Endo/Repro 3 Flashcards

Question

Abortion act 1967 (1990)

Answer 1

Two medical practitioners need to have opinion that: PRE 24 WEEKS - continuing pregnancy poses greater risk than not terminating of injury to physical/mental health of the mother or another child in her family POST 24 WEEKS - termination necessary to prevent grave permanent injury to physical/mental health of woman - continuing pregnancy poses greater risk to woman's life than not continuing - substantial risk that child born would suffer from serious mental or physical abnormalities (life not worth living) Practitioner allowed to conscientiously object, but must refer on to other doctor Early pregnancy more reasons accepted (can feel pain at 32 weeks) 80% abortions at under 10 weeks

Answer 2

Legally, women not held liable for damage they cause to unborn child eg by alcohol (at time of activity, foetus not a person, changes as soon as born)

Answer 3

Invasion of bodily integrity? It is assault and battery to perform surgery without consent But is a woman in labour fully competent? (if a woman has carried the baby to term but would now rather it died than have a C section then can they ever be competent?) If have capacity, cannot override decision Interests of foetus do not take precedence - unborn foetus does not have legal status until born

Answer 4

ART Legally regulated - all embryos outside of the body, use and storage of gametes Potential recipients now include single women, older women, same sex couples, couples with ill health - as well as heterosexual couples ART motivated by compassion, response to medical need (infertility is a disease), having children is intrinsically important Just use of resources? One cycle of IVF £3000

Answer 5

- sperm/egg donated - need to try to match physical characteristics/ethnic background, cannot select irrelevant to health characteristics - no payment beyond reasonable expenses - low success rate - anonymity now removed

Answer 6

- commercially is criminal offence - advertising for commercial arrangements also illegal - legal mother is gestational mother unless relevant court proceedings carried out - only allowed where mother is unable for physical/medical reasons to carry child herself

Answer 7

- risk multiple pregnancies - incidence birth defects - incidence pre-term delivery + don't know long term effects (first IVF baby born in 1978)

Answer 8

``` Unnatural Disposal of surplus embryos Cost/accessibility Justice and priority Risk vs benefit ``` Need to consider potential child, couple/woman seeking treatment, broader social interests Posthumous conception - now not permitted without written permission from father in case of death

Answer 9

- avoid birth of child with inherited condition - choose non-medical traits in child - create 'saviour sibling' Time-consuming, expensive, low success rate Which diseases is it acceptable to use PGD for? CANNOT implant embryo known to have abnormality where there is another that doesn't (eg deaf parents selecting for deaf child) Sex selection banned unless to avoid sex-linked abnormality

Answer 10

The bodily changes that confer fertility - activation of gonads, growth of reproductive tract, development of secondary sex characteristics - gradual - recognised by first (anovulatory) menstruation/(nocturnal) ejaculation Age reaching puberty is declining - due to nutritional factors and maybe increased exposure to artificial light Sequence of maturational change is always the same, age of onset and length of time taken to complete varies

Answer 11

FEMALE Pubic hair, breast buds, growth spurt, menarche MALE Pubic hair, testis enlarges, penis size increases, voice breaks, growth spurt (pubertal staging important to detect anomalies early on)

Answer 12

Adrenarche - weak adrenal androgens (DHEA and androstenedione) -> growth of axillary and pubic hair Reactivation of HPG axis Gonadarche - nocturnal rise of gonadotrophins (diurnal rhythm) before development of adult pattern (sustained higher LH levels) - pulsatility due to GnRH release Progressive rise in overall levels of gonadotrophins and steroids Sex steroid upregulation of GH release and function

Answer 13

Around age 12 in girls, age 14 in boys (hence boys ~10cm taller, as 2 years more growth) Height gain of ~10cm per year (prev 5cm) Increased activity of epiphyseal plates, then ossification - due to combined effects of steroids and GH (GH due to oestrogen) - > sexual dimorphism of body form fully established - size and shape of skeleton, amount of muscle, amount/distribution of body fat differs - girls increase fat, hips widen, boys become leaner, shoulder widening, thickened laryngeal cartilage

Answer 14

OESTRADIOL - increase secretion of GH in pulses -> differentiation and clonal expansion of chondrocytes - release IGFs in cartilage and bone -> increased activity of chondrocytes and oesteoblasts - directly accelerated mineralisation Also need background levels of insulin and thyroxine hormones

Answer 15

Endogenous stimulation of GnRH release is rate-limiting step for puberty - restraint of GnRH secretion must be removed SOMATOMETER HYPOTHESIS - need to achieve critical body weight - 30kg growth spurt, 47kg start menarche in girls, 55kg puberty onset in boys - about fat mass deposition, not just weight - leptin is fat-derived hormone, rises proportional to body mass, signals to hypothalamus to activate GnRH mechanism MELATONIN - melatonin restrains GnRH release - so less melatonin in puberty

Answer 16

PRECOCIOUS - before 7 years in girls/8 years in boys - GnRH dependent or independent - due to endocrine cause (fault in HPG axis) or tumour DELAYED - no puberty by 17 years - may be hypergonadotrophic or hypogonadotrophic (Prader Willi) Common in female athlete triad (lean body mass)

Answer 17

FIRST - onset regular contractions - effacement and dilatation of the cervix > latent phase: onset contractions -> cervix fully effaced > active phase: fully effaced cervix dilates - up to 14 hours long SECOND - full dilatation of the cervix - delivery of baby > propulsive phase: head descends to pelvic floor > expulsive phase: experiencing desire to push - up to 3 hours long - head needs to rotate - transverse through pelvic inlet, diagonal through middle, facing down through pelvic outlet THIRD - after delivery of baby - delivery of the placenta - 30mins

Answer 18

Thinning, softening, relaxing, dilating - inflammatory process - collagen fibres realigned - collagen cross-linkages broken by proteolytic enyzmes - uterine contractions exert pressure on cervix ``` Due to PROSTAGLANDINS - PGE2 mainly - increase collagen degradation - increase chemotaxis for leukocytes (draw in WBCs to increase collagen degradation) - increase interleukins OESTRADIOL REDUCED PROGESTERONE Relaxin Nitric oxide Apoptosis ```

Answer 19

Corticotrophin-releasing hormone Peptide hormone released from hypothalamus, and secreted by placental trophoblasts during pregnancy CRH receptors in myometrium and foetal membranes Three weeks before onset spontaneous labour - rise in plasma CRH - abrupt fall in CRH binding proteins (so more CRH available) - > stimulates release of prostaglandins from amnion and decidua and potentiates their actions - > potentiate oxytocin actions - > synthesis of glucocorticoids - --> positive feedback loop, stimulates placental CRH secretion, drives onset labour

Answer 20

HPA activation in foetus -> production of DHEA -> converted to oestriol in placenta Rise in DHEA and E3 (oestriol) in last 4-6 weeks pregnancy HPA activation also -> cortisol -> increased CRH by placenta Cortisol -> foetal organ maturity, placental expression of uterotonic genes, increased placental production of CRH, oxytocin, prostaglandin

Answer 21

Progesterone in pregnancy - hyperpolarises myometrial cells, inhibits contractions - reduces oxytocin sensitivity - stabilises decidua and membranes - decreases gap junction formation - NO synthesis (uterine quiescence) - inhibits CRH expression at placenta Anti-progesterone -> cervical ripening and initiate labour (but exogenous progesterone doesn't prevent spontaneous labour) SO uncoupled action of progesterone - functional withdrawal

Answer 22

Intracellular calcium waves -> AP threshold, depolarisation Transmitted between myometrial bundles by gap junctions, for coordinated contraction Oxytocin increases the gap junctions and calcium channels

Answer 23

Increase uterine contractility - increase actomyosin and glycogen in myometrium - depolarises myometrial cells - increase gap junctions - increase oxytocin sensitivity - destabilise decidua and membranes (so prostaglandin release) Stimulation is dilatation of cervix by foetal head

Answer 24

Synthesised in hypothalamus, released from posterior pituitary Potent stimulator of myometrium -> contractions (but only works if already primed by oestrogen) Stimulation is dilatation of cervix by foetal head

Answer 25

``` Local tissue hormones - rapidly destroyed in circulation Made by all tissues of uterus Levels rise early in labour - powerful contractors of smooth muscle - can promote labour at any stage ```

Answer 26

1 - prostaglandins 2 - artificial rupture of membranes (allows head to drop and exert pressure on cervix and cause release of prostaglandins and oxytocin) 3 - syntocinon (artificial oxytocin) IF - term past 42 weeks - baby growth compromised - if baby too large (mother diabetic) - preeclampsia/mother's health compromised - foetal demise (miscarriage)

Answer 27

20-30 separate tubulo-alveolar glands Each gland forms a lobe, each has single lactiferous duct to nipple Alveoli supported by connective tissue (before lactation, secretory tissue rudimentary, much of gland made of fat) Pregnancy -> major growth of breast, replace fat with secretory tissue Growth stimulated by oestrogen (ducts) and progesterone (secretory) Prolactin released during suckling -> complete emptying of mammary gland by milk-ejection reflex (can be conditioned) Suckling inhibits release of dopamine from hypothalamus Lactotrophs free of dopamine inhibition, release prolactin

Answer 28

Water - 88% Lactulose - main carbohydrate energy source, promotes growth of lactobacillus in gut, galactose is important in myelin formation Fat - TGs in membrane bound globules, major energy supply medium for vitamins Protein Guidelines to breast-feed exclusively for 6 months

Answer 29

FEMALE - ovulation - egg transport - implantation - sperm transport MALE (- sperm production) - sperm transport

Answer 30

Perfect use/typical use ``` Pill - 0.3-0.5%/8% Injectables and implantations - 0.3%/3% IUDs - 0.5-0.8% Sterilisation - 0.02-0.5% Barrier - 2-5%/15-20% Natural - 2-6%/25% ```

Answer 31

COCP (though same for contraceptive patches and vaginal ring - wear for 3 weeks, 1 week off) Mix of progesterone and oestrogens 1 - prevent ovulation 2 - cervical mucus thickens (halt sperm transport) Usually monophasic (same mix of hormones every day), sometimes bi/triphasic Advantages - effective - easy to use - not intercourse related - reversible - periods lighter and less painful - reduction in PMS Disadvantages - forgetability - needs advance planning before sex - side effects - risk for venous thromboembolus

Answer 32

Low dose progesterone throughout cycle 1 - cervical mucus thickens (halt sperm transport) 2 - 20% prevent ovulation (cerazette) Advantages - effective - easy to use - not intercourse related - reversible - suitable for more - smoker/obese/older/lactating/high BP Disadvantages - forgetability - smaller window that COCP - needs advance planning before sex - side effects

Answer 33

Post-coital contraceptive - progesterone - one pill within 72 hours - prevents/delays ovulation, prevents follicular rupture or cause luteal dysfunction - no prescription needed - no harmful effects if is pregnant - side effects - may not work

Answer 34

Post-coital contraceptive - ulipristal acetate - progesterone receptor modulator - prevents/delays ovulation - up to 120 hours after - no effect if is pregnant - side effects - may not work

Answer 35

Copper bearing intrauterine device Post-coital contraceptive - disrupts egg transport and implantation (still get fertilisation) - up to 120 hours after (can stay in for up to 10 years) - side effects - may not work

Answer 36

Depot of slowly releasing progesterone - prevent ovulation - act on cervical mucus, endometrium and fallopian tubes (same as progesterone only pill, just don't have to take daily) - effective - non-intrusive - long-lasting - fewer side effects (not orally taken) - require operative procedure - injectables cannot be immediately reversed, ~3 months - irregular bleeding common

Answer 37

Hormonal coil - increase thickness of cervical mucus - thinning of endometrium - preventing ovulation - very effective - not user or intercourse dependent - local hormonal action only - reduced periods - reduced risk endometrial cancer - side effects, irregular bleeding

Answer 38

OESTROGEN - pregnancy - focal migraines - venous thromboemolus (risk of) - breast cancer PROGESTERONE - acute porphyria - severe liver cirrhosis - breast cancer

Answer 39

Made of copper or plastic Cause mild inflammatory response -> toxic environment reducing survival of gametes and embryo AND disrupt implantation - work long-term - highly effective - non-intercourse related - no user error - no hormones, don't affect cycle - need to be fitted by expert - heavier periods - may be expelled or displaced (at beginning) - ? increased risk of ectopic pregnancy

Answer 40

Male or female condoms - no medical interference - protective against STIs - need planning - user dependent - intercourse reliant

Answer 41

Monitoring female cycle to avoid intercourse when most fertile: calculation (need to be very regular), temperature measurements, cervical mucus observations, hormone levels in urine, lactation amenhorrea, coitus interruptus (25% failure) - no medical interference - allowable by faith - unreliable - requires periods of sexual abstinence - increased likelihood of fertilisation with aged gametes?

Answer 42

Clip vas deferens/fallopian tubes Permanent Should be considered non-reversible - effective - no side-effects - requires surgery - much more invasive for women - key hole laparoscopy or new essure method via uterus, coils into tubes - some failure rate - clipping wrong tubes, or tubes rejoining

Answer 43

Male pill - testosterone and progesterone - halt sperm production - phase III trials RISUG - reversible inhibition of sperm under guidance - chemical blockage and spermicide in vas deferens - then other chemical to unblock IVD - intra-vas device - injectable plug to vas deferens

Answer 44

3 Ps POWERS - uterine contractions (dehydration) - maternal pushing (exhaustion, epidural) PASSAGES - bony pelvis (hip problems, previous fractures) - soft tissues (masses, fibroids) PASSENGER - suboptimal head position (deflexed) - rotational malposition of head (occipitoposterior, occipitotransverse) - malpresentation of head (brow, face) - size of foetus

Answer 45

Ventouse - silicone cup - plugged into wall for vacuum / kiwi cup - smaller, handheld / metal cup (rare) - head must be occipito-anterior, below spines - requires maternal effort - local analgesia only - bigger bump/bruising left for baby, will go down quickly Forceps - Kiellands / Wrigleys / Neville Barnes / Simpsons - head must be occipito-anterior, below spines - no maternal effort required - need pudendal anaesthetic or epidural - safer for baby, but more maternal trauma

Answer 46

Assisted delivery often done as 'trial' in operating theatre, if not working then -> C section - if baby above ischial spines / brow face or shoulder presenting / pelvic tumour Better for woman to be awake with spinal analgesia - safer for mum and baby (GA crosses placenta), nicer for families (partner can be in room)

Answer 47

Glycogen stores in liver and cardiac muscle - regulated by adrenal cortex Fat stores - white fat - fatty acids - all around body - brown fat - heat generation (many mitochondria) - at specific points around body: neck, under scapulae, back, under adrenals, around kidneys - regulated by foetal insulin

Answer 48

Amino acids - no increase in maternal protein intake - progesterone increases metabolism efficiency Fatty acids - mother accumulates lipids in early pregnancy - placental transfer and foetal synthesis to meet demands Salt and water - maternal retention stimulated by oestrogen and progesterone Iron - maternal absorption enhanced - foetal blood 2-3 x higher concentration (need to take supplements) Calcium - maternal absorption enhanced - foetal ossification needs much calcium Vitamins - folic acid (B9) for amino acid metabolism, risk of neural tube defects if deficient - B12 for fatty acid and amino acid metabolism - at expense of maternal stores (so need to take supplements)

Answer 49

Intrauterine environment relieves foetal organs of need to - respire/digest - placenta - weight bear - amnion makes weightless state - control temperature - isothermal environment in utero -> redundancy in systems But must be developed and mature enough to sustain life immediately after birth

Answer 50

Adaptations - two foetal ventricles pump in parallel (not lub dub) - four foetal shunts to divert blood: > placenta - foetal blood is diverted here instead of to abdominal organs/legs > ductus venosus - through liver - best oxygenated blood needs to go straight to heart first > foramen ovale - flap valve open between right and left atria > ductus arteriosus - vessel joining pulmonary artery to aorta, so bypassing foetal lungs

Answer 51

Four foetal shunts need to close, replacing placental with pulmonary circulation: - placenta stops delivering oxygenated blood, lungs open - pulmonary vascular resistance drops as PO2 rises (with low PO2 get hypoxic vasoconstriction), increased pulmonary blood flow - increased peripheral resistance as placenta lost, pressure on right side heart decreases, left side increases, foramen ovale physiologically and biochemically shuts - ductus venosus stops carrying blood to heart - ductus arteriosus contracts and closes

Answer 52

1-4hours each day spent practise breathing in utero - rapid and irregular - only during REM sleep - diaphragmatic - moving amniotic fluid in and out of lungs Near birth, steroids increase no. type II alveolar cells, increase no. lamellae bodies - so increased surfactant - water reabsorption, switch from Cl- secretion to Na+ absorption - change from CFTR to ENaC salt and water channels to dry out foetal lungs First breath needs most energy to inflate lungs, gets easier

Answer 53

Foetus swallows lots amniotic fluid each day - salt, water, small molecules absorbed in small intestine - debris and large molecules accumulate in large intestine -> meconium Should be no defecation in utero (distress) - to practise - small contribution to foetal nutrition - control amniotic fluid volume (take in)

Answer 54

Placenta, not kidney is organ of excretion - kidneys function to regulate amniotic fluid volume (water turn over at least once every day) (excrete)

Answer 55

Foetus self-sufficient in hormone requirements from early on - foetal hormones influence mother - maternal hormones only influence foetus in disease Specialised functions: - hypothalamus to co-ordinate activity of other endocrine organs - anterior pituitary to regulate other endocrine organs - thyroid for foetal development - pancreas for insulin, regulating rate of glucose use - gonads: ovaries inactive, testis essential for male sexual differentiation