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We are going to be talking about hydatidiform mole pregnancy, also known as a molar pregnancy. I am going to explain what exactly this is and your role in caring for this patient.
With a hydatidiform mole there is abnormal fertilization. It is not viable. So let’s talk about how this happens. It can form in two ways. Either there is an ovum that has no maternal DNA or one ovum is fertilized with two sperm. This created a non viable and non cancerous tumor. A molar pregnancy can either be complete or incomplete. A complete means there is no fetal material. Partial means there might be some fetal material but there is never a fetal heart rate.
So what is the “Mole”. The mole is the clump of growing tissue. The molar pregnancy takes on a grape-like appearance that is caused by the distention of the chorionic villi that would normally implant and create the placenta. As you can see in this image there are clusters. This is the grape like clusters that fill up the uterus. The molar pregnancy will almost always result in a miscarriage but there is rarely fetal material so the miscarrying is of all this extra tissue and grape like clusters. Usually a D&C will need to occur to clean everything out from the uterus. It can develop into choriocarcinoma. Molar pregnancy are mostly all benign tumors. If they become invasive though it can be malignant cancer.
On assessment there will ever be a larger then expected fundal height because of the increased and quick cell division. This is going to cause fast uterine growth. There will be no fetal heart rate detected. Patients can have a high blood pressure. There will be vaginal bleeding reported by the patient. This bleeding will be grape like clusters of bright red to dark brown bleeding. hCG levels will be rising very quickly and higher than expected. hCG levels rise quick and are higher than expected which can cause a lot of nausea because of the rise in hormones.
Let’s discuss what management looks like for this patient. So D&C. Remember the pregnancy is not viable and can turn into a malignancy so it must be removed. The mole must be sent to pathology because we need to make sure it has not become malignant which is called trophoblastic disease. Oxytocin will also be given to contract the uterus after mole is removed. Methotrexate is medication that will be given IM to inhibit the rapid cellular division. hCG levels will be monitored until pre-pregnancy levels are reached and sometimes even for 6 months to a year. If levels continue to rise or more molar tissue is suspected then a hysterectomy might be necessary to remove everything. A huge piece of our management of this patient is to make sure there is no pregnancy during this time. Contraception must be used for at least one year.
What do we want to educate on? We want to to give resources for coping after the loss of pregnancy. We need to offer explanation on why it is not viable and what is happening. This is a confusing thing. Its rare so a lot of patients haven’t heard of it. It is different then a regular miscarriage so we want them to really understand. We also need to educate on methotrexate use. How often they need it and that it is an IM injection. The biggest education item is contraception. We need to educate on the need for contraception and to avoid pregnancy for a year so that the molar pregnancy can be completely resolved.
Nursing concepts are coping because this patient had a positive pregnancy test and thought she was pregnant so we need to help her cope through this hard time. Lab values are another concept because we are monitoring hCG levels. Reproduction is another concept because this has occured because of a problem with reproduction.
So if you understand these key points it will help you have a really good understanding of molar pregnancies. IA hydatidiform mole is a non viable pregnancy. There is no fetus. Very rarely there are fetal pieces but no heart rate which means no viability. It forms from improper fertilization. So there is either 1 ovum and 2 sperm that fertilize or an empty ovum so no maternal DNA and 1 sperm. Rapid cell division occurs causing rapid uterine growth. The uterus fills up with clusters of blood. There is passage of grapelike clusters of blood. This blood is dark brown and bright red. Treatment is IM methotrexate to inhibit the rapidly dividing cells. Patients need to use contraception for 1 year to prevent pregnancy.
Make sure you check out the resources and cheat sheets attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing.