OUR LADY OF FATIMA UNIVERSITY College of Nursing

In Partial Fulfilment of Requirements for RLE 102

HYDATIDIFORMMOLE PREGNANCY/ MOLARPREGNACY

A Group Case Study

Presented To: MAAM EDWINDA YAP MAN, RN Submitted By: LLARENA, IRENE P. LORETO,MELODY MACAPAGAL, DANICA JOYCE MAGAT, JESSIE BOY S. MARQUEZ, DIVINE GRACE MARZAN, SHENALEE MEDINA, ALBERT JONAH NOL, MYRA L. PANTALEON, GERALD

GROUP of 2Y2-2c July 24, 2012

I. INTRODUCTION
We as a nursing student of OLFU provide this case study as for the purpose of this case is to be familiar with Molar Pregnancy; How it is start, what are the causes and what are the signs and symptoms; especially how to prevent, treat and manage the patient by giving medication for treatment and providing rapport. .We chose this case study because this is the first time weve encountered in the entire rotation and because some of the patient in OB Female semi-private room (FSPR) are Normal Spontaneous Delivery (NSD). My group is also fond to know about the important things to consider and word to discuss about this case. Gestational Trophoblastic Disease is proliferation and degeneration of the trophoblastic villi. As the cells degenerate, they become filled with fluid .Grape sized vesicles ,diagnostic of multiple pregnancy or a miscalculated .No fetal heart sound are heard because there is no viable fetus. This fact must be evaluated carefully

II. PATIENT HEALTH HISTORY

A. PERSONAL DATA

On or about July 03, 2012 at 9:40 pm, Ms. Mila Cabang Pilonio was admitted at East Avenue Medical Center with chief complaint of vaginal bleeding. She was placed on Delivery Room, with D5W 1L x 8 was administered. Routine laboratory work-up was done like ultrasound, chest x-ray, and ECG. Placed on moderate high back rest, then Prior to admission she then experience high BP elevation and the doctor give him Catapres as relief to her condition. Then after the doctor has seen that she has relief from her condition, she was the placed on OB Charity Room IVs and oral meds were continued given to her due to her high BP results. The doctors of East Avenue Medical Center to make a plan that Mila Cabang Pilonio must undergo to a operation called D and C, were in the patient will undergo to a certain operation.

B. OTHER INFORMATION

Name: Mila Cabang Pilonio Age: 37, Female Civil status: Single Nationality: Filipino Religion: Catholic B-day: May 18, 1975 Address: 317 Ilang-Ilang St., San oque, Bagong Pag-asa, Quezon City

Admitting History (Admitted July 3) OB score: Vaginal Bleeding LMP: Feb 23 AOG: 18 5/7 weeks Personal and Social History: Drinks and Smokes

Present illness: 4mos PTA- Spotting at 3 days consult at 2mos PTA- Spotting x5 days consult and IE. Advised USG, USG done but was lost, to follow up 6 day PTA- vaginal bleeding,1 pad x5 days consults admission

Past illness: Menstrual HS

Menarche- 16 years old IntervalDuration- 7 days Amount- 3 pad (+) Dysmenorrhea Obstetric HS G4P3 (3003) G1 1991-NSD G2 1993- NSD G3 2003- NSD G4- Present Sexual HS Coitarche- 21 (+) post-coital bleeding (+) Dyspareunia (+) Papsmear (+) Abdominal Vaginal Discharge Physical Assessment: conscious coherent hot in cardio respiratory distress, ambulatory/ stretcher borne BP- 110/70mmhg PR-89 RR-26 T- 36.4 (-) cervical lymphadenopathy (-) neck mass Equal chest expansion, no retraction, clear breath sound (-) murmur IE; cervix closed, uterus enlarged to 18 inch size Ass: molar pregnancy at 18 5/7 when AOG G4P3(3003) Plan: for suction curettage, one cervix is open

C. PAST MEDICAL HISTORY

The client stated that she had measles when she was 12 y/o. She doesnt have any allergies and past injuries, and have complete immunizations when she was a child. She doesnt smoke and drink alcohol.

D. FAMILY HEALTH HISTORY

The patient stated that her family has a history of Hypertension. She also stated that they dont have history of Diabetes, Tuberculosis and other hereditary disease.

E. PHYSICAL ASSESSMENT

Skin Uniform color with warm temperature, dry and smooth. No scars and are evenly distributed. Nails Long and slightly dirty Head and Face The skull is proportionate to body size, no tenderness. Hair is oily, thick evenly distributed. Face is symmetrical and symmetrical facial movement. and hairs

Eyes The client has straight normal eye condition; pupil is black in color and equal in size. Has thin eyebrows. Nose The nose is in septum is in midline, mucosa is pale; both patent but have watery secretion. Mouth The lips are pale, symmetrical, pale mucosa, tongue is in midline. Neck The skin is uniform in color. Neck muscles are equal in size and no tenderness. Breast and Axilla No masses, tenderness upon palpation Abdomen Uniform in color. Symmetrical movement. There is presence of scar and masses, pain, tenderness upon palpation. It is because she is has an irregular enlargement suffering H-mole pregnancy. Abdomen

unlilke on normal pregnancy.

Upper Extremities There is resistance for muscle strength. The skin has scar. Lower Extremities There is resistance for muscle strength. The skin has scar.

III. ANATOMY AND PHYSIOLOGY

The uterus is a hollow muscular organ located in the female pelvis between the bladder and rectum. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main function of the uterus is to nourish the developing fetus prior to birth.

External Female Reproductive System Escutcheon mons veneris/pubis clitoris skenes gland (para urethral gland) vestibule bartholins gland (vulvo vaginal gland) hymen fourchette frenulum labia minora labia majora perineum

anus

Internal Female Reproductive System Fundus Corpus Isthmus ovarian ligament fallopian tube

4 parts of fallopian tube Interstitial-1 Isthmus-2 (tubal ligation) Ampulla-5 (site of fertilization Infandibulum-2

Uterus Head- fundus Body- corpus Neck- isthmus

Corpus- 3 layers Endometrium

Myometrium Perimetrium

Isthmus- 3 parts Internal os Cervical canal External os

IV. PATHOPYHSIOLOGY

V. DIAGNOSIS

A. DEFINITION

Hydatidiform mole is a rare mass or growth which arise from fetal tissue that may form inside the uterus at the beginning of a pregnancy. Frequently there is no fetus at all. In the complete or classic mole, there is marked edema and enlargement of the villi with disappearance of the villous blood vessels. There is proliferation of the trophoblastic lining of the villi. The fetus, cord and amniotic membrane are absent; karyotype is normal. The incomplete or partial mole is characterized by marked swelling of the villi and atrophic trophoblastic changes. Unlike the classic mole, the fetus, cord and amniotic membrane are present and karyotype is abnornal, e.g., triploidy or trisomy. The cause is not completely understood although potential causes, e.g., defects of the ovum (egg), abnormalities within the uterus, and/or nutritional deficiencies, have been suggested. The incidence is increased in women under 20 or over 40 years old. Risk factors implicated include low socioeconomic status and diets low in protein, folic acid, and carotene

B. RISK & PRE-DISPOSING FACTOR

The condition tends to occur most often in women who have a low protein intake in young women (under age of 18 years),in women older than age of 35 years and in women of Asian heritage. With a complete mole,all trophoblastic villi swell and become cystic. If an embryo forms,it dies early at only 1 to 2mm in size with no fetal blood present in the villi.On chromosomal analysis ,although the karyotype is normal 46xx or 46xy,this chromosome component was contributed only by the father or an empty ovum was fertilized and the chromosome material was duplicated with a partial mole, some of the villi from normally .The syncytio-trophoblastic layer of villi,however ,is swollen and misshaper. Although no embryo is present fetal blood may be present in the villi.A macerate embryo of approximately 9 weeks gestation may be present.A partial mole has 69 chromosomes (a triploid formation in which there are 3 chromosomes instead of 2 for every pair one set supplied by an ovum that apparently was

fertilized by 2 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 that did not undergo reduction division supplied 46. The cause os not completely understood .Potential causes may include defects in the egg,problems within the uterus, or nutritional deficiencies. Women under 20 or over 40 years of age have a higher risk. Other risk factors may include diets low protein,folic acid and carotene.

C. SIGNS AND SYMPTOMS

Symptoms occur in conjunction with a potential, suspected, or confirmed pregnancy; vaginal bleeding in pregnancy (first or second trimester); nausea and vomiting, severe enough to require hospitalization in 10% of cases; abnormal size in uterine growth for stage of pregnancy with 50% of cases with excessive in growth and approximately 1/3 of cases with smaller than expected; symptoms of hyperthyroidism, e.g., rapid heart rate, restlessness, nervousness heat intolerance unexplained weight loss, loose stools, trembling hands, skin warmer and more moist than usual in about 10% of cases; symptoms consistent with preeclampsia, e.g., high blood pressure swelling in feet, ankles, legs proteinuria, that occur in the 1st or early in the 2nd trimester; abdominal pain due to theca lutein cysts. Hydatidiform moles can exaggerate the usual symptoms of pregnancy. Many of the symptoms are similar to those associated with miscarriage, and most women with molar pregnancies first believe they have miscarried. Invasive moles and choriocarcinomas can cause symptoms during or after pregnancy, and symptoms can develop after a hydatidiform mole has been removed. The most common symptom is vaginal bleeding, especially between the 6th and 16th weeks of pregnancy. Another symptom is bleeding that continues for a long time after delivery. Small amounts of bleeding can show up as a watery brown discharge from the vagina. Sometimes, a piece of tissue containing grapelike shapes will pass through the vagina, though this is not common. It is important to remember that most vaginal bleeding during or after pregnancy is not associated with a molar pregnancy. However, you should report any bleeding during pregnancy to your health care professional.

A mole or choriocarcinoma also can cause the following symptoms: Abdominal swelling, caused by the uterus becoming larger, which occurs more rapidly than expected for the first trimester of pregnancy Excessive vomiting during pregnancy Fatigue, often caused by anemia from heavy bleeding Sudden severe abdominal pain caused by internal bleeding Pelvic cramping or vaginal discharge Shortness of breath, coughing or blood in coughed-up secretions because choriocarcinoma very rarely spreads to the lungs before it is diagnosed There are many other causes for these symptoms, so if you have such problems don't assume you have a molar pregnancy. Always speak with your health care professional. Usually, these symptoms are associated with a normal pregnancy.

VI. LABORATORY EXAM AND DIAGNOSTIC PROCEDURES

I. LABORATORY EXAM
A. Urinalysis (7-03-12) Lab test Macroscopic Color Transparency Specific Gravity pH Chemical Tests Sugar Albumin Microscopic RBC WBC Result Straw Clear 1.000 6.0 Negative Negative 0-4/ HPF 0-2/HPF Normal Varying degrees of yellow Clear Variable but 1.023 Variable (usually acidic) Negative Negative 0-1/ HPF Female: 0-5/HPF Interpretation Normal Normal Low concentration of urine Normal Normal Normal High due to underlying disease condition Normal

Epithelial cells Mucous threads Bacteria Amorphouserates

Few Occasional Occasional Occasional

Male: 0-2/HPF Few common common Many

A. Hematology (7-03-12) Lab Test Components WBC Hemoglobin Result 8.4 x 10^g/L 120 g/L Normal Adult:5-10 x 10^g/L M: 140-170 gm/L Interpretation Normal Low, due to hemorrhage brought about by underlying disease condition (H.mole) Low, due to hemorrhage brought about by underlying disease condition (H.mole)

Hematocrit

0.382 gm/L

F: 120-140 gm/L

Differential count Neutrophils Lymphocytes Monocytes Eosinophils Platelet MCV MCH MCHC RDW

0.61% 0.30% 0.06% 0.03% 246 x10^g/L 80.6 fL 25.4 pg 315g/L 12.5%

Adult: 0.45-0.65% Adult: 0.25-0.5% 0.02-0.06% 0.02-0.04% 150-450 x 10^g/L 80-100 fL 21.31pg 320-340 g/L 11.6-14.6%

Normal Normal High, a sign of infection Normal Normal Normal but close to being low which indicates anemia Normal Normal Low, due to hemorrhage brought about by underlying disease condition (H.mole)

B. Chemistry Test (7-03-12) Lab Test BUN Creatinine Sodium Potassium Chloride A-AST A-ALT Result 2.3 mmol/L 52 umol/L 138 mmol/L 3.7 mmol/L 108 mmol/L 26 U/L 16 U/L Normal 3.0-9.2 mmol/L 63.6-110.5 umol/L 137-144 mmol/L 3.5-5 mmol/L 98-107 mmol/L 5-34 U/L 0-55 U/L Interpretation Low caused by pregnancy Low caused by loss of muscle mass and pregnancy Normal Normal High caused by acidosis Normal Normal

C. Serology Thyroid Function Test (7-04-12) Lab Test FT 4 TSH 3rd generation Result 1.08 ng/dl 0.74 uIu/ml Normal 0.71-1.85 ng/dl 0.47-4.64 uIu/ml Interpretation Normal Normal

II. DIAGNOSTIC PROCEDURES A. TAH (TOTAL ABDOMINAL HYSTERECTOMY) In a total abdominal hysterectomy the uterus and the cervix are removed The surgeon makes an incision approximately five inches long in the abdominal wall, cutting though skin and connective tissue to reach the uterus. The cut can be either vertical running from just below the navel to just above the pubic bone, or horizontalrunning across the top of the public bone (known as a bikini-line incision).

One advantage of total abdominal hysterectomy is that the surgeon can get a complete, unobstructed look at the uterus and surrounding area. There is also more room in which to perform the procedure. This type of surgery is especially useful if

VII. NURSING CARE PLAN

A. Fluid volume deficit r/t elevated levels of human Chorionic Gonadotropin (hCG) from the proliferating trophoblasts.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE

EVALUATION

S: Dinudugo ako nagiging kulay brown siya O: Urinalysis test for hCG revealed positive,UTZ revealed multiple small cystic structures, negative for fetal parts and fetal heart beat

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

After 4 hours of nursing intervention the patient will be comfortable and understand the situation.

Assess skin turgor and moisture of mucous membranes. Monitor Vital signs. Evaluate peripheral pulses, capillary refill.

Indicators of hydration status/ degree of deficit.

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

to have a baseline data, reflects adequacy of circulating volume.

Client will display adequate fluid balance as evidenced by stable vital signs , moist mucous membranes, skin turgor less than 1 sec, capillary refill of less than 2 secs. and adequate urine output.

Decreasing renal output and concentration of urine suggest developing dehydration and need for fluid replacement. Early identification of problems (which may occur as a result of cancer), allows for prompt intervention.

Observe for bleeding tendencies; Note the amount, lochia/color of the vaginal discharge.

Encourage rest.

Prevent unnecessary energy expenditure related to vomiting (as

may trigger) and bleeding (loss of blood/RBC).

B.

Self-care immobility r/t multiple contraption as manifested by Verbalization for help, to help tulungan Mo Naman Ako Pumunta Ako ng CR

ASSESSMENT DIAGNOSIS PLANNING

INTERVENTION

RATIONALE

EVALUATION

S: Tulungan mo naman ako pupunta ako ng CR as verbalized the patient

O: Limited movement Due to contraction lying on the bed for most of the time.

Self-care immobility r/t multiple contraption as manifested by Verbalization for help, to help tulungan Mo Naman Ako Pumunta Ako ng CR

After 4 hours of nursing intervention the patient will be comfortable and understand the situation.

Asses the extent of need of assistance

To asses degree of disability

Provide assistance in self-care needs

To assist in dealing w/ the situation to promote wellness

Support client in making health related decision and assist in developing self-care practice the promotes health

Client will display adequate fluid balance as evidenced by stable vital signs , moist mucous membranes, skin turgor less than 1 sec, capillary refill of less than 2 secs. and adequate urine output.

C. Self-care immobility r/t multiple contraption as manifested by Verbalization for help, to help tulungan Mo Naman Ako Pumunta Ako ng CR

ASSESSMENT

DIAGNOSIS PLANNING INTERVENTION

Short Term:

RATIONALE EVALUATION

S: Nahihirapan ako

O: patient may manifest the following: >edema >maternal blood pressure of 160/100 mmHg >increased or decreased fetal heart tone

Ineffective uteroplacental tissue perfusion related to vasospasm of spiral arteries secondary to H.Mole

After 4 hours of nursing intervention the patient will be comfortable and understand the situation.

After 2 hours of nursing interventions, the patient will be able to verbalize understanding of condition, therapy regimen and side effects of medications.

Long Term: After 2-3 days of nursing intervention, the patient will be able to

Assist the patient in identifying lifestyle adjustment (e.g., avoiding prolonged sitting, sitting with crossed legs, or standing; developing exercise plan for cardiovascular fitness; avoiding wearing constrictive clothing; maintaining a balance diet with adequate hydration) that may be needed..

Decreases factors that could lead to decreased perfusion of oxygen to uterus.

Permits monitoring of cardiovascular response to illness state .

Check and monitor vital signs hourly.

VIII. Drug Study

GENERIC NAME Ciprofloxacin INDICATION Infections of the resp. tract, middle ear,paranasal sinuses, eyes, kidneys, urinary tract ACTION Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria CONTRAINDICATION Drugs that inhibit peristalsis. Infants and children, growing adolescents. Pregnancy and lactation PRECAUTION/ ADVERSE REACTION PRECAUTION Severe and persistent diarrhea during and after treatment ADVERSE RXN Common:Nausea, diarrhea, vomiting, rash Uncommon: Anorexia, headache,dizziness, fever, GI and abdominal pain, flatulence, confusion, vertigo NURSING CONSIDERATION >Assess pt for previous sensitivity reaction >Assess pt for any s/s of infection before & during treatment >Assess for adverse reactions >assess pt. & familys knowledge of drug therapy

BRAND NAME Ciprobay

DOSAGE 250-500mg BID

GENERIC NAME felodipine BRAND NAME Plendil DOSAGE Adult: 250500mg every 8 hours Children: 2040mg/kg/day divided dosage given every 8 hrs

INDICATION Treatment of hypertension

ACTION Inhibits calcium ion influx across cell membrane, resulting in inhibition of excitation/ contraction.

CONTRAINDICATION Sick sinus syndrome, second or third-degree Av block except with functioning pacemaker, hypotension with systolic BP<90mmHg

PRECAUTION/ ADVERSE REACTION ADVERSE RXN: Peripheral edema, hypotension, syncope, MI, angina, tachycardia, headache, dizziness, lightheadedness, nausea, vomiting, sinusitis, wheezing cough, sneezing

NURSING CONSIDERATION >assess fluid volume status, adequacy of pulses, pitting edema, dehydration, hypotension, dry mouth >monitor cardiac status: BP, pulse, respiration >Assess for angina pain: duration,intensity, aggravating factors

GENERIC NAME Dextrose

BRAND NAME DOSAGE Dosage depends on fluid and caloric requirements

INDICATION
Fluid replacement and caloric supplementation in patient who cant maintain adequate oral intake or who is restricted from doing so.

ACTION
Minimize glyconeogenesis and promotes anabolism in patients who cant receive sufficient oral caloric intake.

CONTRAINDICATION
Hyperglycemia, diabetic coma, intracranial or intra spinal hemorrhage or delirium tremens.

SIDE EFFECTS
Mental confusion, unconsciousness in hyperosmolar nonketotic syndrome. Pulmonary edema Glycosuria, osmotic diuresis Metabolic: hyperglycemia, hypervolemia Rapid termination after long term infusion may cause hypoglycemia rebound hyperinsulinemia. Sloughing and tissue necrosis

NURSING CONSIDERATION
Use cautiously in cardiac or pulmonary disease, hypertension, renal insufficiency urinary obstruction and hypovolemia. Never infuse concentrated solutions rapidly, may cause hyperglycemia and fluid shift. Monitor glucose level carefully. Prolonged therapy can cause depletion of pancreatic insulin production and secretion.

GENERIC NAME felodipine BRAND NAME Plendil DOSAGE Adult: 250500mg every 8 hours Children: 2040mg/kg/day divided dosage given every 8 hrs

INDICATION Treatment of hypertension

ACTION Inhibits calcium ion influx across cell membrane, resulting in inhibition of excitation/ contraction.

CONTRAINDICATION Sick sinus syndrome, second or third-degree Av block except with functioning pacemaker, hypotension with systolic BP<90mmHg

PRECAUTION/ ADVERSE REACTION ADVERSE RXN: Peripheral edema, hypotension, syncope, MI, angina, tachycardia, headache, dizziness, lightheadedness, nausea, vomiting, sinusitis, wheezing cough, sneezing

NURSING CONSIDERATION >assess fluid volume status, adequacy of pulses, pitting edema, dehydration, hypotension, dry mouth >monitor cardiac status: BP, pulse, respiration >Assess for angina pain: duration,intensity, aggravating factors

GENERIC NAME

INDICATION

ACTION

CONTRAINDICATION

PRECAUTION/ ADVERSE REACTION

NURSING CONSIDERATION

DIAZEPAM BRAND NAME Valium DOSAGE Adult: 250500mg every 8 hours Children: 2040mg/kg/day divided dosage given every 8 hrs

Symptomatic relief of anxiety, agitation, tension

Facilitates/ potentiates the inhibitory activity of GABA at the limbic system and reticular formation to reduce anxiety, promote calmness and sleep

Hypersensitivity. Dependence, withdrawal symptoms

PRECAUTION: Hypersensitivity: cardiorespiratory insufficiency, pregnancy, lactation ADVERSE RXN Dizziness, fatigue, blurred vision, dependence, withdrawal reactions

> inform pt. that drug may be taken with food >advice pt. not to abruptly discontinue drug after long term use >advice pt. to avoid driving and activities that require alertness bec, drug can cause drowsiness >inform pt. that smoking may decrease effect

X. Discharge Planning
Management
Instructed the patient to take the following home medication as ordered by the physician.

Exercise / Activity
Inform patient that there are no restrictions in activity as long as her condition becomes okay. She can go back to her daily activities whenever she thinks she can.

Treatment
Remind patient that following mole extraction, she should have a baseline pelvic examination, a chest x-ray, and a serum test for the subunit of hCG. The hCG is analyzed every 1-2 weeks until levels are again normal.

Health Teaching
Advise patient to use contraceptive method such as oral contraceptive agent for 6-12 months so that a positive pregnancy tests (the presence of hCG) resulting from a new pregnancy will not be confused with increasing levels and a developing malignancy. Inform patient that she should delay her childbearing plans for half to one year because her hCG is still been monitored. A higher chance of having another molar pregnancy can occur if she will become pregnant during these times. If the hCG levels are within the normal limits and the patient decides to get pregnant again, advise her to have early screening with ultrasound during a second pregnancy to prevent another molar pregnancy.

OPD
Instruct patient to have a follow up checkup as advised by her doctor.

Spiritual
Advise the family to help the patient to express her anger and sense of unfairness at this situation. She may feel inadequate because something went wrong with her pregnancy. She may experience the same feeling of loss after its evacuation that she would have experienced after the loss of a true pregnancy.