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Effective contraception (preferably birth control pills) should be prescribed Weekly quantitative hCG level measurements are initially required Following successful surgical evacuation, moles show a progressive decline in hCG After two negative weekly tests (< 5 mU/mL), the interval may be increased to monthly for 6 months and then to every 2 months for a total of 1 year If levels plateau or begin to rise, the patient should be evaluated by repeat chest film and dilatation and curettage (D&C) before the initiation of chemotherapy
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For low-risk patients with a good prognosis, methotrexate, 04 mg/kg intramuscularly over a 5-day period, or dactinomycin, 10 12 mcg/kg/d intravenously over a 5-day period, is used (see Table 39 10) The side effects anorexia, nausea and vomiting, stomatitis, rash, diarrhea, and bone marrow depression usually are reversible in about 3 weeks and can be ameliorated by the administration of leucovorin (01 mg/kg) intramuscularly Repeated courses of methotrexate 2 weeks apart generally are required to destroy the trophoblast and maintain a zero chorionic gonadotropin titer, as indicated by -hCG determination Patients with a poor prognosis should be referred to a cancer center, where multiple-agent chemotherapy probably will be given
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Oral contraceptives (if acceptable) or another reliable birth control method should be prescribed to avoid the hazard and confusion of elevated hCG from a new pregnancy The hCG levels should be negative for 6 months to 1 year before pregnancy is again attempted In the pregnancy following a mole, the hCG level should be checked 6 weeks postpartum
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MEDICAL CONDITIONS COMPLICATING PREGNANCY 1 Anemia
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Plasma volume increases 50% during pregnancy, while red cell volume increases 25%, causing lower hemoglobin and hematocrit values, which are maximally changed around
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the 24th to 28th weeks Anemia in pregnancy is often defined as a hemoglobin measurement below 10 g/dL or hematocrit below 30% Anemia is very common in pregnancy, causing fatigue, anorexia, dyspnea, and edema Prevention through optimal nutrition and iron and folic acid supplementation is desirable
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CMDT 2008
A Iron Deficiency Anemia
Many women enter pregnancy with low iron stores resulting from heavy menstrual periods, previous pregnancies, breastfeeding, or poor nutrition It is difficult to meet the increased requirement for iron through diet, and anemia often develops unless iron supplements are given Red cells may not become hypochromic and microcytic until the hematocrit has fallen significantly When this occurs, a serum iron level below 40 mcg/dL and a transferrin saturation less than 10% are consistent with iron deficiency anemia (see 13) Treatment consists of a diet containing iron-rich foods and 60 mg of oral elemental iron (eg, 300 mg of ferrous sulfate) three times a day with meals Iron is best absorbed if taken with a source of vitamin C (raw fruits and vegetables, lightly cooked greens) All pregnant women should take daily iron supplements
cyte-poor washed red cells lower the level of hemoglobin S and elevate the level of hemoglobin A; this minimizes the severity of anemia and the risk of sickle cell crises Genetic counseling should be offered to patients with sickle cell disease or sickle trait They may wish to undergo first-trimester chorionic villus biopsy or second-trimester amniocentesis to determine whether the abnormality has been passed on to the fetus Intrauterine devices and oral contraceptives are relatively contraindicated, but progestin-only contraceptives may be used Women with sickle cell trait alone usually have an uncomplicated gestation except for an increased risk of urinary tract infection Sickle cell-hemoglobin C disease in pregnancy is similar to sickle cell anemia and is treated similarly
ACOG Committee ACOG Practice Bulletin Clinical Management Guidelines for Obstetrician-Gynecologists Number 64, July 2005 (Replaces Committee Opinion Number 238, July 2000): Hemoglobinopathies in pregnancy Obstet Gynecol 2005 Jul;106(1):203 10 [PMID: 15994657]
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