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

Please download to get full document.

View again

of 36
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Information Report
Category:

Health & Medicine

Published:

Views: 8 | Pages: 36

Extension: PDF | Download: 0

Share
Description
The lecture has been given on Nov. 29th & Dec. 1st, 2010 by Dr. Muhabat Salih Saeid.
Transcript
  • 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?
  • We Need Your Support
    Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

    Thanks to everyone for your continued support.

    No, Thanks
    SAVE OUR EARTH

    We need your sign to support Project to invent "SMART AND CONTROLLABLE REFLECTIVE BALLOONS" to cover the Sun and Save Our Earth.

    More details...

    Sign Now!

    We are very appreciated for your Prompt Action!

    x