GESTATIONAL TROPHOBLASTIC DISEASE
Gestational Trophoblastic
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 Trophoblastthat surrounds an embryo tropho – means nutrition blast – 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
Complete Hydatidiform Mole Partial Hydatidiform Mole
Complete Hydatidiform
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
duplicatio
2 No Fetal
4
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)
2 2
2
6 With some fetal tissue mixed with trophoblastic tro phoblastic tissue:
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
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
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) 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
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 5 00 l di i
Complete Blood Count -Normal Ranges/Values RBC- 4.2-5.9 million/mL WBC- 4,300-10,800/mL Platelet – 150,000-350,000/mL Hemoglobin- 120-170g/L Hematocrit- 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 Thyroxinunits/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 h iene
