When babies are born to mothers who are hepatitis B surface antigen positive or are at high risk of developing hepatitis B, they should receive the first dose of the hepatitis B vaccine shortly after birth. Additionally, babies born to surface antigen positive mothers should receive 0.5 millilitres of hepatitis B immunoglobulin within 12 hours of birth. The second and third doses of the hepatitis B vaccine should be given at 1-2 months and 6 months, respectively.

Hepatitis B and Pregnancy: Screening and Prevention

During pregnancy, all women are offered screening for hepatitis B. If a mother is found to be chronically infected with hepatitis B or has had acute hepatitis B during pregnancy, it is important that her baby receives a complete course of vaccination and hepatitis B immunoglobulin. Currently, studies are being conducted to evaluate the effectiveness of oral antiviral treatment, such as Lamivudine, in the latter part of pregnancy.

There is little evidence to suggest that a caesarean section reduces the risk of vertical transmission of hepatitis B. However, it is important to note that hepatitis B cannot be transmitted through breastfeeding, unlike HIV. It is crucial for pregnant women to undergo screening for hepatitis B to ensure the health and safety of both the mother and the baby. With proper prevention and treatment, the risk of transmission can be greatly reduced.

Pregnant women who are obese (with a BMI greater than 30 kg/m²) should be prescribed a high dose of 5mg folic acid. It is recommended that all pregnant women take 400 IU of vitamin D daily throughout their pregnancy. Additionally, folic acid should be taken daily for the first 12 weeks of pregnancy, with the dosage depending on the presence of risk factors for neural tube defects such as spina bifida. If there are no risk factors, the dose is 400 micrograms daily, but if risk factors are present, the dose should be increased to 5 mg daily. As maternal obesity is a risk factor for neural tube defects, pregnant women with a BMI greater than 30 kg/m² should take the higher dose of folic acid.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

Conduct a blood test to measure the levels of beta-human chorionic gonadotropin (hCG) in the serum, and then repeat the test after 120 hours.

Bleeding in the First Trimester: Understanding the Causes and Management

Bleeding in the first trimester of pregnancy is a common concern for many women. It can be caused by various factors, including miscarriage, ectopic pregnancy, implantation bleeding, cervical ectropion, vaginitis, trauma, and polyps. However, the most important cause to rule out is ectopic pregnancy, as it can be life-threatening if left untreated.

To manage early bleeding, the National Institute for Health and Care Excellence (NICE) released guidelines in 2019. If a woman has a positive pregnancy test and experiences pain, abdominal tenderness, pelvic tenderness, or cervical motion tenderness, she should be referred immediately to an early pregnancy assessment service. If the pregnancy is over six weeks gestation or of uncertain gestation and the woman has bleeding, she should also be referred to an early pregnancy assessment service.

A transvaginal ultrasound scan is the most important investigation to identify the location of the pregnancy and whether there is a fetal pole and heartbeat. If the pregnancy is less than six weeks gestation and the woman has bleeding but no pain or risk factors for ectopic pregnancy, she can be managed expectantly. However, she should be advised to return if bleeding continues or pain develops and to repeat a urine pregnancy test after 7-10 days and to return if it is positive. A negative pregnancy test means that the pregnancy has miscarried.

In summary, bleeding in the first trimester of pregnancy can be caused by various factors, but ectopic pregnancy is the most important cause to rule out. Early referral to an early pregnancy assessment service and a transvaginal ultrasound scan are crucial in identifying the location of the pregnancy and ensuring appropriate management. Women should also be advised to seek medical attention if they experience any worrying symptoms or if bleeding or pain persists.

Due to the increased risk of stillbirth associated with intrahepatic cholestasis of pregnancy, induction of labour is typically recommended at 37-38 weeks gestation. Therefore, a normal labour is not appropriate for this patient. Ursodeoxycholic acid is used to treat the intense pruritus associated with this condition. While a caesarean section may be necessary on an emergency basis, it is not necessarily indicated at 37-38 weeks. Similarly, a caesarean section at 40 weeks is not currently warranted, as complications or emergencies may arise later in pregnancy. Induction of labour at 40 weeks is also not recommended, as it is later than the suggested timeline for minimising the risk of stillbirth.

Intrahepatic Cholestasis of Pregnancy: Symptoms and Management

Intrahepatic cholestasis of pregnancy, also known as obstetric cholestasis, is a condition that affects approximately 1% of pregnancies in the UK. It is characterized by intense itching, particularly on the palms, soles, and abdomen, and may also result in clinically detectable jaundice in around 20% of patients. Raised bilirubin levels are seen in over 90% of cases.

The management of intrahepatic cholestasis of pregnancy typically involves induction of labor at 37-38 weeks, although this practice may not be evidence-based. Ursodeoxycholic acid is also widely used, although the evidence base for its effectiveness is not clear. Additionally, vitamin K supplementation may be recommended.

It is important to note that the recurrence rate of intrahepatic cholestasis of pregnancy in subsequent pregnancies is high, ranging from 45-90%. Therefore, close monitoring and management are necessary for women who have experienced this condition in the past.

Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.

The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.

In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.

According to the guidelines of the Royal College, women who experience a fever of over 38 degrees Celsius during labor should be administered benzylpenicillin as a prophylactic measure against GBS.

Group B Streptococcus (GBS) is a common cause of severe infection in newborns. It is estimated that 20-40% of mothers carry GBS in their bowel flora, which can be passed on to their infants during labor and lead to serious infections. Prematurity, prolonged rupture of membranes, previous sibling GBS infection, and maternal pyrexia are all risk factors for GBS infection. The Royal College of Obstetricians and Gynaecologists (RCOG) has published guidelines on GBS management, which include not offering universal screening for GBS to all women and not offering screening based on maternal request. Women who have had GBS detected in a previous pregnancy should be offered intrapartum antibiotic prophylaxis (IAP) or testing in late pregnancy and antibiotics if still positive. IAP should also be offered to women with a previous baby with GBS disease, women in preterm labor, and women with a fever during labor. Benzylpenicillin is the preferred antibiotic for GBS prophylaxis.

Placental Abruption: Causes, Symptoms, and Risk Factors

Placental abruption is a condition that occurs when the placenta separates from the uterine wall, leading to maternal bleeding into the space between them. Although the exact cause of this condition is unknown, certain factors have been associated with it, including proteinuric hypertension, cocaine use, multiparity, maternal trauma, and increasing maternal age. Placental abruption is not a common occurrence, affecting approximately 1 in 200 pregnancies.

The clinical features of placental abruption include shock that is disproportionate to the visible blood loss, constant pain, a tender and tense uterus, and a normal lie and presentation of the fetus. The fetal heart may be absent or distressed, and there may be coagulation problems. It is important to be aware of other conditions that may present with similar symptoms, such as pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.

In summary, placental abruption is a serious condition that can have significant consequences for both the mother and the fetus. Understanding the risk factors and symptoms of this condition is important for early detection and appropriate management.

Cervical screening is typically postponed during pregnancy until…

Cervical Cancer Screening in the UK

Cervical cancer screening is a well-established program in the UK that aims to detect pre-malignant changes in the cervix. This program is estimated to prevent 1,000-4,000 deaths per year. However, it should be noted that around 15% of cervical adenocarcinomas are frequently undetected by screening.

The screening program has evolved significantly in recent years. Initially, smears were examined for signs of dyskaryosis, which may indicate cervical intraepithelial neoplasia. However, the introduction of HPV testing allowed for further risk stratification, and the NHS has now moved to an HPV first system. This means that a sample is tested for high-risk strains of human papillomavirus (hrHPV) first, and cytological examination is only performed if this is positive.

All women between the ages of 25-64 years are offered a smear test. Women aged 25-49 years are screened every three years, while those aged 50-64 years are screened every five years. However, cervical screening cannot be offered to women over 64. In Scotland, screening is offered from 25-64 every five years.

In special situations, cervical screening in pregnancy is usually delayed until three months post-partum, unless there are missed screenings or previous abnormal smears. Women who have never been sexually active have a very low risk of developing cervical cancer and may wish to opt-out of screening.

It is recommended to take a cervical smear around mid-cycle, although there is limited evidence to support this advice. Overall, the UK’s cervical cancer screening program is an essential tool in preventing cervical cancer and promoting women’s health.

Fibrocystic change, breast cancer, and fat necrosis are unlikely based on the ultrasound results and aspiration findings.

Understanding Galactocele

Galactocele is a condition that commonly affects women who have recently stopped breastfeeding. It occurs when a lactiferous duct becomes blocked, leading to the accumulation of milk and the formation of a cystic lesion in the breast. Unlike an abscess, galactocele is usually painless and does not cause any local or systemic signs of infection.

In simpler terms, galactocele is a type of breast cyst that develops when milk gets trapped in a duct. It is not a serious condition and can be easily diagnosed by a doctor. Women who experience galactocele may notice a lump in their breast, but it is usually painless and does not require any treatment. However, if the lump becomes painful or infected, medical attention may be necessary. Overall, galactocele is a common and harmless condition that can be managed with proper care and monitoring.

To determine if iron supplementation is necessary, a cut-off of 110 g/L should be applied during the first trimester.

During pregnancy, women are checked for anaemia twice – once at the initial booking visit (usually around 8-10 weeks) and again at 28 weeks. The National Institute for Health and Care Excellence (NICE) has set specific cut-off levels to determine if a pregnant woman requires oral iron therapy. These levels are less than 110 g/L in the first trimester, less than 105 g/L in the second and third trimesters, and less than 100 g/L postpartum.

If a woman’s iron levels fall below these cut-offs, she will be prescribed oral ferrous sulfate or ferrous fumarate. It is important to continue this treatment for at least three months after the iron deficiency has been corrected to allow the body to replenish its iron stores. By following these guidelines, healthcare professionals can help ensure that pregnant women receive the appropriate care to prevent and manage anaemia during pregnancy.

The recommended position for women with cord prolapse is on all fours, with their knees and elbows on the ground. It is important to avoid pushing the cord back in, but to keep it warm and moist. This position helps to prevent compression of the presenting part of the fetus. However, immediate preparations for a caesarian section should also be made. The Trendelenburg position, which involves tilting the head end of the bed downwards, is not recommended for cord prolapse. The Lloyd Davis position, which involves separating the legs, is also not recommended. The McRoberts manoeuvre, which involves hyper-flexing the legs tightly to the abdomen, is used for shoulder dystocia during vaginal delivery and is not appropriate for cord prolapse. The lithotomy position, which involves raising the legs in stirrups, is commonly used in obstetrics and gynaecology but is not recommended for cord prolapse.

Understanding Umbilical Cord Prolapse

Umbilical cord prolapse is a rare but serious complication that can occur during delivery. It happens when the umbilical cord descends ahead of the presenting part of the fetus, which can lead to compression or spasm of the cord. This can cause fetal hypoxia and potentially irreversible damage or death. Certain factors increase the risk of cord prolapse, such as prematurity, multiparity, polyhydramnios, twin pregnancy, cephalopelvic disproportion, and abnormal presentations like breech or transverse lie.

Around half of all cord prolapses occur when the membranes are artificially ruptured. Diagnosis is usually made when the fetal heart rate becomes abnormal and the cord is palpable vaginally or visible beyond the introitus. Cord prolapse is an obstetric emergency that requires immediate management. The presenting part of the fetus may be pushed back into the uterus to avoid compression, and the cord should be kept warm and moist to prevent vasospasm. The patient may be asked to go on all fours or assume the left lateral position until preparations for an immediate caesarian section have been carried out. Tocolytics may be used to reduce uterine contractions, and retrofilling the bladder with saline can help elevate the presenting part. Although caesarian section is the usual first-line method of delivery, an instrumental vaginal delivery may be possible if the cervix is fully dilated and the head is low.

In conclusion, umbilical cord prolapse is a rare but serious complication that requires prompt recognition and management. Understanding the risk factors and appropriate interventions can help reduce the incidence of fetal mortality associated with this condition.

The first stage of labour begins with the onset of true labour and ends when the cervix is fully dilated at 10cm. During this stage, regular contractions occur and the cervix gradually dilates. It is important to note that although 4 cm and 6cm cervical dilation occur during this stage, it does not end until the cervix is fully effaced at 10cm. The second stage of labour ends with the birth of the foetus, not the first.

Labour is divided into three stages, with the first stage beginning from the onset of true labour until the cervix is fully dilated. This stage is further divided into two phases: the latent phase and the active phase. The latent phase involves dilation of the cervix from 0-3 cm and typically lasts around 6 hours. The active phase involves dilation from 3-10 cm and progresses at a rate of approximately 1 cm per hour. In primigravidas, this stage can last between 10-16 hours.

During this stage, the baby’s presentation is important to note. Approximately 90% of babies present in the vertex position, with the head entering the pelvis in an occipito-lateral position. The head typically delivers in an occipito-anterior position.

Measuring Uterine Growth During Pregnancy

During pregnancy, the size of the uterus can be used to estimate the gestational age of the fetus. At around 20 weeks, the uterus reaches the level of the umbilicus. This can be measured using the symphysio-fundal height (SFH), which is usually equal to the number of weeks of gestation (± 2 cm). To measure the SFH, the fundus of the uterus is first palpated and the tape measure is placed at this point. The tape measure is then rolled over the longitudinal axis of the uterus until it reaches the pubic symphysis, and the length in centimeters is recorded.

At 16 weeks, the uterus would not be palpable at the level of the umbilicus. The fundus of the uterus can be palpated at the midpoint between the umbilicus and the pubic symphysis. Similarly, at 18 weeks, the uterus would not be palpable at the level of the umbilicus.

By 22 weeks, the uterus would be past the level of the umbilicus. And by 24 weeks, the uterus would be higher in the abdomen than the umbilicus. Regular measurement of the SFH can help monitor fetal growth and ensure that the pregnancy is progressing normally.

Pregnant women with a BMI greater than 30 kg/m2 should receive a high dose of 5mg folic acid to prevent neural tube defects. In this case, the patient’s blood pressure is not high enough to require treatment with labetalol. Aspirin 75 milligrams is typically given to pregnant women starting at 12 weeks to lower the risk of pre-eclampsia, but this patient does not have any risk factors for pre-eclampsia and is not currently experiencing hypertension. If the patient had a healthy BMI, they would be prescribed the standard dose of 400 micrograms of folic acid to reduce the risk of neural tube defects.

Folic Acid: Importance, Deficiency, and Prevention

Folic acid is a vital nutrient that is converted to tetrahydrofolate (THF) in the body. It is found in green, leafy vegetables and plays a crucial role in the transfer of 1-carbon units to essential substrates involved in the synthesis of DNA and RNA. However, certain factors such as phenytoin, methotrexate, pregnancy, and alcohol excess can cause a deficiency in folic acid. This deficiency can lead to macrocytic, megaloblastic anemia and neural tube defects.

To prevent neural tube defects during pregnancy, it is recommended that all women take 400mcg of folic acid until the 12th week of pregnancy. Women at higher risk of conceiving a child with a neural tube defect should take 5mg of folic acid from before conception until the 12th week of pregnancy. Women are considered higher risk if they or their partner has a neural tube defect, they have had a previous pregnancy affected by a neural tube defect, or they have a family history of a neural tube defect. Additionally, women with certain medical conditions such as coeliac disease, diabetes, or thalassaemia trait, or those taking antiepileptic drugs, or who are obese (BMI of 30 kg/m2 or more) are also considered higher risk.

In summary, folic acid is an essential nutrient that plays a crucial role in DNA and RNA synthesis. Deficiency in folic acid can lead to serious health consequences, including neural tube defects. However, taking folic acid supplements during pregnancy can prevent these defects and ensure a healthy pregnancy.

The appropriate course of action for a woman exhibiting symptoms of agitation and paranoid delusions after giving birth is to admit her to the hospital for urgent assessment. This is likely a case of postpartum psychosis, which is different from postnatal depression. Postpartum psychosis can include mania, depression, irritability, rapid mood changes, confusion, paranoia, delusions, and/or hallucinations. Prescribing medication to aid in sleep is not appropriate in this case, and reassurance that her low mood will improve with time is also not appropriate due to the risk to herself and her baby. Gradual titration of fluoxetine would not manage her acute symptoms and would not ensure the safety of her or her baby. Ideally, she should be hospitalized in a Mother & Baby Unit.

Understanding Postpartum Mental Health Problems

Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.

‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.

Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.

Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.

Gestational diabetes can be diagnosed if the patient has a fasting glucose level of 5.6 mmol/L or higher, or a 2-hour glucose level of 7.8 mmol/L or higher. This diagnosis is typically made during an oral glucose tolerance test around 24 weeks into the pregnancy for women with risk factors, such as a high BMI or a first-degree relative with diabetes mellitus. In this patient’s case, she was diagnosed with gestational diabetes mellitus during her first pregnancy due to her risk factors. Therefore, the correct answer is a fasting plasma glucose level above 5.6 mmol/L. It is important to note that a 2-hour glucose level above 5.6 mmol/L is not diagnostic of gestational diabetes mellitus, and random plasma glucose tests are not used for diagnosis. Glucose targets for women with gestational diabetes mellitus include a 2-hour glucose level of 6.4 mmol/L after mealtime and a 1-hour glucose level of 7.8 mmol/L after mealtime.

Gestational diabetes is a common medical disorder affecting around 4% of pregnancies. Risk factors include a high BMI, previous gestational diabetes, and family history of diabetes. Screening is done through an oral glucose tolerance test, and diagnostic thresholds have recently been updated. Management includes self-monitoring of blood glucose, diet and exercise advice, and medication if necessary. For pre-existing diabetes, weight loss and insulin are recommended, and tight glycemic control is important. Targets for self-monitoring include fasting glucose of 5.3 mmol/l and 1-2 hour post-meal glucose levels.

Hypertension during pregnancy is a common occurrence that requires careful management. In normal pregnancies, blood pressure tends to decrease in the first trimester and then gradually increase to pre-pregnancy levels by term. However, in cases of hypertension during pregnancy, the systolic blood pressure is usually above 140 mmHg or the diastolic blood pressure is above 90 mmHg. Additionally, an increase of more than 30 mmHg systolic or 15 mmHg diastolic from the initial readings may also indicate hypertension.

There are three categories of hypertension during pregnancy: pre-existing hypertension, pregnancy-induced hypertension (PIH), and pre-eclampsia. Pre-existing hypertension refers to a history of hypertension before pregnancy or elevated blood pressure before 20 weeks gestation. PIH occurs in the second half of pregnancy and resolves after birth. Pre-eclampsia is characterized by hypertension and proteinuria, and may also involve edema.

The management of hypertension during pregnancy involves the use of antihypertensive medications such as labetalol, nifedipine, and hydralazine. In cases of pre-existing hypertension, ACE inhibitors and angiotensin II receptor blockers should be stopped immediately and alternative medications should be prescribed. Women who are at high risk of developing pre-eclampsia should take aspirin from 12 weeks until the birth of the baby. It is important to carefully monitor blood pressure and proteinuria levels during pregnancy to ensure the health of both the mother and the baby.

Differentiating Placental Abruption from Placenta Praevia in Antepartum Haemorrhage

Antepartum haemorrhage refers to bleeding from the genital tract after 24 weeks of pregnancy but before delivery of the fetus. It is important to determine the cause of the bleeding to provide appropriate management. Two common causes of antepartum haemorrhage are placental abruption and placenta praevia.

Placental abruption is characterized by shock that is not proportional to the visible loss, constant pain, a tender and tense uterus, a normal lie and presentation, and an absent or distressed fetal heart. Coagulation problems may also be present, and healthcare providers should be cautious of pre-eclampsia, disseminated intravascular coagulation (DIC), and anuria.

On the other hand, placenta praevia is characterized by shock that is proportional to the visible loss, no pain, a uterus that is not tender, an abnormal lie and presentation, and a usually normal fetal heart. Coagulation problems are rare, and small bleeds may occur before a large one. It is important to note that vaginal examination should not be performed in primary care for suspected antepartum haemorrhage, as women with placenta praevia may experience bleeding.

In summary, distinguishing between placental abruption and placenta praevia is crucial in managing antepartum haemorrhage. Healthcare providers should carefully assess the patient’s symptoms and perform appropriate diagnostic tests to determine the cause of the bleeding.

The symptoms described in this question are indicative of a molar pregnancy. To answer this question correctly, a basic understanding of physiology is necessary. Molar pregnancies are characterized by abnormally high levels of beta hCG for the stage of pregnancy, which serves as a tumor marker for gestational trophoblastic disease. Beta hCG has a similar biochemical structure to luteinizing hormone (LH), follicle-stimulating hormone (FSH), and thyroid-stimulating hormone (TSH). Consequently, elevated levels of beta hCG can stimulate the thyroid gland to produce thyroxine (T4) and triiodothyronine (T3), leading to symptoms of thyrotoxicosis. High levels of T4 and T3 negatively impact the pituitary gland, reducing TSH levels overall.
Sources:
Best Practice- Molar Pregnancy
Medscape- Hydatidiform Mole Workup

Gestational trophoblastic disorders refer to a range of conditions that originate from the placental trophoblast. These disorders include complete hydatidiform mole, partial hydatidiform mole, and choriocarcinoma. Complete hydatidiform mole is a benign tumor of trophoblastic material that occurs when an empty egg is fertilized by a single sperm that duplicates its own DNA, resulting in all 46 chromosomes being of paternal origin. Symptoms of this disorder include bleeding in the first or early second trimester, exaggerated pregnancy symptoms, a uterus that is large for dates, and very high levels of human chorionic gonadotropin (hCG) in the serum. Hypertension and hyperthyroidism may also be present. Urgent referral to a specialist center is necessary, and evacuation of the uterus is performed. Effective contraception is recommended to avoid pregnancy in the next 12 months, as around 2-3% of cases may develop choriocarcinoma.

Partial hydatidiform mole, on the other hand, occurs when a normal haploid egg is fertilized by two sperms or by one sperm with duplication of the paternal chromosomes. As a result, the DNA is both maternal and paternal in origin, and the fetus may have triploid chromosomes, such as 69 XXX or 69 XXY. Fetal parts may also be visible. It is important to note that hCG can mimic thyroid-stimulating hormone (TSH), which may lead to hyperthyroidism.

In summary, gestational trophoblastic disorders are a group of conditions that arise from the placental trophoblast. Complete hydatidiform mole and partial hydatidiform mole are two types of these disorders. While complete hydatidiform mole is a benign tumor of trophoblastic material that occurs when an empty egg is fertilized by a single sperm that duplicates its own DNA, partial hydatidiform mole occurs when a normal haploid egg is fertilized by two sperms or by one sperm with duplication of the paternal chromosomes. It is important to seek urgent medical attention and effective contraception to avoid pregnancy in the next 12 months.

Smoking has been found to decrease the risk of hyperemesis gravidarum, which is believed to occur due to rapidly rising levels of human chorionic gonadotropin (HCG) and oestrogen. This is because smoking is considered to be anti-oestrogenic. Therefore, despite having other risk factors, the fact that the patient is a smoker may decrease her incidence of hyperemesis gravidarum. On the other hand, hypothyroidism is not a risk factor, but hyperthyroidism increases the risk of hyperemesis gravidarum. Obesity and underweight are associated with an increased risk of hyperemesis, but women with these conditions who smoked before pregnancy have been found to have no increased risk. Primigravida status is also associated with an increased risk of hyperemesis, but the reason for this is not clear. Finally, twin pregnancies carry an increased risk of hyperemesis gravidarum due to higher levels of beta-hCG released from the placenta.

Hyperemesis gravidarum is an extreme form of nausea and vomiting of pregnancy that occurs in around 1% of pregnancies and is most common between 8 and 12 weeks. It is associated with raised beta hCG levels and can be caused by multiple pregnancies, trophoblastic disease, hyperthyroidism, nulliparity, and obesity. Referral criteria for nausea and vomiting in pregnancy include continued symptoms with ketonuria and/or weight loss, a confirmed or suspected comorbidity, and inability to keep down liquids or oral antiemetics. The diagnosis of hyperemesis gravidarum requires the presence of 5% pre-pregnancy weight loss, dehydration, and electrolyte imbalance. Management includes first-line use of antihistamines and oral cyclizine or promethazine, with second-line options of ondansetron and metoclopramide. Admission may be needed for IV hydration. Complications can include Wernicke’s encephalopathy, Mallory-Weiss tear, central pontine myelinolysis, acute tubular necrosis, and fetal growth issues.