Describe the anaesthetic Mx of early preg conditions

Molar preg

• what

• RFs

• Sx and Si

• Obs Mx

• Anaes Mx

• WHAT

  • A molar pregnancy (hydatidiform mole) is a rare, noncancerous tumor that develops in the uterus due to an abnormally fertilized egg. It occurs when placental tissue grows into a mass of cysts (grape-like clusters) rather than a healthy fetus, often resulting from genetic errors during fertilization.

  • Abnormal trophoblastic proliferation

• RFs

  • AMA or YMA

  • Previous molar preg

  • Poor nutrition

• Sx and Si

  • Similar to incomplete abortion

  • HMB

  • Abdo pain

  • Delayed period

  • Elevation of HCG ++

  • No foetal cardiac activity

  • Large uterus

  • Passage of vesicles

  • Early preg HTN

  • Hyperemesis

• Obs Mx

  • Prompt evac to avoid malignant disease, mets and comps like htn, anaemia, hyperthyroid

  • USS guided D+C or hysterectomy if completed family

  • Chemo if histology suggests invasive mole or or choriocarcinoma, or rise in bHCG 10% over 2/52, mets, bHCG 6/12 after evac

• Preop

  • Assess for specific comps - htn, anaemia, thyrotoxicosis, hyperemesis, cardiopul distress (can get PET before 20 weeks)

• Intraop

  • Risk of blood loss, 2 x PIVC, blood products, GA ETT, risk of hypotension on induction

  • May need oxytocin

Ectopic Preg

• what

• RFs

• Sx and Si

• Obs Mx

• Anaes Mx

• WHAT

  • Ectopic pregnancy implants outside the uterine cavity usually in the tubes – can lead to death, infertility (30%) and recurrent ectopic pregnancy (5-20%).

  • Incidence of ~16 per 1000 pregnancies

  • Rupture of ectopic = leading cause of 1st trimester deaths

• RFs

  • prior ectopic, prior tubal surgery, PID (especially chlamydia),

  • congenital anatomic distortion, previous pelvic or abdominal surgery, use of intra-uterine device

  • delayed ovulation, hormonal changes associated with ovulation induction or progesterone only OCP,

  • smoking, infertility and assisted reproductive procedures

• Sx and Si

  • Most are stable

  • Approx 15% of ectopics will present as an emerg due to falloian tube rupture and arterial bleeding

• Obs Mx

  • Expectant - if asymptomatic, early ectopic ½ will resolve

  • Medical - use of methotrexate to inhibit trophoblastic cells > 70% success but SEs

  • Surgical - depends on location, HD stability and surgeon. For tubal lap salpingostomy, salpingotomy or salpingectomy

  • If ruptured may need EMLAP

• Anaes Mx

  • In an unruptured tubal pregnancy

    • usually little bleeding, so low risk, can be under spinal, epidural or GA, most PTs prefer GA

• Ruptured ectopic

  • significant blood loss, ~50% >500mls, need large bore IVC, several units of PRBC available,

  • intra-op cell salvage may be useful, arterial line will be useful if haemodynamic instability, significant bleeding

  • temperature monitoring, warm line & bair hugger

Miscarriage

WHAT

• Miscarriage – refers to pregnancy loss before 20 weeks, can be threatened, incomplete, complete and missed

• 5% of pregnancy related deaths due to sepsis, haemorrhage – septic abortion = bad

• Incomplete - where some of the foetal tissue remains

Causes

• chromosomal abnormalities, immunological, infection, endocrine, uterine, incompetent cervix, trauma, environmental exposure

Obs Mx

• Expectant

• Medical

• Surgical - D+C

  • Comps - cervical lac, uterine perf, haemorrhage, RPOC, infection

Anaes Mx depends on

• Fasting

• cervic dilated

Preop

• assess volume status, gestation, bleeding, IV access and resus & analgesia given so far, assess fasting status and GORD and aspiration risk. Anxiolytic premed (e.g. midaz) often useful. Confirm group and hold

Intraop

• Typically GA and LMA

• < 16 weeks - low risk aspiration

• > 16 weeks and GORD, analgesia ++, NV, unfasted then RSI and ETT

• Lithotomy which may interfere with airway Mx

• Short duration with intense stimulus intitially

• Risk of PONV

• May need uterotonics

• Vigilant for bleeding

Postop

• Daycase

• IV opioids and antiemetics

TOP

• See card for miscarriage, similar to D+C

• Often performed electively < 20 weeks gestation