GESTATIONAL

• Hyperemesis Gravidarum


  Nausea and vomiting of pregnancy that is prolonged past week 12 of pregnancy or is so severe that dehydration, ketonuria, and significant weight loss occur within the first 12 weeks of pregnancy
• Hyperemesis Gravidarum


  • Etiology is unknown
  • Rising level of estrogen, progesterone, HCG, thyroxine and thyroid stimulating hormone (TSH)
  • Helicobacter pylori
• Management of Hyperemesis Gravidarum

  1. Hospitalization for about 24 hours

  2. All oral food and fluids are usually withheld

  3. Intravenous fluid (3000 mL of Ringer's lactate with added vitamin B, for example) may be administered

  4. An antiemetic, such as metoclopramide (Reglan), may be prescribed to control vomiting

  5. Carefully measure intake and output, including the amount of vomitus

  6. If there is no vomiting after the first 24 hours of oral restriction, small amounts of clear fluid may be begun and the woman may be discharged home

  7. If she can continue to take clear fluid, small quantities of dry toast, crackers, or cereal may be added every 2 or 3 hours, then she can be gradually advanced to a soft diet, then to a normal diet

  8. If vomiting returns at any point, enteral or total parenteral nutrition may be prescribed
• Ectopic Pregnancy


  Pregnancy in which implantation occurs outside the uterine cavity
• Ectopic pregnancy is the second most leading cause of bleeding early in pregnancy
• Ectopic Pregnancy


  • The most common site is on the ampulla of the fallopian tube
  • It starts as a normal pregnancy, with fertilization occurring in the distal third of the fallopian tube. Because of an obstruction, however, the zygote cannot travel the length of the tube for proper implantation in the uterus
  • Will result to termination of pregnancy
  • 2% of pregnancies are ectopic
• Sites for Ectopic Pregnancy

  • Ampullar portion (80%)
  • Isthmus (12%, very painful)
  • Interstitial or fimbrial (8%)
• Risk Factors for Ectopic Pregnancy

  • Pelvic Inflammatory Disease
  • In vitro fertilization
  • Smoking
  • Previous history of ectopic pregnancy
  • Current use of intrauterine device (IUD)
  • Congenital anomalies that block a fallopian tube
• Medical/Surgical Management of Ectopic Pregnancy

  1. Unruptured tube: IM/oral methotrexate, Mifepristone

  2. Ruptured tube: Initiate intravenous fluid, Laparoscopy (Ligation of bleeding vessels and removal or repair of damaged fallopian tube, Laparoscopic linear sapingostomy, Laparoscopic salpingectomy, Saphingectomy, Hysterectomy)
• Gestational Trophoblastic Disease (Hydatidiform Mole)


  Abnormal proliferation and then degeneration of trophoblastic villi. As the cells degenerate, they become filled with fluid and appear as clear fluid-filled, grape-sized vesicles.

  
• Incidence of Hydatidiform Mole is 1/1500 pregnancies

  
• Risk Factors for Hydatidiform Mole

  • Women with low protein intake
  • Women who got pregnant older than 35 years old
  • Women of Asian heritage
  • Blood group A women who marry blood group O men (no studies are established; based on profiling)
  • Previous molar pregnancy
• Types of Hydatidiform Mole

  • Complete Mole
  • Partial Mole
• Complete Mole


  • ALL trophoblastic villi swell and become cystic
  • If (+) embryo, it dies early at 1-2 mm in size, will not progress to pregnancy
  • On chromosomal analysis, although the karyotype is normal 46XX or 46XY, this chromosome component was contributed only by the father or an "empty ovum" there is division of cells; the only divided was the sperm; the sperm met an empty ovum = no fertilization
  • There is an increased HCG levels, (+) choriocarcinoma

  
• Partial Mole


  • Some of the villi form normally there is a union of a viable ovum and sperm however it forms 69 chromosomes (triploid formation)
  • (+) macerated embryo (9 weeks AOG) there is a fetus formed
  • Fetal blood in villi
  • (-) choriocarcinoma not too dangerous
  • Decreased HCG

  
• Medical Management of Hydatidiform Mole

  1. Immediate evacuation of mole with aspiration/suction D&C

  2. Follow-up of hCG levels for at least 6 months to detect trophoblastic neoplasia. After hCG levels fall to normal for 6 months, pregnancy can be considered.

  3. Avoid another pregnancy for 6 to 12 months.

  
• Premature Cervical Dilatation (Incompetent Cervix)


  A mechanical defect in the cervix that results in painless cervical dilation in the second trimester that can progress to ballooning of the membranes into the vagina and delivery of a premature fetus.
• Possible causes of Incompetent Cervix

  • Increase maternal age
  • Abnormal cervical development from genetics or diethylstilbestrol (DES) exposure
  • Congenital structural defects
  • Trauma to the cervix- such as D&C (dilatation and curettage)

  
• Risks to the Woman and Fetus with Incompetent Cervix


  • Woman: Repeated second trimester or early third trimester birth, Recurrent pregnancy losses (e.g., spontaneous abortions), Preterm delivery, Rupture of membranes/infection

  Fetus: Preterm birth and consequences of prematurity

  
• Medical Management of Incompetent Cervix

  Cervical cerclage is a type of purse string suture placed cervically to reinforce a weak cervix. Prophylactic cerclage may be placed in women with a history of unexplained recurrent painless dilation and second trimester birth, generally between 12 and 16 weeks of gestation. Rescue cerclage is placed after the cervix has dilated with no perceived contractions, up to about 24 weeks of gestation.