Gestational Trophoblastic Disease Nursing Care & Management

A woman comes in for a routine prenatal check and her uterus is measuring weeks ahead of her dates, her hCG is sky-high, and the ultrasound shows no fetus. That picture is gestational trophoblastic disease (GTD), abnormal growth of the trophoblastic cells that should have become a placenta. It runs from molar pregnancy to gestational trophoblastic neoplasia, and your job is early recognition, getting her to evacuation, and supporting a woman who is losing a pregnancy she may not have known was abnormal.

What is Gestational Trophoblastic Disease?

GTD is the degeneration and abnormal proliferation of the trophoblastic villi. The cells fill with clear fluid and take on the look of grape-like vesicles.

Pathophysiology

In a partial mole, two sperm fertilize a single ovum and reduction division (meiosis) fails, leaving 69 chromosomes. In a complete mole, the chromosomes duplicate to 46 and the embryo never develops. Either way the trophoblastic villi proliferate rapidly into fluid-filled, grape-like vesicles.

Risk Factors

GTD occurs in 1 of every 1,500 pregnancies. Watch for these:

• Low protein intake. Protein is needed to build the trophoblastic villi.
• Age over 35. Pregnancy past 35 carries higher risk for H-mole.
• Asian ethnicity. Higher incidence linked to genetics.
• Blood group A woman with a blood group O partner. This pairing is associated with H-mole.

Signs and Symptoms

• Uterus expanding faster than expected. The trophoblast cells proliferate so fast the uterus hits its growth landmarks early.
• Very high serum or urine hCG. Rapidly growing trophoblast cells pump out large amounts of hCG.
• Vaginal bleeding. If the H-mole is still undetected by the 16th week, it announces itself with bleeding, often with clear fluid-filled vesicles.

Diagnostic Tests

• Pregnancy test. Confirms pregnancy but does not pin down the H-mole.
• Urine or serum hCG. A very high result points to an H-mole.
• Ultrasound. Shows dense grape-like vesicles in a snowflake pattern, clear fluid instead of an embryo.

Medical Management

• Methotrexate. A prophylactic course attacks the rapidly growing trophoblastic cells.
• Dactinomycin. Added once metastasis occurs.

Surgical Management

• Suction curettage. The definitive treatment, evacuating the mole before it causes further complications.

Nursing Management

Nursing Assessment

• Measure abdominal girth and fundal height against expected pregnancy landmarks.
• Watch for pregnancy-induced hypertension. With H-mole it shows up before the 20th week.
• Tell her to save every perineal pad with clots or passed tissue.

Nursing Diagnosis

• Grieving related to loss of pregnancy as evidenced by anger and social detachment.

Nursing Interventions

• Measure abdominal girth and fundal height for baseline uterine growth.
• Help her collect a urine specimen for hCG.
• Save all pads used during bleeding to check for clots and tissue.
• Give her an open, trusting environment so she can express what she feels.
• Answer her questions honestly.
• Reassure her this is not her fault to ease guilt and self-blame.

Evaluation

• She expresses her feelings.
• She acknowledges the situation and seeks appropriate help.
• She begins looking forward, one step at a time.

Losing a pregnancy is one of the hardest things a patient will face. Your knowledge, steadiness, and presence are what get her through it.