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ESA4 Old syllabus > Repro > Flashcards

Repro Flashcards

1
Q

How is the development of secondary sex characteristics controlled?

A

Hormones: gonadotrophins + testosterone/oestrogen and progesterone

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2
Q

Describe the migration of germ cells that occurs embryologically.

A

The germ cells arise in the yolk sac then migrate along the dorsal mesentery to the urogenital ridge to reside within the primordial gonad.

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3
Q

How does development of the primordial gonad into the adult gonads differ according to genetic sex?

A

In males, germ cells colonise the medullary region and the cortex region atrophies. The germ cells allow rapid growth of the definitive sex cords which they subsequently invade. In the adult these give rise to the seminiferous tubules. The orignial mesodermal somatic cells form Sertoli cels, Leydig cells develop between the sex cords.
In females, germ cells colonise the cortex and so the medullary cords do not develop. The germ cells become surrounded by somatic mesenchymal cells which will eventually form primordial follicles.

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4
Q

Why can female genitalia be considered the “default”?

A

The cortex of the primordial gonad will develop even if no germ cells arrive.

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5
Q

How are the female internal genitalia formed?

A

The Mullerian / Paramesonephric ducts grow medially towards each other formining the uterus and its tubes, cervix, fornices and upper 2/3 of the vagina. The rest of the vagina is formed from the sinovaginal bulbs from the vaginal plate which grows from the urogenital sinus.

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6
Q

What is the function of Mullerian Inhibitory Hormone (MIH) and what is it secreted by?

A

MIH suppresses the growth of the Mullerian / Paramesonephric ducts in the male. It is secreted by Sertoli cells.

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7
Q

What is the genotype of an individual with true hermaphroditism?

A

Mosaicism of XY and XX or XO

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8
Q

Describe the important features of pseudo-hermaphroditism.

A

Occurs in individuals with XY genotypes but where foetal genitalia are insensitive to testosterone. The testis are undescended in the lumbosacral region, no internal genitalia will be produced and the external genitalia will be female. Undescended testes have an increased risk of developing germ cell tumours.

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9
Q

What genitalia (internal and external) will develop in an XX individual with congenital adrenal hyperplasia?

A

Female gonads but both male and female internal genitalia will develop. External genitalia will be male.

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10
Q

Describe the descent of the testes.

A

Testes start in the lumbosacral region, they then move caudally, crossing the inguinal canal obliquely and an invagination into the scrotum develops to form the processus vaginalis. Around 9 months gestation the testes migrate over the pubic bone to enter the scrotum.

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11
Q

What is the fate of the gubernaculum?

A

In females the guberaculum becomes the ovarian ligaments that join each ovary to the uterus.
In males the guberaculum becomes the scrotal ligament.

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12
Q

What is hypospadia and how does it develop? What is it associated with?

A

Hypospadias are where the urethral opening is on the ventral surface of the penis, they form due to incomplete fusion of the urethral folds. They are always associated with descended testes and sometimes with micropenis.

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13
Q

What is uterus bicornis? How does it develop? What are the consequences of it?

A

Uterus bicornis is where the uterus is “heart shaped” due to incomplete fusion of the paramesonephric ducts. It may cause menorrhagia but fertility is usually unaffected.

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14
Q

Describe the 4 main steps required for gametogenesis.

A

Colonisation of the gonad
Proliferation by mitosis
Introduction of genetic variation by meiosis
Cytodifferentiation

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15
Q

How does meiosis introduce genetic variation? MGD

A

Crossing over when pairs of chromosomes become bivalent

Random assortment as chromosomes line up at metaphase

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16
Q

Where does spermatogenesis occur?

A

In the seminiferous tubules

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17
Q

What is spermiogenesis?

A

Spermiogeneisis is the cytodifferentiation of spermatids into spermatozoa (mature sperm cells)

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18
Q

When do males start producing sperm?

A

At puberty

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19
Q

What is the spermatogenic cycle?

A

The spermatogenic cycle is the time taken for the reappearance of the same stage of spermatogenesis within a given segment of a seminiferous tubule.

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20
Q

What is the spermatogenic wave?

A

The spermatogenic wave is the distance along the seminiferous tubule between cells undergoing the same stage of spermatogenesis.

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21
Q

Where is the majority (by volume) of semen produced?

A

The seminal vesicle

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22
Q

What is the function of secretions from the bulbourethral (Cowper’s) glands?

A

To help lubricate the distal urethra and neutralise any acidic urine present

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23
Q

What is the source of the energy needed by sperm?

A

Fructose within semen is used to form ATP

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24
Q

What do the prostaglandins in semen do?

A

To increase sperm motility and to cause smooth muscle contraction within the female genital tract

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25
Q

What processes are involved in sperm capacitation?

A

Removal of glycoproteins and cholesterol from the cell membrane and the activation of sperm signalling pathways (atypical soluble adenylyl cylase and PKA involved)

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26
Q

What is the acrosome reaction?

A

The acrosome reaction is the process by which polyspermy is prevented at fertilisation. It is triggered by the binding of proteins on the head if the sperm to ZP3 proteins of the zona pellucida and involves at Ca2+ wave.

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27
Q

What are oogonia?

A

Diploid immature female reproductive cells produced by differentiation of the primordial germ cells which later form oocytes

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28
Q

When do oocytes complete meiosis I?

A

In utero - between 3 and 7 months gestation

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29
Q

What cells surround the oocyte once it has become part of a primordial follicle?

A

Flat epithelial cells of gonadal origin

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30
Q

What happens during the pre-antral stage of the maturation of the ovaries?

A

Follicular cells become cuboidal and proliferate to form a stratified epithelium of granulosa cells

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31
Q

What happens during the antral stage of maturation of the ovaries?

A

Fluid filled spaces appear between the granulosa cells and coalesce to form the antrum. The granulosa cells left surrounding the oocyte are then called the cumulus oophorus. The stromal cells form the theca folliculi: the theca externa (outer fibrous layer) and theca interna (inner secretory layer).

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32
Q

When do oocytes complete meiosis II?

A

At fertilisation

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33
Q

What is the polar body?

A

Either of two small cells produced during the first and second meiotic divisions in the development of an oocyte, containing little cytoplasm and eventually degenerating.

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34
Q

What stimulates the formation of the Graafian follicle?

A

The rise in FSH and LH before ovulation

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35
Q

How is the oocyte extruded from the ovary during ovulation?

A

LH surge increases collagenase activity

Prostaglandins increase the response to LH and cause local muscular contractions of the ovarian wall

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36
Q

What is the name of the cells which develop from the ovarian follicle and produce oestrogen and progesterone?

A

Lutein cells

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37
Q

What happens to the ovarian follicle if fertilisation does not occur after ovulation?

A

It degenerates and forms a mass of fibrotic scar tissue known as the corpus albicans

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38
Q

What is the function of human chorionic gonadotropin?

A

To prevent degeneration of the corpus luteum so that progesterone continues to be secreted to support the pregnancy until placental secretion becomes adequate

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39
Q

After ovulation, how is the oocyte transported to the uterus?

A

Fimbrae sweep over the surface of the ovary as the Fallopian tube begins to contract rhythmically. The oocyte is carried into the tube by these sweeping movements and the motion of cilia on the epithelial lining. It is then propelled along the tube by peristalsis and the mucosal cilia

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40
Q

How does the hypothalamus communicate with the posterior pituitary gland?

A

Via impulses that travel through the hypothalmic neurons in the neural stalk

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41
Q

How does the hypothalamus control the anterior pituitary gland?

A

Via the release of hypothalmic hypophysiotrophic releasing hormones (eg GnRH) which reach the ant pituitary via the hypophyseal portal system

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42
Q

What does the posterior pituitary gland produce?

A

ADH and oxytocin

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43
Q

What does the anterior pituitary gland produce?

A

Prolactin, Growth hormone, Thyroid stimulating hormone, Adrenocorticotrophic hormone, Follicle stimulating hormone and Luteinising hormone

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44
Q

How do gonadal cells detect FSH and LH?

A

Via Gs Protein Coupled Receptors

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45
Q

What is the effect of moderate oestrogen and progesterone on the Hypothalmic-Pituitary-Gonadal axis?

A

Oestrogen decreases amount of GnRH released per pulse released by the hypothalamus
while Progesterone decreases the frequency of GnRH pulses released by the hypothalamus

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46
Q

Under stimulation from FSH what do Sertoli cells produce, and what is the function of these products?

A

Androgen binding globulin - binds to testosterone and keeps it within the seminiferous tubules
Inhibin - helps support spermatogenesis and important inhibitory effects

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47
Q

Why is control of reproduction in females so much more complicated than in males?

A

Female reproductive tract needs to prepare for implantation of conceptus if fertilisation is achieved and also wait for a signal to develop from any conceptus formed, thus two phases (ie the follicular and luteal) are required.

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48
Q

Under stimulation from FSH what do the ovaries produce?

A

Inhibin

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49
Q

What is the effect of high [oestrogen] in the absence of progesterone?

A

Gives positive feedback to HPG axis leading to “LH surge”

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50
Q

Why does FSH rise at the beginning of the menstrual cycle?

A

Little inhibition to FSH secretion (as inhibin levels are low)

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51
Q

After ovulation, what part of the corpus luteum produces oestrogen? And which part produces progesterone?

A

Oestrogen secreted by theca lutein cells

Progesterone secreted by granulosa lutein cells

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52
Q

How is menstruation initiated?

A

In absence of further stimulation from LH, the corpus luteum regresses, causing a rapid fall in oestrogen and progesterone. This, in turn, causes the spiral arteries of the endometrium to spasm leading to ischeamic sloughing and thus loss of endometrial tissue

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53
Q

In early pregnancy, what part of the conceptus produces hCG?

A

The placenta

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54
Q

Describe the cervical mucus produced after menstruation but before ovulation

A

Thin, watery and alkaline

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55
Q

Describe the cervical mucus produced after ovulation

A

Thick, sticky and acidic

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56
Q

Describe the main effects of oestrogen on the female genital tract during the follicular phase

A

Increases motility of Fallopian tubes
Thickening of endometrium and growth and increased motility of myometrium
Cervical mucus is thin and alkaline

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57
Q

Besides the effects on the genital tract, what effects does progesterone have on the female body during the luteal phase of the menstrual cycle?

A

Changes in mammary tissue (hypertrophy of ducts)
Increased body temperature
Metabolic changes
Electrolyte changes

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58
Q

What is the thelarche?

A

The beginning of breast development (first stage of female puberty)

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59
Q

How is the pubertal growth spurt controlled?

A

By the Hypothalmic-Pituitary-Gonadal axis

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60
Q

How are the hormonal changes of puberty initiated?

A

Increased Gonadotrophin Releasing Hormone secretion from the hypothalamus causing increased stimulation of HPG axis

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61
Q

How does the initiation of androgen secretion support the pubertal growth spurt (in males)?

A

Stimulates retention of minerals to support bone and muscle growth

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62
Q

What scale is used to assess pubertal development?

A

Tanner standard (also monitoring of growth spurt)

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63
Q

Below what age would starting puberty be considered precocious?

A

8 years old in girls and 9 years old in boys

onset occurring at least 2 standard deviations younger than average age

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64
Q

Why is precocious puberty with a gonadotropin independent cause considered pseudo puberty?

A

It occurs independently of the HPG axis

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65
Q

List some gonadotropin dependant causes of precious puberty

A

Tumours such as gliomas and pineal tumours
CNS trauma or injury
Hamartomas of hypothalamus
Congenital eg hydrocephalus and arachnoid cysts
(very rarely gonadotropin secreting tumours)

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66
Q

How does Turner’s syndrome cause delayed puberty?

A

An absent (or structurally abnormal) X chromosome -> gonadal dysgenesis -> hypergonadotropic hypogonadism

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67
Q

How is the menopause diagnosed?

A

Retrospectively - when cessation of menstrual cycles has been experienced for 12 months

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68
Q

What are “hot flushes” and why do they occur?

A

Transient increases in skin temperature associated with flushing, they occur due to vascular dilation brought on by the hormonal changes of menopause

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69
Q

Why can the menopause cause urinary incontinence?

A

Causes changes in pelvic and bladder tone

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70
Q

How can the menopause lead to osteoporosis?

A

Reduced circulating levels of oestrogens enhances osteoclast ability to reabsorb bone and thus bone mass reduces by 2.5% for several years

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71
Q

What are the risks of HRT?

A

Increased risk of breast cancer
Increased risk of DVT and VTE can cause strokes and BP effects
Small increased risk of ovarian cancer
Side effects including headaches, bloating, nausea and indigestion

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72
Q

Describe and explain the hormonal changes of menopause

A

Cessation of development of ovarian follicles causes a dramatic decrease in oestrogen levels which initially causes dramatic increased FSH and increased LH

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73
Q

What, besides problems in the outflow tract, can cause primary amenorrhea?

A

Gonadal dysgenesis including Turners syndrome
Andogen insensitivity syndrome
Receptor abnormalities for FSH or LH
Congenital adrenal hyperplasia
Or Kallman’s syndrome - problems in hypothalmic devlopment due to a chromosomal defect

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74
Q

What are the most common causes of secondary amenorrhea?

A

Pregnancy (most common cause), Menopause and Polycystic Ovarian syndrome

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75
Q

How may hypo- or hyperthyroidism affect menstruation?

A

They can affect the HPG axis and cause amenorrhea (and other menstrual disturbances such as oligomenorrhea or, in hypothyroidism, polymenorrhagia)

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76
Q

How is prolactin secretion regulated?

A

By Dopamine, Thryotropin releasing hormone (and some other mechanisms)

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77
Q

How can hyperprolactinaemia cause amenorrhea?

A

Inhibition of oestrogen production due to increased prolactin

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78
Q

What drugs can cause hyperprolactinaemia?

A

Any that inhibit dopamine: includes anaethesia, opiates and H2antagonists

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79
Q

What are the main hormonal changes in polycystic ovary syndrome (PCOS)?

A

Increased frequency of GnRH pulse causing an increase in LH pulses and thus increased androgen secretion

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80
Q

What is the linea terminalis?

A

The line around the pelvis made of the pubic crest, the pectineal line and the arcuate line

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81
Q

What is the “true pelvis”?

A

The part of the pelvis between the pelvic inlet and the pelvic outlet

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82
Q

How is the size of the pelvic girdle assessed clinically?

A

By assessing:
Anteroposterior diameter (pelvic inlet)
Bi-spinous diameter (mid-pelvis)
Infra-pubic angle & distance between ischial tuberosities (pelvic outlet)
Distance from the sacral prominence to the the inferior border of the pubic symphysis (diagonal conjugate), allowing an estimate of the true / obstetrical conjugate (the distance between the sacral prominence and the pubic symphysis)

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83
Q

What 2 ligaments are important which regards to the pelvic girdle?

A

Sacrotuberous ligament - between ischial tuberosity and posterioir ileum, lateral sacrum and coccyx
Sacrospinous ligament - divides sciatic foramen

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84
Q

Approximately what angle of supra-pubic arch provides a ‘good’ pelvis for childbirth?

A

> 90’

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85
Q

What symptoms can BPH (benign prostatic hyperplasia) cause and why?

A

Dysuria, Nocturia and Urgency

Due to compresssion of prostatic urethra by enlargement of the middle zone of the prostate

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86
Q

Where are the seminal vesicles located?

A

Lie above prostate between bladder and the rectum

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87
Q

Describe the course of the vas deferens

A

Ascends in spermatic cord, passes through inguinal canal, traverses around bladder, and passes on medial side of ureter to form a dilated ampulla

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88
Q

Describe the internal composition of the penis

A

A pair of corpus cavernosa dorsally
Corpus spongiosum ventrally
All surrounded by tunica albuginea

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89
Q

What is the arterial supply to the penis?

A

Branches of Internal Puodenal arteries which are themselves branches of anterior division of Internal Iliac artery

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90
Q

What is the function of the bulbous spongiosus muscle?

A

Helps expel urine or semen and also helps maintain erections

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91
Q

What is the function of the ischiocaverosus muscle?

A

Compresses veins to help maintain erections

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92
Q

Describe the innervation of the scrotal area

A

Anterior surface - lumbar plexus

Posterioir and inferioir surfaces - sacral plexus

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93
Q

What is the lymphatic drainage of the scrotum?

A

To the superficial inguinal nodes

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94
Q

What is the lymphatic drainage of the testes?

A

To the para-aortic nodes

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95
Q

What is the arterial blood supply to the testes?

A

Direct branches of the abdominal aorta

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96
Q

What is the venous drainage of the testes?

A

Left - L renal vein

Right - IVC

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97
Q

What is the function of the dartos muscle?

A

To wrinkle the scrotal skin to prevent heat loss in cold conditions

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98
Q

Where are the bulbourethral glands located?

A

Within the urogenital diaphragm between the bulb of the penis, the prostate and the rectum

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99
Q

Describe the course a sperm cell takes from production to ejaculation

A

Produced in seminiferous tubules then -> straight tubules / tubuli recti -> rete testes -> efferent ductules -> epididmis where it is stored.
Then on emission passes through vas deferens where it is joined by secretions of seminal vesicles just before entering urethra (prostatic -> membranous -> spongy), pooling in urethral bulb before exiting penis on ejaculation

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100
Q

Describe the contents of the spermatic cord

A 
Genitofemoral nerve (genital branch)
Testicular artery
Cremasteric artery
Artery to vas
Paminiform plexus
Vas deferens
Lymphatics
Processus vaginalis
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101
Q

Describe the coverings of the spermatic cord

A

Superficial fascia and skin
External spermatic fascia (derived from aponeurosis of external oblique muscle)
Cremasteric muscle and fascia (derived from transversalis and external oblique)
Internal spermatic fascia (derived from transversialis fascia)

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102
Q

What is a hydrocoele?

A

A usually painless accumulation of fluid in the tunica vaginalis - can be within spermatic cord or the testis

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103
Q

How can a haematocoele be distinguished from a hydrocoele?

A

Transillumination - shine torch through and haematocoele will be red, hydrocoele will be clear

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104
Q

What is the most common cause of epididymitis?

A

STI

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105
Q

What is a spermatocoele?

A

An epididymal cyst - generally painless accumulation of sperm and fluid that arises from the head of the epididymis

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106
Q

What would you be worried about in a patient with testicular torsion?

A

Necrosis

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107
Q

Describe the epithelium lining the epididymis

A

Pseudo-stratified columnar with sterocilia

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108
Q

Describe the cremasteric reflex

A

Elevation of testis on stroking superior medial thigh. This area is innervated by the ilioinguinal nerve whose genital branch innervates the cremaster muscle

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109
Q

Why can prostatic malignancies spread to the vertebrae and the brain?

A

Through the valveless internal venous plexus

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110
Q

Describe the structure and function of the epithelial cells lining the tubuli recti and rete testis

A

Columnar ciliated and simple cuboidal to absorb fluid and propel sperm along tube

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111
Q

What are the 4 layers of the vas deferens?

A

Epithelium + lamina propria
Inner and outer longitudinal smooth muscle
Middle circular smooth muscle

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112
Q

Describe the epidemiology of testicular tumours

A

High percentage of tumours seen in early life

Vast majority are germ cell tumours

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113
Q

What is the mesovarium?

A

A short peritoneal fold that suspends the ovaries

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114
Q

Where do the ovaries develop?

A

Within the mesonephric ridge on the posterior abdominal wall

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115
Q

What is the lymphatic drainage of the ovaries?

A

To the para-aortic nodes

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116
Q

What is the ovarian ligament?

A

The ligament attaching the ovary to the uterus, it is derived from the gubernaculum

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117
Q

What is the round ligament?

A

The ligament attaching the uterus to the labium majus, it is derived from the gubernaculum

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118
Q

Describe the blood supply to the ovaries.

A

From the ovarian arteries which are direct branches off the abdominal aorta

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119
Q

Describe the venous drainage of the ovaries

A

Left ovarian vein -> L renal vein

Right ovarian vein -> IVC

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120
Q

What is the suspensory ligament of the ovary?

A

The ligament that attaches the ovary to the wall of the pelvis and contains the ovarian vessels, lymphatics and nerves

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121
Q

Where would you find the Fallopian tubes?

A

Extending posterolaterally from the uterus to the pelvic walls before arching anteriorly and superiorly to the ovaries

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122
Q

Describe the parts of the Fallopian tubes

A

Fimbrae - finger like projections
Infundibulum - funnel shaped distal end of the tube that opens into peritoneal cavity
Ampulla - widest and longest part of the tube where fertilisation usually occurs
Isthmus - thick walled part of the tube that enters the uterus

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123
Q

Why is there a higher risk of peritonitis in females?

A

Because in females the peritoneal cavity is open via the ostium of the Fallopian tubes whereas in males the cavity is completely closed

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124
Q

Describe the blood supply to the Fallopian tubes

A

Anastomosis of the ovarian artery and the ascending branch of the uterine artery

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125
Q

Describe what happens to the endometrium at menstruation

A

Spiral arteries spasm, retract back into the deeper evoking ischeamia which leads to desquamation of the outer 2/3 and associated bleeding

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126
Q

What are the 3 layers of the endometrium in the secretory phase?

A

The compact superficial zone
Spongy middle zone
Inactive basal layer

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127
Q

What are the anterior and posterior relations to the uterus?

A

Anterior - uterovesical pouch

Posterior - rectouterine pouch (Pouch of Douglas)

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128
Q

How does the uterus develop?

A

The uterus is formed embryologically by the the Mullerian/paramesonephric ducts which grow to fuse in the midline

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129
Q

What are the 3 layers of the uterine wall?

A

Endometrium
Myometrium
Perimetrium

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130
Q

How is the uterus normally positioned?

A

Anteverted and anteplexed

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131
Q

What is the blood supply to the uterus?

A

Uterine artery from the internal iliac artery

With some anastomosing with the ovarian artery

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132
Q

Describe the venous drainage of the uterus

A

Uterine plexus draining into uterine veins

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133
Q

Where do the ureters run in relation to the uterus?

A

Laterally, under the uterine artery and vein (water under the bridge)

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134
Q

Describe the parts of the cervix

A

Internal os
Endocervical canal
External os

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135
Q

What type of epithelium lines the cervix?

A

Simple columnar with branched glandular cells

Stratified non-keratinised squamous on inner aspect of external os

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136
Q

How is cervical mucus different around the time of ovulation?

A

Has higher water content, is less acidic and higher in electrolytes, acellular clear and “stretchy”

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137
Q

What are Nabothian cysts?

A

Infected, blocked cervical glandular ducts

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138
Q

Explain the clinical consequence of Nabothian cysts

A

Can cause infertility by making vagina in hospitable to sperm

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139
Q

Where may pain likely to be felt by a patient with an ectopic pregnancy?

A

R or L iliac fossae

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140
Q

What ligaments support the uterus within the pelvic cavity?

A

The transverse cervical ligament (lateral stability)

The uterosacral ligaments (oppose anterior pull of round ligament)

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141
Q

Why can ectopic pregnancy often be misdiagnosed as appendicitis?

A

Resultant appendicitis

R iliac fossa pain

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142
Q

How would you examine the uterus?

A

Bimanual palpation - two fingers pressed superiorly into the vagina while the other hand is pressed inferoposterioirly in the pubic region anteriorly

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143
Q

What is endometriosis?

A

Presence of tissue resembling endometrial glands and stroma outside the uterine cavity, inducing a chronic inflammatory reaction

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144
Q

Where are the Bartholin glands located?

A

On each side of the vestibule near the vagina

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145
Q

When are the Bartholin glands palpable?

A

When they are infected

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146
Q

How does the presence of Lactobacillus protect the vagina from pathogens?

A

They utilise glycogen to produce which maintains a low pH

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147
Q

What is culdocentesis?

A

Medical procedure performed to extract accumulated fluid

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148
Q

Describe the innervation of the vagina

A

Inferior 1/5th somatic innervation from pudenal nerve

Superior 4/5ths uterovaginal plexus

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149
Q

What nerves supply the perineum?

A

Pudenal nerve (S2-4) and ilioinguinal nerve

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150
Q

Describe the anaesthetic options available for childbirth

A

Caudal epidural block - anaesthetic through indwelling cather in the spinal canal, affects S2-4, must be administered in advance of delivery
Pudenal nerve block - local anaesthesia for S2-4 dermatomes and inferior quarter of vagina
Spinal anaesthesia - Spinal needle of anaesthetic at L3-L4 level - complete motor and sensory anaesthesia below the waist so mother becomes totally reliant on electrical monitoring for sensation of uterine contractions

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151
Q

Describe and name the levator ani muscles

A

Puborectalis - from pubic symphysis looping around rectum
Pubococcygeus - from pubis to coccyx and sacrum
Iliococcygeus - ischial spine to sacrum and coccyx
Coccygeus - overlying sacrospinous ligament, ischial spines to lateral aspect of sacrum and coccyx

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152
Q

What is the clinical relevance of the superficial perineal pouch?

A

Site where urine collects if the urethra is ruptured below perineal membrane

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153
Q

Describe the layers of the urogenital triangle

A

Skin, Deep perineal fascia, Superficial perineal pouch, Perineal membrane, Transverse perineal muscle contained within Deep perineal pouch which also contains External urethral sphincter

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154
Q

What are the anatomical boundaries of the perineum?

A 
Anterior – Pubic symphysis
Laterally – Inferior pubic rami and inferior ischial rami, and the sacrotuberous ligament
Posterior– The tip of the coccyx
Roof – The pelvic floor
Base – Skin and fascia
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155
Q

Describe the blood supply of the pelvic floor

A

Internal pudenal artery

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156
Q

What is the innervation of the pelvic floor and the spinal roots of this?

A

Pudenal nerve

S2,3&4 (keeps your guts off the floor)

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157
Q

What is the perineal body?

A

Fibromuscular node at the centre of the perineum at the junction of the anterior and posterior perineum that functions as a point of attachment for the muscle fibres of the pelvic floor

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158
Q

What is an episiotomy?

A

Surgical cut to the perineum

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159
Q

How can childbirth damage the pelvic floor?

A

Stretching of the pudenal nerve leading to neuropraxia and muscle weakness
Stretching and damage of pelvic floor and perineal muscles leading to muscle weakness
Stretching and damage of ligaments of pelvic floor leading to ineffective muscle action

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160
Q

What are the surgical treatments for incontinence?

A

Colposuspension

Tension free vaginal tape

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161
Q

Name the organism that causes genital chlamydia

A

Chlamydia trachomatis, generally serotypes D-K

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162
Q

Where would you look up up-to-date advice for STI management?

A

BASHH Guidelines

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163
Q

Which strains of HPV cause cutaneous mucosal and anogenital warts?

A

HPV 6 and 11

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164
Q

How would you treat cutaneous mucosal and/or anogenital warts?

A

Conservatively - majority resolve spontaneously

Otherwise topical podophyllin, cryrotherapy, intralesional interferon, imiquimod or surgery

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165
Q

Specifically, what type of organism causes chlamydia?

A

Obligate intracellular bacterium

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166
Q

What are the signs and symptoms of genital chlamydia?

A

Typically no symptoms!!
Urethritis
Prostatitis (men), procticitis (MSM)
Cervicitis, salpingitis, perihepatitis (women)

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167
Q

How is chlamydia diagnosed?

A

Endocervical or urethral swabs (if refused, first pass urine sample) subjected to nucleic acid amplification techniques
Consider dual testing with N. gonorrhoae

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168
Q

How would you treat chlamydia?

A

Azithromycin (single dose or few days course)

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169
Q

Which strain of herpes simplex virus is associated with genital herpes?

A

HSV2

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170
Q

How is genital herpes different from genital warts?

A

Herpes, unlike warts is typically painful, can cause genital ulceration and inguinal lymphadenopathy

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171
Q

Explain why recurrent herpes infections can occur

A

Latent infection in dorsal root ganglia

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172
Q

How would you diagnose herpes?

A

PCR of vesicle fluid and/or ulcer base

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173
Q

How would you treat herpes?

A

Aciclovir and advice on barrier contraception to reduce transmission risk

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174
Q

Which strains of HPV are strongly associated with cervical and anogenital cancer?

A

16 and 18

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175
Q

What are the symptoms of gonorrhoea?

A

Men: Urethritis, often with purulent discharge, epididimytis, prostatitis (also procitis and pharyngitis in MSM)
Women: Often none! Urethritis, Endocervitis, PID
Also, in disseminated infections - skin and joint lesions

176
Q

Describe the causative organism in genital gonorrhoea

A

Neisseria gonorroeae - a gram negative intracellular diplococcus

177
Q

How would you diagnose gonorrhoea?

A

Swab from urethra or cervix and gram stain

Or urine sample subjected to nucleic acid amplification techniques

178
Q

How would you treat gonorrhoea?

A

Ceftriaxone IM plus testing and/or treatment for chlamydia with azithromycin

179
Q

What is the causative organism in syphilis?

A

Treponema pallidum

180
Q

Describe the 4 stages of syphilis

A

Primary - indurated, painless ulcer
Secondary - rash, fever, lymphadenopathy, mucosal lesions 6-8 wks later
Latent - symptom free years
Tertiatry - neurosyphilis, cardovascular syphilis, gummas (local destruction, often on face)

181
Q

How would you diagnose syphilis?

A

Serology - dark field microscopy

182
Q

How would you treat syphilis?

A

Penicillin and test-of-cure follow up

183
Q

What are the potential sexually transmitted causes of inguinal lymphadenopathy?

A

Genital herpes, secondary stage syphilis
LGV (chlamydia trachomatis serotypes L1,2&3)
Chancroid (Heamophilus ducreyi)
Granuloma inguinale (Klebsiella granulomatis

184
Q

What are the risk factors for vulvovaginal candidiasis?

A

Antibiotics
Oestrogen: pregnancy, obesity, oral contraceptive pill
Diabetes

185
Q

How would you diagnose vulvovaginal candidiasis?

A

High vaginal smear and microscopy +/- culture

186
Q

What are the treatment options for vulvovaginal candidiasis?

A

Topical azoles or nystatin
Oral fluconazole for more problematic cases
And control risk factors!

187
Q

What are the symptoms of BV?

A

Offensive, fishy discharge

188
Q

What are the potential causative organisms in BV?

A

Gardenerella vaginalis, other anaerobes, mycoplasmas

189
Q

How would you treat BV?

A

Metrionidazole

190
Q

What are the symptoms of trichomonas vaginitis?

A

Thin, frothy and offensive discharge

Irritation, dysuria and vaginal inflammation

191
Q

What is the treatment for trichomonas vaginitis?

A

Metronidazole

192
Q

What is the causative organism in trichomonas vaginitis?

A

Trichomonas vaginalis - a flagellated protozoan

193
Q

What are the risk factors for pelvic inflammatory disease?

A

STI risk factors

IUD insertion and removal

194
Q

Describe the aetiology of PID

A

Often polymicrobial, commonly C. trachomatis and N. gonorrhoea but can be gardenerella vaginalis, myoplasma hominis or various anaerobes
Actinomycosis is associated with IUDs

195
Q

Who is PID most common in?

A

Sexually active women in their 20s

196
Q

What are the symptoms of PID?

A

Pyrexia +/- rigors
Lower abdo pain and deep dysparenunia
Abnormal vaginal discharge or bleeding

197
Q

What findings may you illicit on bimanual examination of a patient with (suspected) PID?

A

Adenexal tenderness

Cervical motion tenderness

198
Q

What could you expect to see on speculum examination of a patient with PID?

A

Purulent cervical discharge

Cervicitis

199
Q

Give a differential diagnosis for lower abdominal pain

A

Ectopic pregnancy, endometriosis, ovarian cyst complications,
IBS, Appendictis, IBD,
UTI, bladder or kidney stones,
Functional pain

200
Q

What investigations are implicated in a case of suspected PID?

A 
Diagnostic laproscopy
Pregnancy test
Endocervical and high vaginal swabs - for chlamydia and gonorrhoea 
WBC and CRP
Screening for other STIs
201
Q

Why is there a low threshold for treatment in PID?

A

Delayed treatment increases risk of long term sequalae

202
Q

When would you admit a patient with PID?

A

Severe cases or if patient is pregnant

203
Q

What signs would indicate a case of PID is severe?

A

Pyrexia > 38’c
Signs or tubo-ovarian abscess or pelvic peritonitis
No response to oral therapy

204
Q

What is the UHL regimen for treatment of PID in out-patients?

A

IM Ceftriaxone
With Doxycyclin and Metronidazole tablets
Follow up in 72 hrs

205
Q

How does the UHL regimen for treatment of PID differ for inpatients?

A

Metronidazole IV not PO and give another dose of IM Ceftriaxone

206
Q

Describe Fitz-Hugh-Curtis syndrome

A

RUQ pain and peri-hepatitis, commonly caused by chamydial PID

207
Q

Describe Reiter syndrome

A

(Can’t pee, can’t see, can’t bend at the knee)

Urethritis, Conjunctivitis, Arthritis due to disseminated infection following PID

208
Q

What are the long term sequelae for PID?

A 
Ectopic pregnancy
Infertility
Chronic abdo pain
Fitz-Hugh-Curtis syndrome
Reiter syndrome
209
Q

List the main constituents of semen and their origins

A

Secretions from seminal vesicle (70%) - contains amino acids, fructose, prostaglandins, clotting factors
Secretions from prostate (25%) - contains proteolytic enzymes (to break down clotting factors and reliquify semen), zinc, acid phosphatase
Secretions of Cowper’s glands (

210
Q

Describe the stages involved in the remodelling of spermatids into spermatozoa

A

Nuclear condensation within head
Acrosome formation - Golgi apparatus produces lyosome-like hydrolytic enzymes which enable sperm to penetrate ovum
Packing of mitochondria around contractile filaments in the midpiece
Production of flagellum from microtubules, growing from centriole to form axoneme

211
Q

Briefly describe the sexual response cycle

A

Excitement phase -> plateau phase -> orgasmic phase -> resolution phase (followed by refractory period in males)

212
Q

Which neurons are inhibited during the excitement phase of the sexual response cycle?

A

Thoracolumbar sympathetic neurons

213
Q

How does activation of the limbic system and the sacral parasympathetic neurons lead to the initiation of penile erection?

A

M3 receptors on endothelial cells activated -> stimulates increase in intracellular Ca2+ -> activates eNO synthase -> Nitric oxide produced -> arteriolar vasodilation in corpora cavernosa -> increases penile flow so causing penile filling and tumescence

214
Q

What neural reflex is activated in the plateau stage of the sexual response cycle?

A

Sacrospinous reflex

215
Q

What is the difference between seminal emission and ejaculation (males)?

A

Emission is release of semen into the penis where it pools in the urethral bulb, controlled by thoracolumbar reflex
Ejaculation is explusion of semen from penis, controlled by spinal reflex L1&2

216
Q

What neural reflex is responsible for seminal emission?

A

Spinal reflex L1&2

Filling of urethra stimulates pudenal nerve

217
Q

When is secretion from the Cowper’s and Littre’s glands stimulated?

A

The plateau phase

218
Q

How is penile erection maintained during the plateau stage of the sexual response cycle?

A

Contraction of ischiocavernosus which compresses penis and impedes venous return
(while pressure within corpus caverosa increases above systemic blood pressure decreasing arterial inflow)

219
Q

What neural pathway controls the resolution stage of the sexual response cycle?

A

Activation of Thoracolumar sympathetic pathway

220
Q

What systemic changes occur in the excitement phase of sexual response in females?

A

Increase muscle tone, heart rate and blood pressure

221
Q

By what physiological mechanism is vaginal lubrication achieved?

A

Vasocongestion

222
Q

List some causes of sexual impotence

A

Drugs - alcohol, antihypertensives
Psycological
Vascular - atherosclerosis, diabetic microvascular disease
Trauma - tears in fibrous tissue of corpora cavernosa

223
Q

How does Viagra work?

A

Decreases cyclic GMP breakdown which increases action of nitric oxide

224
Q

When does the fertile period occur?

A

Day of ovulation and 5 days prior

225
Q

Describe the stages of capacitation of sperm

A

Occurs within female genital tract
Protein coat removed from cell membrane to expose acrosomal enzymes
Tail movement changes from beat to whiplike
-> allowing sperm to penetrate corona radiata and zona pellucida and fuse with oocyte cell membrane

226
Q

How is the acrosome reaction triggered?

A

When proteins on sperm head bind to Zp3 proteins of zona pellucida

227
Q

How is polyspermy prevented?

A

By the fast block and cortical reaction of the acrosome reaction
Fast block - Na+ channels in oocyte membrane open causing a wave of depolarisation propagating from site of sperm’s entry
Cortical reaction - Ca2+ released from ER induces local exocytosis of cortical granules -> release enzymes which stimulate the adjacent cortical granules to also undergo exocytosis -> wave of exocytosis from sperm’s entry site

228
Q

ToB Describe the stages of the early embryonic period

A

Cleavage - increased number of cells, size stays same thus increasing nuclear:cytoplasm
Compaction - at 8 cell stage cells form tight junctions
Morula - 16 cell stage at which conceptus passes into uterus
Blastocyst stage - loss of totipotency as conceptus separates into embryoblast and trophoblast
Hatching - local digestion of zona pellucida by enzyme produced in trophoblast
Implantation - trophoblast overlying inner cell mass adheres to endothelium

229
Q

ToB Describe the conceptus at the beginning of week 2

A

Embryoblast has formed bilaminar disc consisting of epiblast and hypoblast
Trophoblast has become cytotrophoblast which is mononucleated and synctiotrophoblast which is multinucleated

230
Q

Describe the placental changes that occur after implantation of the conceptus

A

Placental membrane thins to become haemomonochorial
Chorion establishes basic unit of exchange by forming primary villi which are finger-like projections of trophoblast, these later develop a mesenchyme core at which point they are called secondary villi. The final stage of villi development, after which villi are known as tertiary villi, involves the invasion of this mesenchyme core by foetal vessels.

231
Q

How is the trophoblast prevented from penetrating too far into the endometrium?

A

By the presence of “pre-decidual” cells within the endometrium

232
Q

How is the endometrium prepared for implantation after ovulation?

A

Growth of pre-decidual cells

Elaboration of spiral arterial blood supply

233
Q

What is placenta praevia?

A

A pregancy where the site of implanation is in the lower uterine segment

234
Q

What type of monozygotic twins has the greatest risk of unequal blood supply?

A

Those that share an amnion and a chorion

235
Q

Describe the blood supply to the foetus

A

1 umbilical vein within umbilical cord provides oxygenated blood from placenta to the foetus
2 umbilical arteries within umbilical cord pass deoxygenated blood from the foetus to the placenta
Placenta receives oxygen, water, electrolytes, glucose, amino acids etc. and gives up waste products such as urea by a counter-current exchange mechanism with maternal blood

236
Q

What does the placenta produce?

A 
Glycogen
Fatty acids
Cholesterol -> some of which is used to produce the steroid hormones progesterone and oestrogen
Also produces polypetide hormones:
human chorionic gonadotropin
human chorionic somatotrophin
human chorionic thyrotropin
human chorionic corticotrop
237
Q

What is hCG and what is its function?

A

Human chorionic gonadotropin
Supports corpus luteum to continue producing oetrogen and progesterone to support early pregnancy before placenta can produce its own steroid hormones

238
Q

How does the foetus develop passive immunity to pathogens?

A

Receptor mediated endocytosis of IgG from mother to placenta which then supplies foetus

239
Q

Describe how haemolytic disease of the newborn can develop

A

If baby is Rh positive and mother is Rh negative, during the pregnancy maternal antibodies against the Rh antigen (formed in past pregnancy that was also rhesus incompatible) pass to the foetus through the placenta after which they attack the foetal red blood cells, causing haemolysis.

240
Q

List 6 infectious agents that can pass to the foetus

A 
Varicella zoster
Cytomegalovirus
Treponema pallidum (syphillis)
Toxoplasma gondii
Rubella
HIV
241
Q

What is Rubella syndrome?

A

Range of foetal defects that occur when the mother has contracted Rubella: Microcephaly, patent ductus arteriosus and other CVS defects, cataracts

242
Q

Describe the normal components of ante-natal screening

A

History and examination - identification of risk factors for and signs of gestational diabetes and pre-eclampsia etc
Blood test - for Rhesus status, haemoglobin levels, HIV
Urinanalysis - for proteinuria

243
Q

When does the maternal CVS start to adapt to pregnancy?

A

From the 1st trimester (anticipatory changes)

244
Q

What changes occur in the mother’s CVS during pregnancy?

A

Increased blood volume
40% increased cardiac output due to increased stroke volume and heart rate
30% decrease in systemic vascular resistance
Decrease in blood pressure in early pregnancy, returning to normal in 3rd trimester

245
Q

Why does the maternal blood pressure usually return to normal in the 3rd trimester?

A

Due to compression of abdominal aorta and IVC by gravid uterus

246
Q

What is the pathogenesis and aetiology of pre-eclampsia?

A

Vasoconstriction and plasma contraction due to secretion of unidentified circulating factor in response to foetal hypoxia due to a defect in placentation

247
Q

What is the diagnostic criteria for pre-eclampsia?

A

New onset hypertension

+ Proteinuria >300mg/24hrs in absence of UTI

248
Q

What signs and symptoms may develop in severe pre-eclampsia?

A

Those of CNS dysfunction such as headaches, visual distirbances
Those of liver capsule distention, such as liver tenderness
Pulmonary oedema
Papilloedma
Severe pain just below ribs or vomiting

249
Q

What are the risk factors for pre-eclampsia?

A 
1st time pregnancy
Multiple gestation
Chronic hypertension or renal disease
Race - black
Extremes of age
Positive family history
250
Q

What is eclampsia?

A

Onset of convulsions in a pregnancy complicated by pre-eclampsia

251
Q

How would you manage eclampsia?

A

Maintain airway, O2, place mother on her left side
IV Magnesium sulphate
Delivery is definitive treatment for eclampsia

252
Q

How does the maternal GFR change during pregnancy?

A

55% increase in GFR

253
Q

What is the consequence of the change in maternal GFR during pregnancy?

A

Decreased functional renal reserve thus limited capacity for compensation

254
Q

Describe how the urinalysis ranges for pregnant women are different from normal

A

50% decrease in urea
Increasingly decreasing uric acid
Decreased bicarbonate
Decreased creatinine

255
Q

How does the raised levels of progesterone during pregnancy contribute to an increased risk of UTI, hydroureter and obstruction?

A

Progesterone causes dilation leading to urinary stasis

256
Q

How and why is the maternal functional residual capacity changed during pregnancy?

A

It decreases in 3rd trimester due to displacement of diaphragm by gravid uterus

257
Q

Describe the cause and effects of physiological hyperventilation in pregnancy

A

Due to increased respiratory drive due to increased progesterone
Causes respiratory alkalosis which is compensated by increased renal bicarbonate excretion and 20% increase in oxygen consumption

258
Q

Describe the physiological changes to carbohydrate metabolism in pregnancy

A

Increased peripheral insulin resistance
Increased gluconeogenesis
Decreased fasting blood glucose
Increased post-pranial blood glucose

259
Q

What is gestational diabetes?

A

Carbohydrate intolerance first recognised in pregnancy and not persisting after the pregnancy

260
Q

What are the risk factors for gestational diabetes?

A 
BMI over 30
Previous macrosomic birth
History of gestational diabetes
Family history of diabetes
South Asian, black Caribbean or Middle eastern
261
Q

What are the potential consequences of gestational diabetes?

A

Macrosomic baby
Stillbirth
Congenital defects such as cardiac and neural tube defects
Premature birth and associated Respiratory Distress Syndrome of newborn
Diabetic ketoacidosis
Pre-eclampsia

262
Q

Why is there an increased risk of ketoacidosis in pregnancy?

A

Increased lipolysis from 2nd trimester leads to increased plasma free fatty acids on fasting

263
Q

Describe the effects on the thyroid gland in pregnancy

A

Increased thyroid binding globulin production
Increased T3&4
Which can cause TSH to decrease
Due to stimulatory effects of hCG on thryoid

264
Q

Why is there an increased risk of pancreatitis in pregnancy?

A

Progesterone causes relaxation of smooth muscle, causing stasis

265
Q

What factors contribute to pregnancy being a pro-thrombotic state?

A

Increased fibrin deposition at implantation site
Increased fibrinogen and clotting factors
Decreased fibrolysis
Stasis and venodilation

266
Q

Why does “physiological” anaemia occur in pregnancy?

A

Dilutional - red cell volume doesn’t increase to same degree as plasma volume

267
Q

Why is anaemia more common in pregnant women?

A

Increased iron and folate requirements due to foetus

268
Q

Why is it recommended that pregnant women take folate supplements?

A

Prevent neural tube defects such as spina bifida

269
Q

Why are pregnant women slightly more susceptible to infections?

A

Non-specific immunosuppression of local immune response at materno-foetal interface to prevent rejection of allograffic foetus

270
Q

Describe how oxygen transfer to the foetus is facilitated

A

Low foetal pO2
Increased maternal production of 2,3 DPG
Effects of Foetal haemoglobin - greater affinity for O2
Double Bohr effect - shift of O2 dissociation curve in opposite directions in mother and foetus

271
Q

Describe the double Bohr effect

A

In mother, blood pH falls as CO2 enters into intervillous blood, decreasing affinity of Hb for O2.
While in the foetus, blood pH increases as CO2 is lost, increasing affinity of Hb for O2.
This effect maximises oxygen transfer from materal to foetal blood.

272
Q

How is the transfer of CO2 from foetus to mother facilitated?

A

The Double Haldane effect which is unique to placenta - as Hb gives up O2 it can accept increasing amounts of CO2, foetus gives up CO2 as O2 is accepted so there are no alterations in local pCO2 so CO2 concentration gradient is unaffected.

273
Q

Describe the foetal circulation

A

Liver bypassed by ductus venosus.
Lungs as bypassed by foramen ovale which shunts blood from R to L atrium of the heart, and the ductus artiosus which shunts blood from the R ventricle and pulmonary trunk to the aorta, distal to supply for head and heart.

274
Q

How is the foetus adapted to manage transient hypoxia?

A

Foetal heamoglobin has greater affinty for oxygen and presnet at higher concentration than Hb in an adult.
Can redistriubte flow to protect supply to heart and brain
Vagal stimulation by chemoreceptors detecting low pO2 or high pCo2 stimulates bradycardia

275
Q

What are the potential consequences of chronic foetal hypoxia?

A

Growth restriction
Developmental disorders due to foetal behavioural changes
Risk of cerebral palsy and other consequences of ischaemic injury to the brain

276
Q

Name the hormones necessary for foetal growth

A 
IGFI - dominant in 1st trimester
IGFII - dominant in 2nd and 3rd trimester
Insulin
Leptin
EGF
TGFalpha
277
Q

Why is foetal growth typically unaffected by maternal “morning sickness”?

A

IGFI has large role in controlling foetal growth in 1st trimester, when morning sickness usually occurs. This hormone is “nutrient independent” so is unaffected by the maternal nutritional status, lessening the effect on foetal growth.

278
Q

What factors can affect foetal growth?

A 
Maternal nutritional status
Maternal smoking or alcohol use
Efficiency of placenta
Utero-placental blood flow
Maternal parity
Genetic factors
Race, maternal height and weight
279
Q

What is asymmetrical growth restriction and why might it occur?

A

Intra-uterine growth restriction where admonial fat and glycogen is diminshed but the head and brain are “spared”, may occur due to maternal malnutrition, typically in 3rd trimester

280
Q

What are the functions of amniotic fluid?

A

Provide mechanical protection to foetus and a moist environment for developing skin
Contributes to lung development

281
Q

How is amniotic fluid produced in early gestation?

A

Transudation - passage of fluid across amnion and foetal skin

282
Q

How is amniotic fluid produced for the majority of gestation?

A

Mostly from urine production by foetal kidneys, some contribution from lung fluid and fluid from head.

283
Q

What happens to amniotic fluid after it has been produced?

A

Recycled - Swallowed by foetus and water and electrolytes absorbed, with debris accumulating the the gut

284
Q

What is meconium and what does its presence in the amniotic fluid indicate?

A

1st bowel movement, usually passed after birth.
Consists of accumulated debris from amniotic fluid, intestinal secretions and bile.
If present in amniotic fluid indicates foetus has experienced distress.

285
Q

Is a jaundiced appearance of a neonate alarming and why?

A

No, physiological jaundice of newborn is common as foetus cannot conjugate bilirubin due to immaturity of liver and intestinal processes.

286
Q

Describe the differences in the pattern of growth in the embryonic stage and the foetal stage

A

Embryonic - development of organ systems; absolute growth, besides that of placenta, is very small
Foetal - acceleration of growth and weight gain causing change in body proportion; protein and adipose deposition in mid and late foetal periods respectively

287
Q

Describe how ante-natal foetal well-being is assessed

A

Ask mother about foetal movements
Regularly measure symphysis-fundal height
Ultrasound scan - typically at 20 weeks to assess foetal growth and detect foetal abnormalities

288
Q

When would you perform a non-stress test in a low risk pregnancy?

A

If foetal movements are decreased

289
Q

In what circumstances may a pregnancy be considered “high risk”?

A

Maternal hypertension, renal disease, cardiovascular disease, diabetes or anaemia
Post-term
Multiple pregnancy
Evidence of intra-uterine growth restriction
Suspected oligohydraminios
Placenta abnormality

290
Q

How is foetal well-being monitored in “high risk” pregnancies?

A

Foetal movement charts (“kickcharts”) from 28-32 weeks
Weekly non-stress test and potentially amniotic fluid estimations from 28-32 weeks
Potentially biophysical profiling

291
Q

Describe how you can make an estimation of foetal age

A

Count from last menstrual period, being aware of potential inaccuracy
Assessment of developmental criteria at ultrasound- crown rump length if early in pregnancy or biparietal diameter, abdominal circumference and femur length if later on

292
Q

What is the exact definition of macrosomia?

A

Birth weight over 4500g

293
Q

Describe the foetal development of the respiratory system

A

Pseudoglandular stage at 8-16 wks, where duct system begins to form within the broncho-pulmonary segments created during embryonic period.

Canalicular stage at 16-26 wks, where respiratory bronchioles form via budding from bronchioles formed in pseudo-glandular stage. Epithelium becomes ciliated.

Terminal sac stage at 26 wks - term, where terminal saces begin to form from respiratory bronchioles, and type 1 & 2 alveolar cells /pneumocytes differentiate and surfactant production begins by type 2 alveolar cells.

294
Q

*Describe the initiation of surfactant production

A

In Terminal sac stage of lung development, type 1 & 2 alveolar cells /pneumocytes differentiate. At 20 wks surfactant production begins by type 2 alveolar cells, rapidly increasing at 30 wks and reaching significant levels around 34 weeks

295
Q

What is the function of foetal breathing movements?

A

Conditioning of the respiratory musculature

Drawing of amniotic fluid into lungs, promoting differentiation of pneumocytes / alveolar cells

296
Q

If a pre-term delivery is unavoidable how can you limit the probability of respiratory distress syndrome?

A

Glucocorticoid treatment of the mother - reduces risk by 50%

297
Q

What does foetal bradycardia suggest?

A

Foetal hypoxia and demise

298
Q

When can the foetal heart beat be identified?

A

By transvaginal ultrasound at 5-6 weeks
Doppler stethoscope at 10-12 weeks
Plain stethoscope at 18-20 weeks

299
Q

What would be a typical foetal heart rate at term?

A

140-160 bpm

300
Q

When do the foetal kidneys become functional?

A

Around week 10 gestation

301
Q

What are the potential causes of oligohydramnios?

A

Problems with foetal kidney function including obstruction
Maternal hypertensive disorders incl. pre-eclampsia
Premature rupture of membranes or leakage of amniotic fluid

302
Q

What are the potential causes of polyhydramnios?

A

Problems with foetal swallowing such as oesophageal or atresia or duodenal atresia

303
Q

Why do we measure the levels of alpha fetoprotein in maternal blood?

A

Levels are elevated in open neural tube defects (and also multiple pregnancies)

304
Q

When do foetal movements begin?

A

8th week of gestation

305
Q

What is quickening and when does it occur?

A

Maternal awareness of foetal movements

Typically 17 weeks onwards

306
Q

What is parturition?

A

The process of the explusion of the products of conceptus, includes labour

307
Q

During which weeks of gestation would birth be considered to be at term?

A

37 to 42 weeks

308
Q

What are the 3 stages of labour?

A

Creation of birth canal
Expulsion of foetus
Expulsion of placenta and contraction of uterus

309
Q

Describe how symphysis-fundal height increases over pregnancy, including key anatomical landmarks

A

Distance in cm roughly same as number of weeks gestation, decreasing slightly at term (as baby’s head engages)
Reaches umbilicus around 20 weeks
Reaches xiphisterum by 36 weeks

310
Q

How is the normal positing of the foetus at the beginning of parturition described?

A

Longitudinal lie
Cephalic presentation
Vertex to pelvic inlet at minimum diameter

311
Q

Describe the process of cervical ripening

A

Softening of cervix due to reduction in collagen due to action of collegenases, and
Increased glycosaminoglycans, decorin and hyaluronic acid resulting in reduced aggregation of collagen fibres.

312
Q

How is cervical ripening triggered?

A

By prostaglandins PGE2 and PGF2alpha

Also oestrogen and relaxin

313
Q

How are contractions of the myometrium triggered?

A

Spontaneously triggered action potentials from pacemakers at top of fundus

314
Q

How are contractions of the myometrium controlled?

A

Prostaglandins and oxytocin and oestrogen via the Ferguson reflex

315
Q

Describe the Ferguson reflex

A

Oestrogen induces oxytocin receptors on the uterus.
Oxytocin stimulates uterus to contract and stimulates placenta to make prostaglandins. These prostaglandins stimulate further contractions of the uterus which have a positive feedback effect, stimulating further oxytocin and prostaglandin production / release.

316
Q

When do contractions occur?

A

Throughout pregnancy, increasing in amplitude over time

317
Q

What are Braxton-Hicks and what is their function?

A

Contractions of myometrium starting in middle gestation, often referred to as “practice contractions”.
They pull cells of myometrium closer together to produce a synctium.

318
Q

How can you tell if a women has entered the late stages of labour?

A

Contractions occur every 10 minutes, each lasting 1 minute

319
Q

How does the cervix change during the onset of labour?

A

It undergoes “effacement” where it thins and flattens, it also begins to dilate

320
Q

How can you tell that the 1st stage of labour has been completed?

A

Cervix becomes fully dilated - 10 cm or 4 fingers wide

321
Q

What is brachystasis?

A

The contraction and retraction of myometrium that occurs during labour that causes the myometrial fibres to shorten and drives presenting part of the foetus towards the cervix

322
Q

What is thought to trigger the initiation of labour?

A

Increase in prostaglandins

323
Q

How does the positioning of the baby’s head change as it is delivered in labour?

A

It flexes and rotates internally, then after it is delivered it rotates and extends

324
Q

How long does the 2nd stage of labour last?

A

Up to an hour, but can be very fast in multparous women

325
Q

How is the risk of post-partum haemorrhage reduced in the 3rd stage of labour, physiologically and clinically?

A

Contractions become much stronger and compress blood vessels. Spiral arteries clamped shut by “living ligatures” of myometerial cells.
Clinically this is enhanced by administration of oxytocic drug and manual fundal massage.

326
Q

Explain how the circulatory system of the neonate changes after birth

A

Clamping of umbilical cord results in closure of ductus venosus.
As neonate takes first breath, pulmonary vascular resistance is decreased and blood flows to the lungs, causing a net drop in pressure on the R side of the heart, closing the foramen ovale which causes ductus arteriosus to close.

327
Q

What is “operative delivery” and when is it indicated?

A

When delivery is assisted by forceps or vacuum extraction
Indicated if foetal distress, maternal exhaustion or inadequate maternal explusive efforts due to neuromuscular disease etc

328
Q

How can labour be induced?

A 
Membrane sweep - though not technically an induction
Vaginal PGE2 (prostaglandin)
329
Q

What is a disadvantage of inducing labour?

A

Labour likely to be more painful

330
Q

How can the physiological state of the foetus be assessed during labour?

A

Monitoring of foetal heart rate:
Either by auscultation > 1 minute after a contraction, while maternal pulse is palpated to differentiate
or by foetal scalp electrode if continuous monitoring needed

331
Q

Describe the structure of the breasts

A

Lobulated masses of tissue - the mammary glands, embedded in fibrous and adipose tissue, suspended by Cooper’s ligaments

332
Q

How do oestrogen and progesterone affect breast tissue?

A

Oestrogen stimulates sprouting and hypertrophy of lactiferous ducts and progesterone stimulates hypertrophy of ducts also.

333
Q

Name the physiological stages of lactation

A

Mammogensis
Lactogenesis
Galactokinesis
Galactopoesis

334
Q

How does the breast tissue change in preparation for milk production?

A

Hypertrophy of ductular-lobular-alveolar system
Prominent lobules form
Alveolar cells differentiate from squamous to cuboidal

335
Q

How is mammogenesis controlled?

A

By oestrogen, progesterone, EGF and TGFalpha

336
Q

How is breast milk produced?

A

Within alveolar cells, various cell organelles produce the components of breast milk:
Smooth ER produces fat
Golgi body secretes protein
Sugars are synthesied and secreted

337
Q

Why do neutrophils and macrophages enter the alveolar space during lactation?

A

To protect against from bacterial infections eg E.coli which may ascend into the lobules of the breast via the lactiferous ducts

338
Q

How does colostrum compare to mature breast milk?

A

More protein, fat soluble vitamins, and immunoglobulins especially IgA
Contains maternal neutrophils and macrophages
Less water-soluble vitamins, fat and sugar

339
Q

What is the main source of energy in breast milk?

A

Lactose

340
Q

How is milk secretion stimulated, and how is this controlled?

A

By the fall in progesterone and oestrogen promoted by prolactin which inhibits HPG axis. Prolactin secretion is promoted during suckling to stimulate secretion of milk for the next feed. Prolactin is controlled by the inhibitory action of dopamine.

341
Q

What is the let-down reflex?

A

Mechanism controlling ejection of breast milk where receptors in nipples are stimulated by the baby’s mouth, stimulating oxytocin release form the posterior pituitary. This causes myoepithelial cells around the lactiferous ducts to contract which then squeezes milk out of the breast.

342
Q

Why does milk production cease if suckling does not occur?

A

Prolactin secretion which stimulates milk secretion is promoted by suckling, also if suckling doesn’t occur the breast fills with milk causing turgor induced damage.

343
Q

What can cause lactation to cease (5 points)?

A

Insufficient suckling
Pain from increased turgor due to non-suckling infant or mastoiditis
Menstruation
Supression of prolactin - ergot, diuretics, retained placenta etc
Age - due to gradual shrinking of mammary glands

344
Q

How is the maintenance of lactation achieved?

A

By the neuroendocrine reflex of suckling or anticipation of feed stimulating oxytocin release

345
Q

What type of secretion do breast alveoli (acini) have?

A

Apocrine

346
Q

ToB Describe the 3 types of cellular secretion

A

Apocrine - part of cell pinches off
Holocrine - cell dies
Merocrine - products released in vesicles

347
Q

Describe the changes in breast tissue that occur during the menstrual cycle

A

In follicular phase: lobules are quiescent
After ovulation: proliferation of cells and stromal oedema
At menstruation: decreased size of lobules

348
Q

How does the breast tissue change in pregnancy?

A

Increased size and number of lobules
Decreased volume of stroma
Acini distend and increase in number

349
Q

Why are mammograms easier to interpret in older women?

A

During aging interlobular stroma of breasts replaced by adipose tissue

350
Q

How does the breast tissue change a menarche?

A

Increased number of lobules

Increased volume of interlobular stroma

351
Q

What type of breast pain is concerning? What may it be due to?

A

Focal and non-cyclical

Ruptured cyst, injury, inflammation, or less commonly breast cancer

352
Q

Give a differential diagnosis for a palpable breast mass

A

Cyst
Fibroadenoma
Invasive carcinoma

353
Q

What features of a breast mass would be concerning?

A

Hard, craggy, fixed

354
Q

What questions would be important to ask a patient with spontaneous nipple discharge?

A

Nature of discharge - milky, bloody, serous?
Bilateral or unilateral?
Medications, history or family history of breast cancer, general health

355
Q

List some causes of nipple discharge and describe how they would present

A

Papilloma - bloody discharge
Pituitary adenoma - milky, often bilateral
Medication side effect - milky, often bilateral

356
Q

What do densities and calcifications on a mammogram suggest?

A

Densities - invasive carcinomas, fibroadenomas, cysts

Calcifications - ductal carcinoma in-situ, benign changes

357
Q

Why can breast pathology sometimes be seen in the axilla or groin (for example)?

A

Accessory breast tissue can be found anywhere along milk line

358
Q

What is polythelia?

A

Accessory nipple

359
Q

Describe the aetiology, presentation and treatment of acute mastitis

A

Bacterial, often Staphlococcus aureus, infection from cracked nipple during breast feeding
Erythematous painful breast, pyrexia
Antibiotics and express milk (discard milk)

360
Q

If there is a history of trauma to the breast, what cause of a mass would you consider?

A

Fat necrosis

361
Q

What benign breast changes can mimic carcinoma clinically and mammographically?

A

Fat necrosis
Fibrocystic change
Finroadenoma

362
Q

What is a mobile breast mass, particularly in a young woman, likely to be?

A

Fibroadenoma

363
Q

Describe the histology of a Phyllodes tumour

A

Nodules of proliferating stroma covered by epithelium

Stroma more cellular and atypical than in fbroadenoma

364
Q

Can a Phyllodes tumour be malignant?

A

Yes but only

365
Q

How common is fibrocystic change?

A

Very!
Most common breast lesion
Almost invariablely present in older women

366
Q

Describe the histology and macroscopic appearance of a fibroadenoma

A

Mixture of stromal and epithelial elements, smooth outline

Well circumscribed, rubbery, greyish white

367
Q

Describe 5 causes of gynecomastia

A

Puberty - oestrogen peaks earlier than testosterone
Klinefelter’s syndrome - XXY
Liver cirrhosis - oestrogen excess as not metabolised
Testicular tumor - gonadotropin excess
Drugs such as spironolactone, digitalis, alcohol, marijuana, anabolic steroids, heroin

368
Q

Which histological classification of breast cancer is the most common?

A

Adenocarcinoma

369
Q

In what area of the breast do most cancers develop?

A

Upper outer quadrant

370
Q

What are the risk factors for breast cancer?

A 
Gender
Obesity and high fat diet
Uninterrupted menses
Breast feeding
Early menarche and/or late menopause
HRT
BRCA mutation
Radiation eg for Hodgkin's lymphoma
371
Q

If a woman carries the BRCA1 or BRCA2 genes, what is her lifetime risk of breast cancer?

A

60-85%

372
Q

Describe the histology of ductal carcinoma in situ (DCIS)

A

Central necrosis (comedo) with calcification

373
Q

How is ductal carcinoma in situ (DCIS) likely to present?

A

Calcifications on mammography

374
Q

Describe the presentation of Paget’s disease of the breast

A

Red, crusting nipple, unilateral

375
Q

What is the most common type of invasive carcinoma of the breast?

A

Invasive Ductal Carcinoma, No Special Type

376
Q

Describe the histology of invasive lobular carcinoma

A

Infiltrating cells in single file, cells often lack cohesion

377
Q

Describe the signs of invasive carcinoma

A

Peau d’orange

Newly inverted or retracted nipple

378
Q

Why is it much better to detect invasive carcinoma by mammography than palpation?

A

By the time masses become palpable >50% of patients will have lymph node metastatis

379
Q

Where does breast cancer tend to metastasise to?

A

(thinking, drinking, boning, breathing)

Brain, liver, bone, lungs

380
Q

What factors affect the prognosis in breast cancer?

A

Type and subtype
Tumour grade and stage
Gene expression profile

381
Q

Describe how you would investigate a case of suspected breast cancer

A

Triple approach:
Clinical - history, family history, examination
Radiographic imaging - mammogram and ultra-sound
Pathology - fine needle aspiration cytology, core biopsy

382
Q

What therapeutic approaches are available for breast cancer?

A

Breast surgery - mastectomy or breast conserving
Axillary surgery- sentienal node sampling, then may need axillary dissection
Radiotherapy
Chemotherapy
Hormonal treatments -depending on receptor status - oestrogen on Her2

383
Q

Why has the survival rate for breast cancer improved in recent decades?

A 
Early detection
Neoadjuvant chemo
Use of newer therapies eg herceptin
Gene expression profiles
Prevention in familial cases
384
Q

Why is having a partner with carcinoma of the penis a risk factor for cervical carcinoma?

A

Associated with HPV

385
Q

How does HPV cause cervical intraepithelial neoplasm (CIN) or cervical carcinoma?

A

Infects immature metaplastic squamous cells in transformation zone of cervix ->
Produce viral proteins E6 & E7 ->
These interfere with tumour suppressor protein activity ->
Cells become unable to repair DNA and cellproliferation results

386
Q

How may cervical carcinoma present?

A

Screening abnormality

Post-coital, intermenstual or post-menopausal bleeding

387
Q

Which lymph nodes may be affected in cervical carcinoma?

A

Para-cervical
Pelvic
Para-aortic

388
Q

Describe the grading and corresponding treatment of cervical intraepithelial neoplasm

A

CIN I - follow up or cryrotherapy
CIN II - superficial excision - cone or LLETZ
CIN III - “

389
Q

How likely is it that cervical intraepithelial neoplasm will lead to invasive carcinoma?

A

10% progress to invasive carcinoma in 2-10 years

390
Q

What histological classification of cervical cancer is most common?

A

80% squamous cell carcinoma

391
Q

What is an exophytic cervical carcinoma & what other type of cervical carcinoma is there?

A

One that protrudes

Other type is infiltrative

392
Q

Why is cervical carcinoma suitable for screening?

A

Cervix visible and accessable for sampling
Slow progression
Papanicolaou (pap) test can detect precursor lesions and low stage cancers

393
Q

How can the presence of carcinoma in a cervical scrape sample be identified?

A

Microscopic examination with papanicolaou stain

394
Q

Why is it still important for HPV vaccinated women to be screened for cervical cancer?

A

Vaccine doesn’t protect against all high risk strains (only 16 and 18)

395
Q

MGD Describe a molecular method of testing for HPV

A

Southern blotting:
Digestion with restriction enzymes
Separation with DNA gel electrophoresis
Transfer onto common nylon or nitrocellulose filter with capillary action of paper towels or electrophorectic transfer
Hybridise filter with labelled DNA probes
Detection of hybridisationusing Xray film

396
Q

What are the risk factors for endometrial hyperplasia?

A

Prolonged oestrogen stimulation: anovulation, excess adipose tissue, HRT

397
Q

Does endometrial hyperplasia lead to endometrial carcinoma?

A

Yes, it is a frequent precursor to endometrial carcinoma

398
Q

Describe the histological features of endometrial hyperplasia

A

Increased gland-stroma ratio

Glands can be atypical in appearence

399
Q

Describe the epidemiology of endometrial adenocarcinoma

A

Usually 55-75 year old women, unusual before 40

400
Q

Why does endometrial carcinoma generally have a good prognosis?

A

Generally detected early as symptoms are irregular or post menopausal bleeding which women will tend to present to dr early with

401
Q

Describe the histological appearance of endometrioid endometrial adenocarcinoma

A

Mimics proliferative glands

402
Q

Describe the histological appearance of serous endometrial adenocarcinoma

A

Poorly differentiated

Exfoliating cells

403
Q

What are the risk factors for endometrioid endometrial adenocarcinoma?

A

Exogenous oestrogen (as typically arises from endometrial hyperplasia)

404
Q

Why does serous endometrial adenocarcinoma have a worse prognosis that endometrioid?

A

It is aggressive

Cells tend to exfoliate, travel through Fallopian tubes and implant on peritoneal surfaces

405
Q

What symptoms can leiomyomas (fibroids) cause?

A

Heavy / painful peroids
Urinary frequency
Infertility

406
Q

Describe the histological and macroscopic appearance of leiomyomas

A

Bundles of smooth muscle (identical to normal myometrium)

Well-circumscribed, round, firm and whiteish

407
Q

Are uterine fibroids (leiomyomas) likely to become malignant?

A

No - malignant transformation probably doesn’t occur

408
Q

Describe the behaviour of leiosarcomas

A

Highly maligant

Metastatise early to lungs

409
Q

How likely is it that an ovarian tumour is malignant?

A

Unlikely, 80% are benign

410
Q

What is the serum CA125 test used for?

A

For diagnosis and monitoring of maligant ovarian tumours

411
Q

What symptoms may ovarian tumours present with?

A

Abdo pain and/or distension
Urinary and GI symptoms
Ascites if malignant
Can cause hormonal problems such as mentsrual distirbances

412
Q

Why is the prognosis for ovarian cancer poor?

A

Tends to present late as symptoms are very vague, by this point often have spread to regional lymph nodes and elsewhere

413
Q

Where may ovarian tumours have metastasised from?

A

Most commonly Mullerian tumours (uterus etc)
GI system
Breast

414
Q

What are the 4 main categories of ovarian tumours?

A 
(MEGS)
Metastatic
Epithelial
Germ cell
Sex-cord stromal tumours
415
Q

What are the risk factors for epithelial ovarian tumours?

A

Nulliparity or low parity (maligancy thought to arise after breaching and repair of ovarian epithelium on ovulation)
Smoking
Endometriosis
BRCA1&2 and other heritable mutations

416
Q

Describe the 2 most common types of monodermal ovarian teratomas

A

Struma ovarii - benign thyroid tissue which can be functional and cause hyperthyroidism
Carcinoid - can produce 5HT leading to carcinoid syndrome (diarrhoea, abdo pain, increase HR, anorexia, skin flushing, breathlessness and wheeziness)

417
Q

Describe the 3 types of epithelial ovarian tumours

A

Serous - friable and delicate, often spread to peritoneum
Mucinous - often large cystic masses, usually benign or borderline
Endometroid - contain tubular glands resembling those of the endometrium

418
Q

Why may the presence of endometrioid epithelial ovarian tumours be concerning?

A

Significant % associated with endometrial adenocarcioma (probably arising separately)

419
Q

What abnormal blood test finding would you expect in non-gestational choriocarcinoma?

A

Raised hCG

420
Q

What abnormal blood test finding would you expect in a patient with yolk sac tumours?

A

Raised alpha fetoprotein

421
Q

What type of ovarian teratoma is malignant?

A

Immature teratoma (fortunately this is rare)

422
Q

What is the most common type of ovarian teratoma?

A

Mature (benign) teratoma

423
Q

What signs and symptoms may Sertoli-Leydig cell tumours present with?

A 
Breast atrophy
Amenorrhoea
Hair loss in male pattern
Hirsuitism
Clitoral hypertrophy
Voice changes
Sterility
424
Q

Which age group has the highest incidence of Sertoli-Leydig cell tumours?

A

Teenage girls and women in their 20s

425
Q

What do granulosa cell tumours cause?

A

Precious puberty
Endometrial hyperplasia and carcinoma
Breast disease

426
Q

What would teeth and/or hair in the ovary indicate?

A

A mature ovarian germ cell teratoma - also called a dermoid cyst

427
Q

What is the most common type of vulval cancer?

A

Squamous cell carcinoma

428
Q

What is the most likely cause of vulval cancer in a women in her 8th decade?

A

Longstanding inflammatory or hyperplastic conditions of the vulva such as lichen sclerosis

429
Q

Describe the aetiology of squamous cell carcinoma of the vulva

A

Around 30% arise from VIN, caused by HPV
Around 70% unrelated to HPV, often occur in longstanding inflammatory or hyperplastic conditions of the vulva such as lichen sclerosis

430
Q

Where does vulval cancer tend to spread to?

A

Inguinal, pelvic, iliac and para-aortic lymph nodes

then Lungs and liver

431
Q

Describe the prognosis for choriocarcinoma (gestational)

A

Good if diagnosed and treated - rapidly invasive and metastatises widely but responds well to chemo which very high cure rate

432
Q

What are the symptoms and signs of an invasive mole in the trophoblast?

A

Vaginal bleeding

Uterine enlargement

433
Q

What is a hyatidiform mole?

A

A cystic swelling of chorionic villi and trophoblastic proliferation

434
Q

Why might an invasive mole require hysterectomy?

A

Can cause uterine rupture

435
Q

What are the potential causes of elevated hCG?

A

Pregnancy
Choriocarcinoma - gestational or non-gestational
Invasive mole of uterus

ESA4 Old syllabus (3 decks)

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