3. Hydatidiform mole (complete)
   1. 1. Pathophysiology - chorionic villi degenerate into grapelike cluster of vesicles; may be antecedent to choriocarcinoma.
   2. 2. Etiology - genetic base of complete mole (sperm enters empty egg and its chromosomes replicate; 23 pairs of chromosomes are all paternal); rare complication; more common in women over 45 years of age and Asian women.
   3. Assessment:
      • Uterus - rapid enlargement; fundal height inconsistent with gestational estimate.
      • Brownish discharge - beginning about week 12; may contain vesicles.
      • Signs and symptoms of preeclampsia/ eclampsia (before third trimester), increased incidence of hyperemesis gravidarum.
      • Medical evaluation - procedures:
        1. Sonography, x-ray, amniography - no fetal parts present; "‘snowstorm"
        2. Laboratory test - for elevated human chorionic gonadotropin (HCG) levels.
        3. Follow-up surveillance of HCG levels for at least 1 year; persistent HCG level is consistent with choriocarcinoma; x-ray.
   4. Analysis/nursing diagnosis:
      • Anxiety/fear related to treatment, possible sequelae of hydatidiform mole (choriocarcinoma).
      • Potential for injury related to hemorrhage, perforation of uterine wall, preeclamp-sia/eclampsia.
      • Fluid volume deficit related to hemorrhage.
   5. Nursing care plan/implementation:
      • Medical management
        1. Monitor for pregnancy - induced hypertension (PIH).
        2. Evacuate the uterus - hysterectomy may be necessary.
        3. Strict contraception for at least 1 yearr to enable accurate assessment of status.
        4. Choriocarcinoma - chemotherapy (methotrexate plus Dactinomycin) or radiation therapy, or both.
      • Nursing management
        1. Goal: safeguard status. Observe for hemorrhage, passage of retained vesicles and abdominal pain, or signs of infection (because woman is at risk for perforation of uterine wall).
        2. Goal: health teaching.
           • Explain, discuss diagnostic tests; prepare for tests.
           • Discuss contraceptive options.
           • Importance of follow-up.
        3. Goal: preoperative and postoperative care.
        4. Goal: emotional support. Facilitate grieving.
   6. Evaluation/outcome criteria:
      • Verbalizes understanding of diagnosis, tests, and treatment.
      • Complies with medical/nursing recommendations.
      • Tolerates surgical procedure well.
        1. Bleeding controlled.
        2. Vital signs stable.
        3. Urinary output adequate.
      • Copes effectively with loss of pregnancy,
      • Returns for follow-up care/surveillance.
      • Selects and effectively implements method of contraception; avoids pregnancy for 1 year or more.
      • Tests for HCG remain negative for 1 year; no evidence of malignancy.
      • Achieves a pregnancy when desired.
      • Successfully carries pregnancy to term; normal, uncomplicated birth of viable infant.
4. Ectopic pregnancy (Figure 4-5)
   1. Pathology - implantation outside of uterine cavity.
   2. Types:
      • Tubal (most common).
      • Cervical.
      • Abdominal.
      • Ovarian.
   3. Etiology:
      • PID - pelvic salpingitis and endometritis.
      • 43% caused by STD-related factors: 25%, chlamydial; 20%, previous STD.
      • Tubal or uterine anomalies, tubal spasm
      • Adhesions from PID or past surgeries.
      • Presence of IUD.
   4. Assessment: dependent on implantation site
      • Early signs - abnormal menstrual period (usually following a missed menstrual period), spotting, some symptoms of pregnancy; possible dull pain on affected side.
      • Impending or posttubal rupture - sudden, acute, lower abdominal pain; nausea and vomiting; signs of shock; referred shoulder pain (Kehrs sign) or neck pain - due to blood in peritoneal cavity; blood in cul-de-sac may —> rectal pressure.
      • Sharp, localized pain when cervix is touched during vaginal exam; shock and circulatory collapse in some, usually following vaginal examination.
      • Positive pregnancy test in many women.
   5. Analysis/nursing diagnosis:
      • Fear related to abdominal pain and pregnancy status.
      • Grief related to pregnancy loss.
   6. Nursing care plan/implementation:
      • Medical management: Surgical removal/ repair. Methotrexate, a folic acid antagonist, which acts by inhibiting cell division (may be used in early ectopic pregnancy).
      • Nursing management:
        1. Goal: preoperative and postoperative care, health teaching.
        2. Goal: supportive care for grief reaction; encourage verbalization of anxiety and concerns of further pregnancies.
   7. Evaluation/outcome criteria:
      • Woman experiences uncomplicated postoperative course.
      • Woman copes effectively with loss of pregnancy.