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Med 3 > Menstrual Disorders And Early Pregnancy Problems > Flashcards

Menstrual Disorders And Early Pregnancy Problems Flashcards

1
Q

Sympathetic division of nervous system

A

Function is to prepare the body for an emergency

  • increase heart rate
  • redistribution of blood
    Arterioles of skin and intestine are constricted
    Arteriole of skeletal muscle dilated
  • increase BP

Consists of efferent outflow from the SC, sympathetic trunk, branches, plexuses and ganglia

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2
Q

Sympathetic chain

A

2 ganglionic nerve trunks that extend the while length of the vertebral column

Neck - 3 ganglia
Thorax - 11/12
Abdomen - 4/5
Pelvis - 4/5

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3
Q

Splanchic nerves

A

Lower thoracic
Greater - T5-T9 (T10)
Lesser - T10-T11
Least - T12

Origin: thoracic sympathetic trunk

Target: abdominal
Prevertebral
Ganglia
Preganglionic fibres

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4
Q

Parasympathetic division

A

Function is to conserve and restore energy

  • decrease heart rate
  • peristalsis and glandular activity increased
  • sphincters are opened
  • bladder wall is contracted
  • pupils are constricted
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5
Q

Functions of autonomic nervous system in digestion

A

Sympathetic: inhibits peristalsis, constricts blood vessels to react so blood available for skeletal muscles, contracts internal anal sphincter

Parasympathetic:: stimulates peristalsis and secretions of digestive juices, contracts rectum, inhibits internal anal sphincter

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6
Q

Functions of autonomic nervous system in urinary

A

Sympathetic: Vasoconstriction of renal vessels, contraction of internal sphincter of bladder

Parasympathetic: inhibits contraction of bladder internal sphincter, contract detrusor muscle of bladder wall (urination)

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7
Q

Functions of autonomic nervous system (genital)

A

Sympathetic: ejaculation and vasoconstriction leading to remission of erection

Parasympathetic: erection of erectile tissue of external genitals

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8
Q

What is the enteric nervous system

A

Two important plexuses of nerve cells and fibres extend along / around GI tract

Meissner plexus (submucosal plexus) - controls glandular secretion of mucosa

Auerbach plexus (myenteric plexus) - controls peristalsis

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9
Q

Function of enteric nervous system

A

Second brain
Contains a variety of functional types of neurones and a plethora of neurotransmitters

Controls motility and secretory functions

Complete reflex circuit
- afferent sensory neurones, interneurones and efferent secretomotor neurones

Functions autonomously but modified by sympathetic and parasympathetic nervous systems

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10
Q

Pathology of the enteric nervous system

A

Hirschsprung’s disease

  • congenital birth defect
  • enteric neurones absent from variable lengths of the distal gut

Symptoms: intestinal obstruction or severe constipation

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11
Q

Key events in first trimester

A

Embryo 0.5-24g, placenta 5-80g
Formation of chorionic villi
Development of maternal circulation
Development of fetal circulation

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12
Q

Key events of 2nd trimester

A 
Gets 11-800g
Placenta 28-300g 
Arborization of chorionic villi 
Fetal vessels identity and maturation 
Regulation of blood flow (no nervous system, no lymphatic system) 
Formation of cotyledons
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13
Q

Key events of 3rd trimester

A

Foetus 1000-3000g (larger increase in growth due to fat deposition)
Placenta 500-700g
Angiogenesis: formation of terminal villi and terminal capillaries

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14
Q

Nutritional function of placenta

A

Allows essential nutrients to get across from mum to baby (waste back)

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15
Q

Respiratory function of placenta

A

Allows oxygen to get across and carbon dioxide to return (so acts as lung oxygen gradient)

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16
Q

Barrier function of placenta

A

Main barrier between mother and embryo / fetus (protects from maternal immune system, maternal infection, discriminates solute transport, phagocytosis of unwanted material)

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17
Q

Endocrine function of placenta

A

Produces hormones- progesterone, prolactin etc to influence maternal physiology; for efficient placental function

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18
Q

Alteration in placental fetal vessel identity and endothelial junctional maturity

A

1) artery- vein specification (flow mediated)
2) smooth muscle and pericyte wrapping of endothelial cells
3) maturation of junctions at endothelial - endothelial contacts - tight junctions and adherens junctions

Result: mature blood vessels that are not leaky

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19
Q

Function of terminal villous capillaries

A

Bringing fetal blood close to maternal blood without intermingling

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20
Q

Features of terminal villous capillaries

A

Dilated lumen (more blood flowing through at slower rate; fetal flow = 5ml/min; maternal flow = 20ml/min)

Abutting of endothelium (e) with syncitium (syn) and creating thin exchange area to minimise diffusion distance

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21
Q

Umbilical blood supply

A

Umbilical arteries: takes de oxygenated blood from fetus to placenta

Umbilical vein takes oxygenated blood back to fetus

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22
Q

Maternal fetal transport

A

Simple diffusion: blood glasses, sodium, water, electrolytes, urea, fatty acids, non conjugated steroids and bilirubin

Active transport: hexose sugars, amino acids, water, soluble vitamins, nucleotides, cholesterol, calcium, glucose (fetus has little capacity of gluconeogenesis)

Receptor mediated endocytosis and transcytosis: eg maternal IgG; iron concentration 2-3 times more than in maternal blood

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23
Q

Obstetric problems of umbilical cord

A

Coiling around the fetus
True knots - stops fetal circulation
1 artery - cardiovascular malformations

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24
Q

Mechanisms for efficient materno fetal transport in placenta

A

Branching of chorionic villi and extensive vascular network

1) increase in SA of exchange
- microvilli on syncytiotrophoblast (ST)
- expression of receptors and transporters
- endocytosis: clathrin coated pits and vesicle, endosomes, lysosomes
- synthesis and storage in ST: increased ER

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25
Q

How is diffusion distance decreased in placenta

A

Extrusion of the excess accumulated nuclei in the syncytiotrophoblast

  • aggregation and pinching off nuclei within syncytial knots into the maternal circulation
  • these syncytial debris is phagocytoses by maternal immune cells
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26
Q

Barrier formation process

A

Possession of a syncytial layer (no cell - cell borders of inter cellular spaces; has to go through the syncytium)

A continuous endothelium (no fenestra) with restrictive inter cellular tight and adherens junctions ie most nutrients have to go through endothelial cells

Endothelial inter cellular junctions are size and charge selective to hydrophilic solutes

Presence of macrophages in stromal core of villi

Placenta is freely permeable to alcohol and drugs
Barrier to most viruses except toxoplasmosis, cytomegalovirus, herpes, rubella, HIV
Maternal smoking causes hypoxia and heavy metal poisoning

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27
Q

Volume of amniotic fluid

A

8 weeks: 15ml

20 weeks: 450ml

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28
Q

What is oligohydraminos

A

Insufficient amniotic fluid (renal agenesis) fetal kidney is principal source of amniotic fluid

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29
Q

What is polyhydramnios

A

Excessive fluid (no swallowing, oesophageal atresia)

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30
Q

What is pre eclampsia

A

Mother presents with high BP and protenuria

Reduced invasion of spiral arteries so reduced maternal blood flow to placenta, hypoxia

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31
Q

Way to determine a pregnancy is ectopic

A

If the HCG levels don’t double

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32
Q

Development of blastocyst

A

1) trophoectoderm (will form placenta) - a layer of trophoblast cells
2) inner cell mass (will form embryo)
3) blastocoel cavity

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33
Q

What are the 3 phases of implantation

A

Attachment (apposition), adherence (stable adhesion) and invasion

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34
Q

What does high oestrogen and progesterone in the luteal phase cause

A

The epithelial cells lining the endometrium of the uterus:

  • lose surface glycocalyx
  • lose anionic charges
  • flatten their microvilli
  • have a thin mucin coat

This is called primary decidualisation (occurs at luteal stage of every cycle)

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35
Q

Decidualisation of the endometrium

A

Secondary decidualisation spreads to create 3 decidual layers

Decidua basalis: endometrium underlying the conceptus. This shows the highest changes as this is where the conceptus needs to burrow into. This is also called the basal plate of the placenta

Decidua capsularis: superficial portion overlying the conceptus

Decidua parietalis : remaining uterine mucosa

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36
Q

Function of female reproductive system

A

Produces haploid female gametes

Receives haploid male gametes prior to fertilisation

Provides environment for fertilisation

Accommodates and nourishes the embryo and fetus during pregnancy

Expels the mature fetus at the end of pregnancy

Protects against pathogens

Production of steroid hormones

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37
Q

Histology of clitoris

A

2 corpora cavernosa erectile vascular tissue

Corpora cavernosa can be engorged with blood upon arousal the equivalent of the male penis

38
Q

Structure of vagina

A

Fibromuscular tube 7-9cm
Capable of marked distension and elongation
>90 degree angle with normal anteverted uterus

At inner end, vaginal tube forms a cuff around protruding cervix of uterus creating anterior, posterior, lateral cornices

At outer end it opens into vestibule

39
Q

Histology of vagina

A

1) epithelial mucosa - non keratinised stratified squamous epithelia
2) lamina propria
3) sub mucosa highly vascularised, has elastic fibres - allows distension
4) adventitia elastic fibres and irregular smooth muscle

40
Q

Epithelial mucosal layer of vagina

A

Non keratinised stratified layer of squamous epithelial cells
Glycogen rich (involved in maintenance of pH)
Under influence of oestrogen

Before puberty and after menopause this layer is thin

At ovulation there is increased glycogen production by vaginal epithelium
Breakdown of glycogen by commensal lactobacilli leads to production of lactic acid and a pH of 5.7-3.0

PH restricts vaginal flora to acid loving bacteria nad deters pathogens such as Candida albicans (thrush)

41
Q

Describe the cervix

A

Cylindrical tube 3-4cm long and 2.5cm wide partly protruding into vagina

Ectocervix: portion projecting into vagina (lower pH)
Endocervix: passageway between the eternal OS and uterine cavity (neutral pH) terminates at internal OS

Can distend to 10cm diameter during childbirth

42
Q

Histology of endocervix

A

Single layer of tall columnar mucus secreting epithelial cells
Basal layer of reserve cells
Stroma composed of a matrix of fibre muscular tissue, elastin and collagen fibres

Important for cervical distension during childbirth due to softening of stroma- hydration of matrix; alterations in collagen and elastin fibres

There is a rapid reversal to normal dimensions after childbirth

43
Q

Function of mucin produced by endocervix

A

Lubrication during sex
Protection against bacterial ascent into uterus

Allows ascent of sperm into uterus at correct time

44
Q

Consequences of squamous metaplasia

A

Blocking of endocervical glands - mucus filled nabothian cysts / follicles
Development of abnormal epithelium - lose regular stratified pattern, high nucleus to cytoplasm ratio, increased mitotic activity

Progression to cancer: these cells can breach the basement membrane and invade cervical stoma

45
Q

Where are cervical smears taken

A

At transformation zones to ensure early diagnosis of cancer if present. NHS cervical screening age 24-64 every 3 years
HPV testing occurs with cervical screening

46
Q

What is HPV

A

Infection with HPV is a major causative agent for cervical cancer
Of 100 types, 40 are transmitted by sexual contact
Low risk types 6, 11 can cause genital warts but not cervical cancer
Types 16-18 are high risk that cause cervical cancer

47
Q

What is uterus wall composed of

A

External serosa covered with peritoneum of the pelvic cavity, the perimetrium

48
Q

What is the endometrium

A

Internal mucosa lawyer which lines the entire uterus and is under influence of the menstrual cycle. Fertilised egg will implant in the endometrium of the uterus

49
Q

What does oestrogen stimulate

A

Mitotic activity in glands, proliferation of stromal cells

Increases thickness of endometrium

Increased length of spiral arteries

50
Q

What happens if pregnancy does not occur

A

Degeneration of corpus luteum that leads to cessation of progesterone and oestrogen. This results in

  • involution of functional layer of endometrium
  • rise in endothelin and thromboxane
  • vasoconstriction of spiral arteries, cessation of blood flow and ischaemia of functional endometrium
  • rupture of arteries and shedding of blood into uterus
51
Q

Describe the uterine tubes

A

10-12cm long
Open at infundibulum which is surrounded by fimbrae, finger like projections into the peritoneal cavity. Released ovum from ovary is wafted into and lodges at the ampulla region of the tube

Sperm swims up to and stays at the isthmus (neck of tube) until ovulation draws near, they then travel to the ampulla where fertilisation occurs

52
Q

Histology of ampulla

A

2 layers of smooth muscle in the wall of the tube: the inner being a tight spiral the outer a loose spiral which makes them appear circular and longitudinal respectively

53
Q

Histology of isthmus

A

Mucosa consists of longitudinal folds lined with ciliated and non ciliated columnar epithelium

Muscularis consists of a circular and a longitudinal layer

54
Q

What occurs at the isthmus

A

Capacitation of sperm (where sperm is resting so not really doing anything)
Sperm movement alters here once ovulation draws near and sperm can swim to ampulla.

55
Q

Role of ciliated and non ciliated cells in epithelial mucosa of uterine tube

A

Epithelial mucosa do the entire uterine tube has ciliated and non ciliated cells. Cells are more numerous near ovarian end

  • cilia beat towards the uterus, creating flow in that direction (this is where you want implantation to occur)
  • ciliary height is cycle dependent; highest at time of ovulation, the subsequent decrease in length is progesterone mediated
  • non ciliated cells secrete mucus to aid motion of cells
56
Q

Make up of tubal fluid

A

Watery fluid rich in potassium and chloride ions, immunoglobulins, serum proteins
Provides nutrients to egg during its migration

57
Q

Disorders of uterine tube

A

Tubal ectopic pregnancy (implantation of fertilised ovum)

Acute and chronic Salpingitis (bacterial infection, acute inflammation, pus formation, abscess, scarring, blocked tube)

58
Q

Define fertilisation.

A

Sequence of co-ordinated events that begins with contact between a sperm and an oocyte and ends with intermingling of maternal and paternal chromosomes

59
Q

Site of fertilisation

A

Ovulated oocyte enters Fallopian tube and waits in the ampulla where fertilisation usually occurs

60
Q

Roles of differnt parts of ovulated oocyte

A

Granulosa cells suspended in hyaluron rich matrix produces progesterone and chemo attractants (aromatic aldehydes)

Secondary oocyte continues to obtain nutrients from the cytoplasm, the first polar body

Zona pellucida remains as a protective shell

61
Q

Features of spermatozoa

A

Acrosome: contains the enzyme acrosin

Haploid nucleus

Mid piece: mitochondria (powerhouse)

Plasma membrane of sperm head: odorant receptors (similar to olfactory receptors) that can react to the chemo attractants from oocyte
3 surface binding molecules- ADAM family: fertilin a, B and cyritestin

ADAM: a disintegrin and metalloprotinease membrane

62
Q

Spermatozooal movement from vagina to oviduct

A

Spermatozoa has to undergo capacitation in female tract

Starts in vaginal environment when it is oestrogen primed, pH <5.7

Full capacity is reached by the time the spermatozoa travels through the isthmus to the ampulla region of the oviduct

63
Q

What is capacitation

A

Release of chemo attractants by the oocyte, now in ampulla is received by the odorant receptors on sperm

Changes in movement characteristics to hyper activated motility pattern: regular wave like changes to wide amplitude whiplash beats needed to swim upstream from isthmus to ampulla

64
Q

1st step of fertilisation (penetration of corona radiata)

A

Secretion of hyaluronidase

Digestion of extra cellular matrix

Active movement to reach zona pellucida

65
Q

2nd stage of fertilisation (penetration of zona pellucida)

A

4 sulphated glycoproteins in humans. 3rd one has the dominant binding role but only if its in conjunction with 2nd (ZP2). The ZP2/3 three dimensional framework is species specific and blocks cross species fertilisation

66
Q

Process of attachment to zona pellucida

A

The receptors for ZP proteins (ZP2R and ZP3R) are present on different membrane components for the spermatozoa

The receptor fro ZP3, ZP3R is on the surface of the sperm head

The receptor for ZP2, ZP2R is on the inner acrosomal membrane

67
Q

Step 3 of fertilisation (the acrosome reaction)

A

Binding of ZP3 to its receptor on sperm head plasma membrane leads to:
- calcium influx which causes depolymerisation of the F actin present between the acrosome and sperm head plasma membrane
Obstruction gone: acrosome has room to expand and does so

Increased calcium also leads to increased cAMP and increase in pH from 7.1-7.5

68
Q

Steps of gamete fusion

A

1) after penetration of zona pellucida, spermatozoon lies tangential to oocyte surface. Oocyte microvilli envelop sperm head
2) sperm oocyte binding (binding involved adhesion molecules)

3) specific areas on egg surface are rich in integrins to allow binding in correct areas
4) spermatozoon sinks into oocyte - a zygote formed

69
Q

Post fusion events

A

1) at fertilisation, oocyte is still arrested in second meiotic metaphase (M phase)
2) a rise in Ca++ after fusion leads to exit from M phase
3) one set of chromosomes is dispatched as the 2nd polar Body
4) the other half set of 23 unpaired chromosomes remain behind in the female pro nucleus and can unite with the 23 paternal chromosomes of the penetrating sperm

Gynogenic triploidy is avoided by dispatching the second polar body

70
Q

Avoidance of triploidy

A

If the exiting second polar body encounters the entering spermatozoon there can be mutual interference and all 3 haploid sets of chromosomes remain inside. This triploidy results in fetal death
To avoid this:
Spermatozoa do not bind to oocyte membrane immediately overlying the second metaphase spindle
This ensures avoidance of encounter between the exiting second polar body and the entering sperm

71
Q

Prevention of polyspermy

A 
1) changes in electrical activity or membrane potential of zygote leads to a Ca++ wave from point of sperm entry. 
Ca++ released from internal stores (lasts 2-3 mins) 
Ca spikes (1-2 min duration, every 15 min)

Leads to cortisol reaction

  • release of cortisol granules into perivitelline space
  • enzyme cleaves ZP2 and hydrolyses binding region of ZP3

ZP2 and 3 no longer available for further sperm binding

72
Q

What is aneuploidy

A

An abnormality in number of chromosomes by loss of duplication
Loss: lethal
Extra: trisomy
Trisomy 21 = Down’s syndrome

73
Q

What is parental imprinting

A

Packaging of chromosomes in egg or sperm can influence the organisation of genes and their ability to become transcriptionally active. This epigenetic imprinting is important

Genes affected in spermatogenic lineage may differ from oogenetic lineage
To be fully functional some genes require both parental imprints

74
Q

Function of cervix

A

Fibrous ring that holds the baby in during the pregnancy

75
Q

Mechanism of cervical dilation

A 
Upper segment (smooth muscle) contracts 
Lower segment (collagen) passively dilates
76
Q

Mechanisms of labour

A 
Flexion 
Descent in the transverse position 
Internal rotation (shoulders enter inlet) 
Delivery by extension 
External rotation / restitution (shoulders enter outlet) 
Anterior shoulder 
Posterior shoulder 
Body delivers like a fish
77
Q

Influence of pregnancy hormones on maternal physiology and anatomy

A

Progesterone (corpus luteum and then placenta) 200mg / day by late pregnancy
Oestrogen : cooperation of placenta + fetus

78
Q

What are the pregnancy hormones

A

Placental prolactin : for breast changes and behavioural changes
Placental lactogens for maternal insulin and glucose metabolism, lipolysis and erythropioesis
Corticotropin releasing hormone from placenta leads to increased secretion of cortisol in mother. Stress response
Aldosterone (plasma volume)
Erythropoietin (red blood cells)

79
Q

What is aortocaval compression

A

From mid pregnancy the enlarging uterus compresses both the inferior vena cava and the abdominal aorta when the patient lies supine

Compression of inferior vena cava: reduces venous return to the heart, resultant fall in BP may be severe enough for mother to lose consciousness
Compression of the aorta: reduction in uteroplacental and renal blood flow
During last trimester maternal kidney function is lower in supine than lateral position
No women should lie supine in late pregnancy

80
Q

Anatomical changes to kidneys

A

Enlarge due to increased vasculature
Renal parenchymal volume increase in pregnancy, glomerular diameters are greater
There is dilatation of the calyces, renal pelvic and ureter (caused by progesterone and local pressure effect) increases chances of urinary tract infection
Bladder loses tone: increased urinary frequency

81
Q

Changes in handling of glucose in pregnancy

A

Amount of glucose in urine = amount of glucose filtered through the glomerulus minus the amount re absorbed by the proximal tubule

In non pregnancy: glucose can move freely across glomerular filter. Is reabsorbed leading to almost glucose free urine

In pregnancy: filtration fraction declines but increased renal flow means at any one time there is mroe glucose in the filtrate. The filtered load of glucose rises in pregnancy and exceeds maximal rate of reabsorption so urine is not glucose free

82
Q

Risk for pregnant women of having excess glucose in the urine

A

Increases chances of UTIs

83
Q

Maternal glucose homeostasis

A

Fetus has little capacity for glucoenogenesis, gets all glucose from mother
Glucose readily crosses placenta

This + increased glucose excretion should create a glucose deficit in mother.

84
Q

How do glucose levels revert from normal to mid pregnancy

A

Progesterone increases maternal appetite and stimulates deposition of glucose in fat stores. There is increased insulin secretion which favours lipogenesis

Mid pregnancy onwards:

  • increased absorption of glucose from gut
  • increased maternal gluconeogenesis
  • mobilisation of free fatty acids and lipolysis
  • enhanced lipolysis
85
Q

How does fetus avoid maternal rejection

A

Placenta is a structural barrier stopping direct contact of maternal blood with the fetus
Fetus has major histocompatibility antigens, but placenta, specifically the surface of the syncytiotrophoblast does not so acts as immunological barrier

86
Q

What is the next step if a smear test sample tests positive for high risk human papillomavirus

A

Examine the sample cytologically

To look for any signs of dyskaryosis (cells with abnormal nuclear changes)

87
Q

Why does GFR increase in pregnancy by 30-60%

A

Hormonal changes during pregnancy cause increased blood flow to the kidneys and altered autoregulation, causing GFR to increase through reductions in net glomerular oncotic pressure and increased renal size

88
Q

What is a common risk factor for ectopic pregnancy

A

Pelvic inflammatory disease due to damage of the tubes

Previous ectopic pregnancy

Endometriosis

IUD

IVF

89
Q

What is a threatened miscarriage

A

The fetus is alive but bleeding has occurred

Uterus is the size expected from the dates given and the cervical os is closed only 25% of cases will go on to miscarry

90
Q

Why does multiple gestation lead to hyperemesis gravidarum

A 
Intractable vomiting 
Dehydration 
Weight loss 
Ketonuria 
Multiple gestations cause increased levels of BhCG, this leads to hormone imbalances which increase vomitting

Med 3 (10 decks)

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