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Complications
Michelle M Fynes
MB BCh BAO (Hons) MD (Research) MRCOG DU DipUS
Subspecialty Accredited Urogynaecologist RCOG (2003) and RANZCOG (2002)
CCST Obstetrics and Gynaecology (2003)
Specialist Complex Peri-partum Childbirth Injury and
Paediatric Adolescent and Forensic Gynaecology
Key Points are to understand
December 2012
Support and information giving
Throughout a woman's care, give her and (with agreement)
her partner specific evidence-based information in a variety
of formats. This should include (as appropriate):
What to expect during the time she is waiting for an ultrasound scan.
Regional services organised so EPAU available 7 days a week for women with early
pregnancy complications, where scanning carried out and decisions about management made.
1 2 3 4
TVUS – First trimester
Embryo 9+4 weeks (CRL 28 mm). Sagittal section Above -Embryo at 9+4 weeks (crown–rump length
Embryo at 10 weeks (CRL 32 mm). relative large head. Cavities of the diencephalon 28 mm). Longitudinal section demonstrating the
Section through abdomen - umbilical (Di), mesencephalon (Mes), rhombencephalon (Rh). physiological midgut herniation present as a large
cord. Arrows show the extent of Arrow -genital tubercle, not possible to hyperechogenic mass.
physiological midgut herniation differentiate male /female yet Below – 3D image fetus at 12 weeks
Early Pregnancy Bleeding and Miscarriage
Early pregnancy bleeding and Miscarriage
Scenario
• Physiological event (I in 4 pregnancies miscarry)
• Pathological ? (haemorrhage, Ectopic, recurrent MC 1% couples )
• Personal
Symptoms
• Physical - pain bleeding
• Psychological symptoms of fear and loss
Guidelines TVUS/TAS
Mean GS diameter < 25.0 mm or fetal pole CRL <7.0mm, no FH
Do second scan 7 days (14 days if TAS)
Mean GS> 25.0 mm or CRL>7.0mm TVUS no FH
Get second opinion on viability and/or second scan >7 days
after first before making a diagnosis. TAS 14 days
Management of miscarriage
Medical management – Missed or Incomplete
Threatened miscarriage Indications
Patient choice
Vaginal bleeding and confirmed IUP with FH: Failed EM (eg. Bleeding >14 days)
Bleeding gets worse, or persists > 14 days, return EPAU Therapeutic agent
Bleeding stops, start or continue routine ANC
RU486 (Mifepristone) not used
Expectant management (EM) PV misoprostol missed or incomplete miscarriage.
Oral administration acceptable alternative .
Use EM 7–14 days as first-line strategy for confirmed diagnosis
miscarriage. Missed miscarriage, single dose of 800ug misoprostol
Bleeding not started >24 hours contact EPAU
Explore other management options other than EM if - Consider options
Risk haemorrhage (eg. Late T1) Incomplete miscarriage, single dose of 600 micrograms of
Previous adverse / traumatic pregnancy experience (eg. misoprostol.
stillbirth, MC or APH) 800 micrograms can be used to align protocols for missed and
> risk from haemorrhage (eg. Coagulopathy, unable to have incomplete MC
blood transfusion)
Evidence of infection.
Offer repeat TVUS if after a period EM the bleeding and pain: Inform all women whether expectant or medical management
what to expect throughout the process,
Have not started Length and extent of bleeding
Persisting and/or increasing Potential side effects of treatment - pain, diarrhoea and
vomiting.
Discuss all treatment options ( eg. continued EM or medical)
Offer pain relief and anti-emetics as needed.
Advise to do urine pregnancy test at 3 weeks
If (+ve) return for follow-up exclude molar or ectopic
pregnancy
Experience worsening symptoms, return earlier to EPAU
Management Miscarriage
Expectant management
• All non-sensitised RhD (-ve) spontaneous complete or incomplete MC > 12+0 weeks .
• Anti-D Ig not required spontaneous MC <12+0 weeks
• All anti-D Ig non-sensitised RhD (-ve) surgical evacuation of the uterus ERPC, MTOP, EP.
• Allo-immunisation reported after EP and 25% ruptured tubal EP
Sole medical management for EP or MC, threatened miscarriage, complete miscarriage or PUL
Rhesus D Prophylaxis, The Use of Anti-D Immunoglobulin for RCOG (Green-top 22) 2011
Second Trimester Miscarriage (14-20 weeks)
Investigations
Full PM (fetus and placenta)
Karyotype
TORCH Support services
HVS
Some units have a dedicated
specialist midwife/nurse
Perinatal Pathology trained in bereavement
Normally cremate fetus
counselling.
Counselling support
Pastoral care – service (parents wishes)
They can liaise with perinatal
Follow-up appointment
pathology, gynaecologist, EPAU
and pastoral services on the
Risks mothers behalf.
Bleeding
Lactation
PTSD/Depression
Pregnancy of unknown location (PUL)
Pregnancy of Unknown Location (PUL)
Introduction
Pregnancy site not seen in 8–31% EPAU scans.
Sonographer’s experience influences PUL rate.
• failing PUL
• intrauterine pregnancy
• ectopic pregnancy
• persisting PUL.
44-69% failing PUL resolve spontaneously
Never seen (intra- or extrauterine) on TVUS
Serum progesterone be 20 nmol/l presentation
Serial serum hCG levels will fall.
May have
1. Discharge (physiological/infection)
2. Urinary symptoms (pregnancy or
UTI)
Investigations
1. Urinary pregnancy test (+ve)
2. Serum HCG level (static or serial)
3. TVUS ‘empty uterus’ or sac only
Other tests
1. Serum progesterone
Ectopic Pregnancy
Ectopic pregnancy
Incidence and risks
• 13 Maternal Deaths UK ectopic pregnancy 1997–99.
• Ectopic incidence 11.1/1000 pregnancies
• Laparoscopic management superior haemodynamically stable
• Collapse – most expedient method employed
• Salpingectomy not salpingotomy (healthy contralateral tube)
• Laparoscopic salpingotomy considered as the primary
treatment tubal pregnancy contralateral tubal disease and
desire for future fertility.
• Outcome study IUP rate salpingotomy 49% versus
salpingectomy 27% where contralateral tubal disease
present.
• Salpingotomy - Increased risk further ectopic, persistent
trophoblast in tube, may still need IVF
1. Ruptured ectopic
2. Risks surgery
3. Cornual ectopic
Ovarian ectopic Heterotopic pregnancy
Ectopic pregnancy
Evidenced based
Clinical Algorithms
Clear information (preferably written) re need for further Day 0 -Serum hCG, FBC, U&E, LFT’s, G&S
treatment and adverse effects following treatment should Day 1 - Serum hCG, IM methotrexate 50 mg/m2
be able to return for assessment any time during follow-up. Day 4 - Serum hCG
Day 7 - hCG, U&E, LFT’s . 2nd dose methotrexate
if hCG decrease <15% on D4–7. hCG >15% repeat
• 75% experience abdominal pain following treatment.
hCG weekly until <10 iu
• Occasional conjunctivitis, stomatitis, gastrointestinal upset.
• Differentiating ‘separation pain’ (tubal abortion) from
‘rupture pain’ can be difficult. Mechanism of action of Methotrexate
• Small % need to be admitted for observation, TVUS and
assessment following methotrexate therapy.
• Avoid sex, maintain ample fluid intake, use reliable
contraception for 3mths possible teratogenic risk.
Ectopic pregnancy
Consent Form Laparoscopy
Frequent risks
Intended benefits • Inability identify cause for presenting complaint
• Remove ectopic pregnancy if confirmed by laparoscopy. • Bruising
• Obesity, significant pathology, previous surgery, pre-existing • Shoulder-tip pain
medical conditions quoted risks for serious or frequent
complications increased. • Wound gaping or wound infection
• Persistent trophoblastic tissue, when salpingotomy
Serious risks include performed (4–8 in 100) -8.1–8.3% laparoscopic salpingotomy
• Damage bowel, bladder, uterus, blood vessels requiring and 3.9–4.1% open salpingotomy. Factors that may increase
immediate laparosocpic /open repair risk of persistent trophoblast; high pre-op hCG levels (>3000
• 15% of bowel injuries may not be diagnosed at laparoscopy iu/l), rapid pre-op rise hCG, presence active tubal bleeding.
• Failure to gain entry to abdomen cavity requiring laparotomy • Hernia at site of entry.
• Risk of serious complications from diagnostic laparoscopy is Any extra procedures which may become necessary during the
approximately two in 1000
procedure
• 3-8 /100 000 undergoing laparoscopy die as a result of
complications(very rare). • Laparotomy.
• Salpingectomy.
• Repair of damage to bowel, bladder, uterus or blood vessels.
• Blood transfusion.
• Oophorectomy.
Other investigations
Serum tests – Viable intra-uterine pregnancy (VIP), Ectopic Pregnancy (EP), Spontaneous Abortion (SA)
Activin enhances FSH synthesis and secretion regulates menses cycle Also roles in cell proliferation. Conversely inhibin down
regulates FSH synthesis and inhibits FSH secretion. 17OH progesterone secreted by Corpus Luteum early pregnancy to
maintain. Activin A, Inhibin A and 17OH Progesterone serum markers measured as an adjunct to evaluate PUL possible EP.
1. Ectopic caesarean section scar – Increasing incidence repeat CS. Medical management
methotrexate IM or direct injection under US guidance into sac.
2. Cornual pregnancy – 4/11 (200-2002) ectopic deaths were due to cornual ectopic
rupture. Treatment surgical resection (laparoscopic, open, hysteroscopic) highly vascular
area, may necessitate hysterectomy. Increased risk of uterine rupture in a future
pregnancy. Methotrexate minimises haemorrhage and preserves the uterus for future
pregnancies, treatment suitable in EPAU with clear guidelines on treatment.
3. Ovarian ectopic -0.15-3% of ectopics occur in the ovary (1:3,000-1:7,000 deliveries).
Mature egg not expelled /picked up from. Sperm enters and fertilizes giving intra-
follicular pregnancy. Egg cell fertilized outside ovary could also implant on the ovarian
surface, aided by eg.endometriosis. Rarely go >4 weeks; very rarely pregnancy finds a
sufficient foothold outside ovary to continue as abdominal pregnancy.
4. Heterotopic pregnancy - 0.6-2.5:10,000 pregnancies. Increase incidence with ovulation
induction, IVF and GIFT. Treat ectopic pregnancy laparoscopic. Risk miscarriage.
5. Abdominal pregnancy - 1% of ectopics or about 10 /100,000 pregnancies. Risk factors
similar to ectopic. The maternal mortality 5/1,000 cases (x7 that for ectopics).
Implantation sites include peritoneum outside uterus, POD, Omentum, Bowel.
Placenta may be attached to several organs including tube and ovary. Rare other sites
have been hepatic pregnancy or splenic pregnancy.
From Left to Right –
Caesarean section scar (heterotopic)
Cornual pregnancy (US and laparoscopy)
Ovarian ectopic
Heterotopic pregnancy
Abdominal pregnancy
The Investigation and Treatment of
Couples with Recurrent First-trimester
and Second-trimester Miscarriage
Green-top Guideline No. 17 - April 2011
Recurrent Miscarriage (RM) and risk factors
Miscarriage
Spontaneous loss before fetus viable <24 weeks
RM 3 or > consecutive pregnancies (1% couples)
1–2% of T2 pregnancies miscarry <24 weeks Antiphospholipid syndrome APAS - treatable cause RM.
Association APA – LAC, ACA and anti-B2 glycoprotein-I antibodies
Risk factors with adverse pregnancy outcome or vascular thrombosis
Genetic factors
Anatomical factors
Cervical weakness
Cervical weakness recognised cause T2 MC diagnosis is clinical .
History T2 MC preceded by PSROM or painless cervical dilatation.
Recurrent Miscarriage (RM) and risk factors
Endocrine factors
Disorders DM and thyroid disease associated with MC
High HbA1c levels in T1 are risk for MC and fetal anomaly
Well-controlled DM not a risk factor for RM
Nor is treated thyroid dysfunction.
Prevalence DM and thyroid dysfunction in RM similar to general population.
Immune factors
No evidence HLA incompatibility in partners, absence of maternal leucocytotoxic
antibodies or absence of maternal blocking antibodies.
NK cells are not a marker of events at maternal–fetal interface.
These tests should not be routine investigations for couples with RM.
Infective agents
Severe infection with bacteraemia or viraemia can cause MC.
Role in RM not proven. TORCH screening should be abandoned.
Karyotyping
Cytogenetic analysis POC 3rd and subsequent MC.
Parental karyotyping couples with RM where POC report unbalanced structural chromosome
anomaly.
Genetic factors - Abnormal parental karyotype refer clinical geneticist.
Counselling offers prognosis for future risk with an unbalanced chromosome complement/
opportunity familial chromosome studies.
Options in couples with this issue include -natural pregnancy +/-prenatal testing, gamete
donation and adoption.
Pre-implantation genetic screen at IVF with unexplained RM doesn’t improve live birth rates.
Recommended investigations and treatment for couples with RM in the first
and second trimester?
Anatomical factors
Endocrine factors
4. Supportive care 75% live birth rate (< age and > number MC).
Objectives
• Describe the presentation, management, treatment and
follow-up GTD
• Advice on future pregnancy outcomes and the use of
contraception.
Transvaginal sonography without (A)
and with (B) color Doppler imaging in a
case of GTD with vascular lakes (arrows)
and deep myometrial invasion.
GTD – Complete (CM) and Partial (PM) Moles
• Medical (RU486/Misoprostol) may be safe for PM avoid for CM. Urine HCG
at 3 weeks if POC not sent for histology.
• Management moles with RU486 and misoprostol Ltd. avoided with CM as >
sensitivity uterus to PG’s.
• Preparation cervix ERPC safe no > risk chemotherapy.
• CM
• PM
• Twin pregnancy with CM/PM
• Limited Macro or Micro molar change suggesting possible partial or
early complete molar change
• Choriocarcinoma
• Placental-site trophoblastic tumour (PSTT)
• Atypical placental site nodules: nuclear atypia trophoblast, areas
necrosis, calcification and > proliferation (Ki67 immuno reactivity within
nodule). % may transform to PSTT.
A. OHSS characterized by multiple luteinized cysts in the ovaries with enlargement and
secondary complications.
B. Central feature OHSS - vascular hyper permeability shift of fluids into the third space;
C. hCG causes ovary to luteinize with, large amounts oestrogens, progesterone + local
cytokines released.
D. VEGF is a key substance induces vascular hyper permeability (capillaries "leaky“) and shift
of fluids from the intravascular space into the abdominal and pleural cavity.
E. Supraphysiologic levels of VEGF from many follicles under prolonged effect of hCG is key
to OHSS. As fluid ↑in the third space it forms ascites, pleural effusion, intra-vascular
hypovolemia and risk of respiratory, circulatory with arterial thromboembolism (blood is
now thicker), and renal problems. Patients who are pregnant sustain ovarian luteinization
process through production of hCG.
F. ↓OHSS requires interrupting pathological sequence- avoid use hCG (e.g. use GnRH
agonist). ↓pregnancy rates if a fresh non-donor embryo transfer attempted (due to a luteal
phase defect) but GnRH agonist trigger effective oocyte donors and embryo banking
(cryopreservation) cycles.
Risks
1. OHSS is associated with hCG injection at IVF used to
induce final maturation and/or trigger oocyte release.
2. Risk increased > doses of hCG after ovulation and if
the procedure results in pregnancy.[1]
3. Use GnRH agonist instead of hCG inducing oocyte
maturation and/or release results in an elimination
risk OHSS but a decrease delivery live baby rate x6%.
OHSS- Epidemiology and Classification
Symptoms
Mild - abdominal bloating , nausea, diarrhea, slight weight gain.
Pregnancy
Classification
1. Lower urinary tract infection .
2. Ascending upper urinary tract -pyelonephritis.
3. Urine contains significant bacteria but no symptoms- asymptomatic
bacteriuria.
4. UTI is deemed complicated if it involves
MSU Microscopy - multiple rod- • The upper tract
shaped bacteria shown between • Diabetic
white blood cells indicative of UTI • Immune compromised
• Pregnancy
Anti-microbial therapy
Antibiotic therapy
Oral antibiotics are the treatment of choice for asymptomatic bacteriuria and
cystitis. Appropriate oral regimens include the following:
• Cephalexin 500 mg 4 times daily
• Ampicillin 500 mg 4 times daily
• Nitrofurantoin 100 mg twice daily
• Sulfisoxazole 1 g 4 times daily
Duration therapy
1-, 3-, and 7-day antibiotic courses have been evaluated
10-14 days treatment recommended to eradicate bacteria.
Studies cephalexin, trimethoprim-sulfamethoxazole, amoxicillin indicate
single dose as effective as a 3- to 7-day course
But cure rate is only 70%. The data are insufficient to justify abandoning the
more traditional long-term regimens.
E Coli- UTI Complicated UTI
Treatment success
Depends on eradication bacteria rather than duration of therapy. Check renal function
MSU should show negative findings 1-2 weeks after therapy. Consider renal ultrasound
Non-negative MSU culture result indication for a 10-14 day course different 1. Risk hydronephrosis
antibiotic and then suppressive therapy 2. Exclude other pathology e.g. calculus
(eg, nitrofurantoin 50 mg at bedtime) until 6 weeks postpartum. 3. Rarely - cystoscopy
Urinary sepsis in early pregnancy
UTI common in pregnancy
• May result in significant morbidity for the pregnant woman and fetus.
• All women should be screened for bacteriuria at their first prenatal visit
(5%-10%) women will have asymptomatic bacteruria in the 1st trimester
• Failure to treat bacteriuria during pregnancy may result in 25%
experiencing acute pyelonephritis (1).
• Antibiotics effective in clearing bacteriuria [RR 0.25; 95% CI 0.14-0.48]
and ↓risk [RR: 0.23; 95% CI: 0.13 to 0.41]. (Cochrane review 2007)
• Antibiotics ↓ risk LBW [RR: 0.66 95% CI: 0.49 to 0.89].
• Maternal infection resulting in sepsis may cause up to 30% of ICU
admissions for obstetrics contributes to 2%-3% of maternal mortalities
• Microbiology of sepsis is distinct in pregnancy; endotoxin-producing G(-)
rods e.g. E. coli common aetiologic agent versus G(+) bacteria common
culprits in non-pregnant patients with sepsis.
Trichomonas
Oro-pharyngeal gonorrhoea
Trichomoniasis (T Vaginalis)
Most common non-viral STI causes vulvovaginitis;
10–50% are asymptomatic.
Associated with PTD, LBW, puerperal infection rate unclear
concurrent increase anaerobic bacteria.
Little neonatal morbidity
Test for T. vaginalis by microscopy and/or culture.
NAATs T. vaginalis very sensitive not widely available.
Nitroimidazoles most effective treatment no evidence
teratogenicity with metronidazole pregnancy
90% microbiological cure rate with metronidazole
No protective effect treatment pregnancy outcomes.
Prudent to treat symptomatic women during pregnancy
Test cure recommended if symptoms persist/recur
Anogenital warts
Incidence
Most common viral STI in the UK
Anogenital warts infection low-risk subtypes HPV usually transient; Pregnant
women > rates detectable HPV DNA due to altered immunity, >rate symptoms,
warts can be extensive, rapidly enlarging.
Neonatal Infection
Vertical transmission HPV occurs in 1 in 80 cases
May cause genital and laryngeal warts in infants.
Rare complication vertical transmission low-risk subtypes recurrent respiratory
papillomatosis 4.3/100 000 cases.
<CS compared to VD but given rare operative delivery would not
normally be advised.
Diagnosis
Serology test, enzyme immunoassay, +ve result confirmed with
haemagglutination/particle agglutination suphilis assay.
Non-treponemal test, VDRL test or reactive plasma reagin,
quantitative assay monitor disease activity, treatment response.
Delivery < 30 days completion of treatment, then treat
neonate. Penicillin is the treatment of choice - benzathine
benzylpenicillin G
Screening tests, sites, indications and recommended
treatment and follow-up of STIs in pregnancy.
Chlamydia Inform women <25 years to attend NAAT Endocervix Azithromycin 1 g single dose Erythromycin 500 mg b.d. for 14 days or All pregnant women 5
local National Chlamydia or self- erythromycin 500 mg q.d.s. for 7 days or weeks following
Screening Programme centre (in taken amoxicillin 500 mg t.d.s. for 7 days completion of
England) Women >25 years: Test vulvovagin treatment (6 weeks
if symptoms of infection or baby al swab following azithromycin)
has ophthalmia neonatorum
Gonorrhoea Test if symptoms of infection or Culture or NAAT Endocervix Ceftriaxone 500 mg Amoxicillin 3 g and probenecid 1 g oral In all cases at all
baby has ophthalmia neonatorum plus culture if plus intramuscular single dose single dose (if regional prevalence of affected sites. Three
positive pharynx with azithromycin 1 g stat or penicillin resistance <5%) All should weeks following
and rectum spectinomycin 2 g receive chlamydia treatment completion of
(depending intramuscular single dose treatment
on sexual with azithromycin 1 g stat
activity)
If symptoms
Trichomonas Test if symptoms of infection Culture or NAAT if Posterior Metronidazole 400 mg b.d. 7 unresolved
vaginalis available fornix days
Bacterial Test if symptoms of infection Gram stain Amsel’s Lateral Metronidazole 400 mg b.d. 7 Metronidazole 0.75% gel o.d. vaginally If unresolved or
vaginosis criteria vaginal days Intravaginal treatment for 5 days or clindamycin 2% cream o.d. recurrent symptoms
wall recommended for women vaginally for 7 days
who are breastfeeding
Bartholin’s Cysts and Abscess
Bartholin's duct cysts and gland abscesses
Common problems in women of reproductive age.
Located bilaterally at posterior introitus.
Drain through ducts empty into the vestibule at the 4 o'clock and 8 o'clock positions.
Pea-sized glands palpable only if the duct becomes cystic or a gland abscess develops.
Differential diagnosis includes cystic and solid lesions of the vulva
• Epidermal inclusion cyst
• Skene's duct cyst
• Hidradenoma papilliferum
• Lipoma.
Management
1. Preserve the gland and its function if possible.
2. Office-based procedures include insertion of a Word catheter for a duct cyst or gland abscess.
3. Marsupialization of a cyst; marsupialization should not be used to treat a gland abscess.
4. Broad-spectrum antibiotic therapy is warranted only when cellulitis is present.
5. Excisional biopsy is reserved for use in ruling out adenocarcinoma in menopausal or perimenopausal
women with an irregular, nodular Bartholin's gland mass.
Other Gynaecology Pathology
Adnexal and Uterine Masses
Adnexal masses in pregnancy – 0.4% prevalence at ultrasound
Acute abdomen in pregnancy
Paraovarian cyst with torsion. Midsagittal US scan through the bladder (B)
shows an enlarged, heterogeneous ovary (arrowheads) and an adjacent cyst
(C). No flow could be elicited on color Doppler interrogation. On surgery it
proved to be adnexal torsion related to a paraovarian cyst leading to
ipsilateral salpingo-oophorectomy.
Adnexal masses in pregnancy ?
Sub-mucosal fibroids
• Hysteroscopy and Trans-Cervical-
Resection-Fibroid (TCRF)
May impact on recurrent miscarriage
and suitable for resection
• Treatment recurrent miscarriage
• Pre-treatment with IVF
Fibroids and pregnancy
Other pregnancy related
complications
1. Miscarriage (2nd trimester)
2. Torsion
3. Mal-presentation
4. Pre-term delivery
5. Obstructed labour
6. Fibroid avulsion and delivery
7. Life-threatening haemorrhage
Special circumstances or dilemmas
in early pregnancy
The abnormal cervical smear in pregnancy ?
Cervical Screening in the UK and cancer prevention
Based on slide based cytology screening > 50 years
Vaccination for HPV now primary prevention combined with screening.
Age- England >25, Scotland & Wales >20 years (interval 3-5 years - 65yrs)