CASE PRESENTATION ON MOLAR PREGNANCY

Introduction:
A woman with painless bleeding early in the second trimester may have a hydatidiform mole, or molar pregnancy. A hydatidiform mole is a mass of abnormal, rapidly growing trophoblastic tissue

in which avascular vesicles hang in a grapelike cluster. The mole may be complete or incomplete. The complete mole lacks an embryo or fetus, whereas the partial mole involves a chromosomally abnormal embryo or fetus. Hydatidiform

mole is fairly rare in the united states but much more common in parts of Asia. It is also more common in women older than 40. There is a 1% to 2% increased risk of a repeat occurrence. The cause of a hydatidiform mole is

unknown, but it is theorized that a defect in the egg, stress, or a nutritional deficiency may contribute to its development [Berkowitz, Goldstein, and Bernstein, 1996]. Although very rare, a mole can co-exist with a

normal pregnancy [Urbanski et al, 1996].

Objectives:
General: This case study about molar pregnancy aims for the audience and the researcher to obtain better and deeper knowledge about the case presented.

Specific: At the end of this case presentation, the audience and researchers will be able to: Understand the clients past and present history and be able to relate it to the pts present

condition. Inter-relate the results in the clients physical assessment to the clients condition. Define what molar pregnancy is and its possible causes. Determine the symptomatology

with its rationale. Understand the anatomy and physiology of a molar pregnancy. Discuss the nursing care rendered to the client.

DIAGNOSTIC TESTS
ULTRASOUND: Ultrasound can also determine a molar pregnancy. When doing an ultrasound one sees a "snow storm effect" on the screen.

PREGNANCY TEST Occurrence of pregnancy is generally validated by measuring HCG in the urine. A solution containing monoclonal antibodies specific for HCG is mixed with a small amount of urine the presence

of HCG causes a change in color of the tested urine. DILATION & CURETTAGE: Examination of cervical cannal and endometrium via dilation and scrapping with possible tissue sampling for cytology.

NURSING HEALTH HISTORY

General Information Name: XXX Address: Tacloban City Birthday: September 02, 1988 Birthplace: Tacloban City

Age: 22 Civil Status: Single Religion: Roman Catholic Nationality: Filipino Date Of Admission: July 27, 2011

Time Of Admission: 10:15 Am Ward: Gynecology Admitting Physician: Dr. R. Tan Chief Complaint: Vaginal Bleeding

HEALTH HISTORY: PAST MEDICAL HISTORY: According to the pt, she had no major illnesses when she was young, she only had coughs and colds before and she managed these by taking over the counter

medicines. She had her first child when she was 22 through natural birth. When she gave birth, part of her intestine projected from her anus but was replaced immediately after.

PRESENT HEALTH HISTORY: Patient noted spottings when she was still 2 months pregnant but she did not worry about since she thought it was natural. The spottings were only a few drops of bright red blood on her underwear.

After about 2 months, she began to worry since the blood became dark brown and had a foul odor about it. She went for a check up and she had an ultrasound in which she discovered that she had molar pregnancy. Afterwards, they went

to the hospital for admission and for the removal of the tumors through D&C.

GORDONS FUNCTIONAL HEALTH HISTORY

HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN Before Hospitalization: The patient perceived herself as someone who is healthy. She sees health as something very

important and she manages health through practicing proper hygiene everyday, eating nutritious food as well as physical exercise such as walking.

During Hospitalization:

Patient stated that she finds it hard to move because of the pain in her lower abdomen due to the removal of tumors in her uterus [Dilation & Curettage].

NUTRITIONAL & METABOLIC PATTERN Before Hospitalization: Patient eats three times a day and her meals usually consist of rice with vegetables, meat or fish. She has 32 teeth and has

No problems in eating. She also has no allergies to food. She has good appetite but sometimes it depends on the food served. During Hospitalization: The patient was on NPO prior to D&C. After D&C, patient still

has difficulty in eating since she gets nauseous when she eats and vomits the food although she wants to eat.

ELIMINATION PATTERN Before Hospitalization: Patient usually defecates 1-2 times a day and urinates 5-8 times a day. Her feces are usually brown and semi-hard; her urine is generally yellow,

either dark or light, depending on her fluid intake. She said she sometimes has difficulty in defecating when her feces become hard because during the birthing of her first child, part of her intestine projected from

her anus but was replaced and it becomes painful. During Hospitalization: Patient has not defecated and urinated since she was on NPO before D&C but afterwards, she only urinates 1-2 times a day &

she sometimes doesnt defecate in a day.

ACTIVITY EXERCISE PATTERN Before Hospitalization: The patient walks daily for 15-20 minutes a day. During Hospitalization:

The patient has difficulty in moving because of the pain in her lower abdomen due to the removal of tumors in her uterus [Dilation & Curettage].

SLEEP REST PATTERN Before Hospitalization: Patient generally sleeps at 7:00 pm and wakes up at 6:00 am. She has no difficulties in sleeping and she sleeps continuously.

During Hospitalization: Patient has difficulty in sleeping due to environmental factors as well as some physical discomforts that she feels [pain]. She feels that she lacks sleep.

COGNITIVE PERCEPTUAL PATTERN Before Hospitalization: Patient has normal cognitive abilities & perceptual pattern. She has good memory, can easily comprehend things, and has no

problems with her senses. During Hospitalization: Patient has normal cognitive abilities & perceptual pattern. She has good memory, can easily comprehend things, and has no problems with her senses

although sometimes, she looks weak probably due to fatigue.

SELF PERCEPTION & SELF CONCEPT PATTERN Before Hospitalization: According to patient, she can easily interact with others although she is not yet very fluent with the Visayan

language since she came from Tacloban City, which uses the Waray & Tagalong languages. During Hospitalization: Patient was not very cooperative at first, probably due to fatigue but as we established a

nurse-patient rapport, she began to cooperate & talk more freely.

ROLE RELATIONSHIP PATTERN Before Hospitalization: She is not close to her family. She does not know her father and she was separated from her mother and sister when she was

7 years old. She grew up with her aunt on her fathers side. During Hospitalization: Her primary confidant during her hospitalization is her live-in partner but her aunts also helped financially.

SEXUALITY-REPRODUCTIVE PATTERN Before Hospitalization: Patient had her menarche when she was 12 and her menstruation is regular. She gave birth to her first child when she was 22

through natural birth. During Hospitalization: Patient discovered that she had molar pregnancy and has undergone D&C. She was advised to wait three years to become pregnant again but she

and her live-in partner still has plans to have another child if possible.

COPING STRESS TOLERANCE Before Hospitalization: Before she met her live-in partner, she usually keeps it to herself when she has problems, but when she met him, she confides to him.

During Hospitalization: Her primary confidant during her hospitalization is her live-in partner but her aunts also helped financially.

VALUE BELIEF PATTERN Before Hospitalization: Patient is a roman catholic and she goes to church with her livein partner every Sunday.

During Hospitalization: She cannot go to church every Sunday anymore due to her circumstance but she still strongly believes in god.

PHYSICAL ASSESSMENT
Vital Signs: T- 36.6 C P- 76 bpm R- 20 cpm Bp- 160/100 mmHg

General Survey: Appearance: Weak & Looks The Same As Stated Age Grooming: Clean Loc: Conscious Coherence: Coherent

Nutritional State: Low Appetite Emotional State: Calm Respiratory: Rate: 20 Pattern: Even

Cardiovascular: Rate: 76 Perfusion: Warm, Diaphoretic Nutrition: Person & Place], Restless, Drowsy Appearance: Nourished Appetite: Poor

Diet: As Tolerated Meal Pattern: 3 Times A Day Integumentary: Color: Pale Skin Turgor: Normal Condition: Dry

Neurological: Orientation: Oriented

COMPLETE DIAGNOSIS OF MOLAR PREGNANCY

Definition: Hydatidiform mole: mass in the uterus consisting of enlarged edematous degenerated placental villi growing in clusters resembling

grapes and usually associated with death of the fetus.

Miriam - Websters Medical Desk Dictionary Revised Edition, P.359

Pregnancy in which a cyst-like mole (hydatid mole) instead of the embryo grows from the tissue of

the early stage of the fertilized egg. The signs of pregnancy are all heightened.

The Mosby Medical Encyclopedia, P.476

Is a cystic, hydopic swelling of the chorionic villi accompanied by

variable hyperplastic and anaplastic changes in the chorionic epithelium.

Robins, Copran, Kumar; Pathophysiologic Basis Of Disease, P.115

Consists of chorionic villi which

appear as grapelike clusters of vesicles. They resemble youthful villi in that they are branching structures with one or more layers of trophoblastic cells, but they have no fetal blood vessels, and their stoma is only a loose-meshed

matrix filled with clear gelatinous material.

Frank H. Netter, Md, The Ciba Collection Of Medical Illustrations Volume2, Reproductive System, P.232

ANATOMY & PHYSIOLOGY OF THE FEMALE REPRODUCTIVE SYSTEM

Internal
Vagina The vagina is a fibro muscular tubular tract leading from the uterus to the exterior of the body in females. The vagina is the place where

semen from the anatomic male is deposited into the anatomically female person's body at the climax of sexual intercourse, commonly known as ejaculation. Around the vagina, pubic hair protects the vagina from

infection and is a sign of puberty. The vagina is mainly used for sexual intercourse.

Cervix The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior

vaginal wall. Approximately half its length is visible, the remainder lies above the vagina beyond view. The vagina has a thick layer outside and it is the opening where baby comes out during delivery. The cervix

is also called the neck of the uterus.

Uterus the uterus or womb is the major female reproductive organ of humans. The uterus provides mechanical protection, nutritional support, and waste removal for the developing embryo (weeks 1

to 8) and fetus (from week 9 until the delivery). In addition, contractions in the muscular wall of the uterus are important in ejecting the fetus at the time of birth. The uterus is a pear-shaped

muscular organ. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium, and derives nourishment from blood vessels which develop exclusively for this purpose. The fertilized

ovum becomes an embryo, develops into a fetus and gestates does until children. If the egg not embed in the wall of the uterus, an anatomically female person begins menstruation and the egg is flushed away.

Fallopian tubes The fallopian tubes or oviducts are two tubes leading from the ovaries of female mammals into the uterus. On maturity of an ovum, the follicle and the ovary's wall

rupture, allowing the ovum to escape and enter the fallopian tube. There it travels toward the uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum

is fertilized while in the fallopian tube, then it normally implants in the endometrium when it reaches the uterus, which signals the beginning of pregnancy.

Ovaries The ovaries are small, paired organs that are located near the lateral walls of the pelvic cavity. These organs are responsible for the production of the ova and the secretion of hormones. Ovaries

are the place inside the anatomically female body where ova or eggs are produced. The process by which athe ovum is released is called ovulation. The speed of ovulation is periodic and impacts directly to the length of

a menstrual cycle. After ovulation, the ovum is captured by the oviduct, after traveling down the oviduct to the uterus, occasionally being fertilized on its way by an incoming sperm, leading to

pregnancy and the eventual birth of a new human being. The fallopian tubes are often called the oviducts and they have small hairs (cilia) to help the egg cell travel.

External
Mons pubis The mons pubis (latin for "pubic mound"), also known as the mons veneris (latin, mound of venus) or simply themons, is the adipose tissue lying above the pubic

bone of adult females, anterior to the pubic symphysis. The mons pubis forms the anterior portion of the vulva.

Pudendal cleft The pudendal cleft (also called the cleft of venus, pudendal fissure, pudendal cleavage, pudendal slit, urogenital cleft, vulvar slit, rima vulvae, or rima pudendi) is a part of the vulva,

the furrow at the base of the mons pubis where it divides to form the labia minora.

Labia majora the labia majora (singular: labium majus) are two prominent longitudinal cutaneous folds which extend downward and backward from the mons pubis to the perineum and form the

lateral boundaries of the pudendal cleft, which contains the labia minora, interlabial sulci, clitoral hood, clitoral glans, frenulum clitoris, the harts line, and the vulval vestibule, which contains the external openings of

the urethra and the vagina. Each labium majus has two surfaces, an outer, pigmented and covered with strong, crisp hairs; and an inner, smooth and beset with large sebaceous follicles.

Labia minora The labia minora (singular: labium minus) or nymphae are two longitudinal cutaneous folds on the human vulva. They are situated between the labia mainora, and extend from the

clitoris obliquely downward, laterally, and backward on either side of the vulval vestibule, ending between bottom of the vulval vestibule and the labia majora. In the virgin the posterior ends of the labia minora

are usually joined across the middle line by a fold of skin, named the frenulum labiorum podendi or fourchette. Labia minora may vary widely in size from woman to woman.

Bartholins glands The bartholin's glands (also called bartholin glands or greater vestibular glands) are two glands located slightly below and to the left and right of the opening of the vagina. They secrete mucus

to lubricate the vagina and are homologous to bulbourethral gland in males. However, while bartholin's glands are located in the superficial perineal pouch in females, bulbourethral glands are located in the deep peerineal pouch in males.

Clitoris the clitoris is the most sensitive erogenous zone of the female, the stimulation of which may produce sexual excitement and clitoral erection; its continuing stimulation may produce sexual

pleasure and orgasm, and is considered the key to females' sexual pleasure.

MANAGEMENT OF HYDATIDIFORM MOLES

Suspected cases are initially managed with suction uterine evacuation (sharp curettage is avoided to minimize the risk of uterine perforation).

Medical termination of complete molar pregnancies, including cervical preparation prior to suction evacuation, should be avoided where possible. There is theoretical concern over the potential for inducing embolism and metastatic

disease in the lung. Medical termination can be used for partial molar pregnancies. There may be an increased risk of requiring treatment for persistent trophoblastic neoplasia, but the proportion of women with partial

molar pregnancies needing chemotherapy are very low. Initial evacuation usually removes most molar material and residual tissue involutes. Sometimes the first evacuation is incomplete, with molar

material left behind in the uterine cavity; further evacuation within the next few days may help reduce symptoms and prevent the need for chemotherapy. If little residual material is left after the initial procedure,

the guidelines do not recommend further evacuation for persistent disease, at least until after consultation with a specialist centre.

NURSING IMPLICATION
Nursing Practice The implication of this case study to the nursing practice is to enhance the skills and knowledge of the learner in the field; to develop confidence in dealing with

situations may it be simple or complicated. Nursing Education In nursing education, it helps the learners to enhance their knowledge in the field of this case. It gives us guidelines on how to

apply treatment and what procedures we should do which we gained from our studies and clinical instructors. Nursing Research The implication of this study on nursing research is to let the

learner gain more knowledge on the interventions and procedures to be done in this problem.

BIBLIOGRAPHY
Books: Miriam Websters Medical Dictionary Revised Edition The Mosby Medical Encyclopedia Robins, Copran, Kumar;

Pathophysiologic Basis Of Disease Frank H. Netter, Md., The CIBA Collection Of Medical Illustrations Volumme 2, Reproductive System Brunner & Suddarth Medicalsurgical Nursing Doenges, Et Al. Nurses Pocket

Guide 11th Edition American College Of Physicians, Complete Home Medical Guide Kozier & Erbs, Fundamentals Of Nursing, Volume 1 Nursing Drug Handbook, 2004 & 2007

Barbara L.Bullock, Reet L. Henze, Focus On Pathophysiology Internet: www.wikipedia.com www.google.com