Phys and Pathophys OBGYN Flashcards
1
Q
Describe the FUNCTION of the hypothalamic-pituitary-ovarian cycle
A
Development of sexual characteristics
Coordinating regular periodic body changes
Ovarian Cycle
Uterine Cycle
Plays a role in cervix, vagina, breast function
Maintenance of pregnancy
2
Q
Describe the MECHANISM of the hypothalamic-pituitary-ovarian cycle
A
GnRH by hypothalmus in pulsatile action
FSH and LH made from anterior pitutary
Go to theca (outside) and granulosa cells (inside) called folliculogensis
Dormant until ovulation!
3
Q
What is the sexual the function of FSH and LH
A
estrogen and progesterone
4
Q
What does the estrogen do
A
E = endometrium
tells endometrium to grow (like fertilizer)
stops body hair growth
help libido
thickens vaginal wall
acne formation (because of secretion)
reduced athersclorosis and cholestrol
5
Q
Why do women have lower chance of heart disease?
A
Estrogen reduces atherosclosis by breaking down cholestrol deposits
6
Q
What does progesterone do?
A
P= PREGNANCY
decreases contraction of the uterus (allows growth of the fetus)
promotes breast development
when it decreases, it triggers menstrual flow and also produces milk (so you can lactate after baby is born)
7
Q
What do activins do vs Inhibins
A
Activins = Stimulate FSH and WBC
Inhibins = blocks FSH
8
Q
Follistatins
A
binds and inhibits activins
9
Q
relaxin
A
relaxes everything so that the fetus can grow
10
Q
What does high level of estrogen do
A
increases release of GnRH and LH
11
Q
What does high levels of activin do?
A
promotes gonadotropic cell function
12
Q
Pathologic HPO axis examples
A
Hypogonadism
Polycystic ovarian syndrome (PCOS)
Hyperprolactinemia
Medications (Steroids, Hormones, Opioids)
Weight status
13
Q
Why does weight status affect HPO axis?
A
Excess adipose tissue = more estrogen which can lead cancer even
14
Q
What influences puberty onset?
A
Weight and nutritional status
Genetic factors (sometimes there is familial delay of puberty)
Abnormal hormone levels
15
Q
Adrenarche
A
not technically puberty, but just increase secretion of adnreal adrongens
16
Q
Explain the 2 parts of thelarche and what it is
A
Breast development
FIRST event of puberty in females
Estradiol (estrogen) - duct growth
Progesterone - lobule and alveoli growth
17
Q
After thelarche, what is the next stage?
A
development of pubic and axillary hair
Second event of puberty in females
18
Q
What is menarche
A
first menstrual cycle
Typically anovulatory for first 12-18 monhs
19
Q
What is the length of a normal menstrual cycle
A
28 days +/- 7 days
20
Q
How long does normal menstrual flow last and how much flow?
A
3-5 days
totaling 30 mL of blood loss
21
Q
When are periods irregular
A
Onset and offset
~ 1-2 years after menarche
~ 2-3 years preceding menopause
22
Q
follicular phase
ovulation
luteal phase
A
development of follicle
ovulation = kicking out egg
luteal phase = what the egg does
23
Q
What is the first phase of menstrual cycle?
A
FIRST PHASE
Early in cycle - rise in FSH > rise in LH (because we are trying to develop follicles)
this is the phase that can vary in length
24
Q
How does FSH promote negative feedback?
A
FSH causes production of inhibin B
inhibin B decreases release of FSH later in follicular phase
25
What happens to follicles as they grow?
1 follicle grows very rapidly, becoming dominant follicle
Other follicles regress to become atretic follicles
at day 6
26
What happens as the dominant follicle matures?
LH takes over!
As dominant follicle matures…
Develops LH receptors
Releases estrogens
LH leads to:
Rising estrogen levels → increased GnRH pulses → LH surge → ovulation
27
Explain the midcycle of ovarian cycle
Midcycle - approximately day 14
Mature follicle ruptures (VIOLENT)
Ovum → extruded in abdominal cavity → transported into oviduct
Corpus hemorrhagicum - ruptured follicle fills with blood
Mittelschmerz may occur (which is stingy pain)
28
What is Mittelschmerz?
Stingy pain that is subjective and seen in
29
What is the most strict time-dependent process of the ovarian cycle?
Luteal phase
strictly 14 days
30
Describe the luteal phase
Corpus Luteum - granulosa and theca cells of follicle lining proliferate to form yellowish, lipid-rich luteal cells
Reacts to LH by making progesterone and estrogen
Rising levels of estrogen and progesterone → negative feedback → decline in FSH and LH (because we are done making follicles)
big dominant structure that goes away after a few days after being shed d/t declining levels of progesterone
31
what is the first phase of the UTERINE cycle
proliferative phase
Preovulatory - varying length
At end of menses, all but the deep layer of the endometrium has sloughed - stratum basale
Days 5-16
Estrogen from developing follicles → endometrium regenerates from deep layer
Forms the stratum functionale (outer ⅔)
Uterine glands lengthen but do not become convoluted or secrete anything
sort of like throwing up the walls of a house with insulation but no one is in the house yet
32
What is the secretory phase?
day 14
fixed length
estrogen and especially progesterone is released
33
What does progesterone do?
Stops the building of walls, but adds decoration
dilates blood vessels allowing more blood flow
34
proliferative vs secretory phase imaging
proliferative = straight tissue that is not functioning
secretory phase = coiled tissue
35
which hormone causes ovulation?
LH
36
Function of the cervix
Barrier of external environment (vagina) from internal environment
37
Does the cervix shed? What is it's function?
No
Cervical mucus is acidic though to stop sperm from being hospitable - which thins at the time of ovulation (day 14)
38
What is the function of progesterone for the cervix?
highest one week after ovulation (so day 21)
mucus becomes thick, and this remains during ovulation and pregnancy to house egg
39
What do you wanna see with mucous under microscope?
Some ferning but not too much
40
What is the epithelium of the cervix?
Columnar epithelium (extends from endocervix to ectocervix) allows it to look a little spotty early in women development. Eventually scars and then turns to squamous epithelium.
estrogen keeps columnar cells alive - which can be more vulnerable than squamous
41
What lines the fallopian tube and what stimulates this and what reduces this?
cilia
ciliary beat increased by estrogen and decreased by progesterone
42
What does progesterone d/t blood sugar?
Boosts it
think preggo = more need for sugar
43
What does estrogen and progesterone d/t skin
increases pigmentation
maintains skin collagen
increases hair growth (which is why patients)
44
what does progesterone d/t fat?
fat gain in preggo
45
What happens to organs when pregnant?
All compressed
46
Explain the CV changes in pregnancy?
Heart changes size and shape by 12% (muscle mass and volume)
PMI shift laterally d/t heart moving out of the weigh
47
What is supine hypotension syndrome? What is a risk factor for this?
Laying down compresses the IVC
seen in 10%
hypotension/bradycardia/syncope
later in pregnancy = more mass compressing
48
What happens to SV and HR during pregnancy?
Both increase
HR should not decrease more than 15 BPM above baseline though . Can be increased further by heat.
CO increases because it is HR x SV
49
Does SV and HR reverse after pregnancy?
Most of the time
but if it does not, it can lead to cardiomyopathy
50
what happens to arterial presssure in pregnancy?
dilates and lowers d/t having to contain more blood
pulse pressure increases
51
what happens to LE venous pressure in pregnancy
uterus compresses iliac valves d/t baby being there
52
What happens to peripheral vascular resistance
decreases due to enhanced vasodilation
53
What happens to blood flow distrubtion in pregnancy?
Increased to uterus and breast and skin (all stretching and growing)
54
In addition to uterus, skin, and breast, where does blood flow increase?
Kidneys d/t having to filter more blood
55
What type of murmur is seen in preggo?
systolic murmur in 90% of patients d/t heart pumping really hard
may also see sinus tachy, brady, PAC/PVCs
DO NOT WORRY if asymptomatic
EKG can even show Left axis shift and flattened T waves
56
What happens to capillaries of preggo?
Capillary dilation (can lead to nasal congestion)
57
What happens to rib cage of preggos?
rib cage opens up to make more space
58
What happens to lung volumes and capacity?
Less dead space and more tidal volume d/t rib cage
respiratory rate the same and minute ventilation increased by 50% (facilitated by the above)
needed because the
59
What happens to the renal system during preggo?
Hypertrophy of nephrons d/t hyperfilitration
Hydronephrosis (can lead to UTIs - further exacerbated by decreased immune system d/t not rejecting baby)
plasma flow increases 50-80%
renal artery and vein dilate
GFR increases d/t more blood flow
creatinine clearance increases even though there is more waste products
protein and glucose in urine (because the tubules can only reabsorb so much) should NOT be dramatic
Renin increases to increase fluid retention to increase blood volume and renal flow
60
What happens to GI system of preggo?
Increased salivation
gum hypertrophy from vasodilation (tooth health should not be compromised)
Intestines time decreases in 2nd and 3rd trimesters
gallstone risk increased d/t less
61
What causes acid reflux in preggo
progesterone relaxing smooth muscle of esophageal sphincters
62
What happens to the liver in preggos?
Blood dilutes leading to decreased albumin and calcium (because calcium binds to albumin)
63
What happens to blood volume in preggo?
Increases by 50% due to RAS system
feel thirsty because of the RAS system
need more blood to send to the rest of the body and protects mom and fetus from hypotension d/t vasodilation - mom will also lose blood after baby allowing mom to survive delivery
64
What happens to RBC in women?
RBC increases by 33%
but still anemic because plasma increases by 50%
65
What happens to coagulation in preggo?
Procogulant due to decrease protein S and increase clotting factors
66
What happens to lupus during preggo?
Gets better d/t dampered immune system
67
What happens to the endocrine gland in preggo?
enlarges by 135% during normal pregnancy
GH increased
68
What happens to thyroid hormones in preggo?
Fetus does not have it, so 40-100% increase in thyroid hormone
69
What happens to hypothyroid moms?
hCG
low TSH can mask hypothryoidism
70
What happens to parathyroid in preggo?
decreased in 1st trimester but increased in 2nd and 3rd
leads to more calcium and more vit D which is needed
cortisol increases
71
What happens to eyes in preggo?
Increased thickness of the cornea d/t retaining fluid (which the rest of the body does)
leads to contact issues sometimes
sometimes see spindles in dilated eye exam
mild blurry vision and contacts might not work
72
What happens to skin pigmentation in preggo?
estrogen and progesterone leads to hyperpigmentation
linea nigra: dark line acro
melasma: melanocyte activity form brownish color on cheek (NOT red)
73
What is striae gravidarum?
Stretch marks (red at first d/t increased BF and white with time d/t scar tissue)
younger maternal age
family history
74
What is spider angiomas, palmar erythema, varicosities, nails,
brittle nails d/t nutritional demands
hair thickens and increases (body grew in extra hair and leads to hair loss postpartum)
75
What happens to desire to rest, appetite/thirst, and weight?
All increase
appetite and thirst actually increases even more during breastfeeding actually then being preggo
76
Desribe weight loss after preggo
5.5 kg after delivery
4 kg in next 2 weeks
no more after 2 weeks
greater weight loss in breastfeeding women
77
what happens to water metabolism?
Decreases leading to increased water retention leading to pitting edema in LE
78
What happens to carbohydrate and protein metabolism in preggo?
Mild fasting hypoglycemia
Postprandial hyperglycemia
Hyperinsulinemia and insulin resistance
Typically disappears after delivery
Protein Metabolism
Protein → 1 kg of weight gain
500 g - fetus and placenta
500 g - uterine contractile protein, breast glandular tissue, plasma protein, hemoglobin
79
What happens to electrolytes in preggo?
all decreased d/t increased plasma volume (Na+/K+/Fe2+Ca2+,Mg2+)
phosphate stays the same though
80
What is avg weight gain of preggo?
25-35 with normal BMI
even more with lower BMI
lower with higher BMI
81
What numbers should memorize involved in additional calories needed in preggo vs breast feeding?
additional 300 kcal/d during pregnancy
additional 500 kcal/d during lactation
82
what is the protein recommendation for preggo?
Protein
1 g/kg/day, plus 20 g/d in 2nd half of pregnancy
60-80 g/d in the average woman
Crucial for embryonic development
Lean animal, low-fat dairy, vegetable protein
83
What nutritional deficiencies are we worried about in preggo?
Calcium
Iron (supplement double)
Folic acid
B6
Vit C (sometimes)
make sure to use iodized salt
84
When should you take folic acid for preggo?
1 month prior to conception d/t neural tube development (0.4 mg)
up to 10x reccomendation if hx of neural tube defects
85
What is the role of the placenta
Release hormones and enzymes to maternal bloodstream
Transport of all fetal nutrients and metabolic products
Exchange of O2 and CO2 for fetal circulation
86
What is the DNA of the placenta?
Fetus DNA, but needs the blood from mom
87
What does the placenta do?
Eats into the mom's uterus and have sinuses that have open ended circulatory system and alveoli suck in the blood
88
What causes the mom to keep blood from draining 100% to the placenta?
uterine wall contraction
if this doesn't work it can lead to blood less in mom
if overactive, the preggo may be terminated
89
Does maternal and fetal blood mix?
NO
not until delivery
90
What produces hCG?
placenta
91
What substances do not cross placenta
Large molecular size or charge - minimal transfer
heparin and insulin
large electric charge
92
What is G1P0
G = 1 pregnancy
P = 0 deliveries
93
Weeks 1-4 of gestation
conception
Causes formation of a zygote
Zygote slowly divides → forms a small ball of cells known as the morula
Enters uterus 3-5 days after fertilization
mom has not had the period yet
Gradual accumulation of fluid between cells of morula → becomes a blastocyst
inner cell group → embryo
outer cell group → supportive tissues
Day 6-7 - blastocyst implants and invades the endometrium and myometrium
Day 10 - blastocyst is totally encased in endometrium
94
what becomes the placenta?
Outer cell group
chorionic villi → becomes placenta
95
What composes the inner cell group of the fetus?
Endoderm
Mesoderm
Ectoderm
96
Describe the endoderm, mesoderm, and ectoderm of the fetus?
Endoderm - innermost layer
Epithelial lining of multiple systems
GI, respiratory, endocrine, auditory, urinary
Mesoderm - middle layer
connective tissue - pericardium, peritoneum, pleura
muscle tissue, bone, most of the circulatory and GU systems
Ectoderm - outermost layer
Skin - epidermis, sweat glands, hair, nails
tooth enamel
“outer” epithelium - lining of mouth, nostrils and anus
nervous system
97
When is the blastocyst formed?
3.5 weeks
98
When do major development of organs occur?
Week 5
brain, spinal cord, heart, and GI tract
99
When do limb buds and heart begin to develop?
Week 6-7
100
What is used for energy early in developement?
Yoke sac
101
When do lungs and all essential organs begin to form?
8 weeks = lungs
by week 9 = all essential organs
102
What marks the end of the embryonic period and the start of the fetal period?
Week 10
Also FHT audible by doppler US
103
When can you determine the gender of the fetus?
week 11-14 is when you can visualize the external genitalia on US
also RBC, urine, and ossifications at this stage
104
When is lanugo developed
(probably don't need to know)
15-18
just growing
105
What is the midpoint of pregnancy?
20 weeks
106
What is noticed at weeks 19-21 of fetal development
hearing
fluttering/movement
107
What is the threshold of survivability of fetus?
20-26
25-26 sees major fetal survivability
108
What is seen in week 26?
hand startle reflex
109
What is seen in weeks 27-30?
surfactant development
110
What happens during weeks 31-42?
Chunking up
just getting bigger and fatter and store iron and such
111
When is biggest risk of fetus of toxins/insult?
Pretty much every risk factor is EARLY in pregnancy
this is because the organs are more independent further a long
112
What is needed for a functional male GU tract?
Functional Y chromosome
113
when are major anomalities of Gu structures?
During weeks 4-8
114
What does the Y chromsome do?
Has TDF which tells gonad to make testis rather than ovary
remember, you default female
115
what develops ducts in male?
antimüllerian hormone → suppresses “female” Müllerian (paramesonephric) ducts
testosterone → persistence and differentiation of “male” Wolffian (mesonephric) ducts
116
What is agonadism vs agenesis?
agenesis - gonad did not form at all
agonadism - gonads formed initially and later degenerated
117
What is streak gonads
primordial gonadal formation
no differentiation → lacks germ cells
118
what two other gonadal abnormalities may you see?
May have release of antimüllerian hormone without any production of testosterone - suppresses both ducts
May see ectopic gonadal tissue
119
what is vaginal agenesis, ateresia, septa, and rectovaginal fistula?
Vaginal agenesis - rare - 0.025%
Vaginal atresia - lower portion is only fibrous tissue
Vaginal septa - transverse (blind vaginal pouch) or longitudinal (surgically fixed)
Can have imperforate hymen
May see rectovaginal fistula
120
What does the wollfian/Mesonephric Ducts develop into for male?
Epididymis, ductus deferens, ejaculatory ducts
Vestigial remnant - appendix epididymis
requires presence of gonads (testes)
121
What happens to Müllerian/Paramesonephric Ducts for male?
regresses but may persist as appendix testis
122
What does the wollfian/Mesonephric Ducts develop into for female?
Wolffian/Mesonephric Ducts
Mostly regress
Small portion becomes trigone of bladder
123
What happens to Müllerian/Paramesonephric Ducts for female?
Müllerian/Paramesonephric Ducts
Ductal differentiation does not require ovaries
Midline fusion → uterus
Distal ducts → oviducts
Does not significantly descend in abdomen
Can manifest with complete or partial absence of uterine tube or many possible problems with fusion
124
What are some external abnormalities of the female external Genitalia?
Labia Majora/Minora
Fusion → tissue separation failure or inflammatory reaction
May be hypertrophic or hypoplastic
Clitoris
agenesis - atresia or lack of genital tubercule formation
bifid /double - failure of fusion
hypertrophy - in intersex disorders
Perineum (Male/Female)
Imperforate anus
Anal stenosis
Anal agenesis with fistular ectopic anus
125
What happens to ducts in female and male
female does not need influence
male DOES
