Vescicular mole.pptx

These topics comes under OBG for the first year PbBSc & 4th yr BSc nursing students. it helps the students to learn, understand each of the condition & will be able to provide nursing care accordingly.

1. VESICULAR MOLE/ HYDATIDIFORM MOLE

2. VESICULAR MOLE It is a benign neoplasm of the chorionic villi.

3. PATHOLOGY The uterus is distended by thin walled, translucent, grape-like vesicles of different sizes. These are degenerated chorionic villi filled with fluid. There is no vasculature in the chorionic villi leads to early death and absorption of the embryo.

4. There is trophoblastic proliferation, with mitotic activity affecting both syncytial and cytotrophoblastic layers. This causes excessive secretion of hCG, chorionic thyrotropin and progesterone. On the other hand, oestrogen production is low due to absence of the foetal supply of precursors. High hCG causes multiple theca lutein cysts in the ovaries in about 50% of cases. It also results in exaggeration of the normal early pregnancy symptoms and signs

5. TYPES :- COMPLETE PARTIAL Complete mole: The whole conceptus is transformed into a mass of vesicles. No embryo is present. It is the result of fertilisation of enucleated ovum (has no chromosomes) with a sperm which will duplicate giving rise to 46 chromosomes of paternal origin only.

6. Partial mole: A part of trophoblastic tissue only shows molar changes. There is a foetus or at least an amniotic sac. It is the result of fertilisation of an ovum by 2 sperms so the chromosomal number is 69 chromosomes.

7. SYMPTOMS Amenorrhoea: usually of short period (2-3 months). Exaggerated symptoms of pregnancy especially vomiting. Vaginal bleeding which is usually dark brown and may be associated with passage of vesicles. Abdominal pain: may be, dull-aching due to rapid distension of the uterus, colicky due to starting expulsion, sudden and severe due to perforating mole.

8. SIGNS General examination: Pre-eclampsia develops in 20% of cases, usually before 20 weeks’ gestation. Hyperthyroidism develops in 10% of cases manifested by enlarged thyroid gland, tachycardia and elevated plasma thyroxine level. Breast signs of pregnancy. Abdominal examination: The uterus is larger than the period of amenorrhoea in 50% of cases, corresponds to it in 25% and smaller in 25% with inactive or dead mole. The uterus is doughy in consistency Foetal parts and heart sound cannot be detected except in partial mole.

9. Local examination: Passage of vesicles (sure sign). Bilateral ovarian cysts (5-20 cm) in 50% of cases.

10. INVESTIGATIONS Positive urine pregnancy test Highly elevated serum hCG level Ultrasonography reveals: The characteristic intrauterine "snow storm" appearance, no identifiable foetus, bilateral ovarian cysts may be detected. X-ray: shows no foetal skeleton.

11. COMPLICATIONS Haemorrhage. Infection due to absence of the amniotic sac. Perforation of the uterus. Pregnancy induced hypertension Hyperthyroidism. Subsequent development of choriocarcinoma

12. TREATMENT Suction evacuation Hysterotomy Hysterectomy Medical induction

13. ECTOPIC PREGNANCY

14. ECTOPIC PREGNANCY The term ectopic pregnancy refers to any pregnancy occuring outside the uterine cavity.

15. The commonest site of extra uterine implantation is the uterine tube, usually in the ampullary region. Ectopic implantation may also occur on the ovary, abdominal cavity or in the cervical canal. Abdominal pregnancy may result from direct implantation of the conceptus or it may result from extrusion of a tubal pregnancy with secondary implantation in the peritoneal cavity.

16. Here to the conceptus produces hCG , which maintains the corpus luteum & the production of oestrogen & progesterone. This causes the uterus to enlarge & the endometrium to undergo decidual changes. Trophoblastic cells invade the wall of the tube & erode into blood vessels of the mesosalpinx.

17. This process will continue until the pregnancy ruptures into the abdominal cavity or the broad ligament, or the embryo dies, thus resulting in a tubal mole. Thus absorption or tubal miscarriage may occur. Expulsion of the embryo into the peritoneal cavity or partial miscarriage may also occur with continuing episodes of bleeding from the tube.

18. Vaginal bleeding occurs as a result of shedding of the decidual lining of the endometrium & progesterone levels fall with the failing pregnancy.

19. PREDISPOSING FACTORS Previous history of ectopic pregnancy Failed Sterilisation Pelvic inflammatory disease Subfertility Failed IUCD Previous tubal surgeries

20. CLINICAL PRESENTATION

21. ACUTE PRESENTATION The classical pattern of symptoms include AMENORRHEA, LOWER ABDOMINAL PAIN & VAGINAL BLEEDING. Typical sudden onset of abdominal pain starting on one side of the lower abdomen, but rapidly becomes generalized as blood loss extends into the peritoneal cavity.

22. Sub - diaphragmatic irritation by blood produces referred shoulder tip pain & discomfort on breathing. There may be episodes of syncope. Clinical examination reveals - hypotension, tachycardia, signs of peritonism including abdominal distension, guarding & rebound tenderness. On pelvic examination the cervix is closed & acutely tender when moved because of irritation of the pelvic peritoneum caused by the bleeding.

23. SUB ACUTE PRESENTATION Some or all of the classic symptoms like pain, bleeding & amenorrhea may be absent. It may be possible to feel a mass in one fornix on vaginal examination.

24. DIAGNOSIS Threatened or incomplete miscarriage Transvaginal ultrasound Laparoscopy

25. SURGICAL MANAGEMENT Laparotomy is indicated in the hemodynamically compromised patient & in obese patients or those with extensive pelvic adhesions or haemoperitoneum. Advantages: lower blood loss & reduced need for postoperative pain relief

26. Two main options for surgical removal of the ectopic:- Partial Salpingectomy ( removal of part of the tube) Salpingectomy ( leaving the tube in place & removing the ectopic through an incision in the wall of the tube).

27. MEDICAL MANAGEMENT Inj. METHOTREXATE 1 mg/Kg body weight or 50 mg/ M2. A single dose of this drug given IM , is an antimetabolite that interferes with the synthesis of DNA.

28. ABORTION / TERMINATION

29. INDUCED ABORTION / PREGNANCY TERMINATION

30. According to the Abortion Act of 1967 :- It requires that two doctors agree that continuation of the pregnancy would either involve greater the risk to the physical or mental health of the mother or her other children than termination, or that the fetus is at risk of an abnormality, likely to result it being seriously handicapped.

31. METHODS OF TERMINATION OF PREGNANCY All women should be screened for STDs or offered antibiotic prophylaxis. Administration of Anti- D immunoglobulin to all rhesus negative mothers.

32. SURGICAL TERMINATION OF PREGNANCY Dilatation & curettage in the first trimester Dilatation & evacuation in the 2nd trimester.

33. MEDICAL TERMINATION OF PREGNANCY For the first trimester use the regimes of:- Progesterone antagonist Mifepristone (RU 486) given orally followed 36-48 hrs later by prostaglandins administered vaginal pessary or orally.

34. Second trimester terminations can be performed using:- Vaginal prostaglandins given 3 hourly or as an extra amniotic infusion through a balloon catheter passed through the cervix.

35. COMPLICATIONS OF TERMINATION OF PREGNANCY Bleeding Uterine perforation Cervical laceration Retained products Sepsis