I. INTRODUCTION

The purpose of this case study 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 Sept. 14, 2007 at 9:40 pm, J.V. was admitted at San Juan 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 have relief from her condition, she was the placed on Female Semi- Private

Bed 6. IV’s and oral meds were continued given to her due to her high BP

results. The doctors of SJMC make a plan that JV must undergo to a operation

called HYSTERECTOMY, were in the patient will undergo to a certain operation

A surgical operation to remove the uterus and, sometimes, the cervix. Removal

of the entire uterus and the cervix is referred to as a total hysterectomy. Removal

of the body of the uterus without removing the cervix is referred to as a subtotal

hysterectomy.

B. PRESENT ILLNESS OR PRESENT HEALTH STATUS

2 Days PTA – (+) vaginal bleeding with hypogastric pain, consulted at East

Avenue Medical Center.

(+) cough, non-productive (+) dyspnea

She was diagnosed with Molar Pregnancy,

14-15 weeks AOG, G7P5 TPAL (5-0-1-5)

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. 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.

D. DIAGNOSTIC AND LABORATORY

LABORATORY EXAMINATION

1.) COMPLETE BLOOD COUNT:

2.) PLATELETS COUNT = Adequate

HEMATOLOGY RESULT NORMAL VALUES INTERPRETATION

       

HEMOGLOBIN 86 120 - 170 g/L Decrease protein production causing anemia

HEMATOCRIT 0.25 0.37 - 0.54 Decreased because the patient has

      Significant with hemorrhage

RED BLOOD CELL 2.87 4.0 - 6.0 x 1012 L Decrease O2 production due to

      Vaginal bleeding that cause anemia

WHITE BLOOD CELL 11.2 4.5 - 10 x 109 L Slightly increased because infection started

       

DIFFERENTIAL COUNT:      

NEUTROPHILS 0.75 0.38 - 0.68 Increased because of WBC elevation

LYMPHOCYTES 0.15 0.22 - 0.53 Decreased because immune system is affected

EOSINOPHILS 0.08 0.01 - 0.07 Increased due to parasitic infection

MONOCYTES NOT DONE 0.05 - 0.12 NOT DONE

BASOPHILS NOT DONE 0.002 - 0.01 NOT DONE

STABS NOT DONE 0.0 - 0.05 NOT DONE

3.) RED CELL MORPHOLOGY

MCV (MEAN CORPUSCULAR VOL.) = 90 L F1 IV.U (80 – 96 f1)

4.) PERIPHERAL SMEAR

MCH (MEAN CORPUSCULAR HEMOGLOBIN)

= 30.0 pg IV.U (27 – 33 pg)

MCHC (CORPUSCULAR HEMOGLOBIN CONCENTRATION)

= 33 L 9/L IV.U (320 – 360 9/L)

DEFINITION OF TERMS INDICATED IN THE LABORATORY EXAMINATION

COMPLETE BLOOD COUNT (CBC)

- A complete blood count (CBC), also known as full blood count (FBC) or full blood exam (FBE) or blood panel, is a

test requested by a doctor or other medical professional that gives information about the cells in a patient's blood. A

Medical technologist performs the requested testing and provides the requesting Medical Professional with the results of

the CBC. A CBC is also known as a "hemogram".

- The cells that circulate in the bloodstream are generally divided into three types: white blood cells (leukocytes), red

blood cells (erythrocytes), and platelets or thrombocytes. Abnormally high or low counts may indicate the presence of

many forms of disease, and hence blood counts are amongst the most commonly performed blood tests in medicine.

RED BLOOD CELLS (ERYTHROCYTES)

- Are the most common type of blood cells and the vertebrate body’s principal means of delivering oxygen from the

lungs or grills to body tissue via blood.

- The number of red cells is given as an absolute number per litre.

HEMOGLOBIN

- Is a protein that is carried by the red cells. It picks up oxygen in the lungs and delivers it to the peripheral tissues to

maintain the viabilty of the cells.

- The amount of hemoglobin in the blood, expressed in grams per litre. (Low hemoglobin is called anemia.)

HEMATOCRIT OR PACKED CELL VOL. (PCV)

- This is the fraction of whole blood volume that consists of red blood cells.

MEAN CORPUSCULAR VOL. (MCV)

- the average volume of the red cells, measured in femtolitres. Anemia is classified as microcytic or macrocytic

based on whether this value is above or below the expected normal range. Other conditions that can affect MCV include

thalassemia and reticulocytosis.

MEAN CORPUSCULAR HEMOGLOBIN (MCH)

- the average amount of hemoglobin per red blood cell, in picograms.

- It is diminished in microcytic anemias, and increased in macroanemias.

- It is calculated by dividing the total mass of hemoglobin by the RBC count.

MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION (MCHC)

- the average concentration of hemoglobin in the cells.

- It is diminished (“hypochromic”) in microcytic anemias, and normal (“normochromic”) in macro anemias (due to

large cell size, though the hemoglobim amount or MCH is high, the concentration remains normal).

WHITE BLOOD CELLS (LEUKOCYTES)

- Are cells of the immune system which defend the body against both infectious disease and foreign materials.

- All the white cell types are given as a percentage and as an absolute number per litre.

A complete blood count with differential will also include:

NEUTROPHILS

- This is the main defender of the body against infection and antigens. High levels may indicate an active infection.

- May indicate bacterial infection. May also be raised in acute viral infections.

LYMPHOCYTES

- Is a type of blood cell in the vertebrate immune system.

- Elevated levels may indicate an active viral infections.

- Higher with some viral infections such as glandular fever and. Also raised in lymphocytic leukaemia CLL.

MONOCYTES

- May be raised in bacterial infection

- Is a leukocyte, part of the immune system that protects against bloodborne pathogens and moves quickly to sites

of infections in the tissue.

- Elevated levels may indicate an allergic reactions or parasites.

EOSINOPHILS

- Are white blood cells of the immune system that are responsible for combating infection by parasites in vertebrates.

They are granulocytes that develop in the bone marrow before migrating into blood.

- Increased in parasitic infections.

- High levels are found in allergic reactions.

BASOPHILS

- Circulates vhite blood cells.

- Basophils degranulate to release histamine, proteoglycans (e.g. heparin and chondroitin), and proteolytic enzymes

(e.g. elastase and lysophospholipase). They also secrete lipid mediators like leukotrienes, and several cytokines.

PLATELET COUNT

- Platelets or thrombocytes are the cell fragments circulating in the blood that are involved in the cellular

mechanisms of primary hemostasis leading to the formation of blood clots. Dysfunction or low levels of platelets

predisposes to bleeding, while high levels, although usually asymptomatic, may increase the risk of thrombosis.

- Functions of Platelets can be generalised into a number of categories: Adhesion, Aggregation, Clot retraction, Pro-

Coagulation, Cytokine signalling, Phagocytosis.

- A normal platelet count in a healthy person is between 150,000 and 400,000 per mm³ of blood (150–400 x 109/L).

95% of healthy people will have platelet counts in this range. Some will have statistically abnormal platelet counts while

having no abnormality, although the likelihood increases if the platelet count is either very low or very high.

- Low platelet counts are generally not corrected by transfusion unless the patient is bleeding or the count has fallen

below 5 x 109/L; it is contraindicated in thrombotic thrombocytopenic purpura (TTP) as it fuels the coagulopathy. In

patients having surgery, a level below 50 x 109/L) is associated with abnormal surgical bleeding, and regional anaesthetic

procedures such as epidurals are avoided for levels below 80-100.

RED BLOOD CELL MORPHOLOGY

- Also known as Blood Smear, and Manual differential.

- Was once prepared on nearly everyone who had a complete blood count (CBC) performed. With the automated

blood cell counting instruments currently used, an automated differential is also provided. However, if the presence of

abnormal WBCs, RBCs, or platelets is suspected, a blood smear examined by a trained eye is still the best method for

definitively evaluating and identifying immature and abnormal cells.

- Findings from the blood smear evaluation are not always diagnostic in themselves and more often indicate the

presence of an underlying condition and its severity and suggest the need for further diagnostic testing. Blood smear

findings may include: RBC, WBC and differential count.

PERIPHERAL SMEAR

- A Peripheral smear is a blood test that gives information about the number and shape of blood cells.

DIAGNOSTIC EXAMINATION

GYNECOLOGY = “PELVIC ULTRASOUND” is the examination done to the patient

I. UTERUS

ABNORMALITIES

The uterus is enlarged with a dilated endometrial cavity as measured containing complex structure with multiple cystic

spaces of varied sizes interspersed within suggestive of a molar gestation.

II. ENDOMETRIUM

Thick – 7.96 CM Hyper-echoic

III. ADNEXAE

Within the left ovary is a cystic structure, unilocullar, thin-walled, anechoic, measuring 2.6 x 2.0 cm,

suggestive of cystic follicle.

IMPRESSION:

- Enlarged Anteverted Uterus – when we say anteverted, it is an abnormality of the uterus. Where the uterus leans

forward over the top of the bladder.

- Intra-endometrial content as described, suggestive of molar pregnancy

- Cystic follicle right ovary – cystic means there is an tumor like spaces in the ovary of a female

- Normal left ovary

- Please correlate clinically

V. MEDICAL/SURGICAL NURSING CARE MANAGEMENT

Medical management

Prostaglandins are the most commonly used agents, owing to their ability to

induce uterine contractions and thus expel the products of conception.

Prostaglandins can be given orally, vaginally, or rectally, and administration is

often preceded by oral mifepristone, which primes the uterus by allowing local

production of prostaglandins (normally suppressed by progesterone).

Misoprostol useful to help uterus expel products of conception that are not

adherent to the uterine wall such as blood clots.

Surgical management

Suction Curettage Abortion

A common first trimester abortion procedure is the suction and curettage method.

The abortionist begins by dilating the mom's cervix until it is large enough to

allow a cannula to be inserted into her uterus. The cannula is a hollow plastic

tube that is connected to a vacuum-type pump by a flexible hose. The abortionist

runs the tip of the cannula along the surface of the uterus causing the baby to be

dislodged and sucked into the tube - either whole or in pieces. Amniotic fluid and

the placenta are likewise suctioned through the tube and, together with the other

body parts, end up in a collection jar. Any remaining parts are scraped out of the

uterus with a surgical instrument called a curette. Following that, another pass is

made through the mom's uterus with the suction machine to help insure that

none of the baby's body parts have been left behind. The contents of the

collection jar are examined to assure that all fetal parts and an adequate amount

of tissue commensurate with gestational age are present

Hysterectomy: A surgical operation to remove the uterus and, sometimes, the cervix. Removal of the entire uterus and the cervix is referred to as a total hysterectomy. Removal of the body of the uterus without removing the cervix is referred to as a partial hysterectomy

Nursing Care Management

1. Assess the ff:- v/s

- amount and character of vaginal bleeding

- uterine fundus

2. Assess emotional distress

3. Assess for nausea and vomiting

4. Assess for ability to work

5. Report to health care provider

- abnormal v/s

BP <90

HR >120

RR <12 or >24

- acute abdominal pain

- nausea and vomiting

- excessive emotional distress

- passing of large clots of blood / tissue

6. Administer IV fluids as ordered

7. Provide emotional support; encourage question and expression of feelings

8. Allow one support person at bedside following procedure if desired by

patient

9. Provide written discharge and follow-up instructions

10.Provide and review information about any newly prescribed medications

VII. DRUG STUDY

Name of drug: Clonidine

Phil. Brand/s: Catapres, Drug Maker’s Biotech Clonidine HCl, Melzin

US Brand/s: Catapres, Catapres-TTS, Clonidine HCl, Duraclon

Canada Brand/s: Dixarit

Therapeutic Classification: Vasodilating agent

Indication: Management of all grades of hypertension (HPN) with the exception

of HPN due to phaeochromocytoma. Prophylactic treatment of migraine or

recurrent vascular treatment of migraine. For relief of cancer pain, in combination

with opiates for epidural use.

Contraindication: Hypersensitivity to clonidine. Sick sinus syndrome

Adverse Reation: Local skin irritation, Allergic contact dermatitis, hypo – and

hyperpigmentation of the skin drowsiness, dry mouth, dizziness, headache.

Constipation, depression, anxiety, fatigue, nausea, anorexia, parotid pain, sleep

disturbances, vivid dream, impotence, urinary retention, slight orthostatic

hypotension, burning and itching sensation of the eye.

Route of Administration: PO Route: Give last dose at bedtime

Transdermal Route: Apply patch weekly; remove old

patch and wash off residue; apply to site without hair;

best absorption over chest or upper arm; rotate sites

with each application; apply firmly, especially around

edges.

Nursing Responsibilities: Instruct patient not to discontinue drug abruptly, or

withdrawal symptoms may occur anxiety, increased B/P, headache, insomnia,

increased pulse, tremors, nausea, sweating; Caution patient not to take OTC

(cough, cold, allergy) remedies unless directed by physician; Teach patient not to

skip or discontinue medication without consulting physician; Inform patient that

drug may impair ability to drive or operate machinery, thus should be avoided in

tasks that require mental alertness. Drug may cause dizziness, fainting, light

headache; Instruct patient to notify physician of mouth sores, sore throat, fever,

swelling of hands or feet, irregular heartbeat, chest pain, signs of angioedema,

increased weight.

Name of drug: Ferrous Sulfate

Phil. Brand/s: AM-Europharma Ferrous Sulfate, Brofesol, Feosol Spansule Fer-

In-Sol, Ferglobin, Rhea Ferrous Sulfate, United Home Fersulfate Iron

US Brand/s: Ed-In-Soul, Feosol, Fer-Gen-Sol, Fer Iron Drops, Fero-Grad, Mol-

Iron

Therapeutic Classification: Hematinic agent

Indication: Prevention and control of treatment of iron- deficiency anemia; a

form of the mineral Iron, Iron is for many functions in the body.

Contraindication: Hypersensitivity to any ingredient, hemosiderosis, hemolytic

anemia.

Adverse Reaction: GI irritation, anorexia, nausea, vomiting, diarrhea,

constipation, dark stool. Teeth staining with liquid formulation.

Route of Administration: Through oral administration- Men: 10 mg –Women:

15 mg –Women greater than 51 yrs: 10 mg – Pregnancy: 30 mg –lactation: 15

mg. Iron replacement in deficiency states – Adults: 100 to 200 mg 3x/day.

Children (2-12 yrs old): 3 mg/kg/day in 3 to 4 divided doses. Children (6 mons-2

yrs): up to 6 mg/kg/day in 3 to 4 divided doses. Infants: 10 to 25 mg every day in

3 to 4 divided doses.

Nursing Responsibilities: Instruct patient not to substitute one iron salt for

another because they have different elemental iron content. Swallow the whole

tablet, do not crush or chew, do not double the dose if missed, but take it as soon

as remembered and avoid taking the drug with certain foods that may impair oral

iron absorption like yogurt, cheese, eggs, milk, cereals tea and coffee.

Name of drug: Cefuroxime

Brand Name: Ceftin

Therapeutic Classification: Is a semisynthetic cephalosporin antibiotic,

chemically similar to penicillin.

Indication: Is effective against susceptible bacteria’s causing infections of the

middle ear, tonsillitis, throat infections, laryngitis, bronchitis, and pneumonia. It is

also used in treating urinary tract infections, skin infections, and gonorrhea.

Additionally, it is useful in treating acute bacterial bronchitis in patients with

chronic pulmonary disease (COPD).

Contraindication: Hypersensitivity or with known allergy to cephalosporine type

antibiotics.

Adverse Reaction: Shock, Stevens-Johnson syndrome, erythema multiform,

Lyell’s syndrome, hypersensitivity, renal insufficiency, hematological effects,

hepatic disorders.

Route of Administration: Through oral administration

Nursing Responsibilities: Instruct patient that cefuroxime is generally well

tolerated and side effects are usually transient. Reported side effects include

diarrhea, nausea, vomiting, abdominal pain, headache, rashes, hives, vaginitis,

and mouth ulcers.

JOSE RIZAL UNIVERSITYCOLLEGE OF NURSING

A case study of a patient with MOLAR PREGNANCY

A partial fulfillment of the requirements in Nursing Care Management 101Related Learning Experience

San Juan Medical Center Obstetrics - Gynecology Ward

Submitted by: Group II – A-314

Leader: Gocela, Fritz Adriane

Members: Coo, Ronald

Cubelo, MarycarlDe Vera, Gaudencio

Dela Cruz, Ian DwightDelfin, Sarah

Devera, Mark AnthonyDoronila, Jenny

Duka, MosesEnosario, Mary Blaise

Esquierdo, Cathrina Pia

Submitted to: Maria Blesilda Llaguno

(Clinical Instructor)

1st Semester 2007