GTD encompasses a spectrum of rare trophoblastic disorders arising from placental tissue, ranging from benign hydatidiform moles to malignant gestational trophoblastic neoplasia (GTN). Although uncommon, these conditions are notable for high cure rates when promptly identified and managed, fertility-sparing potential, and the central role of β-hCG monitoring to guide therapy. For nurses, a clear grasp of early recognition, diagnostic pathways, risk stratification, and patient-centered education drives safe, coordinated care.

Gestational Trophoblastic Disease describes proliferative disorders of trophoblast derived from conception. Entities include hydatidiform moles (complete and partial), invasive mole, choriocarcinoma, and rarer placental-site trophoblastic tumor (PSTT) and epithelioid trophoblastic tumor (ETT). Presentation spans the continuum from asymptomatic early pregnancy losses to dramatic bleeding with markedly elevated β-hCG and systemic effects. Timely evacuation of molar tissue, structured β-hCG surveillance, and risk-adapted chemotherapy in selected cases produce excellent outcomes, often preserving reproductive goals.

Table of Contents

Gestational Trophoblastic Disease (GTD)

Key Facts at a Glance

Umbrella term: GTD includes hydatidiform mole (complete/partial) and malignant GTN (invasive mole, choriocarcinoma, PSTT/ETT).
Biomarker: β-hCG is central for diagnosis, response assessment, and surveillance.
Genetics:
- Complete mole: typically androgenetic diploidy (46XX or 46XY) from paternal-only genome; no embryo/fetus.
- Partial mole: triploidy (commonly 69XXY); fetal tissue may be present.
Red flags: vaginal bleeding, uterine size larger than dates, very high β-hCG, hyperemesis, early-onset preeclampsia, hyperthyroidism, theca lutein cysts.
Primary therapy: suction curettage for molar pregnancy; chemotherapy for GTN based on FIGO stage/WHO score.
Follow-up: serial β-hCG to negative, then regular monitoring with reliable contraception during surveillance.
Prognosis: cure rates near 100% for low-risk GTN; high-risk GTN also highly curable with multi-agent therapy.

Definition and Classification

Gestational Trophoblastic Disease comprises neoplastic or pre-neoplastic lesions originating from trophoblastic tissue after conception. Benign forms (hydatidiform moles) may progress to GTN in a minority of cases; malignant forms (choriocarcinoma, PSTT, ETT) require oncologic pathways.

Spectrum of GTD

Hydatidiform mole
- Complete mole
- Partial mole
Gestational trophoblastic neoplasia (GTN)
- Invasive mole (molar tissue invading myometrium)
- Choriocarcinoma (highly malignant, hematogenous spread)
- Placental-site trophoblastic tumor (PSTT)
- Epithelioid trophoblastic tumor (ETT)

Epidemiology and Risk Factors

Epidemiology

Incidence varies globally; molar pregnancy occurs in approximately 1–3 per 1,000 pregnancies in many regions, with higher rates in parts of Asia and Latin America.
GTN may arise after molar pregnancy, term pregnancy, miscarriage, or ectopic pregnancy; post-molar GTN is most common.

Risk Factors (associations may vary by population)

Maternal age extremes: <20 years and ≥40 years (particularly ≥40 for complete mole)
Prior molar pregnancy (recurrence risk higher than baseline; overall risk still modest)
History of miscarriage or subfertility
Nutritional factors (low carotene/vitamin A reported in some cohorts)
Blood group A (associations reported in select studies)
Geographic and ethnic variation

Note: Long-term IUD use is not an established causal risk factor for GTD.

Pathophysiology and Genetics

Hydatidiform Mole

Complete mole:
- Androgenetic diploid conceptus, most often 46XX from duplication of a single sperm genome that fertilized an anucleate ovum; less commonly 46XY (two sperms).
- Diffuse villous edema with circumferential trophoblastic hyperplasia.
- No embryo/fetus; absence of fetal vessels within villi.
- Very high β-hCG, robust trophoblastic proliferation; higher risk of post-molar GTN.
Partial mole:
- Triploid conceptus (69XXX, 69XXY, or 69XYY) from dispermy fertilization of a normal ovum.
- Focal villous edema with scalloping; patchy trophoblastic proliferation.
- Fetal tissue or cardiac activity may be present.
- β-hCG moderately elevated; lower risk of GTN than complete mole.

Malignant GTN

Invasive mole: penetration of molar villi into myometrium; bleeding risk.
Choriocarcinoma: malignant trophoblast without villi; aggressive hematogenous spread to lungs, vagina, brain, liver.
PSTT/ETT: intermediate trophoblast tumors; often low β-hCG relative to tumor burden; slower growth; less sensitive to methotrexate; surgery central to management.

Systemic Effects

Hyperemesis gravidarum from trophoblastic hormones
Early-onset preeclampsia (<20 weeks) due to abnormal placentation
Hyperthyroidism (β-hCG cross-reactivity with TSH receptor)
Theca lutein ovarian cysts due to high β-hCG stimulation (often regress after evacuation)

Clinical Presentation

Symptoms

Vaginal bleeding in first or early second trimester
Excessive nausea/vomiting; weight loss or dehydration
Pelvic discomfort or uterine cramping
Respiratory symptoms in metastatic disease (cough, hemoptysis, dyspnea)
Neurologic symptoms if brain metastasis (headache, seizures)

Signs

Uterine size larger than gestational dates (common in complete mole)
Passage of vesicular tissue (“grape-like”)
Absent fetal heart tones in complete mole
Early-onset hypertension/proteinuria
Signs of thyrotoxicosis (tachycardia, tremor, heat intolerance)
Theca lutein cysts on pelvic ultrasound

Diagnostic Workup

Laboratory Evaluation

Quantitative β-hCG: often markedly elevated in complete molar pregnancy; serves as diagnostic clue and surveillance marker.
CBC: evaluate anemia.
Chemistry and LFTs: baseline for chemotherapy safety and assessment of systemic illness.
Thyroid panel: assess for hyperthyroidism in markedly elevated β-hCG.
ABO/Rh and type & screen: plan for anti-D immunoglobulin if RhD-negative.

Imaging

Transvaginal ultrasound:
- Complete mole: diffuse echogenic intrauterine mass with multiple anechoic cystic spaces—“snowstorm” or “cluster of grapes”; absent embryo.
- Partial mole: gestational sac may be present with fetal tissue; abnormal placenta with cystic changes; growth restriction or structural anomalies.
Chest imaging:
- Chest X-ray for baseline metastasis screen if GTN suspected.
- CT chest/abdomen/pelvis or MRI in selected cases (staging GTN, neurologic symptoms).

Histopathology

Suction curettage tissue sent for histology confirms diagnosis and differentiates complete vs partial mole.
Immunohistochemistry (e.g., p57) aids distinction: p57 negative in complete mole (maternal gene absent), positive in partial mole.

Classification and Staging (FIGO/WHO)

FIGO Anatomic Staging (for GTN)

Stage I: Confined to uterus
Stage II: Extends to genital structures (adnexa, vagina)
Stage III: Lung metastases (with/without genital tract involvement)
Stage IV: All other metastases (e.g., brain, liver)

WHO/FIGO Prognostic Scoring (0–>12)
Factors scored 0, 1, 2, or 4:

Age, antecedent pregnancy (mole vs term), interval months from index pregnancy, pretreatment β-hCG, largest tumor size, site of metastases (e.g., liver/brain), number of metastases, prior chemotherapy.
Risk categories:
- Low risk: total ≤6
- High risk: total ≥7
- Very high risk: ≥13 (subset requiring intensive regimens and specialist center care)
  Staging plus score guides regimen selection.

Management-Principles and Pathways

Initial Stabilization (when bleeding or systemic compromise present)

IV access, hemodynamic monitoring, fluid resuscitation as needed.
Blood products if significant anemia or hemorrhage.
Control of hyperthyroidism or hypertensive features when present.
Anti-D immunoglobulin for RhD-negative patients undergoing uterine evacuation.

Hydatidiform Mole (Complete or Partial)

Preferred procedure: Suction curettage (vacuum aspiration) with cervical dilation under ultrasound guidance; minimizes risk of perforation and reduces embolization of tissue.
Oxytocin infusion after evacuation supports uterine contraction; caution with pre-evacuation uterotonics in markedly enlarged uteri.
Avoid routine hysterotomy; reserve hysterectomy for selected patients who have completed childbearing or intractable bleeding.
Tissue to pathology for confirmation and ploidy assessment.
Contraception: Initiate reliable method post-evacuation; delay IUD until β-hCG normalization due to perforation/infection risk; combined oral contraceptives or progestin-only methods commonly used.

Post-Evacuation Surveillance

β-hCG schedule:
- Weekly until undetectable for three consecutive tests.
- Then monthly for an additional period (commonly 6–12 months from first negative; protocols vary by region and risk).
Criteria for post-molar GTN diagnosis:
- Plateau of β-hCG (±10%) over three weeks (four values)
- Rise in β-hCG >10% for two consecutive weeks (three values)
- Detectable β-hCG ≥6 months after evacuation
- Histologic choriocarcinoma
- Clinically evident metastases
Contraception maintained throughout surveillance to avoid confounding β-hCG interpretation.

Gestational Trophoblastic Neoplasia (GTN)

Low-risk GTN (FIGO score ≤6):
- Single-agent chemotherapy with methotrexate (various protocols with folinic acid) or actinomycin-D.
- Choice influenced by center expertise, contraindications, and anticipated toxicity.
- Cure rates >95–98%; switch agent if plateau/rise in β-hCG.
High-risk GTN (FIGO score ≥7):
- Multi-agent chemotherapy (e.g., EMA-CO: etoposide, methotrexate, actinomycin-D, cyclophosphamide, vincristine).
- Intensive supportive care, antiemetics, infection prophylaxis, and fertility counseling.
- Whole-brain radiation or intrathecal methotrexate for brain metastases; hepatic-directed therapy for liver lesions in selected cases.
- Cure rates >85–90% in specialized centers.
PSTT/ETT:
- Less sensitive to methotrexate; primary treatment often hysterectomy for uterine-confined disease.
- Metastatic PSTT/ETT may require platinum-based chemotherapy; prognosis depends on stage and interval since index pregnancy.

Supportive and Adjunctive Care

Anemia correction with iron or transfusion.
Management of hyperemesis, electrolyte imbalance, and hydration.
Beta-blockers and antithyroid therapy for thyrotoxicosis when indicated.
Pain management, psychosocial support, and practical resource linkage.

Nursing Management-Roles, Responsibilities, and Education

Assessment and Monitoring

Baseline and serial vital signs; observation for bleeding, uterine tenderness, and infection.
Intake/output trends; attention to hyperemesis and dehydration.
Preoperative preparation and postoperative monitoring after curettage (fundal tone, bleeding, pain).
Recognition of signs suggestive of metastases (respiratory or neurologic symptoms).

Medication and Chemotherapy Safety

Verification of chemotherapeutic protocols, doses, and timing.
Vascular access care; prevention of extravasation; double-check processes per policy.
Antiemetic regimens and toxicity monitoring (mucositis, myelosuppression, hepatotoxicity).
Laboratory surveillance coordination (CBC, LFTs, renal function) and critical result reporting.

β-hCG Surveillance and Documentation

Scheduling and tracking of β-hCG draws; consistent laboratory use to limit assay variability.
Clear, time-stamped documentation of values, trends, and thresholds for escalation.
Communication with the multidisciplinary team when patterns meet GTN criteria.

Patient and Family Education

Explanation of GTD spectrum and rationale for suction curettage or chemotherapy.
Outline of β-hCG surveillance plan and importance of reliable contraception to avoid confounding results.
Expected side effects, warning signs (heavy bleeding, fever, chest pain, neuro symptoms), and when urgent evaluation is needed.
Reassurance regarding excellent prognosis and fertility outcomes in most cases.

Psychosocial Support and Cultural Humility

Screening for anxiety, grief, or trauma reactions; referral to counseling services when indicated.
Respect for cultural beliefs around pregnancy loss; inclusion of chosen support persons.
Provide language-concordant materials and interpreter services.

Care Coordination

Timely referral to regional trophoblastic disease centers or gynecologic oncology.
Appointment management, transportation assistance, and financial counseling referrals.
Interprofessional debriefs and quality improvement participation.

Nursing Care Plan Example-GTD Post-Evacuation

Assessment

Objective: β-hCG markedly elevated; ultrasound consistent with complete mole; uterine size > dates; theca lutein cysts present.
Subjective: Reports severe nausea, episodic dizziness; expresses fear about diagnosis and future fertility.

Nursing Diagnoses

Anxiety related to new diagnosis and uncertainty about fertility outcomes.
Risk for bleeding related to recent uterine evacuation and trophoblastic proliferation.
Nausea related to elevated pregnancy hormones and post-procedural effects.
Knowledge deficit related to condition, surveillance, and contraception.

Goals/Expected Outcomes

Anxiety rating reduced; articulates understanding of condition and plan.
Stable hemodynamics; lochia within expected parameters.
Nausea controlled; adequate oral intake and hydration maintained.
Adherence to β-hCG schedule and contraception plan.

Interventions and Rationales

Provide concise, repeated education with written materials; reinforce surveillance importance (supports adherence and reduces anxiety).
Monitor bleeding and fundal tone; report heavy bleeding promptly (early detection of complications).
Administer antiemetics; encourage small, frequent meals and hydration (symptom control).
Coordinate contraception initiation post-evacuation; document method and counseling (prevents confounding β-hCG).
Schedule β-hCG draws; maintain a trend chart; alert provider to plateau/rise (enables rapid GTN detection).
Screen for depressive symptoms; offer mental health referral (addresses psychosocial impact).

Evaluation

Reports lower anxiety; describes surveillance schedule accurately.
Vital signs stable; bleeding minimal; no signs of infection.
Nausea improved; oral intake adequate; no dehydration.
β-hCG values trending downward; contraception in place.

Fertility, Contraception, and Future Pregnancy

Fertility outcomes: Most patients retain fertility; subsequent live birth rates are high after completion of therapy and surveillance.
Recurrence risk: Risk of a future molar pregnancy modestly increased compared with baseline; early ultrasound and β-hCG monitoring in the next pregnancy recommended.
Contraception: Effective contraception during β-hCG surveillance is essential; IUD placement deferred until β-hCG normalizes; hormonal methods commonly used.
Timing of conception: Conception generally deferred until surveillance completes (often 6–12 months after first negative β-hCG for molar pregnancy; center-specific protocols vary).

Special Clinical Considerations

Postpartum and Non-molar GTN

GTN can follow term pregnancy, miscarriage, or ectopic; suspicion should rise with persistent or irregular postpartum bleeding and elevated β-hCG.
Choriocarcinoma after term delivery may present late with metastases; chest and neuro imaging often warranted.

Hyperthyroidism and Severe Nausea

β-hCG cross-reactivity with TSH receptor can cause thyrotoxicosis; management includes beta-blockade and antithyroid agents in select cases.
Aggressive management of hyperemesis with antiemetics, IV fluids, and electrolyte correction.

Resource-Limited Settings

Emphasis on suction evacuation technique, serial β-hCG where available, and prompt referral when plateau/rise occurs.
Prioritization of contraception and symptom control to minimize complications.

Quality and Safety

Use standardized protocols for evacuation, chemotherapy, and β-hCG follow-up.
Implement double-checks for high-alert medications; maintain extravasation kits.
Track outcomes and time-to-treatment metrics; perform regular multidisciplinary reviews.
Provide clear emergency pathways for hemorrhage, infection, or suspected metastasis.

Prognosis and Long-Term Outcomes

Low-risk GTN: Cure rates approach 100% with single-agent chemotherapy.
High-risk GTN: Cure rates exceed 85–90% with multi-agent regimens and specialist care.
PSTT/ETT: Prognosis depends on stage and interval since index pregnancy; surgery central to management.
Survivorship: Menstrual and reproductive function usually recover; long-term oncologic follow-up individualized.

Frequently Asked Questions (FAQ)

What is the difference between a complete and a partial molar pregnancy?

A complete mole is usually androgenetic diploid with no embryo or fetal tissue and shows diffuse villous edema with circumferential trophoblastic proliferation; β-hCG levels are often very high. A partial mole is typically triploid, may include fetal tissue, and shows focal villous changes with patchy trophoblastic proliferation; β-hCG tends to be lower than in complete mole.

How is GTN diagnosed after a molar pregnancy?

Criteria include a plateau of β-hCG over three weeks, a rise in β-hCG across two consecutive weeks, persistence of detectable β-hCG at six months, histologic choriocarcinoma, or evidence of metastases. These findings trigger risk scoring and treatment.

How long is pregnancy generally avoided after molar evacuation?

Conception is typically deferred until β-hCG becomes undetectable and surveillance completes, commonly 6–12 months from the first negative test. Effective contraception is maintained throughout the follow-up period.

What are standard treatments for GTN?

Low-risk GTN is treated with single-agent chemotherapy (methotrexate or actinomycin-D). High-risk disease requires multi-agent regimens such as EMA-CO, along with comprehensive supportive care. PSTT/ETT often require surgery.

Are future pregnancies safe after GTD or GTN?

Most patients achieve successful future pregnancies with outcomes comparable to the general population after appropriate treatment and surveillance. Early obstetric ultrasound and β-hCG checks in the next pregnancy are recommended.

Conclusion

Gestational Trophoblastic Disease represents a rare but highly manageable spectrum of disorders characterized by a reliable biomarker (β-hCG), clear imaging-pathology correlation, and well-validated, risk-adapted treatment pathways. Nursing professionals anchor this care through rapid recognition of atypical pregnancy presentations, meticulous peri-procedural support, rigorous β-hCG surveillance, patient-centered education, and interprofessional coordination. With timely diagnosis, appropriate evacuation, and risk-based therapy, the vast majority of patients are cured and retain reproductive potential—an outcome that underscores the power of organized, evidence-based, compassionate care.

Educational Note
This article supports professional education and does not replace individualized assessment, local protocols, or specialist consultation. For urgent concerns or emergency symptoms (e.g., heavy bleeding, chest pain, neurologic deficits), immediate evaluation is essential.