Repro Flashcards
describe 4 differences between the male and female pelvis
- male pelvis has a deep greater (false) pelvis whereas the female greater pelvis is shallow.
- the male pelvic inlet is heart shaped but the female pelvic inlet is more oval shaped
- the male sub-pubic angle is narrow whereas the female sub-pubic angle is wide.
- the male obturator foramen is round but the female obturator foramen is oval.
- males have a large acetabulum but females have a small one
- females comparatively have a larger pelvic outlet than males
the piriformis muscle lies posterior to the obturator internus muscle - true or false?
true
name the 4 parts of the male urethra
- preprostatic
- prostatic
- membranous (widest part - this is where the bulbourethral gland joins the urethra
- spongy
sperm are stored in the epididymis - true or false?
true
what is the function of Sertoli cells?
- they function to form the blood-testis barrier - blood seminiferous barrier
- they also function to move the developing sperm towards the lumen.
- provision of nutrients to the sperm
- removal of wastes from developing sperm as well as the removal of excess cytoplasm following cell divisions
- support spermiation - mature spermatid is released from sertoli cells into the seminiferous tubule lumen prior to their passage to the epididymis
what are the 3 main processes which must take place for the production of new sperm
- spermatogenesis
- meiosis
- spermiogenesis
the formation of a new sperm takes around 75 days
what is the purpose of the pampiniform plexus?
temperature regulation.
arterial blood going to the testis enters a dense network of capillaries coming from the testis and epididymis before reaching the spermatic cord. the arterial blood is cooled by venous blood and helps maintain a constant testicular temperature.
suggest 3 factors which may affect spermatogenesis
- temperature - in health should be 2 degrees below body temperature
- endocrine - decreased gonadotrophins and anabolic steroids
- loss of blood-testis barrier - physical damage
- immunological reactions - auto-immune
- environment - occupation, radiation, smoking, alcohol
- medication - chemo, anti-hypertensives, anti-depressants
give some of the general effects of androgens
- deepen the voice
- increase male body hair
- increased sebaceous gland activity
- increase protein anabolism
a surge in Follicular stimulating hormone (FSH) will result in ovulation around 36 hours later. true or false?
false.
there is a surge in luteinizing hormone (LH) 36 hours before ovulation
Where is GnRH released in the body?
the hypothalamus
it will then stimulate the release of LH and FSH from the anterior pituitary
LH and FSH are released from the posterior pituitary gland along with oxytocin. true or false?
false. LH and FSH are released from the anterior pituitary
what are the respective functions of LH and FSH?
LH - maintaining the dominant follicle and induce follicular maturation and ovulation. it is also responsible for stimulating CL (corpus luteum) function
FSH - stimulation of follicular recruitment and development
where is oestradiol released? also, what is its function?
oestradiol is released from the granulosa cells.
it will support female characteristics and reproductive organs. allows for negative feedback control of LH and GnRH except for later follicular phase - positive control of LH surge, stimulates proliferative endometrium, negative control of FSH.
Where is progesterone released?
progesterone is released from the corpus leuteum to maintain secretory endometrium, negative feedback control of the HPO axis
where is the site of sperm production in the testis?
seminiferous tubules.
what is the function of the rete testis?
carries sperm from the seminiferous tubules to the efferent ducts. It is the counterpart of the rete ovarii in females.[1] Its function is to provide a site for fluid reabsorption.
what are the typical LH and FSH levels in males?
LH - 1-8
FSH - 1-11
what is the name of the female hormone that is able to elicit both negative and positive feedback control of its prohormones?
oestrogen
a low oestrogen concentration will result in negative feedback most of the month
however
a high oestrogen concentration will result in positive feedback during ovulation
what are the 4 main ligaments fo the uterus?
broad - mesovarium, mesosalpinx and mesometrium
round
suspensory
ovarian
morning sickness is worse when the mother has twins or has a molar pregnancy. true or false?
true morning sickness heavily correlates with HCG levels
a complication of morning sickness is hyperemesis gravidarum
cardiac output increases during pregnancy - true or false?
true.
this also causes the HR to rise and thus women complain of palpitations. At term, blood flow to the uterus must exceed 1L/min
it is important to note that BP will decrease in the second trimester.
what is the effect of pregnancy on the maternal urinary system?
- increase by up to 50%, GFR will increase similarly.
- serum creatinine and urea will decrease (due to increased GFR and the dilution of increased plasma volume)
- increased urinary stasis and hydronephrosis (but this is physiological) - can lead to an increased risk of hydronephrosis.
there is no change in iron requirements by a woman in pregnancy. true or false?
false.
iron requirements increase by 1g. iron supplements should be given if the Hb drops below 110
WBC increases slights and plasma volume and RBC mass also increase.
platelet count will fall by dilution.
what happens to platelet count in pregnancy?
it will fall - due to dilution.
suggest 5 general health measures women should take before pregnancy
- improve diet - obesity affects rates of miscarriage and still-birth. may be challenging when measuring fundal height (monitoring fetal growth). venous thromboembolic events are also more common in obese patients.
- optimise BMI
- reduce alcohol consumption - associated with foetal abnormalities and learning disability
- smoking cessation
- folic acid - 400 mcg daily
- age - teenagers (lack of support, smoke more, antenatal care may suffer), >40 (more prone to having medical conditions or develop complications such as gestational diabetes and hypertension
- parity
- occupation
- substance misuse - heroin, methadone etc can be addictive for the baby (withdrawal)
what is phenylketonuria?
inborn error of metabolism causing inability to metabolise phenylalanine. this can cause mental development impairment.
women with PKU need to restart low phenylalanine diet to prevent high levels reaching the developing foetus.
what is the most common thyroid disease in pregnancy?
hypothyroidism.
treatment is thyroxine. demand for thyroxine will increase during pregnancy, therefore, doses need to be increased. normal thyroxine levels are needed for foetal brain development.
a 22-year-old woman with type II diabetes presents to your clinic as her, and her partner wishes to have a baby. she is on an oral hypoglycemic.
what risks do you want to inform her of?
should you discontinue her medication?
risks of TIIDM in pregnancy :
- pre-eclampsia
- still-birth
- macrosomic infants (smaller babies)
yes, discontinue her medication - switch her to insulin.
what is the main concern for women with epilepsy when having a child?
effect of anti-epileptic medication on the baby.
sodium valproate is an extremely teratogenic drug
during pregnancy, the examination at 20 weeks, suggest 8 things that the women will be checked for.
- detect evolving hypertension
- urinalysis
- diabetes
- UTI
- abdominal palpation
- assess symphyseal fundal height
- estimate the size of baby
- estimate the liquor volume
- determine the foetal presentation
- listen to the foetal heart
what are 4 important infection screens a mother will receive?
- HIV - maternal treatment and careful planning reduces vertical transmission
- syphilis - easily treated with penicillin
- Hepatitis B - if infected can provide passive and active immunisation for the baby
- Rubella - antibodies indicating immunity due to prior infection or immunisation. rubella can result in mental handicap in the child, blindness, deafness and heart defects.
- MSSU - urinary tract infections
all women will receive the top 4 - with their consent
what are the consequences of syphilis infection in pregnancy?
- growth restriction
- hepato-splenomegaly
- anaemia
- thrombocytopaenia
- skin rashes
what is the treatment for iron deficiency anaemia in pregnant women?
Iron tablets
this is actually very common. blood counts are taken at around 28/40 weeks gestation. additional iron is required to make extra maternal RBCs as normal adaptation of pregnancy and needed by the developing fetus and placenta.
what are the antibodies present in Rhesus disease?
anti-D antibodies are present in Rhesus disease. Women who are rheesus negative are given Anti D IgG prophylactically and after potentially sensitising events.
if a rhesus negative woman is carrying a rhesus positive baby she will develop anti-D antibodies if the fetal RBC enter the maternal circulation. it may result in a miscarriage or ectopic pregnancy etc. antibodies will tend to develop during the first pregnancy.
in subsequent pregnancies, the maternal antibodies will cross the placenta and cause the destruction of the fetal red blood cells cause fetal anaemia. screening can allow identification of women at risk (Rheesus negative women) and give them passive immunity to destroy all fetal RBC in maternal circulation before the maternal immune system has opportunity to be activated and produce its own antibodies.
suggest 3 things that will be checked at a woman’s first baby scan (on the US)
- viability of pregnancy
- multiple pregnancies
- abnormalities incompatible with life.
- Down’s syndrome screening
trisomy of which chromosome causes Down’s syndrome?
trisomy 21.
the incidence of Down’s increases with advancing age and family history
at how many weeks is first-trimester screening carried out?
10-14 weeks gestation.
it will use maternal factors such as:
- serum B-HCG
- pregnancy-associated plasma protein A (PAPP-A)
- fetal nuchal translucency (NT)
other tests include:
- chorionic villi sampling
- amniocentesis
- non-invasive prenatal testing (testing maternal blood for fetal cell DNA)
- alpha feto-protein
what is the purpose of the second-trimester scan?
detecting fetal abnormalities
- 50% with T21 will have a normal detailed USS
- 17% with T18 will have a normal USS
- 9% with T13 will have a normal USS
is the Egg a haploid or diploid cell?
haploid.
progesterone, testosterone and oestrogen are all steroid type hormones. true or false?
true.
where do LH and FSH act?
they both act on the ovaries.
LH and FSH will initiate the growth of new follicles, beginning a new ovarian cycle
the ovaries will then go on to produce steroid hormones - oestrogen and progesterone
oestrogen has positive feedback during days 12-14 but will have negative feedback during most of the cycle.
when in the month roughly does ovulation occur?
ovulation tends to occur mid-month - around day 14.
the corpus luteum is formed after this.
when is the endometrial wall thickest?
the endometrial wall is thickest at day 28 - towards the end of the month but grows from day 5.
at what week of pregnancy is a fetal heartbeat able to be detected?
week 6
once a fetal pole is identified, a crown-rump length (CRL) measurement is made from one end of the embryo to the other.
the length of the embryo closely correlates with the gestational age of the pregnancy and allows an estimated due date (EDD) to be decided upon.
anencephaly is what type of disorder?
neural tube defect.
it results when the vault of the skull fails to develop. the brain is unprotected and becomes worn away - not compatible with life.
what may we look for on the first trimester US scan?
- gestational age
- diagnose miscarriage
- multiple pregnancies (2 fetal poles will indicate twins)
- exclusion of other abnormalities - hydatidiform, ectopic pregnancies (pregnancy outwith the uterus), anencephaly
- evaluation of maternal ovaries
what is the overall incidence of trisomy 21?
1 in 700
what is the simplest screening method for Down’s syndrome?
maternal age
incidences of chromosomal abnormalities increases with maternal age.
when is the CUB (combined US and biochemical) screen test carried out and what does it test for?
between 11 and 14 weeks.
if a patient books after this 14 weeks they can still receive a screening in the form a blood test for 4 serum markers between weeks 15 and 20:
- AFP
- total HCG
- unconjugated oestriol
- inhibin
if the patient has levels indicating a high risk then it will necessitate an invasive test to be performed such as an amniocentesis
suggest 3 measurements which could be taken from a mother that would aid in the diagnosis of a fetal chromosomal abnormality
- HCG
- PAPP-A
- nuchal translucency - crown-rump length (CRL)
- AFP is used to screen for neural tube defects
( a serum AFP of >2 MoM - multiples of median - is considered abnormal. an AFP test is offered to all women.
what is the aim of a second-trimester scan?
identify fetal structural abnormalities
what is the function of the third-trimester scan?
ensuring fetal well-being
in the 3rd trimester scan, there is no routine US as there is no evidence of any benefit. scans are indicated if the baby feels small or large for their dates. standard measurements involve the head, abdomen and femur.
what conditions are tested for in the neonatal blood spot test?
- sickle cell
- PKU
- hypothyroidism
- cystic fibrosis
in Tay Sachs disease, what is deficient?
Tay Sachs is a lysosomal storage disease in which hexosaminidase A deficiency results in the build-up of lipid GM gangliosides
there is progressive neurological deterioration and is fatal by 3-5 years old.
name the 4 different kinds of cells present in the testis
- interstitial (Leydig cells)
- Sertoli cells - support the sperm-producing cells and produce inhibin
- germ cells - produce sperm
- seminiferous tubules (containing sustentacular cells and spermatids
where are LH and FSH released from in the body?
they are released by the anterior pituitary
what are the respective functions of LH and FSH?
- LH will act on Leydig cells (interstitial cells ). this will go on to aid in the formation of androgens necessary for secondary sex characteristics (testosterone)
- FSH will act on the spermatogonia in the seminiferous tubules of the testes leading to spermatogenesis. FSH will act on the Sertoli cells
what does oligozoospermia mean and how does this differ from azoospermia?
a low concentration of sperm is oligozoospermia.
azoospermia means no sperm
each cycle of spermatogenesis will lead to the maturation of how many sperm cells?
4
In embryology, during which weeks does gastrulation, neurulation and somite formation take place?
during weeks 3.
what are the 3 embryological renal structures that from the genitourinary system?
- pronephros
- mesonephros
- metanephros
(the cloaca will divide to form the rectum and anteriorly the urogenital sinus)
in males, what embryological structure does the urinary bladder form from?
the urogenital sinus
the caudal end of the urogenital sinus will form the urethra and prostate. in males, the mesonephric duct is responsible for the production of the sex organs while the paramesonephric duct degenerates but…
in females, the mesonephric duct will degenerate and the paramesonephric duct will form the fallopian tube, uterus and cervical part of the vagina. the urogenital sinus will form the bladder and the lower part of the vagina.
what protein is responsible for transforming the indifferent gonads into Sertoli cells?
testis-determining factor (TDF) is the protein and it is encoded by the SRY (sex determining region Y). expression of SRY will form the Sertoli cells.
The Sertoli cells will then secrete MIS (Mullerian-inhibiting substance). MIS promotes the formation of the Leydig cells. after the secretion of MIS then the paramesonephric duct will degenerate.
Leydig cells are responsible for producing testosterone. remember that the Leydig cells are not formed from the epithelium
name 3 complications of undescended testes
- infertility
- malignant transformation (germ cell tumour)
- testicular torsion
management of undescended testes is with an orchiopexy.
what is the effect of pregnancy on the renal system?
- dramatic dilation of the urinary collecting system
- increased renal plasma flow
- GFR increases and creatinine clearance will increase
- protein excretion is increased and microscopic haematuria may be present
- 80% of women develop oedema and glycosuria is common
- urate increases with an increasing gestation
- . urea and creatinine levels will decrease
pregnancy will increase a woman’s platelet count - true or false?
false - platelet count will decrease
WCC, on the other hand, will increase.
when taking an Obs and Gynae history - what are 4 things that you should not forget to inquire about?
- LMP
- Cycle
- contraception/sexually active
- last smear test
suggest 4 common conditions to look out for when taking an Obs and Gynae history
- menorrhagia
- prolapse
- pelvic pain
- early pregnancy bleeding
suggest 4 things we are looking for when performing a vaginal exam
- position
- size
- mobility
of the uterus
- adnexal masses
- tenderness
- cervical excitation
what is the most common kind of contraception?
the combined oral contraceptive pill (COCP)
what are the different methods of using the progesterone only pill?
- pill
- injectable
- implant
all methods of contraception should be 100% reversible - true or false?
true. they should also be 100% effective however no options are actually 100%. the best bet is a vasectomy followed by an implant.
what is the safest type of contraception?
vasectomy followed by an implant
condoms are generally good protection against STIs. Name 2 viruses that condoms don’t protect against
- HSV
2. HPV
what are the two main hormone components of the oral contraceptive pill?
- ethinyloestradiol (EE)
- synthetic progesterone (progestogen)
the COCP is usually taken for 21 days and then there is a pill free week
what is the mode of action of the combined oral contraceptive pill
- it will prevent ovulation by removing the surge of FSH and LH.
2, it will prevent implantation by providing an inadequate endometrium
- it inhibits sperm penetration of the cervical mucus by altering the quality and character of the mucus
suggest a risk associated with using the COCP (combined oral contr…)
- it increases the risks of developing a VTE
- increase in risk of ischaemic stroke
- breast cancer risk
- cervical cancer
suggest some benefits of using the COCP (combined oral contra…)
- reduction in functional ovarian cysts
- 50% reduction in ovarian and endometrial cancer
- improvement in acne
- reduction in benign breast disease, RA, colon cancer
- reduction in osteoporosis
suggest 4 factors aside from the COCP for increased risk of developing a serious VTE
- major surgery and immobility
- thrombophilias
- family history of VTE in those who are aged 45 and younger
- BMI over 30
- underlying vascular disease
- post-natally within 21 days
when using the progesterone only pill (POP) how many days off should you take?
none. there are no pill-free days with the progesterone only pill.
the maximum effect of POP is 48 hours after ingestion.
what is the mode of action of the depot contraception method?
the depot - depot medroxyprogesterone acetate (Depo-Provera) will act by preventing ovulation and altering cervical mucus making it hostile to sperm. it prevents implantation by rendering the endometrium unsuitable.
it is very useful for those who are forgetful - given as an IM injection once every 12 weeks and doesn’t contain oestrogen
what are some of the side effects of using the depot as contraception?
- delay in return to fertility
- reversible reduction in bone density
3 problematic bleeding - weight gain
the marina contraception acts by thinning the endometrium - true or false?
true
it is composed of copper which creates a toxic environment for fertilisation
what is the most effective option for emergency contraception?
CU-IUD (copper intra-uterine device )
it can be used up to 72 hours of unprotected sex
levonorgestrel and newer options are available that cover up to 120 hours. it is less effective however than ongoing contraception.
what is a vasectomy?
a vasectomy is the permanent division of the vans deferens under local anaesthetic.
there is no evidence of a reduction in testosterone and semen will remain the same colour and volume. there is no evidence that vasectomy predisposes to testicular cancer or prosthatic cancer
males that are about to receive a vasectomy should be informed of which 3 things?
- low failure rate in terms of post-procedural pregancies
2. there is less risk associated with the procedure than sterilisation carried out by laparoscopy and laparotomy
at what stage does a termination of pregnancy need to be referred to England?
after 20 weeks.
however, remember that the earlier the procedure, the less the complications.
what are the 3 main types of emergency contraception?
- ellaone (ulipristal cetate) should be given within 120h of unprotected sex. efficacy is not reduced by obesity but levonorgestrel may be)
- levonelle
- IUD - copper coil
suggest 2 forms of non-hormonal contraception
- condoms
- IUD
- diaphragms
- caps - diaphragm stretching from pubic bone to posterior fornix (fit over the cervix)
suggest 4 types of hormonal contraception
- OCP
- contraceptive patch (transdermal)
- vaginal ring
- injection (depot)
suggest 4 risks of using an intrauterine contraceptive device (IUCD)
- they may be expelled
- associated with pelvic inflammatory disease
- risk of ectopic pregnancy
- can cause dysmenorrhoea and menorrhoea
what are 4 contraindications for using an IUCD (intrauterine contra….)
- active pelvic infection/STD
- pregnancy
- allergy to copper
- Wilson’s disease
- heavy painful periods
- gynae malignancy
IUCD will tend to last around 5 years.
can a woman use an IUCD (intrauterine contrac…)if she is pregnant
yes. but do warn the patient about spotting +/- heavy bleeding for the first few weeks following insertion.
what should you discuss with the patient before offering emergency contraception? suggest 6 things
- history of LMP
- normal cycle
- number of hours since unprotected sex
- contraindications to later COCP
- check BP
- explain teratogenicity has not been proven
- discuss future contraception
- offer an infection screen to cover HIV
- offer a follow up in 3-6 weeks if coil is inserted
how long does the patient have to use levonorgestrel after having unprotected sex?
72h
suggest 4 reasons for not using combined hormonal contraception
- venous disease - current or past VTE or giving sclerosing treatment for varicose veins
- arterial disease - avoid if valvular or congenital heart disease
- liver disease- hepatitis, cirrhosis etc
- cancer - breast cancer
- previous pregnancy complications -pruritis, obstetric cholestasis, chorea
- hepatic enzymatic drugs - avoid if taking rifampicin or rifabutin
a migraine with stroke is an absolute contraindication for combined oral contraceptive pill use - true or false?
true
suggest 4 short-term side effects of combined hormonal therapy use
OESTROGENIC
- breast tenderness
- nausea
- cyclical weight gain
- bloating
PROGESTOGENIC 1. mood swings 2. PMT 3. vaginal dryness 4. sustained weight gain decreased libido
HEADACHE
BREAKTHROUGH BLEEDING
suggest 4 risks of using combined hormonal contraception
- VTE risk is doubled
- ischaemic stroke
- breast and cervical cancer
- mood changes
suggest 4 benefits to using combined hormonal therapy
- improvement in acne
- decreased menorrhagia
decreased ovarian, endometrial and bowel cancer
4, decreased menopausal symptoms
what is the method of action of progesterone-only contraceptives?
- thicken cervical mucus
- reduce receptivity of the endometrium to implantation
- inhibit ovulation
they also have advantages of reducing pelvic infection and are used where oestrogen-containing contraceptives are contraindicated.
suggest 4 reasons to avoid a progesterone-only contraception method
- current breast cancer
- trophoblastic disease
- liver disease
- new symptoms or diagnosis of migraine with aura/IHD/stroke
- avoid if SLE with antiphospholipid antibodies
- undiagnosed vaginal bleeding should be investigated before starting
name 4 side effects of using the progesterone only pill
- higher failure rate than COCP
- menstrual irregularities
- increased risk of ectopic pregnancy
- functional ovarian cysts
- breast tenderness
- depression
- acne
- reduced libido
- weight change `
how long will one progesterone implantation give contraception for?
3 years
it has no impact on bone density
in contraception, what is meant by ‘sterilisation’
sterilisation is the permanent, irreversible contraception.
reversal i sonly 50% in either sex and is never funded by the NHS.
a Filshie clip is used for females.
vasectomy is safe than female sterilisation
prostaglandins and oxytocin will increase intracellular free calcium and hence stimulate uterine contraction for labour - true or false?
true
when does the first stage of labour end?
full dilatation
the first stage begins with regular contractions and ends in full dilatation
when does the second stage of labour end?
The second stage starts with full cervical dilatation and ends with delivery of fetus
what is the third stage of labour?
The 3rd stage is the period in between delivery of fetus and delivery of placenta and fetal membranes.
suggest 4 reasons for a woman to have induced labour
induction of labour is when an attempt is made to instigate labour artificially using medications and/or by artificial rupture of membranes (performing an amniotomy)
- diabetes
- post-dates
- maternal health problem that necessitates planning of delivery
- fetal reasons (oligohydramnios)
whta scoring system is used to clinically asses the cervix for cervical ripening?
the bishops score
the higher the score the more progressive change there is in the cervix and this indicates that induction is likely t be successful.
a lower score indicates that induction may be more likely to fail but can still be attempted once the cervix has dilated and effaced, an amniotomy can be performed
what are the parameters of the Bishops score?
- deliation (cm)
- length of cervix (effacement) (cm)
- position - posterior, mid or anterior
- consistency - firm, medium or soft
- station (cm)
assuming that the cervix is not dilated or has not effaced (a low Bishops score) what methods can be taken to bring the woman higher up on the scale?
- vginal prostaglanings
2. once cervix has dilated and effaced, an amniotomy can be performed
what is an amniotomy?
artificial rupture of the fetal membranes (waters) usually using a sharp device.
once amniotomy is performed, IV oxytocin can be used to achieve adequate contractions - aim for 4-5 in 10 mins
what are the 3 P’s of labour?
P - power (contraction)
P - passages (pelvic tract)
P - passenger (baby)
what does cephalopelvic disproportion (CPD) mean?
the fetal head is in the correct position for labour but is too large to negotiate the maternal pelvis and be born. in these circumstances the babies head becomes compressed and caput and moulding develop
aside from cephalopelvic disproportion, (CPD) name another reason why there may be inadequate progress in pregnancy
- malposition - foetal head is in the incorrect position for labour and relative CPD occurs.
the two main presentations are occipito-posterior and occipito-transverse - malpresentation (transverse, shoulder, hands, breech, oblique lies)
- inadequate uterine activity - give synthetic IV oxytocin after excluding obstruction
- ovarian cyst/fibroid
- foetal distress
babies can’t be born if they are in the position
left occipito transverse or
right occipito transverse
true or false?
true
suggest 3 things to check foetal well-being in labour
- intermittent auscultation of the fetal heart
- cardiotocography (CTG) - when there are too many contractions to keep up
- fetal blood sampling - when suspicious or pathological CTG. pH will give a measure of likely hypoxaemia - are they getting enough oxygen
- fetal ECG
suggest some complications of performing a C-section
- infection
- bleeding
- VTE
- visceral injury
what is a very serious complication that can occur in the 3rd stage of labour?
retained placenta
for post-partum haemorrhages what are the 4Ts?
tone
trauma
tissue
thrombin
what is primary postpartum haemorrhage?
blood loss >500ml within 24 hours of delivery
what is secondary postpartum haemorrhage?
blood loss>500 from 24 hours postpartum to 6 weeks
this can be caused by
- retained tissue
- endometritis (infection)
- tears
- trauma
suggest 5 common postnatal problems women have
- postpartum haemorrhage
- venous thromboembolism
- sepsis
- psychiatric disorders of the puerperium
- preeclampsia
what are the causes of primary postpartum haemorrhage
- uterine atony
- local causes such as traumatic tears to perineum/vagina/cervix
- retained tissue/placenta
- coagulopathy
- 4Ts
tone
trauma
thrombin
tissues
what are 3 causes of secondary PPH (postpartum haemorrhage
- retained tissue
- endometritis
- tears/trauma
Women with DVT and PE can be relatively asymptomatic compared to their non-pregnant counterparts. suggest 3 reasons why you would be suspicious
- unilateral leg swelling and/or pain
- SOB
- chest pain
- unexplained tachycardia
why would you give LMW heparin to a woman you are concerned has VTE rather than warfarin?
warfarin is teratogenic
what investigations would you do to investigate VTE in a woman?
- doppler
- ECG
- CXR/VQ
- CTPA
treatment is with low molecular weight heparin
what should be done if you suspect a pregnant woman has sepsis?
- IV antibiotics
- full septic screen
- blood cultures
- LVS
- MSSU
- wound swabs - IV fluids
Almost half of women who died between six weeks and one year after pregnancy died from mental-health related causes
true or false?
false.
1/4 women who died between 6 weeks and 1 year after pregnancy died from mental-health related causes.
name 2 common psychiatric problems affecting pregnant women
- postnatal depression
2. puerperal psychosis
what is the function of progesterone?
progesterone will turn the endometrium into the decidua basalis
- increased vascularity between the glands and vessels
- stromal cells enlarge and become pro-coagulant (stops them bleeding).
- thickening of the endometrium
- increased vascularity if the cells
outside of pregnancy there is a monthly shedding occurs from the endometrium/decidual wall lining
what is the name of the cells that produce beta-hCG in the embryo?
trophoblasts
the b-hCG will act on the corpus luteum in the ovary. its function is to stimulate the corpus luteum to produce progesterone which stops the decidua from shedding
suggest 3 factors which may cause a miscarriage
- chromosomal abnormality
- infection
- maternal issues - ill-health, trauma, hormonal
suggest one medical treatment for an ectopic pregnancy
methyltrexate
typical presentations of an ectopic include
- raised b-hCG
- thickened lining of endometrium
- expanded fallopian tube
where is the most common site for ectopic pregnancies?
the fallopian tubes
what is the most common cause of a molar pregnancy?
2 sperm fertilize one egg
Molar pregnancies result in an imbalance in methylated genes (they become switched off).
Molar pregnancy under microscopy will show some enlarged chorionic villi with abundant trophoblasts.
A molar pregnancy has 2 lots of dad’s genes. This is a problem because in the testis, dad has inactivated several genes by adding methyl groups to stretches of DNA
A molar pregnancy is a form of precancer of trophoblast cells. If it persists can (rarely) give rise to a malignant tumour called choriocarcinoma.
what is the most common structural abnormality found in those with trisomy 21
duodenal atresia
TRisomy 21 can be confirmed with amniocentesis and can be first seen with nuchal thickening on an US
name 3 complications of diabetes in pregnancy
- malformations
- huge babies that obstruct labour (CPD?)
- intrauterine death
- neonatal hypoglycaemia
what is acute chorioamnionitis?
an ascending infection causing acute inflammation
- neutrophils present in membranes, cord and fetal plate of the placenta.
- bacteria are typically perineal/perianal flora (e.coli) which ascend vagina and get into the amniotic sac.
- neutrophils produce a cytokine storm which activates some brain cells, which then get damaged by normal hypoxia of labour
in the cervical spine, there are 8 vertebral bodies and 7 spinal nerves - true or false?
false - there are 7 vertebral bodies ad 8 spinal nerves
which myotome is responsible for the abduction of the arm (lateral deltoid)
C5
which myotome is responsible for the flexion of the hip?
L2
tetraplegia is caused by a lumbar spinal cord fracture - true or false?
false - it is caused by a cervical fracture
there is also the risk of respiratory failure due to the loss of innervation of the diaphragm (C3-5)
what is Brown-Sequard syndrome?
follows the hemi-section of the cord and is usually brought on by penetrating injuries.
patient’s will experience paralysis on the side affected (corticospinal) with a loss of proprioception and fine discrimination (dorsal columns). pain and temperature loss on the opposite side below the lesion is also seen (spinothalamic tract)
what is spinal shock?
transient depression of cord function below the level of an injury.
the patient will experience flaccid paralysis and areflexia. it can last several hours to days after injury
when taking a history from a woman regarding infertility, suggest 7 things you will want to discuss with her
- learn this well for OSCE and system exam
- age and duration of subfertility
- any previous pregnancies and does partner have children
- menstrual history
- regularity, pelvic pain, history of STI’s, previous surgery (tubal or ectopic for pregnancy)
- smoking reduces fertility as does drinking
- medical history and drug history to optimise both.
- frequency of sexual intercourse and any problems during sex including erectile dysfunction
- history of undescended testes, mumps
- duration of infertility
- previous contraception
- fertility in previous relationships
- menstrual history
- medical and surgical history
- sexual history
- previous investigations
- psychological assessment
what is hypospadia?
this is a condition in which the opening of the urethra is on the underside of the penis
genetic conditions such as Klinefelter’s (47 XXY) syndrome can also affect the size of the testis
suggest 3 tests that may be carried out at a fertility clinic
- pelvic US
- semen analysis
- tubal patency test
what are 3 common presentations of polycystic ovarian syndrome?
repeat this question as many times as possible - it is known as the Rotterdam criteria (2/3 need to be present for the diagnosis of PCOS)
- androgen excess
- hirsutism
- abnormal testosterone level
- polycystic ovaries
- found with US - infrequent periods
- anovulation
for ovarian disorders, weight plays a big role ion treatment - encourage the patient to achieve a BMI of between 18 and 35
suggest 5 methods of ovulation induction
- clomiphene citrate (binds to oestrogen receptors and thus tricks the hypothalamus into believing the body is in a hypoestrogenic state - triggering anterior pituitary to release more FSH
it also has vasomotor and visual side effects.
- gonadotrophins - used in specialist centre for clomiphene resistant PCOS or low oestrogen with normal FSH.
- Laparoscopic ovarian drilling - only to be used in women with PCOS
- weight loss or gain
- metformin
what does amenorrhoea mean?
amenorrhoea means the absence of menstrual periods
what investigations do you want to carry out for a patient presenting with azoospermia?
- history
- examination
- FSH, LH, karyotype and PRL
- CF screen
suggest the 4 most common factors causing sub-fertility
- male factors:
- semen abnormality (alcohol, nicotine, varicocele and cancer)
- azoospermia
- immunological
- coital dysfunction
- anovulation - can be caused by premature ovarian failure, turner’s syndrome, surgery, chemo etc
- unexplained
- endometriosis
- tubal factor
suggest 4 primary care investigations of subfertility
- chlamydia screening
- baseline hormonal profile (day 2-5 FSH and LH)
- TSH, prolactin, and testosterone and rubella status (vaccinate if not immune)
- mid-luteal progesterone level to confirm ovulation
- semen analysis - repeat in 3 months if abnormal
suggest 4 secondary care investigations of subfertility
- transvaginal sonography (TVS) - ruling out adnexal masses, submucosal fibroids or endometrial polyps, or help confirm PCOS - polycystic ovarian syndrome
- hysterosalpingogram (HSG) to demonstrate uterine anatomy and tubal patency.
may cause period-like cramping and tubal spasm, giving false positive - only do when the chlamydia swabs are negative - hysterosalpingo-sonography uses US contrast and TVS
- laparoscopy and dye test - gold standard test for assessing tubal patency
suggest 5 factors that may effect the success rates of IVF
- age
- duration of subfertility
- previous pregnancy (higher success rate)
- smoking
- high BMI (low success rate)
- low anti-mullerian hormone (AMH) predict a poorer response
in males, where does spermatogenesis take place
seminiferous tubules
in males, what is the function of LH?
in males, the function of LH is to stimulate Leydig cells to produce testosterone.
the testosterone and FSH will stimulate Sertolli cells to produce essential substances for metabolic support of germ cells and spermatogenesis
plasma FSH is raised in testicular failure - true or false?
true
what tests should you perform on a male experiencing subfertility?
- plasma FSH
- testosterone and LH (androgen deficiency)
- karyotype - to exclude 47XXY
- CF screening (CBAVD - Congenital Bilateral Absence of the Vas Deferens)
main treatment (aside from lifestyle measures) is ICSI
what are the 8 stages of normal labour/birth
- engagement
- descent
- flexion
- internal rotation
- extension
- restitution and external rotation
- expulsion
what stage of labour involves pushing?
stage 2
what are the 3 phases during stage 1 of labour?
- latent phase (0-3cm)
- active phase (3-7cm>)
- transition phase (7-10cm>)
what is the difference in function between the chorion and the amnion
the chorion is responsible for providing the baby with nutrition
the amnion is responsible for providing the baby with warmth and protection
suggest 2 complications of having monoamniotic, monochorionic babies
- placental insufficiency of one of the babies
- cord entanglement
- twin-twin transfusion syndrome
- malpresentation
- hypoxia of the second baby
what is an induction of labour?
this is when an attempt is made to instigate labour artificially using medications and/or by artificial rupture of the amniotic membranes - amniotomy
what is the name of the score used to check cervical ripening?
the bishops score
the higher the score, the more progressive change there is in the cervix and indicates that induction is likely to be successful. a lower score indicates that induction is likely to take longer and may occasionally fail but can still be attempted
what are the 5 factors considered in the bishop’s score?
- dilatation (cm)
- length of cervix (effacement)
- position
- consistency
- station
suggest 3 absolute contraindications of labour
- fetal lie is not longitudinal (you don’t intentionally want to encourage the onset of labour with an abnormal lie)
- known pelvic obstruction ( a tumour or ovarian cyst)
- placental praevia - need C-section due to placental position
- cardiac disease
- fetal distress
relative contraindications include:
- previous c section - uterus has a scar which is at risk of dehiscence if you artificially stimulate labour
- asthma - can cause respiratory smooth muscle contraction
what are the main methods of labour induction?
- oxytocin
- initiates uterine contractions by attaching to the uterine oxytocin receptors; increases the frequency and force of contractions.
- oxytocin is released by the posterior pituitary gland
- women need CTG because there is a risk of uterine hypertonicity
- may lead to hypotension and hyponatraemia
- prostaglandins
- eicosanoids (arachidonic acid derivation)
- they encourage cervical dilatation and effacement - ripening the cervix so it can be used in the induction of labour. the analogues are inserted PV and placed in the posterior fornix
- can lead to N&V, bowel upset, pyrexia and hypotension. be sure to continuously monitor the fetal heart (CTG)
what is meant by augmentation of labour?
augmentation of labour is required when contractions reduce in frequency or strength in active labour even after the spontaneous onset of labour.
what is the pharmacological management of the third stage of labour
- syntocinon - synthetic oxytocin and can cause uterine contractions
syntocinon can also be given as prophylaxis in post partum haemorrhage (PPH) in women where ergometrine is contraindicated (women who can’t receieve syntometrine)
- syntometrine - a mix of oxytocin and ergometrine (only given as M)
suggest some treatment options for primary post-partum haemorrhage (PPH)
- physical
- bimanual compression
- rubbing up a contraction - surgical
- pharmacological
- syntocinon: causes uterine contractions to treat/prevent PPH
- syntometrine
- carboprost - prostaglandin that causes uterine contractions
- misoprostol
- tranexamic acid - antifibrinolytic
what are the general actions of tocolytic drugs?
they function to inhibit uterine contractions
they can be used:
- to facilitate the transfer of a woman in labour to appropriate hospital/appropriate neonatal unit
- given to allow steroids enough time to work
- fetal distress/emergency CS/obstructed labour/hypertonic uterus causing fetal distress
what are the main recommended drugs for tocolysis?
- oxytocin receptor antagonist (atosiban)
- CCB - nifedipine
- B2 agonist - terbutaline, salbutamol (relaxation of smooth muscle)
- indometacin
what are the safest antihypertensives given to women during pregnancy?
- methyldopa
- hydralazine
- combined alpha and beta blockers - labetalol
labetalol is actually the first line treatment for hypertension (it is a combined alpha and beta blocker)
but be careful as it can be contraindicated in asthmatics and in some cardiac conditions such as bradycardias and cardiac failure.
what is the main drug given to women with symptomatic pre-eclampsia or thought to be at risk of eclampsia?
IV magnesium sulphate
ACEI and ARB’s are contraindicated in pregnancy - true or false?
true
spironolactone is also contraindicated
diclofenac and ibuprofen are contraindicated as analgesics
NSAIDs can cause closure of the ductus arteriosus
give 3 examples of simple analgesia and 3 examples of non-pharmacological analgesia
Non-pharmacological
- breathing exercises
- aromatherapy
- warm baths
- TENS therapy
Simple analgesia
- paracetamol
- codeine
- aspirin (avoid in labour as may increase risk of bleeding
- entonox (gas and air) - nitrous oxide
- opiates
- local anaesthetic
suggest 5 signs of local anaesthetic toxicity
- perioral tingling
- seizures
- confusion
- paraesthesia
- light-headedness
- drowsiness
