A patient with persistent gestational trophoblastic disease (GTD) presents with retained trophoblastic tissue and ongoing bleeding. Based on the diagnostic results, which nursing intervention is the priority to prevent complications?

B) Initiate fluid resuscitation to address volume depletion.

A) Administer methotrexate to control trophoblastic proliferation.

B) Initiate fluid resuscitation to address volume depletion.

C) Prepare the patient for repeat surgical intervention.

D) Monitor serial beta-hCG levels to evaluate treatment effectiveness.

A patient with diagnosed persistent gestational trophoblastic disease (GTD) presents with mild hyponatremia and slightly elevated creatinine levels. The healthcare team plans for immediate intervention. What is the priority nursing action to address the patient's current condition?

B) Initiate intravenous fluid resuscitation to correct electrolyte imbalance and improve renal function.

A) Administer methotrexate therapy to inhibit trophoblastic proliferation.

B) Initiate intravenous fluid resuscitation to correct electrolyte imbalance and improve renal function.

C) Prepare the patient for repeat surgical intervention to evacuate retained products.

D) Monitor serial beta-hCG levels to track the progression of GTD.

A patient with gestational trophoblastic disease is experiencing worsening symptoms including increased vaginal bleeding, tachycardia, hypotension, and new onset palpitations. Laboratory results reveal a further decrease in hemoglobin and hematocrit, along with an elevated prothrombin time and INR, suggesting disseminated intravascular coagulation (DIC). What is the nurse's priority intervention in managing this patient's condition?

C) Initiate a blood transfusion protocol to address anemia and coagulopathy.

A) Administer intravenous fluids to manage hypotension.

B) Prepare the patient for an emergency dilation and curettage (D&C).

C) Initiate a blood transfusion protocol to address anemia and coagulopathy.

D) Start methotrexate therapy to target trophoblastic proliferation.

A patient with gestational trophoblastic disease is experiencing complications, including disseminated intravascular coagulation (DIC) and significant vaginal bleeding despite initial stabilization efforts. The patient is scheduled for an emergency dilation and curettage (D&C) and transfusion protocol. Which nursing intervention is the priority to prevent further deterioration in this clinical scenario?

C) Initiate intravenous access with a large-bore needle for blood transfusion.

A) Monitor the patient's vital signs every 4 hours to assess for stability.

B) Prepare the patient for the D&C by ensuring informed consent is signed.

C) Initiate intravenous access with a large-bore needle for blood transfusion.

D) Educate the patient about signs of infection and complications post-procedure.

A patient undergoing treatment for gestational trophoblastic disease with methotrexate presents with moderate vaginal bleeding and a slight decrease in beta-hCG levels. Her vital signs show stabilization, but her condition remains precarious. What should be the priority nursing intervention at this stage of her treatment?

B) Educate the patient on the importance of reporting any increase in bleeding or new symptoms.

A) Increase the frequency of beta-hCG monitoring to assess chemotherapy effectiveness.

B) Educate the patient on the importance of reporting any increase in bleeding or new symptoms.

C) Implement measures to manage potential side effects of methotrexate, such as stomatitis.

D) Arrange for a psychological support session to address the emotional impact of her condition.

A nurse is caring for a patient who has undergone emergency dilation and curettage (D&C) and is receiving methotrexate therapy for gestational trophoblastic disease. The patient's vital signs are stable, and laboratory results show a slight decrease in beta-hCG levels. However, the patient is still experiencing moderate vaginal bleeding. What is the priority nursing intervention at this time?

A) Increase the frequency of vital signs monitoring to detect any signs of hemodynamic instability.

B) Administer additional doses of methotrexate to accelerate the reduction of beta-hCG levels.

C) Educate the patient on the importance of follow-up appointments for ongoing management of gestational trophoblastic disease.

D) Provide reassurance to the patient and family that the bleeding is a normal part of the recovery process.

A patient receiving methotrexate therapy for gestational trophoblastic disease develops increasing abdominal pain, distension, and signs of hemodynamic instability. What is the priority nursing intervention in this situation?

B) Prepare the patient for an urgent exploratory laparotomy

A) Administer antiemetics to control nausea and vomiting

B) Prepare the patient for an urgent exploratory laparotomy

C) Reassess the patient's pain level and administer analgesics

D) Monitor vital signs every hour to assess for further changes

A patient undergoing methotrexate therapy for gestational trophoblastic disease presents with increasing abdominal pain, distension, and signs of hemodynamic instability. Which immediate nursing action is most critical in this situation?

C) Initiate aggressive fluid resuscitation as per protocol.

A) Administer prescribed analgesics to manage the patient's pain.

B) Notify the healthcare provider of the patient's deteriorating condition.

C) Initiate aggressive fluid resuscitation as per protocol.

D) Prepare the patient for an urgent exploratory laparotomy.

A patient recovering from a hemoperitoneum following uterine blood vessel rupture is in the ICU for monitoring. Which of the following nursing interventions is most crucial in the immediate postoperative period to ensure patient safety and recovery?

C) Assess the patient's abdominal distension and pain regularly.

A) Monitor the patient's hemoglobin levels every 4 hours.

B) Administer anti-emetics to prevent nausea and vomiting.

C) Assess the patient's abdominal distension and pain regularly.

D) Encourage early ambulation to prevent deep vein thrombosis.

A patient who underwent an exploratory laparotomy for hemoperitoneum is now in the ICU. Despite stabilization of vital signs, her beta-hCG levels remain elevated. What is the most appropriate nursing action to support the patient's ongoing management?

B) Collaborate with the healthcare team to discuss potential adjustments to the current treatment plan.

A) Encourage the patient to increase oral fluid intake to promote dilution of beta-hCG.

B) Collaborate with the healthcare team to discuss potential adjustments to the current treatment plan.

C) Educate the patient about the importance of relaxation techniques to reduce stress and lower beta-hCG levels.

D) Administer additional packed red blood cells to further stabilize hemoglobin levels and reduce beta-hCG.

Case 1: Post-Operative Hydatidiform Mole Complication A 28-year-old female, G2P1, was admitted for post-operative complications following suction curettage for a complete hydatidiform mole. Two weeks post-procedure, she presented with persistent vaginal bleeding and lower abdominal pain. Initially, she experienced mild spotting, but the bleeding became moderate and bright red. She also reported fatigue and dizziness but denied fever. A physical examination revealed a soft, enlarged uterus with persistent vaginal bleeding. Her vital signs indicated hypotension (100/60 mmHg) and tachycardia (110 bpm), suggesting blood loss. Diagnostic tests included a complete blood count (CBC), which showed anemia (Hb 9.5 g/dL), and a transvaginal ultrasound revealing retained trophoblastic tissue. The patient’s beta-hCG levels remained elevated, raising suspicion for persistent gestational trophoblastic disease (GTD) - Nursing Case Study

Pathophysiology

• Primary mechanism: Retained trophoblastic tissue post-suction curettage continues to produce beta-hCG, maintaining gestational trophoblastic disease (GTD) activity, which can lead to excessive uterine bleeding.

• Secondary mechanism: Persistent trophoblastic proliferation disrupts normal endometrial repair and involution of the uterus, resulting in an enlarged, soft uterus and ongoing vaginal bleeding.

• Key complication: The retained tissue and elevated beta-hCG levels suggest incomplete molar evacuation, risking progression to persistent GTD, characterized by continued hemorrhage, anemia, and systemic symptoms like fatigue and dizziness due to blood loss.

Patient Profile

Demographics:

28-year-old female, previously G2P1, occupation: not specified

History:

• Complete hydatidiform mole treated with suction curettage

• No current medications reported

• No known allergies

Current Presentation:

• Chief complaint: Persistent vaginal bleeding and lower abdominal pain post-procedure

• Key symptoms: Moderate bright red vaginal bleeding, fatigue, dizziness, soft and enlarged uterus

• Vital signs: Blood pressure 100/60 mmHg, heart rate 110 bpm, anemia with Hb 9.5 g/dL, elevated beta-hCG levels

Section 1

New Diagnostic Results:

Following the initial assessment, further diagnostic evaluations were conducted to clarify the extent of the retained trophoblastic tissue and to guide the next steps in management. A repeat transvaginal ultrasound confirmed the presence of echogenic material within the uterine cavity, consistent with retained products of conception. In addition, serial beta-hCG levels were performed, revealing persistently high levels at 150,000 mIU/mL, significantly elevated from the expected decline post-evacuation. This reinforced the suspicion of persistent gestational trophoblastic disease (GTD), necessitating a more aggressive approach to treatment.

In parallel, a comprehensive metabolic panel was ordered to assess for any electrolyte imbalances or renal impairment secondary to the ongoing bleeding and physiological stress. Results indicated mild hyponatremia (sodium 132 mEq/L) and a slightly elevated creatinine level of 1.3 mg/dL, suggesting a degree of prerenal azotemia due to volume depletion. Given these findings, the clinical team recognized the need for both addressing the underlying cause of the bleeding and stabilizing the patient's hemodynamic status. The patient's condition highlighted the importance of interdisciplinary care, involving obstetrics, oncology, and hematology specialists to formulate a holistic management plan.

These diagnostic results emphasized the urgency of intervention to prevent further complications, such as progression to more aggressive forms of GTD or hemodynamic instability. The team planned for immediate re-evaluation with potential repeat surgical intervention, alongside initiation of fluid resuscitation and consideration of methotrexate therapy if indicated. This step aimed to control trophoblastic proliferation and facilitate uterine recovery, setting the stage for the next phase of the patient's treatment journey.

Section 2

New Complications

Following the initial intervention with fluid resuscitation and consideration for methotrexate therapy, the patient experienced a sudden change in her clinical status. Despite initial stabilization efforts, her vital signs indicated increasing tachycardia, now at 125 bpm, and further hypotension with blood pressure dropping to 90/55 mmHg. She also reported worsening dizziness and a new onset of palpitations. This prompted an urgent reassessment, revealing that the vaginal bleeding had intensified, now saturating her pads more rapidly, suggesting a further escalation in blood loss.

Laboratory results from repeat testing showed a further drop in hemoglobin to 8.2 g/dL and a hematocrit of 25%, confirming ongoing anemia. Additionally, her coagulopathy screen revealed an elevated prothrombin time (PT) and international normalized ratio (INR), indicating a developing consumptive coagulopathy. The combination of these findings suggested a shift towards disseminated intravascular coagulation (DIC), a serious complication that required immediate attention. The clinical team quickly recognized the complexity of managing both the persistent gestational trophoblastic disease and the emerging coagulopathy, necessitating a more aggressive therapeutic approach.

In response to these new complications, the multidisciplinary team convened to adjust the management plan. A decision was made to proceed with an emergency repeat dilation and curettage (D&C) to remove retained trophoblastic tissue and mitigate further bleeding. Concurrently, the patient was started on a transfusion protocol to address both anemia and coagulopathy, including packed red blood cells and fresh frozen plasma. The team also expedited the initiation of methotrexate therapy to target the underlying trophoblastic proliferation. These interventions aimed to stabilize the patient and prevent further deterioration, creating a critical juncture in her treatment journey.

Section 3

Response to Interventions

Following the emergency repeat dilation and curettage (D&C), the clinical team closely monitored the patient's response to the interventions. Initially, the patient's vital signs showed slight improvements; her blood pressure stabilized at 95/60 mmHg and her heart rate decreased to 115 bpm. The transfusion protocol, which included two units of packed red blood cells and fresh frozen plasma, successfully raised her hemoglobin levels to 9.0 g/dL, providing some relief from the symptoms related to anemia. Additionally, her prothrombin time (PT) and international normalized ratio (INR) began to normalize, indicating a positive response to the treatment of her coagulopathy.

However, despite these initial improvements, the patient's condition remained precarious. The ongoing methotrexate therapy, aimed at addressing the persistent gestational trophoblastic disease, was closely monitored. Her beta-hCG levels were checked regularly to assess the efficacy of the chemotherapy, and within 48 hours, a slight decrease in levels was observed, suggesting some degree of tumor response. However, the patient continued to experience moderate vaginal bleeding, albeit less severe than before the D&C, warranting continued vigilant observation.

The clinical team recognized that while the immediate crisis had been averted, careful monitoring and further interventions might be necessary. The patient's response to methotrexate would be critical in determining the next steps in her treatment plan. Follow-up care included regular assessments of her hemodynamic status, repeated laboratory tests to ensure further stabilization of her coagulation profile, and continued evaluation of her beta-hCG levels. The patient was also given supportive care measures, including nutritional support and counseling, to aid in her recovery and address the psychological impact of her condition. This phase of management emphasized the importance of comprehensive care and the need for ongoing reassessment to prevent any potential relapse or new complications.

Section 4

New Complications

Despite the initial signs of improvement, the clinical team soon encountered new complications in the patient's recovery process. Three days into the methotrexate therapy, the patient developed increasing abdominal pain and distension, accompanied by nausea and occasional vomiting. A physical examination revealed guarding and tenderness upon palpation of the abdomen, raising concerns for potential gastrointestinal involvement or other intra-abdominal complications. Her vital signs showed a slight increase in heart rate to 120 bpm and a decrease in blood pressure to 92/58 mmHg, suggesting ongoing hemodynamic instability.

Given these concerning symptoms, further diagnostic imaging was warranted. An abdominal ultrasound was performed, revealing free fluid in the peritoneal cavity, consistent with possible hemoperitoneum. This finding, combined with the patient's deteriorating clinical status, prompted the team to suspect a rupture of a uterine blood vessel or another source of internal bleeding, potentially exacerbated by the methotrexate therapy.

In response to these developments, the medical team prepared for an urgent exploratory laparotomy to identify and address the source of the bleeding. The patient's care plan was adjusted to include aggressive fluid resuscitation and the continuation of blood transfusions as needed to stabilize her hemodynamic status. The decision to proceed with surgical intervention underscored the complexity of managing persistent gestational trophoblastic disease and highlighted the need for dynamic clinical reasoning and prompt action in the face of evolving complications. The patient's journey emphasized the critical importance of close monitoring and the readiness to adapt treatment strategies in response to new challenges.

Section 5

Response to Interventions

Following the decision for an urgent exploratory laparotomy, the medical team swiftly mobilized to stabilize the patient. Aggressive fluid resuscitation commenced with the administration of intravenous crystalloids and packed red blood cell transfusions to address her hemodynamic instability. Within hours, her blood pressure improved to 105/65 mmHg, and her heart rate decreased to 105 bpm, indicating a positive initial response to the interventions. However, the patient's abdominal pain persisted, and her distension showed no signs of abating, reinforcing the need for surgical exploration.

In the operating room, the surgical team discovered a significant hemoperitoneum, estimated at approximately 800 mL of blood, confirming internal bleeding. A careful inspection revealed a small rupture in a uterine blood vessel, likely exacerbated by the methotrexate therapy's effect on rapidly dividing cells. The surgeons successfully cauterized the vessel and evacuated the retained blood and clots from the peritoneal cavity. Post-operatively, the patient was transferred to the intensive care unit for close monitoring and further stabilization.

In the ICU, the patient's recovery was closely observed, with continuous monitoring of her vital signs and repeated laboratory tests to assess her hemoglobin levels and beta-hCG titers. Over the next 48 hours, her vital signs stabilized, with a heart rate of 88 bpm and blood pressure of 115/70 mmHg, indicating effective control of the bleeding. Her hemoglobin levels gradually increased to 10.2 g/dL, suggesting successful management of the acute blood loss. However, her beta-hCG levels remained elevated, necessitating ongoing evaluation and potential adjustments to her treatment plan, highlighting the complexity and dynamic nature of managing persistent gestational trophoblastic disease.