Placental Problems Flashcards
Spontaneous miscarriage
Foetal death/delivery <24 weeks of gestation
Recurrent miscarriage
3 or more miscarriages in succession
Threatened miscarriage
Light and painless bleed Foetus is alive Uterus size as expected for gestation Cervical os closed 25% go on to miscarry
Inevitable miscarriage
Miscarriage about to occur Bleeding heavier Foetus may still be alive Cervical os open Crampy pelvic pain
Incomplete miscarriage
Some, but not all foetal parts have been passed
Cervical os open
Complete miscarriage
Miscarriage has happened + finished
Bleeding has stopped/diminished
Uterus no longer enlarged
Cervical os closed
Septic miscarriage
Contents of uterus infected- -endometritis Vaginal loss is offensive Tender uterus Fever may be present May progress to pelvic pain (abdo pain)
Missed miscarriage
Foetus has died/not developed in utero
Only recognised later when bleeding occurs or USS performed
Uterus smaller than expected for gestation
Cervical os closed
Maybe mild abdo pain + bleeding
Ectopic pregnancy
Implantation of a fertilised ovum outside the endometrial cavity
- -> 70% will have subsequent successful pregnancy
- ->10-15% ectopic again
Ectopic pregnancy sites
Tubal (95%) --> Isthmus (25%) --> ampulla (55%) --> fimbriae (17.4%) Other- ovarian, interstitial, cornual, cervical, abdominal
Ectopic pregnancy RFs
Previous ectopic STI/PID Prolapse IUCD Endometriosis Assisted conception Failed sterilisation
Ectopic pregnancy- Clinical features
PV bleeding Lower abdo pain Collapse Tachycardia Abdominal tenderness Unilateral adnexal tenderness Cervical excitation Small uterus Cervical os closed
Ectopic pregnancy Investigations
Urine BetaHCG- to confirm pregnancy
Transvaginal USS- failure to localise in-utero suggests
–> gestation too early to visualise (<5 weeks)
–> complete miscarriage
–> ectopic pregnancy
Gestational trophoblastic disease (molar pregnancy)
When trophoblastic tissue that forms part of blastocyst proliferates more aggressively than usual
- -> non-invasive- hydatidiform mole
- -> locally invasive- invasive mole
- -> metastatic- choriocarcinoma
Partial mole
Two sperms fertilise an egg
Results in triploid conceptus with 69 chromosomes
Foetal tissue present
Malignant change rare
Complete mole
Two types- monospermic and dispermic
Results in a conceptus with 46 chromosomes but all derived from father
No foetal tissue seen at histology, just swollen chorionic villi
Monospermic complete mole
Maternal chromosomes are lost AND paternal chromosomes double up
Dispermic complete mole
Maternal chromosomes are lost AND fertilisation by 2 sperm
Molar pregnancy clinical features
PV bleeding
Hyperemesis gravidarum- excess HCG production
Passage of vesicles PV
Molar pregnancy examination
Large uterus
Early pre-eclampsia + hyperthyroidism
Molar pregnancy investigation
USS- snowstorm appearance
Molar pregnancy management
Evacuation of retained products of conception –> send tissue to histology for diagnosis
Serial bHCG levels- persistent or rising levels suggest malignancy
Pregnancy + COCP avoided until bHCG levels normal
Molar pregnancy recurrence
1 in 60
Antepartum haemorrhage (APH)
PV bleed > 24 weeks gestation but before delivery of baby
APH examples
Placental abruption Placenta praevia Placenta accrete Vasa praevia Uterine rupture Incidental genital tract pathology
Placental abruption
Part or all of placenta separates before delivery
Considerable amount of maternal bleeding- DIC, renal failure, maternal death
Acute foetal distress- foetal death in 30%
Placental abruption RFs
Previous history IUGR Pre-eclampsia Autoimmune disease Smoking Multiparity Polyhydramnios
Placental abruption clinical features
Tender and hard uterus Foetal distress or absent heart sounds Tachycardia Hypotension Abdominal pain Vaginal bleeding
Placental abruption investigations
FBC Urea Creatinine Coagulation screen Cross-match blood USS to rule out placenta praevia CTG Catheterisation with hourly urine output CVP monitoring to access blood loss + replacement
Placental abruption management
Maternal/foetal distress- emergency C section
No foetal distress and >37 weeks- induction of labour
Dead baby- induction of labour
Placenta praevia
Placenta implanted in lower segment of uterus >24 weeks
Placenta praevia RFs
Multiple gestation
High parity
Increased maternal age
Scarred uterus- e.g. previous C section
Placenta praevia issues
Placenta in lower segment obstructs engagement of head- necessitates C section
PPH likely as lower segment is less able to contract + constrict maternal haemorrhage
Placenta accreta
Placenta attaches to site of previous scar- severe PPH risk
Placenta perceta
Invasion completely through uterine wall, sometimes into nearby tissues e.g. bladder
Placenta increta
Placenta invades at least halfway through uterine wall
Vasa praevia
Membranous insertion of the cord- major vessel implanted into membrane, forms branches to placenta
Vasa praevia effect
When membranes rupture, foetal bleeding + rapid exsanguination
Painless/moderate PV bleed at rupture or membranes/amniotomy accompanied by severe foetal distress
CS rarely fast enough to save baby
Uterine rupture
Rarely occurs before labour
Either old C-section scar opening or de novo rupture of uterus
Foetus extruded
Uterus contracts down + bleeds from rupture site
Foetal hypoxia and maternal haemorrhage
Miscellaneous gynaecological causes of APH
Lower genital tract neoplasms- vulval, vaginal, cervical
Cervical polyps
Genital infections
