Part 1
(1)
-The problem is vesicular mole (molar pregnancy)
-Definition: It is a benign tumor during pregnancy in the trophoblastic
tissues
(2)
Management plane :
A- INVESTIGATIONS :
 Pregnancy test in urine ( positive in high dilutions )
 B- h C G in serum ( very high levels )
 U/S ( snow storm appearance in uterus / theca lutein cysts in ovaries )
 Chest x – ray ( canon ball appearance if metastasis occurs )
 Lab . investigations ( CBC. PT.PTT, ALT,…….)
B- Once vesicular mole is diagnosed, immediate evacuation is
mandatory.
Surgical suction evacuation is considered the method of choice in
all cases.
Methods of evacuation:
1-vaginal evacuation: by suction apparatus ,ovum forceps, ring
forceps or digital evacuation.
During vaginal evacuation : I.V Pitocin drip , blood transfusion( IF
NEEDED)
After evacuation : I.V or I.M ergometrie, curettage which is
immediatly or 1-2 weeks later.
Complication of vaginal evacuation: 1- incomplete evacuation
2- excessive bleeding
3- perforation
2-Medical evacuation: by
a) Pitocin drip: start by 10-20 units increased gradually up to 50
units + 500 glucose 5% or saline.
b) Prostaglandins: are more effective for ripening of cervix PGE2,
PGF2α.
Medical evactuation is usually completed by vaginal evacuation
and vaginal evacuation may be preceded by medical induction.
3- Abdominal hysterotomy:
Indications: 1- severe bleeding, the uterus is > 14 weeks and the
Os is closed.
2- Failed medical induction (the uterus > 14 weeks).
4-abdominal hysterectomy:
Indications: 1- Age of PT> 40 y (high risk of choriocarcinoma)
2- Women completing her family
(3)
Follow up:
weekly β-hCG untile –ve for 3 consecutive weeks then monthly
untile –ve for 6 monthes.
Methods of follow up:
1-History: irregular OR persistent vaginal bleeding.
2-Clinical examination : uterus and ovaries.
3- Special investigations: x-ray chest, liver function, U/S ,…..
Contraception during period of follow up is essential to exclude
positive pregnancy test due to pregnancy.
Methods of contraception:
1-if undetectable βhCG : combined oral pills.
2-if high βhCG : use local methods such as condom.
3- IUCD contraindicated due to risk of perforation
Part 2
(1)
Definition of obstructed labor :failure of delivery of the fetus due
to mechanical obstruction in the process of delivery of the fetus
through the passages.
Causes of obstructed labour:
(A) Fetal: 1- fetal macrosomia
2- Congenital anomalies: hydrocephalus.
3- mal presentation and malposition: shoulder, impacted
Frank breech, persistent occipito transverse.
(B) Maternal:
1- Contracted pelvis and tumour of pelvic bones
2- Pelvic tumours : such as cervical fibroid, pedunculated
low Subserous fibroid.
3-cervical dystocia.
4- constriction ring opposite the fetal neck.
5- tumours of the vagina.
6- vaginal stenosis.
(2)
Tyeps of eclampsia:
1-antepartum eclampsia: before onset of labour .
2-intrapartum eclampsia: during labour .
3-postpartum eclampsia: after labour .
Complication of eclampsia:
(A) Immediate: 1- maternal: - Haemorrhage: accidental, cerebral,
DIC.
-Failure: renal, heart, liver, suprarenal.
-aspiration pneumonia and maternal
hypoxia.
- Bone fracture
- Hyperpyrexia
2- Fetal:
- fetal hypoxia.
-intrauterine growth retardation.
-intrauterine fetal death.
-prematurity.
(B) Remote:
1- Residual hypertension
2- Recurrence of pregnancy induced hypertension in
future Pregnancies.
(3)
Definition of placenta previa: situation of the placenta partially or
completely in the lower uterine segment.
Types: -placenta previa lateralis:the lower margin of the placenta
reach the Lower segment but does not reach the in. os.
-placenta previa marginalis:the lower margin of the
placenta reach the In. os but does not cover it.
-placenta previa incomplete centralis:the lower margin of
the placenta Partially cover the in. os.
-placenta previa complete centralis: the lower margin of the
placenta Completely cover the in. os.
Clinical presentation:
(A)symptoms:
1- vaginal bleeding: - painless due to Braxton hicks contraction
and There is no retention of blood inside
uterus.
-causless: as the cause of separation is
Placenta physiologic Process as the lower
segment enlarged more than the upper
segment.
-recurrent: as the enlargement of the lower
segments Progressive.
2- Symptoms of anemia: sweating, easy fatigue, palpitation,
dyspnea.
(B) Signs:
1- General examination: with severe vag. Bleeding the patient
signs of Shock (rapid weak pulse, low blood pressure, subnormal
temp) .
Pallor will appear with recurrent bleeding with small amount
of blood or with severe attack
2- Abd. Examination: -fundal level equals amenorrhea period
- NO abdominal Tenderness or rigidity
-fetal heart sounds
- Abdomen is lax
- Fetal parts can be easy felt
3-Vag. Examination: not done except with presence of certain
precautions:
In the operating theatre, complete aseptic condition, blood
transfusion is ready and C.S equipment are ready.