antenatal/before birth Flashcards
list some sections included in the redbook
child and family details, information and advice, immunisations, screening, the child’s firsts and growth charts.
Give a definition of Herd immunity and the herd immunity threshold
Herd immunity occurs when a significant proportion of the population have been vaccinated with this providing protection for unprotected individuals.
The herd immunity threshold is the proportion of a population that need to be immune in order for an infectious disease to become stable in that community
list negative associations linked to smoking in pregnancy
congenital malformations
miscarriages
premature births
perinatal death
outline additional key health promotion roles of gp during early stages of pregnancy other than smoking cessation
diet management - folic acid, vitamin D
Lifestyle advise - BMI and weight, exercise
Managing mental wellbeing - assessment and support
list initial assessments of female infertility that can be arranged within primary care
Examination – BMI + weight, pelvic examination, ultrasound – pcos, fibroids,
Taking history – smoking, GYNECOLOGICAL HISTORY: previous miscarriages etc, menstrual cycle (irregular cycles), length of time trying to get preg. Time scale – 1 year.
State some causes of female infertility
Failure of ovulation caused by: Blocked fallopian tubes Endometriosis Fibroids Anatomical age
Whar is polycystic ovaries?
Enlarged ovary large no. of follicles peripherally arranged follicles irregular cycles hirsuitsm and acne raised BMI
What is PCOS?
Increased number of follicles in the ovary = pcos
increased ovarian androgen production
failure to ovulate
what are some investigations for female infertility?
Assessment of tubal patency Hysterosalpingogram (HSG X-Ray) Hysterosalpingo Contrast Sonography (HYCOSY Ultrasound) Laparoscopy
what are the hormonal assessments for female infertility?
Follicle Stimulating Hormone FSH 3-10 is normal 10-15 Low reserve Above 30 - Menopausal Anti Mullerian Hormone AMH Less than 3 very low reserve 3-17 Low reserve 17-35 average reserve Above 35 good reserve or PCO
how is an ultrasound used to assess female infertility?
Ultrasound scan Antral follicle count – each ovary 1-2 Follicles very low reserve 3-5 Follicles Low reserve 6-11 Average reserve 12 or more follicles good reserve or polycystic ovaries.
what are some causes of male infertility?
No sperms low sperm numbers -- 10-15 million low -- < 5 million very low poor sperm motility (<50%) Progressive motility (<30%) High no. of abnormal forms Vasectomy
What are some treatment options for infertility?
Lifestyle measures
Cycle monitoring/Ovulation induction - PCO
Intra-uterine insemination- IUI (placing live sperm into uterus)
– Low sperm count and motility and single or
same sex couples( donor sperms)
In-vitro fertilisation- IVF – Unexplained, tubal
factor or low ovarian reserve.
Intra cytoplasmic sperm injection-ICSI male factor
or failed fertilisation following IVF
- Egg donation
- PGS/PGD
- Surrogacy
- Fertility preservation - Egg/embryo freezing
- Ovarian tissue freezing
what are the problems with resource allocation in infertility?
Health Authority
Funding for all treatments is limited
Funding varies from place to place with some health
authority no treatment is funded (eg Croydon) and
others three cycles are provided on the NHS.
The criteria for Providing treatment and Refusing
treatment also varies within regions
Why do some people get refused treatment for infertility?
Either partner has children
Short relationship( duration the couple have been
trying to conceive before treatment is offered – 2
years)
Obesity and Raised BMI. The criteria for providing
treatment and
Smoking – cessation for 6 months
Age – 40 and some centres 42 no treatment is
provided
Why might someone who smoked be denied treatment (female)?
Good evidence that smoking in the female is
• associated with impaired fecundity and
increased risks of spontaneous abortion and
ectopic pregnancy. ? Fetal ovarian reserve.
• Smoking appears to accelerate the loss of
reproductive function and may advance the
time of menopause by 1-4 years.
• There is good evidence that smoking is
negatively associated with ART outcomes such
that smokers require nearly twice the number of
IVF attempts to conceive as nonsmokers.
Concept
why might someone who smokes be denied treatment (male)?
Semen parameters and sperm function tests are
lower in smokers than in nonsmokers and the
effects are dose-dependent, but smoking has
not yet been conclusively shown to reduce
male fertility.
• Passive smoking side effects are now
established, and there is good evidence that
nonsmokers with excessive exposure to tobacco
smoke may have reproductive consequences
as great as those observed in smokers.
What is the correlation between obesity and fertility?
Many obese women and men are fertile.
• Obesity in women is associated with ovulatory
dysfunction, reduced ovarian responsiveness to
stimulation tx, altered oocyte, endometrial functions,
and lower birth rates.
• Obese women are at increased risk of developing
maternal and fetal complications during pregnancy.
• Obesity in men may be associated with impaired
reproductive function.
• Lifestyle modification in women and men is the first-
line treatment for obesity, followed by adjunctive
medical therapy.
• Bariatric surgery in women and men is an important
adjuvant to lifestyle modification and medical
therapy for weight loss, but pregnancy in women
should be deferred for 1 year postoperatively.
what is the embryoselection criteria?
Embryo selection criteria are currently based on the rate of
embryo development and embryo morphology
what are some advantages of next generation IVF?
improving Clinical Outcomes by PGS:
Avoid transfer + storage of aneuploid embryos
• Mitigates the effect of maternal age1
• Increase Implantation Rates 2,3
• Increase pregnancy & live birth rates/embryo transfer 3,4
• Reduce miscarriage rate 2,4,5,6
• Select euploid blastocysts to support single-embryo transfer 2,3,4,5
• Reduce time to live birth & costs 6
Why do some people choose to freeze their eggs?
single
not planning pregnancy at present.
couples can choose to freeze their embryos
Why do some people opt for egg donation?
Options for women with low ovarian reserve
- premature ovarian failure
- Poor ovarian reserve
Critically discuss why obesity is a big factor in consideration of provision of fertility treatment
Differential treatments. Explain, evidence. Etc
Risk – obesity comes in association with plenty of risks: Hormonal changes, gestational problems etc effects rate of success in ivf.
Obesity associated with reduced response to stimulation – physiological evidence based – reduce success rate. Birth rate
Technically more difficult
Resources are finite – choosing allocation of resources based on evidence.
Counter argument:
Discrimination against people who are unable to lose weight. Also a lot of people against target weight do become pregnant so obesity is not necessarily unlikely to not give birth.
Eligibility for treatment – sociodemographic changes. Are obesity rates the same in each population? Should you be discriminated according to your population. Ccg Set critetia lowe
What is the role of primary care in the
management of subfertility?
First point of contact History & examination: cycle / PCOS features / other diagnostic patterns / information for referral Lifestyle factors and advice Blood tests / scans Liaison / Shared NHS and private care Male semen analysis Referral – NHS and Private Prescribing Psychological support
What are some issues to consider in fertility cases?
Ethical: Right to fertility treatment. Resources: - Allocation - Commissioning; who is paying? - Limited and finite Local vs National guidance: inequality Psychological impact: - Dr/Pt relationship - Direct for pt and partner - Inequality /sense of injustice - cost to NHS Societal issues: -Demographic changes - social change Evidence base: Evidence behind guidelines
What are the nice guidelines on fertility treatment?
he updated NICE Clinical Fertility Guideline published on the 20th February 2013 recommends that women aged up to and including 39 should access three full cycles of IVF treatment; it also recommends that women aged between 40 and 42 who have never had IVF treatment and who do not have a low ovarian reserve should be able to access one full cycle of IVF. However in reality this is only a guideline and is not mandatory in England.
Research has shown that over 80% of CCGs fail to provide the recommended cycles.
What is antenatal care?
This is the care you receive while you’re pregnant to make sure you and your baby are as well as possible.
The midwife or doctor providing your antenatal care will:
check the health of you and your baby
give you useful information to help you have a healthy pregnancy, including advice about healthy eating and exercise
discuss your options and choices for your care during pregnancy, labour and birth
answer any questions you may have
