HD Flashcards
Anterior and posterior divisions of the Internal iliac
Anterior division.
- Obturator artery.
- Uterine Artery:
• Goes into a circuit with the ovarian artery (comes directly from the abdominal aorta).
• Gives off the vaginal branch (1/3 of vagina and cervix) and ascending branch (supplies uterus).
- Vaginal Artery (supplies lower 2/3 of vagina).
• Can also be branch of the uterine a.
Posterior Division
- Superior Gluteal
- Inferior Pudendal
- Inferior Gluteal
Lumbar Plexis important branches
Femoral: anterior compartment of thigh (L2, 3, 4)
Obturator: medial compartment of thigh (L2, 3, 4)
Genitofemoral: skin of scrotum/cremaster muscle/labium majorum (L1, 2)
Lumbosacral Trunk
fibres from L4 and L5 join = lumbosacral trunk, which emerges medial to the psoas, runs inferiorly over the pelvic brim and joins the sacral plexus
Pudendal Nerve to pelvic floor
(S2, 3, 4): leaves the pelvis through the greater sciatic foramen and then enters the perineum through the lesser sciatic foramen (goes around the sacrospinous ligament)
Travels through the pudendal canal - also, contains the pudendal artery/vein (IIA).
Pelvic parasympathetic to pelvic floor
(S2, S3, S4) to pelvic viscera.
Micturition, defecation, genital erection (point and shoot).
Sympathetic supply to pelvic floor
Allows filling of bladder and contraction of internal urethral sphincter (hypogastric), simulates contraction of the seminal vesicles and vas deferens.
Obstetric Anaesthetic Options
Spinal Aesthesia: subarachnoid space (L4-L5) - Complete anaesthesia below waist monitoring of uterine contractions
Pudendal Nerve Block:
Peripheral nerve block S2-S4: perineum and lower ¼ vagina - Mother can feel/assist contractions.
Caudal Epidural Block:
Administered to catheter in sacral canal (S1-S5) - Limbs unaffected.
Penis and Ovarian/testes Lymphatic drainage
Penis = drained by deeper Inguinal lymph nodes
Ovarian/testes = drained by Preaortic lymph nodes.
Infertility Definition
The failure to achieve a clinical pregnancy within 12 months of unprotected sex.
Primary infertility
Unable to ever bear a child
Secondary infertility
Unable to bear/ability to carry a child following a previous pregnancy
Spermatic Cord contents
Contains the vas deferens, testicular artery, genital branch (of the genitofemoral nerve), Pampiniform plexus, lymphatic vessels, tunica vaginalis.
Testes Blood supply and drainage
Supply:
Abdominal artery branches to form the gonadal testicular artery
Venous Drainage:
Right testicle = drained by to the inferior vena cava (also lies on the right side)
Left testicle = drained to the left renal vein (a lot longer).
Ovarian Cycle
Follicular phase: days 1 to 10
• 5-12 primordial follicles stimulated each month: one grows and matures.
• GnRH secreted from hypothalamus: stimulates anterior pituitary to secrete LH and FSH.
o These stimulates follicle to grow.
• Mature follicle secretes oestrogen.
o Inhibits further LH and FSH secretion by anterior pituitary (negative feedback).
o Stimulates growth of endometrium.
Ovulatory phase: days 11 to 14
• Negative feedback is temporary: oestrogen stimulates HPA resulting in burst of LH and FSH.
o Completion of meiosis I, onset of meiosis II in the oocyte.
Luteal phase: days 15 to 18
• Granulosa cells of mature follicle divide and form the corpus luteum
• Secretes progesterone and oestrogen. Prepares uterine endometrium for implantation
Menstrual Cycle
Menstrual phase (day 1-5): • Due to withdrawal of steroid support (oestrogen/progesterone) the endometrium collapses. • Endometrium is shed with blood from ruptured arteries (blood loss: 50-150ml).
Proliferative phase (day 6-14): • Oestrogen from mature follicle stimulates thickening of the endometrium. • Glands/spinal arteries form. • Oestrogen also causes the growth of progesterone receptors on endometrial cells.
Secretory phase (day 15-28): • Progesterone from corpus luteum: acts on endometrium. Enlargement of glands --> secret mucus and glycogen in preparation for implantation of fertilised oocyte. • No fertilisation = corpus luteum degenerates --> corpus albicans. Progesterone levels fall.
Conception Advice
Intercourse throughout the cycle (not just at certain parts)
No smoking, alcohol.
Reduce weight, stress, drugs.
Take folic acid (400mg).
Causes of Infertility
Ovulatory Causes (25%)
Tubal and Uterine Causes of Infertility (30%)
Unexplained Fertility
Ovulatory Causes of Infertility
Type 1: Hypopituitary failure (anorexia).
Management:
- Increase weight, decrease exercise.
- Consider pulsatile GnRH
Type 2: Hypopituitary dysfunction (e.g. PCOS, hyperprolactinaemia)
Management for HP: bromocriptine
Type 3: Ovarian Failure (premature ovarian failure if under 40 years).
- Involves persistent FSH raised.
Management: donor eggs, alternative parenting.
Polycystic Ovarian Syndrome
Diagnostic Criteria:
Clinical hyperandrogenaemia (excessive testosterone)
Oligomenorrhoea (infrequent periods)
Polycystic ovaries on ultrasound.
Menstrual disturbance, acne.
Raised LH with normal FSH, raised testosterone
Management:
First line: Clomiphene or metformin
Second line: combined clomiphene and metformin, laparoscopic ovarian drilling and Gn theraphy.
Tubal and Uterine Causes of Infertility
Pelvic Inflammatory Disease:
- Symptoms (NOTE: may be asymptomatic):
o Pelvic pain
o dyspareunia (painful sexual intercourse)
o fever.
(Investigate with full blood count and raised ESR).
Caused bacteria and STIs (chlamydia and gonorrhoea).
- Management: antibiotics, rest and abstinence.
Endometriosis
Symptoms:
o Pain
o Dysmenorrhoea (painful menstruation).
o Menorrhagia (abnormally heavy bleeding)
o Dyspareunia (difficult/painful sexual intercourse).
Management
• NSAIDs, COCP, GnRH agonists, surgery
Fibroids
• Benign tumours of smooth muscle of the myometrium (uterine leiomyoma).
o Complain of heavy, regular periods.
• Treated with (COCP), LARCs, surgical.
Male Factors of Infertility
- Testicular (infection, cancer, surgical, congenital and trauma)
- Azoospermia (absence of motile sperm).
- Reversal of vasectomy.
- Ejaculatory problems (retrograde and premature).
- Hypogonadism.
Assisted Conception
Intrauterine Insemination (IUI): Sperm is separated in lab, removal of slower speed sperm before partner is inseminated - tried 12 cycles before IVF
In-Vitro Fertilisation (IVF): o Women under 40 who have not conceived after 2 years of unprotected intercourse o Women 40-42 offered one cycle if: Never had IVF. 6 or more UII cycles. No evidence of low ovarian reserve.
Intracytoplasmic Sperm Injection (ICSI):
• Single sperm injected directly into egg.
• Is offered to:
o Severe deficits in semen quality
o Obstructive and non-obstructive azoospermia.
o Failure of IVF treatment.
Function of the Prostate
Makes about 30% of alkaline seminal fluid that contains an anticoagulant (PSA) to that sperm can swim and survive in the female vaginas acidic environment.
Regions of the Prostate
Peripheral Zone (PROSTATE CANCER) Central Zone Transition Zone (BENIGN PROSTATE ENLARGEMENT)
Testosterone Proliferation and Apoptosis in Benign Prostatic Hyperplasia
Stromal cells: converted to estradiol
• Causes stromal cell proliferation (binds to ER alpha).
Epithelial cells: converted to DHT and prevents apoptosis.
Signs and Symptoms of Benign Prostatic Hyperplasia
• Weak/interrupted flow of urine. • Frequent urination (nocturia). • Trouble urinating. • Pain/burning during urination. o Blood in urine/semen
SHITE = slow stream, hesitancy, intermittent flow, terminal dribbling, emptying incomplete. FUN = frequency, urgency, nocturia.
Diagnosis of Benign Prostatic Hyperplasia
Diagnosis:
• History
• Digital Rectal Exam (DRE)
• Ultrasound (biopsy) = allows an estimate of the width/height/length of prostate.
• Blood test = PSA (gamma-seminoprotein or kalikrein-3)
Treatment of Benign Prostatic Hyperplasia
Pharmacotherapy.
o Alpha-1 adrenergic blockers - Relaxes smooth muscle in bladder and prostate (Tamulosin).
o 5-Alpha-reductase inhibitors - Tries to block conversion of testosterone to its active form (dihydrotestosterone). DHT normally binds to androgen receptor causing cell proliferation.
Two types: dutasteride and finasteride
Surgery
o Transurethral resection of the prostate - Cuts out transitional zone but leaves PZ
Done when:
• Urinary tract infection.
• Recurrent gross haematuria.
• Failed voiding trials.
• Renal insufficiency secondary to obstruction
Open Prostatectomy
o For very large prostates (>75g)
Laser Ablation/Transurethral Microwave/High Energy US Therapy
• Going through urethra with laser (will cook TZ cells and kill them so you can increase size).
Urolift: opening of urethra
Prostate Cancer
Symptoms of BHP may be like prostate cancer - PSA tends to be much higher than in BPH
Mechanism of Smooth Muscle Relaxation in Erection
- Non-adrenergic non-cholinergic parasympathetic neuron releases nitric oxide.
a. Diffuses across to smooth muscle - NO binds to soluble guanylyl cyclase and produces cGMP
- This causes smooth muscle relaxation (decreases calcium inflow).
a. Signals from the sympathetic neuron does the opposite.
Treatment of Erectile Dysfunction
Can target cGMP and stop its breakdown to cause relaxation. E.g. • Phosphodiesterase type 5 inhibitor: o Sildenafil (Viagra) o Vardenafil (Levitra) o Taladafil (Cialis)
Peyronie’s Disease (Bent Penis)
Scar tissue forms on shaft of penis
Where do varioceles in the testes usually develop
ALWAYS in the left testis.
Types of Miscarriage
Threatened: light/painless bleeding from vagina (PV)
• Fetus is alive - cervical os is closed
Inevitable: bleeding heavier vs threatened.
• Fetus may be alive at this point - cervical os is open.
o Miscarriage about to occur.
Incomplete: only some of the fetal parts have passed.
• Cervical os is open.
• PV bleeding continues.
Complete: All fetal tissues have been passed.
• Bleeding has diminished stopped.
• Uterus no longer enlarged - cervical os is closed
Septic: contents of uterus infected = endometritis.
• Tender uterus, fever may be absent.
• May progress to pelvic infection.
Missed
• Fetus has not developed and died in utero.
o Cervical os is closed
Causes of Recurrent Miscarriage
Causes: • Autoimmune disease (e.g. anti-phospholipid syndrome): 25%. • Chromosomal defects (4%). • Hormonal factors • Anatomic factors. • Infection. • Others
Presentation of Ectopic Pregnancy
Clinical Presentation
• Women of reproductive age with PV bleeding.
• Lower abdominal pain.
• Collapse (shoulder tip pain).
• Amenorrhoea for 4-10 weeks (absence of menstruation)
Molar Pregnancy/Gestational Trophoblastic Disease
When trophoblastic tissue that forms part of blastocyst proliferates more aggressively than normal
Hydatidiform mole: no fetus, only the placenta forms
Partial Hydatiform: some evidence of embryonic development can be found
Examination
• Large uterus
• Early pre-eclampsia and hyperthyroidism may occur.
Investigations
• Ultrasound: snowstorm appearance.
Infections in Pregnancy
TORCH
Toxoplasmosis Other (influenza, parvovirus B19) Rubella Cytomegalovirus (CMV) Herpes Simplex Virus, HIV, Hepatitis.
Congenital Cytomegalovirus Symptoms
Wide Range Symptoms
• Severe: intra uterine growth retardation (IUGR) –> very non-specific.
o Hepatosplenomegaly, microcephaly.
o Sensorineural deafness (commonest congenital cause)
Treatment: • IV Ganciclovir OR • Valganiclovir (pro-drug of Ganciclovir) o Inhibits DNA synthesis. o Oral medication.
Congenital Varicella Syndrome Symptoms
Symptoms:
• Skin lesions (73%): limb hypoplasia
• CNS (62%): microcephaly, hydrocephaly, neurodevelopmental delay.
• Cataracts/other eye problems.
• GI, Genitourinary and cardiac abnormalities
Neonatal HSV Infection treatment
Acquire infection while passing through birth canal (and kissing the child)
Management
• Mortality (untreated) 65% reduced to 25% with aciclovir treatment
Congenital Rubella
The risk is greater the earlier there is contraction. Risks involve: o Microcephaly o Heart disease o Petechiae and purpura.
Congenital Toxoplasmosis
Mother infection due to parasite toxoplasma gondii ( Natural host is cat)
Clinical Features: IUGR (intrauterine growth restriction), hydrocephalus, cerebral calcification, microcephaly, hepatosplenomegaly.
Syphilis
Sexually transmitted infection due to spirochete Treponema pallidum.
Treatment: penicillin
Congenital Syphilis: Early 0 to 2 years • Rash • Rhinorrhoea (thin clear nasal discharge) • Osteochondritis • Perioral fissures • Lymphadenopathy
Late i.e. >2 years • Hutchinson’s teeth • Clutton’s joints • High arched palate • Deafness • Saddle nose deformity • Frontal bossing
Stages of Labour
1st Stage of Labour Latent Phase: 0-3cm cervical dilatation. Active Phase: 3-10cm cervical dilatation. • Primigravida: 1-3cm/hr. • Multigravida: 3-6cm/hr.
2nd Stage of Labour
Primigravida: 40 minutes
Multigravida: 20 minutes.
• Propulsive phase: from full dilation to present part reaching pelvic floor.
• Expulsive Phase: from reaching the pelvic floor to delivery of the baby
3rd Stage of Labour
• From delivery of the baby to expulsion of the placenta (30 mins)
Macrosomia causes
- Maternal diabetes (common).
- Maternal Obesity
- Previous large babies
- Prolonged pregnancy
Management of Failure to Progress in pregnancy
Powers: Uterine Inertia (absence of effective contractions).
o Give syntocinon (oxytocin)
Passenger: Malpresentation or malposition.
o Consider ECG/rotation forceps/C-section
Passages: contracted pelvis/rigid cervix.
o C-section.
Signs of Foetal Distress in Labour:
• Meconium (faeces in abdomen due to distress)
• Fetal heart rate abnormalities
o Bradycardia <110/mt, tachycardia >160/mt
• Decelerations.
Closure of Foetal circulatory vessels
Closure of ductus arteriosus (increased oxygen levels).
o In utero ductus is kept open under influence of PG E1
• Closure of foramen ovale.
o Due to drop in pressure in pulmonary circulation/right side of heart.
Shunting is reversed and valve closes
• Closure of ductus venosus.
o Due to decrease in blood flow in inferior vena cava.
What causes the blue look in cyanosis
Amounts of deoxygenated Hb
Deoxygenated Hb >50g/l in capillaries OR >34/l in arterial blood
Eisenmenger shunt
Pulmonary oedema impairs gas exchange (increased PAP from left –> right shunts)
Pulmonary hypertension causes right to left shunting as there is higher pressure on right side
Neural Tube Defects
Spina Bifida Occulta = failure of one or more vertebrae in spine to form properly
o Myelomengocoele is the most serious form (neural tissue exposed on babies back)
Meningocoele = meninges protruding from spinal column.
Encephalocoele = protrusion of neural tissue (brain) from head.
Anencephaly = absence of major portion of brain, skull, and scalp.
Treatment and consequences of Myelomeningocele
Closure reduces risk of infection but does not restore normal neural function.
Also: closure may lead to hydrocephalus (build-up of CSF).
o Treated with a plastic catheter that is put through the valve and runs under the skin into the peritoneal cavity to be rapidly absorbed into the circulation
Consequences:
Mixed sensory, motor and autonomic problems.
o Dependent on level of lesions and degree of neural disruption.
Loss of bladder control, faecal incontinence and loss of sensation in legs.
Abdominal Wall Defects
Gastroschisis (abdominal cavity open)
Exomphalos (Herniation through umbilical cord)
Causes of Primary Post-Partum Haemorrhage (PPH)
Are traditionally the 4Ts:
T: Tone = uterus not contracting (70%)
T: Tissue = placenta/membranes left behind (20%)
T: Trauma = episiotomy/tear which keeps bleeding (9%)
T: Thrombin = clotting disorders that need to be corrected (1%).
Management of Primary PPH
Uterotonics • Syntometrine (oxytocin and Ergemetrine). o Syntocinon (synthetic oxytocin). o Ergemetrine (vasoconstriction). • Misoprostol (prostaglandin E1) • Carboprost (prostaglandin F2alpha).
Surgery
• Bakri Balloon: device used for the temporary control and reduction of PHH (inflates: keeps uterus contracted and stops bleeding).
• B-Lynch: mechanical compression of atonic uterus using sutures.
Uterine Artery Embolization (catheter to deliver small particles that block the blood supply to uterine body).
(!) Resort to hysterectomy (removal of uterus) sooner rather than later
• Especially in cases of placenta accreta (vessels grow too deeply into uterine wall)/uterine rupture.
