Anatomy and early pregnancy problems

Question 1

What is the perineum?

Answer 1

• Area between vaginal opening and anus

Question 2

What is the Vulva ?

Answer 2

• Mons, labia major, clitoris, labia minor, vestibule, external urethra meatus, bartholins glands and hymen.
• Mons = pad fat that lies over public symphysis
• Labia major = two folds skin enclose vaginal opening, fatty tissue, covered in hair after puberty
• Clitoris = erectile tissue, attached to pubic arch by crura
• Labia minor = delicate skin folds, fibrous tissue, erectile tissue, BVs, no hair
• Vestibule = area between labia minor in which vagina opens, external meatus urethra anterior, bartholin glands posterior
• Bartholins glands = secrete during sexual excitement. (slightly posterior and right and left to the opening of the vagina).
• Hymen = fold squamous epithelium and connective tissue partly closing vaginal opening in young females. Ruptured by intercourse, tampon insertion.

Question 3

What is the Vagina?

Answer 3

• Fibromuscular canal extending from vestibule of vulva to cervix
• Three layers:
• Outer connective tissue layer, ligaments attaches, BVs, nerves, lymphatics
• Muscular layer, outer longitudinal and inner circular layers
• Epithelium, stratified squamous, basal function and cornified layers. Undergoes cyclical changes, changes during pregnancy, after menopause atrophies (smears contain large numbers basal cells)
• Vaginal fluid result of cervical secretions

Question 4

What is the Cervix ?

Answer 4

• Canal at bottom uterus
• Connective tissue, with muscle at internal and external os
• Lined with columnar epithelium, undergoes squamous metaplasia at external os – transformation zone (where neoplasia can occur)
• High oestrogen levels (pregancy, combined oral contracetive pill) transformation zone can present on outer surface cervix as ectropian. After menopause retreats back into cervix, difficult to detect abnormal cells
• Secretes fluid from glands in columnar epithelium. Oestrogen makes it thin, whereas progesterone makes it viscid and creamy

Question 5

What is the Uterus?

Answer 5

• Three layers muscular tissue:
• Outer - thin, longitudinal layer. Merges with ligaments
• Middle - thick, spiral layer with blood vessels in between
• Inner - thin, oblique layer. Condensation at upper and lower cervical canal = internal and external os.
• Blood supply from uterine (branch internal iliac) and ovarian arteries
• Supported by transverse cervical ligament, uterosacral ligament and round ligament. In pregnancy stretch and thicken, relaxed by progesterone
Broad ligament = two layers peritoneum run over fallopian tubes anteriorly to uterovesical reflection and posteriorly to rectovaginal reflection

Question 6

What is the Fallopian tube ?

Answer 6

• Oviduct carrying sperm from uterus to point of fertilsation and carrying ova (egg) from ovary to uterine cavity
• Fertilsation usually occurs in distal part tube
• Four parts:
• Intramural
• Isthmus
• Ampulla
• Infundibulum – fimbriae surround outer opening tube
• Three coats:
• Outer serous layer of peritoneum
• Muscle layer with outer longitudinal and inner circular fibres
• Mucosa/endosalpinx – thrown into longitudinal folds, ruggae. Ciliated cells, secretory cells, intercilliary

Question 7

What is the Ovary?

Answer 7

• Gameotogenesis + steroid production
• Attached to broad ligament through mesovarium which supplies blood and nerves
• Blood supply = ovarian arteries arising from aorta below the renal arteries
• Outer cortex + inner medulla
• Fibrous capsule = tunica albuginea
• Cortex ovary at menarche contains approx 500,000 primordial oocytes, produce estradiol and androgens
• Ovarian cycle mediated by hypothalamic pituitary axis

• Perineal body – mass fibrous tissue, fibres levator ani and deep transverse perineal muscles insert (muscles often torn during labour)

Question 8

What is the Bony pelvis?

Answer 8

• Longest axis changes from pelvic inlet – pelvic outlet

* Fetus must rotate

Question 9

What are the Pelvic muscles?

Answer 9

• Lining lateral walls = pyriformis, obturator internus

* Pelvic diaphragm = Levator ani: pubococcygeus + iliococcygeus, ischiococcygeus

Question 10

What are Early pregnancy problems?

Answer 10

Problems arising in the first trimester of pregnancy (pre 12 weeks)

Question 11

What is Miscarriage ?

Answer 11

the loss of a pregnancy before viability

This applies up to 24 weeks of pregnancy, after which it becomes a stillbirth or neonatal death.

Question 12

What is Recurrent miscarriage?

Answer 12

Recurrent miscarriage (1% of couples) is the loss of 3 or more consecutive pregnancies with the same partner

Question 13

When does a woman has a higher risk of miscarriage?

Answer 13

• Is over age 35
• Has certain diseases, such as diabetes or thyroid problems
• Has had three or more miscarriages

Question 14

What are the Causes of miscarriage?

Answer 14

• Isolated non-recurring chromosomal abnormalities in foetus (MOST COMMON)
o Sporadic chromosomal most common
o Structural malformation (e.g. neural tube)
o 1/3 of Downs miscarry
o 99% of triploidies – extra set of chromosomes
• Acute maternal pyrexia
• Chronic maternal disease (e.g. renal failure, diabetes, thyroid disease)
• Hormone problems
• Immune system responses

Question 15

What are the Causes of recurrent miscarriage?

Answer 15

– a cause can be found in only 20% of cases and includes:
- Antiphospholipid antibody syndrome = thrombosis in uteroplacental circulation
• Aspirin + low-dHx ose LMWH
- Chromosomal defects in the parents (e.g. chromosomally imbalanced sperm/egg)
• Parental karyotyping + referral to clinical geneticist (karyotyping of other family members)
• Prenatal diagnosis using CVS/amniocentesis
• Donor oocytes/sperm or preimplantation genetic screening of IVF embryos
- Uterine abnormalities (e.g. weakness, adhesions, bicornuate uterus) or cervical incompetence (late miscarriage/preterm labour) – may be caused by surgical Rx
• USS (or hysterosalpigogram)
- Infection (late miscarriage/preterm labour)
• Rx of bacterial vaginosis
- Others: obesity, smoking, PCOS, excess caffeine and higher maternal age

Question 16

What is a Threatened miscarriage?

Answer 16

= viable pregnancy
Symptoms of bleeding +/- pain cramping suggest miscarriage but the pregnancy continues (foetus viable). On examination the cervical is closed and uterine size correct for dates. 25% miscarry – the cause is unknown and if miscarriage does not occur, there is no long-term harm to the baby or implications for the remainder of the pregnancy. USS shows viable foetus. Rx: watch and wait. <5% go on to abort.

Question 17

What is a Inevitable miscarriage?

Answer 17

Presents in the process of miscarriage and nothing can be done to save the pregnancy. There is heavier vaginal bleeding and the cervical is open. US would show nonviable foetus. Increasing bleeding and cramps +/- rupture of membranes. Cervix closed until products start to expel the external os opens. Rx: a watch and wait, b) misoprostol 400-800ug PO/PV c) D&C +/- oxytocin

Question 18

What is a Incomplete miscarriage?

Answer 18

Not all the products of conception have been expelled from the uterus by the miscarriage process. There is continued bleeding, the cervical os remains open and a scan shows mixed debris in the uterus (products of conception). Medical or surgical treatment may be offered to complete the miscarriage. Extremely heavy bleeding and cramps Increasing bleeding and cramps +/- passage of tissue noticed. Cervix open USS shows products of conception.

Question 19

What is a Complete miscarriage?

Answer 19

The process has completed without intervention. Presents with bleeding which has now lessened. The uterus has returned to a near normal size and the cervix has closed. The history of bleeding, pain and the findings of an empty uterus on scan (no products of conception) are suggestive of the diagnosis but care is needed to ensure ectopic pregnancy has been excluded. – on the scan she would look like she was never pregnant
Bleeding and complete passage of sac and placenta. Cervix openbut no signs on USS.

Question 20

What is a Missed or delayed miscarriage?

Answer 20

The entire gestation sac, which can include the embryo, is retained within the uterus. The pregnancy has stopped growing or developing and the fetal heart has stopped. No/minimal bleeding, the cervical os closed but the uterus smaller than the gestational age. May be found incidentally on routine scan.
a watch and wait, b) misoprostol 400-800ug PO/PV c) D&C +/- oxytocin

Question 21

What is a Septic miscarriage ?

Answer 21

– contents of uterus are infected, causing endometritis. Vaginal loss usually offensive, uterus is tender, but a fever can be absent. If pelvic infection occurs there is abdominal pain and peritonism
Rx: D&C and IV broad spectrum antibiotics.

Question 22

What is an Ectopic pregnancy?

Answer 22

you see an empty uterus. Usual treatment is to surgically remove all the remaining material.

Question 23

What are the Clinical findings of a miscarriage?

Answer 23

– can be an INCIDENTAL FINDING
• Vaginal bleeding (unless missed miscarriage) – amount and type of loss varies with type of miscarriage and gestation
• Abdominal pain – from uterine contractions (causes confusion with ectopic pregnancy)
Regression of pregnancy symptoms incidental finding at routine antenatal visit
• Uterine size and state of cervical os are dependent on type of miscarriage
• Severe tenderness unusual (although septic miscarriage does cause uterine tenderness)

Question 24

What are the Investigations for a miscarriage?

Answer 24

usually via EPAU (early pregnancy assessment units)
• FBC and cross-match (if shocked)
• Pregnancy test – remains +ve for several days after foetal death
• Ultrasound scan (transvaginal) – will show if a foetus is in the uterus and viable; may detect retained foetal products; unlikely to be ectopic if foetus in utero (unless IVF Rx  heterotopic pregnancy)
o If any doubt if it is a very early pregnancy or non-viable pregnancy  repeat in 1wk
• Blood tests – serum β-HCG levels (↑ with viable intrauterine preg.) and rhesus group
o Urine or blood pregnancy test
o Note: with serum HCG – if scan shows empty uterus, could be miscarriage OR ectopic OR viable intrauterine pregnancy too early to see:
 Serum HCG levels will rise rapidly in a normal pregnancy (by >66% in 48hrs), fall rapidly in a miscarriage but rise slowly and plateau/decline in an ectopic pregnancy
 Caution required, as heterotopic pregnancy can still occur, esp. if assisted pregnancy

Question 25

What is the Management miscarriage ?

Answer 25

always provide written and verbal explanations
- Initial management
• Admission necessary if: ectopic pregnancy suspected, septic miscarriage or heavy bleeding
 Resuscitation occasionally required if sig. haemorrhage: ABCDE, IV access: HCG, Rh, FBC, X-match
• USS to exclude ectopic + indicate foetal viability
• Products of conception in cervical os (cause pain, bleeding, vasovagal shock)  remove via speculum using polyp forceps
• IM ergometrine – reduces bleeding by contracting the uterus, only if foetus is non-viable
• If fever swabs for bacterial culture + IV broad-spectrum Abx (co-amoxiclav) for septic abortion
• Rh anti-D Ig 250 units IM given to women who are Rh –ve if miscarriage treated surgically/medically, or if bleeding after 12wks’ gestation
 Reduces risk of isoimmunisation and rhesus disease in future pregnancies
• Gynae referral threatened abortion pts may be allowed home after USS + gynae review

• Viable intrauterine pregnancy (threatened miscarriage) OR complete miscarriage: no Rx necessary
• Non-viable intrauterine pregnancy: expectant, medical or surgical Rx
  • Expectant – can be continued as long as the woman is willing and there are no signs of infection
   Usually recommended to naturally wait for 14 days before discussing further options (usually successful within 2-6wks)
   This involves allowing the body to complete the miscarriage “naturally”
   Chosen by few women as course unpredictable and can take weeks to complete but avoids hospital admission and use of all drugs
   If not bled yet (14 days) or getting worse offer second USS and move onto medical management
  • Medical – involves the use of PO/SL/PV prostaglandins (e.g. misoprostol) + mifepristone (oral antiprogesterone – taken first)
   To induce uterine contractions and expel remaining POC
   Can take place in hospital or at home
   Can be complicated by heavy bleeding and moderate abdominal pain
   There is a 5% incidence of retained products/failure of treatment
  • Surgical – ERPC (evacuation of retained products of contraception) under GA using vacuum aspiration
   Suitable if woman prefers it, heavy bleeding, signs of infection or expectant/medical management fails (under antibiotic cover)
   Tissue examined histologically to exclude molar pregnancy
   Complications include intrauterine infection (3%), damage to the cervix, haemorrhage and retained products (5%)
   NOT offered after 12wks – baby too big
• Counselling
  • Tell pt. miscarriage was not the result of anything they did/did not do and could not have been prevented
  • Reassurance as to high chance of successful future pregnancies
  • Inform of benefits of pre-conceptual folic acid and other general health measures for successful pregnancy (e.g. smoking advice)
  • Referral to support group

Question 26

What are the Complications of a miscarriage?

Answer 26

• Vaginal bleeding with expectant/medical management can be heavy and painful
  • Risk of needing surgical evacuation
• Infection – similar for all 3 managements
  • If becomes systemic endotoxic shock, hypotension, AKI, ARDS and DIC
• Asherman’s syndrome or perforate uterus if surgical evacuation partially removes endometrium
• Long-term conception rates do not differ between the 3

Question 27

What is the Prognosis of a miscarriage?

Answer 27

Miscarriage is common. Recurrent miscarriage requires further investigation and even more emotional support + counselling, and a clearly defined pregnancy plan in terms of USS monitoring (esp. late pregnancy – ‘high risk’ monitoring).

Question 28

What is a Ectopic pregnancy?

Answer 28

implantation of the fertilised ovum outside the body of the uterus. 95% are tubal ectopic but can implant in cervix or cornu of the uterus which can be very serious. Rarer sites of implantation include the ovary and the peritoneal cavity – a so-called abdominal pregnancy which in rare cases have gone to term.

Question 29

What is Maternal mortality due to ectopic?

Answer 29

10 deaths in the 2006-08 maternal mortality report due to failed recognition

Question 30

What is the Cause of Ectopic pregnancy?

Answer 30

usually due to damage to fallopian tube and/or cilia
• *Pain typically 6-7 weeks gestation; can be sharp, dull and/or crampy and mimic appendicitis (esp. on lower right side)
• ▪Bleeding usually >6 weeks after last menstrual period
• Usually both pain + PV bleeding, but one can occur without the other

Question 31

What are the Investigations for a Ectopic pregnancy?

Answer 31

• Pregnancy test (urine HCG) – for all women of reproductive age presenting with abdominal pain, bleeding or collapse regardless of the specialty they present to a negative test confidently excludes an ectopic pregnancy
• USS – transvaginal: to confirm an intra-uterine pregnancy (very rarely confirms an ectopic pregnancy, i.e. see a gestation sac outside the uterus). If the uterus is empty and the pregnancy test positive the differential diagnosis is:
• A very early pregnancy, too early to see on scan
• A complete miscarriage
• Ectopic pregnancy
• Other ultrasound findings suggestive of an ectopic pregnancy include free peritoneal fluid (in pouch of Douglas), a thickened endometrium, and an adnexal mass adjacent to the ovary. Also intrauterine pseudosac, tubal ring.
• Ovarian cysts are common in early pregnancy (corpus luteum) and are not suggestive of an ectopic unless complex
• Serum β-HCG (>1000 IU = ectopic) if uterus is empty – if <1000 IU, monitored to differentiate from a miscarriage or an early pregnancy. Levels will rise rapidly in a normal pregnancy (by >66% in 48hrs), fall rapidly in a miscarriage but rise slowly and plateau/decline in an ectopic pregnancy
• Caution required, as heterotopic pregnancy can still occur, esp. if assisted pregnancy
• Other bloods: FBC, U&E, blood sugar, G&S, Rh status
• Laparoscopy – definitive diagnosis but is invasive – only advised if doubt exists about the diagnosis

Question 32

What are the Predisposing factors of a Ectopic pregnancy?

Answer 32

PID/salpingitis – esp. chlamydia
Results in scarring
Endometriosis
Previous ectopic pregnancy
Sterilisation/infertility
Reversal of sterilisation
Use of IUD
Tubal surgery (ligation)
Intrauterine surgery (D&C)
Smoking
Exposure to DES
Advanced maternal age
Lower S/E status

Question 33

What are the clinical features of Ectopic pregnancy?

Answer 33

Symptoms
• Abdominal/pelvic pain*
• Scenty, dark vaginal bleeding▪
• Collapse and shoulder tip pain suggest intraperitoneal blood loss (due to tubal rupture - v. dangerous!!!!)
• Diarrhoea/vomiting
• May see Sx of pregnancy – N&V, urination, fatigue, breast tenderness
• Amenorrhoea of 4-10wks is usual, but the pt. may be unaware that she is pregnant and interpret a PV bleed as a period

Signs
• Abdominal (+ rebound) tenderness
• Cervical excitation due to stretching of inflamed tissues
• Unilateral adnexal tenderness (Adnexal mass very very rarely palpated in conscious patient)
• Small uterus for gestation date
• Cervical os closed
• Tachycardia if blood loss, hypotension and collapse in extremis

Question 34

What is the Management of Ectopic pregnancy?

Answer 34

• Where Sx are present admit pt
• Oxygen
• NBM
• IV access – resuscitate initially with crystalloids
• FBC and cross-match 6 units of blood
• Check Rh status and give anti-D Ig 250 units IM if –ve
• Refer urgently to gynae (may deteriorate quickly)
• Acute presentation
• Alert theatre + anaesthetics team if haemodynamically unstable (sig. haemorrhage) = resuscitation + surgery (laparoscopic preferred if experienced, but usually laparotomy = salpingectomy of affected tube)
• Subacute presentation
• Surgery (laparoscopic preferred if haemodynamically stable)  salpingostomy (removing ectopic) or salpingectomy
• Required in:
• Tubal rupture
• Mass >3.5cm diameter
• Free fluid >50ml
• Foetal heart beat on USS
• Salpingostomy = 10% risk of persistence of ectopic (detected by failure of serum hCG to fall on follow-up), requiring repeat surgery, and risk of repeat ectopic (as damaged tube remains). However, if contralateral tube is damaged, may allow for future conception whereas salpingectomy requires IVF (if normal, similar rates bt. both procedures)
• Medical – methotrexate if ectopic unruptured with no cardiac activity, and hCG <3000IU/ml
• Given IM. Takes 4-6 weeks to completely resolve (may require second dose) and 10% ultimately require surgery. Recommended for cervical and cornual ectopics in particular
• Conservative – not generally recommended unless the hCG levels are already very low and falling, ectopic is small and unruptured, or location of pregnancy not clear

Complications and Prognosis

• Women treated with salpingostomy, medical or conservative management must have serial hCG measurements until <20IU/mL to confirm ectopic resolution
• Support, esp. to women who ‘lost baby’ through a life-threatening condition and have undergone surgery + have reduced fertility = support groups
• 70% have successful subsequent pregnancy; 10% have recurrence of ectopic (higher if tubal damage)

Question 35

What is a Molar pregnancy?

Answer 35

Also known as Gestational Trophoblastic disease –
group of conditions in which tumours grow inside a woman’s uterus

More common at extremes of reproductive age and in Asians

• Different types/stages of moles:
o Hydatidiform mole (localised and non-invasive)
 Complete Mole – where a sperm fertilizes an empty egg and divides by mitosis (diploid 46XX), producing a proliferation of trophoblastic tissue (swollen chorionic villi) that is entirely paternal in nature (no foetus develops)
 Partial Mole – where 2 sperm fertilise one egg (triploid) variable evidence of foetus (if present, abnormal and can’t survive and develop into baby)
o Malignant (i.e. persistent gestational trophoblastic disease = gestational trophoblastic neoplasia)
 Invasive mole – invasion of proliferation within uterus
 Choriocarcinoma – metastasis of tissue
 Placenta-site trophoblastic tumour (rare)

Question 36

What are the clinical features of Molar pregnancy?

Answer 36

Examination – uterus often large. Early pre-eclampsia and hyperthyroidism may occur
History – vaginal bleeding usual and may be heavy (esp. first 3mths; may contain small, grape-like lumps); severe vomiting (hyperemesis)
- However, often no signs that pregnancy is molar (these signs fairly common in pregnancy) spotted during routine ultrasound scan at 8-14 weeks or during further tests carried out after a miscarriage

Question 37

What are the investigations for Molar pregnancy?

Answer 37

Investigations – ultrasound shows ‘snowstorm’ appearance of swollen villi with complete moles, but diagnosis can only be confirmed histologically. Serum hCG levels may be very high

Question 38

What are the investigations for Molar pregnancy?

Answer 38

Treatment (register with supraregional centre to guide management and follow-up)
• Suction curettage (ERPC) – usually done under GA + diagnosis confirmed histologically
o Bleeding often heavy
o Afterwards, serial blood hCG levels taken – if persisting/rising consider malignancy
o Pregnancy and COCP avoided until hCG levels normal as may increase need for chemotherapy
• Can also use medication (if too large to suck out) or hysterectomy (if done having children)
• If malignant may need chemo (highly malignant, but v. chemosensitive)
o ‘Low-risk’ methotrexate with folic acid
o ‘High-risk’ combination chemo

Question 39

What are the complications of Molar pregnancy?

Answer 39

• Recurrence (1/60) after every future pregnancy, further hCG samples taken to exclude recurrence
• GTN (invasive mole/choriocarcinoma) follows 15% of complete moles and 0.5% of partial moles
  • Can also follow miscarriage/normal pregnancy usually presents as persistent PV bleeding; diagnosis made by:
   Persistently elevated/rising hCG levels
   Persistent vaginal bleeding
   Evidence of blood-borne metastasis (commonly to lungs)
  • 5-yr survival with chemo approaches 100%