GESTATIONAL TROPHOBLASTIC
DISEASE
Gestational Trophoblastic Disease
(GTD) abnormal growth of
tumors inside a woman’s uterus that started in the cells that would normally develop in the placenta during pregnancy
Trophoblast- layer of cells that surrounds an embryo
tropho – means nutritionblast – means bud“early developmental
cell”
In normal development, these cells form finger-like projections called Villi
These villi grow into the lining of the uterus
The trophoblast layer develops into the placenta that nourishes and protects the fetus
Most GTD’s are benign and does not metastasize but some are malignant
It may spread to the lungs brain and liver
Types of GTD’s
Hydatidiform Mole Invasive Mole Choriocarcinoma Placental Site
Trophoblastic Tumor
Hydatidiform Mole
also known as Molar pregnancy
Moles are villi that have become swollen with fluid and grows into clusters that look like bunches of grapes
Hydatidiform Mole
Two Types of Hydatidiform Mole
Complete Hydatidiform Mole
Partial Hydatidiform Mole
Complete Hydatidiform Mole
It develops when either 1 or 2 sperm cells fertilize an “empty” egg cell
empty-means no DNA All genetic material came
from the sperm cell
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0
duplication
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No Fetal Tissue
Partial Hydatidiform Mole
2 sperms fertilize a normal egg
Or a sperm that has failed to undergo meiotic division fertilize a normal egg
Tumors contain some fetal tissue but not viable (able to live)
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23
2369
With some fetal tissue mixed with trophoblastic tissue: fetus is not viable
Invasive Mole
Chorioadenoma destruens Mole that grows into the
myetrium Can be complete or partial
mole but complete moles are more invasive
Risks of Developing an Invasive Mole
Long time interval between LMP and Tx
Uterus become very large Woman older than 40 yrs Woman has had GTD in
the past
They are not completely removed by surgery
When it grows completely in the myometrium, may result to bleeding and can be life threatening
Metastasizes to other parts most often the lungs
Choriocarcinoma
Malignant form of GTD Much more likely to grow
quickly and spread to organs away from the uterus
Placental Site Trophoblastic Tumor
It develops where the placenta attaches to the uterus
It develops after a normal pregnancy or abortion
It does not spread to other sites but invades the muscle layer of the uterus
Predisposing Factors
Age- woman over age 40 and younger than 20
Prior molar pregnancy Prior miscarriages or
problem getting pregnant Blood type A or AB
Birth control pills Low beta-carotene in diet Family history Asian race have higher
risk
PATHOPHYSIOLOGY
Hydatidiform Mole Type of GTD
Predisposing Factors
Partial Mole or Complete Mole
Villi becomes filled with fluid(hydropic vesicle)
Trophoblastic Proliferation
(A, B, C, D)
A. Uterus expands faster than normal causing abdominal pain (S/S)
B. high secretion of HCG
severe nausea and vomiting
(S/S)
C. High Chorionic Thyrotropin
hyperthyroidism
enlarged thyroid gland,tachycardia
(S/S)
D. High Progesterone
decreased uterine contraction
separation of vesicles from uterine wall
a, b, c
a. Vaginal bleeding and discharge of vesicles
b. Pallor indicating anemia
c. Preeclampsia (toxemia) presented as headache
and edema
CLINICAL MANIFESTATIONS
Hydatidiform Mole Vaginal bleeding Pallor indicating anemia Abdominal swelling with
dull aching pain Hyperemesis gravidarum
Preeclampsia Hyperthyroidism
Invasive Mole and Choriocarcinoma
Vaginal bleeding and bleeding into the abdominal cavity
Infection Abdominal swelling Lung symptoms like
hemoptysis, dry cough, chest pain or dyspnea
Other symptoms of distant spread
Placental Site Trophoblastic Tumor
Vaginal bleeding Abdominal swelling
DIAGNOSTIC EXAMS
A. LAB STUDIES Quantitative beta-HCG-HCG levels 100,000
indicates exuberant trophoblastic growth
Serial HCG Determination –to determine if tx is working & to detect if the disease has come back after tx
Uterine Pregnancy Test-Normal Pregnancy- 1/100-1/200- highly suggestive of a
possible GTD-1/500-surely diagnostic
Complete Blood Count-Normal Ranges/ValuesRBC- 4.2-5.9 million/mLWBC- 4,300-10,800/mLPlatelet – 150,000-
350,000/mLHemoglobin- 120-170g/LHematocrit- 0.38-0.48
Elevated values in WBC suggests infection and tissue necrosis
Elevated values in platelet and depressed values in RBC, hgb and hct suggests anemia and hemorrhage
Thyroxin- NV:0.5-5.0 m units/L
-elevated values above the reference range of pregnancy suggests hyperthyroidism
B. IMAGING STUDIES
Ultrasound (sonogram)-normal imaging shows a
picture of the developing fetus
-with GTD, it detects the large grape-like swollen villi
Chest X-ray –done in cases of persistent GTD like invasive mole to see if it has spread to the lungs
Computed Tomography (CT) scan & Magnetic Resonance Imaging (MRI) scan – to see if the GTD has metastasized elsewhere (lungs,brain,liver)
Nursing Responsibilities
Assess the appearance & amount of vaginal bleeding and monitor vital signs for developing shock
Prepare the pt physically & emotionally for the dx exams to be performed
Knowledge of the normal values and/or results of the exams and be able to know the indications of any deviation from the normal values
Collect & organize all data taken
After the examinations, inform other members of the health team if the patient may be at risk or needs immediate attention.
MEDICAL MANAGEMENT
A. SURGERY Suction D&C (dilation and
curettage)-doctor dilates the cervix and
then inserts a vacuum like device that removes most of the tumor
-Then the doctor uses the curette to scrape the lining of the uterus to remove molar tissue remains
Suction D&C
Hysterectomy
Involves removal of the uterus w/c ensures removal of all tumor cells
-std tx for PSTT
Abdominal Hysterectomy
Vaginal Hysterectomy
Nursing Responsibilities
Obtain baseline vital signs Preoperatively observe
the patient for signs of complications, such as hemorrhage, uterine infection, and vaginal passage of vesicles
Prepare the Pt emotionally and physically for surgery
Save any expelled tissue for laboratory analysis
Postoperatively, , monitor vital signs and fluid intake and output, and assess for signs of hemorrhage
Encourage the patient and her family to express their feelings
Encourage the patient to resume activity as tolerated
Instruct the patient not to become pregnant for 1 year after the evacuation of the uterus. Adequate contraception is recommended during this period. This is to avoid confusion about the development of the malignant disease
Emphasize the importance of consistent follow-up care.
Monitor serial beta-HCG values at the recommended time interval.
B.CHEMOTHERAPY Methotrexate – DOC for
choriocarcinoma type of GTD. It has the ability to dissolve fast-growing tissues. It is given IM, IV or intrathecal. To reduce its side effects, another drug called Leucovorin is given simultaneously with it.
-Side Effects – diarrhea, mouth sores,
conjunctivitis, pain in the chest or abdomen, skin rash or irritation in genital region, increased chance of infection and bleeding, fatigue
Dactinomycin – this drug may be especially useful in pts with liver problems, because it is less toxic to the liver. It is usually given IV
- Side Effects – nausea and vomiting, possible hair loss, fatigue, increased chance of infections and bleeding
Nursing Responsibilites
Assess patient’s condition before therapy
Assess for signs and symptoms indicating allergic reactions
Monitor for possible occurrence of drug-induced adverse reactions
Advise patients that side effects are short-term and to go away after the treatment is finished
Advise patients that contraceptive measures are recommended during therapy because the drugs they’re using are teratogenic
Instruct the patient on infection control and bleeding precaution
NURSING DIAGNOSES
A. Anticipatory Grieving related to the loss of the pregnancy secondary to GTD
Nursing Interventions Establish rapport with
patient and significant others. Listen and encourage patient/significant others to verbalize feelings
Provide safe environment for expression of grief
Remain with patient throughout procedures
Provide realistic information about health status without false reassurances or taking away hope
B. High Risk for Fluid Volume Deficit related to vaginal bleeding secondary to GTD
Nursing Interventions Monitor blood pressure
and pulse frequently
Observe the patient for behaviors indicative of shock, such as pallor, clammy skin, perspiration, dyspnea, or restlessness
Count and weigh pads to assess amount of bleeding over a given time period; save any tissue or clots expelled
Prepare for intravenous (IV) therapy. There may be standing orders to begin IV therapy on patients that are bleeding
Obtain an order to type and crossmatch for blood if evidence of significant blood loss exists
C. Imbalanced Nutrition: Less than Body Requirements related to persistent vomiting secondary to hyperemesis
Initially, give patient nothing by mouth (NPO) and administer IV fluids
Administer antiemetics as ordered
Maintain a relaxed, quiet environment away from food odors or offensive smells
Once oral feedings resume, food needs to be attractively served
Promote oral hygiene
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