Jaffesuction Curettage For Gestational Trophoblastic Disease

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Summary of Procedures
Small Mole < 16
Large Mole > 16 Weeks' Size
Position

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Lithotomy ⇐

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Incision

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None ⇐

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Special instrumentation

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Suction evacuation kit ⇐

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Unique considerations Small Mole < 16 ⇐

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If mole > 12 wk size, laparotomy setup should be readily available. Oxytocin drip. In some cases, thyrotoxicosis may be present, requiring control with β-blockers.

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consideration Large Mole > 16 Weeks' Size

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± central hemodynamic monitoring with TEE or PA catheter; avoid overzealous use of crystalloids and blood transfusions. Preop ABG.

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Surgical time
EBL

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30–60 min ⇐
200–400 mL ⇐

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Postop care

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Outpatient small
ICU admission in selected cases large

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Respiratory
Pulmonary edema may complicate ?, which occurs in 25% of patients with GTD.

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preeclampsia

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If respiratory distress is present, it also may be 2° embolization of ?

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tumor to lungs.

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Avoid overhydration →

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pulmonary complications in patients with large moles.

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Tests:

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Consider preop ABG if pulmonary function impaired, and in patients at high risk of developing trophoblastic embolization. Others as indicated by H&P.

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Cardiovascular
Dehydration and/or ↓ blood volume may exist due to

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hyperemesis and vaginal bleeding.

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Adequate hydration should be given preop if patient shows Sx of

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hypovolemia (e.g., tachycardia, orthostatic ↓ BP, low UO).

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? also may complicate this disease and can be diagnosed by HTN, proteinuria, and edema.

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Preeclampsia

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If the patient has preeclampsia, invasive monitoring of

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BP may be advisable.

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Also, if patient is receiving Mg++ therapy, a serum level should be [check mark]'d preop.

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Mg++ therapy may inhibit myocardial contractility in high doses.

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? is the preferred antidote for myocardial depression. MgSO4 → uterine atony →↑blood loss.

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Ca++

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Neurological
Sz prophylaxis with Mg++ is indicated for women with severe ?.

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preeclampsia

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If Sz occurs a small dose of ?

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STP (50–100 mg) or midazolam (1–2 mg) should be given iv and respiration assisted with supplemental O2 by mask.

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The trachea should be intubated for airway protection in patients with

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full stomachs and in those who are difficult to ventilate by mask.

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Musculoskeletal [check mark]reflexes if patient has received

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Mg++.

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Reduce amount of ? to compensate for the effects of Mg++ on muscle strength.

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muscle relaxant

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Hematologic
Anemia may be masked by ?

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hypovolemia.

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Rh– patients with Rh+ partners should receive

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300 mcg of Rh immune globulin (RhoGAM) within 72 h postop to ↓ possibility of Rh isoimmunization in future pregnancies.

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Tests:

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CBC; [check mark]Plt in preeclamptics.

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If patient has received chemotherapy recently, [check mark]

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HCT; complete blood count (WBC, Plt).

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Endocrine
? occurs in 5% of women with hydatidiform moles and is 2° the thyroid-stimulating effects of HCG.

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Hyperthyroidism

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Tests: for endocrine

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Thyoid function tests should be [check mark]'d preop in women with Sx of hyperthyroidism, and managed before surgery.

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Laboratory

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Serum HCG level; consider thyroid function tests; LFTs; PT; PTT; Plt count; Mg++ level; UA—as indicated from H&P.

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Premedication

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Consider midazolam 1–2 mg iv. A nonparticulate antacid (Na citrate 30 mL 0.3 M) should be given po just before induction.

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Intraoperative
Anesthetic technique:

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Usually GETA, although may be carried out under spinal or epidural anesthesia.

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General anesthesia:
Induction
Maintenance

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A rapid-sequence induction (p. B-4) with cricoid pressure should be used.
Standard maintenance (p. B-2).

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Control BP, if preeclamptic, with

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labetalol, hydralazine, or SNP. Try to keep DBP at 90–100 mmHg.

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Emergence

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Extubate when fully awake and protective airway reflexes have returned. Consider PONV prophylaxis. Give supplemental O2.

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Regional anesthesia:
Spinal

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A T8 sensory level is desirable; bupivacaine (10–12 mg) may be used.

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Epidural

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Use 2% lidocaine ± epinephrine 1:200,000 (10–20 mL) or 0.25% bupivacaine (10–15 mL)

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Blood and fluid requirements Possible large blood loss
IV:
NS/LR at

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16–18 ga × 1
2–4 mL/kg/h

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? iv line should be placed and blood readily available.

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One large-volume

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The usual causes of bleeding are

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uterine perforation, cervical laceration, or uterine atony.

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Control of bleeding

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Oxytocin (30 U/L) infusion Oxytocin is begun about halfway through procedure at 30–60 drops/min (consult obstetrician).

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Epidural

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Use 2% lidocaine ± epinephrine 1:200,000 (10–20 mL) or 0.25% bupivacaine (10–15 mL)

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Blood and fluid requirements Possible large blood loss
IV:
NS/LR at

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16–18 ga × 1
2–4 mL/kg/h

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? iv line should be placed and blood readily available.

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One large-volume

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The usual causes of bleeding are

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uterine perforation, cervical laceration, or uterine atony.

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Control of bleeding

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Oxytocin (30 U/L) infusion Oxytocin is begun about halfway through procedure at 30–60 drops/min (consult obstetrician).

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Large oxytocin boluses may →

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↓BP.
↑% volatile anesthetic may → ↓uterine tone

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Try to keep anesthetic <

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1 MAC to prevent uterine relaxation.

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Ergonovine maleate 0.2 mg im may be given

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for severe bleeding.

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Ergonovine can cause HTN, it is contraindicated in

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cases of preeclampsia with elevated BP.

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Monitoring Standard monitors
±

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Arterial catheter
± CVP/PA catheter
Foley catheter

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An arterial catheter and CVP are indicated in cases of

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thyrotoxicosis, preeclampsia, or significant hemorrhage.

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The use of vasodilators, such as SNP, is also an indication for

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invasive monitors.

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Positioning

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[check mark] and pad pressure points
[check mark] eyes

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* NB: peroneal nerve compression at lateral fibular head →

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foot drop.

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Lifting the legs may cause the level of spinal or epidural anesthesia to move cranially if performed

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too quickly after the block.

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Complications

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Embolization of trophoblastic material
Embolization may occur, especially if > 16 wk gestation.
Significant respiratory and cardiac compromise may occur, requiring postop ventilation and PEEP, hemodynamic support, ICU.

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Postoperative
Complications
Pain management Oral analgesics Acetaminophen (325–650 mg po). Vicodin, or ketorolac (15–30 mg iv). Patients receiving Mg++ for preeclampsia may require less opiates for pain control. This may be 2° NMDA receptor antagonism.

P.767

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Bleeding Continue oxytocin infusion.
Significant hemorrhage should be evaluated by surgeons for possible perforation, laceration, or atony.
PONV: Consider PONV prophylaxis with odansetron 4 mg.
HTN BP should be monitored closely in preeclamptics.
↓ BP Consider trophoblastic embolization and manage aggressively.
Peroneal nerve injury (2° to lithotomy position)
Nerve injury manifested as foot drop and loss of sensation over dorsum of foot.