general Flashcards
1
Q
what day(s) after LH surge does cell devision ~32 cells take place in the Fallopian tube?
A
2-4
cells are totipotent at this stage
2
Q
what day does the blastocyst enter the uterine cavity and what day does implantation occur?
A
5 and 6-7 days after LH surge
3
Q
what is the fate of the blastocysts trophoblast cells and inner cell mass?
A
trophoblast cells –> placenta (inner cut-trophoblast and outer syncytiotrophoblast)
inner cell mass –> foetus (1st divides into epiblast and hypoblast cells –> embryo proper and yolk sac, respectively)
4
Q
what causes the conceptus (fertilised egg) to be held in the fallopian tube tube during cell division -> morula -> blastocyst formation?
A
oestogen (maintains contraction of smooth muscle near where fallopian the enters wall of uterus)
5
Q
what test would show if a women has ovulated?
A
day 21 progesterone
6
Q
a) what cell type can form all the cell types in the body and give an example
b) what cells type can form as above PLUS extra embryonic or placental cells?
c) what cell type can develop into more than one cell but are more limited?
A
a) pluripotent cells e.g. embryonic stem cells
b) totipotent cells e.g. embryonic cells within 1st couple of cell divisions
c) multipoint cells e.g. adult stem cells and cord blood stem cells
7
Q
what cell type is the blastocyst and why is this clinically relevant?
A
pluripotent - means that a cell can be removed for testing without damage to the embryo
8
Q
why must the preimplantation embryo act to preserve the function of the corpus luteum?
A
progesterone - initially secreted by the corpus luteum, then placenta - is essential for establishing and maintaining pregnancy (prepares supportive uterine environment increasing glandular tissue). day 6/7 the blastocyst leaves the zone pellucida and is bathed by uterine secretions for 2 days
9
Q
what are the 2 secretions in the uterus that bathe the blastocyst for 2 days?
A
progesterone (prepares supportive uterine environment increasing glandular tissue) and oestrodiol (required to release the glandular secretion)
10
Q
what is the decidua?
A
the pregnant/modified endometrium (mucosal lining of the uterus). endometrial cells become highly characteristic under the influence of progesterone -> syncytiotrophoblast cells flow into the endometrium causing oedema, glycogen synthesis and increased vascularisation
(end of week 1)
11
Q
what is meant by primitive placental circulation?
A
syncytiotrophoblast cells erode through the walls of large maternal capillaries which then bleed into spaces/lacunae that fuse to form a network where early maternal/foetal exchange occurs
(day 13 - implantation)
12
Q
List the tissue layers that comprise the placental membrane (separates the maternal and foetal circulation)
*NB syncytitrophoblast is bathed in maternal blood
A
innermost later surrounding the foetus = amnion
middle layer (derived from embryonic hindgut) = allantois (blood vessels originating from the umbilicus transverse this membrane)
the outermost layers comes into contact with the endometrium = chorion (composed of two layers inner cut-trophoblast and outer syncytiotrophablast)
(The chorion and allantois fuse to form the chorioallantoic membrane)
13
Q
Explain the endocrine functions of the placenta
A
-syncytiotrophoblasts secrete hCG soon after implantation; maintains progesterone secretion from the corpus luteum until the placenta can synthesis its own progesterone (LH supports CL previously)
(NB LH helps maintain steroid secretion of the corpus luteum until implantation)
- progesterone
- main oestrogen production is oestrodiol
- synthesises steroids and proteins that affect both maternal and foetal metabolism
14
Q
list 3 functions of the placenta other than an ‘endocrine gland’
(synthesises steroids and proteins that affect both maternal and foetal metabolism)
A
acts as a:
1. foetal gut - supplying nutrients
- foetal lung - exchange O2 and CO2
- foetal kidney - regulates fluid volumes and disposing waste metabolites
15
Q
What molecules and organisms can cross the placenta?
A
- water and electrolytes diffuse freely
- glucose passes via facilitated diffusion
- amino acids are actively transported
- lipids cross as free fatty acids
- vitamins
- simple diffusion of gases
- rubella, mumps, poliomyelitis, smallpox, rubeola, syphilis, malaria, toxoplasmosis, and infections caused by S typhosa, V fetus, L monocytogenes, cytomegalovirus, and herpes simplex virus
*most molecules can pass through the membrane. after 20 weeks placental membrane thins even more with loss of cyt-trophoblast
16
Q
list ways of imaging the pregnant woman
A
- X-ray
- MR
- CTPA
- (V)Q scan
- ultrasound**
17
Q
why is CTPA used to Ix pulmonary embolism instead of D-Dimer in pregnacy?
A
D-Dimer test doesn’t work. there is a small increase in breast cancer for pregnant women therefore, need to council them
18
Q
define the lower segment of the uterus
A
the lower part of the uterus that develops from the upper part of the cervix usually from 25weeks. By the time full dilation is achieved in labour, all the cervix has been replaced by lower segment
19
Q
the upper part of the lower segment is marked by what anatomical structure?
A
utero-vesicle fold (peritenium)
20
Q
where is the incision made in c-section?
A
Lower uterine segment caesarian section (LUSCS)
21
Q
what structures are imaged in a pregnant women?
A
Uterus
- anomalies (e.g. bicornuate uterus)
- uterine tumours/fibroids
- cervix length (predictor for onset of labour)
- uterine artery blood supply (a predictor fro pre-eclampsia)
placenta
- location (major (covers internal cervical os) or minor (doesn’t cover os) placenta praevia - inserts into lower uterine segment)
- location of cord vessels (vasa praevia)
- abnormal placentation (accrete (deep into endometrium)/percreta (into myometrium))
22
Q
what name is given to the endometrium in pregnancy?
A
decidua
23
Q
list reasons why the baby might be imaged
A
up to 13 weeks:
- check if alive
- location (intra-uterine or ectopic)
- no. of foetuses
- size/gestation
- anatomical anomalies
later in pregnancy:
- alive
- foetal anomaly screening (18-21 weeks)
- growth (abdominal/head circumference/femur length)
- wellbeing (liquor volume/fetal blood flow/umbilical artery doppler)
- presentation (cephalic, breach, transverse, oblique)
- position of head
24
Q
other than the umbilical artery what other foetal blood flow measurements are used?
A
middle cerebral a. –> foetal anaemia or hypoxia
ductus venous –> reversal wave form in pre-terminal hypoxia (very last thing before death)
25
List the main modalities for making a laboratory diagnosis of infection
- identify the infecting organism for Dx advice
- susceptibility testing for Tx advice
- identify organisms that are spreading for infection control
E.g. microscopy; culture; serology; molecular; direct examination
26
Describe what specimens can be taken and methods used
WHERE AND KNOW ORGANISMS LIKELY TO BE PRESENT:
*UTI - midstream urine
wound - pus or swab
meningitis- CSF + blood
Pyrexia of unknown origin (PUO) - blood for culture +serology
Pneumonia - sputum, lavage, serology
throat swabs
* stool sample
* abscess pus
* LRTI sample
* = specimens with multiple pathogens
27
Describe the impact of modern molecular diagnostics
examples of molecular techniques = DNA hybridisation and nuclear acid amplification testing (NAAT)
future: see increase in molecular tests, faster results (but issues with sensitivity and specificity; treatment monitoring, whole genome sequencing used to infer susceptibility results and transmission in a hospital/community environment
28
Define the terms sensitivity, specificity and relate them to the doctor patient interaction
sensitivity --> the ability of a test to detect all the true +ve's. dual to the number of +ve's obtained divided by the total number of positives
specificity --> ability to identify the number of true -ve's. equal to the number of negatives obtained divided by the number of true negatives
29
Understand the nature of the diagnostic process and the role of the infection specialist
- it is a back up
- alert specialist to patients who have infection, but it has not been flagged up
- help with antibiotic Tx
- detect outbreaks
- provide intelligence system (what strains with what resistance pattern are circulating)
- challenging because the speed of progression of infection is much greater than the time taken to generate results
- lab data can be complex
role of infection specialist:
- provide quality diagnostic tests
- provide clinical consultation service for patients with suspected infection
- provide clinical advice to the interpretation of Dx tests
- provide advice on therapy of serious infections
- manage control of infection issues within the hospital environment
30
define oogenesis
production or development of an ovum. 1st phase occurs in foetal life. 2nd phase at ovulation.
primordial germ cell --> oogonium (primordial ovum) --> primary oocyte - meiosis 1 -> secondary oocyte - ovulated - fertilised -meiosis 2> ovum (zygote)
* oocyte exists in a state of suspended meiotic division until ovulation
* LH stimulates meiosis continuation
31
at what stage is the primary and secondary oocyte arrested in?
primary = meiotic prophase I
secondary = metaphase II (only completed in oocytes that are fertilised)
32
Explain the development, structure and endocrinology of and associated with small, medium and large follicles
small:
- primordial follicule
- single layer of granulosa cells around oogonium/oocyte
- before birth
- most numerous!!
- secrete anti-Mullerian hormone (AMH)
medium:
- Primary follicle surround primary oocyte that has developed from oogonium before birth
- throughout life, cohorts of small follicles recruited to begin a period of slow growth (independent of hormones)
- granulosa cells divide forming 3 layers (takes 85days) around the oocyte (separated by zone pellucida with gap junctions for nutrients and chemical messengers)
large:
- secondary/Graafian follicle/preovulatory follicle that surrounds the secondary oocyte that has developed from primary oocyte (finishing off first meiotic division)
- FSH stimulates rapid development- 14days - leads to ovulation or atresia
- zona pellucida encloses oocyte and masks its antigens
- many granulosa layers
- antrum develops and fills with fluid
- LH activates theca interna cells to synthesise androstenedione, which via a few steps, gives the granulosa the precursor for estrogen manufacturing
33
what does the AMH blood test reflect?
secreted by the primordial follicles/ single layer of granulosa cells. the ovarian follicular reserve and therefore can be measured to assess ovarian ageing/ egg count
34
Describe the development of the corpus luteum
- develops from the remains of the Graafian follicle after ovulation after its astral fluid and end is discharged
- granulosa cells enlarge, and form gland-like structure (CL)
- Functions as an endocrine organ (produce progesterone, oestrogens and inhibin) supporting pregnancy and preventing menstruation
- Formed during the luteal phase of the menstrual cycle
- degenerates by apoptosis if fertilisation and pregnancy does not occur
35
what is the fundamental reproductive unit in a female?
single ovarian follicle, composed of one germ cell (oocyte), surrounded by endocrine cells
36
compare mitosis and meiosis
mitosis:
- one round of cell devision
- creates 2 daughter cells that are identical to the parent cell
- diploid
meiosis:
- two rounds of devision
- creates 4 daughter cells/ gametes
- haploid
37
name 4 functions of the ovaries
1. oogenesis
2. maturation of oocyte
3. expulsion of the mature oocyte (ovulation)
4. secretion of female sex steroid hormones (oestrogen and progesterone) and peptide hormone inhibin
38
summarise follicular growth
initial growth is independent of hormones and takes 85 days
final growth is dependent on FSH and takes 10-14days
39
what chemical mechanics has to occur for ovulation to take place?
LH surge - induces prostaglandin endoperoxide synthase in granulose cells
40
compare spermatogenesis and oogenesis
spermatogenesis:
- male
- continuous
- mitotic proliferation occurs after puberty
- meiotic division of primary spermatocyte produces 4 mature spermatozoa
- products of meiosis (spermatids) undergo substantial differentiation in the maturing process
- meiosis begins at puberty (indirectly dependent on progesterone)
- low temp required
- production of infinite numbers of sperm
- gametes are motile
oogenesis:
- female
- mitotic proliferation occurs prior to birth
- meiotic divisions of oocyte produces only one mature ovum
- 2nd meiotic division completed only upon fertilisation
- discontinuous (2periods of arrest)
- normal body temperature
- meiosis begins before birth (initial stimulus is not steroidal)
- finite number of oocytes
- immotile gametes
41
in the earliest stages of pregnancy the anatomical link between mother and foetus develops through a series of 3 phases. what are these?
1. invasion -> of conceptus to endometrium
2. decidualisation -> i.e. endometrial remodelling including secretory transformation of the uterine glands, influx of specialised uterine natural killer cells and vascular remodelling
3. placentation -> placenta formation
42
define luteal phase defect
lack of appropriate hormonal support (progesterone) that may account for early pregnancy loses. endometrium should be about 8mm thick for successful implantation
43
what is the role of hCG and when is it measurable?
secreted by syncytiotrophoblast cells soon after implantation to maintain progesterone secretion by the CL and prevent follicular development (LH maintains this until then). PREVENTS MENSTRUATION!
measurable by day 7-8 postconception
44
what is the 'main effect' of human chorionic gonadotropin
- secreted by syncytiotrophoblast cells just after implantation
- prevents menstruation
- most importantly, prevents involution of the CL at the end of the monthly female sexual cycle. instead causes the CL to secrete larger quantities of progesterone and oestrogen for the next few months
45
what is the 'main effect' of oestrogen secretion by the placenta
- different from oestrogen secreted by ovaries
- proliferative function; enlargement of the mothers uterus, breasts and external genitalia
- relax pelvic ligaments
- rate of cell reproduction in the early embryo
46
what is the 'main effect' of progesterone secretion by the placenta
* essential for successful pregnancy
- causes decidual cells to develop in the uterine endometrium (important in nutrition of the early embryo)
- decreases contractility of the pregnant uterus
- contributes to the development of the conceptus by increasing the sections from the Fallopian tubes and uterus to provide appropriate nutritive matter for the developing morula and blastocyst
- also help oestrogen prepare the mothers breasts for lactation
47
what is the 'main effect' of human chorionic somatomammotropin by the placenta
role unclear
| -regulate metabolism in the pregnant woman?
48
Outline the metabolic and nutritional changes that occur in the mother during pregnancy
metabolic:
- basal metabolic rate increases about 15% during the latter half of pregnancy, due to increased secretion of hormones (e.g. thyroxine, adrenocortical hormones and sex hormones)
- frequent sensations of becoming overheated
- extra load, greater amounts of energy than normal must be expended for muscle activity
nutrition:
- in anticipation for the growth needs of foetus in last trimester, the mothers body has stored protein, calcium, phosphates, iron
- maternal deficiencies can occur of nutritional elements are not present in diet
49
Outline how kidney function changes in pregnancy
- rate of urine formation is increased because of increased intake and increased load of excretory products
- renal tubules' reabsorptive capacity for sodium, chloride and water is increased as much as 50% (increased production of salt and water retaining hormones, especially steroid by placenta and adrenal cortex)
- renal blood flow and GFR increase by 50% as a result of vasodilation (maybe due to relaxin hormone or levels of NO increase)
50
Define preeclampsia and eclampsia and outline current ideas about pathogenesis
- about 5% of pregnant women experience pregnancy-induced HTN/ preeclampsia--> rapid rise in arterial blood pressure to hypertensive levels during the last few months (occurs after 20weeks!) of pregnancy that is also associated with leakage of large amounts of protein in the urine
Theories of preeclampsia:
- caused by excessive secretion of placental or adrenal hormones, but proof is lacking
- results from some type of autoimmunity or allergy in the mother caused by the presence of the foetus (acute symx disappear a few days after birth)
- initiated by insufficient blood supply to the placenta, resulting in the placenta's release of substances that cause widespread dysfunction of the maternal vascular endothelium
eclampsia = extreme degree of preeclampsia characterised by vascular spasms throughout the body; clonic seizures in the mother, sometimes followed by coma, greatly decreased kidney output, malfunction of the liver, often extreme HTN, generalised toxic condition of the body.
-> immediate treatment with vasodilators and termination of pregnancy
51
# define fetotoxicity
Define tetogenicity
the ability of a drug to cause functional changes to the foetus in the 2nd or 3rd trimester
The ability of a drug to cause fetal malformations (1st trimester)
52
Outline the principles that inform safe prescribing in pregnancy and when breastfeeding
- use drugs that have been used extensively in pregnancy and appear to be safe
- risk to foetus vs benefit to mother
- all drugs avoided, if possible, in the first trimester
- smallest effective dose
- screening procedures followed if known risk of certain defects
- absence of data does not imply safety
- consult with specialists in maternal medicine if pt has serious health condition (i.e. congenital heart defect)
- ALWAYS consult the BNF, a pharmacist, or an obstetrican colleague prior to prescribing medication for a pregnant patient
- TAD advised over SSRI (if SSRI indicated, use fluoxetine)
53
Outline the principles that inform safe prescribing in pregnancy and when breastfeeding
- pre-conception councelling
- use drugs that have been used extensively in pregnancy and appear to be safe
- risk to foetus vs benefit to mother
- all drugs avoided, if possible, in the first trimester
- smallest effective dose
- screening procedures followed if known risk of certain defects
- absence of data does not imply safety
- consult with specialists in maternal medicine if pt has serious health condition (i.e. congenital heart defect)
- ALWAYS consult the BNF, a pharmacist, or an obstetrican colleague prior to prescribing medication for a pregnant patient
- TAD advised over SSRI (if SSRI indicated, use fluoxetine)
54
what drug class should be avoided in pregnancy as it can cause premature closure of the ductus arteriosus
NSAIDs
55
what is the first line anti-emetic in pregnancy?
cyclizine or promethazine
56
what anti-epileptic drug is particularly teratogenic?
sodium valproate
57
A 26 year old woman is thinking of becoming pregnant. Her epilepsy is well controlled with Carbamazepine. What advice should she be given regarding taking Folate supplements
5mg once daily
recommended dose of FA for women on AEDs at least 6 weeks prior to conception
58
what risks are associated with smoking in pregnancy?
```
miscarriage
stillbirth
prematurity
low birth weight
sudden infant death syndrome
increased infant mortality
```
59
A 32 year old woman who is 12 weeks pregnant develops a tension headache. After ruling out any serious pathology, what first line medication could be taken if analgesia was required?
Paracetamol 1g
Iburpofen 400mg
Aspirin 300mg
Codeine 30mg
paracetamol 1g
Opiods - if taken around time of delivery may lead to neonatal respiratory depression. Long term use may !ead to neonatal respiratory depression
Anticoagulants associatdd with teratogenicity
Nsaid lead to prem closure of ductus arteriosus
60
A woman is 8 weeks into her pregnancy, and is suffering from morning sickness. If an anti-emetic is required, what would be your first line choice?
Ondansetron
Cyclizine
Dexamethasone
cyclizine
61
A 27 year old who is 34 weeks pregnant develops moderate hypertension. She has no protein in her urine. What would be the first line anti hypertensive of choice?
Oral Labetalol
Ramipril
Bendroflumethiazide
Oral Labetalol
62
A 24 year old woman is currently 36 weeks pregnant. She is suffering from Gastro Oesophageal Reflux Disease (GORD). Conservative measures (including taking Gaviscon) have failed. What would be the next line of treatment?
Ranitidine 150mg BD
Omeprazole 20mg OD
lansoprazole 30mg OD
Ranitidine 150mg BD
63
what are the 3 arguments defining infertility?
- what is it? 3 arguments for this; (a) a dysfunction (but not a disease); (b) a socially constructed disease; (c) a 'terrible disease affecting out sexuality and well being'
64
list causes for infertility in women and men
women:
- abnormal ovulation (PCOS, early menopause)
- damage to Fallopian tubes (surgery, PID)
- endometriosis
men:
- low sperm count/quality
- damage to testicles and/or failure to ejaculate
65
list assisted reproductive technologies/methods to treat infertility
- intrauterine insemination (IUI)
- In vitro fertilisation (IVF)
- IVF with intracytoplasmic sperm injection (ICSI)
- use of donor sperm/eggs
- surrogacy
66
Describe some of the risks associated with IVF for both the mother and the child
ovarian hyperstimulation syndrome:
- complication of fertility Tx (usually gonadotrophin that's simulate egg growth)
- abdominal pain/swelling, w.gain, nausea, dehydration, blood clots, SOB
multiple births:
- transferral of several embryos
- recommendation now is for single embryo transfer
welfare of child:
- needs to be considered
- risk assessment is carried out
- the need for supportive parenting (2008)... women shall not be provided with Tx unless account has been taken about the welfare of any child who may be born as a result of the Tx and any other child who may be affected by the birth
67
Outline the Scottish Government's most recent recommendations for IVF on the NHS
<40 y/o offered up to 3 cycles (where there is reasonable expectation of a live birth) if:
- infertility with an appropriate cause of any duration OR
- unexplained infertility of 2 years - heterosexual couples
- unexplained infertility following 6-8 cycles of donor insemination - same sex couples
40-42 y/o only 1 cycle will be offered if:
- no IVF before
- no evidence of low ovarian reserve
- there has been a discussion if implications of IVF and pregnancy at this age
68
Understand the role of the HFEA in regulating assisted reproduction in the UK
- aim to ensure that everyone who steps into a fertility clinic, and everyone born as a result of treatment, receives high quality care
- licensing, monitoring and inspecting fertility clinics
- providing free, clear and impartial information about fertility treatment, clinics and egg, sperm and embryo donation
- regulator and information provider
- regulate Tx (inspect and license clinic) and research (licenses for human embryo research)
- ensure transparency between nhs/private healthcare
69
Identify and discuss some of the ethical issues arising at key stages in the IVF process, and in surrogacy arrangements
1. Access to IVF (on NHS)
- heterosexual couples
- same sex couples (NSH greater Glasgow example)
- single women (Elizabeth Pearce)
- -> in 1990 needed to think about role of father if thinking about funding IVF, challenged in 2008, and now thinking about supportive parenting
2. Gametes
- how long should we keep them for? what happens if one of the couple dies, can you still use them?
- should you get paid to donate? in uk only compensation (£750;m egg sharing is allowed)
- should there be a limit to number of children created from donated gametes? in uk, 10 families
- should children be able to find out who genetic parent is. prior to 2005 you couldn't, can now get more info at 18y/o
3. Embryos
- how many should we make?
- how many should be implanted? risk of multiple pregnancies
- what do we do with those not used?
4. Reproductive tourism
- sustainability and ethics of healthcares in diff countries
- cost
- waiting lists
- avoid legal restrictions
5. mitochondrial replacement
- ethical considerations of modifying embryos and changing the germline
- implications for identity and the status of the mitochondria donor
- general views on the permissibility of the techniques
- licensing models and further regulatory issues
70
what placental condition can be life-threatening to mother and baby and is associated with repeat c-sections?
placenta accrete/percreta
usually results in hysterectomy at the time of CS (due to massive blood supply of pregnancy can be very tricky and result in major haemorrhage)
difficult to spot reliably - MR may help a bit
71
what placental condition can be life-threatening to mother and baby and is associated with repeat c-sections?
placenta accrete/percreta
usually results in hysterectomy at the time of CS (due to massive blood supply of pregnancy can be very tricky and result in major haemorrhage)
difficult to spot reliably - MR may help a bit
72
who is at high risk of conceiving a child with NTD and how do we prevent it?
- either partner with a NTD
- previous pregnancy with NTD
- FHx of NTD
- women is on AEDs
- women has coeliac disease or other malabsorption states, diabetes, sick cell anaemia, or thalassaemia
- women is obesities (BMI >or= 30kg/m2
```
normal risk = 400mcg of FA daily until 12th week of pregnancy.
high risk (as above) = 5mg of FA daily until 12th week pregnancy (throughout pregnancy if women has sickle cell disease, thalassaemia or thalassamia trait)
```
+ preconception if possible
73
what is involved in preconception counselling?
- healthy weight?
- folic acid
- quit smoking
- nutrition and anaemia
- alcohol and drugs/medication
- chronic disease review and implication on fatal health and development
- effect of pregnancy and labour on pre-existing maternal conditions
- discuss the risks to make a balanced choice
- optimise health, disease control (esp. diabetes) and medications
- is it safe to conceive? what would happen if parent were to die? who would look after the child? quality of life?
74
discuss the effect of common respiratory problems on pregnancy?
Asthma:
- treat as normal
- no need to come to hospital unless severe
CF:
- MDT management
- make sure they can cope with and don't neglect physio
- usually known condition with planned pregnancy (preconception counselling)
- poor lung function means poor perfusion to placenta. growth scans later in pregnancy, may induce early to delivery asap
75
discuss the effect of epilepsy on pregnancy
- good to plan. start FA (5mg) and get condition under control
- most cope very well with pregnancy
- in general, foetus is resistant to short eps of hypoxia but status epileptics is dangerous for both mother and baby
76
what AEM are commonly used and are safe in pregnancy compared to the tetrogenic potential of the anticonvulsant med sodium valporate
lamotrigine and levetiracetam
77
a) what is the target HbA1c to reduce the risk of congenital malformation (+ miscarriage, stillbirth and neonatal death)?
b) women with a HbA1c of ..... should avoid pregnancy until better control has been established?
a) below 48 mmol/mol
b) above 86 mmol/mol
* NB good glycemic control reduces the risk but does not eliminate these risks
78
T or F
metformin can be used as an adjunct or alternative to insulin in those with Type 2 diabetes but other oral hypoglycaemic should be discontinued?
True
79
retinal complications are common in diabetes. how often are the eyes checked in diabetic pregnancies?
once every trimester
80
how would medication for hypothyroidism change if a women gets pregnant?
- increase thyroxine dose by 25mcg at positive pregnancy test
- repeat TFTs every 12 weeks/trimester (between 2-4)
- postnatally 6-12 weeks repeat TFT
81
what are the risks of HTN and pregnancy? what medication should be used?
risks:
- increase risk of pr-eclampsia
- increased risk of placental abruption and neonatal morbidity and mortality
- ACEi and ARBs are contraindicated. stop and switch for labetalol (1st-line) or methyldopa, BB (labetalol, propranolol, metoprolol), and nifedipine
82
what is the target BP in pregnancy?
140/90 mmHg
83
are statins contraindicated in pregnancy?
yes
84
what cardiac diseases have minimal maternal mortality risk and what cardiac diseases are high risk?
minimal:
- ASD
- VSD
- PDA
- corrected Fallot's tetralogy
- benign arrhythmia
high (pregnancy is contraindicated):
- primary pulmonary HTN
- Eisenmenger's syndrome
85
define puerperal cardiomyopathy
uncommon form of heart failure that happens during the last month of pregnancy or up to 6months after giving birth
RFs= maternal age, HTN, multiparty and multiple pregnancy
Pcx = SOB, poor exercise tolerance, palpitations, peripheral and pulmonary oedema
prognosis variable
86
define antiphospholipid syndrome and its effect on pregnancy
disorder of the immune system that causes an increased risk of blood clots
increased pregnancy loss, thromboembolic disease and stroke. early onset pre-eclampsia, IUGR
Tx with Aspirin and LMWH
87
what coagulation factor is monitored (blood tests) in a pregnancy with coagulation disorders?
8
88
what is the effect of chronic renal disease on pregnancy?
mild:
- plasma creatinine <125micromol/l without HTN and proteinuria of 1gram/day
- little effect
moderate:
- plasma creatinine 125-250 micromol/l
- high risk of HTN and increase in proteinuria --> poor obstetric outcome
severe:
- plasma creatinine >250
- marked anaemia, HTN, pre-eclampsia, polynyaamnios
- should avoid pregnancy
on dialysis:
- prone to complications of fluid overload, HTN, pre-eclampsia, polyhydramnios
- may need up to 50% increase
89
we should be aware that there is a 50% chance of what condition in pregnant women with bipolar and schizophrenia?
puerperal psychosis
90
90% of pregnant women develop ureteric dilation. what causes this and what is the effect?
cause:
combination of progestogenic relaxation of ureteric smooth muscle and pressure from expanding uterus
effect:
- increase urinary stasis
- compromised ureteric valves
- vesicoureteric reflux
- -> facilitates bacterial colonisation and ascending infection
91
what bacterial organism accounts for 80-90% of urinary tract infections in pregnancy?
Escherichia coli
92
UTI in pregnancy can be asymptomatic or symptomatic. symptomatic bacteriuria is associated with....?
- preterm delivery and low birthweight
- increased risk of preeclampsia
- anaemia
- chorioamnionitis (infection of foetal membrane)
- postpartum endometritis
- fetal growth retardation
Tx - appropriate AB for 7days based on culture and sensitivity (NB this is done at booking)
93
what is the likely diagnosis - dysuria, frequency, urgency and suprapubic pain in the absence of systemic illness?
acute cystitis
Tx is hydration and ABs
94
what is the most serious urogenital tract condition in pregnancy (can lead to sepsis) that may present as sepsis, loin pain, urinary symptoms?
pyelonephritis (infection of the renal papilla, which if untreated can spread to multiple papillae and occasionally to renal cortex)
Tx= ABs for 10-14days
95
what is the condition characterised by extreme, persistent nausea and vomiting during pregnancy?
hyperemesis gravidarum - can lead to dehydration, weight loss (can be more than 5%), and electrolyte imbalance
Management = hydration, antiemetics and multivitamin supplements
96
who is at risk of hyperemesis gravidarum?
- twins
- molar pregnancy
- Hx of hyperemesis in previous pregnancy or motion sickness
97
list possible causes of bleeding in early pregnancy
- implantation bleed
- miscarriage
- ectopic pregnancy
- cervical causes - ectropion/polyp, rarely Ca
- molar pregnancy
98
define miscarriage
loss of pregnancy during the first 22weeks
(symptoms = vaginal bleeding, cramping and lower abdominal pain. causes = unknown, chromosomal, placental problems, uterine anomalies, cervical incompetence, autoimmune conditions)
99
what are the different types of miscarriage?
1. threatened miscarriage:
pregnancy remains viable, baby still alive but there has been bleeding
2. missed miscarriage:
nonviable pregnancy. not much bleeding, came for scan and no bible foetus
3. incomplete miscarriage:
products of conception partly expelled. need to take remaining part of pregnancy out
4. complete miscarriage:
products of conception completely expelled. scan and no foetus, prob major bleed
5. recurrent miscarriage:
3 or more consecutive miscarriages. send to secondary care
100
how would you diagnose and manage a miscarriage?
transvaginal USS
give mifepristone or misoprostol to induce miscarriage if incomplete. surgical evacuation of the uterus by suction evacuation or curettage
101
if women is blood group Rh -ve what is she given/administered?
anti-D
- for pregnancies <12weeks anti-d prophylaxis is indicated if ectopic, molar, therapeutic termination and in cases of heavy uterine bleeding: min = 250IU
- for sensitising events between 12 and 20 weeks: min 250IU within 72hrs of the event
- for sensitising events >20weeks: min of 500IU writing 72hrs of the event
102
a 26 year old is admitted to A+E with the following symptoms:
- lower abdominal pain, more on one side
- vaginal bleeding or brown watery discharge
- shoulder tip pain
- discomfort while micturating or opening bowels
- +ve preganti test and other signs of pregnancy.
what is the diagnosis?
how would you Ix?
what is the management?
Ectopic pregnancy
Ix = USS and blood test
Mx = medical with methotrexate or surgical with salpingectomy
*can be life threatening!
103
hydatiform mole (molar pregnancy) presents with early bleeding than can be profuse with expulsion of grape-like tissues. how is this condition diagnosed and what is the Tx?
USS and high levels of beta-hcg
surgical evacuation and notify molar pregnancy register
104
what defines bleeding after 22 weeks of pregnancy?
antepartum haemorrhage
causes = placental abruption, placenta previa, vasa previa, cervicitis, trauma, vulvo-vaginal varicosities, genital tumours and infection
105
what test reveals the presence of Rh +ve foetal cells in the maternal circulation?
Keilhauer test
106
what defines preterm labour?
onset of labour before 37 weeks of gestation
107
what are the risk factors of preterm labour?
multiple pregnancies
Hx of preterm labour
polyhydramnios
infection
108
a pregnant pt of 34weeks undergoes a fetal fibronectin test that is +ve and therefore suggestive of preterm labour. what management can be done to delay labour?
Tocolysis
- to slow labour for administration of steroids and in-utero transfer if needed
steroids
- for fetal lung maturation
magnesium sulphate
- for neuro-protection
109
list the risk groups, diagnosis and management of preterm ore-labour rupture of membranes (spontaneous rupture of membranes before 37 weeks of gestation in the absence of regular painful uterine contractions)
risk groups:
- polyhydramnios
- previous Hx of PPROM
- uterine anomalies
- infections
Dx:
- examination swabs
- USS
Mx:
- tocolysis
- ABs
- steroids
- delivery
110
compare intra uterine growth retardation and small for gestational age
IUGR:
- failure of the foetus to achieve the expected weight for given gestational age
- causes = chromosomal, uteroplacental, environmental
SGA:
- fetus estimated birth weight on USS is below the 10th gentile for the given population
- causes = constitutionally small or growth restricted
both:
- DX = regular SFH (symphysis-fundal height), use of customised growth charts, USS
- Mx = careful monitoring and appropriate intervention
111
define obstetric choestasis
multifactorial condition of pregnancy characterised by pruritus in the absence of a skin rash with abnormal liver function tests, neither of which has an alternative cause and both of which resolve after birth. Tx is symptomatic
112
after how many weeks does preeclampsia typically occur? list symptoms, risk factors, complications and management
after 20 weeks - combination of raised BP and protein in urine
symx = asymptomatic, headaches, vision changes, pain in the right hypochondriac region, oedema
RFs = diabetes, high BP or kidney disease before starting pregnancy, lupus or antiphospholipid syndrome, personnel or FHx of preeclampsia, 1st pregnancy, maternal age >40, high BMI, multiple pregnancies
complications = eclampsia, intracranial haemorrhage, pulmonary oedema, HELLP syndrome, placental abruption, stillbirth, IUGR
management = regular BP monitoring and ant-hypertensives, foetal growth monitoring and delivery
113
how many weeks is typical gestation and how do we estimate due date?
38weeks
40 weeks from last menstrual period. conception happens at ovulation, which happens approx 2 weeks after LM
114
list 3 Ddx of vaginal bleeding early in pregnancy
1. threatened miscarriage or non-continuing intrauterine pregnancy (miscarriage identified on USS before process (i.e. bleeding) occurs)
2. ectopic pregnancy
3. unexplained. pregnancy still healthy. may be due to pathology from cervix eg ectropion
115
what initial examinations/investigations would you do after a pregnancy lady presents with vaginal bleeding?
```
abdominal exam
urinalysis
USS
general obs
FBC
```
116
if a pt wants to find out the chances of her baby having Down syndrome, what is the Ix for this in the 1st and 2nd trimester? what is NIPT/S?
1st trimester combined test:
- uses maternal age
- nuchal translucency measurement (USS)
- free beta HCG and PAPP-A (bloods)
- alongside gestational age calculated from crown rump length
2nd trimester:
- maternal age
- 4 biomarkers; AFP, HCG, unconjugated oestradiol and inhibin-A
-->if there is a high chance the pt is offered a diagnostic test (invasive and comes with risks)
Non-invasive prenatal testing/screening:
- analysis of fragments of free circulating DNA in the maternal plasma, of which 5% is fatal in origin from about 10wks gestation
117
list 3 conditions that are screened for in fatal anomaly scan at 18-22 weeks
1. gastroschisis
2. open spina bifida
3. cleft lip
118
at 28weeks what Ix and prophylactic Tx is offered?
Ix:
- FBC
- group and save
- BP
- urinalysis
prophylactic Tx:
- anti-D IM
119
if a pregnancy women is Rh -ve why is this a red flag?
if she has a Rh +ve baby and some of the baby and mothers blood mixes in the maternal circulation, it stimulates an immune response. the mother produces anti-D to clear the rhesus +ve cells. this can adversely affect future pregnancies, leading to Rhesus disease --> condition where antibodies in mothers blood destroys her baby blood cells (AKA haemolytic disease of the newborn. this doesn't harm the mother but can cause the baby to become anaemic and jaundice
120
what are the Ddx is a pregant women presents at 31 weeks with headache and altered vision for past 24hours?
1. hypertension in pregnancy:
- development of new HTN after 20weeks without the presence of proteinuria
2. preeclampsia
3. HeLLP syndrome:
- complication of pregnancy characterised by hemolysis, elevated liver enzymes and low platelet (thrombocytopenia)
4. if not sustained, might be insignificant BUT must rule out potential Dx that include: benign pregnancy headache, migraine, dural venous sinus thrombosis and benign intracranial hypertension
121
what are the Tx of preeclampsia?
- no Tx that improves corse of disease
- labetalol is first line antihypertensive (be careful in asthmatics). alternatives = methyldopa or nifedipine
- IV infusion of magnesium sulphate in severe cases. usually only started when there is a clear need to deliver the baby. can provide some fetal-neuro protection.
- steroids may be given to improve foetal lung maturity. max effect 2days after administration
122
what type of seizure is eclampsia?
grand mal seizure
123
there is a small increase in developing hypertension in later life and a 90% of developing pre-eclamsia again in the next pregnancy. in future pregnancy, what is recommended?
aspirin 150mg daily should be started early (no later than 12 wks)
BP and urinalysis every appointment
fatal surveillance with USS to check growth - typically starting at 28 weeks and performed every 4 weeks
