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what are the different types of miscarriage?

threatened - bleeding, but foetus still alive (can hear HR), good size for dates and os closed
inevitable/incomplete - bleeding, foetus might still be alive, but os is open
complete - all foetal tissue passed (empty sac on scan), os closed, bleeding diminished
septic - uterine contents infected, causing endometritis, offensive loss, tender uterus
missed miscarriage - not picked up till scan, or bleeding a long time after baby stopped developing/died - os closed, uterus small


what causes miscarriage?

often unknown - isolated non-recurring chromosomal abnormalities account for >60% of one off miscarriages

if had 3+ consecutively - consider causes of recurrent miscarriage


what are the clinical features suggesting miscarriage?

bleeding is main one.
often around 12 weeks.
may have pain from uterine contractions - be careful not to mix up with ectopic


how would you investigate a woman presenting with what you suspect might be a miscarriage?

examine - uterine size/cervical os depends on type of miscarriage.
USS for a viable intrauterine pregnancy - if in doubt, repeat scan in a week
blood HCG - levels should rise by >66% in 48h if pregnancy is viable (i.e. take one, then take another in two days and compare)


describe the different management options for miscarriage

expectant management - might use if not heavily bleeding, particularly for incomplete miscarriage (offer rescan in 2 weeks to ensure completed)

medical management - mifepristone to prime, then 24-48h later misoprostal/prostaglandin (oral or vaginal). bleeding can continue for 3 weeks. most successful in earlier miscarriages.

surgical management - if heavy or persistent bleeding, or pt request - surgical evac of retain products of concept (ERPC), under GA.


define recurrent miscarriage

loss of 3+ consecutive pregnancies at <24 weeks, by same biological father.
affects 1% of women.


list some possible causes of recurrent miscarriage

antiphospholipid abs --> thrombosis in the uteroplacental circulation, treat with aspirin and LMWH
chromosomal defects - e.g. a balanced translocation in parents
anatomical factors e.g .uterine abnormalities, more common with late miscarriage though
infection - BV associated with 2nd trimester loss
others - obesity, smoking, PCOS, maternal age, excess caffeine


what happens during days 1-4 of the menstrual cycle?

endometrium shed as its hormonal support is withdrawn
myometrial contraction can --> cramps/pain


what happens during days 5-13 of the menstrual cycle?

proliferative phase:
- GnRH pulses (from hypothalamus) stimulate LH and FSH release --> follicular growth
- follicles produce oestradiol and inhib --> suppress FSH (neg feedback), so only one follicle/oocyte matures
- as oestradiol rises, 'positive feedback' on hypothalamus and pituitary --> LH levels to rise sharply
- ovulation occurs 36h after LH surge
- oestradiol causes endometrium to re-form + become 'proliferative' --> thickens as stromal cells proliferate, glands elongate


what triggers ovulation in menstrual cycle / when does it occur?

LH surge - ovulation occurs 36h after.

LH surge occurs after oestradiol levels have risen to certain point (I think)


what happens during days 14-28 of the menstrual cycle?

luteal/secretory phase
- follicle from which egg was released becomes corpus luteum - produces oestradiol and progesterone
- progesterone levels peak a week later (day 21)
- this triggers 'secretory' changes in endometrium where stromal cells enlarge, glands swell, and blood supply increases
- towards end of luteal phase, corpus luteum starts to fail if egg not fertilized, so progesterone + oestrogen levels decrease
- endometrium then breaks down as this hormonal support is removed, and cycle restarts


differentiate between the following:
- primary amenorrhoea
- secondary amenorrhoea
- oligomenorrhoea

amenorrhoea = absence of menstruation
primary = menstruation hasn't started by age 16
secondary = prev normal menstruation stops for >6 months
oligomenorrhoea = menstruation occurs every 35 days to 6 months


what five things need to be 'normal' for 'normal' menstruation to occur?
OR - what five different things can cause pathological problems with menstruation?

for normal menstruation you need:
- hypothalamic function
- pituitary function
- ovarian function
- endometrial function
- patent cervix and vagina ('outflow tract')

so - menstrual disturbance can be caused by issues on any of these 5 levels


what is 'physiological' secondary amenorrhoea?

amenorrhoea due to pregnancy or menopause - by far the most common causes of amenorrhoea


give some causes of post-coital bleeding

cervical trauma, polyp, cervical/endometria/vaginal carcinoma, cervicitis or vaginitis of any cause


explain how you decide how to investigate primary amenorrhoea?

in absence of pubertal development - investigate as for delayed puberty
if normal puberty - exclude genital tract anomaly, then investigate as for secondary amenhorrhoea
abnormal pubertal development - exclude chromosomal anomaly (e.g. Turner's) and causes of hyperandrogenism


what is the main hypothalamic cause of secondary amenorrhoea? how do you diagnose/treat?

hypothalamic hypogonadism - due to psychological factors (stress), low weight/anorexia, excessive exercise

GnRH (+ thus LH/FSH) low - although may see normal LH/FSH

treat - supportive + oestrogen replacement (COCP/HRT)


what pituitary causes of secondary amenorrhoea are there? how do you diagnose/treat?

hyperprolactinaemia - due to pituitary hyperplasia or benign adenomas, can be due to thyroid issues

treat - bromocriptine, cabergoline or sometimes surgery


what are the key ovarian disorders that lead to secondary amenorrhoea?

PCOS - most common
ovarian insufficiency/failure aka premature menopause
congenital - Turner's, gonadal dysgenesis


what tests might you order if a woman came to clinic with secondary amenorrhoea?

- beta HCG
- serum free androgen index (raised in PCOS)
- prolactin
- testosterone levels
- may do MRI if prolactin levels really high


how would you manage a woman with secondary amenorrhoea?

treatment depends on cause
can involve HRT/COCP use to replace oestrogen
correct genital tract anomaly if poss
weight gain/stress management/reduction of extreme exercise

for PCOS - main treatment is weight loss, might use COCP or metformin


define menorrhagia

menstrual blood loss >80ml per period

clinically - blood loss affecting quality of life


give some possible causes of menorrhagia

uterine fibroid (30%)
uterine polyps (10%)

thyroid disease, clotting disorder
endometrial carcinoma
iatrogenic - copper coil, anticoagulants

NO KNOWN CAUSE - 'dysfunctional uterine bleeding'


how do fibroids cause menorrhagia?

1) by enlarging uterine cavity, leading to increased surface are of endometrium for bleeding to come from (this is similar to how polyps cause menorrhagia)
2) might produce prostaglandins, which might cause menorrhagia


what tests might you order for a woman complaining of menorrhagia?

- FBC, maybe also TFTs and clotting studies
- pelvic/transvaginal USS to assess for polyps/fibroids (endometrial thickness)

- if woman >40yrs, or women <40y with history/scan results that are suspicious, do endometrial biopsy (via hysteroscopy)
- hysteroscopy is also the best way to rule out fibroids/polyps for sure


how do you treat a woman suffering menorrhagia?

1) correct anaemia, treat any systemic causes/focal pathology
2) medical treatment - Mirena coil 1st line, then transexamic acid, NSAIDs (mefenamic acid) or COCP 2nd line, then high dose progestogens or GnRH agonist (for 6 months only)
3) surgical treatment - only if unresponsive to medications - endometrial ablation (reduces fertility), myomectomy or uterine artery embolization (retain fertility) - if fibroids >3cm and no wish for further fertility then consider hysterectomy


what is a myomectomy?

open or laparoscopic removal of fibroids from myometrium

used when woman wishes to retain fertility, as endometrial ablation/hysterectomy renders women infertile


define postmenopausal bleeding

vaginal bleeding >12 months after LMP
ALWAYS exclude malignancy


list some causes of postmenopausal bleeding

ovary - Ca ovary, oestrogen-secreting tumour
uterus - submucous fibroid, atrophic changes, polyp, endometrial carcinoma/hyperplasia (premalignant)
cervix - atrophy, polyp, squamous Ca or adenocarcinoma
vulva - vulvitis, malignancy, dystrophy
vagina - atrophic vaginitis
withdrawal bleed from HRT
haematuria/PR bleed
PREGNANCY - if not truly menopause!


how would you investigate a woman presenting to clinic complaining of postmenopausal bleeding?

perform bimanual examination, speculum exam, might do smear (cytology) if cervical pathology - or refer for colposcopy. pipelle biopsy if suspicious of cancer.
transvaginal US - looking for endometrial thickness, other pelvic pathology
if endometrial thickness >4mm or fluid-filled cavity, do hysteroscopy and biopsy