Hydatidiform Mole (Gestational Trophoblastic Disease)

It is a tumor that forms in the uterus as a mass of cysts resembling a bunch of grapes.
Moles occur during the childbearing years. They do not spread outside of the uterus.
However, a malignancy called choriocarcinoma may start from a hydatidiform mole.
(http://www.medterms.com)

It is defined by Pillitteri as an abnormal proliferation and then degeneration of the

trophoblastic villi. Instead of the normal embryonic cell division that results in the
development of a fetus, the placental material grows uncontrolled and develops into a
shapeless mass of watery, small, blister-like sacs (vesicles). The cause of hydatidiform
mole is unknown, but is thought to be caused in part by chromosomal abnormalities.

Signs and Symptoms

1. Complete mole:
• Uterine enlargement greater than expected is caused by excessive trophoblastic
growth and retained blood.
• Vaginal bleeding is the most common classic symptom of a complete mole.
Molar tissue separates from the decidua, causing bleeding. The uterus may
 become distended by large amounts of blood, and dark fluid may leak into the
vagina.
• Patients may also report severe nausea and vomiting. This is due to
extremely high levels of human chorionic gonadotropin (hCG).
• Signs and symptoms of hyperthyroidism like heat intolerance, loose stools, rapid
heart rate, unexpected weight loss, and warm and moist skin than usual can be
present due to stimulation of the thyroid gland by the high levels of circulating
hCG or by a thyroid stimulating substance like thyrotropin produced by the
trophoblasts.
• Theca lutein cysts: These are ovarian cysts greater than 6 cm in diameter and
accompanying ovarian enlargement. These cysts are not usually palpated on
bimanual examination but are identified by ultrasonography. Patients may report
pressure or pelvic pain. Because of the increased ovarian size, torsion is a risk.
These cysts develop in response to high levels of beta-hCG. They spontaneously
regress after the mole is evacuated, but it may take up to 12 weeks for complete
regression.
• Symptoms similar to preeclampsia that occur in the 1st trimester or early 2nd
trimester

2. Partial Mole
Patients with partial mole do not have the same clinical features as those with
complete mole. These patients usually present with signs and symptoms consistent
with an incomplete or missed abortion.
• Vaginal bleeding
• Absence of fetal heart tones
• Uterine enlargement and preeclampsia is reported in only 5% of patients.
• Theca lutein cysts, hyperemesis, and hyperthyroidism are extremely rare.
• With a partial mole, an embryo or fetus (the term used after the eighth week
of pregnancy) partially develops but usually does not survive. In this case, the
fetus may be identifiable on ultrasound, but fetal heart tones will be absent.
Diagnostic and Laboratory Tests

• A pelvic examination may show signs similar to a normal pregnancy, but the size
of the womb may be abnormal and the baby's heart sounds are absent. There
may be some vaginal bleeding.

• Ultrasonography is the criterion standard for identifying both complete and partial
molar pregnancies. The classic image, using older ultrasonographic technology,
is of a snowstorm pattern representing the hydropic chorionic villi. High-resolution
ultrasonography shows a complex intrauterine mass containing many small
cysts.

• 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 (see eMedicine's article Gestational Trophoblastic Neoplasia).

• Quantitative beta-hCG: hCG levels greater than 100,000 mIU/mL indicate

exuberant trophoblastic growth and raise suspicion for a molar pregnancy.
However, a molar pregnancy may have a normal hCG level.

• Complete blood cell count with platelets: Anemia could be present and
coagulopathy could occur.

• Clotting function: Test clotting function to exclude the development of a

coagulopathy or to treat one if discovered.

• Liver function tests

• Blood urea nitrogen (BUN) and serum creatinine

• Thyroxine: Although women with molar pregnancies are usually clinically

euthyroid, plasma thyroxine is usually elevated above the reference range for
pregnancy. Patient may present with signs and symptoms of hyperthyroidism.

• Serum inhibin A and activin A: Serum inhibin A and activin A have been shown to
be 7- to 10-fold higher in molar pregnancies than normal pregnancies at the
same gestational age. The fall in inhibin A and activin A after evacuation may
prove helpful.28 However, of the readily available markers, serum hCG levels is
the standard of care.

Pathophysiology
 hydatidiform mole type of GTD

Predisposing factors

Partial mole or complete mole

villi becomes filled with fluid

hydropic vesicle

trophoblastic proliferation High secretion

of HCG

Uterus expands
faster than normal Severe nausea
causing abdominal and vomiting
pain
High progesterone
High chorionic thyrotropin

Decreased uterine contraction Hyperthyroidism

Enlarged thyroid gland, tachycardia

Separation of vesicles from uterine wall

Vaginal bleeding and discharge Palor indicating anemia Preeclampsia presented as headache
of vesicles and anemia
 • Trophoblastic villi cells located in the outer ring of the blastocyst (the structure
that develops via cell division around 3 to 4 days after fertilization) rapidly
increase in size, begin to deteriorate, and fill with fluid.

• The cells become edematous, appearing as grapelike clusters of vesicles.

• As a result, the embryo falls to develop past the early stages.

A complete mole contains no fetal tissue. Ninety percent are 46,XX, and 10% are
46,XY. Complete moles can be divided into 2 types:

• Androgenetic complete mole

o Homozygous

 These account for 80% of complete moles.

 Two identical paternal chromosome complements, derived from

duplication of the paternal haploid chromosomes.

 Always female; 46,YY has never been observed.

o Heterozygous

 These account for 20% of complete moles.

 May be male or female.

 All chromosomes are of parental origin, most likely due to

dispermy.
 • Biparental complete mole: Maternal and paternal genes are present but failure of
maternal imprinting causes only the paternal genome to be expressed. The
biparental complete mole is rare.

o A recurrent form of biparental mole, which is familial and appears to be

inherited as an autosomal recessive trait, has been described.

o Mutations in NLRP7 at 19q13.4 have been identified as causative in

recurrent molar pregnancies.

With a partial mole, fetal tissue is often present. Fetal erythrocytes and vessels in the
villi are a common finding. The chromosomal complement is 69,XXX or 69,XXY. This
results from fertilization of a haploid ovum and duplication of the paternal haploid
chromosomes or from dispermy. Tetraploidy may also be encountered. As in a
complete mole, hyperplastic trophoblastic tissue and swelling of the chorionic villi occur.

Treatment

If your doctor suspects a molar pregnancy, a suction curettage (D and C) may be

performed.
A hysterectomy may be an option for older women who do not wish to become pregnant
in the future.
After treatment, serum HCG levels will be followed.

Nursing Management

• Provide emotional support

• Watch for and be prepared to treat thyroid storm, a rare complication.

• Respiratory distress can occur 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.

• Advise that 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 2-4 weeks after evacuation of the uterus, and the
patient is instructed not to become pregnant for 6 to 12 months. Effective
contraception is recommended during this period.

• Advise that if an intrauterine contraceptive device (IUD) is selected, insertion

should await involution of the uterus and normalization of serum hCG levels to
avoid uterine perforation and bleeding.

References:

Maternal and Child Health Nursing: Care of the Childbearing and Childrearing
Family 6th Edition

Obstetric and Pediatric Pathophysiology

http://health.nytimes.com/health/guides/disease/hydatidiform-mole/overview.html

http://emedicine.medscape.com/article/254657-treatment

http://www.mdguidelines.com/hydatidiform-mole

http://www.scribd.com/doc/19894953/Gestational-Trophoblastic-Disease-
Powerpoint-Presentation

http://nursingcrib.com/nursing-notes-reviewer/gestational-trophoblastic-disease/