Gynecology 5th year, 3rd & 4th lectures (Dr. Muhabat Salih Saeid)

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Health & Medicine


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The lecture has been given on Nov. 29th & Dec. 1st, 2010 by Dr. Muhabat Salih Saeid.
  • 1. Early pregnancy bleeding Dr. Muhabat Salih Saeid MRCOG-London-UK
  • 2. Goals of the talk: <ul><li>Differential diagnosis/work up for first trimester bleeding </li></ul><ul><li>Different types of first trimester pregnancy loss </li></ul>
  • 3. <ul><li>Bleeding in Early Pregnancy </li></ul><ul><li>Abortion </li></ul><ul><li>Ectopic Pregnancy </li></ul><ul><li>Trophoblastic disease </li></ul><ul><li>Lesions of cervix or vagina </li></ul><ul><li>Placentation </li></ul>
  • 4. History Examination Investigations Diagnosis Management Assessment
  • 5. History and examination LMP Duration of amenorrhea Menstrual history Contraceptive history Planned? Nature of bleeding pain <ul><li>Observations ? Haemodynamically stable </li></ul><ul><li>Abdominal palpation </li></ul><ul><li>Speculum examination- look for lacerations, warts, vaginitis, cervical polyps, fibroids, ectropion, cervicitis, neoplastic process </li></ul><ul><ul><li>Vaginal examination- assess adnexal/cervical tenderness, adnexal masses, uterine enlargement </li></ul></ul>
  • 6. <ul><li>Cornerstone of evaluation </li></ul><ul><li>Most useful with positive preg test where IUP not previously seen </li></ul><ul><li>Uses: location of pregnancy (intra- or extrauterine), </li></ul><ul><li>viability (+/- FCA), </li></ul><ul><li>other rare findings (GTD, partial loss of multiple gestation) </li></ul><ul><li>Transvaginal </li></ul><ul><li>Look for pregnancy within the uterus </li></ul><ul><li>Presence of fetal heart </li></ul><ul><ul><li>Should be present 6 weeks </li></ul></ul><ul><ul><li>If CRL< 6mm or MSD<20mm with no yolk sac/fetus – rescan </li></ul></ul><ul><ul><li>Uncertain viability and unknown location </li></ul></ul><ul><li>Presence of yolk sac </li></ul><ul><li>Adnexal masses </li></ul><ul><li>Free fluid/ endometrial thickness </li></ul>USS findings
  • 7. Subserosal Fibroid
  • 8. <ul><li>Pregnancy hormone </li></ul><ul><li>Should approximately double in the first trimester every 48 hours </li></ul><ul><li>Usually see something in the uterus on TV scan at 1000 (1500 TA) </li></ul><ul><li>Ectopics usually visible at this level </li></ul><ul><li>Serial measurements are important – every 48 hours </li></ul><ul><ul><li>Rising, falling, stable, suboptimal rise </li></ul></ul>β HCG
  • 9. <ul><li>FBC - can indicate volumes of blood loss </li></ul><ul><li>Progesterone - <25 mmmol/l is associated with a non viable pregnancy. </li></ul><ul><ul><li>Absolute levels here </li></ul></ul><ul><ul><li>>60 v.strongly associated with viable pregnancy </li></ul></ul><ul><li>Blood group – need for anti D </li></ul>Other investigations
  • 10. <ul><li>Abortion: </li></ul><ul><li>Definition: Loss of pregnancy before viability. </li></ul><ul><li>i.e. before 24 weeks gestation or <500 grams (WHO </li></ul><ul><li>criteria) </li></ul><ul><li>Abortion is either: Spontaneous (Miscarriage) or </li></ul><ul><li> induced (Therapeutic / illegal) </li></ul><ul><li>Abortion may occur at any gestational age from 5 to 24 </li></ul><ul><li>weeks </li></ul><ul><li>* <12 weeks – first trimester abortion </li></ul><ul><li>* 12-14 weeks _ second trimester abortion </li></ul><ul><li>Commonest complication of pregnancy affecting up to </li></ul><ul><li>20% of women </li></ul><ul><li>Etiology is multifactorial </li></ul><ul><li>No single Rx can be applicable to all cases </li></ul>
  • 11. threatened inevitable incomplete missed
  • 12. <ul><li>Types of abortions: </li></ul><ul><li>1. Threatened Abortion </li></ul><ul><li>On history : a. Minimal vaginal bleeding: Red(fresh) </li></ul><ul><li> or dark(old) </li></ul><ul><li> b. Minimal or no abdominal pain </li></ul><ul><li>On examination: </li></ul><ul><li> a. The size of uterus is equivalent to that of expected for gestational age </li></ul><ul><li> b. Cervix is closed </li></ul><ul><li> c. Positive fetal heart sounds </li></ul><ul><li>*Ultrasound : Viable fetus. </li></ul><ul><li>* Management: </li></ul><ul><li>* Bed rest (though there is no evidence that rest will alleviate the course of pregnancy </li></ul>
  • 13. 2-Inevitable Abortion: O/H :lower abdominal pain similar to dysmenorrhoea which persist/worse O/E:Cervix is open Abortion will take its course Management: as incomplete abortion
  • 14. 3. Incomplete abortion: * OH: as inevitable i,.e. abdominal pain and passage of clots and tissues * O.E: Cervical os open - If bleeding is severe, the patient may be shocked - Suprapubic tenderness, the uterine size is corresponding to expected gestational age - Bimanual examination: products of conception may be left in the os or in vagina * Ultrasound : remnant of conception in the uterus * Management: - Treatment of shock (plasma expanders and blood transfusion) - Evacuation of retained products under general anaesthesia
  • 15. 4. Complete abortion: * History of abdominal pain and vaginal bleeding as well as passage of clots and tissues * On examination: The uterine size is smaller than expected for gestational; the cervical os is closed (the uterus expelled its contents) * Ultrasound shows empty uterus * Management : Patient usually well and fit to go home Threatened - ※Inevitable ※Incomplete ※ Complete Preg. Continues (majority)
  • 16. Complete miscarriage Bleeding and cramps which are usually settling
  • 17. 5. Septic abortion: * If abortion is associated with infection, it is called septic abortion * It is usually associated with incomplete induced abortion * History of abdominal pain, vaginal bleeding and may have foul vaginal discharge * On examination: the patient usually looks unwell; pyrexia with tachycardia If severe; the patient might have septic (endotoxic) shock Lower abdominal tenderness and enlarged tender uterus on bimanual examination
  • 18. <ul><li>* Management: </li></ul><ul><li>Admission to hospital </li></ul><ul><li>Check CBC (anaemia, leukocytosis) </li></ul><ul><li>vaginal swab for cs to identify the causative organism (commonest organism is Escherichia coli and streptococcus faecalis) </li></ul>
  • 19. <ul><li>* Treatment </li></ul><ul><li>Hypovolemia: </li></ul><ul><li>Monitor: BP, CVP, cardiac output, renal output </li></ul><ul><li>Treatment: intravenous rehydration </li></ul><ul><li>* Infection: </li></ul><ul><li>Broad spectrum antibiotics to cover all organisms then adjust the treatment according to vaginal swab C/S results </li></ul><ul><li>Evacuation of uterus under general anaethesia (suction evacuation) </li></ul><ul><li>This is a serious problem and may lead to renal failure, respiratory failure and even maternal death </li></ul>
  • 20. Missed miscarriage Spotting only usually. Expected to be 6-12 weeks by LMP. Fetal pole seen
  • 21. Missed Miscarriage
  • 22. 6. Missed abortion - Embryo dies and the uterus does not expel its contents - Loss of pregnancy symptoms - Uterine size is smaller than expected - Ultrasound showed: *no fetal heart * Embryo / Fetus size is smaller than expected for gestational age Management: If uterus size <12 weeks - evacuation under general anaethesia (suction currtage) bec. Risk of perforation if use sharp one as the uterus in this condition is soft. If uterine size >12 weeks - Extra-amniotic prostaglandins
  • 23. <ul><li>7. Therapeutic Abortion: </li></ul><ul><li>- Medical termination of pregnancy </li></ul><ul><li>- Indication </li></ul><ul><li>* To save the mother’s life </li></ul><ul><li>* To preserve the mother’s health </li></ul><ul><li>* To prevent the birth of a severely congenital abnormal child </li></ul><ul><li>T.O.P is indicated if the pregnancy constitutes a risk to the mother’s life or the fetal abnormality is incompatable with life (anecephaly) </li></ul><ul><li>Methods of T.O.P: </li></ul><ul><ul><ul><li>* If uterine size <12 weeks </li></ul></ul></ul><ul><ul><ul><li>- Evacuation under general anaethesia (suction </li></ul></ul></ul><ul><ul><ul><li>currtage) </li></ul></ul></ul><ul><ul><ul><li>* If uterine size >12 weeks </li></ul></ul></ul><ul><ul><ul><li>- Extra amniotic prostaglandins </li></ul></ul></ul>
  • 24. RECURRENT MISCARRIAGE Definition: Three or more consecutive pregnancy loss before viability Incidence 1% Etiology: * Genetic * Anatomical * Infective * Systemic * Immunological * Endocrine
  • 25. 1. Genetic: - Rare (5% of recurrent abortion will have paternal abnormal chromosomes) - usually cause early trimester abortion - Parental karyotyping: * Balanced reciprocal translocation * Invertions & mosaisms Management: Genetic counseling Karyotyping the product of conception Prenatal diagnosis Preimplantation diagnosis
  • 26. 2. Anatomical Causes: - Abnormal mullerian development (Bicorneate uterus, septate uterus, unicorneate uterus) - Uterine Fibroid (submuscous fibroid) - Uterine Synechae (intrauterine adhesion due to previous curettage - Cervical incompetence These causes usually lead to midtrimester miscarriages/preterm deliveries
  • 27. <ul><li>- Diagnosis: HSG </li></ul><ul><li>Ultrasound scan </li></ul><ul><li>Laparoscopy/hysterscopy </li></ul><ul><li>- Management according to the cause: </li></ul><ul><ul><li>Bicorneate uterus: Strassman’s Metroplasty. </li></ul></ul><ul><li>Complication of surgery: Adhesion formation which may lead to infertility. </li></ul><ul><li>Septate uterus: Hysteroscopic resection of septum </li></ul><ul><li>Cervical incompetence cervical cerclage (Mckdonald suture, Shirodkar suture). </li></ul><ul><li>Complications of surgery: Infection, rupture of membranes, bleeding. </li></ul><ul><li>Submucus bibroid: Hysteroscopic resection </li></ul><ul><li>Uterine Synechia:Hysteroscopic division of adhesions </li></ul>
  • 28. 3. Infective causes: - Rare - TORCH screen unhelpful (reinfection rare in these cases) - Bacterial Vaginosis may lead to recurrent late losses and preterm labour
  • 29. *Normal uterus at laparoscopy *Normal HSG
  • 30.
  • 31.
  • 32. 4. Immunological causes: Antiphospholipid syndrome (API) Definition: Presence of antibodies to patient`s own phospholipids and associated with thrombosis, thrombocytopenia and recurrent abortions. Incidence upto 40%of recurrent abortion. Theory: Disordered platelet function: release of thromboxane. Disordered endothelial function: reduce prostacyclin release  Altered ratio of thromboxane /prostacycline ratio
  • 33. Complications: Obstetrics complications : Fetal losses (early and late); Abruptio placentae; intrauterine growth restriction Vascular complications: arterial and venous thrombosis. Neurological: TIA Diagnosis Lupus Anticoagulant (LA) Positive prolonged APTT Positive anticardiolipin antibodies (ACA) Treatment: Baby Aspirin Heparin Immunoglobulins (under investigations)
  • 34. <ul><li>5. Endocrine causes : </li></ul><ul><li>* Diabetes/Hypothyroidism: In asymptomatic patients GTT and TFT are non-informative. </li></ul><ul><li>Luteal phase defeciency: Low progesterone level reflects a failing pregnancy (not a cause but a consequence). Therefore exogenous progesterone/hcg in early pregnancy is of no benefit. </li></ul><ul><li>PCO (polycystic ovarian disease): </li></ul><ul><li>Common (56% of recurrent abortion) </li></ul><ul><li>High secretion of LH is associated with poor pregnancy </li></ul><ul><li>outcome: </li></ul><ul><li>* Fertilization </li></ul><ul><li>* Poor implantation </li></ul><ul><li>* Rate of miscarriage </li></ul>
  • 35. In Conclusion: Patients with recurrent abortion needs to be investigated by the following tests For all: * Chromosomal analysis of both partners * Serum LH (day 5) for PCO * Antiphospholipid Antibodies (LA, ACA) * Pelvic ultrasound * Rubella antibodies (if negative, vaccinate) For selected patients: * Hysteroscopy/hysterosalpingography
  • 36. Thank you Questions?
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