Placental Problems

Question 1

Spontaneous miscarriage

Answer 1

Foetal death/delivery <24 weeks of gestation

Question 2

Recurrent miscarriage

Answer 2

3 or more miscarriages in succession

Question 3

Threatened miscarriage

Answer 3

Light and painless bleed
Foetus is alive
Uterus size as expected for gestation
Cervical os closed
25% go on to miscarry

Question 4

Inevitable miscarriage

Answer 4

Miscarriage about to occur
Bleeding heavier
Foetus may still be alive
Cervical os open
Crampy pelvic pain

Question 5

Incomplete miscarriage

Answer 5

Some, but not all foetal parts have been passed

Cervical os open

Question 6

Complete miscarriage

Answer 6

Miscarriage has happened + finished
Bleeding has stopped/diminished
Uterus no longer enlarged
Cervical os closed

Question 7

Septic miscarriage

Answer 7

Contents of uterus infected- -endometritis
Vaginal loss is offensive
Tender uterus
Fever may be present
May progress to pelvic pain (abdo pain)

Question 8

Missed miscarriage

Answer 8

Foetus has died/not developed in utero
Only recognised later when bleeding occurs or USS performed
Uterus smaller than expected for gestation
Cervical os closed
Maybe mild abdo pain + bleeding

Question 9

Ectopic pregnancy

Answer 9

Implantation of a fertilised ovum outside the endometrial cavity

• -> 70% will have subsequent successful pregnancy
• ->10-15% ectopic again

Question 10

Ectopic pregnancy sites

Answer 10

Tubal (95%)
--> Isthmus (25%)
--> ampulla (55%)
--> fimbriae (17.4%)
Other- ovarian, interstitial, cornual, cervical, abdominal

Question 11

Ectopic pregnancy RFs

Answer 11

Previous ectopic
STI/PID
Prolapse
IUCD
Endometriosis
Assisted conception
Failed sterilisation

Question 12

Ectopic pregnancy- Clinical features

Answer 12

PV bleeding
Lower abdo pain
Collapse
Tachycardia
Abdominal tenderness
Unilateral adnexal tenderness
Cervical excitation
Small uterus
Cervical os closed

Question 13

Ectopic pregnancy Investigations

Answer 13

Urine BetaHCG- to confirm pregnancy
Transvaginal USS- failure to localise in-utero suggests
–> gestation too early to visualise (<5 weeks)
–> complete miscarriage
–> ectopic pregnancy

Question 14

Gestational trophoblastic disease (molar pregnancy)

Answer 14

When trophoblastic tissue that forms part of blastocyst proliferates more aggressively than usual

• -> non-invasive- hydatidiform mole
• -> locally invasive- invasive mole
• -> metastatic- choriocarcinoma

Question 15

Partial mole

Answer 15

Two sperms fertilise an egg
Results in triploid conceptus with 69 chromosomes
Foetal tissue present
Malignant change rare

Question 16

Complete mole

Answer 16

Two types- monospermic and dispermic
Results in a conceptus with 46 chromosomes but all derived from father
No foetal tissue seen at histology, just swollen chorionic villi

Question 17

Monospermic complete mole

Answer 17

Maternal chromosomes are lost AND paternal chromosomes double up

Question 18

Dispermic complete mole

Answer 18

Maternal chromosomes are lost AND fertilisation by 2 sperm

Question 19

Molar pregnancy clinical features

Answer 19

PV bleeding
Hyperemesis gravidarum- excess HCG production
Passage of vesicles PV

Question 20

Molar pregnancy examination

Answer 20

Large uterus

Early pre-eclampsia + hyperthyroidism

Question 21

Molar pregnancy investigation

Answer 21

USS- snowstorm appearance

Question 22

Molar pregnancy management

Answer 22

Evacuation of retained products of conception –> send tissue to histology for diagnosis
Serial bHCG levels- persistent or rising levels suggest malignancy
Pregnancy + COCP avoided until bHCG levels normal

Question 23

Molar pregnancy recurrence

Answer 23

1 in 60

Question 24

Antepartum haemorrhage (APH)

Answer 24

PV bleed > 24 weeks gestation but before delivery of baby

Question 25

APH examples

Answer 25

``` Placental abruption Placenta praevia Placenta accrete Vasa praevia Uterine rupture Incidental genital tract pathology ```

Question 26

Placental abruption

Answer 26

Part or all of placenta separates before delivery Considerable amount of maternal bleeding- DIC, renal failure, maternal death Acute foetal distress- foetal death in 30%

Question 27

Placental abruption RFs

Answer 27

``` Previous history IUGR Pre-eclampsia Autoimmune disease Smoking Multiparity Polyhydramnios ```

Question 28

Placental abruption clinical features

Answer 28

``` Tender and hard uterus Foetal distress or absent heart sounds Tachycardia Hypotension Abdominal pain Vaginal bleeding ```

Question 29

Placental abruption investigations

Answer 29

``` FBC Urea Creatinine Coagulation screen Cross-match blood USS to rule out placenta praevia CTG Catheterisation with hourly urine output CVP monitoring to access blood loss + replacement ```

Question 30

Placental abruption management

Answer 30

Maternal/foetal distress- emergency C section No foetal distress and >37 weeks- induction of labour Dead baby- induction of labour

Question 31

Placenta praevia

Answer 31

Placenta implanted in lower segment of uterus >24 weeks

Question 32

Placenta praevia RFs

Answer 32

Multiple gestation High parity Increased maternal age Scarred uterus- e.g. previous C section

Question 33

Placenta praevia issues

Answer 33

Placenta in lower segment obstructs engagement of head- necessitates C section PPH likely as lower segment is less able to contract + constrict maternal haemorrhage

Question 34

Placenta accreta

Answer 34

Placenta attaches to site of previous scar- severe PPH risk

Question 35

Placenta perceta

Answer 35

Invasion completely through uterine wall, sometimes into nearby tissues e.g. bladder

Question 36

Placenta increta

Answer 36

Placenta invades at least halfway through uterine wall

Question 37

Vasa praevia

Answer 37

Membranous insertion of the cord- major vessel implanted into membrane, forms branches to placenta

Question 38

Vasa praevia effect

Answer 38

When membranes rupture, foetal bleeding + rapid exsanguination Painless/moderate PV bleed at rupture or membranes/amniotomy accompanied by severe foetal distress CS rarely fast enough to save baby

Question 39

Uterine rupture

Answer 39

Rarely occurs before labour Either old C-section scar opening or de novo rupture of uterus Foetus extruded Uterus contracts down + bleeds from rupture site Foetal hypoxia and maternal haemorrhage

Question 40

Miscellaneous gynaecological causes of APH

Answer 40

Lower genital tract neoplasms- vulval, vaginal, cervical Cervical polyps Genital infections