Saint Louis University

College of Nursing

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GESTATIONAL TROPHOBLASTIC DISEASE (GTD)

Or
HYDATIDIFORM MOLE (H Mole)

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A Case Study Presented To:

Mrs. R. Ochoco
Level III Clinical Instructor

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In Partial Fulfillment
of Related Learning Experience
(RLE)

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Submitted By:
ALCANTARA, N.
CERIACO, C.
EGALLA, F.
MACAYAN, A.
SORIANO, M.
ZARATE, M.
BSN III-K1

November 24, 2007

 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.

History of Present Illness:

The patient was apparently well until 2 months prior to admission when the patient noted
hyperactive pain with associated profuse vaginal bleeding. Consult was done into another
institution where the patient was a manifest as a cause of abortion. The patient was
discharged; improved after seven hospital days and was given the following home
medicines: Amoxicillin 500 mg TID, Methyl dopamine 250 mg 1 tab BID, and Isoxsuprine.
On follow-up, ultrasound was done revealing H mole. The patient was then referred into
this institution for further management and work-up.

Past Medical History:

September 2007: Bokod, Benguet; threatened abortion.
2006: Normal Spontaneous Delivery to a live fetus (male) delivered by a Barangay Health
Worker.
No other known general medical condition.
OB-Gyne History: OB Score: G2P1 (1011)
G1: 2006, NSD to a live term (M) by a BHW, house delivery.
G2: present pregnancy.
No known gynecologic illness
 Patient’s Diagnostic Results:
Result Reference Value
a. BUN-Crea low ALT = 25 u/L 30-65 u/L
low Crea = 32.1 umol/L 53-88 umol/L
b. Hematology low Hgb = 113 g/L 120-160 g/L
low Hct = 0.33 u/L 0.37-0.47 u/L
high WBC = 10.3 5-10x109/L
c. Immunochemical high free t4 = 1.96 mg/dL0.71-1.85 mg/dL
low ultrasensitive hTSH II Gen 0.49-4.67 mIU/mL
= <0.02 mIU/mL
d. Chemiluminiscent Immuno-assays highb-hCG = 364,000 mIU/mL 0-5.0 mIU/mL
e. UTZ no gestational sac; uterus
enlarged; multiple anechoic area
of varied sizes seen interspersed
in the H mole
 II. WHAT IS GESTATIONAL TROPHOBLASTIC DISEASE?

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.

Two types of molar growth can be identified by chromosomal analysis:

Complete Mole: All trophoblastic villi swell and become cystic. If an embryo forms, it dies early at only 1 to
2 mm in size, with no fetal blood present in the villi. On chromosomal analysis, although the karyotype is a
normal 46XX or 46XY, this chromosome component was contributed only by a father or an “empty ovum”
was fertilized and the chromosome material was duplicated (Fig. 1).

Sperm Ovum

2 + + Duplication = 4

Fig. 1.Complete mole.

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

or

+ + 2 = 6

Fig. 2. Partial mole.

FEATURES COMPLETE PARTIAL

• Embryonic/fetal tissue Absent (whole conceptus is Present (with fetus or at least an
transformed into a mass of amniotic sac)
vesicles)

• Swelling of villi Diffuse Focal

Diffuse Focal
• Trophoblastic
hyperplasia
Paternal 46XX (97%) or 46XY Paternal and maternal 69XXY or
• Karyotype
(47%) 69XYY
5-10% Rare
• Malignant changes

Table 1. Various features of a complete and a partial mole.

III. PREDISPOSING FACTORS

A. Diet: Low CHON and low Vitamin A (carotene) intake.
B. Age: Women older than 35 years. GTD is higher toward the beginning and toward the end of child
bearing period. It is ten times more in women who are 45 years old and beyond.
C. Race: Asian heritage. Molar pregnancy has no racial or ethnic predilection, although Asian countries
show a rate 15 times higher than the US rate.

IV. SIGNS AND SYMPTOMS

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.

• Blood may be concealed in the uterus, thereby causing enlargement.

5. abdominal pain: may be dull-aching due to rapid distension of uterine by mole or by concealed
hemorrhage; colicky due to start of expulsion
6. ovarian pain due to stretching of ovarian capsule or complication in the cystic ovary as torsion

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

Chronic villi degenerates and become filled with fluid

No vasculature in chorionic villi

Early death & absorption of embryo Absence of FHT

Uterus
expands Abdominal
Trophoblastic proliferation faster than pain
normal

High secretion of hCG High progesterone low estrogen High chorionic

thyrotropin

Decreased contraction Amenorrhea

Marked nausea &
vomiting Hyperthyroidism

Separation of vesicles from

uterine wall
Multiple theca lutein cysts Enlarged thyroid
in the ovaries gland; tachycardia
Vaginal bleeding &
discharge of vesicles

Ovarian
pain

Pallor Preeclampsia

Note: Those inside the boxes end up as the signs & symptoms of H mole.
 VI. DIAGNOSTIC FINDINGS

A. Lab Studies pregnancies. The classic image,

• Quantitative beta-HCG: HCG using older ultrasonographic
levels greater than 100,000 technology, is of a snowstorm
mIU/mL indicate exuberant pattern indicating hydropic
trophoblastic growth and raise chorionic villi. High-resolution
suspicion that a molar ultrasonography shows a
pregnancy should be excluded. complex intrauterine mass
A molar pregnancy may have a containing many small cysts
normal HCG level. (usually bilateral ovarian cysts).
• Uterine Pregnancy Test. • Once a molar pregnancy is
Positive in high dilution. 1/200 is diagnosed, a baseline chest
highly suggestive. 1/500 is radiograph should be taken. The
surely diagnostic.In normal lungs are a primary site of
pregnancy, it is positive in metastasis for malignant
dilution up to 1/100. trophoblastic tumors.
• Complete blood cell count with • X-RAY of abdomen. The
platelets: Anemia is a common procedure reveals no fetal
medical complication, as is the skeleton.
development of a coagulopathy. C. Histological Findings:
• Blood urea nitrogen (BUN) and • Complete mole: Fetal tissue is
creatinine studies. Positive if absent, and severe
levels are increased. srophoblastic proliferation,
• Thyroxin: Although women with hydropic villi, and chromosomes

molar pregnancies are usually 46,XX or 46,XY are present.

clinically euthyroid, plasma Additionally, complete moles

thyroxin is usually elevated show overexpression of several

above the reference range for growth factors, including c-myc,

pregnancy. Hyperthyroidism epidermal growth factor, and c-

may be the presenting erb B-2, compared to normal

symptom. placenta.

B. Imaging Studies: • Partial mole: Fetal tissue is

• Ultrasonography is the criterion often present as well as amnion

standard for identifying both and fetal red blood cells.

complete and partial molar Hydropic villi and trophoblastic

proliferation are also observed.
 VI. MANAGEMENT

A. Medical/Surgical Management:

Medical Care:

• Stabilize the patient.

• Transfuse for anemia.
• Correct any coagulopathy.
• Treat hypertension.
• Administration of Methotrexate. Some physicians give women who have had GTD a prophylactic
course of this drug – the drug of choice for choriocarcinoma. Because the drug interferes with
WBC formation (Leukopenia), prophylactic use must be weighted carefully. If malignancy should
occur, it can be treated effectively in most instances with Methotrexate at that time. (Methotrexate
has the ability to dissolve fast-growing tissues).
• Administration of Dactinomycin. It is added to the regimen of Methotrexate if metastasis occurs. It
is an antibiotic used as an antineoplastic agent prescribed in the treatment of a variety of
malignant neoplastic diseases.

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.

Further Outpatient Care:

• Serial quantitative beta-HCG levels should be determined.

o Draw the first level 48 hours after evacuation and then every 2 weeks until the levels are
within reference ranges.
o Levels should consistently drop and should never increase.
o Once levels have reached reference ranges, check them each month for a year.
o Any rise in levels should prompt a chest radiograph and pelvic examination to facilitate
early detection of metastases.

• Contraception is recommended for 6 months to a year after evacuation.

• Patients with a prior complete or partial molar pregnancy have a 10-fold risk of a second mole in
a future pregnancy. Work with the team to evaluate all future pregnancies early with
ultrasonography.

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.)