Medical Insights on Pregnancy-related Topics

Gehad Sayed . Enumerate the risk factors of undisturbed tubal pregnancy 1. Previous ectopic gestation: recurrence rates for an ectopic pregnancy may reach up to 30%. 2. Endo-Salpingitis: inflammation of the tubal mucosa causes destruction and scarring of tubal lumen with strictures associated with partial or complete tubal obstruction. 3. Endometriosis: leading to peritubal adhesions causing tubal kinking and stenosis. 4, Pelvic and tubal surgery: leading to tubal scarring or pelvic adhesions 5, Progesterone effect: results in alteration of tubal motility thus interfering with oocyte and sperm transfer. 5. ICSI procedure is a known risk factor possibly due to multiple ovulation and high PRG support. 7. Cu IUD: prevents intrauterine pregnancy rather than extrauterine. Enumerate causes of septic abortion - Prolonged presence of retained products of conception (POC) as missed or incomplete abortion - Pregnancy in presence of an lUD. - Positive cultures for group B-haemolytic streptococcus infection (GBS) in early pregnancy. - Criminal induction of abortion using non properly sterilized instruments. Enumerate factors increasing the risk of pregnancy loss Gehad Sayed 1. Increased maternal age; incidence increases with maternal age > 35 years and more > 40 years 2. Multiparity: incidence increases with increased parity > 5 3. Previous and recurrent pregnancy loss especially > 2 successive abortions 4. Heavy smoking and regular alcohol intake 5. Psychosocial stress, and domestic violence 6. Infections as Mycoplasma, Listeria and Toxoplosma 7. Medical disorders; as severe thyroid disorders, uncontrolled DM, and SLE 8. Morbid maternal obesity Enumerate causes of recurrent pregnancy loss a. Anatomic uterine abnormalities; as uterine anomalies and submucus leiomyomas (SML) b. lmmunologic disorders as antiphospholipid syndrome (ApS) c. Thrombophilias; as protein-S and protein-C deficiencies !. d. Genetic and chromosomal abnormalities * e. Endocrine disorders; as severe hypothyroidism, and uncontrolled DM f. Incompetent isthmus; habitual 2nd trimesteric abortion Enumerate complications of abortion 1. Haemorrhage; which if severe may cause haemorrhagic shock 2. Infection; may cause endometritis, salpingitis, and peritonitis, all leading to infertility Gehad Sayed 3. Septicaemia; which if severe may cause septicaemic shock, DlC, and renal failure 4. Complications of Surgical Evacuation SE: as uterine perforation and intestinal injury Mention management of septic abortion - Antibiotics: broad spectrum IV antibiotics covering both aerobic and anaerobic organisms including Cephalosporins, Flagyl, and Clindamycin - Ecbolics as Ergometrin (Methergine) and prostaglandins (Misoprostol) are also used to augment complete expulsion of all retained POC. - Surgical Evacuation: to ensure complete evacuation of uterine contents, with gentle curettage. Enumerate complications of septic abortion Septic endometritis; that may lead to intrauterine adhesions and infertility - Spread of infection: leading to salpingitis and pelvic peritonitis. - Septic shock that may predispose to Acute renal failure - Disseminated intravascular coagulopathy (DlC); this is triggered by the release of inflammatory mediators like cytokines Mention management of threatened Abortion Reassurance by US to ensure an intact pregnancy with > 90% chances to continue safely Physical and mental rest may decrease stress, and help patient stabilization. Progesterone support: the use of oral, vagina l, or IM PRG although popular, yet is at least controversial without evidence of being really beneficial, except in cases with luteal phase defect. Gehad Sayed Mention management of a case of recurrent pregnancy loss 1. Surgical correction of anatomic abnormalities; removal of a uterine septum, endometrial polyp, or submucus leiomyomas (SML) 2. Folic acid 800 ug daily started before pregnancy and throughout 1st trimester 3. PRG support in luteal phase and throughout 1st trimester. 4. Control of DM and thyroid disorders before and during pregnancy 5. Treatment of maternal infections as Toxoplasma 6' Low dose aspirin (LDA) 75-81 mg/day throughout pregnancy to protect against micro-thrombi and placental insufficiency 7. Low molecular weight Heparin in cases of thrombophilia and APS especially with history of IUGR, severe placental insufficiency, and recurrent late 1st trimester IUFD 8. Cerclage for cases strongly suspected to have isthmic incompetence Mention the diagnosis of cervical incompetence History of previous one or more mid-trimester abortion or PTL characterized by a sudden onset, rapid and relatively painless course, with a foetus born with no signs of serious FCA. Signs in the 2nd trimester: the cervix may admit tip of finger, with the membranes occasionally protruding through the dilated internal os. US criteria: Shortened cetavical canal < 2.5 cm in length Funneling at the region of the isthmus (Y shaped isthmus) Protrusion of membranes into the cervical canal through the dilated internal os. Gehad Sayed Mention the TTT of cervical incompetence (A) General measures: - Physical and mental rest, and especially avoid fatigue and exertion. - Prophylactic progesterone support given orally or vaginally on daily doses throughout the 2nd trimester helps in minimizing PTL (B) Cervical cerclage procedures: Cervical cerclage procedures describe the placement of a circumferential suture into the cervix, encircling the upper cervical canal at the cervicovaginal junction - VaginalCerclage procedures: are the most commonly performed procedures including; McDonald's procedure: This is the most popular procedure being rapidly and easily performed with excellent results. Shirodkor's procedure. It is mainly indicated when there are deep cervical lacerations or failed Mc Donald's. - Abdominal Cerclage Procedure: In rare occasions an abdominal approach for cerclage via laparotomy may be recommended in cases of recurrent abortion with previously failed vaginal cerclage and in cases where vaginal approach is difficult with distorted cervical anatomy. Mention aetiology of tubal ectopic pregnancy No identifiable aetiology can be sited in almost 1\3 of cases of ectopic pregnancy. Tubal stricture; caused by inflammation, scarring, kinking and adhesions is the commonest aetiological factor encountered. Abnormal tubal motility; secondary to a progesterone effect is a less common cause. Gehad Sayed Mention the diagnosis of undisturbed tubal pregnancy A) Symptoms & signs: - Delayed cycle; with a positive pregnancy test. Unilateral lower abdominal pain; dull aching in character, usually not severe. Mild recurrent vaginal bleeding; usually falsely diagnosed as threatened abortion. B) Examination: - General examination is normal in hemodynamically stable patients. Abdominal examination; unilateral lower abdominal tenderness. Vaginal examination: marked pain and tenderness on touching or moving the cervix. Adnexal fullness or mass can be felt during bimanual examination Mention the management of undisturbed tubal pregnancy Surgical: 1. Salpingectomy: the whole fallopian tube is completely excised whenever it is damaged by rupture or severe distension. 2. Salpingostomy: the tube is opened by a linear incision on its antimesenteric border at the implantation site, the products of conception are removed, and haemostasis established. Medical TTT with MTX Mention the diagnosis of disturbed tubal pregnancy SYMPTOMS & signs: In addition to delayed cycle and recurrent bleeding there may be; - Severe lower abdominal pain; sharp stabbing or colicky in nature. Gehad Sayed - Symptoms suggestive of internal hemorrhage; as irritability, drowsiness, and sometimes loss of consciousness which is relevant to the amount of internal bleeding. - General signs of intraperitoneal haemorrhage including tachycardia, hypotension, oliguria, tachypnea, etc - Abdominal examination; marked abdominal tenderness, rigidity, and rebound tenderness. - Vaginal examination: tenderness on touching or moving the cervix with adnexal fullness. Mention the diagnostic investigations in a molar pregnancy 1. Ultrasonography is the gold standard in diagnosis of molar pregnancy; - Complete mole: shows a characteristic picture of snow storm appearance due to presence of vesicles surrounded by blood in absence of foetal echoes or amniotic sac. , Ovarian theca lutein cysts are usually present in association with complete moles - Partial Mole: An embryo usually in the first trimester, commonly associated with multiple foetal congenital anomalies (FCA) and vesicular hydropic changes within the placenta. 2. Serum F-hCG; - Abnormally high serum P-hCG levels, reaching >100,000 m IU/ml in the first 8 weeks gestation are usually the hall mark of GTD due to abnormal trophoblastic proliferation. Enumerate complications of vesicular mole 1. Severe bleeding when starting expulsion which may lead to hypovolemic shock Gehad Sayed 2. Early onset pregnancy induced hypertension (Gestational HTN or preeclampsia PE) 3. Hyperthyroidism: in 7% of cases may occur due to thyroid stimulating effect of hCG. 4. Trophoblastic embolization to the lungs causing RDS 5. Complications of ovarian cysts (torsion, haemorrhage, rupture...) 6. Risk of developing an invasive Mole (20% in a complete mole, and 4To in a partial moles) 7. Risk of developing Choriocorcinoma (5% of cases Outline management of molar pregnancy A. Suction evacuation curettage: - This is the gold standard technique for evacuating molar pregnancies - Performed by a suction evacuation apparatus with cannulas introduced through the cervix B. Hysterectomy: Abdominal hysterectomy has a limited place in the management of HDFM only in elderly patients with severe bleeding, infection, invasion, or high risk for GTN. Follow up after evacuation of molar pregnancies - Repeated serum B-hcG assays made at 48 hours post-evacuation, then weekly until results are negative for 3 successive weeks, then monthly for 6 months. - Physical examination and pelvic US at regular monthly intervals; to ensure complete evacuation, normal involution of pelvic organs, and disappearance of theca lutein cysts. - contraception for 1 year after evacuation of a HDFM is highly recommended and best achieved by hormonal contraception. Gehad Sayed