FACULTY OF NURSING, UNIVERSITY OF IBADAN.

TITLE: HYDATIDIFORM MOLE

BY

GROUP 11

COURSE CODE: NSG 414

COURSE TITLE: MIDWIFERY III

JULY, 2024.
S/ NAME MATRIC NO.
N

1. Aluele Bernadette 229437

2. Oluwafemi Emmanuella 229472

3. Olaiya Deborah Omodunni 229466

4. Familusi Oladunmade Victoria 229449

5. Olayinka Oluwatomide 223990

GROUP MEMBERS
INTRODUCTION, PREVALENCE AND PATHOPHYSIOLOGY

Hydatidiform mole is an abnormal form of pregnancy which is characterized by the presence of a

benign tumour which implants in the uterus instead of a viable foetus. It is a gross mass of the
trophoblast in which the chorionic villi proliferate and become avascular. (Marshall & Raynor,
2020)

It falls under the category of gestational trophoblastic diseases.

Gestational trophoblastic disease (GTD) is a term used for a group of pregnancy-related tumours.
These tumours appear when cells in the womb start to proliferate uncontrollably. The cells that
form gestational trophoblastic tumours are called trophoblasts and come from the tissues that
grow to form the placenta during pregnancy.

A fertilised egg implants into the uterus, but some cells around the foetus (the chorionic villi) do
not develop properly. The pregnancy is not viable and the normal pregnancy process turns into a
benign tumour. There are two subtypes of hydatidiform mole; complete hydatidiform mole and
partial hydatidiform mole.

Prevalence and epidemiology

GTD is a rare event, with hydatidiform moles being the most common form. It is prevalent
among women of Asian origin and women who are below 16 or above 45. It occurs once in
every 1,000 pregnancies in the US, with much higher rates in Asia (up to one in 100 pregnancies
in Indonesia). Women who have had any form of GTD are also at a higher risk of having this
condition. (Seckl, et al., 2013)

Pathophysiology

Partial Hydatidiform Mole

In partial moles, an embryo is formed. A sperm cell fertilizes a viable egg cell and an embryo is
formed. The formed embryo and placenta develop into an abnormal growth or cell mass, causing
the pregnancy to be miscarried or progress into a malignant tumour.

A partial molar pregnancy occurs when an abnormal placenta forms along with an embryo, and
two sperm fertilize one egg. In these cases, the growing embryo has an extra set of
chromosomes. The embryo may start to develop but generally can’t survive. A normal egg is
fertilized by one or two sperm cells, which then reduplicates resulting in genotypes of 69XXY
(triploid) or 92XXXY (tetraploid).

Partial moles could be invasive as well but are not associated with choriocarcinomas (Kumar,
Abbas, & Aster, 2020)

In some very rare cases, a GTD can coexist with a normal foetus. This is called a twin
pregnancy. The probability of achieving a healthy baby is approximately 40%, but there is a risk
of complications, e.g. pulmonary embolism and pre-eclampsia. (True, et al., 2007)

Complete Hydatidiform Mole

In complete moles, no embryo forms. It happens when a sperm fertilizes an empty egg. Because
the egg is empty, the embryo can’t grow.

The placental tissue grows but is abnormal and contains fluid-filled cysts (or tumours). This
tissue produces the pregnancy hormone HCG (human chorionic gonadotropin), which is made by
a healthy placenta during pregnancy. An affected woman will elicit a positive pregnancy test.

A complete mole is caused by a single sperm (most times) or two sperm cells (10% of the time)
fertilizing an egg that has lost its DNA. The sperm reduplicates, leading to the formation of a
"complete" 46-chromosome set. The genotype is often 46XX (diploid) due to subsequent mitosis
of the fertilizing sperm. It can also be 46XY (diploid) but 46YY (diploid) is not observed.

Complete moles can become malignant and invasive i.e. spreading to other parts if the body.
Three to four percent of complete hydatidiform moles progress to form choriocarcinomas, which
is a malignant variation of the disease. (Prabhu & Rosenbaum, 2020)

RISK FACTORS AND ETIOLOGY

Risk Factors

1. Age of the mother: the extremes of maternal age, women below 20 years and above 35
years, are implicated in the incidence of molar pregnancy. For women past 35 years, the
risk escalation ranges from fivefold to tenfold. This occurs as a result in the decrease in
egg quality. (Florea, et al., 2023)
 2. Parity: studies show that nulliparity is indeed a risk factor for hydatidiform mole. In a
study done, it was found that 29% of the patients presenting with hydatidiform mole were
nulliparous. This constituted the highest percentage. (Igwegbe & Eleje, 2013)

3. Previous abortion: studies show there is a significant association between hydatidiform

mole and histories of abortion. (Milani, Abdollahi, Torbati, Asbaghi, & Azargashb, 2017)

4. Ethnicity: studies show that the incidence of molar pregnancies across different ethnic
groups reveals higher rates in Asian populations compared to other ethnicities. (Altman,
Bentley, & Murray, 2008)

5. History of OCP: research reveals that there is an association between use of oral
contraception and molar pregnancies. (Milani, Abdollahi, Torbati, Asbaghi, & Azargashb,
2017)

6. Blood group: studies show that blood group A is more frequent in women with molar
pregnancies compared to other blood groups. (Milani, Abdollahi, Torbati, Asbaghi, &
Azargashb, 2017)

7. Gene mutations: Several genes have been linked to recurrent hydatidiform moles such
as the NLRP7 and KHDC3L. They are responsible for 48-80% and 5% of recurrent
hydatidiform moles respectively. These are maternal-effect genes that play a key role in
genomic imprinting. (Florea, et al., 2023)

8. Environmental factors: studies show that husbands of women with complete molar
pregnancies were more involved in physical jobs involving manual labour and including
exposure to copious amounts of dust and soil. (Milani, Abdollahi, Torbati, Asbaghi, &
Azargashb, 2017)

9. Nutrition: dietary factors including women that have deficiencies in their diets in
carotene (vitamin A precursor) and animal fats. (Ghassemzadeh, Farci, & Kang, 2023)

Etiology

For complete hydatidiform moles, these are typically diploid. Complete moles often cause higher
levels of the human chorionic gonadotropin. The karyotype is 46, XX 90% of the time and 46,
XY 10% of the time. It occurs when an enucleated egg becomes fertilized by either two sperms
or by a haploid sperm that duplicates thereby expressing only paternal DNA.

For partial hydatidiform moles, the karyotype is triploid 90% of the time, either manifesting as
69, XXX or 69, XXY. This can happen when normal sperm fertilizes a haploid ovum or when
two sperms fertilize a single haploid ovum. Both maternal and paternal DNA are expressed.
(Ghassemzadeh, Farci, & Kang, 2023)

CLINICAL MANIFESTATIONS AND COMPLICATIONS

Signs & Symptoms

1. Abnormal Uterine Bleeding: One of the most common symptoms is abnormal uterine
bleeding. This bleeding is usually dark brown to bright red and can occur during the first
trimester. It may be intermittent or continuous, and it often starts before 20 weeks of
gestation. The bleeding is due to the abnormal tissue causing a disruption in the normal
endometrial lining of the uterus. (Whitaker & Critchley, 2016)

2. Hyperemesis Gravidarum: Hyperemesis gravidarum, or severe nausea and vomiting, is

more prevalent in molar pregnancies than in normal pregnancies. This is likely due to the
elevated levels of human chorionic gonadotropin (hCG) produced by the abnormal
trophoblastic tissue. High hCG levels can exacerbate the symptoms of nausea and
vomiting.

3. Rapid Uterine Growth: In a molar pregnancy, the uterus may grow more rapidly than
expected for the gestational age. This accelerated growth is due to the proliferation of the
trophoblastic tissue. Clinically, this can be observed as a uterine size that is larger than
would be expected based on the last menstrual period.

4. Presence of Grape-like Vesicles Passing from the Vagina: these grape-like vesicles are
clusters of swollen chorionic villi. These vesicles are usually seen when the molar tissue
begins to break down and pass through the cervix. The appearance of these vesicles is
quite characteristic and can help in diagnosing the condition. (Berkowitz & Goldstein,
2009)

Complications and Co-morbidities

 1. Persistent Gestational Trophoblastic Neoplasia (GTN): Persistent GTN occurs when
molar tissue remains and continues to grow after a molar pregnancy. This condition can
occur in approximately 15-20% of complete molar pregnancies and 1-5% of partial molar
pregnancies. Persistent GTN is characterized by rising or plateaued hCG levels after
evacuation of the molar tissue. It can be invasive, spreading to the uterine muscle and, in
some cases, beyond the uterus. (Soper, 2022)

2. Choriocarcinoma: Choriocarcinoma is a highly malignant form of GTN that can

develop after any type of pregnancy, including a molar pregnancy. It is characterized by
the rapid growth and spread of trophoblastic cells to distant organs, such as the lungs,
liver, and brain. Choriocarcinoma requires prompt chemotherapy treatment due to its
aggressive nature.

3. Preeclampsia: Preeclampsia is a condition characterized by high blood pressure and

signs of damage to other organs, often the kidneys, and can develop before 20 weeks of
gestation in molar pregnancies due to elevated hCG levels. This early onset of
preeclampsia is uncommon in normal pregnancies but is a significant complication of
molar pregnancies.

4. Hyperthyroidism: Hyperthyroidism can result from the high levels of hCG in molar
pregnancies, as hCG can mimic thyroid-stimulating hormone (TSH). This condition leads
to symptoms such as rapid heart rate, weight loss, and heat intolerance, requiring careful
management to avoid severe complications. (Goodwin, Montoro, Mestman, Pekary, &
Hershman, 1992)

DIAGNOSTIC STUDIES

A series of diagnosis studies can be done to identify hydatidiform mole.

1. Ultrasound: A pelvic ultrasound is a key diagnostic tool for identifying a hydatidiform

mole. The ultrasound may reveal a characteristic "snowstorm" pattern or "cluster of
grapes" appearance, which represents a mass of abnormal trophoblastic tissue and cystic
spaces. This condition can be classified into complete and partial moles, with different
ultrasound characteristics for each type.
 A. Findings in a Complete Hydatidiform Mole

i. Absence of Foetal Parts: In a complete hydatidiform mole, there are no

identifiable foetal parts or amniotic fluid. In a partial mole, there may be some
foetal tissue, but it is typically abnormal and non-viable.

ii. "Snowstorm" or "Cluster of Grapes" Appearance: The ultrasound image shows a

heterogeneous mass with numerous small cystic spaces, representing the swollen
chorionic villi.

iii. Large Uterus for Gestational Age: The uterus may appear larger than expected for
the gestational age due to the abnormal growth.

iv. Ovarian Theca-Lutein Cysts: These cysts can be seen due to high levels of hCG
produced by the molar tissue.

v. Increased Vascularity: Doppler ultrasound may show increased blood flow within
the molar tissue.

B. Findings in a Partial Hydatidiform Mole

i. Presence of Foetus: There may be a foetus, but it is usually malformed and not
viable.

ii. Abnormal Placenta: The placenta may show areas of cystic changes with presence
of some normal tissue i.e. mixed echoes which is the presence of both normal and
abnormal placental tissue.

iii. Increased Uterine Size: The size of the uterus might be appropriate or slightly
larger for the gestational age.

iv. Focal Cystic Changes: These changes are less pronounced than in complete
moles.

Types of Ultrasound

a. Transvaginal Ultrasound: It is the preferred method as it provides a clearer and more

detailed image of the uterus and its contents and is more sensitive in detecting early signs
of a hydatidiform mole. It can identify the absence of an embryo or foetus, the presence
 of multiple cysts, and increased uterine size. A complete mole often appears as a
"snowstorm" or "cluster of grapes" pattern due to the presence of numerous small cystic
spaces without an identifiable foetus. A partial mole may show an abnormal placenta with
some cystic spaces and possibly a foetus with severe anomalies.

b. Transabdominal Ultrasound: This type involves moving a transducer over the abdomen
to get images of the uterus. It's typically used in the early stages of pregnancy and can
help detect a hydatidiform mole by showing an abnormally large uterus for gestational
age or a "snowstorm" pattern, which indicates the presence of multiple small cystic
spaces. (Committee on Practice Bulletins-Gynecology, American College of Obstetricians
and Gynecologists, 2004)

2. Laboratory Tests

a. Serum Beta-Human Chorionic Gonadotropin (β-hCG) Levels: Extremely elevated

levels of β-hCG are typically seen in cases of molar pregnancy. Levels are usually
much higher than those seen in normal pregnancy.

b. Thyroid Function Tests: Due to the similarity between β-hCG and thyroid-stimulating
hormone (TSH), hyperthyroidism can occur, so thyroid function tests may be
indicated.

MEDICAL MANAGEMENT AND NURSING MANAGEMENT

A Hydatidiform mole / molar pregnancy cannot be allowed to continue. To prevent

complications, the affected placental tissue must be removed. The medical management usually
involves one or more of the following steps:

1. EVACUATION OF THE MOLAR TISSUE

a. Dilation and Curettage (D&C)

This is the primary treatment procedure where the healthcare provider (usually the doctor)
removes the molar tissue from the uterus through suction. It is typically performed in a hospital
or surgery centre. (Elias, Shoni, bernstein, Goldstein, & Berkowitz, 2012)

b. Hysterectomy
This is an alternative considered, where the uterus is completely removed in cases where no
future pregnancy is intended and there is a high risk of gestational trophoblastic neoplasia
(GTN). (Bruce & Shaina, 2024)

2. MONITORING AND FOLLOW UP

a. Serum beta-hCG Monitoring

After the evacuation, regular monitoring of the human chorionic gonadotropin (hCG) levels is
crucial to ensure they return to normal. Persistent high levels may indicate residual molar tissue
or progression to GTN, necessitating further treatment. (Seckl, et al., 2013)

b. Post-treatment Contraception

Effective contraception is recommended during the monitoring period, usually for six to twelve
months, to avoid confusion in interpreting hCG levels.

3. CHEMOTHERAPY

For persistent GTN, chemotherapy is often required. Common regimens include methotrexate or
a combination of EMA/CO (etoposide, methotrexate, actinomycin D/cyclophosphamide, and
vincristine) or EMA/EP (etoposide, methotrexate, actinomycin D/etoposide, and cisplatin).

4. FURTHER EVALUATION FOR METASTASES

If GTN is diagnosed, further imaging (e.g., CT scans of the chest, abdomen, and pelvis) may be
done to check for metastases. This helps in staging the disease and planning the appropriate
treatment.

NURSING MANAGEMENT AND RESPONSIBILITIES

The nursing management of a hydatidiform mole (HM) involves comprehensive care that
includes monitoring, education, emotional support, and coordination with other healthcare
professionals.

Nursing Management

1. Initial Assessment and Monitoring

a. Vital Signs - Monitor for signs of preeclampsia, such as hypertension and proteinuria.
b. Symptoms Assessment - Check for symptoms like vaginal bleeding, excessive nausea,
and enlarged uterus disproportionate to gestational age.

c. Ultrasound and Lab Tests - Assist in scheduling and preparing the patient for ultrasounds
and blood tests (e.g., beta-hCG levels). (Seckl, et al., 2013)

2. Post-Evacuation Care

a. Monitor for Complications - Watch for signs of infection, haemorrhage, and retained
molar tissue.

b. Serial hCG Monitoring - Ensure regular blood tests are conducted to monitor hCG levels
until they return to normal.

c. Contraceptive Counselling - Advise on the use of effective contraception for 6 to 12

months to prevent pregnancy, which could complicate monitoring.

3. Education and Emotional Support

a. Patient Education - Inform about the nature of the disease, the importance of follow-up,
potential complications, and treatment plans.

b. Emotional Support - Provide psychological support, as a molar pregnancy can be a

distressing experience. Refer to counselling services if needed.

c. Support Groups - Encourage participation in support groups for women who have
experienced molar pregnancies.

4. Coordination of Care

a. Interdisciplinary Collaboration - Work with obstetricians, oncologists, and other

healthcare providers to ensure comprehensive care.

b. Follow-Up Appointments - Assist in scheduling and ensuring the patient attends all
necessary follow-up appointments.

5. Documentation

Accurate Record Keeping - Maintain detailed records of all assessments, interventions, and
patient responses to treatment.
NURSING CARE PLAN

Case Study:

Mrs Ali, a 38-year-old female, presented to the emergency department with severe abdominal
pain, vaginal bleeding, and a rapidly enlarging uterus. She has a history of one miscarriage. An
ultrasound revealed a "snowstorm" pattern consistent with a hydatidiform mole, and her hCG
levels were markedly elevated.

NURSING CARE PLAN FOR MRS. ALI WITH HYDATIFORM MOLE

Nursing Nursing Nursing Scientific Evaluation

Diagnosis Objectives Interventions Rationale

Acute Pain 1. The patient 1. Assess and 1. It gives a 1. The patient's

related to will report a pain monitor the baseline data reported pain
uterine level of 3 or less patient's pain score is 3 or less.
distension and on a 0-10 scale level every 2 2. Non-
molar tissue within 40 hours. pharmacological 2. The patient
minutes of methods can uses non-
nursing 2. Encourage the enhance pain pharmacological
intervention. use of relaxation relief and reduce techniques when
techniques, such anxiety. experiencing
2. The patient as deep pain.
will demonstrate breathing 3. Heat or cold
the use of non- exercises, and therapy can
pharmacological provide a quiet provide
pain environment. additional pain
management relief.
techniques. 3. Apply heat or
cold packs as 4. Analgesics are
per patient's effective in
preference and reducing pain
tolerance. intensity.

4. Administer
prescribed
analgesics as
needed.

Anxiety related 1. The patient 1. Provide a 1. A supportive 1. The patient

to fear of future will verbalize calm and environment reports feeling
pregnancies and decreased supportive allows the less anxious and
risk of anxiety levels environment for patient to express verbalizes
recurrence and express the patient to and process understanding of
feelings openly express emotions. anxiety
within an hour of concerns and management
nursing fears. 2. Relaxation techniques.
intervention. techniques can
2. Educate the help reduce 2. The patient
2. The patient patient on anxiety attends and
will participate relaxation symptoms. engages in
in counseling techniques and counseling or
sessions or encourage their 3. Professional support group
support groups use. counseling and sessions.
as appropriate. peer support can
3. Refer the provide
patient to a emotional
counselor or support and
support group coping strategies.
specializing in
post-surgical or
pregnancy-
related anxiety.

Deficient 1. The patient 1. Provide 1. Educating the 1. The patient

Knowledge will demonstrate detailed patient reduces accurately
related to future understanding of information anxiety and describes future
pregnancy future pregnancy about the risks increases pregnancy
planning and planning and risk and signs of compliance with planning and risk
risk of of recurrence by recurrence, and medical advice. factors.
recurrence the end of the the importance
hospital stay. of regular 2. 2. The patient
follow-ups. Understanding has a scheduled
2. The patient future pregnancy follow-up
will create a 2. Discuss future planning helps in appointment and
follow-up care pregnancy making informed a clear care plan.
plan with the planning, decisions.
healthcare including
provider. timing, 3. Written
necessary tests, materials provide
and a reference for
consultations the patient to
with specialists. review
 3. Offer written information later.
materials and 4. Follow-up
resources for the appointments
patient to review ensure
at home. continuous care
and monitoring.
4. Schedule a
follow-up
appointment
with the
healthcare
provider before
discharge.

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