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 nutrition
blast – 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
 duplicatio
n
2 0
3
No
Fetal
Tissue
4
6
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)
2
3
2
3 6
2 9
With some fetal tissue
3
mixed with
trophoblastic tissue:
 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/Values
RBC- 4.2-5.9 million/mL
WBC- 4,300-10,800/mL
Platelet – 150,000-350,000/mL
Hemoglobin- 120-170g/L
Hematocrit- 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