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Ростовский Государственный Медицинский Университет
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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Fasting:<5.3mmol/L Post-meal:1houraftermeal<7.8mmol/Lor2hoursaftermeal<6.4mmol/L Ifoninsulinorglibenclamide:>4mmol/L.
Whentomonitor:
T1DM/T2DM/GDMonmultipledailyinsulinregimen:fasting,premeal,1-hourpostmeal,and bedtime T2DM/GDMondiet/exercise,oraltherapy,orsingle-doseinsulin:fastingand1-hourpostmeal.
Ketonemonitoring
Offer women with T1DM blood ketone testing strips and a meter—advise them to test for ketonaemiaandseekurgentmedicaladviceiftheybecomehyperglycaemicorunwell Test urgently for ketonaemia if a pregnant woman with any form of diabetes presents with hyperglycaemia,orisunwell,toexcludeDKA(seeChapter15) IfDKAissuspectedduringpregnancy,admittohighdependencycarewithmedicalandobstetric input.
Complications
General
Womenwithpre-existingdiabetesshouldtake75–150mgaspirindailyfrom12weekstobirthto reducetheriskofpre-eclampsia(seeChapter61) PerformUSSforfetalgrowthandamnioticfluidvolumeat28,32,and36weeks.
Retinopathy
Assessment:
Offeratbookingandagainat28weeks Ifthereisretinopathyatbooking,assessagainat16–20weeks.
Ifretinopathyisdiagnosedatanypoint,referforophthalmologicalfollow-up.
Nephropathy
Assessment:
Arrangeatbookingifnotdonewithintheprevious3months Refertonephrologyifcreatinine≥120μmol/L,urinaryACR>30mg/mmolortotalurinaryprotein >0.5g/day.
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Monitoringandfollow-up
Offer women with a diagnosis of GDM a review with the joint diabetes and antenatal clinicwithin1week.Patientsshouldbeseenevery1–2weeks.
Timingandmodeofdelivery
T1DM/T2DMwithnocomplications:electivebirthbyinductionoflabourorcaesareansection
between37+0and38+6weeks
T1DM/T2DMwithcomplications:considerdeliverybefore37+0weeks GDM:advisedeliverynolaterthan40+6weeks;offerelectivebirthifnotdeliveredbythen(if
complications,considerearlierelectivebirth) Explaintowomenwithamacrosomicfetusabouttherisksandbenefitsofvaginalbirth(e.g.↑risk ofshoulderdystocia),inductionoflabour,andcaesareansection Steroids can be used in preterm labour with careful glucose monitoring. As steroids can cause elevatedbloodglucoselevels,patientsrequiringsteroidswilloftenneedaVRIIfor24hours.
Intrapartummanagement
MonitorCBGhourlyduringlabourandhalf-hourlyifcaesareansectionundergeneralanaesthetic. Target=4–7mmol/L AllpatientswithT1DMandsomewithT2DM/GDMmayrequireaVRIIinestablishedlabour.Ifa VRIIisused,reducetherateby50%(orchangetolowestscale)oncetheplacentaisdelivered, andthenfollowtheinsulinplanmadeantenatally
Postpartummanagement
Pre-existingdiabetes
Women with insulin-treated pre-existing diabetes should reduce their insulin immediately after birthastheyareatriskofhypoglycaemia CarefulCBGmonitoring(4×daily)willbeneededtoestablishwhatthenewdosewillbe Contactthediabetesteamtoreviewongoinginsulinrequirement Womenshouldhaveamealorsnackbeforeorduringbreastfeedingtopreventhypoglycaemia WomenwithT2DMwhoarebreastfeedingcancontinuemetformin,glibenclamide,andinsulin,but therearelimiteddataonsafetyinbreastfeedingwithotherbloodglucose-loweringagents Remindthepatientoftheimportanceofcontraceptionandpreconceptioncarewhenplanningfuture pregnancies.
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Gestationaldiabetes
Discontinueallbloodglucose-loweringtherapyimmediatelyafterbirth Continue to monitor CBG pre and 1 hour post meal for up to 24 hours to capture pre-existing diabetes,new-onsetdiabetes,andtoavoidhypoglycaemia Ifbloodglucosehasreturnedtonormal,performafastingtestorHbA1c6–13weeksafterbirth.If postnataltestisnegative,offerannualHbA1ctesting ExplaintheriskofGDMinfuturepregnancies.TheriskofdevelopingT2DMisalsosignificantly increasedsoemphasizetheimportanceofpreventativemeasures,e.g.healthydiet,weightcontrol, andexercise.
Furtherreading
1. RCOG (2018). Care of women with obesity in pregnancy (GTG72). Available at:
https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg72/
2. RCOG (2012). Shoulder dystocia (GTG42). Available at: https://www.rcog.org.uk/en/guidelines-
research-services/guidelines/gtg42/
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Chapter60
Ectopicpregnancyandmiscarriage
Guideline:NICENG126(Ectopicpregnancyandmiscarriage:diagnosisand
initialmanagement):https://www.nice.org.uk/guidance/ng126
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Vaginal bleeding and/or abdominal pain are common presentations seen in early pregnancy.Around20%ofpregnanciesmiscarryinthefirsttrimesterandearlypregnancy lossaccountsfor>50,000admissionsannuallyintheUK.Ectopicpregnanciesoccurin11 per 1000 pregnancies, and their complications (e.g. rupture) can lead to significant morbidityandmortality.
Diagnosis
History
A miscarriage commonly presents with vaginal bleeding ± passage of tissue (after amenorrhoea)and/orabdominal/pelvicpain.AmiscarriagemayalsobeidentifiedonUSS whenanon-viablepregnancyisfoundincidentallywithnoprecedingsymptoms.
Ectopic pregnancy can also present with vaginal bleeding and/or abdominal/pelvic
pain,usuallybetween4–10weeksgestation.Otherreportedsymptomsmayinclude:
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Breasttenderness,missedperiod(andothersignsofearlypregnancy) Diarrhoea,tenesmus,rectalpressure,orpainwithdefecation Dizzinessorsyncope Shouldertippain(duetoperitonealirritation) Urinarysymptoms.
Riskfactorsforectopicpregnancy
Historyoftubaldamageorsurgery Pelvicinflammatorydisease Smoking Previousinfertility Invitrofertilization Intrauterinecontraceptivedeviceinsitu Endometriosis.
Athirdofectopicpregnanciesoccurintheabsenceofanyriskfactors.
Examination
Remember that any woman of reproductive age is pregnant until proven otherwise! A pregnancy test should always be performed if there is any doubt about the patient’s reproductivestatus.
Possible signs are listed in Table 60.1. However, signs may be limited to abdominal/pelvicpainand/orvaginalbleeding.Callforhelpearly.Rememberthatyoung women compensate well and may not show signs of cardiovascular compromise until theyhavelostsignificantamountsofblood.
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Table60.1Examinationfindingsinectopicpregnancyormiscarriage
C Tachycardia(heartrate>100bpm)
Hypotension(bloodpressure<100/60mmHgororthostatic) Shock/collapse
D Reducedconsciouslevel
E Pallor
Abdominaldistension* Enlargeduterus
Abdominal/pelvictenderness±
reboundtenderness/peritonitis
*
 Cervicalexcitation(painonpalpationofthecervix)* Adnexalmassortenderness
*
Signsinboldmay besuggestiveofamajorhaemorrhagesecondarytoarupturedectopicpregnancyor miscarriage.
*
indicatesspecificfindingssuggestiveofectopicpregnancy
Suspectedectopicpregnancy
If ectopic pregnancy is suspected following history and examination, the patient should be referredtoanearlypregnancyunit(EPU)/gynaecology If the patient is high risk for rupture (previous ectopic or pelvic infection) OR is haemodynamically unstable OR is in significant pain, they should be urgently referred to EPU/gynaecology, or directly to the emergency department as this is a gynaecological emergency Ectopicpregnanciescanruptureatanytimeandmaybelife-threatening,soitisadvisablethat patientswitha suspectedectopicpregnancywhoaredischargedfromhospital,shouldremain withanadultwhocouldcallanambulanceatalltimes.
Investigations
Bedside
Urinepregnancytest(UPT) Urinalysis:lookforblood,ruleoutothercausesofabdominalpainsuchasaUTI.
Bloods
SeeTable60.2.
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Table60.2Bloodsfortheinvestigationofectopicpregnancyandmiscarriage
Test Rationale
FBC Haemoglobinvaluetoquantifybloodloss
βHCG UsuallyperformedonlyafterUSStoguidemanagementinpregnanciesofunknownlocationorafter
diagnosistodirecttreatmentoptionswithmethotrexate
U&E Differentialdiagnosisofabdominalpain
Baselinecheckpriortoprescribingmethotrexateinectopicpregnancies
LFT Differentialdiagnosisofabdominalpain
Baselinecheckpriortoprescribingmethotrexateinectopicpregnancies
Group andsave
ToassessrhesusDstatusandcross-matchforbloodifrequired
Imaging
Ultrasound
IfUPTispositive,aUSSshouldbeperformedtoidentifythelocationandstatusofthepregnancy, andtoassessifafetalpoleand/orheartbeatispresent(Fig.60.1) Patientsshouldbemadeawarethatitisnotpossibletodiagnosemiscarriagewith100%certainty onaUSS,especiallyatearlygestations Transvaginal ultrasound is preferable, but transabdominal ultrasound may be necessary if the patienthaspelvicpathology,e.g.fibroids,orduetopatientpreference Patientsmayrequiretwoscans,aminimumof7daysapart,andcanbereassuredthatwaitingfora repeatscanwillnotimpacttheoutcomeoftheirpregnancy TheUSSmayshowthefollowingfindings:
Viableintrauterinepregnancy:pregnancyseenwithintheuterinecavitywithafetalheartbeat Missed or incomplete miscarriage: pregnancy tissue seen within the uterine cavity, but pregnancyisnotviableorhaspartiallymiscarried Ectopicpregnancy:pregnancyoramassseenoutsideoftheuterinecavity Complete miscarriage: no pregnancy tissue seen within uterine cavity. This can only be diagnosedifthepatienthashadapreviousscanshowinganintrauterinepregnancy,otherwise itshouldbelabelledasapregnancyofunknownlocation Pregnancyofunknownlocation:nointrauterineorextrauterinepregnancyseenontransvaginal USS(see‘Management’andFig.60.2) Heterotopicpregnancy:concurrentviableintrauterineandectopicpregnancies.
Afullpelvicscanshouldalwaysbedoneevenifthereisanobviousectopicpregnancytorule outaheterotopicpregnancyandtoreliablyexaminetheadnexae.
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Fig.60.1Ultrasoundinvestigationofviability.
Management
Acutemanagement
IVaccess andIV fluidsforresuscitation (seeChapter96)ifhaemodynamically unstable. Cross- matchthepatienturgentlyandactivatethemajorhaemorrhageprotocolifnecessary Makepatientnilbymouthifawaitingsurgery Giveanalgesiaandantiemeticsasrequired Providethepatientwithappropriateinformationinasensitivemanner(Box60.1).
Box60.1Providinginformation
Rememberthatpregnancylosscancausesignificantdistressandgrief.Womenandtheir partners should be given information in a sensitive manner. Information should be givenon:
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Treatmentoptions,includingtherisksandbenefits What to expect during the course of the miscarriage,e.g. potential length of bleeding, advice regardingpainrelief Whenand how to seek help if symptoms change or new symptoms develop • What to expect duringtherecoveryperiod,e.g.whenitispossibletotrytoconceiveagain Signpostingandsupportforbereavement.
Pregnancyofunknownlocation
Pregnancyof unknownlocation isdiagnosedwhenthe patienthasa positivepregnancy test but no intrauterine or extrauterine pregnancy can be seen on a transvaginal USS. Eventualoutcomesmayincludeahealthypregnancy(whichwasmissedor toosmallto be detected on scan), a miscarriage that has already occurred (the pregnancy test may remainpositiveforanother2–3weeks),oranectopicpregnancywhichistooearlytobe seenonscanorwasmissed.ManagementissummarizedinFig.60.2.
Fig.60.2InterpretationofserialβHCGlevelsinthemanagementofpregnancyofunknownlocation.
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Treatmentafterstabilization:miscarriage
Threatenedmiscarriage
Any vaginal bleeding in early pregnancy should be considered a threatened miscarriage if the patienthasaconfirmedviableintrauterinepregnancy If haemodynamicallystable andno previousmiscarriages,adviseconservativemanagementwith furtherassessmentifworseningsymptomsorifbleedingpersistsfor>14days If there is a confirmed viable intrauterine pregnancy with vaginal bleeding AND a history of miscarriage, offer vaginal micronized progesterone 400mg BD until 16 completed weeks gestation.
Confirmed(missedorincomplete)miscarriage
Expectantmanagement
‘Watchandwait’for7–14days Mostwomenwillnotrequirefurthertreatment Arepeatscanisneededat14daysifbleedingand/orpainhasnotstarted(suggestingtheprocess hasnotbegun)orifsymptomsarepersistent/worsening(possibleincompletemiscarriage) Ifbleedingstopswithin14days,advisethewomantorepeattheUPTafter3weeksandseekhelp ifitispositive Expectantmanagementisnotsuitableinthefollowingcases:
Evidenceofinfection ↑ risk of haemorrhage/complications from haemorrhage (late first trimester, history of coagulopathy) Previousadverseexperienceinpregnancy,e.g.haemorrhageorpregnancyloss Notacceptabletothewoman Chanceofamolarpregnancy.
Pharmacologicalmanagement
800microgramsvaginal/oralmisoprostol Thiscanbegivenasanoutpatient,orasaninpatientiftheriskofbleedingisconsideredtobehigh Painreliefandantiemeticsshouldbeprovidedasneeded Patientsshouldalsobegivenadviceonwhattoexpectthroughtheprocessincludingtheextentof the bleeding andside effects such as pain, diarrhoea,and vomiting. They should also be given clearinstructionsoncircumstancesinwhichtheyshouldcontactahealthcareprofessional.Patients shouldknowwhotocontactoutofhoursintheeventofheavybleedingorotherconcerns PatientsshouldrepeataUPTafter3weeksandseekfurtherreviewifthetestispositiveorthey haveworseningsymptoms.
Surgicalmanagement
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