common conditions --> Endometriosis, miscarriages, ectopics and bleeding

Question 1

what is endometriosis

disease of reproductive age women

Answer 1

is a condition in which endometrial, or endometrial like tissue grows outside of the uterus.

Question 2

what are the main clinical features of endometriosis

Answer 2

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

Question 3

risk factors for endometriosis

Answer 3

strong family history link
early hysterectomy

Question 4

definitive test can be laparoscopy what is this

what other investigation may be done to rule out other conditions

Answer 4

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.

Question 5

what is the treatment of endometriosis

Answer 5

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.

Question 6

what is an ectopic pregnancy

Answer 6

Implantation of conceptious outside uterine cavity - it is fertilised - ampullarf region normally

Question 7

risk factors for ectopic

Answer 7

History of infertility
Assisted conception
History of PID (especially Chlamydia trachomatis)
Endometriosis
Prev Pelvic/ tubal surgery
Previous ectopic
IUCD in situ
Smoking
pop

Question 8

symptoms of an ectopic c

Answer 8

pelvic pain
pain on should tip to ectopic phrenic nerve
brown watery discharge
amenorrhea (6-8 weeks)
vaginal bleeding

Collapse due to shock

Question 9

what does progesterone indicate in a pregnancy

Answer 9

Progesterone

know whether pregnancy failing/ not
<20 nmol/L – suggestive failing
>60mmol/l – ongoing pregnancy

Question 10

how often should you repeat beta HCG

pattern normally

Answer 10

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

Question 11

Ix for ectopic

Answer 11

preg test
progesterone
beta HCG
laparoscopy - gold standard
FBC. - degree of blood loss

Question 12

treatment of ectopic
medical and surgical

Answer 12

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

Question 13

symptoms of a miscarriage

Answer 13

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

Question 14

what tests should be performed if a woman has bleeding in early pregnancy

Answer 14

ALL women with bleeding in early pregnancy should have USS and B-HCG tests (two tests 48hr apart) performed.
progesterone too

Question 15

Late miscarriage is defined as miscarriage between

Answer 15

13-24 weeks

Question 16

risk factors for a miscarriage

Answer 16

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)

Question 17

what is offered during medical mamangement of a misscarriage

Answer 17

vaginal misoprostol

Question 18

what is a threatened miscarriage

Answer 18

Defined as bleeding in the first 12 weeks of pregnancy, without evidence of miscarriage or ectopic pregnancy
Usually painless
Cervical os remains closed

Question 19

inevitable miscarriage is the obvious one what is shown

when does it become complete
how does this differ from incomplete

Answer 19

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

Question 20

what is a missed or delayed miscarriage

Answer 20

gestational age of dead foetus with symptoms of exclusions
Light bleeding with cervicla os closed

Question 21

septic miscarriage

Answer 21

contents of the uterus are infected causing endometriosis
vaignal loss is usually offensive and the uterus will be tender

Question 22

what is menorrhagia

Answer 22

Menorrhagia describes abnormally heavy menstrual bleeding (often associated with increased period pain) during periods.

Question 23

main differential of menorrhagia

Answer 23

endometrial cancer

Question 24

what investigations would you do for heavy bleeding

Answer 24

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

Question 25

acute heavy bleeding how do you manage it

Answer 25

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

Question 26

if non acute heavy bleeding how do you treat

Answer 26

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

Question 27

treatment for heavy bleeding

Answer 27

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

Question 28

if the bleeding was prior to treatment of mefanamic acid and ferrous sulphate what would you be thinking

Answer 28

Urgent referral for oesophago-gastro-duodenoscopy (OGD) under 2 week wait

Question 29

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

Answer 29

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

Question 30

three cardinal signs of endometriosis

Answer 30

pelvic pain
dyspareunia
dysmenorrhoea

Question 31

irregular periods and acne what to give

Answer 31

COCP

Question 32

what investigations should you do in recurrent miscarriage

Answer 32

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

Question 33

how to manage recurrent misccariage

Genetic disorder

Uterine structural abnormality

Cervical incompetence

Polycystic ovary syndrome

Antiphospholipid syndrome

Thrombophilia

Diabetes

Answer 33

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

Question 34

how to manage antiphospholipid syndrome in pregnancy

Answer 34

heparin or low-dose aspirin

Question 35

endometriosis increases your risk of what cancers and why

Answer 35

endometrial cancer

breast cancer - this is due to increased oestrogen circulating - ER positive breast cancer