common conditions --> Endometriosis, miscarriages, ectopics and bleeding Flashcards
what is endometriosis
disease of reproductive age women
is a condition in which endometrial, or endometrial like tissue grows outside of the uterus.
what are the main clinical features of endometriosis
chronic pelvic pain
secondary dysmenorrhea - Pain both pre-menstrual and menstrual – often beings a few days before menstruation and settles a few days afterwards - cyclical
deep dyspareunia(vag pain)
dysuria
urine urgency
haematuria
painful bowel movements
risk factors for endometriosis
strong family history link
early hysterectomy
definitive test can be laparoscopy what is this
what other investigation may be done to rule out other conditions
viewing organs in abdomen
Often, imaging such as USS is not able to detect areas of endometriosis within the abdomen, however it is frequently performed to assess for other causes – such as fibroids or ovarian cysts. USS is often normal in endometriosis. A transvaginal scan is preferred over transabdominal scan as it provides better quality images, but may not be appropriate in some (particularly younger) patients.
what is the treatment of endometriosis
1st line NSAID or paracetamol
Analgesia may help, but is not particularly effective
Suppression of ovarian function is effective at controlling pain. This can be achieved through hormonal means, or surgically
COCP can be first line too
2nd line miring/IUD
if patients don’t respond after 3-6 months surgical options include
Incision or ablation of the pelvic adhesions
Last resort – Total hysterectomy and bilateral salpingo-oophorectomy.
what is an ectopic pregnancy
Implantation of conceptious outside uterine cavity - it is fertilised - ampullarf region normally
risk factors for ectopic
History of infertility
Assisted conception
History of PID (especially Chlamydia trachomatis)
Endometriosis
Prev Pelvic/ tubal surgery
Previous ectopic
IUCD in situ
Smoking
pop
symptoms of an ectopic c
pelvic pain
pain on should tip to ectopic phrenic nerve
brown watery discharge
amenorrhea (6-8 weeks)
vaginal bleeding
Collapse due to shock
what does progesterone indicate in a pregnancy
Progesterone
know whether pregnancy failing/ not
<20 nmol/L – suggestive failing
>60mmol/l – ongoing pregnancy
how often should you repeat beta HCG
pattern normally
repeat 48 hours later
pattern ; doubling every 48 hours until 6w in normal pregnancy
rise >66% indicate IUP
suboptimal rise à suggest Ectopic Pregnancy
If serum b-hCG <5 mIU/ml à ectopic is excluded
if serum hCG >1500IU, US scan should visualise Intrauterine /Ectopic pregnancy
Need to monitor serum hCG, initially and then every 48 hours until level fall, then weekly until <15IU
Ix for ectopic
preg test
progesterone
beta HCG
laparoscopy - gold standard
FBC. - degree of blood loss
treatment of ectopic
medical and surgical
Methotrexate (Folate antagonist) à destroys trophoblastic tissue
use contraception fro 3 months afterwards
Laparoscopy/ Laparatomy
Laparoscopy is preferable than laparotomy in haemodinamically stable patient
Salpingectomy - Fallopian tubes removed if mass greater than 35mm or over 5cm not sure
symptoms of a miscarriage
vaginal bleeding
May include large clots or other tissue – the products of conception
Pain – typically worse than normal period pain
Indications for immediate referral to emergency department for assessment for ectopic pregnancy:
Severe pelvic pain
Marked lower abdominal tenderness
Hypotension
Syncope
Tachycardia
what tests should be performed if a woman has bleeding in early pregnancy
ALL women with bleeding in early pregnancy should have USS and B-HCG tests (two tests 48hr apart) performed.
progesterone too
Late miscarriage is defined as miscarriage between
13-24 weeks
risk factors for a miscarriage
Increased maternal age (particularly >35)
Paternal age >45 (irrespective of maternal age)
Smoker
High alcohol intake
Illicit drug use
Poorly controlled diabetes
Infectious diseases – particularly listeria and rubella
PCOS
Poorly controlled thyroid disease
Fertility problems
Connective tissue disorders (SLE, antiphospholipid syndrome)
what is offered during medical mamangement of a misscarriage
vaginal misoprostol
what is a threatened miscarriage
Defined as bleeding in the first 12 weeks of pregnancy, without evidence of miscarriage or ectopic pregnancy
Usually painless
Cervical os remains closed
inevitable miscarriage is the obvious one what is shown
when does it become complete
how does this differ from incomplete
about to occur
heavy bleeding with clots and pain
cervical os will be open
complete when the bleeding stops as all metal tissue has passed and the cerivcal os will close
differs as incomplete will pain and bleeding still due to not all products of conception being expelled so os is still open
what is a missed or delayed miscarriage
gestational age of dead foetus with symptoms of exclusions
Light bleeding with cervicla os closed
septic miscarriage
contents of the uterus are infected causing endometriosis
vaignal loss is usually offensive and the uterus will be tender
what is menorrhagia
Menorrhagia describes abnormally heavy menstrual bleeding (often associated with increased period pain) during periods.
main differential of menorrhagia
endometrial cancer
what investigations would you do for heavy bleeding
Bloods
FBC
Iron studies
Coags – INR / PT / APTT / fibrinogen / platelets
B-hCG
TFTs
Autoantibodies – e.g. ANA for SLE
Consider hormones – LH, FSH, estradiol, prolactin
Consider pelvic / transvaginal USS
Ideally should be reserved for women who fail conservative management, or are at high risk of endometrial cancer
Perform in first half of cycle when endometrial thickness can be measured
>12mm in premenopausal or >5mmin post menopausal women requires endometrial biopsy
acute heavy bleeding how do you manage it
If haemodynamically unstable – refer to emergency department
If haemodynamically stable but Hb <80 – refer for urgent gynaecology assessment (also consider going via emergency department)
To stop acute bleeding
Tranexamic acid 1g to 1.5g PO every 8 hours – until bleeding ceased
or
Medroxyprogesterone 10mg PO every 4 hours until bleeding stops
Consider urgent USS
if non acute heavy bleeding how do you treat
Consider prompt USS
Treat any iron deficiency
If USS is normal, age <35 and no red flags, can treat in the community. –> Intra-uterine device (e.g. Mirena)
Combined hormonal contraceptive (provided no contra-indications).
Tranexamic acid 500mg PO BD or TDS for 2-3 days with periods
Progestins are considered third line, after IUS, CHC / NSAIDs / tranexamic acid
Hysterectomy may be considered as a last resort in women who are certain they do not want any (more) children
treatment for heavy bleeding
Mirena® coil
Mefenamic acid and ferrous acid - side effects include darker stool
Tranexamic acid
Hormonal contraception e.g. the combined oral contraceptive pill
(In rare cases refractory to medical managment) endometrial ablation or hysterectomy
if the bleeding was prior to treatment of mefanamic acid and ferrous sulphate what would you be thinking
Urgent referral for oesophago-gastro-duodenoscopy (OGD) under 2 week wait
pregnancy of unknown origin can be due to an early viable or failing intrauterine pregnancy, a complete miscarriage or an ectopic pregnancy
what should serum b-hcg be done
repeat after 48hr
if level fall then suggested foetus will not develop or miscarriage
slight increase or plates in beta levels then ectopic
normal increases suggest foetus growing nroamlyl but do not exclude ectopic
three cardinal signs of endometriosis
pelvic pain
dyspareunia
dysmenorrhoea
irregular periods and acne what to give
COCP
what investigations should you do in recurrent miscarriage
Investigations include blood tests (antiphospholipid antibodies, thrombophilia screen), cytogenetic analysis of products of conception (if abnormal then the parents should be karyotyped), and pelvic ultrasound to identify uterine abnormalities
how to manage recurrent misccariage
Genetic disorder
Uterine structural abnormality
Cervical incompetence
Polycystic ovary syndrome
Antiphospholipid syndrome
Thrombophilia
Diabetes
Genetic disorder - refer to a clinical geneticist for genetic counselling. Options include continuing pregnancy attempts with prenatal diagnosis or use of a donor egg/sperm
Uterine structural abnormality - may be treated surgically. For some congenital uterine malformations there is insufficient evidence to recommend surgical treatment
Cervical incompetence - regular ultrasound monitoring of the cervix. May use cervical cerclage
Polycystic ovary syndrome - difficult to manage as pathophysiology is not fully understood. There is no consensus on the most appropriate management. Suppression of the high LH has not been found to be effective
Antiphospholipid syndrome - heparin or low-dose aspirin
Thrombophilia - heparin may increase the live birth rate
Diabetes - improve glycaemic control
how to manage antiphospholipid syndrome in pregnancy
heparin or low-dose aspirin
endometriosis increases your risk of what cancers and why
endometrial cancer
breast cancer - this is due to increased oestrogen circulating - ER positive breast cancer
