Concurrent Gestational Trophoblastic Cancer in a Full-Term Pregnancy

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Gestational trophoblastic disease complicates about 1–2 pregnancies out of 1,000. This disease commonly presents as a nonviable hydatidiform mole diagnosed in first or early second trimester. Gestational choriocarcinoma is an aggressive form of cancer. It is very rare and occurs in 1 in 40,000 pregnancies. The case demonstrates specialty nursing coming together to provide family-centered care to meet the needs of a unique family. Collaborative nursing care is not unusual; however, the combination of a late diagnosis of a twin pregnancy, with one normal fetu, and advanced metastatic choriocarcinoma presented challenges that nursing teams had not experienced before. This case study discusses a gravida 2 para 1 patient with Stage IV choriocarcinoma who was at 34-weeks gestation when she was transferred to tertiary care due to shortness of breath. On arrival she was dyspneic, with coughing, wheezing, and an oxygen saturation level of 92%. Her scans showed nodules in lungs, liver, and brain. Initial quantitative β-hCG level was 1.3 million mIU/ml. Her placental pathology showed an International Federation of Gynecology and Obstetrics Grade IV choriocarcinoma, and her score on the World Health Organization (WHO) Risk score was 14. Women who have a WHO score greater than 7 require combination chemotherapy; a score greater than 13 increases risk of death related to hemorrhage. The maternal and oncology staff created a care plan that was acceptable to the patient, as she had planned a holistic home birth with a lay midwife. The couple declined all prenatal labs, tests, or ultrasound. Their preference was the most holistic methods possible. This patient did not believe in chemotherapy and wanted to leave the “smallest carbon footprint possible.” Initial recovery from her cesarean was done on the maternity unit where the oncology nurses provided support and education to the staff and family regarding extensive preparation. The obstetrics staff collaborated on the oncology unit when the patient started combined chemotherapy. Education regarding breastfeeding, donor breast milk, support of the family through emotional distress, infant separation, and fertility was provided. The complexity of caring for a patient with very strong holistic sense of self and devotion to protecting the environment led to discovery of nurse-led improvements.