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 invasiveusually widely metastatictumor 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 38C , 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 38C 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 patients 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 longterm 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 familys 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 familys 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 patients and familys 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 %.

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 prophylacticcourse of this drug the drug of choice for choriocarcinoma. Because the drug interferes withWBC formation (Leukopenia), prophylactic use must be weighted carefully. If malignancy shouldoccur, it can be treated effectively in most instances with Methotrexate at that time. (Methotrexatehas the ability to dissolve fast-growing tissues). Administration of Dactinomycin. It is added to the regimen of Methotrexate if metastasis occurs. Itis an antibiotic used as an antineoplastic agent prescribed in the treatment of a variety ofmalignant neoplastic diseases. Surgical Care: Evacuation of the uterus by dilation and curettage is always necessary. Suction curettage: amethod of curettage in which a specimen of the endometrium or the products of conception areremoved by aspiration. The procedure is done through general anesthesia, but not which relaxesthe uterus as it may induce severe bleeding. A cannula is connected to a suction pump adjustedat 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 continuedpostoperatively to reduce the likelihood of hemorrhage. Consideration of using other uterotonicformulations (eg, Methergine, Hemabate) is also warranted. Respiratory distress is often observed at the time of surgery. This may be due to trophoblasticembolization, high-output congestive heart failure caused by anemia, or iatrogenic fluid overload.Distress should be aggressively treated with assisted ventilation and monitoring, as required.

What is a Molar Pregnancy (Hydatidiform Mole)? There are two types of molar pregnancy (hydatidiform mole): complete molar pregnancy (complete hydatidiform mole) and partial molar pregnancy (parital hydatidiform mole). A complete molar pregnancy (complete hydatidiform mole) occurs when a sperm fertilized an "empty egg". Due to the fact that there is no maternal genetic material there is no fetus, there is just abnormal placental cells that proliferate. Because the placenta is formed hCG is produced and is usually higher then expected. A partial molar pregnancy (partial hydatidiform mole) is when a fertilized egg produces both a fetal parts and abnormal proliferative cells. These abnormal cells will destroy the fetus in a short amount of time. The diagnosis of a molar pregnancy (hydatidiform mole) is usaully considered after fetal heart tones are not heard, the hCG levels are unusually high, and / or the size of the uterus does not match with the gestational age of the fetus. a ultrasound will then be performed which will show no fetal heart tones and a cluster of cells which has been described as a "cluster of grapes".

Signs and Symptoms of Molar Pregnancy (Hydatidiform Mole) The most common sign and symtom of a molar pregnancy (hydatidiform mole) is nause and / or vomiting due to the abnormally elevated serum hCG levels. Other signs and symptoms of a molar pregnancy (hydatidiform mole) include dark brown vaginal spotting, lower abdominal pain and/ or cramping, and inability to hear or see fetal heart tones. Usually the diagnosis of a molar pregnancy (hydatidiform mole) is made after the doctor can not see or hear fetal heart tones and / or notices that the uterus is not the proper size for the gestational age. To confirm the diagnosis of a molar pregnancy (hydatidiform mole) an ultrasound will be performed which will show a cluster of abnormal cells or sometimes described as a "cluster of grapes". To learn more Go to Signs and Symptoms of Miscarriage.

Causes of Molar Pregnancy (Hydatidiform Mole) The cause of a molar pregnancy (hydatidiform mole) is dependent on which type occurs. In a complete molar pregnancy (complete hydatidiform mole) a sperm fertilizes an "empty" egg. The sperm abnormally divides creating a proliferation of abnormal cells. There is no fetal components with a complete molar pregnancy (complete hydatidiform mole). In a parital molar pregnancy (partial hydatidiform mole) two sperm fertilize one egg. The cells begin to divide and a abnormal cluster of cells develop. The abnormal cells will proliferate and destroy any fetal component that is there. To learn more Go to Causes of Miscarriage.

Treatment of Molar Pregnancy (Hydatidiform Mole) A molar pregnancy (hydatidiform mole) should be treated immediately. The only treatment option is surgical intervention with a D&C (dilatation and

curettage). This treatment requires the woman to go into the hospital and have anesthesia will a obstitrician dilates her cervix with instruments, then using either suction or curettage (scraping) the endometrial lining to ensure removal of all molar tissue. The procedure is a same day surgery which means that the woman will go home the same day the surgery is performed. The benefit for this treatment is that the tissues are sent to a pathologist who can assess the products of conception. To learn more Go to Treatment of Miscarriage. The other important treatment that must be performed with a molar pregnancy (hydatidiform mole) is serial serum hCG levels. This allows the physician to make sure that all the molar tissue has been removed. If all the tissue is not removed there is a risk of developing trophoblastic cancer. There for serum hCG levels are usually evaluated six months to one year. Also the emotional difficulty withcoping with miscarriage must be addressed in the treatment plan. It is recommended that a couple who have just experienced a molar pregnancy (hydatidiform mole) wait one year before attempting to conceive.
A hydatidiform mole is a rare mass or growth that forms inside the uterus at the beginning of a pregnancy. It is a type of gestational trophoblastic disease (GTD).

Causes
A hydatidiform mole, or molar pregnancy, results from over-production of the tissue that is supposed to develop into the placenta. The placenta normally feeds a fetus during pregnancy. In this condition, the tissues develop into an abnormal growth, called a mass. There are two types: Partial molar pregnancy Complete molar pregnancy A partial molar pregnancy means there is an abnormal placenta and some fetal development. In a complete molar pregnancy, there is an abnormal placenta but no fetus. Both forms are due to problems during fertilization. The exact cause of fertilization problems are unknown. However, a diet low in protein, animal fat, and vitamin A may play a role.
Back to TopSymptoms

Abnormal growth of the womb (uterus) Excessive growth in about half of cases Smaller-than-expected growth in about a third of cases Nausea and vomiting that may be severe enough to require a hospital stay

Vaginal bleeding in pregnancy during the first 3 months of pregnancy Symptoms of hyperthyroidism

Heat intolerance Loose stools Rapid heart rate Restlessness, nervousness Skin warmer and more moist than usual Trembling hands Unexplained weight loss

Symptoms similar to preeclampsia that occur in the 1st trimester or early 2nd trimester -- this is almost always a sign of a hydatidiform mole, because preeclampsia is extremely rare this early in a normal pregnancy High blood pressure

Swelling in feet, ankles, legs

Back to TopExams

and Tests

A pelvic examination may show signs similar to a normal pregnancy, but the size of the womb may be abnormal and the baby's heart sounds are absent. There may be some vaginal bleeding. A pregnancy ultrasound will show an abnormal placenta with or without some development of a baby. Tests may include:

HCG blood test Chest x-ray CT or MRI of the abdomen Complete blood count Blood clotting tests Kidney and liver function tests
Back to TopTreatment

If your doctor suspects a molar pregnancy, a suction curettage (D and C) may be performed. A hysterectomy may be an option for older women who do not wish to become pregnant in the future. After treatment, serum HCG levels will be followed. It is important to avoid pregnancy and to use a reliable contraceptive for 6 - 12 months after treatment for a molar pregnancy. This allows for accurate testing to be sure that the abnormal tissue does not return. Women who get pregnant too soon after a molar pregnancy have a greater risk of having another one.
Back to TopOutlook

(Prognosis)

More than 80% of hydatidiform moles are benign (noncancerous). The outcome after treatment is usually excellent. Close follow-up is essential. After treatment, you should use very effective contraception for at least 6 to 12 months to avoid pregnancy.

In some cases, hydatidiform moles may develop into invasive moles. These moles may grow so far into the uterine wall and cause bleeding or other complications. In a few cases, a hydatidiform mole may develop into a choriocarcinoma, a fast-growing cancerous form of gestational trophoblastic disease. See: Choriocarcinoma
Back to TopPossible

Complications

Lung problems may occur after a D and C if the woman's uterus is bigger than 16 weeks gestational size. Other complications related to the surgery to remove a molar pregnancy include: Preeclampsia Thyroid problems

Clinical presentation and diagnosis

Molar pregnancies usually present with painless vaginal bleeding in the fourth to fifth month of pregnancy.[1] The uterus may be larger than expected, or the ovaries may be enlarged. There may also be more vomiting than would be expected (hyperemesis). Sometimes there is an increase in blood pressure along with protein in the urine. Blood tests will show very high levels of human chorionic gonadotropin (hCG).[14] The diagnosis is strongly suggested by ultrasound (sonogram), but definitive diagnosis requires histopathological examination. On ultrasound, the mole resembles a bunch of grapes ("cluster of grapes" or "honeycombed uterus" or "snow-storm"[15]). There is increased trophoblast proliferation and enlarging of the chorionic villi.[16] Angiogenesis in the trophoblasts is impaired as well.[16] Sometimes symptoms of hyperthyroidism are seen, due to the extremely high levels of hCG, which can mimic the normal Thyroid-stimulating hormone (TSH).[14] [edit]Treatment Hydatidiform moles should be treated by evacuating the uterus by uterine suction or by surgical curettage as soon as possible after diagnosis, in order to avoid the risks ofchoriocarcinoma.[17] Patients are followed up until their serum human chorionic gonadotrophin (hCG) level has fallen to an undetectable level. Invasive or metastatic moles (cancer) may require chemotherapy and often respond well to methotrexate. The response to treatment is nearly 100%. Patients are advised not to conceive for one year after a molar pregnancy. The chances of having another molar pregnancy are approximately 1%. Management is more complicated when the mole occurs together with one or more normal fetuses. Carboprost medication may be used to contract the uterus. [edit]Prognosis More than 80% of hydatidiform moles are benign. The outcome after treatment is usually excellent. Close follow-up is essential. Highly effective means of contraception are recommended to avoid pregnancy for at least 6 to 12 months. In 10 to 15% of cases, hydatidiform moles may develop into invasive moles. This condition is named persistent trophoblastic disease (PTD). The moles may intrude so far into the uterine wall that hemorrhage or other complications develop. It is for this reason that a post-operative full abdominal and chest x-ray will often be requested.

In 2 to 3% of cases, hydatidiform moles may develop into choriocarcinoma, which is a malignant, rapidly-growing, and metastatic (spreading) form of cancer. Despite these factors which normally indicate a poor prognosis, the rate of cure after treatment with chemotherapy is high. Over 90% of women with malignant, non-spreading cancer are able to survive and retain their ability to conceive and bear children. In those with metastatic (spreading) cancer, remission remains at 75 to 85%, although their childbearing ability is usually lost.