PBL seen scenario 1 Flashcards
Metformin MoA and side effects
Decreases hepatic gluconeogenesis
Decreases intestinal absorption of glucose
Inhibits lipolysis
Increases muscle utilisation and uptake of glucose - increasing insulin sensitivity
Side effects: Nausea and vomiting
DURING PREGNANCY: crosses placenta but safe during pregnancy and breastfeeding (not teratogenic)
Antenatal schedule
Dating scan (8-14 weeks): Determine due date and screen for possible conditions - Down Syndrome, Edwards and Patau syndromes
20 week scan:
HIV, syphilis and hepatitis B screening
Detailed USS of baby (organ development)
Sex of baby
28 weeks:
Offer screening tests
Polycystic Ovarian Syndrome Pathophysiology
Insulin resistance –> hyperinsulinaemia –> increased androgen synthesis by theca cells
Hyperinsulinaemia reduces liver production of sex hormone binding globulin (binds to free testosterone) –> free testosterone might increase
Increased androgen synthesis by theca cells can increase LH secreted by anterior pituitary
Polycystic Ovarian Syndrome Diagnosis
Rotterdam criteria:
Hyperandrogenism, oligomenorrhea, polycystic ovaries on ultrasound
PCOS Blood screen:
Raised LH, normal fSH –> raised LH:fSH ratio (>3:1)
Glucose due to raised insulin resistance
Day 21 progesterone - should be high (ovulatory phase). Released by corpus luteum; low –> no ovulation
Differential Diagnoses:
Thyroid function test, prolaction levels, Cushing’s
Polycystic Ovarian Syndrome Presentation
Hirsutism and acne Acanthosis nigricans (due to insulin resistance) Central obesity Menstrual disturbance - Oligomenorrhea - Amenorrhea
Polycystic Ovarian Syndrome Treatment
Lose weight
Treatment:
- 1st line: Clomiphene - selective oestrogen receptor blocker (brain thinks oestrogen is low –> more fSH = ovulation)
- 2nd line: Metformin (combat insulin resistance)
Laparoscopic drilling - destroys androgen producing theca and granulosa cells
Injectable Gonadotropins (fSH)
COCP - restore menstrual regularity
Surgery to remove cysts
Anti-androgens - to treat acne/hirsutism
Polycystic Ovarian Syndrome Complications
Infertility
T2D
CVD
Pregnancy complications:
Increased risk of gestational diabetes (Pregnant with PCOS –> 24-28 week test for GD) pre-eclampsia, premature labour
How is risk measured
Incidence is used as a measure of risk
number of new cases (or deaths) per 100,000 people per year
Relative risk
Incidence of disease in exposure population / incidence of disease in unexposed population
What does 95% CI represent
95% of a sample relative risk contains the population relative risk with a probability of 95%
What is a confounder
A confounder is a factor that is associated both with the exposure and the disease
Adjusting for confounders:
RR for heavy drinkers dying from lung cancer compared to non-drinkers = 2
RR for smoking (heavy drinkers dying from lung cancer compared to non-drinker) = 1
Reasons for illegitimate association between exposure and disease
- Bias
- Recall Bias
- Selection Bias
- Reverse Causality
- Confounding
- Incorrect analysis
- Chance
- Causal
Bradford Hill Criteria for Causation
- Strength of association
- Dose response
- Time sequence
- Consistency of findings
- Similar studies on different populations
- Biological plausibility
- Coherent of the evidence: other types of studies
- Reversibility
How can consultations improve adherence
Patient-centred, decision making is shared
What is adherence influenced by
Illness perception, background beliefs, concerns (perceived needs)
Self-regulatory model of illness behaviour
Identify, time-line, consequences
Influences on beliefs
Medical establishment
family/friends
Culture
Media
Health belief model
Depends on perceived susceptibility/severity/benefits/barriers and cues to action and self-efficacy
Theory of planned behaviour
- Confidence in performing behaviour
- Intentions (important indicator whether people will take action), depends on attitude and subjective norm
Diagnosis of intrauterine growth restrictions and types
Diagnosis:
Lag in symphysiofundal height of 4 weeks or more –> symphysiofundal height should increase 1cm/week in weeks 14-32
Amniotic fluid 5-25cm range (<5cm = Oligohydramnios)
Types:
Physiological foetal growth
Symmetrical/type I IUGR
Asymmetrical/type II IUGR
Physiological foetal growth
Conception - 28 weeks:
hyperplasia (increase in number of cells)
Weeks 28 - 34:
hypertrophy (increase in size of cells)
Symmetrical/type I IUGR
Aetiology: Genetics, Infection, Multiparity
Inhibition of growth in hyperplastic stage –> baby has overall less cells
Head + abdo circumference, height, width, weight all below 10th percentile
NORMAL HC:AC Ratio (1)
Asymmetrical/Type II IUGR
Aetiology: anything that causes uteroplacental insufficiency (maternal hypertension, pre-eclampsia, vasculopathies, smoking, diabetes)
Inhibition of growth in hypertrophic stage –> normal cell numbers, but cell size reduced
foetus has to redistribute cardiac output = brain and heart receive normal flow at expense of splanchnic vessels –> small abdomen
Smaller foetal kidneys –> Oligohydramnios
REDUCED/normal HC:AC Ratio (< or = 1)
folic acid and metabolism
400mg/day 3 months before conception and till 12 weeks of pregnancy (to increase chance of conception/successful preg.)
Converted to 5-MTf –> required for re-methylation of homocysteine to methionine
Methionine converted to S-adenosylmethionine (SAM), methyl donor for DNA, neurotransmitter production
Lack of folate –> homocysteine build up, CVD risk
Lack of folate also causes B12 deficiency –> macrocytic anaemia
Types of Neural tube defects
Spina Bifida Occulta - some vertebrae don’t close –> exposed spinal column
Meningocoele - meninges bulge out and form a fluid-filled cyst coming out from gap in the spinal column
Myomeningocoele - SC + spinal nerve roots grow into the bulging cyst
Anancephaly - lack of skull vault –> exposed top part of brain
Causes of PV bleeding in early pregnancy
Implantation bleeding - 10-14 days after conception (could be mistaken as period)
Ectopic pregnancy (e.g. caused by PID)
Miscarriage
STI - chlamydia, gonorrhoea, herpes
Preparation for birth - mucous plug sometimes contains a bit of blood
Expected hormone levels during pregnancy
hCG levels double every 48-72 hours until peak at week 8-11, then falls
Oestrogen - steadily increases throughout
Progesterone - corpus luteum (early pregnancy) then placenta
- Luteal placental shift–> point when the corpus luteum no longer needed to make progesterone as placenta big enough to produce its own
Signs of miscarriage (spontaneous loss of pregnancy before 20th week)
Loss of foetal heartbeat on ultrasound
Decreasing hCG levels on blood test
Cervix dilation (pelvic exam), closed cervical OS
Woman experiences: cramping, spotting/bleeding, no more pregnancy symptoms (e.g. morning sickness)
Premature labour
Before 37 weeks
Tocolysis: delays preterm labour
Stress, uterine bleeding and twins
Complications:
Necrotising enterocolitis (breastfeed to lower risk)
Rotavirus
How do you calculate corrected age
Chronological/calendar age - number of weeks premature
e.g.
Born at 30wks, calendar age 28
40 - 30 = 10 weeks premature
28 - 10 = 18 (corrected age)
Signs and symptoms of labour
Regular contractions - interval of less than 10 mins
Mucus show plug
Water breaking
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)
Failure to progress
20+ hrs in 1st pregnancy
Otherwise 14+ hours
Give:
Oxytocin, misoprostol and surgery
Breech = forceps
Otherwise Ventouse
