Rosen & Barkin's 5-Minute Emergency Medicine Consult (355 page)

• β-hCG
  
• Blood type, Rh, and cross-match
  
• CBC to assess for anemia and thrombocytopenia
  
• Coagulation profile to assess for disseminated intravascular coagulation
  
• Electrolytes with BUN and creatinine
  
• LFTs
  
• TSH and thyroxin (free T
  ₄
  ) if hyperthyroidism suspected
  
• Urinalysis to evaluate for protein if preeclampsia suspected
  

• US:
  
  • May be performed at bedside
    
• CXR:
  
  • Assess for pulmonary edema in acute respiratory distress
    
  • Check for metastatic disease
    
  • For baseline study
    

Pathology/histology:

• All conception products should be sent for formal evaluation
  
• Products may be the only way to diagnose a partial molar pregnancy
  
• Complete mole:
  
  • Edematous chorionic villi
    
  • Hyperplasia of trophoblasts
    
• Partial mole:
  
  • Fetal tissue and vessels
    
  • Amnion
    
  • Edematous chorionic villi
    

• Threatened abortion
  
• Missed abortion
  
• Incomplete abortion
  
• Ectopic pregnancy
  
• Hyperthyroidism
  
• Hyperemesis gravidarum
  
• Hypertension
  
• Preeclampsia
  

TREATMENT

• Ensure patent airway, provide oxygen
  
• IV access
  
• Treat convulsions appropriately with benzodiazepine
  
• Save passed tissue for histologic evaluation
  

• IV access
  
• Cardiac monitoring
  
• Type and cross-match for blood, especially if patient requires uterine extraction
  

• Acute respiratory distress:
  
  • Intubation and mechanical ventilation
    
  • CXR
    
• Hyperthyroidism:
  
  • β-adrenergic blockers:
    
    • Administer before molar evacuation
      
    • Stress of anesthesia or surgery may precipitate thyroid storm
      
• Preeclampsia/eclampsia:
  
  • Convulsions
    
    • Administer benzodiazepine (diazepam)
      
    • Administer magnesium sulfate
      
  • Hypertension:
    
    • Administer hydralazine or labetalol
      
• Coagulopathy:
  
  • Transfuse with blood products as needed
    
  • Human anti-D immunoglobulin (RhoGAM):
    
    • Although fetal blood not present in complete mole, may be delay in distinguishing partial vs. complete
      
• Suction curettage:
  
  • Done by obstetrician, possibly in ED
    
  • Curative in 80% of cases
    
  • Method of choice in women wishing to preserve fertility
    
  • Oxytocin infusion to induce myometrial tone, may require other uterotonic formulations
    
• Chemoprophylaxis:
  
  • Very controversial
    
  • Prescribed by obstetrician only for patients with follow-up
    
  • Usually used in high-risk complete mole or if hormonal monitoring is unavailable
    
• Hysterectomy:
  
  • Patients in older age group
    
  • Patients not interested in keeping fertility
    
  • High-risk disease
    
  • Does not prevent possible metastasis
    

• Diazepam: 0.2–0.4 mg/kg IV, or 0.3–0.5 mg PR, up to 5–10 mg, for max. 30 mg
  
• Hydralazine: 5–10 mg IV q20min, up to 60 mg.
  
• Labetalol: 20 mg IV with doubled dosing q10m for max. 300 mg
  
• Magnesium sulfate: 4–6 g IV over 15–20 min then maintain 1–2 g/h
  
• Oxytocin: Postpartum bleeding, 10 U IM
  
• Propranolol: 1 mg IV increments q2m
  
• RhoGAM: 300 μg within 72 hr
  

FOLLOW-UP

• Enlargement of uterus beyond 16 wk of gestation size:
  
  • The larger the uterus, the greater the risk for uterine perforation during suction curettage, hemorrhage, and pulmonary complications due to embolism
    
• Clinical evidence of preeclampsia hyperthyroidism, respiratory distress
  
• Hysterectomy
  
• Partial molar pregnancy
  
• Hemodynamic instability
  

• Uncomplicated dilation and curettage of low-risk and small-size mole in reliable patient
  
• Stress importance of follow-up
  
• Pelvic rest for 4–6 wk after uterine evacuation
  
• Recommend no pregnancies for 12 mo
  
• Future pregnancies should have early sonographic evaluation due to increased risk in future pregnancies
  

• Close follow-up and monitoring by OB-GYN
  
• Serial hCG levels:
  
  • Obtained weekly for at least 4 wk, then monthly intervals
    
  • Levels should consistently drop and never increase
    
  • If increase is noted, evaluation for metastatic disease should ensue
    
• Use contraception
  
• US:
  
  • Early in all future pregnancies
    
  • Increased risk for future molar pregnancies (1–1.5% with 2nd, 20% after 2 moles)
    

• Missed diagnosis in conjunction with:
  
  • Normal pregnancy
    
  • Preeclampsia, especially <24 wk gestation
    
  • Hyperemesis with normal pregnancy
    
• The importance of follow-up must be stressed:
  
  • If hCG is not followed, may lead to undiagnosed metastatic disease
    
  • 20% can develop malignancy
    

• Hydatidiform Mole. Emedicine. Available at
  http://emedicine.medscape.com/article/254657-overview
  
• Sebire NJ, Seckl MJ. Gestational trophoblastic disease: Current management of hydatidiform mole.
  BMJ
  . 2008;337:a2076.
  
• Soper JT, Mutch DG, Schink JC, et al. Diagnosis and treatment of gestational trophoblastic disease: ACOG Practice Bulletin No. 53.
  Gynecol Oncol
  . 2004;93:575–585.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Preeclampsia/Eclampsia
  
• Pregnancy
  

CODES

630 Hydatidiform mole

BASICS

• Main complication from hydrocarbon exposure is aspiration:
  
  • Hydrocarbon aspiration primarily affects central nervous and respiratory systems.
    
• Physical properties determine type and extent of toxicity:
  
  • Viscosity (resistance to flow):
    
    • Higher aspiration risk from products with lower viscosity
      
  • Volatility (ability of a substance to vaporize):
    
    • Hypoxia from aromatic hydrocarbons displacing alveolar air
      
  • Surface tension (ability to adhere to itself at liquid’s surface):
    
    • Low surface tension allows easy spread from oropharynx to trachea, promoting aspiration (e.g., mineral oil, seal oil).
      
• Volatile-substance abuse:
  
  • Common solvents abused:
    
    • Typewriter correction fluid
      
    • Adhesive
      
    • Gasoline
      
    • Cigarette-lighter fluid
      
  • Sniffing:
    Product inhaled directly from container
    
  • Huffing:
    Product inhaled through a soaked rag held to face
    
  • Bagging:
    Product poured into bag and multiple inhalations taken from bag
    
• Major classes of hydrocarbons:
  
  • Aliphatics:
    
    • Include kerosene, mineral oil, seal oil, gasoline, solvents, and paint thinners
      
    • Pulmonary toxicity via aspiration
      
    • Asphyxiation from gaseous methane and butane by displacement of alveolar oxygen
      
  • Halogenated hydrocarbons:
    
    • Include carbon tetrachloride and trichloroethane
      
    • Found in industrial settings as solvents
      
    • Well absorbed by lungs and gut
      
    • High toxicity
      
    • Liver and renal failure associated with ingestion
      
  • Cyclics or aromatic compounds include toluene and xylene:
    
    • Highly volatile and well absorbed from gut
      
    • Death from benzene reported with 15 mL ingestion
      
  • Terpenes or wood distillates include turpentine and pine oil:
    
    • Significant GI tract absorption
      
    • Significant CNS depression