Gynaecological core conditions 2 Flashcards
Molar pregnancy
Abnormal proliferation of trophoblastic tissue (1-2.5/1000)
Types of molar pregnancy
- Complete hydatiform mole: no normal fetal tissue forms
- Partial hydatidiform mole: incomplete fetal tissue develops alongside molar tissue
- Invasive mole: contain many villi, but these may grow into or through the muscle layer of the uterus wall, persistently high HCG
- Choriocarcinoma: have cytotrophoblasts and syncytiotrophoblasrs but no villi form
Complete mole
- Most common type of hydatidiform mole. Diffuse thropoblastic hyperplasia, hydropic swelling of chorionic villi, no fetal tissue or membrane present
- Hydropic villi and focal trophoblastic hyperplasia are associated with 46XX or 46XY
- 10% INVADE AND 3% CHORIOCARCINOMA
Clinical features of a complete mole
- Vaginal bleeding -97%
- Uterus larger than date -51%
- Hyperemesis gravidarum – 26%
- B-hcg > 100,000
- No fetal heart beat
- Presentation similar to threatened/ spontaneous/ missed miscarriage
Incomplete molev
- Often triploid (69(XXY,XYY,XXX) with chromosome complement from both parents 2 sperm fertilize 1 egg or 1 sperms with reduplication.
- 1% RISK OF INVASION, does not become choriocarcinoma
Investigations for molar pregnancy
- UPT (urine pregnancy test): B-hcg level
- U/S Complete – no fetus, classic snow storm
- U/S Incomplete – molar degeneration of placenta +/- fetal anomalies, multiple echogenic regions corresponding to hydropic villi and focal intrauterine haemorrhage
- CXR – may show metastatic lesions
Molar pregnancy: features of high risk neoplasm
- Local uterine invasion
- Beta hG >100,000
- Excessive uterine size
- Prominent theca- lutein cyst
Molar pregnancy- treatment
- Suction and curettage
- Anti-D in rhesus -ve
- If bleeding hysterectomy may ne needed
- Chemotherapy for chorio-carcinoma
Molar pregnancy- follow up
- Register with the national centres
- B-hcg 2/52 till normal
- Follow up monthly for 1 year
- Follow up 3 monthly in 2nd year
Hyperemesis Gravidarum- complications
- Inability to keep down fluids or solids leading to dehydration, electrolytes and nutrients deficiency.
- Leading to weight loss (2-5 kg)
- Dehydration
- Electrolyte imbalance
- Vitamin B deficiency(B6-polyneuropathy, Thiamine deficiency-Wernicke’s encephalopathy)
- Rarely liver failure, renal failure , fetal and maternal mortaliy.
- Mallory-Weiss tears of oesophagus and haematemesis
- Wernicke’s encephalopathy , osmotic demylination syndrome-(pyramidal tract sighs, spastic quadriparasis, pseudobulbar palsy and impaired consciousness).
Hyperemesis gravidarum- risk factors
- Higher levels of HCG
- Multiple pregnancies
- Molar pregnancies
Hyperemesis gravidarum- differential diagnosis
- Maternal medical conditions leading to excessive vomiting
- Anorexia nervosa and Bulimia
- Thyrotoxicosis
- Diabetic ketoacidosis
- Infections- UTI, GI problems, cholecystitis
Hyperemesis gravidarum- Investigations
- FBC and clotting
- U&E, Haematocrit, LFTs, Thyroid Function Tests if prolonged
- Urine for ketones, culture and sensitivity
- USS ? Multiple pregnancies, molar pregnancy
- Social aspects
Hyperemesis gravidarum
Most severe form of nausea and vomiting during pregnancy. This can lead to dehydration and weight loss. Different from morning sickness
Hyperemesis gravidarum- Wernickes encephalopathy
Diplopia, abnormal ocular movement, ataxia and confusion. Typical ocular signs are 6th nerve palsy, gaze palsy or nystagmus
Occurs in the pregnant women secondary to thiamine deficiency
Wernicke’s encephalopathy can be precipitated by I/V dextrose solutions. Severe hyponatremia as well as rapid correction-osmotic demylation syndrome-central pontine mylinolysis
Hyperemesis gravidarum- treatment
- Mild cases can be dealt in Pregnancy assessment unit. Refractory cases will need admission.
- I/V fluids -normal saline, hartman solution and electrolyte replacements.
- Anti-emetics (avoid ondanstron)
- Small frequent meals
- Vitamin B supplements specially thiamine.
- Social and mental health Support.
- Rarely parenteral feeding and steroids.
- Usually Termination of pregnancy is not required and multi-disciplinary care with involvement of Psychiatry, Gasroenterology ,dietetician and obstetric team will resolve the problem.
Ovarian hyperstimulation syndrome
Seen in some forms of infertility treatment. It is postulated that the presence of multiple luteinized cysts within the ovaries results in high levels of not only oestrogens and progesterone but also vasoactive substances such as vascular endothelial growth factor (VEGF). This results in increased membrane permeability and loss of fluid from the intravascular compartment. Most likely seen following gonadotropin or hCG treatment
Up to 1/3 of patients undergoing IVF may have a mild form of OHSS
Mild and moderate OHSS
Mild= abdominal pain, abdominal bloating
Moderate= as for mild, nausea and vomiting, ultrasound evidence of ascites
Severe and critical OHSS
Severe= as for moderate, clinical evidence of ascites. Oliguria, Haematocrit >45%, hypoproteinaemia
Critical= as for severe, thromboembolism, acute respiratory distress syndrome, anuria, tense ascites
Endometriosis
Presence of endometrial like tissue outside the uterus, which induces a chronic inflammatory reaction
About 2-10% of the population and 50% of infertile women.
Common sites: pelvic organs, peritoneum, occasionally other parts of the body like lungs
Clinical features of endometriosis
- Chronic pelvic pain
- Secondary dysmenorrhoea: pain often starts days before bleeding
- Deep dyspareunia
- Subfertility
- Non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements)
- On pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen
- Chronic fatigue
- Can be asymptomatic. Little correlation between stage and type/severity of pain symptoms
Endometriosis- risk factors
- Age
- Increased peripheral body fat
- Greater exposure to menstruation
- Genetic predisposition 6-10 times more common in the first degree relatives of affected women
- Protective factors-smoking ,cocp pills, exercise