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x REPRO > 4/11, 14 Endocrinology/Phys of Pregnancy & Delivery > Flashcards

4/11, 14 Endocrinology/Phys of Pregnancy & Delivery Flashcards

1
Q

definiton of labor

A

physiologic process by which the uterus expels the fetus and placenta at >20wks

(<20 wks = “abortion”)

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2
Q

clinical diagnosis of labor?

A

painful uterine contractions that cause cervical effacement and dilatation

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3
Q

how does the baby know when its time to come out? How does the baby, or mom, make this happen at the right time? To answer this, mention at least 4 signaling factors that change during the initaiton of parturition.

A

initiation of parturition - involves:

  • progesterone withdrawal - increased levels during pregnancy up until 32-34 weeks and then it tends to level off.; medically it is used to relax the uterus or stop pre-term labor
  • oxytocin - increased levels after the initiation of labor
  • fetal cortisol - “shift in balance” of progesterone relative to estrogen (incr E production due to fetal conversion of DHE-AS to E)
  • prostaglandins (PGE2, PGF2) - hh levels released around labor
  • Uterus contractions from the fundus (top portion of uterus)
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4
Q

Substances that uterine irritability and contractility

A
  • estrogen
  • oxytocin
  • PGF2α
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5
Q

Substances that decrease uterine irritability (smooth muscle to relax)

A
  • progesterone
  • ß2-agonists
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6
Q

How does the uterus go from contracting asyncrhonously to sychronously?

A
  • Initially the uterus contracts without synchronicity because there aren’t that many gap junctions present
  • When progesterone relative to estrogen decreases (in other words, more estrogen is being produced) during labor, prostaglandins increase, the uterus and cervix distends, and the brain releases oxytocin, which causes the smooth muscles to express more gap junctions and become more coordinated in their contractions
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7
Q

What 2 factors induces labor?

A
  • prostaglandins dramatically increase as soon as labor starts and help remodel cervix and initiate labor 24hrs earlier
  • oxytocin
    • uterine contractions -

assist the uterus in clotting the placental attachment point postpartum
* acts at the mammary glands, causing milk to be ‘let down’

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8
Q

What controls parturition?

A

Corticotropin-releasing hormone (CRH)

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9
Q

What produces CRH? What does it indicate?

A
  • produced by the placenta
  • maternal blood CRH levels predicts when labor will beging
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10
Q

What are the effects of CRH? name at least 2

A
  • increase fetal adrenal production of **DHEA-S **(dihydroepiandrosterone sulfate)

increase fetal adrenal production of cortisol

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11
Q

What is the role of DHEA-S in parturition?

(what signals its production?)

A
  • produced in the placenta via CRH signaling
  • placenta converts DHEA-S -> Estrogen
    • Progesterone levels remain high but the ratio of E to P is now shifted (due to increased conversion in the placenta)
  • resultant increased E:P ratio is conducive to uterine contractions (remember progesterone keeps the uterus “quiet”)
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12
Q

What is the role of fetal cortisol in parturition?

(what signals its production?)

A
  • Cortisol INCREASES production of placental CRH (+ feedback) -> increased CRH production
  • Cortisol -> fetal lung maturation (surfactant proteins, phospholipids) and increase prostaglandin -> cervical remodeling, inflammatory infiltrate, and matrix MMP
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13
Q

What is the role of increased prostaglandins during parturition?

A

increase prostaglandin -> cervical remodeling, inflammatory infiltrate, and matrix MMP

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14
Q

3 phases of pregnancy?

A
  • Phase 0 = Pregnancy - “functional quiescence”, uterus is kept quiet via inhibitors such as progesterone, prostacyclin, relaxin, NO
  • Phase 1 = Uterine priming - release of inhibition as well as uterotropins such as estrogens -> increase ion channels, gap junctions
  • Phase 2 = Stimulation/Labor (increase uterine irritability and contractility) by prostaglandins E2, F2a, oxytocin
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15
Q

3 stages of labor?

A
  • Prodrome- prelabor changes; may take days (braxton contractions)
  • Stage 1- from beginning of labor until full cervical dilation (10 cm); hours
  • Stage 2- from full dilation to delivery of fetus; minutes
  • Stage 3- from delivery of fetus to delivery of placenta and membranes; minutes
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16
Q

What are “braxton contractions”?

A
  • sporadic uterine contractions that sometimes start around 6 wks into a pregnancy; thought to prepare the uterus for birth.
  • prodromal labour or “practice contractions”
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17
Q

What are the phases of the prodromal stage of partuition?

A
  • Cervical ripening (by prostaglandins) - collagen chains break, incr. hydrophilic glycosaminoglycans, incr. H2O g softer, thinned out cervix
  • Lightening - dropping (baby drops into the pelvis); mom notices more room to breathe, eat, and increased sensation to pee
  • Passage of the mucus plug (may be bloody = big glob)
  • Braxton-Hicks contractions - from 10 wks on, non-propagated (non-synchronous), may not be felt by patient
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18
Q

Difference btwn false labor and true labor?

A

FALSE labor

  • Irregular contractions
  • Interval may stay same
  • Walking may make it less painful
  • Abdominal pain only
  • Contractions Subside

TRUE labor

  • Regular contractions
  • Interval decreases (hfrequency)
  • Walking makes worse
  • Abdomen AND back pain
  • Mild sedation has no effect on contractions
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19
Q

3 P’s of labor?

A

Power

Passenger

Passage

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20
Q

What are the signaling mechansims that make the myometrium contract?

A
  • Gap junctions allow rapid transmission and coordination of contraction signals; marked increase in #s in late pregnancy
  • Connexin43 - impt gap junction
  • Making the contraction:

increase intracellular calcium in myometrial cells -> incr. activity of Ca Calmodulin complex -> incr. MLCkinase -> **contraction **

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21
Q

What kind of cells are myometrial cells?

A

interwoven bundles of smooth muscle cells arranged in a spiral arrangement; when these contract, uterus decreases in size (contractions happen in multiple dimensions of the uterus)

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22
Q

What factors make for a good contraction?

A
  • Covers entire uterus
  • Gradient so all parts reach peak at same time
  • Intrauterine pressure about 50-60 mmHg above baseline (<20mmHg)
  • Frequency - every 2-4 minutes
  • Complete relaxation btwn contractions to allow for rest and blood flow to myometrium and baby
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23
Q

How can contractions can be measured?

A

tocodynamometry (internal or external) - absolute numbers aren’t meaningful: relative numbers have meaning (because any movement can result in a “contraction of the abd wall)

24
Q

What are the 4 effects of contractions?

A
  • Cervical effacement - obliteration (shortening) of cervical canal and thinning of cervix
  • Cervical dilatation - enlargement of cervical opening
  • Fetal descent to lower station (through pelvis)
  • PAIN
25
Q

There are 2 stages of pain during pregnancy. What are they?

How do you block each stage?

A

Stage 1:

  • contractions -> cervical dilatation
    • pain is carried via visceral afferents (sympathetic) of T10,11,12
  • alleviation:
    • nonpharmacologic methods (breathing)
    • epidural (L3-5) removes sensations from the waist down

Stage 2:

  • distention of pelvic floor, vagina, perineum
    • pain transmitted via sensory branches of pudendal nerve S2,3,4
  • alleviation
    • pudendal, local nerve block (epidural may not be good enough for perineal pain)
26
Q

What 3 things can you employ to stop contractions/labor?

A
  • Ca channel blocker (or Mg sulfate)
  • oxytocin receptor antagonists (not commonly used)
  • increase intracellular cAMP -> negative feedback
27
Q

What factors complicate the PASSAGE of baby through the pelvis?

A

baby’s head has to fit through these pelvic structures.

  • Ischeal spines + ischeal tuberosity + coxxyx = affects exit of baby
  • Pubic symphysis + sacroiliac joints = most fluid in a mature pelvis
28
Q

Definition of lie.

A

long axis of fetus to long axis of mom (aka longitudinal, oblique, transverse)

29
Q

definition of presentation/presenting part

A

what can be felt on vaginal exam, a point of reference

  • cephalic (=vertex)
  • breech (when the fetus’s head is opposite of the cervical os)
  • shoulder
30
Q

definition of position

A

relationship of baby’s head to the four quadrants of maternal pelvis; can be felt and manually manipulated (Leopold maneuvers) ->

  • OA = occiput anterior (baby’s occiput is anterior side of mom); usual position
  • OP = occiput posterior (sunny side up!)
  • ROT = R Occiput transverse (baby’s occiput is to mom’s right)
  • LOT = L Occiput transverse (baby’s occiput is to mom’s left)
31
Q

definition of Attitude

A

relationship of fetal parts to itself (flexed, military, extended)

32
Q

definition of Dystocia

causes? solutions?

A

Dystocia=difficult labor (i.e. when it is not working)

  • Power: uterine dysfunction -> augmentation (oxytocin), pain relief, amniotomy
  • Passenger: abnormalities of size, presentation, development (ie hydrocephalus) -> change maternal position, fetal position
  • Passage: abnormalities of pelvic size or architecture -> change maternal position to open pelvis
33
Q

What are complications of SVD (spontaneous vaginal delivery)?

A
  • Nuchal cord
  • Meconium
  • Shoulder dystocia
  • Fetal heart rate abnormalities
34
Q

Cards from hereon out are from the endocrinology of Pregnancy lecture on 4/11

A

Cards from hereon out are from the endocrinology of Pregnancy lecture on 4/11

35
Q

How to determine if one is pregnant
?

A
  • Measure from the first day of her last menstrual period (LMP)
    • if a woman has a 28d cycle, she ovulates on d14
  • Pregnancy test: hCG detected by a maternal serum or urine pregnancy test
36
Q

What does corpus luteum produces?

A
  • progesterone
  • 17-alpha hydroxy progesterone
  • estradiol
  • androstendione

corpus luteum produces a HEAP of hormones!

37
Q

What hormones does the placenta produce. Be specific.

A

Syncytiotrophoblast – acts like a pituitary

  • hCG
  • estriol

Cytotrophoblast – has individual cells, acts as a hypothalamus

  • dIA
  • CRH
38
Q

2 cell types of the placenta that produces hormones

A

Syncytiotrophoblast

Cytotrophoblast

39
Q

hCG

what produces it?

When is it first detectable?

what is its main role?

When do levels begin to decline?

A
  • produced by Syncytiotrophoblast (Pituitary-like peptides)
  • first detectable with a pregnancy test ~8-10d post conception
  • roles:
    • maintain the corpus luteum during the first trimester to allow it to secrete progesterone
    • fetal:maternal immunity (prevents mom from attacking baby
    • stimulate adrenal and placental steroidogenesis
    • stimulate fetal testes in males to induce internal virilization
  • By 120d = significant decrease in hCG production as the placenta takes over and begins to make more estrogen and progesterone
40
Q

What other peptide does hCG resemble?

A

LH and hCG are very similar (they have the same a chain, but the a different ß chain to confer specificity)

41
Q

what is the role of hCG in fetal/maternal immunity?

A

Downregulate maternal lymphocyte function (hCG is highly (-) charged and may repel maternal immune cells from entering the placental, thereby protecting the fetus (= hCG allows the mother to carry a genetically dissimilar person inside them)

42
Q

What is the rule of thumb when determining if there is a viable pregnancy?

A

hCG should increase by at least 66% every 48 hours in early pregnancy (first 7-8 weeks)

If this does not occur, you should be concerned for an ectopic, molar (placental tissue only, high hCG), loss (high hCG), or multiple gestations (high hCG)

43
Q

Patient with vide variation in maternal levels in her first trimester. Are you concerned?

A

no. this is normal according to the prof, but it should increase by at least 66% every 48 hours in early pregnancy (first 7-8 weeks)

44
Q

Estrogen & Progesterone

When can it first be detected?

A
  • Estradiol and progesterone secretion by conceptus (zygote) and cumulus (granulosa) detectable in vitro before implantation, but the rises are more obvious once its implanted
45
Q

Estrogen

made by what?

functions?

A
  • made by fetus, placenta and maternal compartment
  • roles
    • increase uterine blood flow
    • ∆ = blood, skin, breast development, respiration, GI, carbohydrate metabolism
46
Q

primary estrogen of pregnancy

A

Estriol; rapidly cleared

47
Q

Progesterone

made by what?

functions?

A

initially made by the corpus luteum (6-10 wks) and then by placenta production; transition period is marked by a transient decrease in circulating levels at 8-10 wks

functions

  • Decidual reaction
  • Decrease myometrial contractility
  • Increase stretchiness of uterine muscle
  • Breast development
  • most important; allows pregnancy to continue
48
Q

endorphins

produced by what?

function?

A

placenta

make pregnancy a bit more pleasant

49
Q

CRH

produced by what?

function?

A

placenta

regulates pregancy (increase DHEA-S and cortisol)

50
Q

What is the QUAD SCREEN?

When is it offered?

A

test that measures 4 proteins to determine chromosomal abnormalities or defects

  • AFP
  • Estriol
  • hCG
  • Inhibin A (dIA)

offered during the second trimester at about 15-21 weeks

51
Q

What is AFP?

What is it a marker of?

A
  • protein made in fetal liver
  • first biochemical marker for fetal trisomy 21 or spina bifida
    • Trisomy 21: LOW AFP
    • neural tube or body wall defects: HIGH AFP; released into the ammonic fluid and crosses the placenta
52
Q

Estriol

What makes it?

What is it a marker of?

A
  • produced by Syncytiotrophoblast
  • marker of trisomy 21: LOW
53
Q

What is HcG? What produces it??

A
  • produced by Syncytiotrophoblast
  • marker of trisomy 21: HIGH
54
Q

Inhibin A (dIA)

made by what?

marker of?

A
  • Cytotrophoblast
  • trisomy 21: HIGH
55
Q

What does Trisomy 21 show on the quad screen?

A
  • AFP = low
  • Estriol = low
  • hCG = high
  • Inhibin-A = high

hCG, Inhibin = **HI **

also alphabetically, first two are low, last two are high

56
Q

Prostaglandins

made by what?

roles in myometrium?

role in cervical ripening?

role in the fetus?

A
  • made in amnion/chorionic membranes of placenta
  • Roles in the myometrium (uterine smooth muscle)
    • stimulate contractility
    • enhanced response of uterine tonicity to PGE2 and PGF2α when progesterone is elevated
  • role in labor
    • increase cyclic uterine contractions at term and augments uterine responsiveness to oxytocin.
  • roles in cervical ripening
    • PGE2 remodels the collagen matrix to allow for it to become more pliable (goes from feeling like a nose cartilage to a stick of butter on a warm day)
  • roles in the fetus
    • prevent closure of the ductus arteriosus.
      • PG inhibitors induce early closure of the ductus arteriosus (NSAIDs); therefore, only use PG inhibitors for preventing preterm labor with great caution
57
Q

Why would you use PGE2 during pregnancy?

A
  • mid-trimester or at term: Cervical ripening / induction of labor
  • termination of pregnancy

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