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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Surgical management can be performed under local anaesthetic (manual vacuum aspiration) or generalanaesthetic Pregnancytissueshouldbeanalysedtoexcludemolarpregnancy.
Treatmentafterstabilization:ectopicpregnancy
Possibleectopic
Untilanectopicpregnancyormiscarriageisdiagnosed,thepatientshouldbetreatedasa pregnancyof unknownlocation. Thiswillrequirefollow-upinanEPU. Patientsshould beadvisedtoattendtheEPUatanytimeiftheyhavepainorworseningbleeding.
Confirmedectopic
ConfirmedectopicpregnanciesshouldbemanagedontheEPU.Patientsshouldbesafety nettedcarefullyand able to attend the EPU atanytimeifanycomplications develop. If notundergoingsurgicalmanagement, patientsshould live with an adult who could call forhelpifrequired,duetotheriskofrupture.
Expectantmanagement
Offerif:
Clinicallystableandpainfree InitialserumβHCG<1500IU/L Acceptabletothepatient Abletoreturnforfollow-up:
RepeatβHCGatdays2,4,and7 IfβHCGlevelsdecrease>15%betweentests,repeatweeklyuntilnegativeresult(<20IU/L), otherwisearrangeurgentseniorreview Bepreparedtoabandonexpectantmanagementiftherearesymptomsofpainorbleeding.
Medicalmanagement
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Should be offeredifexpectant managementcriteria fulfilled andnosignificantpain, and βHCG <1500IU/L Consider offering medical management if expectant management criteria fulfilled and no significantpain,andβHCG1500–5000IU/L
TreatmentisIMmethotrexateatadoseof50mg/m2.Estimatedbodyarea(m2) canbe calculated basedonthepatient’sheightandweight It must only be offered if there is a definitive diagnosis of ectopic pregnancy and a viable intrauterinepregnancyhasbeenexcluded Side effects include GI upset (flatulence and bloating), transient liver function abnormalities, stomatitis,andbonemarrowsuppression FollowupwithrepeatβHCGatdays4and7,withweeklylevelsuntilnegative.A15%decrease inβHCGshouldbeexpectedbyday7.Iflevelsplateauorrise,reassessclinically Patientswithfailedmedicalmanagementarelikelytorequiresurgicalmanagement.
Surgicalmanagement
Laparoscopicsalpingectomyorsalpingostomy Offer surgery as first line if significant pain, adnexal mass >35mm, fetal heartbeat present, or βHCG>5000IU/L FollowupwitharepeatUPTin3weeks Ifriskfactorsforinfertility(e.g.previousectopic,contralateraltubedamage,previoussurgeryor pelvic inflammatory disease), consider salpingostomy. One in five women will need further treatment (e.g.methotrexateand/or salpingectomy) and follow-up includes βHCGat day7, and weeklyuntilanegativeresultisobtained.
Anti-Dprophylaxis(250IUor50micrograms)shouldonlybegiventowomenwhoundergoa surgicalproceduretomanageanectopicpregnancyormiscarriage.
Furtherreading
1. RCOG (2016). Diagnosis and management of ectopic pregnancy (GTG21). Available at:
https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/
2.MiscarriageAssociationwebsite.Availableat:https://www.miscarriageassociation.org.uk/
3.TheEctopicPregnancyTrustwebsite.Availableat:https://ectopic.org.uk
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Chapter61
Hypertensioninpregnancy
Guideline: NICE NG133 (Hypertension in pregnancy: diagnosis and
management):https://www.nice.org.uk/guidance/ng133/
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
Hypertensioninpregnancyincludesthefollowingconditions:
Chronichypertensionwhichrequiresongoingmanagementwhilethepatientispregnant Gestationalhypertension Pre-eclampsia.
Carefulbloodpressure(BP)monitoringiscriticalforbothmaternalandfetalwell-being, and antihypertensive treatment (AHT) may be required. Severe pre-eclampsia and eclampsia are life-threatening, and patients may require critical care support. See Fig.
61.1.
Diagnosis
History/diagnosticcriteria
Hypertension in pregnancy is defined as systolic BP >140mmHg, or diastolic BP >90mmHg.
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Fig.61.1Hypertensivedisordersofpregnancy.
Ifthepatienthaschronichypertension,determinewhichAHTtheyareusingcurrently.
Historyinpre-eclampsiamayinclude:
Severeheadache Visualdisturbances(e.g.blurring,flashinglights) Severeupperabdominalpain(rightupperquadrantand/orepigastricpain) Nauseaandvomiting Suddenswellingoftheface,hands,andfeet Feelinggenerallyunwell.
Riskfactorsforgestationalhypertensionandpre-eclampsiaarelistedinBox61.1.
Box61.1Riskfactorsforgestationalhypertensionandpre-eclampsia
Nulliparity Age>40years Pregnancyinterval>10years Multiplepregnancy Familyhistorypre-eclampsia
BMI>35kg/m
2
Renaldisease Vasculardisease Historyofpre-eclampsiaorgestationalhypertension.
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Pre-eclampsiaprophylaxis
Patientswithanyof the following risk factors should take 75–150mg ofaspirin daily from 12 weekstobirthaspre-eclampsiaprophylaxis:
Autoimmunedisease,e.g.systemiclupuserythematosusorantiphospholipidsyndrome Chronichypertension CKD Historyofhypertensioninapreviouspregnancy
T1DMorT2DM Patientswithtwo ormore ofthe following riskfactors should take75–150mg of aspirindaily from12weekstobirthaspre-eclampsiaprophylaxis:
Age>40years
BMI≥35kg/m2atfirstcontact
Familyhistoryofpre-eclampsia
Firstpregnancy
Multiplepregnancy
Pregnancyinterval>10years.
Examination
PossibleexaminationfindingsinthehypertensivepregnantpatientarelistedinTable61.1.
Table61.1Examinationfindingsinahypertensivepregnantpatient
B Tachypnoea:possiblepulmonaryoedema
Hypoxia:possiblepulmonaryoedema
C Hypertension:systolicBP>160mmHgparticularlyconcerning
Tachycardia:possiblepulmonaryoedema Oliguria:possiblerenalinsufficiency
E Rightupperquadrantorepigastrictenderness
Swollenface,hands,orfeet Clonus,hyperreflexia,orothersignsofimpendingeclampsia Seizures(eclampsia) Visualscotomata Signsoffetalcompromise
Investigations
Bedside
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Urinalysis:screenforproteinuria.Donotusefirstmorningvoid:
Ifpositive(>1+),sendACRorprotein:creatinineratio(PCR)
Significantproteinuria=ACR≥8mg/mmolORPCR≥30mg/mmol.
Bloods
FBC:
Thrombocytopenia—aconcerningsigninpre-eclampsia
Haemolysis
LFT:
↑transaminases(ALTorAST>40IU/L)—aconcerningsigninpre-eclampsia
U&E:
↑creatinine(>90μmol/L)—aconcerningsigninpre-eclampsia
Notebaselinecreatinineislowerduringpregnancy
Coagulationprofile:
PossibleDIC
Imaging
Ultrasound:mayfindfetalgrowthrestriction,abnormalumbilicalarteryflow,orstillbirth.
Other
CTG:assessfetalwell-being Placentalgrowthfactortesting:usedwhenpre-eclampsiaissuspectedinwomenbetween20–
35weekswithchronicorgestationalhypertension.Abnormallylowplasma/serumlevelssuggest placentaldysfunctionandmayindicatethedevelopmentofpre-eclampsia.
Management
Acutemanagement
AntenatalantihypertensivetreatmentoptionsarelistedinFig.61.2.
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Fig.61.2AntenatalAHTchoices.
Managementofchronichypertension
Table61.2summarizesthemanagementofchronichypertensioninpregnancy.
Table61.2Managementofchronichypertensionduringpregnancy
Lifestyle advice
Weightmanagement,exercise,healthyeatingincludingsaltreduction
AHT Newdiagnosis:
StartAHTasperFig.61.2
IfalreadyusingAHT:
Ifmedicationsaresafeinpregnancy,continueunlesssys tolicBP<110mmHgordiastolicBP<70mmHg ACEinhibitorsandangiotensin IIreceptorblockers(ARBs) are ass ociated with ↑risk of congenitalabnormalities,therefore s top immediatelyandseekasafealternative.Thiazidesandthiazide-likediureticsmayalsoincreas etheriskofcongenitalabnormalities
Aspirin Giveaspirin75–150mgdailyfrom12weeksuntilbirth
BPtarget ≤135/85mmHg
BP measurement
Reviewevery2–4weeksifBPisbelowtarget.Ifpoorcontrol,reviewweekly
Fetal assessment
Arrangeultrasoundgrowthscansat28,32,and36weeks
PerformaCTGonlyifclinicallyindicated
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Managementofgestationalhypertension
Table61.3summarizesthemanagementofgestationalhypertension.
Table61.3Managementofgestationalhypertension
Gestationalhypertension BP140/90mmHg-159/109mmHg
Severegestationalhypertension BP>160/110mmHg
Admission No Yes
AHT AsperFig.61.2
TargetBP ≤135/85mmHg
BP measurement
1–2times/weekuntilBPbelowtarget Every15–30minutesuntilBP<160/110mmHg
Urinalysis WithBPmeasurements Dailywhileadmitted
Bloods FBC,U&E,andLFTatpresentation,thenweekly
Fetal assessment
Auscultatefetalheartateveryappointment
Ultrasoundassessmentatdiagnosis.Ifnormal, repeatevery2–4weeksasclinicallyindicated
Ultrasoundassessmentatdiagnosis.Ifnormal, repeatevery2weeksifseverehypertension persists
CTGonlyifclinicallyindicated CTGatdiagnosis.Ifnormal,onlyrepeatif
clinicallyindicated
Managementofpre-eclampsia
Table61.4summarizesthemanagementofpre-eclampsia.
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Table61.4Managementofpre-eclampsia
Pre-eclampsia BP140/90mmHg-159/109mmHg
Severepre-eclampsia BP>160/110mmHg
Admission Yes,ifclinicalconcernsorhighrisk Yes
AHT AsperFig.61.2
TargetBP ≤135/85mmHg
BP measurement
Atleastevery48hours,moreoftenif admitted
Every15–30minutesuntilBP<160/110mmHg,thenat least4times/day
Urinalysis Repeatonlyifclinicallyindicated(e.g.newsymptoms,uncertaindiagnosis)
Bloods FBC,U&E,andLFTtwiceaweek FBC,U&E,andLFTthreetimesaweek
Fetal assessment
Auscultatefetalheartateveryappointment
Ultrasoundassessmentatdiagnosis.Ifnormal,repeatevery2weeks
CTGatdiagnosisandifnormal,onlyrepeatifclinicallyindicated
Managementofseverepre-eclampsia
Getseniorhelp ConsiderlabetalolPO/IV,nifedipinePO,orhydralazineIV Considergivingmagnesiumsulphateasprophylaxistoallpatientswithseverepre-eclampsiaafter discussionwithaseniorclinician Givealoadingdose4gIVover5–15minutes,followedbyaninfusionof1g/hourmaintainedfor 24hoursafterdelivery Patientswhohavehadseizuresshouldalsobegivenaloadingdoseandmaintenancedosetotreat theseizureandpreventfurtherseizures Recurrentfitscanbetreatedwithanadditionaldoseof2–4gIVover5–15minutes.
Bloodpressuremeasurementandmanagementinlabour
Allwomeninlabourshouldhavetheirbloodpressuremeasuredhourly In severe hypertension, blood pressure should be checked every 15–30 minutes until <160/110mmHg ContinueusualAHTduringlabour.
Treatmentafterstabilization
Patienteducation
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Informthepatientthattheirriskisapproximately1in5ofahypertensivedisorderoccurringina futurepregnancy Informthepatientofan↑riskofhypertensionandcardiovasculardiseaseinlaterlife.
Timingofbirth
Modeandtiming ofdeliveryshould be decidedby a senior obstetrician—consider whetherthe neonatalteamshouldbepresent Ifanearlybirthisplanned,considerwhethertogiveantenatalsteroidsandmagnesiumsulphate.
Postnatalmanagementandmonitoring
The use of antihypertensive medications postnatally is summarized in Fig. 61.3. Table
61.5summarizesthepostnatalmanagementofhypertensivedisordersofpregnancy.
Fig.61.3PostnatalAHTchoices.
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