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Year 4 - Reproductive Health > 2.01 - Physiology of Pregnancy > Flashcards

2.01 - Physiology of Pregnancy Flashcards

1
Q

Sexual intercourse that results in the deposition of sperm in the vagina at the level of the cervix is known as coitus.

In order for coitus to occur, there are a five stages:

A

1) sexual arousal
2) excitement phase
3) plateau phase
4) orgasmic phase
5) resolution phase

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2
Q

Excitement phase of male sexual function.

a) nervous system stimulated

b) consequence

A

a) sacral parasympathetic neurones (psychogenic or somatic stimuli).

b) arteriolar vasodilation in corpora cavernosa, increasing penile blood flow and causing erection.

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3
Q

Plateau phase of male sexual function.

a) nervous system stimulated

b) consequence

A

a) sacrospinous reflex

b) testes become completely elevated; stimulates secretion from accessory glands and lubricates distal urethra*.

*Also neutralises acidic urine in urethra.

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4
Q

Orgasmic phases of male sexual functios:

A

1) Emission

2) Ejaculation

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5
Q

Emission orgasmic phase of male sexual function.

a) nervous system stimulated

b) consequence

A

a) thoracolumbar sympathetic reflex

b) contraction of smooth muscle in ductus deferens, semilar vesicle and prostate; semen pools in urethral bulb.

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6
Q

Ejaculation orgasmic phase of male sexual function.

a) nervous system stimulated

b) consequence

A

a) spinal reflex with cortical control (L1, L2 sympathetic).

b) contraction of glands, ducts and urethral sphincter; contraction of genital organs, ischiocavernosus and bulbocavernosus, resulting in expulsion of semen.

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7
Q

Resolution phase of male sexual function.

a) nervous system stimulated

b) consequence

A

a) thoracolumbar sympathetic pathway

b) increased venous return leads to flaccidity, resulting in refractory period.

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8
Q

Excitement phase of female sexual function.

a) nervous system stimulated

b) consequence

A

a) sacral parasymathetic neurones

b) vaginal lubrication; clitoris engorges with blood; uterus elevated; inner two-thirds of vagina lengthens and expands.

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9
Q

Plateau phase of female sexual function.

a) nervous system stimulated

b) consequence

A

a) sacrospinous reflex

b) labia minora deepens in colour; clitoris withdraws; Bartholin gland secretions for lubrication.

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10
Q

Orgasmic phase of female sexual function.

a) nervous system stimulated

b) consequence

A

a) spinal reflex with cortical control (L1, L2 sympathetic).

b) orgasmic platform contracts rhythmically 3-15 times; uterus and anal sphincter contracts.

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11
Q

Resolution phase of female sexual function.

a) nervous system stimulated

b) consequence

A

a) thoracolumbar sympathetic pathway.

b) clitoris and uterus descends; vagina shortens and narrows; no refractory period so multiple orgasms possible.

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12
Q

Describe the key differences in the physiological sexual response of males and females.

A
  • emission and ejaculation do not occur in females
  • females are capable of several orgasms
  • female orgasms may last longer than that of a male
  • females can return to the unstimulated state without orgasm
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13
Q

What changes occur in the sexual response of females as a result of ageing?

A
  • reduced vaginal lubrication
  • vaginal and urethral tissue lose elasticity
  • length and width of vagina decreases
  • number of orgasmic contractions reduced
  • more rapid resolution
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14
Q

What are the types of sexual dysfunction caused by an abnormality in desire?

A
  • hypoactive (little or no interest)
  • aversion (revulsion or fear of sex)
  • hyperactive
  • nymphomaniac (uncontrollable sexual desire)
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15
Q

What are some causes of impotence?

A
  • psychological
  • tears in tissue of corpora cavernosa
  • vascular abnormalities (atherosclerosis, diabetes)
  • drugs (e.g. beta blockers)
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16
Q

What are some causes of vaginismus?

A
  • stress
  • previous abuse
  • substance misuse
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17
Q

Describe the transport of sperm through the female reproductive tract.

A

1) Semen immediately coagulates after ejaculation to hold the sperm at the cervical os and protect against acidic pH.

2) Cervical mucus presents a barrier to sub-motile sperm, and is thus a means of sperm selection.

3) Pro-ovarian contractions of the uterine myometrium propel the sperm towards the fallopian tubes.

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18
Q

Describe the process of sperm capacitation.

A

The final maturation process of sperm is stimulated by uterine secretions:

  • activation of proteins on plasma membrane of sperm head (acrosomal reaction)
  • increased number of CatSper channels on the flagellum (increased motility)
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19
Q

Describe the acrosomal reaction.

A

The sperm’s acrosome releases hydrolytic and proteolytic enzymes, digesting the zona pellucida of the oocyte and enabling the sperm to reach the cell membrane.

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20
Q

What is the physiological mechanism behind polyspermy prevention?

A

Binding of sperm to cell membrane depolarises the cell, making the oocyte more positive (Na+ influx) and repelling further sperm.

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21
Q

Describe the process of zygote formation and implantation.

A

The pronucleus of the ovum (n) fuses with the pronucleus of the sperm cell (n), producing the zygote (2n).

The zygote divides via mitosis into a morula (16 cells, day 3), then blastocyst (day 5). The blastocyst implants on day 7.

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22
Q

Describe the affect of pregnancy on the thyroid.

A

Increased oestrogen production by the placenta increases hepatic production of TBG. More free T3 and T4 bind to TBG, causing more FSH release from anterior pituitary. As a result, free T3/T4 levels are unchanged but total levels rise.

Increasing T3/T4 levels in the mother ensures there is a constant supply of thyroxin to the foetus in early pregnancy.

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23
Q

Describe the affect of pregnancy on insulin.

A

Increase in anti-insulin hormones, so there is insulin resistance in the mother and the peripheral uptake of glucose is lower.

This ensures there is a constant supply of glucose for the foetus.

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24
Q

Why is pregnancy associated with an increased risk of ketoacidosis?

A

Lipolysis rates increase maternally so fatty acids in the plasma rise, providing a substrate for maternal metabolism.

The breakdown of lipids can result in ketogenesis, increasing risk of ketoacidosis.

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25
Q

Describe the affect of pregnancy on the cardiovascular system.

A

Increased progesterone decreases systemic vascular resistance, decreasing diastolic blood pressure. In response, cardiac output increases by about 40%.

Pregnancy activates RAAS, leading to an increase in sodium levels and water retention. Therefore, total blood volume increases.

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26
Q

Describe the affect of pregnancy on the respiratory system.

A

Growth of the foetus causes upward displacement of the diaphragm, however due to increase in transverse and AP diameters of the thorax, total lung volume is unchanged.

Increased progesterone increases respiratory drive, resulting in hyperventilation (respiratory alkalosis).

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27
Q

Describe the affect of pregnancy on the gastrointestinal system.

A

Upward displacement of the stomach due to foetus growth increases intra-gastric pressure, predisposing the mother to GOR and n+v.

Increased progesterone causes smooth muscle relaxation to decrease gut motility. This allows more time for nutrient absorption, but can also lead to constipation.

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28
Q

Describe the affect of pregnancy on the urinary system.

A

Increased cardiac output during pregnancy increases renal plasma flow, so GFR increases by 50-60%. The levels of urea and creatinine are lower.

Increased progesterone relaxes the ureter and muscles of the bladder, which can cause urinary stasis > UTIs > pyelonephritis.

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29
Q

Describe the haematological changes in pregnancy.

A

Increased risk of thromboembolic disease due to:
- increased fibrinogen
- increased clotting factors
- decrease in fibrinolysis
- increase progesterone (venous stasis)

Note warfarin is teratogenic so LMWH heparin is given to pregnant women if required.

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30
Q

Why does anaemia occur in pregnancy?

A

Plasma volume increases significantly, more than red cell mass.

This results in dilutional anaemia.

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31
Q

Pathophysiology of gestational diabetes mellitus (GDM).

A

Usually, there is an increase in insulin resistance during pregnancy. This can be counteracted by increasing insulin production.

In gestational diabetes, the compensatory rise in insulin levels does not occur, resulting in higher blood sugar levels.

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32
Q

Risk factors for GDM.

A
  • increased age
  • high BMI before pregnancy
  • FHx T2DM
  • smoking
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33
Q

Diagnostic criteria for GDM.

A
  • fasting plasma glucose >5.6mmol/L
  • two-hour plasma glucose >7.8mmol/L
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34
Q

What is the management of GDM.

A

Conservative management includes changing diet and physical activity levels.

Insulin or metformin can be given when lifestyle measures do not help.

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35
Q

What are the risks of GDM.

A
  • macrosomia (causing complications during birth)
  • intrauterine growth retardation
36
Q

How does breast tissue change during pregnancy?

A

Significant hypertrophy of the ductular-lobular-alveolar system, with differentiation to allow milk production capacity.

There is little milk secretion due to a high progesterone:oestrogen ratio, which favours growth rather than secretion.

37
Q

What is the composition of breast milk?

A
38
Q

Describe the regulation of breast milk production.

A

A high progesterone:oestrogen ratio during pregnancy favours the development of alveoli, but not secretion.

When the placenta is delivered, progesterone falls and breast milk begins to form within 24-48 hours.

Prolactin stimulation is promoted by suckling, increasing milk production.

39
Q

What is the milk let-down reflex?

A

In response to suckling, oxytocin is released from the posterior pituitary gland. This causes contraction of ducts and squeezes milk out of the breast.

40
Q

How is milk production maintained?

A

Suckling - as soon as suckling stops, milk production will cease gradually.

41
Q

What are the benefits of breastfeeding for mother and baby?

A
  • meets all baby’s nutritional needs
  • breast milk protects baby from infection
  • breast milk is available whenever needed
  • breastfeeding can build a strong emotional bond between mother and baby
42
Q

For the mother, what are some specific health benefits of breastfeeding?

A

Breastfeeding lowers risk of:
- breast cancer
- ovarian cancer
- osteoporosis
- cardiovascular disease
- obesity

43
Q

How long after birth is breastfeeding recommended?

A

The first six months of baby’s life, after which breast milk can be given alongside solid foods.

Breast milk adapts as the baby grows to meet the changing needs.

44
Q

What are Braxton-Hicks contractions?

A

Throughout the third trimester, involuntary contractions of uterine smooth muscle beings to occur.

They are thought to be a form of ‘practice’ contraction, but are not regarded as part of labour.

45
Q

What is cervical ripening?

A

Softening of the cervix before labour in response to oestrogen, relaxin and prostaglandins, allowing the cervix to dilate.

Ripening involves:
- reduction in collagen
- increase in glycosaminoglycans
- increase is hyaluronic acid
- reduced aggregation of collagen fibres

46
Q

Outline the role of oxytocin during labour.

A

At ~36 weeks gestation, oestrogen levels increase the number of oxytocin receptors in the myometrium.

Pulsatile release of oxytocin causes contractions. As contractions occur, there is a positive feedback loop that results in further release of oxytocin. This allows for stronger and more frequent contractions (Ferguson reflex).

47
Q

What is defined as the beginning of labour?

A

When regular, painful contractions lead to dilatation of the cervix.

48
Q

What changes occur in the first stage of labour?

A

The first stage of labour results in the creation of the birth canal, lasting from the beginning of labour until the cervix is fully dilated (~10cm).

Contractions occur every 2-3 minutes and foetal membranes rupture if not already.

49
Q

What changes occur during the second stage of labour?

A

The period of time between the cervix being fully dilated, and the foetus being expelled. Approx. 40 mins in nulliparous and 20 mins in multiparous women.

Passive stage - lasts until the head of the foetus reaches the pelvic floor.

Active stage - pressure of foetal head of the pelvic floor brings the desire to push.

Myometrial contractions are forceful and frequent under the influence of prostaglandins and oxytocin, which helps with expulsion of the foetus.

50
Q

What changes occur during the third stage of labour?

A

The period of time between delivery of the baby until delivery of the placenta.

Uterine muscle continues to contract until the placenta and the membranes have been delivered.

51
Q

By which week of gestation should most women enter labour?

A

By week 42

52
Q

What is induction of labour (IOL)?

A

The process of starting labour artificially.

Approximately 1 in 5 pregnancies will require an induction.

53
Q

Women with uncomplicated pregnancies should be offered IOL between how many weeks gestation?

A

40+0 to 40+14

The aim is to avoid the risks of foetal compromise and stillbirth associated with prolonged gestation.

54
Q

Give some indications of IOL.

A
  • prolonged gestation (>40 weeks)
  • fetal growth restriction
  • premature rupture of membranes
  • maternal health problems (e.g. hypertension, pre-eclampsia, diabetes)
  • intrauterine fetal death
55
Q

Outline the management for preterm premature rupture of membranes (PPROM):

a) <34 week’s gestation

b) >34 weeks gestation

c) >37 weeks gestation

A

a) delay IOL unless obstetric factors indicate otherwise

b) timing of IOL depends on risks vs benefits of delaying pregnancy further

c) offer IOL, or offer expectant management for a maximum of 24 hours

56
Q

What are the absolute contraindications for IOL?

A
  • cephalopelvic disproportion
  • vasa praevia
  • cord prolapse
  • transverse lie
  • active primary genital herpes
  • previous classical Caesarean section
57
Q

What are the relative contraindications for IOL?

A
  • breech presentation
  • triplet
  • > 2 previous low transverse Caesarean sections
58
Q

What are the main methods of IOL?

A
  • vaginal prostaglandins (most common)
  • amniotomy
  • membrane sweep
59
Q

Outline the role of vaginal prostaglandins in IOL.

A

Prostaglandins ripen the cervix, and help stimulate contraction of the uterus.

They are the mainstay of induction for labour (NICE, 2008).

60
Q

Outline the role of amniotomy in IOL.

A

Artificial rupture of the membranes using an amnihook. This releases prostaglandins in an attempt to expedite labour.

It is only performed where the cervix has been deemed as ripe, and vaginal prostaglandins are contraindicated.

61
Q

Outline the role of membrane sweep in IOL.

A

Offered at 40-41 weeks gestation, used as an adjunct to IOL.

Insertion of a gloved finger through the cervix and rotating against the fetal membranes, helping to release natural prostaglandins to initiate labour.

62
Q

How is cervical ripeness assessed?

A

Bishop Score

≥ 7 suggests cervix is ‘ripe’ and so induction of labour is possible.

<4 suggests labour is unlikely to progress naturally and vaginal prostaglandins are required.

63
Q

A pregnant person is 40+6 weeks gestation with a Bishop score of 3.

a) What is the first line management?

b) What management is required if first line fails?

A

a) vaginal prostaglandins

b) Caesarean section

64
Q

Prior to induction of labour, a reassuring fetal heart rate must be confirmed.

How is this performed?

A

Cardiotocography (CTG)

or

Intermittent auscultation

65
Q

What are the complications of labour induction?

A
  • failure of induction
  • uterine hyperstimulation
  • cord prolapse
  • infection
  • pain
  • uterine rupture
66
Q

What is the role of midwifery led antenatal care?

A

Uncomplicated pregnancies, involving 10 appointments over the course of a pregnancy for nulliparous women, and 7 if it is a second pregnancy.

67
Q

What is the role of obstetrician led antenatal care?

A

If classes as higher risk including multiple pregnancy and maternal health problems.

Consists of all the midwifery appointments PLUS joint clinics to cover mental health, haematology issues, diabetes etc.

68
Q

Give some maternal health issues that increase the risk of neural tube defects.

A
  • epilepsy
  • previous baby with neural tube defects
  • BMI ≥ 35kg/m2
  • T1DM / T2DM
  • sickle cell disease
  • Crohn’s disease
69
Q

How can the risk of neural tube defect be mitigated in women determined to be at higher risk?

A

Folic acid (5mg) taken for three months before pregnancy, and up to the first 12 weeks.

Offer all women Vitamin D (10mcg) to reduce the risk of rickets.

70
Q

What occurs at the booking visit?

A

The first appointment covering education on lifestyle, nutrition and aspects of physical and mental health.

  • measure BMI
  • blood pressure
  • urine dipstick
  • FBC
  • blood group
  • antibodies and RhD status
  • screen for Thalassaemias and Sickle cell
  • offer screening for HIV, HepB and syphilis
71
Q

When should anti-D prophylaxis be administered antenatally?

A

If RhD-ve woman, administer at:
- sensitising events (amniocentesis, antepartum bleed, abdominal trauma)
- routinely offer prophylaxis at 28 and 34 weeks

72
Q

How can the dose of anti-D required after a sensitising event be checked?

A

Kleihauer-Betke test

73
Q

How is foetal growth determined after 24 weeks gestation?

A

Measure symphysis fundal height (SFH) at each antenatal appointment after 24 weeks. If there are concerns, send for an ultrasound assessment.

74
Q

Indications for regular USS to assess foetal growth after 24 weeks.

A
  • multiple pregnancy
  • BMI >35
  • large or multiple fibroids

Abdominal palpation is unlikely to be accurate in these instances.

75
Q

What lifestyle advice can be given antenatally?

(Food)

A

Avoid raw meat, fish, eggs, unpasteurised milk or cheese, pate and shellfish.

Wash fruit and vegetables.

76
Q

What lifestyle advice can be given antenatally?

(Exercise)

A

Strenuous exercise is a risk factor for small for gestational age babies.

Encourage exercise at the same level as pre-pregnancy if this was not vigorous, or advise to start a gentle regular programme.

Advise to avoid contact or high risk sorts, and scuba diving.

77
Q

What lifestyle advice can be given antenatally?

(Smoking)

A

Encourage smoking cessation and counsel about risks.

Limited evidence exists on nicotine replacement therapy but can be prescribed if the mother wishes.

78
Q

What lifestyle advice can be given antenatally?

(Alcohol)

A

High use may result in foetal alcohol syndrome.

To avoid the risk, the advice is to exclude completely.

79
Q

What lifestyle advice can be given antenatally?

(Recreational drugs)

A

Cocaine particularly associated with adverse complications (e.g. spontaneous abortion, placental abruption, growth restriction).

Refer patients for early intervention for good outcomes. Interventions can include:
- CBT
- couples therapy
- talking therapy

If people are addicted to opiates such as heroin and are struggling to quit, refer to the methadone programme.

80
Q

What lifestyle advice can be given antenatally?

(Travel)

A

Increased risk of VTE during pregnancy.

Recommend compression stockings and check with individual airlines on gestation limits.

Advise patients even if they are low risk for VTE to be active daily and keep well hydrated to reduce the risk of VTE.

81
Q

What are some common problems in pregnancy?

A
  • reduced foetal movements
  • nausea and vomiting
  • heartburn
  • constipation
82
Q

What advice can be given for reduced foetal movements during pregnancy?

A

Advise to immediately contact maternity services if there is concern about a baby’s movement.

There should be no change to the pattern or number of movements after 28 weeks gestation.

83
Q

What advice can be given for nausea and vomiting during pregnancy?

A

Normally starts between the 4th and 7th week, and should settle by week 20.

Suggest ginger and acupuncture, progressing to antiemetics if severe.

If prolonged and severe, consider treatment for hyperemesis gravidarum.

84
Q

What advice can be given for heartburn during pregnancy?

A

Alleviate by sitting up after meals, reducing fat and spice and eating smaller portions.

Can suggest Gaviscon or omeprazole in severe cases.

85
Q

What advice can be given for constipation during pregnancy?

A

Encourage increased fibre and oral fluids.

Suggest bran or wheat fibre supplements.

86
Q

According to the MBRRACE 2021 report, the risk of maternal death is highest in women with complex social factors:

A
  • substance misuse (alcohol and drugs)
  • teenage pregnancy
  • asylum seekers, recent migrants, refugees or those with a language barrier
  • victims of domestic abuseA
87
Q

The MBRRACE 2021 report evidenced the disparity of mortality and poor obstetric outcomes amongst women from ethnic minority groups:

A
  • risk of maternal death >4x in Black women compared to white women.
  • stillbirth rates >2x in Black women compared to white women.
  • stillbirth rates ~2x for women living in most deprived areas compared with least deprived areas

Year 4 - Reproductive Health (12 decks)

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