Gestational trophoblastic disease or Hydatidiform Mole Nursing Care Plan to Mrs. Smith Assessment: S> Mrs.

Smith, a 35 year old,married Chief complaint: Vaginal bleeding that varies from dark brown spotting for 1 day duration. 3 days PTA, Mrs. Smith experienced excessive vomiting that occurs in the morning. O> Urinalysis test for hCG revealed positive, UTZ revealed multiple small cystic structures, negative for fetal parts and fetal heart beat. Nursing Diagnosis: Nursing Interventions: Independent: - Assess skin turgor and moisture of mucous membranes
Indicators of hydration status/ degree of deficit

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

- Monitor Vital signs. Evaluate peripheral pulses, capillary refill

to have a baseline data, reflects adequacy of circulating volume

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

Decreasing renal output and concentration of urine suggest developing dehydration and need for fluid replacement.

- Weigh daily
Sensitive measurement of fluctuations in fluid balance

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

Early identification of problems (which may occur as a result of cancer), allows for prompt intervention.

-Encourage increase fluid intake as tolerated

To compensate with the fluid volume deficit problem

-Encourage ice chips on mouth

For the vomiting episodes

-Encourage rest
Prevent unnecessary energy expenditure related to vomiting (as may trigger) and bleeding (loss of blood/RBC)

Dependent:

1. Blood Transfusion for Anemia Monitor VS Monitor signs of allergy Check blood package Monitor IV line and regulate drops

2. Correction of Coagulopathy

Assist

3. Hypertension Treatment Monitor VS Give meds as ordered Health teaching: diet and exercise Promote exercise

4. Dilation and Curettage for Evacuation of the Uterus Medication-Drug: Assist

5. Intravenous Oxytocin
to be started with the dilation of the cervix and continued postoperatively to reduce likelihood of hemorrhage. Consideration of using other uterotonic formulations such as Methergine or Hemabate is also accepted.

Monitor IV line and regulate drops

6. Assisted Ventilation and Monitoring for Respiratory

Distress

during surgery, this can happen due to trophoblastic embolization, high-output congestive heart failure caused by anemia, or iatrogenic fluid overload. Ventilation and monitoring should be done during such situation.

Assist

7. Monitor HCG for 1year

Increased HCG results to Choriocarcinoma (malignant)

8. Drug of Choice: Methotrexate (drug analysis on last

page)
(chemo-therapeutic drug)

9. Anitemetics

Diagnostic Procedure: o

For the vomiting episodes

Pretest

>Urine test for hCG

positive up to 100th day of pregnancy 1 2 million IU compared with a normal pregnancy level of 400,000 IU)

>Ultrasound >Laboratory test of vaginal discharge o After mole extraction to r/o tumor

> Pelvic examination > Chest x-ray > Serum test for the beta subunit of hCG

2 weeks until levels are normal, thereafter, levels are assessed every 4 weeks for 6 12 months. Increased levels after this suggest that malignant transformation has occurred.

Nursing Responsibility

- explain the procedure to client - ask client to void before the procedure - label and preserve specimen Collaborative: Dietary Department protein, folic acid, B12-rich food
To help patient develop new mature red blood cells to prevent further anemia due to blood loss for further evaluation and proper treatment

OB-Gyne Department

Patient Health Teaching:

- Encourage to have a high protein, folic acid and carotene diet R: Avoid use of OTC drugs and aspirin, gastric irritants
Affect clotting mechanism and potentiate to bleeding.

Patient Outcome:

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

Medical Management 1. Patient Stabilization 2. Blood Transfusion for Anemia 3. Correction of Coagulopathy 4. Hypertension Treatment 5. Dilation and Curettage for Evacuation of the Uterus 6. Intravenous Oxytocin to be started with the dilation of the cervix and continued postoperatively to reduce likelihood of hemorrhage. Consideration of using other uterotonic formulations such as Methergine or Hemabate is also accepted. 7. Assisted Ventilation and Monitoring for Respiratory Distress During surgery, this can happen due to trophoblastic embolization, high-output congestive heart failure caused by anemia, or iatrogenic fluid overload. Ventilation and monitoring should be done during such situation. 8. Monitor HCG x 1year= Increased HCG results to Choriocarcinoma (malignant)

Nursing Management 1. Asses for signs and symptoms of h mole such as vaginal bleeding, nausea and vomiting, abnormal growth in the size of uterus for the stage of pregnancy and symptoms of hyperthyroidism 2. Explain the importanceof adequate nutrition in order to reduce the risk of h mole 3. Explain the risk factors such as women under 20 or over 40; other risk factors include a diet low in protein folic acid and carotene 4. Enumerate the possible potential causes such as defect in the egg, abnormality within the uterus, or nutritional deficiency. 5. Instruct the patient to plan the next conception after 12 months to prevent false result of pregnancy 6. Instruct to use a reliable contraceptive method such as an oral contraceptive for 12 months so that a (+) pregnancy test resulting from a new pregnancy will not be confused with increasing levels and devloping malignancy. 7. Explain the importance of oral contraceptives 8. Monitor HCG levels 9. Encourage to verbalize feelings about the loss of a possible child

Gestational trophoblastic disease or Hydatidiform Mole

(Reproductive System)

IV- B12
Aguirre, Maria Felicidad Alabastro, Robin Niceno Arancon, Dominique Baula, Maria Feliza De Leon, Adriane Jerel Gomintong, Aura Mae Lim, Giselle Marie Osorio, Maria Christiana Reyes, Ana Katrina Simon, Stephanie Lou Tiburcio, Maria Victoria

Methotrexate Mechanism of Action: Inhibits dihydrofolate reductase, preventing reduction of dihydrofolate to tetrahydrofolate, subsequently resulting to decreased synthesis of purines and consequently DNA. Its activity is cell cycle specific. Indication: Patients with Hydatidiform mole. Nursing Responsibilities: Assess patients condition before therapy and reassess regularly thereafter to monitor drug effectiveness. Monitor for severe allergic reaction: rash, pruritus, urticaria, itching and flushing. Avoid contact with skin, since this drug is very irritating. Give in the morning so drug can be eliminated at bedtime. Take medication on an empty stomach. Encourage diligent mouth care to reduce risk for oral infections. Avoid use of aspirin or NSAIDS, sharp objects to reduce risk for bleeding. Instruct patient to report signs of anemia such as faintness, shortness of breathe. Contraceptive measures may be advised. Hair may be lost during treatment. Advise patient not to use sunblock or protective clothing to avoid burns.

Hydatidiform Mole / Molar Pregnancy (H-Mole)

a developmental anomaly of the placenta, resulting in the proliferation & degeneration of chorionic villi w/c develops into a grape like clusters of vesicles. Incidence of H-mole most common lesion anteceding choriocarcinoma.

Diagnostics

Ultrasound reveals no fetal skeleton High HCG level in urine or blood

Risk Factors: Can predispose but not really cause

Taiwanese & Mexicans - protein diet (noodles) Familial Tendency buntis pero di bata ang laman , buwa incidence w/ advanced maternal age; assoc. w/ induction of ovulation by Clomiphine Therapy (hormone) 35 & 18 yr. old In women w/ socio-economic status

Clinical Manifestations ADEA

Anemia due to loss of blood Discharge of brownish red fluid (like prune juice) from vagina, around the 12th wk. w/c may contain clear fluid filled grape sized vesicles. Exaggerated symptoms of pregnancy Uterus too large for pregnancy Excessive Nausea & vomiting Early signs of PIH (before 24 weeks.) Absence of Fetal Heart sound

Complications DICT

DIC Disseminated Intravascular Coagulation Infection Choriocarcinoma is possible Trophoblastic embolization after evacuation of molar pregnancy can cause Cardio-pulmonary arrest

Management

D & C to empty the uterus

Medical mgmt after D & C Follow-up supervision (1 yr.) monitor HCG level every wk., on 3-4 mos. every other wk., then every month until 1 year is completed. If there is rising titer of HCG, indicates pathology of choriocarcinoma. Drug of choice: Methotrexate (chemo-therapeutic drug) Pregnancy shld. be avoided for at least 1 yr. can use contraceptives but not pills (alters HCG levels)