OB test 1 Flashcards
Male infertility
Female infertility
Primary fertility
Secondary fertility
Risk factors for subfertility or infertility
Infertility treatments
infertility Patient education
Psychosocial aspects of infertility
Patient education for supporting fertility
Fundus
The uppermost, rounded part of the uterus, which contains the greatest volume of smooth muscle
Corpus
The main body of the uterus, located between the isthmus and the fallopian tubes
Isthmus
The area of the uterus between the cervix and the corpus, which has thinner, more narrow musculature
Cervical internal Os
The opening between the cervix and the body of the uterus
Cervical canal
The canal between the internal os and outer os
Outer cervical Os
The opening between the cervix and the vagina
interstitial fallopian tubes
The portion of the tube that travels through the musculature of the uterus
Fallopian isthmus
The portion of the tube between the interstitial and the ampulla
Fallopian ampulla
The distal portion of the tube, located between the isthmus and the infundibulum, where fertilization most often occurs
Fallopian infundibulum
The funnel-shaped part of the tube, located between the fimbriae and the ampulla
fallopian fimbriae
A fringe of tissue at the end of the fallopian tube, not attached to the ovary, that gently draws the ovum into the fallopian tube with a sweeping motion
Ovarian ligaments
A pair of ligaments attaching the ovaries to the uterus
Round ligaments
A pair of ligaments starting where the fallopian tubes join the uterus (the “uterine horns”) and ending deep in the pelvis. Stretching of these ligaments in pregnancy can cause pain.
Broad ligaments
A wide ligament connecting the uterus to the pelvis
Hypothalamic-pituitary-ovary axis (HPO axis)
regulates female reproductive cycle
Gonadotropin-releasing hormone (GnRH)
released from hypothalamus
What hormones are released from anterior pituitary in response to GnRH release?
LH and FSH
Follicle stimulating hormone (FSH)
primary hormone responsible for maturation of the follicles of the ovary that will release eggs for fertilization
Luteinizing Hormone (LH)
responsible for the final maturation and release of the egg from the follicle
-levels peak about 12-24 hours prior to follicle rupture (ovulation)
Luteinization
process of LH stimulating the ruptured follicle, free of it’s ovum
Corpus luteum
previously the follicle, now free of its ovum- produces large amounts of progesterone and smaller amount of estrogen
What is the function of progesterone secreted by the corpus luteum?
responsible for the secretory phase of the endometrial cycle- lining of uterus is nourished and maintained in the event of a fertilized embryo/implantation
When does the secretion of progesterone and estrogen from the corpus luteum start to lower?
one week after ovulation
What is triggered by the decreased progesterone and estrogen secretion after ovulation?
the hypothalamus produces GnRH- which triggers the anterior pituitary to release FSH and LH: restarts the cycle
(if a pregnancy doesn’t cue the continuation of the corpus luteum and endometrium maintenance)
estrogen
responsible for female patterns of fat distribution (including breasts), dominant in first 1/2 of menstrual cycle prior to ovulation, causes growth of endometrial lining after menstruation, contributes to maturation of ovarian follicles
progesterone
helps maintain uterine lining as well as relaxes smooth muscle of uterus to support implantation of pregnancy. Causes a small rise in body temp that occurs after ovulation- if it dips 2 weeks later, no pregnancy. A stabilized rise in temp after expected time of menstruation means pregnancy is likely.
Ovarian Cycle Phases
follicular phase and luteal phase
Follicular phase
prior to ovulation, as short as 8 days up to 21 days. (differences in menstrual cycle lengths is likely due to variations in this phase)
produces the Graafian follicle
Luteal phase
starts with ovulation and lasts for 12-14 days. (shortens with menopause) corpus luteum produces progesterone to make a healthy uterine environment. Corpus luteum starts to disintegrate after a week unless the ovum is fertilized within a 6-24 hour period
Graafian follicle
lined with granulose cells that produce progesterone after ovulation when it empties and becomes the corpus luteum.
enlarges and moves close to the capsule (outside the ovary)
What is the next step after fertilization of ovum?
after implantation, the pregnancy secretes HcG, which stimulates maintenance of corpus luteum until the placenta takes over the production of progesterone
What happens to the corpus luteum when it is no longer needed for progesterone production? (no fertilization occurred or the placenta took over)
it becomes scar tissue, called the corpus albicans
Menstrual cycle (uterine cycle)
time between the start of one menses to the start of the next (usually 21-35 days) (variations due to follicular stage differences)
-4 stages: menstrual, proliferative, secretory and ischemic
Menstrual stage
occurs when an ovum is not fertilized and the lining of the endometrium is no longer maintained by progesterone released by the corpus luteum.
-begins 12-14 days after ovulation
-illness and stress can impact the timing of menses
-only 10-80mL of blood loss over 2-7 days
proliferative stage
endometrial glands enlarge and the endometrium thickens in response to estrogen produced by the ovaries. Close to ovulation, the cervical mucus becomes particularly elastic with a consistency akin to egg white.
secretory stage
After ovulation, the endometrium is maintained by progesterone. Increased blood and secretions to the endometrium, as well as reduced contractility of the uterine smooth muscles, create a hospitable environment for implantation. If fertilization occurs, this process continues. If it does not occur, the final phase of the menstrual cycle, the ischemic phase, begins.
ischemic stage
begins as the corpus luteum begins to disintegrate, eliminating the source of progesterone. Vascular changes lead to necrosis and the breakdown of the endometrial lining, which sheds during menstruation, leaving behind the tips of the glands from which a new endometrium will grow.
gametogenesis
occurs via meiosis where 4 daughter cells are produced (haploid meaning each cell only has one set of chromosomes
pre embryonic stage
begins with conception and ends about 2 weeks later with establishment of fetal membranes
embryonic stage
8 weeks long.
implantation occurs, 3 germ layers differentiate, neural tube fuses and heart begins to beat, fetal blood type manifests at 6 weeks, head and tail fold inward, C shaped embryo, respiratory and GI tracts begin to form, as well as muscle/bone, epidermis, internal ear, thyroid.
limb buds appear, 4 chambered heart begins to arise until final form at week 6, outer ear and nose develop
sex differentiation begins in week 7, GI development, blood formation, first brain waves detected at week 8 and nerve fibers start to form.
zygote
fertilized egg, diploid
Primitive Streak
first trace of the embryo in a fertilized ovum, of a higher vertebrate
blastomeres
very small cells that together amount to a similar size to the original ovum
morula
12-32 very small cells that make up the pre embryonic mass, still residing in the fallopian tube. These cells remain in the zone pellucid layer of the ovum until implantation
-days 3-4
trophoblast
form the placenta and chorion.
-outer layer within the zone pellucida, which is filled with fluid (blastocoel)
- responsible for hatching from zona pellucida to allow for implantation
blastocyst
go on to form the embryo and the amnion
embryoblast
inner cell mass adherent to the surrounding trophoblastic ring
-implants on uterus wall between days 6 and 10 after fertilization
ectoderm
outer layer of embryonic disk forms 15-16 days after fertilization
-goes on to form PNS and CNS, epithelium, sinuses, anal canal, tooth enamel, eye lens and cornes, hair nails and much more. sweat, mammary and pituitary glands
mesoderm
middle layer of embryonic disk forms 15-16 days after fertilization
-goes on to form the dermis, skeleton and cartilage, smooth/striated and skeletal muscles, circulatory system: bone marrow, blood, heart, spleen and lymphatic tissue. Lidenys, adrenals, and GU systems
endoderm
inner layer of embryonic disk forms 15-16 days after fertilization
-goes on to form mucosal lining of GI and resp systems, endocrine organs (pancreas, liver, thyroid, and parathyroid), GI organs and urinary bladder
amnion
the inner layer embryonic membrane that arises from ectoderm and is smooth. Forms the amniotic cavity (day 10-12) the blastocyst is considered an embryo
Chorion
the outer embryonic membrane comes from trophoblastic cells. form projections called villi that eventually form the fetal portion of the placenta
at first, this is larger than its counterpart unit they merge to form the amniotic sac
yolk sac
develops at the same time as the embryonic membranes. very little nutrition contained here
Neural tube
develops into brain and spinal cord
-fuses at its center during week 3 and fusion concludes in week 4
fetal pole
earliest form of the embryo that may be visualized on ultrasound (5-6 weeks of pregnancy)
-most susceptible to teratogens and spontaneous abortion in the embryonic stage
fetal circulation
oxygenated blood moves from the umbilical vein to the inferior vena cava via the ductus venous (deoxygenated and oxygenated blood mix here). Blood then enters the right atrium, then directly through the foramen oval (normal opening between atria in a fetus) or follow through the typical route of circulation: tricuspid valve into right ventricle.
Blood is then pumped through pulm valve into the pulm artery. the ductus arterioles allows blood to be shunted between the palm artery and descending aorta to bypass the lungs. Oxygen poor blood leaves the fetal circulation via the umbilical arteries to return it the placenta.
Fetal stage
begins the ninth week after fertilization (11th week gestation), ends with birth
-vulnerability to teratogens declines significantly (besides the CNS- continues to change dramatically throughout pregnancy)
-rapid growth, refinement of organs and structures
placenta
grows from site where the blastocyst implants on the uterine wall- made of tissues from both the blastocyst and uterus
-parental side is formed by decidua basalis, fetal side is formed by chorionic villi and amnion
-mother and fetal blood don’t mix
-passive immunity (not universal: rubella, drugs, alcohol etc)
human chorionic gonadotropin (hCG)
produced by placenta, signals the corpus luteum of the follicle abandoned by the ovum to continue excreting progesterone and estrogen (for the sake of safe uterine environment)
-rises in early pregnancy, and doubles every 48-72 hours throughout embryonic stage until week 8 when it plateaus then drops.
-if this process doesn’t occur, chances of miscarriage are high
umbilical cord
contains one large vein and two smaller arteries
-wharton jelly surrounding the vessels
-2 vessel cords are associated with congenital abnormalities
Gravidity (G)
number of pregnancies- regardless of how it ended
Parity (P)
number of births
GTPAL
Gravidity, Term, Preterm, abortion, living children
Term (T)
all pregnancies that ended at or beyond 37 weeks (twins =1 pregnancy)
preterm
pregnancy that ended between 20-36 weeks 6 days
abortion
pregnancy ending prior to 20 weeks- both spontaneous and elective
Goals of preconception care
risk identification, patient education and interventions to mitigate those risk
Why is preconception care important?
First few weeks of pregnancy, are most critical (organ formation, etc) Early education and interventions is critical for healthy pregnancies, mom and neonate.
-decreased incidence of complications of pregnancy
Modifiable risk factors to identify during preconception care:
Medications they’re taking (teratogenic), optimizing treatment and control of chronic illnesses, substance use, BMI (18.5-30) prior to pregnancy, vaccination updates, nutrition (folic acid supplement 400-800 mcg/day), some environmental factors/teratogen exposure
What are some important aspects of the comprehensive health history at the first prenatal appt?
-Gyn hx: age of first menses, date of LMP, cycle length and regularity, STIs, gynecological surgeries and conditions.
-OB history: gestational age of deliveries, #, mode of delivery, location, outcome, sex of children, birth wt, length of labor, complications etc.
-Immunization hx
What labs are important during a first prenatal visit?
(individual to pt)
All: HIV, STI screening
Genetic carrier testing, A1C (diabetics),
Prenatal Education:
Risk factors based on their age, medication that are or aren’t safe to take during pregnancy, effects of substance use during pregnancy, impact of weight and nutrition
prenatal visits
Q4 weeks until 28 weeks gestation. 3rd trimester: Q2 weeks from 28-36 weeks. After that, weekly until patient goes into labor
First prenatal visit
-between 8-12 weeks gestation
-health hx obtained, s/s of pregnancy, then pregnancy is confirmed based on LMP or ultrasound.
-physical exam, labs obtained, UA
-patient teaching for keeping healthy during pregnancy, schedule next visit
2nd prenatal visit
limited exam and visit with provider, labs if needed (sequential screenings- for neural tube defects), more education
second trimester prenatal appointments
testing for gestational diabetes between (24-28 weeks)
weight, BP, fundal measuring,
quad marker screen (measures 4 maternal serum levels: alpha fetoprotein- for neural tube defects, hCG, unconjugated estriol, and inhibit-A), H&H or CBC, blood type and Rh (and antibody screen for Rh negative persons
-complete obstetric ultrasound 16-20 weeks gestation
glucose testing for gestational diabetes
occurs between 24-28 weeks
- 1 hour glucose challenge test (GCT)- no NPO requirement
-drink glucose solution (50g of carb dextrose), one hr later the BG is taken
-if BG > 130 serum, >140 finger stick)- pt is scheduled for 3 hr GTT
-for 3 hr GTT- pt must be NPO for night/morning before- blood drawn before drinking solution of 100g carb- BG is taken again 1, 2 and 3 hours after.
-IF pt BG is elevated in two or the four blood draws, they are diagnosed with gestational diabetes
Rh factor
If negative, antepartum Rho(D) immune globulin (Rhogam) is given to the patient to prevent isoimmuniztation (attacking baby’s blood) in next pregnancy if blood products are needed for the current pregnancy.
Normal maternal physical changes
n/v, increased frequency in urination, pelvic and back pain (due to spine curvatures), intermittent epigastric pain, dizziness (BG drop)
abnormal maternal physical changes
n/v that leads to dehydration and weight loss, dysuria, hematuria (UTI -> pyelonephritis), vaginal bleeding, temp >38.3, constant or strong abdominal pain (placental abruption, appendicitis, ro GI infection), frequent dizziness (anemia, dehydration, or cardiac condition), leaking fluid from vagina
