I.

INTRODUCTION
The purpose of this case study 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 Sept. 14, 2007 at 9:40 pm, J.V. was admitted at San Juan 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 have relief from her condition, she was the placed on Female Semi- Private Bed 6. IVs and oral meds were continued given to her due to her high BP results. The doctors of SJMC make a plan that JV must undergo to a operation called HYSTERECTOMY, were in the patient will undergo to a certain operation A surgical operation to remove the uterus and, sometimes, the cervix. Removal of the entire uterus and the cervix is referred to as a total hysterectomy. Removal

of the body of the uterus without removing the cervix is referred to as a subtotal hysterectomy. B. PRESENT ILLNESS OR PRESENT HEALTH STATUS 2 Days PTA (+) vaginal bleeding with hypogastric pain, consulted at East Avenue Medical Center. (+) cough, non-productive (+) dyspnea She was diagnosed with Molar Pregnancy, 14-15 weeks AOG, G7P5 TPAL (5-0-1-5) 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 hairs are evenly distributed. Nails Long and slightly dirty Head and Face The skull is proportionate to body size, no tenderness. Hair is oily, thick and evenly distributed. Face is symmetrical and symmetrical facial movement.

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 suffering H-mole pregnancy. Abdomen has an irregular enlargement 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. 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.

D. DIAGNOSTIC AND LABORATORY LABORATORY EXAMINATION 1.) COMPLETE BLOOD COUNT: 2.) PLATELETS COUNT = Adequate HEMATOLOGY HEMOGLOBIN HEMATOCRIT RED BLOOD CELL WHITE BLOOD CELL DIFFERENTIAL COUNT: NEUTROPHILS LYMPHOCYTES EOSINOPHILS MONOCYTES BASOPHILS STABS 0.75 0.15 0.08 NOT DONE NOT DONE NOT DONE 0.38 - 0.68 0.22 - 0.53 0.01 - 0.07 0.05 - 0.12 0.002 - 0.01 0.0 - 0.05 Increased because of WBC elevation Decreased because immune system is affected Increased due to parasitic infection NOT DONE NOT DONE NOT DONE RESULT 86 0.25 2.87 11.2 NORMAL VALUES 120 - 170 g/L 0.37 - 0.54 4.0 - 6.0 x 1012 L 4.5 - 10 x 109 L INTERPRETATION Decrease protein production causing anemia Decreased because the patient has Significant with hemorrhage Decrease O2 production due to Vaginal bleeding that cause anemia Slightly increased because infection started

3.) RED CELL MORPHOLOGY MCV (MEAN CORPUSCULAR VOL.) = 90 L F1 IV.U (80 96 f1) 4.) PERIPHERAL SMEAR MCH (MEAN CORPUSCULAR HEMOGLOBIN) = 30.0 pg IV.U (27 33 pg) MCHC (CORPUSCULAR HEMOGLOBIN CONCENTRATION) = 33 L 9/L IV.U (320 360 9/L) DEFINITION OF TERMS INDICATED IN THE LABORATORY EXAMINATION COMPLETE BLOOD COUNT (CBC) A complete blood count (CBC), also known as full blood count (FBC) or full blood exam (FBE) or blood panel, is a test requested by a doctor or other medical professional that gives information about the cells in a patient's blood. A Medical technologist performs the requested testing and provides the requesting Medical Professional with the results of the CBC. A CBC is also known as a "hemogram". The cells that circulate in the bloodstream are generally divided into three types: white blood cells (leukocytes), red blood cells (erythrocytes), and platelets or thrombocytes. Abnormally high or low counts may indicate the presence of many forms of disease, and hence blood counts are amongst the most commonly performed blood tests in medicine.

RED BLOOD CELLS (ERYTHROCYTES) Are the most common type of blood cells and the vertebrate bodys principal means of delivering oxygen from the The number of red cells is given as an absolute number per litre. lungs or grills to body tissue via blood.

HEMOGLOBIN Is a protein that is carried by the red cells. It picks up oxygen in the lungs and delivers it to the peripheral tissues to The amount of hemoglobin in the blood, expressed in grams per litre. (Low hemoglobin is called anemia.) maintain the viabilty of the cells.

HEMATOCRIT OR PACKED CELL VOL. (PCV) This is the fraction of whole blood volume that consists of red blood cells.

MEAN CORPUSCULAR VOL. (MCV) the average volume of the red cells, measured in femtolitres. Anemia is classified as microcytic or macrocytic based on whether this value is above or below the expected normal range. Other conditions that can affect MCV include thalassemia and reticulocytosis. MEAN CORPUSCULAR HEMOGLOBIN (MCH) the average amount of hemoglobin per red blood cell, in picograms. It is diminished in microcytic anemias, and increased in macroanemias.

It is calculated by dividing the total mass of hemoglobin by the RBC count.

MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION (MCHC) the average concentration of hemoglobin in the cells. It is diminished (hypochromic) in microcytic anemias, and normal (normochromic) in macro anemias (due to

large cell size, though the hemoglobim amount or MCH is high, the concentration remains normal). WHITE BLOOD CELLS (LEUKOCYTES) Are cells of the immune system which defend the body against both infectious disease and foreign materials. All the white cell types are given as a percentage and as an absolute number per litre.

A complete blood count with differential will also include: NEUTROPHILS This is the main defender of the body against infection and antigens. High levels may indicate an active infection. May indicate bacterial infection. May also be raised in acute viral infections.

LYMPHOCYTES Is a type of blood cell in the vertebrate immune system. Elevated levels may indicate an active viral infections.

Higher with some viral infections such as glandular fever and. Also raised in lymphocytic leukaemia CLL.

MONOCYTES May be raised in bacterial infection Is a leukocyte, part of the immune system that protects against bloodborne pathogens and moves quickly to sites Elevated levels may indicate an allergic reactions or parasites.

of infections in the tissue.

EOSINOPHILS Are white blood cells of the immune system that are responsible for combating infection by parasites in vertebrates. Increased in parasitic infections. High levels are found in allergic reactions. They are granulocytes that develop in the bone marrow before migrating into blood.

BASOPHILS Circulates vhite blood cells. Basophils degranulate to release histamine, proteoglycans (e.g. heparin and chondroitin), and proteolytic enzymes

(e.g. elastase and lysophospholipase). They also secrete lipid mediators like leukotrienes, and several cytokines. PLATELET COUNT

Platelets or thrombocytes are the cell fragments circulating in the blood that are involved in the cellular

mechanisms of primary hemostasis leading to the formation of blood clots. Dysfunction or low levels of platelets predisposes to bleeding, while high levels, although usually asymptomatic, may increase the risk of thrombosis. Functions of Platelets can be generalised into a number of categories: Adhesion, Aggregation, Clot retraction, ProA normal platelet count in a healthy person is between 150,000 and 400,000 per mm of blood (150400 x 109/L). Coagulation, Cytokine signalling, Phagocytosis. 95% of healthy people will have platelet counts in this range. Some will have statistically abnormal platelet counts while having no abnormality, although the likelihood increases if the platelet count is either very low or very high. Low platelet counts are generally not corrected by transfusion unless the patient is bleeding or the count has fallen below 5 x 109/L; it is contraindicated in thrombotic thrombocytopenic purpura (TTP) as it fuels the coagulopathy. In patients having surgery, a level below 50 x 109/L) is associated with abnormal surgical bleeding, and regional anaesthetic procedures such as epidurals are avoided for levels below 80-100. RED BLOOD CELL MORPHOLOGY Also known as Blood Smear, and Manual differential. Was once prepared on nearly everyone who had a complete blood count (CBC) performed. With the automated

blood cell counting instruments currently used, an automated differential is also provided. However, if the presence of abnormal WBCs, RBCs, or platelets is suspected, a blood smear examined by a trained eye is still the best method for definitively evaluating and identifying immature and abnormal cells.

Findings from the blood smear evaluation are not always diagnostic in themselves and more often indicate the

presence of an underlying condition and its severity and suggest the need for further diagnostic testing. Blood smear findings may include: RBC, WBC and differential count. PERIPHERAL SMEAR A Peripheral smear is a blood test that gives information about the number and shape of blood cells.

DIAGNOSTIC EXAMINATION GYNECOLOGY = PELVIC ULTRASOUND is the examination done to the patient I. UTERUS ABNORMALITIES The uterus is enlarged with a dilated endometrial cavity as measured containing complex structure with multiple cystic spaces of varied sizes interspersed within suggestive of a molar gestation. II. ENDOMETRIUM Thick 7.96 CM Hyper-echoic

III. ADNEXAE Within the left ovary is a cystic structure, unilocullar, thin-walled, anechoic, measuring 2.6 x 2.0 cm, suggestive of cystic follicle. IMPRESSION: Enlarged Anteverted Uterus when we say anteverted, it is an abnormality of the uterus. Where the uterus leans Intra-endometrial content as described, suggestive of molar pregnancy Cystic follicle right ovary cystic means there is an tumor like spaces in the ovary of a female Normal left ovary Please correlate clinically forward over the top of the bladder.

V. MEDICAL/SURGICAL NURSING CARE MANAGEMENT

Medical management
Prostaglandins are the most commonly used agents, owing to their ability to induce uterine contractions and thus expel the products of conception. Prostaglandins can be given orally, vaginally, or rectally, and administration is often preceded by oral mifepristone, which primes the uterus by allowing local production of prostaglandins (normally suppressed by progesterone). Misoprostol useful to help uterus expel products of conception that are not adherent to the uterine wall such as blood clots.

Surgical management
Suction Curettage Abortion A common first trimester abortion procedure is the suction and curettage method. The abortionist begins by dilating the mom's cervix until it is large enough to allow a cannula to be inserted into her uterus. The cannula is a hollow plastic tube that is connected to a vacuum-type pump by a flexible hose. The abortionist runs the tip of the cannula along the surface of the uterus causing the baby to be dislodged and sucked into the tube - either whole or in pieces. Amniotic fluid and the placenta are likewise suctioned through the tube and, together with the other body parts, end up in a collection jar. Any remaining parts are scraped out of the uterus with a surgical instrument called a curette. Following that, another pass is made through the mom's uterus with the suction machine to help insure that none of the baby's body parts have been left behind. The contents of the collection jar are examined to assure that all fetal parts and an adequate amount of tissue commensurate with gestational age are present

Hysterectomy: A surgical operation to remove the uterus and, sometimes, the cervix. Removal of the entire uterus and the cervix is referred to as a total hysterectomy. Removal of the body of the uterus without removing the cervix is referred to as a partial hysterectomy

Nursing Care Management

1. Assess the ff: - v/s amount and character of vaginal bleeding uterine fundus

2. Assess emotional distress 3. Assess for nausea and vomiting 4. Assess for ability to work 5. Report to health care provider abnormal v/s BP <90 HR >120 RR <12 or >24 acute abdominal pain nausea and vomiting excessive emotional distress passing of large clots of blood / tissue

6. Administer IV fluids as ordered 7. Provide emotional support; encourage question and expression of feelings 8. Allow one support person at bedside following procedure if desired by patient 9. Provide written discharge and follow-up instructions 10. Provide and review information about any newly prescribed medications

VII. DRUG STUDY

Name of drug: Clonidine Phil. Brand/s: Catapres, Drug Makers Biotech Clonidine HCl, Melzin US Brand/s: Catapres, Catapres-TTS, Clonidine HCl, Duraclon Canada Brand/s: Dixarit Therapeutic Classification: Vasodilating agent Indication: Management of all grades of hypertension (HPN) with the exception of HPN due to phaeochromocytoma. Prophylactic treatment of migraine or recurrent vascular treatment of migraine. For relief of cancer pain, in combination with opiates for epidural use. Contraindication: Hypersensitivity to clonidine. Sick sinus syndrome Adverse Reation: Local skin irritation, Allergic contact dermatitis, hypo and hyperpigmentation of the skin drowsiness, dry mouth, dizziness, headache. Constipation, depression, anxiety, fatigue, nausea, anorexia, parotid pain, sleep disturbances, vivid dream, impotence, urinary retention, slight orthostatic hypotension, burning and itching sensation of the eye. Route of Administration: PO Route: Give last dose at bedtime Transdermal Route: Apply patch weekly; remove old patch and wash off residue; apply to site without hair; best absorption over chest or upper arm; rotate sites with each application; apply firmly, especially around edges. Nursing Responsibilities: Instruct patient not to discontinue drug abruptly, or withdrawal symptoms may occur anxiety, increased B/P, headache, insomnia, increased pulse, tremors, nausea, sweating; Caution patient not to take OTC (cough, cold, allergy) remedies unless directed by physician; Teach patient not to skip or discontinue medication without consulting physician; Inform patient that drug may impair ability to drive or operate machinery, thus should be avoided in tasks that require mental alertness. Drug may cause dizziness, fainting, light headache; Instruct patient to notify physician of mouth sores, sore throat, fever,

swelling of hands or feet, irregular heartbeat, chest pain, signs of angioedema, increased weight. Name of drug: Ferrous Sulfate Phil. Brand/s: AM-Europharma Ferrous Sulfate, Brofesol, Feosol Spansule FerIn-Sol, Ferglobin, Rhea Ferrous Sulfate, United Home Fersulfate Iron US Brand/s: Ed-In-Soul, Feosol, Fer-Gen-Sol, Fer Iron Drops, Fero-Grad, MolIron Therapeutic Classification: Hematinic agent Indication: Prevention and control of treatment of iron- deficiency anemia; a form of the mineral Iron, Iron is for many functions in the body. Contraindication: Hypersensitivity to any ingredient, hemosiderosis, hemolytic anemia. Adverse Reaction: GI irritation, anorexia, nausea, vomiting, diarrhea, constipation, dark stool. Teeth staining with liquid formulation. Route of Administration: Through oral administration- Men: 10 mg Women: 15 mg Women greater than 51 yrs: 10 mg Pregnancy: 30 mg lactation: 15 mg. Iron replacement in deficiency states Adults: 100 to 200 mg 3x/day. Children (2-12 yrs old): 3 mg/kg/day in 3 to 4 divided doses. Children (6 mons-2 yrs): up to 6 mg/kg/day in 3 to 4 divided doses. Infants: 10 to 25 mg every day in 3 to 4 divided doses. Nursing Responsibilities: Instruct patient not to substitute one iron salt for another because they have different elemental iron content. Swallow the whole tablet, do not crush or chew, do not double the dose if missed, but take it as soon as remembered and avoid taking the drug with certain foods that may impair oral iron absorption like yogurt, cheese, eggs, milk, cereals tea and coffee. Name of drug: Cefuroxime Brand Name: Ceftin Therapeutic Classification: Is a semisynthetic cephalosporin antibiotic, chemically similar to penicillin.

Indication: Is effective against susceptible bacterias causing infections of the middle ear, tonsillitis, throat infections, laryngitis, bronchitis, and pneumonia. It is also used in treating urinary tract infections, skin infections, and gonorrhea. Additionally, it is useful in treating acute bacterial bronchitis in patients with chronic pulmonary disease (COPD). Contraindication: Hypersensitivity or with known allergy to cephalosporine type antibiotics. Adverse Reaction: Shock, Stevens-Johnson syndrome, erythema multiform, Lyells syndrome, hypersensitivity, renal insufficiency, hematological effects, hepatic disorders. Route of Administration: Through oral administration Nursing Responsibilities: Instruct patient that cefuroxime is generally well tolerated and side effects are usually transient. Reported side effects include diarrhea, nausea, vomiting, abdominal pain, headache, rashes, hives, vaginitis, and mouth ulcers.

JOSE RIZAL UNIVERSITY COLLEGE OF NURSING A case study of a patient with MOLAR PREGNANCY A partial fulfillment of the requirements in Nursing Care Management 101 Related Learning Experience San Juan Medical Center Obstetrics - Gynecology Ward

Submitted by: Group II A-314 Leader: Gocela, Fritz Adriane Members: Coo, Ronald Cubelo, Marycarl De Vera, Gaudencio Dela Cruz, Ian Dwight Delfin, Sarah Devera, Mark Anthony Doronila, Jenny Duka, Moses Enosario, Mary Blaise Esquierdo, Cathrina Pia

Submitted to: Maria Blesilda Llaguno (Clinical Instructor)

1st Semester 2007