osteonecrosis

Aetiology and pathogenesis

Sites which are peculiarly vulnerable to ischaemic

necrosis are the 

• femoral head, 
• the femoral condyles,
• the head of the humerus, 
• the capitulum and the 
• proximal
• parts of the scaphoid and talus.

MAIN CONDITIONS ASSOCIATED WITH

NON-TRAUMATIC OSTEONECROSIS

Infections

• Osteomyelitis

• Septic arthritis

Haemoglobinopathy

• Sickle cell disease

Storage disorders

• Gaucher’s disease

Caisson disease

• Dysbaric osteonecrosis

Coagulation disorders

• Familial thrombophilia

• Hypofibrinolysis

• Hypolipoproteinaemia

• Thrombocytopenic purpura

Other

• Perthes’ disease

• Cortisone administration

• Alcohol abuse

• SLE (? increase in antiphospholipid antibodies)

• Pregnancy (? decreased fibrinolysis; ? fatty liver)

• Anaphylactic shock

• Ionizing radiation

SLE, systemic lupus erythematosus.

dilatation and curretage

Indications for D&C

Irregular bleeding: You may experience irregular bleeding from time to time, including spotting between periods. If the spotting develops into continuous midcycle bleeding, your doctor may perform a D&C to investigate the cause of bleeding. The endometrium lining tissue is sent to the laboratory for histopathological analysis.

Heavy vaginal bleeding: Bleeding with long, heavy periods, or bleeding after menopause, can signal a number of problems.

a)     Fibroids and polyps: Fibroid are non-cancerous muscle growths that appear within the uterus or on its surface. Some of them grow on the wall of the uterus while others grow into the cavity of the uterus. When it enlarged, there will be heavy menses and severe pain. Polyps are fleshy tissues that grow from the uterine lining into the uterine cavity. Both the polyps and fibroids can cause irregular vagina bleeding. Hysteroscopy (a telescope inserted into the uterine cavity) can differentiate the two.

b)     Endometrial cancer:  D&C are commonly performed for woman above 40 years of age with abnormal vaginal bleeding to confirm cancer of the endometrium.

Therapeutic D&C: D&C is done for missed abortion or incomplete miscarriage. If the product of conceptus is left in the uterine cavity untreated, the woman will have heavy vaginal bleeding, infection will set in. The product of conceptus will prevent the uterus from contracting and it is a good medium for bacteria to grow. D&C is also done when there is retained product of conceptus after a normal delivery. The retained tissue in the uterine cavity will cause excessive bleeding which can be life threatening to the mother.

complete vs incomplete hydatidiform mole

Complete or classical hydatidiform mole is described
as a generalized swelling of the villous tissue, diffuse
trophoblastic hyperplasia and no embryonic or fetal
tissue.

Partial hydatidiform mole is characterized by
focal swelling of the villous tissue, focal trophoblastic
hyperplasia and embryonic or fetal tissue.

intramural fibroid

Symptoms of Intramural Fibroids
Intramural fibroids are generally asymptomatic, but in some women, they may cause problems such as:

• Heavier menstrual bleeding
• Pelvic pain
• Pain in back and the back of the legs
• Constipation and bloating
• Constant urge to urinate
• Lower-abdominal pressure or heaviness due to the weight of large intramural fibroids
• Abnormally large abdomen
• Pain or discomfort during intercourse, if the fibroids are located in the cervix area
• In some extreme cases, intramural fibroids may result in uterine hemorrhage

Intramural Fibroids and Infertility
Normally, intramural fibroids have no effect on fertility and pregnancy. However, in about 3% of women, these uterine fibroids are linked with infertility. Women who have multiple intramural fibroids or very large fibroids may find conceiving troublesome.

Intramural fibroids can prevent sperm from entering the uterine cavity, particularly when the fibroids are located at the cervix. These fibroids can also enlarge the uterine cavity, thereby increasing the distance that sperm need to travel to reach the fallopian tubes. Additionally, intramural fibroids may affect the uterus’s ability to contract, which has a direct impact upon sperm migration and ovum transport.

Implantation of the embryo can also be inhibited by intramural fibroids as they distort the uterine cavity, impairing the blood supply to the endometrium and disturbing the endometrium structure. Even if implantation has occurred successfully, intramural fibroids may interfere with the development of the foetus.

Uterine fibroids usually enlarge as the pregnancy proceeds. Due to this, there is a tussle for space between the growing baby and the intramural fibroids. This struggle may either induce developmental defects in the unborn child or may cause a miscarriage.

Treatment of Intramural Fibroids
If intramural fibroids aren’t interfering with a woman’s ability to get pregnant and aren’t causing any pain, it is likely they will be left untouched. However, if the intramural fibroids are large, treatment might be necessary to reduce the symptoms produced by them.

These uterine fibroids are generally treated by means of three types of surgical procedures:

1. Removal of one or more intramural fibroids by open abdominal surgery called abdominal myomectomy.
2. Destruction of the fibroids through uterine artery embolization in which polyvinyl alchol beads are injected into the uterine artery with a catheter to block the flow of blood to the intramural fibroids
3. Hysterectomy which looks to remove the uterus

fibroid treatment

fibroid  treatment

Treatment


Conservative management is appropriate where
asymptomatic fibroids are detected incidentally.

It may
be useful to establish the growth rate of the fibroids by
repeat clinical examination or ultrasound after a 6-12-
month interval. 

Where treatment is required, the only
practical currently available medical treatment is ovarian
suppression using a gonadotrophin-releasing hormone
(GnRH) agonist. Unfortunately,while very
effective in shrinking fibroids, when ovarian function
returns, the fibroids regrow to their previous dimensions.

Mifepristone (an antiprogestogen) has been
shown to be effective in shrinking fibroids at a low dose,
but is not available for use in this indication.

The optimal
dose, duration of treatment and long-term effects
have yet to be established.

mechanisms of labour

Inevitable

Inevitable miscarriage

An inevitable miscarriage can be complete or incomplete,
depending on whether or not all fetal and placental
tissues have been expelled from the uterus (Fig. 8.5).

The typical features of incomplete abortion are heavy,
sometimes intermittent, bleeding with passage of clots
and tissue, together with lower abdominal cramps. If
these symptoms improve spontaneously, a complete
abortion is more likely. Ultrasound examination is
important in determining the absence or persistence
of conception products inside the uterine cavity.


Incomplete miscarriage 
Persistence of conception products inside the uterine cavity on TVS
Management ----- Surgical evacuation (ERPC) or medical induction (RU486 + Pgs)