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Forosan Dr. threatened abortion. Paggao. and Isoxsuprine. 2006: Normal Spontaneous Delivery to a live fetus (male) delivered by a Barangay Health Worker. Kabayan. ultrasound was done revealing H mole. On follow-up. Benguet Married 23-May-1978 29 y/o Filipino Roman Catholic .I. Consult was done into another institution where the patient was a manifest as a cause of abortion. The patient was discharged. Dr. T. M. No other known general medical condition. OB-Gyne History: OB Score: G2P1 (1011) G1: 2006. C. Past Medical History: September 2007: Bokod. NSD to a live term (M) by a BHW. G2: present pregnancy. 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. Benguet. The patient was then referred into this institution for further management and work-up. house delivery. PATIENT’S PROFILE Name: Address: Civil Status: Birth date: Age: Nationality: Religion: Admission: Date: Time: Admitting Clerk: Attending Physician: Admitting Diagnosis: Chief Complaint: H mole. Methyl dopamine 250 mg 1 tab BID. No known gynecologic illness 09-Nov-2007 11:20 AM F. improved after seven hospital days and was given the following home medicines: Amoxicillin 500 mg TID. Cariaga G2P1(1001) Gestational Trophoblastic Disease Mrs. Asocong Gusaran.
BUN-Crea b.3 c.02 mIU/mL d.67 mIU/mL = <0. Chemiluminiscent Immuno-assays e.96 mg/dL0. uterus 0-5.Patient’s Diagnostic Results: Result a.37-0. Hematology low ALT = 25 u/L low Crea = 32.33 u/L high WBC = 10.1 umol/L low Hgb = 113 g/L low Hct = 0.000 mIU/mL no gestational sac.85 mg/dL low ultrasensitive hTSH II Gen 0. UTZ highb-hCG = 364.0 mIU/mL enlarged. Immunochemical Reference Value 30-65 u/L 53-88 umol/L 120-160 g/L 0.49-4. multiple anechoic area of varied sizes seen interspersed in the H mole .71-1.47 u/L 5-10x109/L high free t4 = 1.
500 pregnancies. partial moles rarely lead to choriocarcinoma. with no fetal blood present in the villi. they become filled with fluid and appear as clear fluid-filled. is swollen and misshapen. 2). however.II. The syncytiotrophoblastic layer of the villi. 1. Partial Mole: With a partial mole. is a condition associated with second-trimester bleeding. The incidence of gestational trophoblastic disease is approximately 1 in every 1. On chromosomal analysis. It is an abnormal proliferation and degeneration of the trophoblastic villi.Complete mole. it dies early at only 1 to 2 mm in size. With this condition. the embryo fails to develop beyond a primitive start. grape-sized vesicles. Sperm 2 3 + Ovum + Duplication = 4 6 Fig. Two types of molar growth can be identified by chromosomal analysis: Complete Mole: All trophoblastic villi swell and become cystic. gestation may be present in the villi. 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). some of the villi form normally. As the cells degenerate. . WHAT IS GESTATIONAL TROPHOBLASTIC DISEASE? Gestational Trophoblastic Disease. existing in many terms like Hydatidiform Mole. If an embryo forms. 1). a rapidly metastasizing malignancy. A partial mole has 69 chromosomes (a triploid formation in which there is three chromosomes instead of two for every pair. Such structures must be identified because they are associated with choriocarcinoma. A macerated embryo of approximately 9 weeks. In contrast to complete moles. 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. this chromosome component was contributed only by a father or an “empty ovum” was fertilized and the chromosome material was duplicated (Fig. although the karyotype is a normal 46XX or 46XY.
Sperm 4 6 or 2 3 + 2 3 Fig. Various features of a complete and a partial mole. PREDISPOSING FACTORS . III. Ovum 2 3 6 9 + = + 2 3 = 6 9 • FEATURES Embryonic/fetal tissue Absent vesicles) COMPLETE (whole conceptus into a mass is of PARTIAL Present (with fetus or at least an amniotic sac) Focal Focal Paternal and maternal 69XXY or 69XYY Rare transformed • • • • Diffuse Diffuse Swelling of villi Trophoblastic hyperplasia Karyotype Malignant changes Paternal 46XX (97%) or 46XY (47%) 5-10% Table 1. 2. Partial mole.
Symptoms: 1. Age: Women older than 35 years. symptoms of preeclampsia that may be present as headache and edema 4. C. Signs: 1. exaggerated symptoms of pregnancy especially vomiting 3. IV. 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. although Asian countries show a rate 15 times higher than the US rate. GTD is higher toward the beginning and toward the end of child bearing period. usually before 20 weeks’ AOG 2. SIGNS AND SYMPTOMS A. pallor indicating anemia may be present 3. It is ten times more in women who are 45 years old and beyond. colicky due to start of expulsion 6. Molar pregnancy has no racial or ethnic predilection. Blood may be concealed in the uterus. Race: Asian heritage. due to the separation of vesicles from the uterine wall and there may be blood-stained. Diet: Low CHON and low Vitamin A (carotene) intake. amenorrhea 2.A. 5. abdominal pain: may be dull-aching due to rapid distension of uterine by mole or by concealed hemorrhage. thereby causing enlargement. ovarian pain due to stretching of ovarian capsule or complication in the cystic ovary as torsion B. PATHOPHYSIOLOGY . vaginal bleeding as the main complaint. B. preeclampsia develops in 20 – 30 % cases. 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 thyroidstimulating effect) V.
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 Trophoblastic proliferation Uterus expands faster than normal Abdominal pain High secretion of hCG High progesterone low estrogen High chorionic thyrotropin Marked nausea & vomiting Decreased contraction Separation of vesicles from uterine wall Amenorrhea Hyperthyroidism Multiple theca lutein cysts in the ovaries Ovarian pain Vaginal bleeding & discharge of vesicles Enlarged thyroid gland. tachycardia Pallor Preeclampsia Note: Those inside the boxes end up as the signs & symptoms of H mole. DIAGNOSTIC FINDINGS . VI.Low intake of proteins and vitamin A.
reveals no pregnancy. C. MANAGEMENT Hyperthyroidism the presenting . • Uterine highly surely Pregnancy suggestive. using older ultrasonographic technology. as is the development of a coagulopathy. and cerb B-2. Additionally. compared to normal placenta. B. Once a molar pregnancy is diagnosed. is in • • Positive in high dilution. may be symptom. srophoblastic and severe proliferation. including c-myc. above the reference range for pregnancy.000 exuberant a molar pregnancies. Hydropic villi and trophoblastic proliferation are also observed. diagnostic. Positive if levels are increased. A molar pregnancy may have a normal HCG level. complete moles show overexpression of several growth factors. The lungs are a primary site of metastasis X-RAY procedure skeleton. Imaging Studies: • Ultrasonography is the criterion standard for identifying both complete and partial molar VI. Complete blood cell count with platelets: Anemia is a common medical complication. is of a snowstorm pattern chorionic complex indicating villi.A. • Partial mole: Fetal tissue is often present as well as amnion and fetal red blood cells. The classic image. hydropic shows a mass High-resolution indicate that trophoblastic growth and raise pregnancy should be excluded. is usually plasma elevated hydropic villi.XX or 46. Lab Studies • Quantitative levels mIU/mL suspicion beta-HCG: than HCG greater 100. of for malignant The fetal trophoblastic tumors. abdomen.XY are present. and chromosomes 46. epidermal growth factor. Histological Findings: • Complete mole: Fetal tissue is absent. • Thyroxin: Although women with molar pregnancies are usually clinically thyroxin euthyroid. 1/200 is 1/500 positive normal ultrasonography intrauterine containing many small cysts (usually bilateral ovarian cysts). a baseline chest radiograph should be taken.In it is Test. • dilution up to 1/100. • Blood urea nitrogen (BUN) and creatinine studies.
• Administration of Dactinomycin. Administration of Methotrexate. It is added to the regimen of Methotrexate if metastasis occurs. Nursing Management: Nursing Considerations: . If malignancy should occur. The procedure is done through general anesthesia. prophylactic use must be weighted carefully. Suction curettage: a method of curettage in which a specimen of the endometrium or the products of conception are removed by aspiration. high-output congestive heart failure caused by anemia. Some physicians give women who have had GTD a prophylactic course of this drug – the drug of choice for choriocarcinoma. • • Prostaglandin or oxytocin induction is not recommended because of the increased risk of bleeding and malignant sequelae. It is an antibiotic used as an antineoplastic agent prescribed in the treatment of a variety of malignant neoplastic diseases. • Respiratory distress is often observed at the time of surgery. B. or iatrogenic fluid overload. Treat hypertension. This may be due to trophoblastic embolization.A. Methergine. Consideration of using other uterotonic formulations (eg. Distress should be aggressively treated with assisted ventilation and monitoring. Medical/Surgical Management: Medical Care: • • • • • Stabilize the patient. but not which relaxes the uterus as it may induce severe bleeding. Hemabate) is also warranted. it can be treated effectively in most instances with Methotrexate at that time. Intravenous oxytocin should be started with the dilation of the cervix and continued postoperatively to reduce the likelihood of hemorrhage. 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. (Methotrexate has the ability to dissolve fast-growing tissues). Correct any coagulopathy. Surgical Care: • Evacuation of the uterus by dilation and curettage is always necessary. Transfuse for anemia. Because the drug interferes with WBC formation (Leukopenia). as required.
the importance of consistent follow-up care must be emphasized. • Future pregnancies should undergo early sonographic evaluation because of the increased risk of recurrence of a molar gestation. Any rise in levels should prompt a chest radiograph and pelvic examination to facilitate early detection of metastases. No special diet is required. the elevation in beta-HCG would be confused with development of malignant disease. If a pregnancy does occur. check them each month for a year. Work with the team to evaluate all future pregnancies early with ultrasonography. If a pregnancy occurs. • Monitor serial beta-HCG values to identify the rare patient who develops malignant disease. o o o o Draw the first level 48 hours after evacuation and then every 2 weeks until the levels are within reference ranges. Patients may resume activity as tolerated. . the elevation in beta-HCG levels cannot be differentiated from the disease process. 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. Effective contraception should be used.• • • • A gynecologic oncologist should be consulted if the patient is believed to be at risk for or has developed malignant disease. Patient Education: • Because of the small but real potential for development of malignant disease and because these malignancies are absolutely curable. Levels should consistently drop and should never increase. Patients with a prior complete or partial molar pregnancy have a 10-fold risk of a second mole in a future pregnancy. Once levels have reached reference ranges. • • Contraception is recommended for 6 months to a year after evacuation. Further Outpatient Care: • Serial quantitative beta-HCG levels should be determined. • The patient must avoid pregnancy for 1 year to avoid any confusion about the development of malignant disease. Adequate contraception is recommended during this period.
5 to 1 in 17.5. Smeltzer (et.) . Reference: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing-11th edition by Suzanne C. al.• The risk of recurrence is 1-2%. the risk of recurrence has been reported as 1 in 6. After 2 or more molar pregnancies.
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