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Course: Maternity Nursing

Topic: Hydatidiform Mole and Ectopic Pregnancy

The Nurses International Community

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Module Goals

The learner will be able to:

Define hydatidiform mole and ectopic pregnancy
Identify signs and symptoms of hydatidiform mole and ectopic pregnancy
Describe management and treatment of hydatidiform mole and ectopic pregnancy
Identify client teaching regarding these complications

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What is Hydatidiform Mole?

Gestational trophoblastic disease (GTD) is the proliferation of trophoblastic tissue in pregnant or recently pregnant woman
Hydatidiform mole (HM) is defined as products of conception that show gross cyst-like swellings of the chorionic villi that are caused by an accumulation of fluid
Also called molar pregnancy, HM is a benign form of GTD
80% hydatidiform moles are non-cancerous while the remainder invades surrounding tissues
2% to 3% become malignant choriocarcinomas

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Hydatidiform Mole

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HM: Type

Complete HM:

Placental tissue is abnormal, and fetal tissues does not form.
Local invasion occurs in 15% of cases
Metastatic disease occurs in 5% of cases

Partial HM:

There may be normal placental tissue with abnormal placental tissue.
Fetus may develop but does not survive. Usually, miscarrage occurs early in the pregnancy
Local invasion occurs in up to 3% to 5% of cases
Metastatic disease is rare

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HM: Risk Factors

Risk factors for HM:

Mothers younger than 20 years of age, and older than 35 years of age are at increased risk
History of HM

1% risk in subsequent pregnancy.
25% risk with more than one prior HM.

Choriocarcinoma risk factors:

Most commonly follows a molar pregnancy
Note: choriocarcinoma can also follow a:

Normal pregnancy
Ectopic pregnancy
Abortion

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HM: Signs/Symptoms

Initial manifestations of HM suggest early pregnancy, and test positive for pregnancy
Most common presenting signs:

Heavy vaginal bleeding
Rapidly enlarging uterus or uterus larger than the dates.

Other presenting symptoms/signs:

Dilated cervix, uterus softer than normal, passage of grape-like tissue
Pelvic pain or sensation of pressure
Hyperemesis gravidarum
Hyperthyroidism
Pre-eclampsia in early pregnancy

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HM: Signs/Symptoms

Pregnant women must be counseled to seek medical advice if:

They have any bleeding or dark discharge from the vagina
They feel or are sick often (severe morning sickness)
They think their abdomen looks bigger than it should for their stage of pregnancy
They have any other symptoms they are worried about.

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HM: Diagnostics

Initial diagnostic evaluation:

Serum beta subunit of human chorionic gonadotropin (beta-hCG)
Pelvic ultrasonography
Biopsy

Ultrasonography should be done during early pregnancy if:

Uterine size is much larger than expected dates
Symptoms or signs of preeclampsia are present
Beta-hCG is unexpectedly high

Biopsy is required for definite diagnosis, and staging of the disease

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HM: Diagnostics

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HM: Treatment

Evacuation is the treatment of choice for HM:

Cervical dilation with suction curettage (D&C)
Hysterectomy for women who no longer wish to bear children
Induction of labor with oxytocin or prostaglandins

Perioperative evaluation consists of:

Complete physical examination
Baseline serum hCG level
Chest roentgenogram
Hematologic profile
Renal and liver function tests
Thyroid function tests

Many cases of pregnancy-induced hypertension, or uterus enlarged more than 14 -16 weeks gestational size, will develop respiratory insufficiency after evacuation; thus, ABGs should be measured preoperatively

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According to MSD Professional Version- ‘Gestational Trophoblastic Disease’:

Hydatidiform mole, invasive mole, placental site trophoblastic tumor, and epithelioid trophoblastic tumor are evacuated by suction curettage, or hysterectomy (if childbearing is not planned).

According to Hammond, C, Soper, J, Glob. libr. women's med., 2008:

· Induction of labor with oxytocin or prostaglandins carries the potential increased risk for disseminating trophoblast throughout systemic circulation caused by uterine contractions against an undilated cervix. Significant blood loss and incomplete evacuation often occur requiring suction D&C.

· Hysterectomy is also associated with increased blood loss when compared with suction D&C.

· Vertical, uterine incision frequently results in the requirement for cesarean section.

· Reports indicate hysterectomy for the evacuation of HM resulted in a higher incidence of post molar malignant sequelae than did suction D&C.

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HM: Post-treatment

After tumor removal, a chest x-ray is taken, and serum Beta-hCG is measured
If hCG level does not normalize within 10 weeks, the disease is classified as persistent
Persistent disease:

CT of brain, chest, abdomen and pelvis is done to determine nonmetastatic or metastatic stage
Usually treated with chemotherapy
Treatment is considered successful if at least 3 consecutive serum beta-hCG measurement at 1 week intervals are normal
Hormonal family planning method must be recommended to the patients for at least one year to prevent pregnancy

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According to the National Cancer Institute webpage on ‘Gestational Trophoblastic Disease Treatment - Health professional version’:

· The prognosis for cure is good even when the disease has spread to distant organs; especially when only the lungs are involved.

· The probability of cure depends on the following:

o Histologic type- invasive mole or choriocarcinoma

o The extent of spread of disease/largest tumor size

o Level of serum beta-hCG

o Duration of disease from initial pregnancy event to the start of treatment

o The number and specific sites of metastases

o Nature of antecedent pregnancy

o The extent of prior treatment

According to MSD Professional Version- ‘Gestational Trophoblastic Disease’:

Poor prognosis is suggested by the following (National Institutes of Health [NIH] criteria)

· Urinary hCG excretion > 100,000 IU in 24 hrs

· Duration of disease > 4 months (interval since prior pregnancy)

· Brain or liver metastasis

· Disease after a full-term pregnancy

· Serum hCG > 40,000 mIU/mL

· Unsuccessful prior chemotherapy

· WHO score ≥ 7

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Case study:

Rita, 42-years-old and mother of three children, reported to the OB-GYN clinic where she complained of unusual menstrual bleeding. The bleeding began three days ago with abdominal cramping, nausea, vomiting and lower back pain. Her temperature was 98.6 F, blood pressure 119/64 mmHg, heart rate 123 bpm, respiratory rate of 16 breaths per minute, and a pulse oximetry of 98% on room air. Further physical assessment showed that her skin was cold and clammy, and her fundal height was 2 cm below umbilicus. Rita is sexually active, and using the calendar method as birth control. Her last menstrual period was exactly six weeks ago.

What would the nurse suspect from these complaints and physical assessment findings?
What would be important considerations for treatments in Rita’s case?

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What would the nurse suspect from the chief complaints and physical assessment findings?

1. The nurse would suspect Rita being at increased risk of hypovolemic shock because of :

· Lowering blood pressure of 116/64 mmHg

· Rapid heart rate of 123 beats/min

· The respiratory rate at the higher side of 16 breaths/min

· Skin presentation is cold and clammy

1. The nurse would also suspect molar pregnancy because of:

· Classic symptoms and signs of pregnancy:

o The last menstrual period being 6 weeks ago with Rita being sexually active, and not using reliable contraception.

o Chief complaints of nausea, vomiting indicating hyperemesis gravidarum during pregnancy.

o Abdominal cramping and lower back pain indicating uterine contractions.

· A most significant indication of molar pregnancy:

o Fundal height 2 cm below umbilicus indicating uterine size much larger than expected at 6 weeks pregnancy.

What would be important considerations for treatments in Rita’s case?

Prevention and management of hypovolemic shock would have to be the priority.

· Consideration for arranging cross-matched blood in case of emergency is important.

A medical check-up by the doctor and further investigation for identifying molar pregnancy is needed.
If molar pregnancy is identified, counseling Rita regarding disease and treatment is needed.
Rita’s desire for future pregnancies is an important factor to be considered in identifying the best treatment options for Rita.

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Ectopic Pregnancy

Pregnancy in which implantation occurs outside the uterine cavity
The fallopian tube is the most common site of ectopic implantation (greater than 90%)
Ectopic pregnancy is life-threatening and needs to be terminated

Sites and incidence of ectopic pregnancies

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Ectopic Pregnancy: Risk Factors

Factors that particularly increase the risk include:

Prior ectopic pregnancy (10 to 20% risk of recurrence)
History of pelvic inflammatory disease (especially Chlamydia trachomatis)
Prior abdominal or particularly tubal surgery, including tubal ligation

Other specific risk factors include:

Intrauterine device (IUD) use
Multiple sex partners
Fertility treatments
Cigarette smoking
Prior induced abortion
Maternal age between 35 to 40 years old

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Ectopic Pregnancy: Signs/Symptoms

Unruptured ectopic pregnancy symptoms/signs:

Symptoms of early pregnancy:
Irregular spotting or bleeding, nausea, swelling of breasts, bluish discoloration of vagina and cervix, softening of cervix, slight uterine enlargement, increased urinary frequency
Abdominal and pelvic pain

Patient must be counseled to seek medical advice if a combination of any of the above symptoms are present

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Ectopic Pregnancy: Signs/Symptom

Ruptured Ectopic pregnancy symptoms/signs:

Collapse and weakness
Fast, weak pulse (>100 beats/min) or more
Hypotension
Hypovolemia
Acute, abdominal, pelvic pain
Abdominal distention
Rebound tenderness
Pallor

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Ectopic Pregnancy: Signs/Symptom

Patients must be counseled to immediately seek medical care if they had a combination of:

Sharp, sudden and intense pain in abdomen
Felt very dizzy or faint
Felt sick
Looked very pale

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Ectopic Pregnancy: Diagnostics

Suspected in any female of reproductive age with pelvic pain, vaginal bleeding, or unexplained syncope or hemorrhagic shock
Diagnostic evaluation and tests are:

Rapid pregnancy test
Sensitive hCG assays
Potentially a culdocentesis
Transvaginal ultrasonography

Culdocentesis :

If non-clotting blood is obtained, suspect ectopic pregnancy and prepare for immediate surgery
If clear or yellow fluid is obtained, might still have unruptured ectopic pregnancy

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Ectopic Pregnancy: Treatment

Post methotrexate treatment management:

Regular blood tests to determine if treatment is working
Second dose or surgery may be needed if not effective
Counsel patient:

Use reliable contraception for 3 months because methotrexate harm fetus if pregnant during this time
Avoid alcohol consumption because it can damage liver

Side effects of treatment i.e., stomach pain (usually mild, should pass within 1-2 days), dizziness, feeling and being sick and diarrhea

Patient must be counseled on warning symptoms/sign of fallopian tube rupture and seek immediate medical care if present

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Ectopic Pregnancy: Treatment

Three main treatments:

Expectant management
Medication
Surgery

Expectant management under careful observation:

Await for spontaneous expulsion of products of conception.
It is only an option for patients with:

Extreme surgical risk
Falling hCG titers
Research setting

If fertilized egg does not dissolve itself; then medication or surgery is required

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Ectopic Pregnancy: Treatment

Medication:

Methotrexate, intramuscular or oral, used to terminate pregnancy
Methotrexate interferes with the synthesis of DNA
Patient should be hemodynamically stable and desire future pregnancy
Contraindications:

Ruptured ectopic
Ectopic mass greater than 3.5 cm
Fetal cardiac activity
High level hCG value (10,000 IU)
Breastfeeding
Immunodeficiency
Elevated creatinine or liver function tests
Alcoholism
Active pulmonary or gastrointestinal disease

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Ectopic Pregnancy: Treatment

Surgery:

Often laparoscopy (keyhole incisions in the abdomen) is performed under general anaesthesia before pregnancy becomes too large.
Immediate laparotomy (larger incisions in the abdomen) is performed in case of ruptured ectopic pregnancy
For extensive tube damage, salpingectomy is performed that removes both bleeding tube and products of conception
Rarely, if little tubal damage, salpingostomy is performed where products of conception are removed and the tube is conserved

Risk of another ectopic pregnancy is high in this case; thus, should only be done when the conservation of fertility is very important to the woman

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Ectopic Pregnancy: Treatment

Prior to surgery ensure patient is informed about the reason for the surgery
Informed consent is obtained for the specific procedure prior to surgery
Post surgery patient care:

Postoperative care for prevention of wound infection, bleeding and shock is provided while in-hospital.
Patient may leave hospital a few days after surgery
Patient counseled about wound care to prevent infection, and danger sign/symptoms of infections
RhoGam should be given to women who are RH negative
Emotional and psychological support is provided to women struggling with the sense of grief after loss of pregnancy

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Case study:

A 31-year-old female presents to the emergency room with abdominal pain and experiencing light vaginal bleeding. Upon questioning, the nurse discovers that the patient has an IUD, and she missed her last period. The patient is currently sexually active with multiple partners.

Should nurse be concerned about ectopic pregnancy in this case?
Why?
What should the nurse do?

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References:

DeCherney, A., Agel, W., et al. (2008). Ectopic Pregnancy. Global Library of Women’s Medicine. Retrieved from: https://www.glowm.com/section_view/heading/Ectopic%20Pregnancy/item/47

Hammond, C, Soper, J, Glob. libr. women's med.,(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10263. Retrieved from: https://www.glowm.com/section_view/heading/Gestational%20Trophoblastic%20Diseases/item/262

National Cancer Institute (July 2020). Gestational Trophoblastic Disease Treatment (PDQ )- Health Professional Version. Retrieved from: https://www.cancer.gov/types/gestational-trophoblastic/hp/gtd-treatment-pdq

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Reference:

NHS UK (November 2018). Ectopic pregnancy. Retrieved from: https://www.nhs.uk/conditions/ectopic-pregnancy/

Ramirez, P.T. & Salvo, G. (2020). Gestational Trophoblastic Disease. MSD Manual Professional Version-’’. Retrieved from: https://www.msdmanuals.com/professional/gynecology-and-obstetrics/gynecologic-tumors/gestational-trophoblastic-disease?query=gestational%20trophoblastic%20disease

WHO (2017). Managing complications in pregnancy and childbirth: a guide for midwives and doctors (2nd ed.) Licence: CC BY-NC-SA 3.0 IGO. Retrieved from: https://apps.who.int/iris/handle/10665/255760

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