Gestational Trophoblastic Disease – Early Pregnancy Bleeding (Nursing)

by Jacquelyn McMillian-Bohler, PhD, CNM

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      Slides Gestational Trophoblastic Disease Early Pregnancy Bleeding Nursing.pdf
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      Review Sheet Trimesters of Pregnancy Nursing.pdf
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      Reference List Maternity Nursing Care of the Childbearing Family.pdf
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    00:01 Now let's talk about gestational trophoblastic disease, also known as GTT, also known as hydatidiform mole, or molar pregnancy, they're all the same.

    00:10 So this particular disease is really results from the production and breakdown of trophoblastic tissue in the placenta.

    00:17 So sometimes there's a fetus involved, but it definitely doesn't develop past the primordial state.

    00:23 And sometimes the tissue that's there can become carcinogenic.

    00:27 So we have to be extremely careful with this one because it can lead to death of the birthing person.

    00:33 This occurs in about one out of 1000 pregnancies.

    00:38 Let's break down the different types of gestational trophoblastic disease.

    00:42 We'll start with a partial mole.

    00:44 So in a partial mole, there is the presence of maternal and paternal genetic material.

    00:49 So we have an egg and sperm getting together, except in this case instead of one egg and one sperm, we have one egg and two sperm.

    00:59 So that creates extra DNA, which causes lots of problems within fetal development.

    01:05 So we do have some formation of some fetal parts but there are lots of anomalies that make this condition incompatible with life.

    01:15 In a complete mole, there's absolutely no maternal genetic material.

    01:20 So all of this is a result of changes with the sperm.

    01:25 So there's no fetus,there's no placenta, and there's no amniotic fluid.

    01:30 So you can see inside this graphic that we have no baby at all, and it's all trophoblastic tissue.

    01:37 So this is going to lead to lots of bleeding within the uterine cavity.

    01:42 What's really important to understand is that with this particular type of mole, 20% of them will go on to develop into a carcinoma.

    01:50 So someone can actually die from this type of mole if it's not treated.

    01:54 Now let's talk about risk factors.

    01:56 So risk factors for either partial or complete mole include a previous molar pregnancy.

    02:01 So if a client has had one before, we always need to be highly suspicious that any pregnancy could be a repeat.

    02:08 Also a maternal age greater than 40, or a maternal age less than 20.

    02:13 So making sure that when you have clients on either side of the extreme that you're on the lookout.

    02:19 How does it present? Well, we may notice dark brown bleeding, so it looks kind of like old blood, want to pay attention to that.

    02:27 The clients may also present with really early pregnancy symptoms.

    02:32 Let's break down the why of that.

    02:34 So one of the things is that we know that HCG is produced in the placenta.

    02:39 Clients with gestational trophoblastic disease have lots of placenta.

    02:44 So there's going to be a lot of extra HCG that is produced.

    02:48 So any symptoms that are related to HCG production are going to be exaggerated.

    02:53 So one of the most common is nausea and vomiting, so hyperemesis gravidarum.

    02:59 This is someone who really can't keep any food down, and they're displaying changes of an electrolyte imbalance because of their inability to eat and keep things down.

    03:08 So any client that presents with hyperemesis gravidarum, you need to absolutely confirm that it is not a molar pregnancy.

    03:15 So without an ultrasound, where you see an intrauterine pregnancy, or following an HCG, or any of those other things, you want to make sure that you do not have a mole before you continue.

    03:27 We can also do an ultrasound.

    03:28 So if we have any suspect that we're not sure what is going on, then an ultrasound will allow us to see inside the uterine cavity and diagnose whether we have a molar pregnancy or not.

    03:42 Thinking about management, the only way that we're going to be able to manage GTD is to remove it.

    03:48 So we're going to prepare the client for a suction curettage or a suction and evacuation.

    03:53 We have to get every piece of this particular placenta so that it does not grow.

    03:58 It is like a weed so anybody's ever done any gardening, you know if you have one here, tomorrow, you'll have three.

    04:04 So we have to keep that particular tissue from dividing, we have to get every single piece.

    04:10 And in order to know that we've gotten everything, we'll monitor the HCG levels.

    04:14 So we'll draw blood at least once a week and make sure those HCG levels are trending down.

    04:19 And we will follow them until the HCG gets to be less than 5.

    04:24 We're going to have to spend a lot of time educating the client both about the fact that this is not a normal pregnancy, the seriousness of it and then making sure that they know they need to avoid pregnancy for up to a year.

    04:36 The newer information is saying six months may be okay but we definitely want to talk to them about this.

    04:42 And why? because if there are any particular cells that are left that we missed, if they get a whiff of HCG from a new pregnancy, they'll start to divide all over again.

    04:52 And specifically in the case of the complete mole and knowing that can go on and become carcinogenic, then we absolutely do not want that to happen.

    05:01 We need to offer the client support.

    05:03 Now remember I just said, well, there's no fetal tissue, there's no baby.

    05:07 That's not something we necessarily want to say to the client, because they feel pregnant.

    05:11 They're explaining, they're experiencing all the symptoms, and everything else so we have to be sensitive to our word choice and supporting the client through this process.

    05:20 And then the idea of not being able to try again, for up to a year, that can be really difficult as well.

    05:26 So making sure we're offering support for all of those things.

    About the Lecture

    The lecture Gestational Trophoblastic Disease – Early Pregnancy Bleeding (Nursing) by Jacquelyn McMillian-Bohler, PhD, CNM is from the course Bleeding in Pregnancy (Nursing).

    Included Quiz Questions

    1. Partial mole
    2. Complete mole
    3. Incomplete mole
    4. Aborted mole
    5. Viable mole
    1. Previous molar pregnancy
    2. Maternal age > 40
    3. Infertility
    4. History of birth control
    5. Maternal age < 40 and > 20
    1. Suction and curettage
    2. hCG levels monitored
    3. Client support
    4. C-section
    5. Preparation for labor

    Author of lecture Gestational Trophoblastic Disease – Early Pregnancy Bleeding (Nursing)

     Jacquelyn McMillian-Bohler, PhD, CNM

    Jacquelyn McMillian-Bohler, PhD, CNM

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