Carcinoma of the cervix

-gynaecological malignant disease occurring in pregnancy The condition presents with vaginal bleeding and increased vaginal discharge. On speculum examination the appearance of the cervix may lead to a suspicion of carcinoma diagnosed by colposcopy or a cervical biopsy. -primary origin cervical l intraepithelial neoplasia (CIN) -diagnosed from an abnormal Papanicolaou (Pap) smear. - diagnosed at an early stage, treatment can usually be postponed after pregnancy -The Pap smear is not routinely carried out during pregnancy - carried out every 3 years.

-Treatment for cervical carcinoma in pregnancy will depend on 1- the gestation of the pregnancy 2- the stage of the disease, explanations of treatments and possible outcomes should be given to the woman and her family. For carcinoma in the early stages, treatment may be delayed until the end of the pregnancy, or a cone biopsy may be performed under general anaesthetic to remove the affected tissue.

risk of operation 1-haemorrhage due to the increased vascularity of the cervix in pregnancy 2-a risk of miscarriage. If the disease is more advanced, a termination of pregnancy in order to receive treatment, as the effects of chemotherapy and radiotherapy on the fetus late second and third trimester the obstetric and oncology teams will consider the optimal time for birth

Spontaneous miscarriage Definition miscarriage a spontaneous pregnancy loss in preference to the term of abortion which is associated with the deliberate مقصود ending of a pregnancy. A miscarriage is seen as the loss of the products of conception prior to the completion of 24 weeks of gestation, with an early pregnancy loss being one that occurs before the 12th completed week of pregnancy .

-10–20% loss of pregnancies -1–2% of second trimester pregnancies will result in a miscarriage -In all cases of miscarriage, the woman and her family will need guidance and support -Following the miscarriage, the parents may wish to see and hold their baby, and will need to be supported

For a pregnancy loss prior to 24 weeks' gestation, there is no legal requirement for a baby's birth to be registered -Following a miscarriage, blood tests may be carried out on the woman, and depending on gestational age, the parents may be offered a post mortem examination of the fetus to establish a reason for the pregnancy loss. -many cases there is no identifiable cause. -early pregnancy losses are due to chromosomal malformations, resulting in a fetus that does not develop.

A spontaneous miscarriage have a history of bleeding and/or lower abdominal pain. types 1-A threatened miscarriage -vaginal bleeding -in early pregnancy - which may or may not be accompanied by abdominal pain. -The cervical os remains closed, -80% of women will continue. - where viability of the pregnancy has been confirmed - no specific treatment - bed rest to preserve pregnancy is not supported by evidence so women should be neither encouraged nor discouraged from doing this.

2-an inevitable miscarriage -the abdominal pain persists - the bleeding increases - the cervix opens -the products of conception will pass into the vagina

3-an incomplete miscarriage. Should some of the products be retained Infection is a risk with incomplete miscarriage therapeutic termination of pregnancy. -s&s of miscarriage are present - accompanied by uterine tenderness -offensive vaginal discharge -pyrexia. - the options for treatment will often depend on gestational age and the condition of the woman

4 - a complete miscarriage, no required treatment if the woman's condition is stable, apart from the support and guidance she and her family will require to deal with their loss. 5- septic miscarriage -sepsis - hypotension - renal failure - disseminated intravascular coagulation (DIC). -It is important that women are educated to actively observe for signs of infection and know what to do if they suspect this.

6- a complete miscarriage. - remaining products may be passed spontaneously to become 7-a missed or silent miscarriage a pregnancy sac with identifiable fetal parts is seen on ultrasound - no fetal heart beat. -some abdominal pain - bleeding but the products of the pregnancy are not always passed spontaneously. 8- recurrent miscarriage: Tests may be carried out on the woman and fetus following a miscarriage to try to establish any underlying cause. This is especially important where there is a history of recurrent miscarriage

Following a history of three or more miscarriages a Intervention of vaginal bleeding : -to ensure that she is haemodynamically stable. - Profuse bleeding may occur where the products of conception are partially expelled through the cervix.

-assessing hCG levels may be used as an indication of the pregnancy's viability. - distinguish an ectopic pregnancy from a complete miscarriage where the uterus is empty on an ultrasound scan. -As a pregnancy progresses, transvaginal ultrasound and/or abdominal ultrasound may be used to confirm the presence or absence of a viable pregnancy sac . A gentle vaginal or speculum examination may also be performed to ascertain if the cervical os is open to observe for the presence of any products of conception within the vagina.

Miscarriages may be managed surgically, medically or expectantly Miscarriages may be managed surgically, medically or expectantly. In many cases the appropriate management is to wait for the products of the conception to be passed spontaneously. Management of miscarriage: 1-The surgical method, where the uterine cavity is evacuated of the retained products of conception (ERPC) prior to 14 weeks' gestation is suitable for women who do not want to be managed expectantly and who are not suitable for medical management. Under either a general or local anaesthetic the cervix is dilated and a suction curettage is used to empty the uterus. The use of prostaglandins prior to surgery makes the cervix easier to dilate, thus reducing the risk of cervical damage.

the main complications of E&C perforation of the uterus tears to the cervix hemorrhage.

2-Medical management of miscarriages includes - the use of prostaglandins, such as misoprostol, -use of an anti-progesterone such as mifepristone for a missed miscarriage - progesterone alone for an incomplete miscarriage. the complications include abdominal pain and bleeding, overall the medical management of miscarriage reduces both the number of hospital admissions and the time women spend in hospital.

Causes: 1-Genetic reasons through karyotyping of the fetal tissue, as well as both parents. 2-Women should also be tested for lupus anticoagulant and anticardiolipin antibodies, with treatment of low dose aspirin and heparin

Ectopic pregnancy -pregnancy occurs when a fertilized ovum implants outside the uterine cavity, often within the fallopian tube. -implantation can also occur within the abdominal cavity (for instance on the large intestine or in the Pouch of Douglas) the ovary or in the cervical canal. -The conceptus produces hCG in the same way as for a uterine pregnancy, maintaining the corpus luteum - leads to the production of oestrogen and progesterone and the preparation of the uterus to receive the fertilized ovum. following implantation in an abnormal site the conceptus continues to grow and in the more common case of an ectopic pregnancy in the fallopian tube until the tube ruptures, often accompanied by catastrophic bleeding in the woman, or until the embryo dies.

-Many ectopic pregnancies occur with no identifiable risk factors damage to the fallopian tube through a previous ectopic pregnancy or previous tubular surgery previous ascending genital tract infections. an intrauterine contraceptive device (IUCD) in situ the woman conceives while taking the progestogen-only pill

Clinical picture: -Ectopic (tubal) pregnancies present with vaginal bleeding - a sudden onset of lower abdominal pain, one sided, but spreads as blood enters the peritoneal cavity. -There is referred shoulder tip pain caused by the blood irritating the diaphragm. -hypotension and tachycardia.

On abdominal palpation: -abdominal distension, guarding and tenderness, - the majority of cases the presentation is less acute, so there should be a suspicion of ectopic pregnancy in any woman who presents with amenorrhea and lower abdominal pain. -??a threatened or incomplete miscarriage, thus delaying appropriate treatment.

-A transvaginal ultrasound of the lower abdomen is a useful diagnostic tool in confirming the site of the pregnancy. -A single blood test for hCG level may be either positive (where the corpus luteum remains active) or negative,

treatment in the acute,: ** surgical removal of the conceptus and ruptured fallopian tube as these threaten the life of the woman if she is not stabilized and treated rapidly. In the majority of cases, surgery is currently by laparoscopy as opposed to a laparotomy, as this reduces blood loss, as well as postoperative pain. The ectopic pregnancy may either be removed through an incision in the tube itself, a salpingotomy, or by removing part of the fallopian tube, i.e. a salpingectomy. Although a salpingotomy will enable a higher chance of a uterine pregnancy in the future, it is associated with a higher incidence of subsequent tubal pregnancies

-Where the fetus has died, hCG levels will fall and the ectopic pregnancy may resolve itself - the products either being reabsorbed or miscarried. **Medical management is also a choice where the diagnosis of an ectopic pregnancy is made and the woman is haemodynamically stable.

Methotrexate is given in a single dose according to the woman's body weight works by interfering with DNA (deoxyribonucleic acid) synthesis preventing the continued growth of the fetus -Women who are Rhesus-negative should be given anti-D immunoglobulin

Box 12.2 No t e o n a nt i- D im m uno g lo bulin For all women who are Rhesus-negative, there is an increased risk of sensitization occurring during any form of pregnancy loss, and threatened miscarriage Anti-D immunoglobulin prophylaxis should be considered for non-sensitized women presenting with a history of bleeding after 12 weeks' gestation. Where the bleeding persists throughout the pregnancy, anti-D should be repeated at 6-weekly intervals. Anti-D immunoglobulin should also be administered to all non-sensitized Rhesus- negative women following miscarriage, ectopic pregnancy or therapeutic termination