Gynae 2 Flashcards
(85 cards)
What is an ectopic pregnancy?
Implantation of a fertilised ovum outside the body of the uterus
Where do ectopic pregnancies mostly occur?
Where are some rarer sites of implantation?
97% are in the Fallopian tubes - mostly ampulla or isthmus portions
Rarer sites:
- Cervix
- Ovary
- Peritoneal cavity
- Previous CS scars
What are 3 possible consequences of the implantation of a gestational sac in the Fallopian tube?
1) Extrusion (tubal abortion) into the peritoneal cavity
2) Spontaneous involution of pregnancy
3) Rupture through the tube causing pain and bleeding
Where is it particularly dangerous for an ectopic pregnancy to be located? Why?
The uterine horn - pregnancy may reach 10-14 weeks before rupture
Which ectopic pregnancies can proceed almost to term?
Intraperitoneal pregnancies
List some risk factors for ectopic pregnancy
1) Hx of infertility or assisted conception (esp IVF)
2) Hx of PID
3) Endometriosis
4) Pelvic or tubal surgery
5) Previous ectopic (recurrence risk 10-20%)
6) IUCD in situ
7) POP = does not cause an ectopic pregnancy but if a woman conceives whilst using it, the pregnancy is more likely to be ectopic as progesterone decreases tubal motility
NB anything that slows the ovum’s passage to the uterus is a predisposing factor
What are some symptoms of an ectopic pregnancy?
Always think ectopic in a sexually active woman with abdominal pain, bleeding, fainting or diarrhoea + vomiting!!!
- Often asymptomatic
- Amenorrhoea (typically 6-8 weeks gestation)
- Pain = lower abdo, often mild and vague, classically unilateral
- Vaginal bleeding - starts after onset of pain; often small amount and brown
- Diarrhoea and vomiting
- Shoulder tip pain = diaphragmatic irritation of intra-abdo blood
- Collapse = if ruptures
What are some signs of an ectopic pregnancy? (5)
Vaginal + speculum examinations do not rupture ectopic pregnancies!
Often no specific signs
- Uterus usually normal size
- Abdominal tenderness +/- peritonism due to haemoperitoneum if ruptured
- Cervical motion tenderness occasionally due to stretching of inflamed tissues
- Unilateral adnexal tenderness
What is the very first investigation to do in a patient with ? ectopic ?
Pregnancy test - a negative test excludes an ectopic
What are the strict criteria for expectant and medical management of a diagnosed ectopic pregnancy ?
- Clinically stable
- Asymptomatic and no pain
- hCG < 1000 for expectant; <3000 for medical
- Size < 30mm
- No fetal heartbeat
- No rupture/haemoperitoneum
- Live in close proximity to hospital and have support at home
- Pt deemed reliable to return for follow up
What is the expectant management of an ectopic pregnancy?
- With an already low and falling hCG and fulfilling the required strict criteria
- Take hCG level, which takes a day to process then repeat 48 hours later and if it has fallen significantly, can continue with continue with expectant management
- Repeat serum hCG every 48hrs until repeated fall in level, then weekly until <15IU
(basically the body is expelling it anyway you let it continue)
What is the medical management of an ectopic pregnancy?
Methotrexate IM single dose 50mg/m2
hCG levels should be measured at 4 and 7 days and another dose of methotrexate given (up to 25% of cases) if the fall in hCG is <15% on days 4-7
Sexual intercourse should be avoided during treatment and reliable contraception used for 3 months as methotrexate = teratogenic
SE = conjunctivitis, stomatitis, GI upset - stomach pain may be difficult to differentiate from pain of rupturing an ectopic
When should an ectopic pregnancy be managed surgically?
Surgery should be offered to those women who cannot return for follow-up after methotrexate or if they have:
- Severe pain
- Size >35mm
- Ruptured
- Foetal heartbeat visible on scan
- Serum hCG >5000 IU/L
What is the surgical management that is preferred for an ectopic pregnancy and why? What medication should be given?
Laparoscopy preferred vs laparotomy:
- Shorter operating time and hospital stay
- Less analgesia requirements
- Less blood loss
In haemodynamically unstable patients, laparotomy is more appropriate as quicker
Anti-D should be given to all rhesus negative women who have a surgical procedure to remove an ectopic pregnancy
What is the treatment of an ectopic pregnancy if haemodynamically unstable?
Resuscitation:
- 2 large bore IV lines and IV fluids
- Cross match 6 units of blood
- Call senior help and anaesthetic assistance urgently
Surgery:
- Laparotomy with salpingectomy once the patient has been resuscitated
What can happen if an ectopic pregnancy is not correctly treated?
Tubal or uterine rupture (depending on location of pregnancy), which can lead to massive haemorrhage, shock, DIC and death
What do molar pregnancies arise from?
Molar pregnancies arise from an abnormality in the chromosomal number during fertilisation
The placenta is made of millions of cells called trophoblasts
In trophoblastic disease - abnormal overgrowth of all / part of the placenta causing what is called a molar pregnancy or hydatidiform mole
What is a hydatidiform mole?
Hydatidifom mole = the commonest kind of trophoblastic disease
It is a pre-malignant condition i.e. it is not cancerous but could become malignant
It includes partial moles and complete moles
Are there good cure rates of GTD? Why?
Excellent cure rates
- Central registration and monitoring in UK
- Use of beta-hCG as a biomarker
- Development of effective treatments
What is the classification of GTD?
Premalignant = hydatidiform mole
- Complete hydatifiform mole
- Partial hydatidiform mole
Malignant = GTN
- Invasive mole
- Choriocarcinoma
- Placental site trophoblastic tumour
- Epithelioid trophoblastic tumour
What is the pathophysiology of a complete molar pregnancy?
All the genetic material comes from the father
An empty oocyte lacking maternal genes is fertilised by one sperm, which duplicates so there are 46 chromosomes of paternal origin
The whole placenta is abnormal and usually grows very quickly
There is no developing foetus in these pregnancies
Can also occur when an empty ovum is fertilised by two sperm - causes foetal karyotypes: 46XX, 46XY, (46YY - not viable)
What is the pathophysiology of a partial molar pregnancy?
One ovum with 23 chromosomes is fertilised by two sperm, each with 23 chromosomes so there are 69 chromosomes in the cells (triploidy)
Instead of forming twins an abnormal fetus forms - not viable outside womb
Part of an apparently normal placenta overgrows (proliferates) and part develops normally
69 XXX, XXY, XXY
What is an invasive mole?
Develops from a complete mole and invades the myometrium
What is a choriocarcinoma?
Malignancy of trophoblastic cells
Most often follows a molar pregnancy but can follow a normal pregnancy, ectopic pregnancy or abortion