nursing molar pregnancy

O U R L A D Y O F F A T I M A U N I V E R S I T YCollege of Nursing

In Partial Fulfilment of Requirements for RLE 102

“ H Y D A T I D I F O R M M O L E

P R E G N A N C Y /

M O L A R P R E G N A C Y ”A Group Case Study

Presented To:

MA’AM EDWINDA YAP MAN, RN

Submitted By: LLARENA, IRENE P.LORETO,MELODY

MACAPAGAL, DANICA JOYCEMAGAT, JESSIE BOY S.

MARQUEZ, DIVINE GRACEMARZAN, SHENALEE

MEDINA, ALBERT JONAHNOL, MYRA L.

PANTALEON, GERALD

GROUP of 2Y2-2c

July 24, 2012

I. INTRODUCTION

We as a nursing student of OLFU provide this case study as for the purpose of this case

is to be familiar with Molar Pregnancy; How it is start, what are the causes and what are

the signs and symptoms; especially how to prevent, treat and manage the patient by

giving medication for treatment and providing rapport. .We chose this case study because

this is the first time we’ve encountered in the entire rotation and because some of the

patient in OB Female semi-private room (FSPR) are Normal Spontaneous Delivery

(NSD). My group is also fond to know about the important things to consider and word

to discuss about this case.

Gestational Trophoblastic Disease is proliferation and degeneration of the trophoblastic

villi. As the cells degenerate, they become filled with fluid .Grape –sized

vesicles ,diagnostic of multiple pregnancy or a miscalculated .No fetal heart sound are

heard because there is no viable fetus. This fact must be evaluated carefully

II. PATIENT HEALTH HISTORY

A. PERSONAL DATA

On or about July 03, 2012 at 9:40 pm, Ms. Mila Cabang Pilonio was admitted at East Avenue

Medical Center with chief complaint of vaginal bleeding. She was placed on Delivery Room,

with D5W 1L x 8° was administered. Routine laboratory work-up was done like ultrasound, chest

x-ray, and ECG. Placed on moderate high back rest, then Prior to admission she then experience

high BP elevation and the doctor give him Catapres as relief to her condition. Then after the

doctor has seen that she has relief from her condition, she was the placed on OB Charity Room

IV’s and oral meds were continued given to her due to her high BP results. The doctors of East

Avenue Medical Center to make a plan that Mila Cabang Pilonio must undergo to a operation

called D and C, were in the patient will undergo to a certain operation.

B. OTHER INFORMATION

Name: Mila Cabang Pilonio

Age: 37, Female

Civil status: Single

Nationality: Filipino

Religion: Catholic

B-day: May 18, 1975

Address: 317 Ilang-Ilang St., San oque, Bagong Pag-asa, Quezon City

Admitting History (Admitted July 3)

OB score: Vaginal Bleeding

LMP: Feb 23

AOG: 18 5/7 weeks

Personal and Social History: Drinks and Smokes

Present illness:

4mos PTA- Spotting at 3 days consult at

2mos PTA- Spotting x5 days consult and IE. Advised

USG, USG done but was lost, to follow up

6 day PTA- vaginal bleeding,1 pad x5 days consults admission

Past illness:

Menstrual HS

Menarche- 16 years oldInterval-Duration- 7 daysAmount- 3 pad(+) Dysmenorrhea

Obstetric HS

G4P3 (3003)G1 1991-NSDG2 1993- NSDG3 2003- NSDG4- Present

Sexual HS

Coitarche- 21(+) post-coital bleeding(+) Dyspareunia(+) Papsmear(+) Abdominal Vaginal DischargePhysical Assessment:

conscious coherent hot in cardio respiratory distress,ambulatory/ stretcher borne

BP- 110/70mmhg PR-89 RR-26 T- 36.4

(-) cervical lymphadenopathy

(-) neck mass

Equal chest expansion, no retraction, clear breath sound (-) murmur

IE; cervix closed, uterusenlarged to 18 inch size

Ass: molar pregnancy at 18 5/7 when AOG G4P3(3003)

Plan: for suction curettage, one cervix is open

C. PAST MEDICAL HISTORY

The client stated that she had measles when she was 12 y/o. She doesn’t have any allergies and

past injuries, and have complete immunizations when she was a child. She doesn’t smoke and

drink alcohol.

D. FAMILY HEALTH HISTORY

The patient stated that her family has a history of Hypertension. She also stated that they don’t

have history of Diabetes, Tuberculosis and other hereditary disease.

E. PHYSICAL ASSESSMENT

Skin

Uniform color with warm temperature, dry and smooth. No scars and hairs

are evenly distributed.

Nails

Long and slightly dirty

Head and Face

The skull is proportionate to body size, no tenderness. Hair is oily, thick and

evenly distributed. Face is symmetrical and symmetrical facial movement.

Eyes

The client has straight normal eye condition; pupil is black in color and equal in

size. Has thin eyebrows.

Nose

The nose is in septum is in midline, mucosa is pale; both patent but have watery

secretion.

Mouth

The lips are pale, symmetrical, pale mucosa, tongue is in midline.

Neck

The skin is uniform in color. Neck muscles are equal in size and no tenderness.

Breast and Axilla

No masses, tenderness upon palpation

Abdomen

Uniform in color. Symmetrical movement. There is presence of scar and masses,

pain, tenderness upon palpation. It is because she is suffering H-mole pregnancy. Abdomen

has an irregular enlargement unlilke on normal pregnancy.

Upper Extremities

There is resistance for muscle strength. The skin has scar.

Lower Extremities

There is resistance for muscle strength. The skin has scar.

III. ANATOMY AND PHYSIOLOGY

The uterus is a hollow muscular organ located in the female pelvis between the bladder

and rectum. The ovaries produce the eggs that travel through the fallopian tubes. Once the egg

has left the ovary it can be fertilized and implant itself in the lining of the uterus. The main

function of the uterus is to nourish the developing fetus prior to birth.

External Female Reproductive System

Escutcheon

mons veneris/pubis

clitoris

skene’s gland (para urethral gland)

vestibule bartholins gland (vulvo vaginal gland)

hymen

fourchette

frenulum

labia minora

labia majora

perineum

anus

Internal Female Reproductive System

Fundus

Corpus

Isthmus

ovarian ligament

fallopian tube

4 parts of fallopian tube

Interstitial-1

Isthmus-2 (tubal ligation)

Ampulla-5 (site of fertilization

Infandibulum-2

Uterus

Head- fundus

Body- corpus

Neck- isthmus

Corpus- 3 layers

Endometrium

Myometrium

Perimetrium

Isthmus- 3 parts

Internal os

Cervical canal

External os

IV. PATHOPYHSIOLOGY

V. DIAGNOSIS

A. DEFINITION

Hydatidiform mole is a rare mass or growth which arise from fetal tissue that may form

inside the uterus at the beginning of a pregnancy. Frequently there is no fetus at all. In the

complete or classic mole, there is marked edema and enlargement of the villi with disappearance

of the villous blood vessels. There is proliferation of the trophoblastic lining of the villi. The

fetus, cord and amniotic membrane are absent; karyotype is normal. The incomplete or partial

mole is characterized by marked swelling of the villi and atrophic trophoblastic changes. Unlike

the classic mole, the fetus, cord and amniotic membrane are present and karyotype is abnornal,

e.g., triploidy or trisomy. The cause is not completely understood although potential causes, e.g.,

defects of the ovum (egg), abnormalities within the uterus, and/or nutritional deficiencies, have

been suggested. The incidence is increased in women under 20 or over 40 years old. Risk factors

implicated include low socioeconomic status and diets low in protein, folic acid, and carotene

B. RISK & PRE-DISPOSING FACTOR

The condition tends to occur most often in women who have a low protein intake in

young women (under age of 18 years),in women older than age of 35 years and in women of

Asian heritage.

With a complete mole,all trophoblastic villi swell and become cystic. If an embryo

forms,it dies early at only 1 to 2mm in size with no fetal blood present in the villi.On

chromosomal analysis ,although the karyotype is normal 46xx or 46xy,this chromosome

component was contributed only by the father or an “empty ovum” was fertilized and the

chromosome material was duplicated with a partial mole, some of the villi from normally .The

syncytio-trophoblastic layer of villi,however ,is swollen and misshaper. Although no embryo is

present fetal blood may be present in the villi.A macerate embryo of approximately 9 weeks

gestation may be present.A partial mole has 69 chromosomes (a triploid formation in which there

are 3 chromosomes instead of 2 for every pair one set supplied by an ovum that apparently was

fertilized by 2 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 that did not undergo reduction division supplied 46.

The cause os not completely understood .Potential causes may include defects in the

egg,problems within the uterus, or nutritional deficiencies. Women under 20 or over 40 years of

age have a higher risk. Other risk factors may include diets low protein,folic acid and carotene.

C. SIGNS AND SYMPTOMS

Symptoms occur in conjunction with a potential, suspected, or confirmed pregnancy;

vaginal bleeding in pregnancy (first or second trimester); nausea and vomiting, severe enough to

require hospitalization in 10% of cases; abnormal size in uterine growth for stage of pregnancy

with 50% of cases with excessive in growth and approximately 1/3 of cases with smaller than

expected; symptoms of hyperthyroidism, e.g., rapid heart rate, restlessness, nervousness heat

intolerance unexplained weight loss, loose stools, trembling hands, skin warmer and more moist

than usual in about 10% of cases; symptoms consistent with preeclampsia, e.g., high blood

pressure swelling in feet, ankles, legs proteinuria, that occur in the 1st or early in the 2nd

trimester; abdominal pain due to theca lutein cysts.

Hydatidiform moles can exaggerate the usual symptoms of pregnancy. Many of the

symptoms are similar to those associated with miscarriage, and most women with molar

pregnancies first believe they have miscarried. Invasive moles and choriocarcinomas can cause

symptoms during or after pregnancy, and symptoms can develop after a hydatidiform mole has

been removed.

The most common symptom is vaginal bleeding, especially between the 6th and 16th

weeks of pregnancy. Another symptom is bleeding that continues for a long time after delivery.

Small amounts of bleeding can show up as a watery brown discharge from the vagina.

Sometimes, a piece of tissue containing grapelike shapes will pass through the vagina, though this

is not common. It is important to remember that most vaginal bleeding during or after pregnancy

is not associated with a molar pregnancy. However, you should report any bleeding during

pregnancy to your health care professional.

A mole or choriocarcinoma also can cause the following symptoms:

Abdominal swelling, caused by the uterus becoming larger, which occurs more rapidly than

expected for the first trimester of pregnancy

Excessive vomiting during pregnancy

Fatigue, often caused by anemia from heavy bleeding

Sudden severe abdominal pain caused by internal bleeding

Pelvic cramping or vaginal discharge

Shortness of breath, coughing or blood in coughed-up secretions because choriocarcinoma very

rarely spreads to the lungs before it is diagnosed

There are many other causes for these symptoms, so if you have such problems don't assume you

have a molar pregnancy. Always speak with your health care professional. Usually, these

symptoms are associated with a normal pregnancy.

VI. LABORATORY EXAM AND DIAGNOSTIC PROCEDURES

I. LABORATORY EXAM

A. Urinalysis (7-03-12)

Lab test Result Normal InterpretationMacroscopicColor Straw Varying degrees of

yellowNormal

Transparency Clear Clear NormalSpecific Gravity 1.000 Variable but 1.023 Low concentration of urinepH 6.0 Variable (usually acidic) Normal Chemical TestsSugar Negative Negative NormalAlbumin Negative Negative NormalMicroscopicRBC 0-4/ HPF 0-1/ HPF High due to underlying

disease conditionWBC 0-2/HPF Female: 0-5/HPF

Male: 0-2/HPFNormal

Epithelial cells Few FewMucous threads Occasional common

Bacteria Occasional commonAmorphouserates Occasional Many

A. Hematology (7-03-12)

Lab Test Result Normal InterpretationComponentsWBC 8.4 x 10^g/L Adult:5-10 x 10^g/L NormalHemoglobin 120 g/L M: 140-170 gm/L Low, due to hemorrhage

brought about by underlying disease condition (H.mole)

Hematocrit 0.382 gm/L F: 120-140 gm/L Low, due to hemorrhage brought about by underlying disease condition (H.mole)

Differential countNeutrophils 0.61% Adult: 0.45-0.65% NormalLymphocytes 0.30% Adult: 0.25-0.5% NormalMonocytes 0.06% 0.02-0.06% High, a sign of infectionEosinophils 0.03% 0.02-0.04% NormalPlatelet 246 x10^g/L 150-450 x 10^g/L NormalMCV 80.6 fL 80-100 fL Normal but close to being

low which indicates anemiaMCH 25.4 pg 21.31pg NormalMCHC 315g/L 320-340 g/L NormalRDW 12.5% 11.6-14.6% Low, due to hemorrhage

brought about by underlying disease condition (H.mole)

B. Chemistry Test (7-03-12)

Lab Test Result Normal InterpretationBUN 2.3 mmol/L 3.0-9.2 mmol/L Low caused by pregnancyCreatinine 52 umol/L 63.6-110.5 umol/L Low caused by loss of

muscle mass and pregnancySodium 138 mmol/L 137-144 mmol/L NormalPotassium 3.7 mmol/L 3.5-5 mmol/L NormalChloride 108 mmol/L 98-107 mmol/L High caused by acidosisA-AST 26 U/L 5-34 U/L NormalA-ALT 16 U/L 0-55 U/L Normal

C. Serology Thyroid Function Test (7-04-12)

Lab Test Result Normal InterpretationFT 4 1.08 ng/dl 0.71-1.85 ng/dl NormalTSH 3rd generation

0.74 uIu/ml 0.47-4.64 uIu/ml Normal

II. DIAGNOSTIC PROCEDURES

A. TAH (TOTAL ABDOMINAL HYSTERECTOMY) In a total abdominal hysterectomy the uterus and the cervix are removed

The surgeon makes an incision approximately five inches long in the abdominal wall, cutting though skin and connective tissue to reach the uterus. The cut can be either vertical running from just below the navel to just above the pubic bone, or horizontal—running across the top of the public bone (known as a bikini-line incision).

One advantage of total abdominal hysterectomy is that the surgeon can get a complete,

unobstructed look at the uterus and surrounding area. There is also more room in which

to perform the procedure. This type of surgery is especially useful if

VII. NURSING CARE PLAN

A. Fluid volume deficit r/t elevated levels of human Chorionic Gonadotropin (hCG) from the proliferating trophoblasts.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION

RATIONALE EVALUATION

S: “Dinudugo ako nagiging kulay brown siya”

O: Urinalysis test for hCG revealed positive,UTZ revealed multiple small cystic structures, negative for fetal parts and fetal heart beat

Fluid volume deficit r/t elevated levels of human Chorionic Gonadotropin (hCG) from the proliferating trophoblasts.

After 4 hours of nursing intervention the patient will be comfortable and understand the situation.

Assess skin turgor and moisture of mucous membranes.

Monitor Vital signs. Evaluate peripheral pulses, capillary refill.

Monitor I&O; include all output sources (e.g., emesis, diarrhea.

Observe for bleeding tendencies; Note the amount, lochia/color of the vaginal discharge.

Encourage rest.

Indicators of hydration status/ degree of deficit.

to have a baseline data, reflects adequacy of circulating volume.

Decreasing renal output and concentration of urine suggest developing dehydration and need for fluid replacement.

Early identification of problems (which may occur as a result of cancer), allows for prompt intervention.

Prevent unnecessary energy expenditure related to

Client will display adequate fluid balance as evidenced by stable vital signs , moist mucous membranes, skin turgor less than 1 sec, capillary refill of less than 2 secs. and adequate urine output.

http://en.wikipedia.org/wiki/Human_chorionic_gonadotropin




vomiting (as may trigger) and bleeding (loss of blood/RBC).

B. Self-care immobility r/t multiple contraption as manifested by Verbalization for help”, to help “tulungan Mo Naman Ako Pumunta Ako ng CR”

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S: “Tulungan mo naman ako pupunta ako ng CR” as verbalized the patient

O: Limited movement Due to contraction lying on the bed for most of the time.

Self-care immobility r/t multiple contraption as manifested by Verbalization for help”, to help “tulungan Mo Naman Ako Pumunta Ako ng CR”


Asses the extent of need of assistance

Provide assistance in self-care needs

Support client in making health related decision and assist in developing self-care practice the promotes health

To asses degree of disability

To assist in dealing w/ the situation

to promote

wellness

Client will display adequate fluid balance as evidenced by stable vital signs , moist mucous membranes, skin turgor less than 1 sec, capillary refill of less than 2 secs. and adequate urine output.

C. Self-care immobility r/t multiple contraption as manifested by Verbalization for help”, to help “tulungan Mo Naman Ako Pumunta Ako ng CR”

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S: “Nahihirapan ako”

O: patient may manifest the following:

>edema

>maternal blood pressure of 160/100 mmHg

>increased or decreased fetal heart tone

Ineffective uteroplacental tissue perfusion related to vasospasm of spiral arteries secondary to H.Mole


Short Term:

After 2 hours of nursing interventions, the patient will be able to verbalize understanding of condition, therapy regimen and side effects of medications.

Long Term:

After 2-3 days of nursing intervention, the patient will be able to

Assist the patient in identifying lifestyle adjustment (e.g., avoiding prolonged sitting, sitting with crossed legs, or standing; developing exercise plan for cardiovascular fitness; avoiding wearing constrictive clothing; maintaining a balance diet with adequate hydration) that may be needed..

Check and monitor vital signs hourly.

Decreases factors that could lead to decreased perfusion of oxygen to uterus.

Permits monitoring of cardiovascular response to illness state .

VIII. Drug Study

GENERIC NAME

INDICATION ACTION CONTRAINDICATIONPRECAUTION/

ADVERSE REACTION

NURSING CONSIDERATION

Ciprofloxacin

BRAND NAMECiprobay

DOSAGE250-500mg BID

Infections of the resp. tract, middle ear,paranasal sinuses, eyes, kidneys, urinary tract

Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria

Drugs that inhibit peristalsis. Infants and children, growing adolescents. Pregnancy and lactation

PRECAUTIONSevere and persistent diarrhea during and after treatment

ADVERSE RXNCommon:Nausea, diarrhea, vomiting, rashUncommon:Anorexia, headache,dizziness, fever, GI and abdominal pain, flatulence, confusion, vertigo

>Assess pt for previous sensitivity reaction>Assess pt for any s/s of infection before & during treatment>Assess for adverse reactions >assess pt. & family’s knowledge of drug therapy

GENERIC NAME INDICATION ACTION CONTRAINDICATIONPRECAUTION/

ADVERSE REACTIONNURSING

CONSIDERATIONfelodipine

BRAND NAMEPlendil

DOSAGEAdult: 250-500mg every 8 hoursChildren: 20-40mg/kg/day divided dosage given every 8 hrs

Treatment of hypertension

Inhibits calcium ion influx across cell membrane, resulting in inhibition of excitation/ contraction.

Sick sinus syndrome, second or third-degree Av block except with functioning pacemaker, hypotension with systolic BP<90mmHg

ADVERSE RXN:Peripheral edema, hypotension, syncope, MI, angina, tachycardia, headache, dizziness, lightheadedness, nausea, vomiting, sinusitis, wheezing cough, sneezing

>assess fluid volume status, adequacy of pulses, pitting edema, dehydration, hypotension, dry mouth >monitor cardiac status: BP, pulse, respiration >Assess for angina pain: duration,intensity, aggravating factors

GENERIC NAME INDICATION ACTION CONTRAINDICATION SIDE EFFECTS NURSING CONSIDERATION

Dextrose

BRAND NAME

DOSAGEDosage depends on fluid and caloric requirements

Fluid replacement and caloric supplementation in patient who can’t maintain adequate oral intake or who is restricted from doing so.

Minimize glyconeogenesis and promotes anabolism in patients who can’t receive sufficient oral caloric intake.

Hyperglycemia, diabetic coma, intracranial or intra spinal hemorrhage or delirium tremens.

Mental confusion, unconsciousness in hyperosmolar nonketotic syndrome.

Pulmonary edema Glycosuria,

osmotic diuresis Metabolic:

hyperglycemia, hypervolemia

Rapid termination after long term infusion may cause hypoglycemia rebound hyperinsulinemia.

Sloughing and tissue necrosis

Use cautiously in cardiac or pulmonary disease, hypertension, renal insufficiency urinary obstruction and hypovolemia.

Never infuse concentrated solutions rapidly, may cause hyperglycemia and fluid shift.

Monitor glucose level carefully. Prolonged therapy can cause depletion of pancreatic insulin production and secretion.



CONSIDERATIONfelodipine

BRAND NAMEPlendil


Treatment of hypertension

Inhibits calcium ion influx across cell membrane, resulting in inhibition of excitation/ contraction.

Sick sinus syndrome, second or third-degree Av block except with functioning pacemaker, hypotension with systolic BP<90mmHg

ADVERSE RXN:Peripheral edema, hypotension, syncope, MI, angina, tachycardia, headache, dizziness, lightheadedness, nausea, vomiting, sinusitis, wheezing cough, sneezing

>assess fluid volume status, adequacy of pulses, pitting edema, dehydration, hypotension, dry mouth >monitor cardiac status: BP, pulse, respiration >Assess for angina pain: duration,intensity, aggravating factors



CONSIDERATIONDIAZEPAM

BRAND NAMEValium


Symptomatic relief of anxiety, agitation, tension

Facilitates/ potentiates the inhibitory activity of GABA at the limbic system and reticular formation to reduce anxiety, promote calmness and sleep

Hypersensitivity. Dependence, withdrawal symptoms

PRECAUTION:Hypersensitivity: cardiorespiratory insufficiency, pregnancy, lactation

ADVERSE RXNDizziness, fatigue, blurred vision, dependence, withdrawal reactions

> inform pt. that drug may be taken with food>advice pt. not to abruptly discontinue drug after long term use>advice pt. to avoid driving and activities that require alertness bec, drug can cause drowsiness>inform pt. that smoking may decrease effect

X. Discharge Planning

Management

Instructed the patient to take the following home medication as ordered by the physician.

Exercise / Activity

Inform patient that there are no restrictions in activity as long as her condition becomes okay. She can go back to her daily activities whenever she thinks she can.

Treatment

Remind patient that following mole extraction, she should have a baseline pelvic examination, a chest x-ray, and a serum test for the subunit of hCG. The hCG is analyzed every 1-2 weeks until levels are again normal.

Health Teaching

Advise patient to use contraceptive method such as oral contraceptive agent for 6-12 months so that a positive pregnancy tests (the presence of hCG) resulting from a new pregnancy will not be confused with increasing levels and a developing malignancy.

Inform patient that she should delay her childbearing plans for half to one year because her hCG is still been monitored. A higher chance of having another molar pregnancy can occur if she will become pregnant during these times.

If the hCG levels are within the normal limits and the patient decides to get pregnant again, advise her to have early screening with ultrasound during a second pregnancy to prevent another molar pregnancy.

OPD

Instruct patient to have a follow up checkup as advised by her doctor.

Spiritual

Advise the family to help the patient to express her anger and sense of unfairness at this situation. She may feel inadequate because something went wrong with her pregnancy. She may experience the same feeling of loss after its evacuation that she would have experienced after the loss of a true pregnancy.

nursing molar pregnancy

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