Gestational Trophoblastic Disease (H-Mole) Practice Exam

EXPLANATION

✔Correct answer:

Clusters resembling grapes. In gestational trophoblastic disease (GTD), also known as a molar pregnancy, the ultrasonography typically reveals clusters of cells that resemble a bunch of grapes. This appearance is due to the abnormal proliferation of trophoblastic tissue, which forms multiple cystic structures instead of a normal placenta. These clusters, also called hydropic villi, are a hallmark of GTD and indicate that the pregnancy is not developing normally.

GTD occurs when there is abnormal fertilization, leading to the growth of trophoblastic tissue that should have developed into the placenta. In a complete molar pregnancy, no normal fetal tissue is present, and the uterus fills with these grape-like clusters. In a partial molar pregnancy, there may be some abnormal fetal tissue, but it is not viable. The overgrowth of this abnormal tissue causes the uterus to enlarge more rapidly than expected for gestational age.

Imagine planting seeds that should grow into a tree, but instead, they form a cluster of abnormal, grape-like structures. These "grapes" are not normal growths and indicate that something has gone wrong, similar to how gestational trophoblastic disease develops in the uterus.

Nurse Maria should prepare the patient for further testing and possible treatment, which may include dilation and curettage (D&C) to remove the abnormal tissue. The patient will also need follow-up care to monitor hCG levels to ensure that all trophoblastic tissue has been removed and to detect any possible malignant transformation.

• Educate the patient about gestational trophoblastic disease, including the potential need for treatment and close monitoring afterward.
• Provide emotional support, as the diagnosis of GTD can be distressing, particularly when it involves the loss of a pregnancy.
• Monitor the patient’s hCG levels post-treatment to ensure that they return to normal, indicating that all abnormal tissue has been removed.
• Discuss the importance of avoiding pregnancy for a specified period as recommended by the healthcare provider to monitor for potential recurrence.

✘Incorrect answer options:

An empty gestational sac. An empty gestational sac is more commonly associated with a blighted ovum, where the pregnancy sac forms but the embryo does not develop. This is not typically seen in gestational trophoblastic disease.

A severely malformed fetus. While some forms of GTD, such as a partial molar pregnancy, may involve an abnormal fetus, the characteristic ultrasonographic finding is the grape-like clusters of trophoblastic tissue, not just fetal malformation.

A pregnancy located outside the uterus. A pregnancy located outside the uterus describes an ectopic pregnancy, which is a different condition. Ectopic pregnancies occur when the embryo implants outside the uterine cavity, most commonly in the fallopian tube, and are not associated with the grape-like appearance seen in GTD.

EXPLANATION

✔Correct answer:

Advanced maternal age and previous molar pregnancy. Trophoblastic disease, including hydatidiform mole, has well-established risk factors that include advanced maternal age (typically over 35 years old) and a history of a previous molar pregnancy. Women who have had a molar pregnancy are at an increased risk of recurrence in subsequent pregnancies. Additionally, age is a significant factor, as women over 35, and especially over 40, have a higher likelihood of developing this condition.

The exact mechanism linking these risk factors to trophoblastic disease is not fully understood, but advanced maternal age is associated with an increased likelihood of abnormal fertilization, which can lead to the development of a molar pregnancy. A previous molar pregnancy indicates a predisposition that may be due to underlying genetic or environmental factors.

Consider the process of planting a seed. If the soil has had issues in the past with certain types of plants (previous molar pregnancy) or if the conditions are less than ideal, such as poor weather (advanced maternal age), there’s a higher chance that the seed might not grow correctly, leading to a problem similar to a molar pregnancy.

Nurses should focus on educating patients who fall within these risk categories about the importance of early prenatal care and monitoring.

• Provide counseling to patients with a history of molar pregnancy about the risks and the importance of regular follow-up and early ultrasound to monitor the pregnancy.
• Advise patients over 35 about the increased risk and discuss the importance of prenatal care and early screening.
• Monitor hCG levels closely in patients with a history of molar pregnancy, as these levels can help in early detection of recurrent trophoblastic disease.

✘Incorrect answer options:

Obesity and hypertension. While obesity and hypertension are risk factors for many pregnancy-related complications, they are not specifically associated with trophoblastic disease. These conditions are more commonly linked to gestational diabetes, preeclampsia, and other cardiovascular complications.

Multiple gestations and preterm labor. Multiple gestations and preterm labor are not recognized risk factors for trophoblastic disease. Multiple pregnancies can complicate pregnancy in other ways, such as increasing the risk of preterm labor and gestational hypertension, but they do not directly increase the risk of a molar pregnancy.

Diabetes and polycystic ovary syndrome. While diabetes and polycystic ovary syndrome (PCOS) are significant risk factors for infertility, gestational diabetes, and metabolic syndrome, they do not directly correlate with an increased risk of trophoblastic disease.

EXPLANATION

✔Correct answer:

Dilation and curettage (D&C) to remove molar tissue from the uterus. The primary treatment for a molar pregnancy is the surgical removal of the abnormal trophoblastic tissue from the uterus, typically through a procedure called dilation and curettage (D&C). This procedure involves dilating the cervix and then using surgical instruments to remove the molar tissue. It is essential to ensure complete removal of the molar tissue to reduce the risk of complications, such as persistent gestational trophoblastic disease (GTD) or, in rare cases, choriocarcinoma, a malignant form of GTD.

Molar pregnancies result from abnormal fertilization that leads to the growth of trophoblastic tissue instead of a normal fetus. D&C is performed to remove this abnormal tissue, which is necessary to prevent further growth and potential malignant transformation.

Imagine if a garden was overtaken by invasive weeds (molar tissue) that could harm the other plants (uterine health). The gardener (the surgeon) would need to carefully dig up and remove all the weeds (perform D&C) to ensure the garden could be healthy again and to prevent the weeds from spreading or causing more damage.

Nurses play a critical role in educating patients about the procedure, providing emotional support, and emphasizing the importance of follow-up care.

• Educate the patient about the D&C procedure, including what to expect before, during, and after the procedure.
• Provide emotional support, as the loss of a pregnancy can be distressing.
• Emphasize the importance of follow-up care, including monitoring hCG levels to ensure that all molar tissue has been removed and to detect any potential complications.
• Advise the patient on the recommended waiting period before attempting another pregnancy, typically 6 to 12 months, to ensure proper monitoring and recovery.

✘Incorrect answer options:

Administration of methotrexate to dissolve the molar tissue. Methotrexate is a chemotherapeutic agent used to treat certain types of cancer and ectopic pregnancies. While it may be used in cases of persistent gestational trophoblastic disease or choriocarcinoma, it is not the first-line treatment for a molar pregnancy itself. The primary treatment remains D&C to physically remove the molar tissue.

Immediate cesarean section to remove the molar pregnancy. A cesarean section is not appropriate for the treatment of a molar pregnancy, as there is no viable fetus to deliver. Cesarean sections are used for the delivery of a baby in certain obstetric situations, not for removing abnormal trophoblastic tissue.

Long-term administration of anticoagulants to prevent clotting disorders. Anticoagulants are used to prevent or treat blood clots in various medical conditions but are not relevant to the treatment of molar pregnancies. The primary concern in a molar pregnancy is the removal of the abnormal tissue, not the prevention of clotting disorders.

EXPLANATION

✔Correct answer:

True. Molar pregnancies are indeed classified into different types, including complete and partial molar pregnancies. These are the two primary categories of molar pregnancies. However, the spectrum of gestational trophoblastic disease (GTD) also includes more advanced conditions such as invasive moles and malignant forms like choriocarcinoma.

• Complete Molar Pregnancy: Occurs when an "empty" egg, which lacks genetic material, is fertilized by a single sperm that duplicates, leading to a pregnancy composed entirely of abnormal trophoblastic tissue with no fetal development.
• Partial Molar Pregnancy: Involves the fertilization of a normal egg by two sperm or a single sperm that duplicates, leading to the presence of some fetal tissue alongside abnormal trophoblastic growth. This results in a triploid karyotype and partial development of a non-viable fetus.
• Invasive Mole: A type of GTD where molar tissue grows into the muscular layer of the uterus, potentially spreading to other parts of the body. It can occur after a complete or partial molar pregnancy.
• Malignant GTD (e.g., Choriocarcinoma): A rare but aggressive form of cancer that can develop from molar tissue and spread to other organs. It requires chemotherapy for treatment.

Consider molar pregnancies like different types of abnormal growths in a garden. Some are less severe and stay within the garden (complete and partial moles), while others are more aggressive and might spread to other areas (invasive moles and malignant forms).

Nurses should ensure that patients understand the distinctions between these types of molar pregnancies and the potential implications for treatment and prognosis.

• Educate the patient about the specific type of molar pregnancy they have and the recommended treatment plan.
• Discuss the importance of follow-up care, including monitoring hCG levels and recognizing signs of more invasive or malignant forms of GTD.
• Provide emotional support and resources, as the diagnosis of any type of molar pregnancy can be distressing and may have implications for future pregnancies.

EXPLANATION

✔Correct answer:

Absence of fetal movement in the 6th month. Mrs. Lopez should be instructed to contact her healthcare provider immediately if she notices an absence of fetal movement in the 6th month of pregnancy. Fetal movement is a key indicator of the baby's well-being. By around 20 weeks of gestation (5 months), most pregnant women start to feel the baby move, and by the 6th month, these movements should become more regular. A noticeable decrease or absence of fetal movement can be a sign of fetal distress, intrauterine growth restriction, or other complications, and it requires prompt evaluation by a healthcare provider to ensure the safety and well-being of both the mother and the baby.

Fetal movements are a sign of a healthy, active baby, and changes in these movements can be an early indicator of potential problems such as hypoxia (lack of oxygen) or placental insufficiency. Monitoring fetal movement is a simple but effective way for mothers to track their baby's health. If a significant decrease or absence of movement is observed, it may indicate that the baby is not receiving adequate oxygen or nutrients, necessitating further assessment, such as a non-stress test or biophysical profile.

Think of fetal movement like a car's dashboard light that signals the engine is running smoothly. If the light suddenly goes out (absence of movement), it could indicate a problem that needs immediate attention to prevent further complications.

Nurse Karen should educate Mrs. Lopez on the importance of monitoring fetal movements daily and knowing when to seek medical help. She should also instruct Mrs. Lopez on how to perform "kick counts" and what to do if she notices a reduction in movement.

• Teach the patient how to perform daily "kick counts" to monitor fetal movement, particularly after meals when the baby may be more active.
• Instruct the patient to lie down in a quiet place, preferably on her left side, and count the number of movements felt in one hour; fewer than 10 movements in two hours should prompt a call to the healthcare provider.
• Emphasize the importance of contacting her healthcare provider immediately if she notices any significant decrease or absence of fetal movement.
• Reassure the patient that it is better to be cautious and seek medical advice if she is unsure or concerned about fetal movement.

✘Incorrect answer options:

The first fetal movement is detected. Feeling the first fetal movement, also known as quickening, is a normal and expected part of pregnancy and usually occurs around 18-20 weeks of gestation. This does not require medical attention unless the movements stop after being felt.

Mild uterine contractions. Mild uterine contractions, often referred to as Braxton Hicks contractions, are common in the second and third trimesters. These contractions are usually infrequent and not painful, and they do not necessarily indicate labor. However, if contractions become regular, painful, or more frequent, medical advice should be sought.

Slight shortness of breath in the last month of pregnancy. Slight shortness of breath is common in the last trimester as the growing uterus pushes up against the diaphragm, making it harder for the lungs to fully expand. While this can be uncomfortable, it is generally not a cause for immediate concern unless it is severe or accompanied by other symptoms like chest pain or dizziness.

EXPLANATION

✔Correct answer:

A "snowstorm" pattern on ultrasound with no fetus or gestational sac. A hydatidiform mole, also known as a molar pregnancy, is a type of gestational trophoblastic disease that occurs when there is an abnormal fertilization of the egg, leading to the formation of a non-viable pregnancy. The trophoblastic tissue, which normally develops into the placenta, proliferates abnormally and forms numerous cystic structures. On an ultrasound, this results in a characteristic "snowstorm" or "cluster of grapes" appearance, with no identifiable fetus or gestational sac. This pattern is a hallmark diagnostic feature of a complete hydatidiform mole.

In a complete molar pregnancy, there is no formation of normal fetal tissue. Instead, the chorionic villi swell and form fluid-filled cysts. This proliferation and swelling of the trophoblastic tissue give rise to the distinctive ultrasound appearance. This pattern is essential for diagnosis, as it differentiates a molar pregnancy from other types of gestational abnormalities.

Imagine expecting to see a tree growing in a garden (representing a normal pregnancy). Instead, when you look through a camera (the ultrasound), you see only a dense fog with no sign of the tree—just clusters of tiny bubbles (the cysts). This foggy image with bubbles is what the "snowstorm" pattern looks like in a hydatidiform mole.

Nurses should be prepared to support the patient emotionally and provide clear education about the condition, as this diagnosis often leads to emotional distress due to the loss of a planned pregnancy.

• Provide emotional support and counseling, as the diagnosis can be distressing.
• Educate the patient about the nature of the condition and the need for follow-up care, including serial hCG monitoring to ensure complete resolution and to detect any potential malignant transformation.
• Discuss the possibility of surgical intervention, such as dilation and curettage (D&C), to remove the abnormal tissue.
• Advise the patient to avoid pregnancy for a recommended period (usually 6 to 12 months) following treatment to allow for proper monitoring and to reduce the risk of recurrence.

✘Incorrect answer options:

Heavy, bright red bleeding every 21 days. While irregular vaginal bleeding, which may be dark brown or bright red, is a common symptom of a hydatidiform mole, it does not occur in a regular 21-day pattern. The bleeding is typically irregular and can be more significant than normal pregnancy spotting.

Detection of fetal cardiac motion after 6 weeks gestation. In a complete hydatidiform mole, no fetus forms, so fetal cardiac motion cannot be detected. The absence of a fetus and fetal heart activity is one of the key diagnostic features of this condition.

Benign tumors in the smooth muscle of the uterus. This option describes uterine fibroids (leiomyomas), which are not related to a hydatidiform mole. Fibroids are benign growths of the uterine muscle and do not involve the trophoblastic tissue or present with a "snowstorm" ultrasound pattern.

EXPLANATION

✔Correct answer:

Fertilization of an egg with no genetic material by a single sperm. A "complete" molar pregnancy occurs when an egg that lacks any genetic material (an "empty" egg) is fertilized by a single sperm. The sperm then duplicates its genetic material, leading to a diploid set of chromosomes, but all the genetic information comes from the father. Since there is no maternal contribution, no fetal tissue forms, only abnormal trophoblastic tissue that proliferates excessively, resulting in a molar pregnancy.

In a complete molar pregnancy, because the egg is empty and contains no maternal DNA, the resulting tissue is entirely paternal in origin. The lack of maternal DNA prevents the development of a fetus, and the trophoblastic tissue grows abnormally, forming the characteristic cystic structures without any fetal parts. This abnormal growth is what leads to the "complete" nature of the molar pregnancy, meaning there is no normal embryonic development.

Imagine trying to build a house (a baby) but starting with a blueprint (egg) that has no information on what the house should look like. If a builder (sperm) tries to follow this empty blueprint and then copies the same empty instructions, the result is a structure (trophoblastic tissue) that doesn't look like a house at all, but something completely different.

Nurses should educate the patient about the nature of the condition and provide emotional support due to the loss of a potential pregnancy.

• Explain to the patient that a complete molar pregnancy involves abnormal growth with no possibility of a viable fetus.
• Discuss the importance of follow-up care, including monitoring hCG levels to ensure that all molar tissue has been removed and to detect any potential complications.
• Provide emotional support and resources, as the diagnosis can be emotionally challenging.

✘Incorrect answer options:

Fertilization of an egg by two sperm, leading to a triploid karyotype. This scenario is associated with a "partial" molar pregnancy, not a complete one. In a partial molar pregnancy, there is a combination of normal and abnormal trophoblastic tissue, and some fetal tissue may develop alongside the molar tissue. This results in a triploid karyotype, where the fetus has three sets of chromosomes.

Partial development of fetal tissue alongside abnormal placental tissue. This description refers to a "partial" molar pregnancy, where some fetal tissue may develop alongside the abnormal trophoblastic tissue. In a complete molar pregnancy, there is no fetal development at all, making this option incorrect.

Fertilization of a normal egg by a sperm carrying an extra chromosome. This situation could potentially lead to a chromosomal abnormality but is not characteristic of a complete molar pregnancy. In a complete molar pregnancy, the egg is empty and lacks genetic material, while the genetic material is entirely paternal in origin.

EXPLANATION

✔Correct answer:

Hydatidiform mole. The most likely diagnosis based on the findings is a hydatidiform mole. A hydatidiform mole, also known as a molar pregnancy, is a type of gestational trophoblastic disease that results from abnormal fertilization. It leads to the proliferation of trophoblastic tissue and the formation of fluid-filled cysts that resemble a "grape-like" cluster within the uterus.

Key indicators that suggest a hydatidiform mole include:

• Fundal height greater than expected for gestational age, as the uterus is often enlarged due to the overgrowth of trophoblastic tissue.
• No detectable fetal heartbeat, which is consistent with the absence of a viable fetus in a complete molar pregnancy.
• Mrs. Adams reports that her last menstrual period was 5 months ago, corresponding to a gestational age where fetal heart tones would normally be detectable, yet they are absent.

This combination of findings—an enlarged uterus with no fetal heartbeat at a gestational age where one would be expected—strongly suggests the presence of a hydatidiform mole.

Imagine blowing up a balloon that's filled with marbles (abnormal tissue) instead of air (a developing fetus). The balloon (uterus) grows larger than normal, but the content inside isn't what you'd expect, and there's no sign of a functioning system (no fetal heartbeat).

Nurse Megan should notify the healthcare provider of her assessment findings immediately, as further diagnostic testing, such as ultrasound and hCG level measurement, is needed to confirm the diagnosis. Early detection is essential to manage the condition and prevent complications.

• Communicate the assessment findings to the healthcare provider to initiate further diagnostic testing, such as an ultrasound and hCG levels.
• Prepare the patient for the possibility of treatment, which may include dilation and curettage (D&C) to remove the abnormal tissue.
• Provide emotional support, as the diagnosis involves the loss of a pregnancy and can be distressing.
• Educate the patient on the importance of follow-up care to monitor hCG levels and ensure complete resolution of the molar tissue.

✘Incorrect answer options:

Missed abortion. A missed abortion refers to a situation where the fetus has died but is retained in the uterus. While the absence of a fetal heartbeat could suggest a missed abortion, the fundal height being larger than expected makes this diagnosis less likely.

Pelvic inflammatory disease (PID). PID is an infection of the female reproductive organs and does not typically present with an enlarged uterus or absence of a fetal heartbeat. Symptoms of PID include pelvic pain, fever, and abnormal vaginal discharge, which are not mentioned in this scenario.

Ectopic pregnancy. An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, usually in a fallopian tube. It typically presents with pain and may cause vaginal bleeding but does not result in an enlarged uterus with no fetal heartbeat as described here.

EXPLANATION

✔Correct answer:

Rapid uterine growth that is larger than expected for gestational age. Rapid uterine growth that is larger than expected for gestational age is a hallmark sign of a hydatidiform mole, a type of gestational trophoblastic disease (GTD). In a molar pregnancy, abnormal trophoblastic tissue proliferates excessively, leading to the formation of fluid-filled cysts that cause the uterus to enlarge much faster than in a normal pregnancy. This rapid and disproportionate growth is a key indicator that Nurse Jessica would recognize as suspicious for a hydatidiform mole.

In a hydatidiform mole, abnormal fertilization results in the overgrowth of trophoblastic tissue, leading to elevated levels of hCG and the rapid expansion of the uterus. This abnormal tissue forms grape-like clusters that fill the uterine cavity, causing the uterus to grow larger than expected for the gestational age. Early identification of this condition is crucial because a hydatidiform mole can lead to complications such as persistent gestational trophoblastic disease or even choriocarcinoma if not treated promptly.

Imagine inflating a balloon, expecting it to grow slowly and steadily, but instead, it suddenly expands very quickly. This rapid growth indicates something unusual is happening inside, just like rapid uterine enlargement suggests something abnormal like a hydatidiform mole in early pregnancy.

Nurse Jessica should immediately refer Mrs. Carter for further diagnostic testing, including an ultrasound and hCG level measurement, to confirm the presence of a hydatidiform mole. Early diagnosis is important to prevent potential complications and to begin appropriate treatment.

• Advocate for an ultrasound to confirm the presence of the characteristic "grape-like" clusters of a hydatidiform mole.
• Measure hCG levels, which are typically much higher than normal in cases of a molar pregnancy.
• Prepare the patient for potential treatment, such as dilation and curettage (D&C), to remove the abnormal tissue.
• Provide emotional support, as the diagnosis involves the loss of pregnancy and the need for careful follow-up to monitor for complications.

✘Incorrect answer options:

Elevated blood pressure in the first trimester. Elevated blood pressure is more commonly associated with preeclampsia, which typically develops later in pregnancy, not in the first trimester. While hydatidiform mole can sometimes lead to early-onset preeclampsia, it is not the most definitive sign.

Severe nausea and vomiting. Severe nausea and vomiting (hyperemesis gravidarum) can occur in molar pregnancies due to elevated hCG levels, but they are not as specific as rapid uterine growth. Nausea and vomiting can also occur in normal pregnancies, making them less reliable as a diagnostic indicator.

Mild cramping and spotting. Mild cramping and spotting can occur in early pregnancy for various reasons, including implantation bleeding or a threatened miscarriage. While these symptoms can be associated with a molar pregnancy, they are not as distinctive as rapid uterine growth.

EXPLANATION

✔Correct answer:

Hydatidiform mole. The term "hydatidiform mole" refers to a specific type of gestational trophoblastic disease (GTD), which is a group of conditions involving abnormal growth of trophoblastic tissue, the tissue that normally develops into the placenta. A hydatidiform mole is characterized by the abnormal proliferation of trophoblasts and the formation of fluid-filled cystic structures that resemble grape-like clusters within the uterus. There are two types of hydatidiform moles: complete and partial. In a complete mole, no normal fetal tissue is present, while a partial mole may involve some abnormal fetal tissue, but the pregnancy is not viable. Hydatidiform moles can sometimes lead to more severe forms of gestational trophoblastic neoplasia, such as choriocarcinoma, if not appropriately managed.

Hydatidiform moles develop when an abnormal fertilization event occurs, leading to the overgrowth of trophoblastic tissue. This can result in a significantly enlarged uterus and elevated levels of hCG (human chorionic gonadotropin). The primary concern with hydatidiform moles is the potential for them to progress to more malignant forms of GTD, such as invasive moles or choriocarcinoma, necessitating careful monitoring and follow-up after treatment.

Imagine a normal pregnancy as planting a seed that grows into a healthy tree. A hydatidiform mole is like planting a seed that turns into an overgrown, abnormal cluster of vines instead of a tree, with the potential to become more aggressive if not controlled.

Nurse Laura should educate the patient on the nature of a hydatidiform mole, including the need for treatment and follow-up care to monitor hCG levels and prevent potential complications. Emotional support is also critical, as the diagnosis can be distressing, particularly due to the loss of the pregnancy.

• Educate the patient on the importance of follow-up care and monitoring of hCG levels after treatment to ensure all abnormal tissue has been removed.
• Discuss the potential need for repeat ultrasounds and other diagnostic tests to monitor for any signs of persistent or invasive disease.
• Provide emotional support and resources to help the patient cope with the diagnosis and the loss of the pregnancy.
• Advise the patient on the importance of delaying future pregnancies until cleared by her healthcare provider, typically after hCG levels have normalized and remained stable.

✘Incorrect answer options:

Dermoid cyst. A dermoid cyst is a benign tumor typically found in the ovaries that contains a variety of tissues, such as hair, teeth, and skin. It is not related to gestational trophoblastic disease.

Doderlein’s bacilli. Doderlein's bacilli are normal, beneficial bacteria found in the vagina that help maintain its acidic pH and protect against infections. They are not related to gestational trophoblastic disease.

Bartholin’s cyst. A Bartholin’s cyst occurs when the Bartholin's glands, located on either side of the vaginal opening, become blocked and filled with fluid. This is not associated with gestational trophoblastic disease.