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What happens in endometriosis

Once the fragments of endometrium have implanted they begin to respond to the fluctuating levels of the menstrual cycle hormones in the same way as the endometrium lining the uterus. Thus, the implants thicken and swell with blood and then break down and bleed each month. This blood then cannot escape from the body so it bleeds directly onto the surface of the surrounding organs, causing irritation which leads to inflammation, scarring and, sometimes, the development of adhesions.

As the disease progresses the implants gradually enlarge in size and may form small cysts.

As a cyst enlarges, the pressure within the cyst may cause it to rupture during menstruation, spilling the contents onto the adjacent tissues. This may in turn lead to the development of new implants.

What does endometriosis look like

Classical implants

Until recently, endometrial implants were thought to be fairly uniform in appearance. However, in the last few years there has been a growing appreciation that they have a range of characteristic appearances.

It is now understood that what were traditionally recognized as being classical implants are, in fact, probably only one end of the spectrum of appearances and that they are probably only typical of older implants.

Classical implants usually appear as tiny dots, or clusters of dots, on the surface of the organ or ligament on which they have implanted. They are usually only pinhead in size but they may be up to a centimeter or more in diameter. They range in colour from brown to black depending on how much old blood they contain. When magnified they may look like clusters of black grapes.

Atypical implants

The newly recognized implants are often called atypical implants but they are probably younger implants which, as yet, have very little old blood deposited in them.

Atypical implants are usually very small and are sometimes difficult to see. They may occur alone or in clusters and may be clear, white, yellow, orange or red in colour.

Microscopic endometriosis

In the early stages of endometriosis the implants may be too small to be seen without the use of a microscope. This type of endometriosis is often referred to as microscopic endometriosis.

Endometriomas

Endometrial cysts on the ovary are also known as endometriomas. They are usually less than two or three centimeters in diameter but occasionally may be 10 or more centimeters in diameter. They may be embedded in the ovary itself or they may lie on its surface. They are sometimes referred to as ‘chocolate cysts’ because they contain old dark blood which often has the appearance and consistency of melted chocolate.

Adhesions

Adhesions are bands of tissue which bind or matt together organs of the pelvic cavity and they may be formed as a result of endometriosis. They may have the appearance of sticky toffee which has been stretched from one organ to another.

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Abnormal presentation

‘Presentation’ means the part of the baby that passes through the birth canal first. Normal presentation is head first, facing backwards, and with the neck bent forward so that the crown leads the way through the birth canal. With the head in this position, its narrowest diameter passes through the pelvic outlet.

The most common abnormal presentation is breech, which is bottom first. There are two main reasons why breech presentation causes problems in delivery. First, the soft breech is effective as a dilator of the cervix sol the first stage of labour is usually prolonged. Second, the largest and least compressible part (the head) comes last and may have to pass through an inadequately dilated birth canal. When the head comes first it has plenty of’ mould to the shape of the pelvic during the first stage of labour: note breech presentation. If the head won’t fit through the pelvis, labour will be obstructed. If the body is already delivered,
this is a serious problem.

Some foetuses in the breech position
will spontaneously turn before labour begins, and sometimes a doctor or midwife can turn a breech by manipulations through the mother’s abdominal wall.

A breech delivery will need more intervention and birth injury to the baby more common, even in the best hands. If breech is suspected and confirmed ultrasound before labour commences, caesarean delivery is often advised, especially if the mother’s pelvis is smaller average. In vaginal breech delivery, forceps are usually needed to deliver the head and protect it from injury due to сcompression.

Less common abnormal head presentations include positions of the foetal h” (such as face or brow first, or the head facing the mother’s abdomen rather than her spine) that don’t direct its narrowest diameter through the mother’s pelvic оoutlet. Usually the head can be manipulated into the most favourable position for livery – facing the mother’s spine with crown coming first.

Shoulder presentation is rare, and usually results from an abnormality of the uterine cavity. Transverse lie describes a foetus lying sideways in the mother’s uterus so that its back or side lies over the cervical outlet. Delivery in these positions is impossible and if the foetus can’t be turned, caesarean delivery is the only answer.

Multiple pregnancy

The chance of a twin pregnancy is one in ninety. With triplets it’s one in about 8000; it’s one in about 750 000 with quadruplets. Multiple pregnancy is more common after some treatments for subfertility such as IVF, GIFT and those that stimulate ovulation.

Multiple pregnancy is suspected when die uterus enlarges more quickly than expected.
It can be confirmed by ultrasound. The problems of multiple pregnancy
(in addition to the discomfort of having an extra ‘passenger’ in your uterus) include increased risks of pregnancy-induced
hypertension, pre-term delivery, abnormal presentation, difficult delivery and babies with a low birth weight (sometimes one twin much smaller than the other).

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Problems in pregnancy are those that increase the health risks for the mother, the foetus or both. Problems arise in about one out of ten pregnancies. There are two broad categories of pregnancy problems:

1 those that arise as a result of the pregnancy

2 those that existed before pregnancy and that may become more severe during pregnancy.

Pregnancy can cause problems such as pregnancy-induced hypertension, placental bleeding, abnormal presentation, multiple pregnancy, foetal growth retardation, gestational diabetes and Rhesus iso-immunisation.

Pregnancy-induced hypertension (PIH)

This condition was previously (and is still sometimes) called toxaemia of pregnancy or pre-eclamptic toxaemia. Its signs are raised blood pressure, fluid retention leading to swollen hands and feet, and protein in the urine. It rarely causes symptoms except for the swollen hands and feet, though in very severe cases headaches and visual disturbances! occur.

The cause of PIH is unknown. It ally doesn’t appear until 28 weeks w and is more common in first pregnancies and multiple pregnancies. It is also common if the mother is under 18 or; 35 years of age.

Early detection of PIH is one of most important reasons for regularly measuring blood pressure and testing
urine during antenatal supervision. If detected and treated and the blood sure continues to rise, the mother have fits (eclampsia) and, in extreme kidney failure and brain haemorrhage.

Raised blood pressure also reduces the blood supply to the placenta so that foetus doesn’t receive adequate оxygen and nourishment, which can lead to
growth retardation. It can also cause ration of the placenta, which leads to severe bleeding: emergency caesarean livery may be needed to save the lives of mother and baby.

If the mother has raised blood pressure, the first treatment is rest. If the blood pressure is very high or there is protein the urine, rest in hospital is necessary. Rest usually brings the blood pressure down and keeps it within normal limits. If not, either labour will be induced or the mother is given medication (that won’t harm mother or foetus) to reduce blood pressure until the foetus is mature enough for induction of labour. Pregnancy-induced hypertension disappears after delivery and rarely recurs in subsequent pregnancies.

Placental bleeding

Bleeding from the placenta before birth is called antepartum haemorrhage and is due to premature separation of the placenta.

If the placenta is implanted in the normal position in the upper part of the uterus, bleeding from premature separation is called accidental haemorrhage, which may result from pregnancy-induced hypertension or occur for no apparent reason. If feeding is slight there is no danger to the mother, but even small amounts of bleeding can reduce the supply of oxygen and nutrients to the foetus. Accidental haemorrhage is often associated with lower abdominal pain.

If the placenta is implanted in the lower part of the uterus, over or very close to the cervical outlet, it is called placenta praevia (meaning placenta before the foetus). Parts of a placenta praevia can separate during contractions of the uterus, resulting in heavy bleeding that can be a danger for both mother and foetus. Abdominal pain is unusual with bleeding from placenta praevia. If you have any bleeding during pregnancy, contact your doctor or go to hospital immediately. An ultrasound examination will show whether the bleeding is accidental or due to placenta praevia. If accidental haemorrhage is slight and stops soon, you will usually be able to go home provided your blood pressure is normal and there is no continuing risk to the foetus.

If placenta praevia is found, you’ll be advised to stay in hospital, as the bleeding is likely to recur and may be severe enough for you to need a transfusion. The aim is to maintain the pregnancy until about 37 weeks. Delivery is usually by caesarean section, though if the edge of the placenta just reaches the cervical opening (this is called marginal placental praevia), vaginal delivery may be possible. Sometimes emergency caesarean delivery must be done earlier to save the mother and foetus.

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