GESTATIONAL THROPOBLASTIC DISEASE HYDATIDIFORM MOLE

I.

INTRODUCTION:

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). A hydatidiform mole is growth of an abnormal fertilized egg or an overgrowth of tissue from the placenta. It is a neoplastic proliferation of the trophoblast in which the terminal villi are transformed into vesicles filled with clear viscid material Two types of molar growth can be identified by chromosomal analysis: COMPLETE MOLE: All trophoblastic villi swell and become cystic. If an embryo forms, it dies early at only 1 to 2 mm in size, with no fetal blood present in the villi. On chromosomal analysis, although the karyotype is a normal 46XX or 46XY, this chromosome component was contributed only by a father or an empty ovum was fertilized and the chromosome material was duplicated (Fig. 1).

Sperm 23

Ovum + + Duplication = 46

Fig. 1.Complete mole. PARTIAL MOLE: With a partial mole, some of the villi form normally. The syncytiotrophoblastic layer of the villi, however, is swollen and misshapen. A macerated embryo of approximately 9 weeks; gestation may be present in the villi. A partial mole has 69 chromosomes (a triploid formation in which there is three chromosomes instead of two for every pair, 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). 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. 2). In contrast to complete moles, partial moles rarely lead to choriocarcinoma.

Sperm 46

Ovum 23 69

+ 23 or 23 23

69

Fig. 2. Partial mole.

FEATURES Embryonic/fetal tissue

COMPLETE

PARTIAL Present (with fetus or at least an amniotic sac) Focal Focal Paternal and maternal 69XXY or 69XYY Rare

Absent (whole conceptus is transformed into a mass of vesicles) Swelling of villi Diffuse Trophoblastic hyperplasia Diffuse Karyotype Paternal 46XX (97%) or 46XY (47%) Malignant changes 5-10% Table 1. Various features of a complete and a partial mole. II. A. B. C.

PREVELANCE AND POPULATION AT RISK.

North America and Europe: 1:1000 to 1:1500 pregnancies Asia and Latin America: 1:400 to 1:200 pregnancies Philippines: 1:250 III. RISK FACTORS

A. Diet: Low CHON, Folic Acid and low Vitamin A (carotene) intake. B. Age: Women younger than 25 years and older than 35 years. GTD is higher toward the beginning and toward the end of child bearing period. It is ten times more in women who are 45 years old and beyond.

C. Race: Asian heritage. Molar pregnancy has no racial or ethnic predilection, although Asian countries show a rate 15 times higher than the US rate.
D. History: Prior Molar Pregnancy; The risk of recurrence is 1-2%. After 2 or more molar pregnancies, the risk of recurrence has been reported as 1 in 6.5 to 1 in 17.5. E. High Parity

IV. PATHOPHYSIOLOGY

PRECIPITATING FACTORS -DIET: Low CHON, Folic Acid and low

Vitamin A (carotene) intake.

PREDISPOSING FACTORS
- Women younger than 25 years and older than45 years. - Asian heritage - Prior Molar Pregnancy

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

Amenorrhea
Marked nausea & vomiting

Decreased contraction

Hyperthyroidism

Separation of vesicles from uterine wall Multiple theca lutein cysts in the ovaries
Vaginal bleeding & discharge of vesicles Ovarian pain Pallor Preeclampsia

Enlarged thyroid gland; tachycardia

V. PATHOLOGICAL CONSEQUENCES 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. Possible Complications Lung problems may occur after a D and C if the woman's uterus is bigger than 16 weeks gestational Other complications related to the surgery to remove a molar pregnancy include: Preeclampsia Thyroid problems VI. DIFFERENTIAL DIAGNOSIS A. Lab Studies

Quantitative beta-HCG: HCG levels greater than 100,000 mIU/mL indicate exuberant trophoblastic growth and raise suspicion that a molar pregnancy should be excluded. A molar pregnancy may have a normal HCG level. Uterine Pregnancy Test. Positive in high dilution. 1/200 is highly suggestive. 1/500 is surely diagnostic.In normal pregnancy, it is positive in dilution up to 1/100. Complete blood cell count with platelets: Anemia is a common medical complication, as is the development of a coagulopathy. Blood urea nitrogen (BUN) and creatinine studies. Positive if levels are increased. Thyroxin: Although women with molar pregnancies are usually clinically euthyroid, plasma thyroxin is usually elevated above the reference range for pregnancy. Hyperthyroidism may be the presenting symptom. B. Imaging Studies:

Ultrasonography It is the criterion standard for identifying both complete and partial molar pregnancies. The classic image, using older ultrasonographic technology, is of a snowstorm pattern indicating hydropic chorionic villi. High-resolution ultrasonography shows a complex intrauterine mass containing many small cysts (usually bilateral ovarian cysts). Chest Radiograph Once a molar pregnancy is diagnosed, a baseline chest radiograph should be taken. The lungs are a primary site of metastasis for malignant trophoblastic tumors. X-RAY of abdomen. The procedure reveals no fetal skeleton.

C.

Histological Findings:

Complete mole: Fetal tissue is absent, and severe srophoblastic proliferation, hydropic villi, and chromosomes 46,XX or 46,XY are present. Additionally, complete moles show overexpression of several growth factors, including c-myc, epidermal growth factor, and c-erb B-2, compared to normal placenta. Partial mole: Fetal tissue is often present as well as amnion and fetal red blood cells. Hydropic villi and trophoblastic proliferation are also observed.

VII. MANIFESTATION AND SURVEILLANCE

A. Symptoms: 1. Amenorrhea 2. Exaggerated symptoms of pregnancy especially vomiting 3. Symptoms of preeclampsia that may be present as headache and edema. 4. Vaginal bleeding as the main complaint; due to the separation of vesicles from the uterine wall and there may be blood-stained, 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. Blood may be concealed in the uterus, thereby causing enlargement. 5. Abdominal pain: may be dull-aching due to rapid distension of uterine by mole or by concealed haemorrhage; colicky due to start of expulsion 6. Ovarian pain due to stretching of ovarian capsule or complication in the cystic ovary as torsion B. Signs: 1. Preeclampsia develops in 20 30 % cases, usually before 20 weeks AOG 2. Pallor indicating anemia may be present 3. 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 thyroid-stimulating effect)
VIII. CLINICAL MANAGEMENT

A. 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 prophylactic course of this drug the drug of choice for choriocarcinoma. Because the drug interferes with WBC formation (Leukopenia), prophylactic use must be weighted carefully. If malignancy should occur, it can be treated effectively in most instances with Methotrexate at that time. (Methotrexate has the ability to dissolve fast-growing tissues). Administration of Dactinomycin. It is added to the regimen of Methotrexate if metastasis occurs. It is an antibiotic used as an antineoplastic agent prescribed in the treatment of a variety of malignant neoplastic diseases.

Surgical Care:

Evacuation of the uterus by dilation and curettage is always necessary. Suction curettage: a method of curettage in which a specimen of the endometrium or the products of conception are removed by aspiration. The procedure is done through general anesthesia, but not which relaxes the uterus as it may induce severe bleeding. 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. 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 continued postoperatively to reduce the likelihood of hemorrhage. Consideration of using other uterotonic formulations (eg, Methergine, Hemabate) is also warranted. Respiratory distress is often observed at the time of surgery. This may be due to trophoblastic embolization, high-output congestive heart failure caused by anemia, or iatrogenic fluid overload. Distress should be aggressively treated with assisted ventilation and monitoring, as required.

B. Nursing Management:

A gynecologic oncologist should be consulted if the patient is believed to be at risk for or has developed malignant disease. No special diet is required. Patients may resume activity as tolerated. 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. Adequate contraception is recommended during this period. Monitor serial beta-HCG values to identify the rare patient who develops malignant disease. If a pregnancy does occur, the elevation in beta-HCG would be confused with development of malignant disease.
Further Outpatient Care:

Serial quantitative beta-HCG levels should be determined. Draw the first level 48 hours after evacuation and then every 2 weeks until the levels are within reference ranges. Levels should consistently drop and should never increase. Once levels have reached reference ranges, check them each month for a year. Any rise in levels should prompt a chest radiograph and pelvic examination to facilitate early detection of metastases. Contraception is recommended for 6 months to a year after evacuation. Patients with a prior complete or partial molar pregnancy have a 10-fold risk of a second mole in a future pregnancy. Work with the team to evaluate all future pregnancies early with ultrasonography.
Patient Education:

Because of the small but real potential for development of malignant disease and because these malignancies are absolutely curable, the importance of consistent follow-up care must be emphasized. The patient must avoid pregnancy for 1 year to avoid any confusion about the development of malignant disease. Effective contraception should be used. If a pregnancy occurs, the elevation in beta-HCG levels cannot be differentiated from the disease process. Future pregnancies should undergo early sonographic evaluation because of the increased risk of recurrence of a molar gestation.

IX. CONCEPTUAL MODELS AND FRAME WORKS (Theories Applied)

Interpersonal Model by Hildegard Peplau The main goal of this in caring for the patient is to educate to recognize and respond to need of help. Adaptation Theory by Sister Callista Roy Its goal is to help the person adapt to any changes in physiological needs, self-concept, role function and interdependent relations during health and illness Behavioral System Model by Dorothy Johnson Focuses on how the client adapts to illness; the goal of nursing is to reduse stress so that the client can move more easily through recovery.

X.

CASE SCENARIO

After my husband and I tried to get pregnant for 2 years exactly, I finally got a + test! It was so exciting. We told everyone after getting up off the ground from crying and praising God for the good news. Doctors didnt want to have me come in until 10 weeks. At 9.5 weeks, I began bleeding a very little bit with no pain. My mother came to take me to the ER but then it stopped so I didnt worry. We went out to eat and when we were leaving there, I went to the bathroom and I bled out like crazy and had INTENSE pain. Rushed to the ER and they couldnt find a fetus. It was almost like they thought I was lying about begin pregnant to begin with. I ended up being transferred to another hospital and had a D&C. We thought it was just a miscarriage until 4 weeks later when we went to an appointment and found out it was a_________. On one hand, it was horrible, because we now had to wait to try again, on top of having weekly blood work for who knows how long until the levels went down to zero. On the other hand, I sort of felt good that it was not a child that died, but rather a problem with conception that did not produce a fetus. We ended up trying 6 months later and got pregnant right away.