Disorders Of Early Pregnancy Flashcards
Dose of mifepristone for TOP
200mg oral
Use mifepristone with caution in
Anemia, suspected adrenal failure, severe systemic disease, and avoid in breastfeeding
What is an invasive mole’s usual karyptype and clinical features
Androgenically diploid
Molar tissue invading the myometrium and may cause uterine rupture if not treated
Choriocarcinoma karyotype, clinical features
Maternal and paternal c’somes
Most follow live birth/stillbirth/miscarriage/ectopic but can arise from hydatiform mole. Frequently mets and highly curable with chemo.
Placental site trophoblastic tumor karyotype and clinical features
Contains maternal and paternal c’somes
Slow-growing malignancy invading the myometrium and potentially Mets to the lungs. hcg levels less elevated than in chorioca. Usually treated w surgery and chemo
Investigations for GTN
UPT, PET, serum B-hcg
Pelvic USS - snowstorm appearance, bilateral theca lutein cyst
Mets screen: liver USS, CXR, CT brain + abdo
Management for GTN
Surgery: D&C/hysterectomy + removing localized Mets
Follow up: serial b-hcg weekly toll negative, monthly for 6 months then bi-monthly for next 6 months
Contraception: cannot get pregnant for 12 months
Chemo: if persistent trophoblastic dx, elevated b-hcg after D&C, choriocarcinoma, Mets to other organs
- first line is methotrexate every 2 weeks till b-hcg normal
Eligibility for medical management of ectopic
Clinically stable with no peritonism Can return for follow up < 8 weeks gestation Gestational sac < 5cm bHCG < 5000 adnexal mass < 35 mm No visible heart sound Minimal free fluid
What is the medical management for ectopic
Methotrexate 1mg/kg IM
need to do FBC, RFT, LFT
Cannot have liver, renal, pulm disease, any hemato abnormalities, any sensitivity to methotrexate
Monitor patient’s bHCG at day 4 &7 (should decrease by 15% otherwise must give repeat dose) then weekly
Cannot get pregnant for 3 months
Surgical management for ectopic and indications
Significant pain
bHCG > 5000
Adnexal mass > 5cm
Free fluid
Visible fetal heartbeat
If severe hemodynamics instability, laparotomy otherwise laparoscopy
After procedure need to observe 1 day, then give contraception
Indications for and the expectant management of ectopic
Clinically stable Pain-free Can return for follow-up bHCH < 1000 repeat bHCG on day 2,4,7 then weekly till negative
Investigations for ectopic pregnancy
Bedside: UPT
Blood: FBC, serum bHCG, serum progesterone, blood group and hold, coagulation profile
TVS
How to differentiate between threatened and inevitable miscarriage?
Cervical os will be open if inevitable
Medical management for miscarriage
Misoprostol
- 400 micrograms sublingual/vaginal, every 3 hours (max 4 doses)
SE: bleeding, pain/cramps, fever/chills, vomiting and diarrhoea
CI: hemorrhagic disorder, IHD, MI, severe asthma
Monitor serial weekly serum bHCG until negative
Surgical management for miscarriage indication
Indication
- failed expectant/medical mx
- heavy bleeding/pain and prolonged symptoms
- intact gestational sac with no live embryo, haven’t expelled products in 2 weeks
Surgical management for miscarriage
<13 weeks: suction curettage
>13 weeks: D&E
Risks: bleeding, infection, failed evacuation, uterine perforation, Asherman’s
Follow up for miscarriage
Bleeding should cease within 10 days (14 for expectant) otherwise may have retained placenta
Perform Kleihauer on Rh- mothers, and give anti-D
Tests for miscarriage
Bedside: urine dipstick
Blood: FBC, U&E, serum bHCG, blood group and hold, viral serology, urine test
Ultrasound
Misoprostol use with caution in
Serious systemic disease like hepatic/renal impairment, severe asthma/COPD
What to do prior to Surgical management for TOP
Need to administer 400 micrograms of misoprostol vaginally 3 hours prior and prophylactic doxycycline
Surgical management for TOP
- D&C
- before 14 weeks
- complications: infection, cervical trauma, uterine perforation, hemorrhage, death, adhesions - D&E
- after 14 weeks
- more pain and bleeding compared to d&c
- similar complications at higher rates
Hyperemesis gravidarum description
severe and persistent vomiting onset in first trimester (esp between week 5 and 16) with biochemical changes:
- electrolyte abnormalities
- ketosis secondary to dehydration
- weight loss > 5% of TBW
What complication can occur as a result of huperemesis gravidarum
Wernicke’s encephalopathy
- ophthalmoplegia
- ataxia
- confusion
What to rule out if suspecting hyperemesis gravidarum?
Multiple pregnancy GTN - vaginal bleed, PET symptoms, thyrotoxicosis, abd pain, passage of grape-like vesicles Appendicitis Gastroenteritis UTI
Tests for hyperemesis gravidarum
Bedside: urine dipstick (ketones), urine MC&S
Blood: FBC, UEC (Na and Cl low, urea and creat high), LFT, bHCG, thiamine
Imaging: ultrasound
If hyperemesis gravidarum hydrated and tolerating orally
Avoid sensory stimuli that provoke nausea
Acupressure
Ginger tea or tablets
Prochlorperazine: 5-10mg orally up to 4 times a day
Metoclopramide: 10mg orally 8hrly, Max 5 days
When to admit hyperemesis gravidarum
Admit to hospital and start IV rehydration if
- dehydrated and or ketotic
- unable to tolerate orally
- unable to tolerate oral anti-emetic
IV rehydration for hyperemesis
- sodium chloride 0.9%, usually 2 or more liters over 2-3 hours before reassessing
- check electrolytes
- add potassium if needed
- multivitamine supplementation IV if needed including thiamine 100mg daily if persistent vomiting
- ongoing IV rehydration might be needed 2-3 times a week if cannot maintain orally and dehydrated
Other management for hyperemesis gravidarum with dehydration
Consider parenteral anti-emetics
- Metoclopramide 10mg IM 8 holy
Consider CS if symptoms still severe despite parenteral anti-emetics
- hydrocortisone 100mg BD till clinically improving
- then convert to prednisone 50mg for 3 days, 25 mg for 3 days, reduce dosage daily by 5mg till lowest dose sufficient
Complications of hyperemesis gravidarum
Maternal; - dehydration - malnutrition - convulsions - arrhythmias - mallory-weiss tears - anemia - iatrogenic Fetal - SGA - preterm labour
