TEALE FENNING

bronwyn

"A woman presents to your antenatal clinic at 16 weeks gestation in her fourth pregnacy. She has recently undergone an endometrial resection and was advised not to conceive. How would you advise her?"
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Bronwyn Bell
SpR
Portsmouth

Nick Raine-Fenning · Posted: Fri Jul 21, 2006 7:28 am Post subject:

I'm operating this morning so I'll think about this.

It's another nice question but I doubt it wil come up.

Strangely enough my colleague was the first to report this when it happened to him in Oxford!

Bubbles already starting to form in my head ......... Wink

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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Nick Raine-Fenning · Posted: Sat Jul 22, 2006 10:10 am Post subject:

General Points

What category is this?

High risk obstetrics

What approach is required?

Advice = Counselling = Management

The 'advice' part means you need to be a bit more detailed with the counselling part Wink

What do we know?

Had endometrial resection
Presumably her family was complete
She is pregnant and 16 weeks (the 16 weeks may mean you need to disucss screening as she has presumably missed her NT scan and will need afp/hCH or an amnio as presumably she is >35 years)

What don't we know?

Her age
Her Past Obstetric History (complications, mode of delivery: she has had 3)
Her general medical history (any risk factors, medical disorders)
Her feelings towards this pregnancy
She was told not to conceive so presumably she was made aware TCRE is not a contraceptive but was this documented and contracpetion discussed as there may be medico-legal issues if not?
Is she 16 weeks by dates / scan?
Is she considering TOP?
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"Teale Fenning Medical Education" delivering evidence-based, exam-orientated learning since 1997

Xerxes I · Posted: Sat Apr 05, 2008 7:17 am Post subject:

Just a few random points about this,

data on pregnancy after TCRE comes from case reports so the evidene is weak and in some cases thoretical.

Risks to the mum:
- higher risk of morbidly adherent placena
- Higher risk of placenta praevia
- Risk of uterine rupture unknown but may theoretically be higher depending on depth of resection or an unrecognised intraoperative perforation.
-If higher age group, all of age risks associated with that
- Psychological effects of carrying a presumably unwanted pregnancy
-Unknown if higher risk of PET but likely if poor placentation

Risks to baby,
- Growth restriction
- being the unwanted child!
- limited data on other risks

management
- be nice, don't blame, "Sh** happens" approach
- is a high risk pregnancy
- discuss screening, depends on age, amniocentesis may be justified.
- accordin to the new College guideline, color doppler or MRI have a value in detecting accreta
- Of course look for praevia
- UAD no evidence but makes sense or does it?
- If considering TOP, manage accordingly
- Elective Caesarean may be justified in selected cases especially where we know perf as risk unknown. decided by senior person on case to case basis
- there might be stronger case for Elective delivery if there is suspic of morbidly adherent placenta. appropriate people to be around, blood, ready to take the damn thing out.
reliable contraception postpartum, if CS, TL may be justified if she wants.
wait for periods to return, if still heavy consider Mirena, hysterectomy, etc. Ablaion not advised, in some cases like novasure contraindicated post TCRE.
If she wants a hysterectomy, should not be done at time of CS as an elective procedure Laughing

(u never know what sort of nonsense can get a point!)
Make sure no child protection issues (get her to kiss the baby in front of you and judge if she loves the baby enough! Laughing

)

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

Xerxes I · Posted: Sun Jun 08, 2008 7:04 am Post subject:

Does Aspirin not work by preventing micro clots, hence better mivrocirculation? Don't know, always assumed this to be the case Confused

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

Nick Raine-Fenning · Posted: Sun Jun 08, 2008 8:05 am Post subject:

Serial growth scans 4 -weekly - absolutely. Add UA Doppler velocimetry if there are abnormailites in growth or liquor volume but it does not have a role in their absence.

Aspirin, aspirin, aspirin ... the wonder drug. There is little if any evidence for the use of aspirin in any obstetric condition other than DVT prophylaxis where it works well and has a good evidence base. Even the latest work challenges its role in APAS where heparin is essential. Pre-eclampsia - very debatable as well and almsot everyone misquotes the CLASP Study - just ask Phil Baker! The analysis in high risk women was a retrospective one so we are none the wiser. Good evidence - NO. Some evidence - YES. Safety - probable but again have a read of CLASP (and not just the abstract) and come back to me - there is a challenge to you all!!

Would I give aspirin to this lady - no. There is no pathophysiological process here that aspirin, even if it worked, could address. The problem is one of placentation onto abnormal endometrium. It is incredibly high risk and unlikely to be without complication.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 918

thanks nick,
that answers it for me.
r
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Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SpR O&G Wessex Region