early pregnancy problems and benign tumours Flashcards
what is miscarriage
loss of a pregnancy before it is viable
what do you call the loss of pregnancy before 24 weeks
miscarriage
what do you call the loss of pregnancy after 24 weeks?
stillbirth/neonatal
what is the most common time for a miscarriage to take place
week 12 - ie first trimester
what is recurrent miscarriage
3 or more consecutive miscarriage with the same partner
how common is miscarriage
12% of all pregnancy
what are the causes of miscarriage
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
what are the most common symptoms of miscarriage
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
what are some investigations for miscarriage
history and examination
transvaginal USS
beta hCG - pregnancy test
blood group and rhesus status
what are the normal USS findings of a viable pregnancy
at week 5 - gestational sac of 5-6 mm +/- yolk sac
at week 5 - foetal pole possible to be seen, foetal heart activity
what are the USS findings of a non-viable pregnancy
gestational sac with foetus but not heartbeat
what are the USS findings of a pregnancy with an uncertainty
sac and foetus but no heart beat
when is the cut off point for a pregnancy to be non-viable
gestational sac > 7mm and no heartbeat
what should you do when you discover a pregnancy of uncertain viability
rescan 7-14 days
what are the management of miscarriage
expectant
surgical
medical
what are the medical management of miscarriage
- 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
what are the surgical management of miscarriage
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
what are some causes to recurrent miscarriage
PCOS
antiphospholipid antibody syndrome
uterine abnor
what count as heavy bleeding in pregnancy
3 pad in < 1 hour
or
pass clot larger than the size of your palm
if occurs will need to contact someone urgently
how long does it take for hCG/pregnancy test to become normal/-ve
hCG excreted by kidney
can take up to 3 wks before levels becomes undetectable
What is the definition of ectopic pregnancy
when implantation of the fertilised egg outside the body of uterus
what is the most common place for ectopic pregnancy
tubal - 90%
what are other places where ectopic pregnancy can occur
abdo
cervix - dangerous
C-section scars
ovaries
what are the risk factors of ectopic pregnancy
ovary
- IVF
tubal
- PID - chlamydia
- previous ectopic pregnancy
- previous tubal surgery
- failed sterilisation
endometrium
- IUD
- endometriosis
smoking
symptoms of ectopic pregnancy
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
signs of ectopic pregnancy
usually vague and not specific
tenderness +/- rebound
peritonism - due to severe blood irritation
cervical excitation - unilateral adnexal tenderness
ix for ectopic pregnancy
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
what is the typical TV USS findings for an ectopic pregnancy
empty uterus
thickened uterus
free peritoneal fluid
adnexal mass next to the uterus
and +ve pregnancy test
if -ve pregnancy = complete miscarriage
management of ectopic pregnancy
conservative
surgical
medical
what does the conservative management of ectopic pregnancy involve?
nothing done but serial serum hCG should be taken until undetectable
what does the medical management of ectopic pregnancy involve?
methotrexate - teaks 4-6 weeks to work
5% of pt will still need surgery
recommended for cervical ectopic
side effect of methrotriexate
GI upset (difficult to distinguish from normal abdo disturbance in pregnancy)
stomatitis
conjuntivitis
what does the srugical management of ectopic pregnancy involve?
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
what must you provide for a patient with ectopic pregnancy
anti-D for rhesus -ve women
what is the prognosis in terms of future pregnancy in ectopic pregnancy
60% will have an intrauterine pregnancy subsequently
recurrence rate = 10%
What is another name for molar pregnancy
Gestational trophoblastic disease
What is the aetiology of gestational trophoblastic disease
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
What are the different types of hydatidiform mole?
Complete
Incomplete
Malignancy
What is complete hydatidiform mole
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
What is incomplete hydatidiform mole
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
What is malignant hydatidiform mole
Can be localised to the uterus - invasive
Can be mets - choriocarcinoma
What is choriocarcinoma
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
What ar the symptoms of molar pregnancy
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
Ix for molar pregnancy
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
Treatment of molar pregnancy
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
Prognosis of molar pregnancy
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
What is another name for fibroid
Leiomyomata of the myometrium of uterus
What is the aetiology of leiomyomata
Due to oestrogen (probs progesterone) level inc, the myometrium proliferate and become a benign tumour
When will leiomyomata regress?
Usually after menopause due to diminishing oestrogen level
What is the incidence of leiomyomata?
20-40% in reproductive age
Highest incidence in Afro-Caribbean worm n
What are the different types of leiomyomata
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
What are the symptoms of leiomyomata
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,
What are the investigation for leiomyomata
Clinical examination - Bimanual - shows a large, irregular firm mass in the uterus
USS - can be abdo or TVS - shows irregular mass
Hysteroscopy
Biopsy
Treatment of leiomyomata
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
What are the medication used in medical theory of fibroids?
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
What are the complications of leiomyomata
Torsion of the pedunuculated fibroid
Degeneration of the uterus - red (particular in pregnancy), calcification in postmenopausal
Malignancy - leiomyoscarcoma
What make fibroid malignant more likely
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
