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Y4 - GOSH > early pregnancy problems and benign tumours > Flashcards

early pregnancy problems and benign tumours Flashcards

1
Q

what is miscarriage

A

loss of a pregnancy before it is viable

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2
Q

what do you call the loss of pregnancy before 24 weeks

A

miscarriage

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3
Q

what do you call the loss of pregnancy after 24 weeks?

A

stillbirth/neonatal

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4
Q

what is the most common time for a miscarriage to take place

A

week 12 - ie first trimester

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5
Q

what is recurrent miscarriage

A

3 or more consecutive miscarriage with the same partner

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6
Q

how common is miscarriage

A

12% of all pregnancy

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7
Q

what are the causes of miscarriage

A

age - inc age dramatically inc risk of miscarriage

chromosomal abnor - either spontaneous or inherited (eg Downs’)

PCOS

acute pyrexial illness (TORCH syndrome)

chronic maternal illness eg DM, renal failure

thyroid problems

structural abnor of the uterus

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8
Q

what are the most common symptoms of miscarriage

A

abdo pain/supra-pubic pain

PV bleeding - amount and pattern depends on the types of miscarriage

regression of pregnancy symptoms

can just be incidental findings

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9
Q

what are some investigations for miscarriage

A

history and examination

transvaginal USS

beta hCG - pregnancy test

blood group and rhesus status

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10
Q

what are the normal USS findings of a viable pregnancy

A

at week 5 - gestational sac of 5-6 mm +/- yolk sac

at week 5 - foetal pole possible to be seen, foetal heart activity

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11
Q

what are the USS findings of a non-viable pregnancy

A

gestational sac with foetus but not heartbeat

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12
Q

what are the USS findings of a pregnancy with an uncertainty

A

sac and foetus but no heart beat

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13
Q

when is the cut off point for a pregnancy to be non-viable

A

gestational sac > 7mm and no heartbeat

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14
Q

what should you do when you discover a pregnancy of uncertain viability

A

rescan 7-14 days

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15
Q

what are the management of miscarriage

A

expectant
surgical
medical

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16
Q

what are the medical management of miscarriage

A
  • M&M - misoprostol (prostaglandin and progesterone receptor blocker to induce contraction within the body), can take up to 14 days to work, mifepristone
  • can cause severe bleeding and abdo pain
  • 5% chance that product of conception will remain in situ
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17
Q

what are the surgical management of miscarriage

A

2 different types

1) evacuation of uterus - GA and in-patient
2) manual vacuum aspiration - LA and day patient

5% risk of product remain in situ

chance of haemorrhage, trauma to cervix

will need to take a pregnancy test in 3 weeks’ time

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18
Q

what are some causes to recurrent miscarriage

A

PCOS
antiphospholipid antibody syndrome
uterine abnor

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19
Q

what count as heavy bleeding in pregnancy

A

3 pad in < 1 hour
or
pass clot larger than the size of your palm

if occurs will need to contact someone urgently

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20
Q

how long does it take for hCG/pregnancy test to become normal/-ve

A

hCG excreted by kidney

can take up to 3 wks before levels becomes undetectable

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21
Q

What is the definition of ectopic pregnancy

A

when implantation of the fertilised egg outside the body of uterus

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22
Q

what is the most common place for ectopic pregnancy

A

tubal - 90%

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23
Q

what are other places where ectopic pregnancy can occur

A

abdo
cervix - dangerous
C-section scars
ovaries

24
Q

what are the risk factors of ectopic pregnancy

A

ovary
- IVF

tubal

  • PID - chlamydia
  • previous ectopic pregnancy
  • previous tubal surgery
  • failed sterilisation

endometrium
- IUD
- endometriosis
smoking

25
Q

symptoms of ectopic pregnancy

A

abdo pain

shoulder tip pain - blood irritation to the diaphragm

Diarrhoea - blood irritation to the colon/rectum

collapse - if ruptured

PV bleeding/amenorrhoea (due to pregnancy)

usually occur around 6-7 wks of pregnancy

26
Q

signs of ectopic pregnancy

A

usually vague and not specific

tenderness +/- rebound

peritonism - due to severe blood irritation

cervical excitation - unilateral adnexal tenderness

27
Q

ix for ectopic pregnancy

A

pregnancy test - if -ve then exclude ectopic pregnancy

serial serum hCG - if inc 63% then intrauterine pregnancy, if sub-optimal inc = ectopic, if dec = miscarriage

serum progesterone - to distinguish if a pregnancy is failing - <20nmol s highly suggestive

TVUSS - confirm if intra-uterine pregnancy presence but does not confirm pregnancy (although highly suggestive)

laproscopy = definitive investigation

28
Q

what is the typical TV USS findings for an ectopic pregnancy

A

empty uterus
thickened uterus
free peritoneal fluid
adnexal mass next to the uterus

and +ve pregnancy test

if -ve pregnancy = complete miscarriage

29
Q

management of ectopic pregnancy

A

conservative
surgical
medical

30
Q

what does the conservative management of ectopic pregnancy involve?

A

nothing done but serial serum hCG should be taken until undetectable

31
Q

what does the medical management of ectopic pregnancy involve?

A

methotrexate - teaks 4-6 weeks to work

5% of pt will still need surgery

recommended for cervical ectopic

32
Q

side effect of methrotriexate

A

GI upset (difficult to distinguish from normal abdo disturbance in pregnancy)

stomatitis

conjuntivitis

33
Q

what does the srugical management of ectopic pregnancy involve?

A

usually salpingotectomy - take the affected fallopian tube away

but can do salpingotomy - aspirate/only remove the affected area in the fallopian tube if the other fallopian tube already affected in some way

34
Q

what must you provide for a patient with ectopic pregnancy

A

anti-D for rhesus -ve women

35
Q

what is the prognosis in terms of future pregnancy in ectopic pregnancy

A

60% will have an intrauterine pregnancy subsequently

recurrence rate = 10%

36
Q

What is another name for molar pregnancy

A

Gestational trophoblastic disease

37
Q

What is the aetiology of gestational trophoblastic disease

A

Normally the trophoblastic tissue (part of the blastocyst) invades the endometrium to form the placenta

However, this proliferation of trophoblasts are too aggressive due to various reason that it takes over space meant for the growth of foetus leading to non-viable pregnancy

38
Q

What are the different types of hydatidiform mole?

A

Complete
Incomplete
Malignancy

39
Q

What is complete hydatidiform mole

A

It is when a single sperm fertilised with an empty ovum which normally does not implants to the endometrium, but somehow it does

There is no genetic materials in the gestational sac only a disorganised mass of tissue but not embryo

40
Q

What is incomplete hydatidiform mole

A

It is when 2 sperms fertilised a normal ovum

There is too much genetic materials leading to extra trophoblasts proliferation but this leaves no room for growth of foetus and so some foetal materials present but incomplete

41
Q

What is malignant hydatidiform mole

A

Can be localised to the uterus - invasive

Can be mets - choriocarcinoma

42
Q

What is choriocarcinoma

A

Local spread of trophoblastic tissue that commonly spread to lungs

50% of choriocarcinoma preceded by molar pregnancy
40% in normal pregnancy
5% by miscarriage
5% by non-gestational origin

43
Q

What ar the symptoms of molar pregnancy

A

PV bleeding most common - due to stimulation of oestrogen

Pregnancy symptoms - amenorrhoea, breast tenderness, N+V

No symptoms at all - usually diagnosed with a routine screen scan

Rare - hyperemesis gravidarum, HTN and symptoms of hyperthyroidism

44
Q

Ix for molar pregnancy

A

Serum hCG - if > 1000 IU/L then should suspect molar pregnancy

Large for gestational age - proliferation issues

TV USS - shows no foetal materials, snowstorm appearance (multiple vesicular appearance in the uterus)

CXR - to rule out spread and choriocarcinoma

GC+S - in case of surgery needed

45
Q

Treatment of molar pregnancy

A

Dilation and evacuation of the pregnancy - manual dilation with the help of oxytocin for softening of the cervix

Can do hysterectomy if no future fertility desire

Chemo if choriocarcinoma

46
Q

Prognosis of molar pregnancy

A

50% end up have a choriocarcinoma (which is v. Invasive but very sensitive to chemo)

90-100% 5 years survival rate

Only 1 in 60 will have future pregnancies problem

47
Q

What is another name for fibroid

A

Leiomyomata of the myometrium of uterus

48
Q

What is the aetiology of leiomyomata

A

Due to oestrogen (probs progesterone) level inc, the myometrium proliferate and become a benign tumour

49
Q

When will leiomyomata regress?

A

Usually after menopause due to diminishing oestrogen level

50
Q

What is the incidence of leiomyomata?

A

20-40% in reproductive age

Highest incidence in Afro-Caribbean worm n

51
Q

What are the different types of leiomyomata

A

Submucosa - > 50% into the uterine cavity

Inter-mural - whithin the myometrium layer

Subserous - > 50% outside of the uterine contour

Intra-uterine polyps

Subserous polyps

Cervical - uncommon but can be surgically difficult since it is very close to the bladder

Pedunuculated - mobile and prone to torsions

Parasites - separated from the uterus and can attach to other organs

52
Q

What are the symptoms of leiomyomata

A

Usually no symptoms at all

Can have dysmenorrhoea, menorrhagia, pressure symptoms eg frequency, sub fertility/infertility

Bloating

IMB

Pregnancy - pelvic pain, obstruction in difficult C-section if it is cervical fibroids, abnor lie,

53
Q

What are the investigation for leiomyomata

A

Clinical examination - Bimanual - shows a large, irregular firm mass in the uterus

USS - can be abdo or TVS - shows irregular mass

Hysteroscopy

Biopsy

54
Q

Treatment of leiomyomata

A

Not treatment - if minimal symptoms

GnRH analogue (Leuprorelin) to try and shrink the fibroids

Myomectomy - open, laparoscopic or hysteroscopy

Hysterorectomy

Uterine artery embolisation - last resort

55
Q

What are the medication used in medical theory of fibroids?

A

Leuprorelin - GnRH analogue which is used as new-adjuvant prior to surgery

Mifepristone (anti-progesterone analogue) - help to reduce size of fibroid which depends on progesterone to a degreee

56
Q

What are the complications of leiomyomata

A

Torsion of the pedunuculated fibroid

Degeneration of the uterus - red (particular in pregnancy), calcification in postmenopausal

Malignancy - leiomyoscarcoma

57
Q

What make fibroid malignant more likely

A

Uncommon for them to be malignant but if

Pain and rapid growth

Repaid growth in post-menopausal and not on HRT

Poor response to GnRH treatment

Y4 - GOSH (12 decks)

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