal bleeding.

2.     Start intravenous (IV) infusion with an 18-gauge intracatheter.

3.     Prepare for surgery according to preoperative protocol, and type and cross match 2 to 4 units of blood as ordered.

4.     Postoperative IV infusions with oxytocin added are usually continued initially to facilitate uterine contractions and decrease uterine bleeding.

5.     Do not massage a boggy uterus if ovaries are enlarged since it can cause ovarian rupture.

6.     Notify physician of first signs of bleeding.

 

¨     High Risk for Infection related to invasive qualities of a hydatidiform mole or surgical intervention.

 

Desired out come:

 

The patient will remain infection free postoperatively as indicated by her temperature remaining below 38°C , absence of foul-smelling vaginal discharge, and a white blood cell count between 4500 and 10,000/mm.

 

Interventions

 

1.     Assess for indicators of infection by checking temperature every 4 hours and assessing vaginal discharge for a foul odor.

2.     Monitor laboratory data especially white blood cell count.

3.     Teach the importance of perineal care.

4.     Administer antibiotics at the first sign of an infection as ordered.

5.     Notify physician if temperature is greater than 38°C or if foul smelling vaginal discharge develops.

 

¨     Potential Complication: Respiratory Compromise related to trophoblastic emboli, fluid overload, cardiac failure caused by gestational hypertension, or thromboembolism.

 

Desired Outcome:

 

Sings and symptoms of respiratory compromise will be minimized/managed as measured by normal breath sounds, arterial blood gas results consistent with patient’s baseline parameters (pH 7.35 to 7.45, PaO2 equal to or greater than 80 mmHg, and PaCO2 less than 45 mmHg.

 

Interventions

 

1.     Auscultate breath sounds postoperatively.

2.     Monitor patient for signs and symptoms of hypoxia: restlessness, agitation, and changes in level of consciousness.

3.     Monitor serial arterial blood gas values if ordered.

4.     Administer oxygen as prescribed.

5.     Notify physician of first signs of respiratory compromise such as decreased breath sounds, changes in level of consciousness, decreasing PaO2 or increasing PaCO2.

 

High Risk for Altered Urinary Elimination (pattern): oliguria related to the antidiuretic effect of oxytocin.

 

Desired outcome: The patient will maintain a urinary output greater than 120 ml/4 hr.

 

Interventions

 

1.     Monitor intake and output.

2.     Administer oxytocin intravenously as ordered, and monitor flow rate closely.

3.     Notify attending physician if urine output drops below 120 ml per 4 hr.

 

¨     Fear related to the possible development of gestational trophoblastic neoplasia, future threat to family planning, and financial concern regarding long-term medical care.

 

 

Desired Outcome:

 

The patient and family members will be able to communicate their fears and concerns openly.

 

Interventions

 

1.     Provide time for the patient and her family to express their concerns regarding the possible outcome and inconvenience to the mother and family during the treatment and long follow-up assessment. Encourage them to vent any feelings, fears, and anger they may be experiencing.

2.     Assess family’s support system and coping mechanisms.

3.     Provide information to the family regarding the disease process, plan of treatment, and risk for the patient.

4.     Explain all treatment modalities and reasons.

5.     Keep patient informed of health status and results of tests.

6.     Discuss risk of a gestational trophoblastic neoplasia based on whether the patient had a partial or complete mole.

 

¨     Anticipatory Grieving related to loss of an anticipated infant, state of wellness, and possible threat to fertility.

 

Desired Outcome:

 

The patient and her family will verbalize their feeling of grief appropriately and identify any problems as they work through the grief process.

 

Interventions

 

1.     Assess significance of loss to all family members and level of guilt or blame.

2.     Assess family’s communication pattern and support systems.

3.     Reaffirm with the family their losses, and let them know you are aware that these are real.

4.     Provide physical care such as a back rub or nourishment as needed.

5.     Consider any significant cultural beliefs or values.

6.     Refer to psychiatric services when deemed necessary.

 

¨     High Risk for Health Management Deficit related to follow-up assessment and chemotherapy regime if metastasis occurs.

 

Desired Outcome:

 

The patient and her family will verbalize compliance, outline the proposed follow-up assessment, and utilized a contraceptive method during the follow-up care.

 

Interventions

 

1.     Assess the patient’s and family’s understanding of the disease and risks of an ongoing gestational trophoblastic neoplasia

2.     Explain the disease and the plan of treatment.

3.     Educate about the importance of the follow-up assessment in order to detect early a gestational neoplasia when it is almost 100 % curable.

4.     Educate about the importance of avoiding pregnancy during the follow-up assessment to prevent masking the hCG rise of a gestational trophoblastic neoplasia

5.     Teach that any effective contraceptive method may be used except an intrauterine device (IUD) because of bleeding irregularities associated with the IUD. Oral contraceptives are the preferred method since they are highly effective.

6.     Explain the treatment program if a gestational trophoblastic neoplasia develops.

7.     Future family planning can be facilitated when the couple is reassured that even following chemotherapy, they can anticipate a normal reproductive outcome in the future with no increased risk of congenital fetal malformations. The risk of a repeat molar pregnancy is 1 %.

 

 

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