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Physiology Flashcards

1
Q

Describe the follicular phase of the ovarian cycle

A

The follicular phase is dominated by FSH released by the pituitary in response to GnRH

This stimulates egg development so that follicles ready to be released

Mid-cycle; rise in oestrogen causes LH surge which causes egg to be released and ovulation to occur

Follicle releases egg and becomes corpus luteum

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2
Q

Describe the Luteal phase of the ovarian cycle

A

Follicle becomes corpus luteum which starts to release hormones; oestrogen and progesterone

Initially following LH surge oestrogen drops (-ve feedback) but then corpus luteum begins to release it

Progesterone makes the endometrium receptive to egg implantation

If this does not happen then a period will occur

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3
Q

Describe the uterine cycle

A

Day 0 = period starts with vasoconstriciton of vessels and breakdown of endometrium

Menses leads into proliferative phase where oestrogen starts to repair endometrium; thickening and development of gland crypts

Ovulation occurs and progesterone released which leads into secretory phase; making endometrium receptive to implantation of fertilised egg

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4
Q

What is the difference between the ovarian cycle and uterine cycle?

A

Ovarian cycle is in terms of hormones and egg production

Uterine cycle is in terms of the endometrium

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5
Q

What is the role of GnRH in female reproductive system?

A

From hypothalamus

Stimulates LH and FSH secretion from anterior pituitary

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6
Q

What is the role of FSH in female reproductive system?

A

From anterior pituitary

Stimulates follicular recruitment and development

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7
Q

What is the role of LH in female reproductive system?

A

From anterior pituitary

Maintain dominant follicle, induce follicular maturation and ovulation, stimulate CL function

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8
Q

What is the role of oestradiol in female reproductive system?

A

One of the oestrogens (strongest of the three)

  • supports female secondary sexual characteristics and repro organs
  • negative feedback control of LH and GnRH
    EXCEPT for late follicular phase (positive control LH surge)
  • Stimulates proliferative endometrium
  • negative control of FSH
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9
Q

What is the role of progesterone in female reproductive system?

A

From corpus luteum

  • maintains secretory endometrium
  • -ve feedback control of HPO
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10
Q

What are the systemic effects of oestrogen?

A
  • protein, carbohydrate and lipid metabolism
  • water and electrolyte balance
  • blood clotting
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11
Q

What are some targets for oestrogen?

A 
CNS
Anterior pituitary 
Fat distribution
Mammary gland
Bone maturation and turnover
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12
Q

Describe oogenesis

A

Oognium are stem cells in ovaries; undergo mitosis to produce primary oocytes shortly or after birth

Meiosis starts but arrested in prophase I

Group primary oocytes hormone responsive each cycle; one completes meiotic division and releases haploid secondary oocyte

Extra genetic material becomes polar body

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13
Q

Describe sperm production

A

Occurs in testis; seminiferous tubule

Germ cells produce sperm

Sertoli cells support sperm producing cell and produce inhibin

Interstitial leydig cells produce testosterone

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14
Q

What does FSH control in males?

A

induces spermatogenesis in seminiferous tubules of testis

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15
Q

Wha does LH control in males?

A

Induces leydig cells to produce testosterone

Testosterone acts on sertli cells to support sperm developing cells

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16
Q

Describe the normal process of ejaculation

A

Sperm created in testis

Travels through vas deferens to urethra

Seminal vesicles and prostate create semen which is carried along with sperm to urethra

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17
Q

Describe the lifespan of spermatozoa

A

Produced from puberty throughout life

About 30million per day

60-75 days for sperm production

10-14 days for transport to epididymis

20-100million released per ml of ejaculate

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18
Q

What factors can affect oogenesis/spermatogenesis?

A

Problem with hormonal control i.e. genetic, tumours, meds, functional

Problem at site of production i.e. genetic, cancer treatment induced, surgery, trauma, infections

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19
Q

What changes occur in the breast during pregnancy?

A

Increased size and vascularity; warm, tense and tender

Increased pigmentation areola and nipple

Secondary areola appears

Montgomery tubercles appear on areola

Colostrum-like fluid can be expressed from end of third month

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20
Q

What are postpartum CV changes?

A

Return to normal by 3 months (mostly)

BV decreases by 10% post-partum

BP initially falls then increases again days 3-7 (pre-preg levels by 6 weeks)

HR returns pre-preg over two weeks

CO increases by up to 80% 1st hr post delivery then continues to fall over next 24hrs

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21
Q

Describe changes in the respiratory system during pregnancy

A

Significant increase in O2 demand

40-50% increase in minute ventilation

Raised TV, relatively normal RR

Decreased functional residual capacity

Reduced PCO2

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22
Q

Describe renal system changes in pregnancy

A

Dramatic dilation urinary collecting system; more pronounced on right

Increased renal plasma flow

Raised GFR

Creatinine clearance raises by up to 50%, so creatinine reduced

Protein excretion raised, glycosuria common

Microscopic haematuria may be present

80% women develop oedema

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23
Q

What haematological changes occur in pregnancy?

A

Plama vol increases

Reduced hg, hcrit,

Increased rcc but this is diluted by plasma

Reduced platelet count

2-3 fold increase in Iron requirement

10-20 fold increase in folate requirement

WCC increases

HYPERcoaguable

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24
Q

What is the definition of normal labour?

A

Process in which foetus, placenta and membranes are expelled via birth canal

Spontaneous, 37-42 weeks gestation

Foetus presenting by vertex

Results in spontaneous vaginal birth (SVD)

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25
Q

Describe the initiation of labour

A

Triggered by paracrine and autocrine signals generated by maternal, foetal and placental factors

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26
Q

What physiological changes must occur to allow expulsion of foetus?

A

Cervix softens

Myometrial tone changes to allow co-ordinated contractions

Progesterone decreases whilst oxytocin and prostaglandins increase to allow for labour to initiate

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27
Q

Describe stage I of labour

A

Latent first stage

  • established first stage
  • complete when cervix is fully dilated
  • length of established first stage of labour varies
  • anticipated progress 0.5-1 cm per hour
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28
Q

Describe stage II of labour

A

From full cervical dilation to birth of baby

Passive second stage and active second stage

Primagravida birth would be expected within two hours of active second stage

Multigravida birth would be expected within one hour of active second stage

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29
Q

Describe stage III of labour

A

Time from birth to expulsion of placenta and membranes

Active management of third stage OR Physiological management of third stage

Prolonged third stage if it is not completed within 30 mins of birth with active management or 60 mins of birth with physiological managment

30
Q

How do you check progression and monitor labour?

A
  • maternal observations
  • abdominal palpation
  • vaginal examination
  • monitoring of liquor
  • auscultation of fetal heart
  • palpation of uterine muscle contractions

EXTERNAL SIGNS; rhomboid of Michaelis and anal cleft line

31
Q

Describe the mechanism of labour

A
  • descent
  • flexion
  • internal rotation of head
  • crowning and extension of head
  • restitution
  • internal rotation of shoulders
  • external rotation of h head
  • lateral flexion
32
Q

What are indications for induction of labour?

A
  • Diabetes
  • Failure to start labour
  • Overdue Term + 7 days
  • maternal health problem necessitating planning of delivery i.e. on DVT treatment
  • foetal reasons eg. growth concerns
33
Q

What does induction involve?

A

An attempt to instigate labour artificially using medications and/or devices to “ripen cervix” followed usually by artificial rupture or membranes

Vaginal prostaglandin pessaries or balloon can be used to open cervix

Bishop’s score is used to clinically assess the cervix - score 7 or more means ready for amniotomy

Once amniotomy performed, IV oxytocin can be used to achieve adequate contrations

34
Q

What is Bishop’s score?

A

Used to clinically assess the cervix

Determined by dilation, length, position, consistence, station

35
Q

What is amniotomy?

A

Artificial rupture of waters

36
Q

Describe some problems with powers (contractions) in labour

A

Inadequate progress

  • cephalopelvic disproportion
  • malposition
  • malpresentation
  • inadequate uterine activity
  • other reasons for obstruction i.e. ovarian cyst

Foetal distress

37
Q

How is progress monitored in labour?

A

Cervical effacement, cervical dilatation, descent of foetal head through maternal pelvis

38
Q

What is moulding?

A

Where sutures cross over one another

Can occur due to cephalopelvic disproportion

39
Q

Describe position in labour

A

The position of the baby’s head in reference to the mother’s symphysis pubis

40
Q

What is a CTG?

A

Cardiotocography

Continuous monitoring of baby’s heart beat

41
Q

In what situations should you advise not to labour?

A

Obstruction to birth canal; major placenta praevia, masses

Malpresentations; transverse, shoulder, hand, breech(?)

Medical conditions where labour would not be safe for woman

Specific previous labour complications; previous uterine rupture

Foetal conditions

42
Q

What can be used in assisted/instrumental delivery?

A

Accounts for around 15% of births

Forceps
Vacuum extraction

43
Q

What are some 3rd stage complications in labour?

A

Retained placenta

Post-partum haemorrhage; 4 Ts tone trauma tissue thrombin

Tears; graze, 1st-4th degree

44
Q

What are some common post-partum problems?

A

All women 6 week post-natal check at GP

  • problems with infant feeding
  • problems with bonding
  • social issues (partner, other children, financial)
45
Q

What is the “puerperium”

A

The post partum period

from birth - 6 weeks after

46
Q

What hormone do trophoblast cells produce?

A

B-hCG

Beta human Chorionic Gonadotropin

47
Q

What is the target and function of B-hCG?

A

Target is corpus luteum in ovary

Function is to stimulate corpus luteum to produce progestogen which stops decidua from shedding

This hormone forms the basis for pregnancy tests

48
Q

Describe analgesia in labour

A
  • breathing, massage, TENS, paracetamol, dihydrocodeine
  • water
  • Entonox (inhaled)
  • Opioids
  • Remifentanil patient controlled analgesia
  • Epidural

CONSIDER; Maternal position and mobility can also affect pain

49
Q

Define infertility

A

An inability of a couple to conceive after 12 months of regular intercourse without use of contraception

50
Q

What is the chance of conception?

A

> 80% couples in general population will conceive within 1 year is woman under 40 and do not use contraception whilst having regular intercourse

Of those that don’t conceive in first year, about half will in second year

51
Q

What is considered at an infertility consultation?

A

Are eggs available?

Are sperm available?

Can they meet?

Can embryo implant?

52
Q

What female history is considered at infertility consultation?

A
  • duration of infertility
  • previous contraception
  • fertility in previous relationships
  • previous pregnancies and complications
  • menstrual history
  • medical and surgical history
  • sexual history
  • previous investigations
  • psychological assessment
53
Q

What female examination is important in an infertility consultation?

A
  • weight
  • height
  • BMI
  • fat and hair distribution
  • galactorrhoea
  • abdo exam
  • pelvic exam
54
Q

What do we look for on pelvic examination?

A 
Mases
Pelvic distortion
Tenderness
Vaginal septum
Cervical abnormalities

Fibroids

55
Q

What baseline investigations are carried out at infertility consultation?

A

Female partner

  • rubella immunity
  • chlamydia
  • TSH
  • if period regular; mid luteal progesterone
  • if period irregular day 1-5 FSH, LH, PRL, TSH, testosterone

Male partner
- semen analysis

56
Q

How are suspected tubal and uterine abnormalities investigated?

A

Women without co-morbidities i.e. PID, previous ectopic, endometriosis

Offered Hysterosalpingography (HSG) to screen for tubal occlusion

Less invasive and more efficient use of resources than laparoscopy

57
Q

What is important to consider in the male history at an infertility consultation?

A

Developmental

  • testicular descent
  • change in shaving freq
  • loss body hair

Infections

  • mumps
  • STDs

Surgical

  • varicocele repair
  • vasectomy

Previous fertility

58
Q

What examination of male is considered at infertility consultation?

A
  • weight
  • height
  • BMI
  • fat and hair distribution
  • abdominal and inguinal exam
  • genital exam; epididymis, testes, vas def, varicocele
59
Q

Describe varicocele

A

Dilation of pampiniform plexus of spermatic veins in scrotum

Affects semen parameters including low sperm concentration

Surgical varicocele treatment will not improve pregnancy rate

60
Q

Describe Klinefelter syndrome

A

One of most common causes of primary hypogonadism with impaired spermatogenesis and testosterone deficiency

Characterised by sex chromosome aneuploidy with extra X being most frequent

Often very small testes and almost always azoospermia

61
Q

Describe group I ovulatory disorders

A

Hypothalamic pituitary failure

i.e. hypothalamic amenorrhoea or hypogonadotrophic hypogonadism

Can improve chance of pregnancy by raising BMI if <19, moderating exercise levels if do a lot of exercise

Offer pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins with LH to induce ovulation

62
Q

Describe group II ovulatory disorders

A

Hypothalamic-pituitary-ovarian dysfunction

Predominantly Polycystic ovary syndrome

63
Q

Describe group III ovulatory disorders

A

Ovarian failure

64
Q

Describe polycystic ovary syndrome

A
  1. Androgen excess; clinical (hirsutism), biochemical (testosterone)
  2. Infrequent periods; anovulation
  3. Polycystic ovaries; US
65
Q

How can ovulation be induced?

A

Clomiphene; blocks oestrogen receptors in AP to increase FSH secretion

Gonadotrophins; risk of multifollicular recruitment and thus multiple pregnancy, monitoring scans reduce risk

GnRH

66
Q

Describe clinical use of clomifene

A

Selective oestrogen receptor modulator for inducing ovulation

Monitoring;

  • follicle scanning in 1st cycle
  • 15% require dose adjustment

Side effects

  • vasomotor
  • visual
67
Q

What is hydrosalpinx?

A

When the fallopian tube (salpinx) is blocked by a watery fluid (hydro)

Should have surgery for this before IVF treatment as improves chances of live birth

Surgery is salpingectomy

68
Q

what are the types of Azoospermia?

A

Testicular

  • normogonadotrophic
  • hypogonadism
  • hypergonadotrophic

Post-testicular

  • iatrogenic
  • congenital
  • infective
69
Q

What is azoospermia?

A

medical condition where man’s semen contains no sperm

70
Q

What investigations are there for azoospermia?

A

History
Examination
FSH, LH, testosterone, Karyotype, PRL
CF screen

71
Q

What do you do for women with unexplained fertility?

A

Don’t give ovarian stim agents (i.e. clomifene)

Advise to try for total of 2 years before IVF will be considered

Offer IVF

Reproductive (11 decks)

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