After the management of patients with Hydatidiform mole, they are required to have a birth control method in the next 6 – 12 months for accurate monitoring of their HCG level.Doctors would send in a referral form on the family planning department for assistance. Most often than not, the appointment date for family counseling would be moved because the patient is undergoing chemotherapy. The first time I heard that chemotherapy is involved in the treatment of Hydatidiform mole, I was confused. Why use chemotherapy if it is a benign trophoblastic disease? Due to my utter confusion, I decided to delve deeper by researching about the disease and interviewing doctors to enlighten us about Hydatidiform mole.Without further ado, let us start by defining Hydatidiform mole.
Hydatidiform mole (H. mole), or Kyawa in vernacular, is a disease caused by an abnormal proliferation of trophoblastic villi which leads to a grape-like mass in the uterus. It is the benign kind of Gestational Trophoblastic Disease (GTD) while the cancerous kind is Invasive mole, Epithelioid trophoblastic tumor, Choriocarcinoma and Placental Site Tumor. H. Mole could lead to Invasive moles or Choriocarcinoma if not treated immediately with prophylactic chemotherapy.Cagayan, MS. in her research said that the prevalence rate of H. mole at the University of Philippines-Philippine General Hospital (UP-PGH) is 14 in every 1,000 pregnancies during the years 2002 to 2008.
The patient will have a positive pregnancy test because of the human chorionic gonadotropin (hCG) released by the trophoblast cells. However due to the hyperplastic activities of the aforementioned cells, the growth of the fetus will be thwarted. The abnormal growth will be obvious right after the third trimester when there are no positive signs of pregnancy present.
Types of Hydatidiform Mole: Complete vs. Partial
H. mole pregnancies are either classified as complete or partial moles depending on the appearance and the chromosome analysis seen on histology.
For Complete H. mole: Just remember that if it is complete it is an ‘EMPTY OVUM’ meaning there is an abnormal sac but no fetus. Studies show that this type often leads to Choriocarcinoma. The hCG levels for this type is also higher than partial.
For Partial H. mole: If the complete is known to have an empty ovum, partial H. Mole has partially formed normal villi with a macerated embryo present. Partially formed because there is a misshapen part of the trophoblast and macerated embryo because the embryo has an abnormally high chromosome levels.
Signs and Symptoms
Patients who have a probable pregnancy will come to their doctors complaining of irregular vaginal bleeding and a rapid growth of the womb causing pelvic pressure. Due to bleeding there will be pallor. In some cases there will be sudden abdominal pain in the first trimester because of internal bleeding and mass distention. There will be nausea and vomiting. In rare cases there will be signs and symptoms of hyperthyroidism like tremor, restlessness, and high blood pressure in the first trimester may be present due to high level of hCG that causes weak thyroid stimulation. Aside from high levels of hCG, no fetal heart tones present, no fetal parts present, and no viable fetus are the most important signs present in H.mole.
Doctors would request for Labs and Radiology to diagnose the disease. After the medical and surgical management doctors will then request for histology.
I. Laboratory Tests
Quantitative beta hCG test (bhCG)
This is a blood test to check if there is hCG present in the blood serum. It reflects levels of hCG usually results over 25 mIU/ml means you are pregnant, anything extremely higher than that needs further evaluation. Remember that this is not the definitive test for H. mole but this test is important to monitor any reoccurrence after the management. Sometimes a Thyroid function test is required to rule out hyperthyroidism.
If no fetal heart tones are heard, an ultrasound will be ordered. Transvaginal or pelvic results will show a grape-like vesicle or a classic snowstorm-like appearance. This test however is not the definitive test for H. mole. See Image 1 for the snowstorm appearance. Image 2 for anultrasound featuring a fetus 11 weeks old.
Chest X-ray or Lung CT
These tests will be ordered if H mole pregnancy is already confirmed and metastasis is a big concern since Choriocarcinoma and other GTD spreads really fast.
After the procedure to remove the H. mole, doctors would send a specimen for histopath. This is important for it is the definitive test to check if it is an H. mole or a cancerous kind of GTD. If it is an H. mole, the biopsy will confirm if it is partial or complete type of molar pregnancy.
When it is confirmed that the patient has an H mole the doctor would perform suction curettage. It is the standard treatment for both complete and partial molar pregnancies. Sometimes they use medical evacuation if the mass is with fetal parts that are hard to remove. Doctors perform hysterectomy if a patient no longer wants to have kids and opted for this surgery rather than the D&C.
After D&C the specimen will be sent for a histopath. Management will then be based on the findings. If it is an H. Mole which is a benign, the patient will then be monitored by getting the hCG serum level that should fall to 0. Usually the serum hCG test will be for 6 to 12 months. Within this period of monitoring the hCG levels, patients should have a contraceptive method to avoid pregnancy for accurate monitoring. It is because hCG levels would increase if you are pregnant and pregnancy might trigger another H.mole. Patients usually opt for implants or pills. They are not eligible for intrauterine devices (IUDs) to lessen the risk of bleeding and infection.
Chemotherapy will be done if the hCG levels is not decreasing even though there is no conceptus left in the uterus. The most commonly used drug is Methotrexate but the drug Dactinomycin also used. The chemotherapy also depends on the staging done by the pathologist. In some institutions, whether or not the hCG levels decrease, they would still give a prophylactic chemotherapy.
There can be a lot of nursing diagnosis for H mole. You can use Acute pain, Activity intolerance, Hyperthermia, and Anxiety to name a few. As for nursing care, remember to do the following:
- Remember to assess the BP, check if the patient is bleeding profusely, and make sure to notify the doctor immediately.
- Teach deep breathing techniques to alleviate the pain. Use diversional activities if possible.
- Check for abdominal pain, assess the abdominal area for signs of internal bleeding (e.g. Cullen’s)
- If nausea and vomiting are present, make sure the patient would not aspirate it.
- After D&C patient is at risk for infection. Make sure the patient has a good perineal hygiene.
- Administer all medications as ordered. Observe the 10 Rs
- Remember that this might very hard for the patient to accept, make sure to provide emotional support. Explain to the patient that it is not her fault this happened.
- Discussed the family planning methods available for her. Remember to reiterate the importance of
- monitoring the hCG level and follow-ups.
- Cagayan, MS. “Changing trends in the management of gestational trophoblastic diseases in the Philippines.” Department of Pharmacology and Toxicology and the Section of Trophoblastic Diseases, UP Manila. 2010 May-Jun; 55(5-6):267-72.Web. Accessed 3 May 2013.Fu J, Fang F, Xie L, Chen H, He F, Wu T, Hu L, Lawrie TA.
- “Prophylactic (preventive) chemotherapy for Hydatidiform mole (molar pregnancy) to prevent cancerous growth later.” The Cochrane Library. October 17, 2012. Web. Accessed 3 May, 2013.
- Gestational Trophoblastic Disease. 2013 American Cancer Society, Inc. Medical Review: 09/26/2012. Accessed 5 May, 2013.
***photos from Google and flicker.