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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