HPT,PPH,fibroids Flashcards
What is hypertension in pregnancy and how is it diagnosed
Why does it occur in some women but not some
Hypertension in pregnancy is defined as a sustained systolic BP ≥140 mmHg and/or diastolic BP ≥ 90 mmHg. Two successive readings of the blood pressure at least 6 hours apart may be required to make a diagnosis of hypertension.
Severe hypertension is defined as systolic BP ≥ 160mmHg or diastolic BP ≥ 110mmHg.
It occurs due to abnormal presentation. This causes production of thromboxane A or TXA3 which leads to vasoconstriction and increased TPR which raises bp
Production of thromboxane also leads to vasospasms causing convulsions
Abnormal placentation causes endothelial injury leading to edema and this edema can be in the braid thus causing convulsions.
The abnormal placentation also makes vessels in pregnancy highly resistant leading to reduced blood flow and causing IUGR
All the above can happen in any of the organs. So since the problem is with the placenta, till it is delivered, the high bp will still be there ( if the high bp is due to pregnancy)
It is normal for Increased in plasma volume, which begins by 6th week and plateus at 30 weeks with a fall in hematocrit levels
Increased cardiac output which increases at 5th week and peak at 30-34 weeks, remain static till term, increases further in labour and immediately after delivery
But if it increases too much and causes problems then it’s not Norma
True or false
State the different classifications of hypertension disorders in pregnancy
True
Pregnancy induced hypertension (PIH) or Gestational hypertension(we say this not this)-
Pre- eclampsia
Pre eclampsia with severe features
Chronic hpt with Pre eclampsia
Chronic hpt with Pre eclampsia with severe features
Eclampsia
Chronic Hypertension: if you diagnose this, find out if it’s primary or secondary hpt by screening for secondary causes of HPT
primary hpt is due to obesity, increased salt intake, etc
True or false
What is transient hypertension?
State the five leading causes of maternal mortality in Ghana
What is chronic hpt in pregnancy
Transient hypertension (elevated BP due to environmental factors, or the pain of labour)
1. Hameorrhages(ectopic APH PPH)
2. Hypertensive disorders
3. Infections or Sepsis
4. Abortion
5. Obstructed labour or ruptured uterus
Chronic Hypertension :is defined as blood pressure exceeding 140/90 mm Hg before pregnancy or before 20 weeks’ gestation or which persists for more than 6 weeks postpartum(puerperium ). The hypertension may be essential, secondary to renal disease, endocrine disease or from other causes.
What is
What is a fibroid
Causes of fibroids
A fibroid is a benign tumour of uterine smooth muscle termed a ‘leiomyoma’
•They are the commonest tumours in the uterus and the commonest indication for hysterectomy.
Cause still unknown
•Commoner in black women than among Caucasians
•Hormone-dependent as it is seen during the reproductive age but reduces or disappears after menopause. Also estrogen and progesterone receptors are identified in fibroids
•Commoner in nulliparous or women of low parity
What are the characteristics of a fibroid
State the types of fibroids and where they are located
Why does the uterus become big in pregnancy
Arises from the smooth muscle of the uterus
•Appears as firm round tumour in the uterine wall
•May appear as single or multiple
•Cut surface reveals tumour in a false capsule of compressed myometrium
•Appears whitish/pale with whorled appearance
•Nodules are relatively avascular (white appearance) but the bed can bleed at myomectomy
Intramural- within the myometrium
•Subserous- projecting from the serosa
•Intraligamentary- between the layers of broad ligament
•Submucous- projecting into the uterine cavity
•Pedunculated–subserous fibroids may grow a pedicle and become pedunculated. These may adhere to omentum, gain secondary blood supply then detach from the uterus giving rise to ‘parasitic fibroids’. Pedunculated submucous fibroids may protrude though the cervix giving rise to fibroid polyps.
Due to hyperplasia and hypertrophy
What will you ask in the history of a patient with suspected fibroid
Usually asymptomatic and I’ll be detected when coming for other things
1.Age ( extremes of ages don’t get fibroids because they’ve not experienced estrogen for long or have stopped experiencing estrogen. Cuz fibroids are due to unopposed estrogen exposure. Pre menarche and then in menopause don’t get fibroids)
2. Heavy menstrual bleeding per vaginum. Assess this by asking;
a.number of pads ( if more than 4,ask if it’s due to hygiene or due to the amount of blood flow being too much). Intermenstrual bleeding
b. Flooding (blood overflows to thighs or body)
c. Number of days they bleed (not more than 8 days)
d. Number or size of clots ( shouldn’t be a 50p coin or bigger)
3.Ask about symptoms of anemia such as easy fatiguability , dizziness, palpitations, headache
4. If there’s a mass in the abdomen, If the mass is increasing in size and how long it’s been there
5. If they have pain during menses such thag they can’t do normal physical activities when they’re not in their period
If they have pain even when not on their menses
If they experience pain during sex
6. Pressure symptoms due to the mass:
Leg swelling of the mass is sitting on an important vein.
DVt
Urine retention if fibroid blocks bladder neck
Constipation
6. Reproductive problems such as infertility. Pregnancy complications such as recurrent abortions, abruptio placenta, placenta praevia, pre term labour, PROM, prolonged labor
7. Early menarche
8. Nulliparous cuz they’re exposed to estrogen for long
9. Black women
10. Obesity
11. Fam history of fibroids
12. Previous history of fibroids
State six risk factors for the development of fibroids
(Name the symtpms associated with each location of a fibroid
Women in reproductive age
Early menarche
Nulliparous
Late menopause: more than 50 years
Black women
Obesity
Fam history of fibroids
Previous history of fibroids
PCOS - Many PCOS patients have unopposed estrogen stimulation for prolonged periods of time
Submucousal- heavy periods
Intramural- pain
Pressure symptoms- intramural and subserosa
Infertility- sub mucosal
Asymptomatic- sub serosa
Name the investigations used for fibroids
USS - TV if small and TA if big fibroids
Saline induced sonohysterogram 100-200mls
Hysteroscopy ( pass probe through cervix to visualize the uterine cavit) its limited. Hz you can’t see anything outside the uterine cavity
Laparoscopy - limited cuz you can’t see inside the uterus
MRI
Supportive investigation:
FBC
Grouping and cross matching
Transvaginal Ultrasound scan (TVUSS): good for detecting and locating submucous fibroids and small intramural fibroids
•Transabdominal ultrasound scan (TAUSS): good for detecting larger intramural and subserosal fibroids and excluding hydronephrosis secondary to pressure from fibroids obstructing the ureters
•Saline Infusion Sonohysterogram (SIS): good for detecting and locating submucosal fibroids and endometrial polyps
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Hysteroscopy:
•good for detecting submucosal fibroids and endometrial polyps;
•good for planning subsequent hysteroscopic surgical treatment;
•surgical hysteroscopy can remove polyps, adhesions and submucosal fibroids.
Magnetic resonance imaging (MRI):
•good for describing the morphology and location of fibroids;
•indicated prior to uterine artery embolization and to monitor treatment response.
How are fibroids managed and what does management depend on
Depends on :
Age of patient
Fertility wishes
Fitness for surgery
Type of fibroid
Symptoms of patient
Size of fibroid
- Conservative management(for asymptomatic patients, Small tumours
•Symptomless fibroid close to menopause
) - Medical management (those with symptoms but near menopause) : hormonal drugs such as COCP, progestin, dep provera. GnRH analogues . Androgens. Ulipristal acetate is prescribed to reduce the size of the fibroids before the surgery. The female hormone progesterone is thought to play a role in the development of fibroids. Ulipristal acetate works by blocking the effects of progesterone. This stops the fibroids from growing and they shrink in size.
- Surgical management - myomectomy, hysterectomy, Hysteroscopy. These are indicated in Large fibroids
•Symptomatic fibroids eg menorrhagia, pain, urinary retention.
Hysteroscopic myomectomy: minimally invasive, day-case procedure for submucous fibroids that avoids surgical incisions and is effective in resolving HMB and improving fertility. Will not treat other types of fibroid
•Myomectomy: fertility sparing and will treat Heavy Menstrual Bleeding and bulk symptoms. Usually requires a laparotomy, but a less invasive laparoscopic approach is possible with smaller and fewer fibroids. Associated with intraoperative bleeding from vascular fibroids, a 1% risk of unplanned hysterectomy and postoperative intra-abdominal adhesions.
•Hysterectomy: indicated for women with no future fertility desires. May be achieved vaginally, laparoscopically or via open surgery depending on the size of the uterus. Definitive, guaranteeing amenorrhoea but as invasive as myomectomy
NSAIDs]/COCP/LNG-IUS (Mirena®): all are simple and fertility sparing (although COCP/LNG-IUS are contraceptive) and avoid more invasive interventions, but they are generally less effective in the presence of submucosal fibroids or a uterus >12 weeks size where an enlarged uterine cavity can be expected
•COCP: contains oestrogen, which may increase the growth of oestrogen-dependent fibroids.
•LNG-IUS: increased likelihood of expulsion if cavity is enlarged or distorted by submucosal fibroids.
GnRH-agonists: reduce fibroid volume prior to surgery but induce a temporary oestrogen deficient ‘menopausal’ state precluding long-term use.
•Ulipristal acetate (SPRM): oral medication and, as with GnRH-agonists, it reduces fibroid volume prior to surgery, but more data about safety with long-term use are needed.
Explain the acute management of fibroids
Emergency management:
you treat the condition here not the fibroids
Likely to come with heavy bleeding, pain, pressure symptoms
So for bleeding, IV fluids if looking dehydrated, take blood samples for what what. Transfuse depending on hb
Give tranexamix acid 1mg stat
For pain- give mefenemic acid 500mg tds
Pressure symptoms- urinary pass catheter
Refer to gynae
What do you expect to see on examination of a patient with fibroids
General: signs of anaemia.
•Abdominal examination: visible and/or palpable abdominal mass arising from the pelvis.
•Bimanual examination: enlarged, firm, smooth or irregular, non-tender uterus palpable
Complications of fibroids
State three effects of pregnancy on fibroids
Infection. This is common with submucous fibroids or fibroid polyps, especially during puerperium
b.Torsion. This is when a pedunculated fibroid twists on its pedicle and causes an acute abdomen
c.Degenerative changes. Several types occur:
•Hyaline - asymptomatic softening and liquefaction of the fibroid
•Cystic - asymptomatic central necrosis leaving cystic spaces at the centre
•Red degeneration can occur at any time, but most common in pregnancy; Diffuse or focal infarction and necrosis and thrombosis of peripheral vessels
•Calcific - calcium deposition leading to calcification
PROM
Premature labour
Infertility
Placenta abruptio
Placenta praevia
a
Effects of Fibroids on Pregnancy (and fertility)
•Infertility
•Abortions
•wrong dating (larger-than-dates)
•abnormal lie
•mal-presentations
•obstructed labour (fibroids in lower segments/cervical fibroids)
•inefficient uterine contractions, leading to prolonged labour
•primary postpartum haemorrhage (PPH)
a.fibroids flatten out during pregnancy
b.increase in size
c.Soften
d.degenerative changes, especially red degeneration
