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Reproductive > Pathological Issues > Flashcards

Pathological Issues Flashcards

1
Q

Post-partum haemorrhage

A

Primary; blood loss >500ml within 24 hours of delivery

TONE TRAUMA TISSUE THROMBIN

Secondary; blood loss >500ml from 24 hours to 6wks post-partum

NB lochia normal for 3-4 weeks postnatal “should be a period or less”

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2
Q

Thromboembolic disease

A

Pregnant woman 6-10x as likely to develop thromboembolism (DVT or PE)

high quality risk assessment and appropriate thromboprophylaxis required to reduce risk

D-dimer unreliable in pregnancy

Investigate;

  • ECG
  • leg dopplers
  • CXR +/- VQ scan

Treat with LMWH

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3
Q

Maternal sepsis

A

Leading cause of maternal death in UK

May present atypically

In any woman you suspect; prompt IV AB administration

Perform full septic screen; blood cultures, LVS, MSSU, wound swabs

antipyretic measures, IV fluids, referral to hospital if concerned about sepsis

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4
Q

Describe postnatal depression

A

Can continue from baby blues or start sometime later

Has classical ‘depressive’ symptoms

Affects functioning, bonding and often requires treatment

Increased risk in women with personal or FH of affective disorder

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5
Q

Describe puerperal psychosis

A

Rare but serious psychotic illness of postnatal period

Women can be a danger to themselves and their babies

Requires inpatient psychiatric care

Much more common in women with personal or FH of affective disorder, bipolar disorder or psychosis

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6
Q

Describe postnatal hypertensive disorders

A

Most eclamptic seizures occur in postnatal period

Pre-eclampsia can develop post-natally or may worsen several days following delivery

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7
Q

Describe how a case may present with a miscarriage

A

Woman misses period and has positive pregnancy test

Vaginal bleeding X weeks after missed period

US shows no foetus but membranes and decidua lining uterus are there

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8
Q

What are some causes of miscarriage?

A

Chromosomal abnormality

Infection

Maternal issues; ill-health, trauma, hormonal problems

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9
Q

How may an ectopic pregnancy present?

A

Woman misses period; X weeks pregnant, small amount bleeding per vaginum

B-hCG raised

US shows thickened lining of endometrial cavity, expanded fallopian tube on one side

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10
Q

Describe how a ruptured ectopic pregnancy may present

A

Women with sudden severe abdo pain

May collapse

Admission to A&E with fast pulse, low BP

Blood given and emergency laparotomy; several litres of blood in abdomen flowing from fallopian tube area

Microscopy; blood, fragments of fallopian, occasional chorionic villi

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11
Q

What is an ectopic pregnancy?

A

A pregnancy in the wrong anatomical site

Most common in fallopian tube

Lack of proper decidual layer and small size of tube predispose to haemorrhage and rupture

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12
Q

What is a molar pregnancy?

A

Abnormal form of pregnancy in which a non-viable fertilised egg implants and fails to come to term

This is a gestational trophoblastic disease and will have chorionic villi clusters, presenting like bunches of grapes

It is a form of precancer of trophoblast cells

If it persists it can (rarely) give rise to a malignant tumour called choriocarcinoma

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13
Q

Describe normal fertilisation with altered genes

A

Mum to be switches off certain genes in ova (eggs) by methylating them

Dad to be switches off different genes in sperm by methylating them

If BOTH have changes; Changes in mum promote early baby growth
Changes in dad promote early placenta growth via trophoblast proliferation
They will balance out

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14
Q

What are causes of molar pregnancy?

A

Various but most often caused by 2 sperm fertilising one egg with NO chromosomes

This results in an imbalance in methylated (switched off) genes

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15
Q

What is the treatment for molar pregnancy?

A

If B-cHG returns to normal then no further treatment

If B-cHG stays high then cure by methotrexate

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16
Q

What is maternal mortality?

A

The death of a woman while pregnant or within 42 days of termination of pregnancy

Irrespective of duration and site of pregnancy

From any cause related to or aggravated by the pregnancy or its management, but not accidental or incidental causes

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17
Q

What is maternal morbidity?

A

Severe health complications occurring in pregnancy and delivery not resulting in death

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18
Q

What is the maternal mortality ratio?

A

Number of maternal deaths during given time period per 100,000 live births during same time period

REPRESENTS RISK ASSOCIATED WITH EACH PREGNANCY

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19
Q

What is the maternal mortality rate?

A

Number of maternal deaths in given time period per 100,000 women of reproductive age, or women-years fo risk exposure, in same time period

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20
Q

What is the lifetime risk of maternal death?

A

Probability of maternal death during a woman’s reproductive life, usually expressed in terms of odds

A MEASURE FO THE RISK OF BECOMING PREGNANCY AS WELL AS RISK OF DYING WHILE PREGNANT

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21
Q

What is the proportionate mortality ratio?

A

Maternal deaths as proportion of all female deaths of those of reproductive age - usually defined as 15-49 years - in a given time period

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22
Q

What are some facility based methods for measuring maternal death?

A
  • Health information systems
  • Registries
  • Confidential enquiries
  • Maternal death review
  • Audit; critical incident audit, criterion based clinical audit
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23
Q

What are some community/population based methods for measuring maternal death?

A
  • notification by law
  • vital registration
  • census
  • surveys or surveillance; sisterhood method, verbal autopsy
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24
Q

Why do mothers die?

A

Direct deaths; those related to obstetric complications or resulting from treatment received

Indirect deaths; those associated with a disorder, the effect of which is exacerbated by pregnancy e.g. malaria

Late deaths occur ≥ 42 days after end of pregnancy but within one year

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25
Q

Describe the three delays model

A

Focuses on global scene

  • Delay in decision to seek care
  • Delay in reaching care
  • Delay in receiving care
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26
Q

How can we prevent maternal mortality?

A

Antenatal care
- 4 visits, monitoring weight, BP and proteinuria, folic acid, malaria prophylaxis

Skilled attendant at birth

Emergency obstetric care
- clean delivery, active management III stage

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27
Q

What is stillbirth?

A

Birth of a dead baby after 20/24/28 weeks of gestation weighing more than 500g

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28
Q

What is early neonatal death?

A

Death of a baby within first week of life

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29
Q

What is late neonatal death?

A

Death of a baby within first 28 days of life

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30
Q

What is perinatal mortality?

A

Includes stillbirth and neonatal mortality

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31
Q

What is infant mortality?

A

Death of an infant within first year of life

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32
Q

What is child mortality?

A

Death of a child within first 5 years of life

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33
Q

What is some essential newborn care?

A

Ensuring baby is breathing

Starting newborn on exclusive breastfeeding right away

Keeping warm

Washing hands before touching baby

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34
Q

What is the incidence of spontaneous miscarriage and the categories?

A

~15%, maybe higher

Threatened
Inevitable
Incomplete
Complete
Septic
Missed
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35
Q

Describe threatened miscarriage

A

Vaginal bleeding +/- pain first 20 weeks

Viable pregnancy

Closed cervix on speculum examination

36
Q

Describe inevitable miscarriage

A

Viable pregnancy

Open cervix with bleeding that could be heavy (+/- clots)

May follow threatened miscarriage or without warning

37
Q

Describe missed miscarriage

A

No symptoms or could have bleeding/brown loss vaginally

Gestational sac seen on scan

No clear foetus or foetal pole with no foetal heart

38
Q

Describe incomplete miscarriage

A

Most of pregnancy expelled out but some products of pregnancy remain in uterus

Open cervix, vaginal bleeding (may be heavy)

39
Q

Describe complete miscarriage

A

Passed all products of conception, cervix closed, bleeding stopped

40
Q

Describe septic miscarriage

A

Especially in cases of incomplete miscarriage; development of infection in uterus

41
Q

What are causes of spontaneous miscarriage?

A

Abnormal conceptus; chromosomal, genetic, structural

Uterine abnormality; congenital, fibroids

Cervical incompetence; primary, secondary

Maternal; increasing age, diabetes

42
Q

How do you manage a threatened miscarriage?

A

Conservative

43
Q

How is an inevitable miscarriage managed?

A

If bleeding heavy may need evacuation

44
Q

How is a missed miscarriage managed?

A

Conservative

Medical; prostaglandins (misoprostol)

Surgical; surgical management of miscarriage (SMM)

45
Q

How is a septic miscarriage managed?

A

Antibiotics and evacuate uterus

46
Q

What is an ectopic pregnancy?

A

A pregnancy implanted outside the uterus

47
Q

What are risk factors for ectopic pregnancy?

A

Pelvic inflammatory disease
Previous tubal surgery
Previous ectopic
Assisted conception

48
Q

Describe possible presentation of ectopic pregnancy

A

Period of ammenorrhoea (with +ve urine pregnancy test)

+/- vaginal bleeding
+/- pain abdomen
+/- GI or urinary symptoms

49
Q

How do you investigate a query ectopic pregnancy?

A

Scan; no intrauterine gestational sac, may see adnexal mass, fluid in Pouch of Douglas

Serum bHCG; may need to serially track over 48hours

Serum progesterone; with viable IU pregnancy high levels >25ng/ml

50
Q

How do you manage a ectopic pregnancy?

A

Medical; methotrexate

Surgical; mostly laparoscopical i.e. salpingectomy, salpingotomy for few indications

51
Q

When would a salpingectomy be indicated?

A

If a woman has an ectopic pregnancy

This procedure removes one of her fallopian tubes to remove the ectopic

52
Q

When would a salpingotomy be indicated?

A
  • patient desires to preserve her fertility
  • patient is haemodynamically stable
  • tubal pregnancy accessible
  • unruptured and <5cm in size
  • contralateral tube is absent or damaged
53
Q

What is ante-partum haemorrhage?

A

Haemorrhage from genital tract after the 24th week of pregnancy but before delivery of the baby

54
Q

Causes of ante-partum haemorrhage

A 
Placenta praevia
Placental abruption
APH of unknown origin 
Local lesions of the genital tract
Vasa praevia (very rare)
55
Q

Describe placenta praevia

A

This is when the placenta is lying low in the womb, near to or covering the cervix

This may block the baby’s way out

Classifications are Grade I - IV

56
Q

Describe placental abruption

A

This is when the placenta separates early from the uterus

Occurs most commonly around 25 weeks

Symptoms include lower abdominal pain, vaginal bleeding and dangerously low BP

57
Q

Describe vasa praevia

A

A condition in which foetal blood vessels cross or run near the internal opening of the uterus

The vessels are at risk of rupture when the supporting membranes rupture as they are supported by the umbilical cord or placental tissue

58
Q

Grade I placenta praevia

A

Placenta encroaching on lower segment but not internal cervical os

59
Q

Grade II placenta praevia

A

Placenta reaches internal os

60
Q

Grade III placenta praevia

A

Placenta eccentrically covers the os

61
Q

Grade IV placenta praevia

A

Central placenta praevia

62
Q

How can placenta praevia present?

A

Painless PV bleeding

Malpresentation of foetus

Incidental

63
Q

What are the clinical features of placenta praevia?

A

Maternal condition correlates with amount of bleeding PV

Soft, non-tender uterus +/- foetal malpresentation

64
Q

How is placenta praevia diagnosed?

A

US to locate placental site

Vaginal examination MUST NOT be done with suspected placenta praevia

65
Q

How is placenta praevia managed?

A

Depends on gestation and severity

C-section, watch for PPH

66
Q

How is PPH managed?

A

Medical management; oxytoci, ergometrine, carbaprost, tramexamic acid

Balloon tamponade

Surgical; B lynch suture, ligation of uterine, iliac vessels, hysterectomy

67
Q

What factors are associated with placental abruption?

A
  • pre-eclampsia / chronic hypertension
  • multiple pregnancy
  • polyhydramnios
  • smoking, increasing age, parity
  • previous abruption
  • cocaine use
68
Q

What are the clinical types of placental abruption?

A
  • revealed
  • concealed
  • mixed (concealed and revealed)
69
Q

Describe the presentation of placental abruption

A

Pain

Vaginal bleeding (may be minimal bleeding)

Increased uterine activity

70
Q

General management of Ante-Partum Haemorrhage

A

Varies from expectant treatment to attempting a vaginal delivery to immediate C-section depending on;

  • amount of bleeding
  • general condition of mother and baby
  • gestation
71
Q

What are complications of placental abruption?

A

Maternal shock, collapse (may be disproportionate to amount of bleeding seen)

Foetal death

Maernal DIC, renal failure

PPH

72
Q

Describe pre-term labour?

A

Onset of labour < 37 weeks gestation

32-36 weeks mildly pre-term
28-32 weeks very pre-term
24-28 weeks extremely pre-term

Can be spontaneous or induced

73
Q

What are pre-disposing factors to preterm labour?

A 
Multiple pregnancy
Polyhydramnios
APH
Pre-eclampsia
Infection eg UTI
Prelabour premature rupture of membranes
74
Q

How do you manage pre-term delivery?

A

Diagnosis; contractions with evidence of cervical change on VE

Consider possible cause
- abruption, infection

<24-26 weeks

  • generally v poor prognosis
  • decision made with both parent and neonatologists

All cases are considered viable

  • consider tocolysis to allow steroids/transfer
  • steroids unless contraindicated
  • transfer to unit with NICU facilities
  • aim for vaginal delivery
75
Q

What are tocolytics?

A

Drugs that prevent preterm labour and uterine contractions

  • magesium sulfate
  • beta-mimetics
  • oxytocin antagonists
  • Calcium channel inhibitors
  • adrenergic beta-receptor agonists
76
Q

Do opiates cross the placenta?

A

yes

77
Q

If an IV heroin user is pregnant what is the procedure for birth and post-natal care?

A

Prebook to deliver in maternity unit beside neonatal unit

This is so baby can be admitted and treated for heroin withdrawal

78
Q

Describe the usual presentation after baby is born if the mother was an IV opiate user

A

Pregnancy often proceeds well if mother eating properly

Immediate heroiin withdrawal when baby born

Later withdrawal fro methadone

79
Q

Describe presentation of intrauterine death

A

Normal pregnancy to term, decreased movements at ~40 weeks

Scan shows no heart movement

80
Q

Describe overtwisted cord

A

A common cause of intrauterine death and neonatal illness

81
Q

Describe possible presentation of placental abruption

A

vaginal bleed at 35 weeks

US shows separation placenta from uterus with haematoma behind placenta

Treatment is emergency caesarian

82
Q

What is seen histologically on a yolk sac tumour?

A

Schiller-Duval bodies

83
Q

What is seen histologically on a Granulosa cell tumour?

A

Call-Exner bodies

84
Q

What is seen histologically on a Krukenberg tumour?

A

signet cell appearance

85
Q

What is the difference between hirsutism and hypertrichosis?

A

Hirsutism is androgen dependent hair growth

Hypertrichosis is androgen independent hair growth

86
Q

What are some causes of hypertrichosis?

A

Anorexia nervosa

Poryphyria cutanea tarda (photosensitivity)

Drugs; minoxidil, ciclosporin, diazoxide

Reproductive (11 decks)

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