Aims of Management:

• Complete evacuation of molar pregnancy.
• Prevention of complications (hemorrhage, infection, DIC).
• Early detection and management of persistent trophoblastic disease (PTD).

Management at the Maternity Centre (Pre-Referral):

Assessment:

• Detailed history including LMP, menstrual cycle regularity, symptoms (amount and character of vaginal bleeding, abdominal pain, uterine size), previous pregnancies, family history of GTD.
• Physical examination: Vital signs (BP, pulse, respiration, temperature), abdominal examination (uterine size, tenderness, consistency), pelvic examination (speculum exam to assess vaginal bleeding, cervical changes).
• Preliminary β-hCG testing if not already obtained.

Stabilization:

• Assessment for hypovolemic shock if significant bleeding (tachycardia, hypotension).
• IV fluid resuscitation with crystalloids (e.g., normal saline) if needed to maintain hemodynamic stability.
• Oxygen supplementation if necessary.
• Continuous monitoring of vital signs.

Referral Preparation:

• Contact the receiving hospital to confirm acceptance and availability of resources.
• Prepare a detailed referral note including all pertinent clinical information.
• Arrange for appropriate transportation (ambulance if unstable; private transport if stable).

Referral Note: 

• Patient demographics and medical history
• Presenting complaint and findings of the physical exam
• β-hCG level (if available)
• Results of any preliminary investigations (e.g., ultrasound)
• Assessment of the patient’s overall condition
• Reasons for referral
• My assessment and plan of care

Transportation: Ensure safe and timely transport; accompany patient if possible.

Hospital Management (Post-Referral):

Reception & Admission: (As before)

Stabilization: (As before, more detailed monitoring and interventions)

Doctor’s Orders & Investigations:

• Complete blood count (CBC) to assess for anemia.
• Blood type and cross-match in case of significant blood loss requiring transfusion.
• Coagulation profile (PT, PTT, INR, fibrinogen) to assess for DIC.
• Liver function tests (LFTs) and kidney function tests (KFTs) to assess organ function.
• Chest X-ray to rule out lung metastasis.
• Serial β-hCG measurements to monitor disease activity.
• Transvaginal or abdominal ultrasound to confirm diagnosis, assess for invasion, and rule out other pathology.

Medical Management:

• Blood transfusion: If significant blood loss necessitates it.
• Methotraxate: If indicated (e.g., for incomplete evacuation, low-risk PTD) Dosage would depend on patient weight and renal function; it’s generally given IM or IV in multiple doses, with close monitoring of renal and liver function as well as blood counts. For example, 50mg/m2 of body surface area might be an initial dose.
• Dacarbazine (DTIC): An alternative chemotherapeutic agent for PTD management, used in situations where methotrexate is contraindicated or ineffective. The dosage regimen depends on several factors, including type and extent of disease, patient performance status, and prior treatment.
• Antibiotics: Broad-spectrum antibiotics (e.g., ampicillin/sulbactam or clindamycin/gentamicin) prophylactically to prevent infection, especially if there’s significant vaginal bleeding or signs of infection.
• Pain Management: Analgesics (e.g., paracetamol or NSAIDs) as needed for post-operative pain.

Surgical Management:

• Suction Curettage (D&C): The primary surgical method for removing the molar tissue. It involves inserting a cannula into the uterus and using suction to evacuate the contents. The uterine cavity is then curetted to ensure complete removal of the molar tissue.
• Hysterectomy: May be considered if the patient desires sterilization, has significant risk factors for PTD, or if there are complications during suction curettage (e.g., uterine perforation). This would involve the surgical removal of the uterus.

Nursing Care:

• Continuous monitoring of vital signs (BP, pulse, respiration, temperature).
• Assessment of vaginal bleeding (amount, color, consistency).
• IV fluid management and administration of medications as prescribed.
• Pain management and comfort measures (analgesics, repositioning).
• Monitoring for signs and symptoms of infection (fever, chills, abdominal tenderness).
• Education on post-operative care (wound care, hygiene, activity restrictions).
• Emotional support and counseling.
• Monitoring for complications (hemorrhage, infection, thromboembolic events).
• Accurate documentation of all assessments, interventions, and responses.
• Close monitoring of laboratory values (hCG levels, CBC, coagulation studies).
• Patient and family teaching related to the disease process, treatment, and long-term monitoring.
• Assistance with ambulation and activities of daily living as the patient’s condition allows.

Discharge Advice: After a few days post-surgery, and once the patient is stable and hCG levels are beginning to fall, discharge planning will start. Discharge instructions will include:

• Regular follow-up appointments to monitor hCG levels.
• Instructions on recognizing signs and symptoms of complications (hemorrhage, infection, fever, etc.)
• Contraceptive advice (avoiding pregnancy for at least 1 year).
• Information about PTD and the need for long-term monitoring.
• Information about support groups and mental health resources.