Repro Flashcards
State the layers of the testes
Skin Dartos External spermatic fascia Cremasteric fascia Internal spermatic fascia Tunica vaginalis Tunica albuginea
How do the abdominal wall layers change as they go into the testes
Abdo: External abdo oblique, internal abdo oblique, transversus abdominus
Testes: External spermatic fascia, Cremasteric spermatic fascia, Internal spermatic fascia
Which blood vessels are in the penis
Superficial (outer layer) and deep (one layer in) dorsal veins, plus dorsal artery and cavernous artery (in the cavernosum)
Which nerve is in the penis
Dorsal nerve
Tell me about the contents and structure of the spermatic cord
3 fascial layers: ex sperm fas, cremasteric, int sperm fasc
3 arteries: cremasteric, testicular, artery to vas
3 veins: cremasteric, testicular, vein to vas
3 nerves: ilioinguinal, cremasteric, sympathetics
Tell me about the lymphatic drainage of testes vs scrotum
Testes drained by para-aortic (that’s where they came from)
But scrotum via superficial inguinal
Tell me about the content of ejaculate
Prostate: 30%, enzymes to cut ejaculate clot and zinc for motility
Seminal vesicles: 60%, fructose for food
Bulbourethral glands: 10% alkaline and lube
5% sperm
Three zones of prostate and their locations
Central at the top and anterior, transitional in the middle and where BPH is, peripheral is inferior and posterior and what you feel on DRE where prostate cancer is
What are the 3 parts of the urethra and which is the narrowest and least distensible
Prostatic urethra, membranous urethra (narrowest and least distensible), spongy urethra
What are the 4 muscles in the root of the penIS
x2 ischiocavernosus
x2 bulbospongiosus
Fractured penis =
ruputured tunica albuginea
Describe the route of sperm
Out of seminiferous tubules, through epididymis, into vas deferens, joined by seminal vesicle stuff to make ejaculatory duct, join with prostatic urethra, joined by bulbourethral stuff in membranous urethra, then spongy urethra and out
Name scrotal swelling differentials
Hydrocoele, varicocele, spermatocele, epididymitis, inguinal hernia, testicular cancer, torsion, haematocoele, epididymal cysts
What’s a varicocoele and what would make it more concerning?
Distension of paminiform plexus. More concerning if on the right because this has acute angle of entry to IVC so suggests IVC compression
Where is a hydrocoele
Excess fluid in tunica vaginalis
Describe the progression of an ovarian follicle
Primary follicle, secondary follicle (antral follicle), tertiary follicle (Graafian follicle), ruptured follicle, active corpus luteum, regressing corpus luteum, corpus albicans
What’s the ovary covered by
Parietal peritoneum
What’s cervical ectropion?
Around the cervical external os appears red and inflamed but its a normal response to oestrogen during a menstrual cycle where the cervix unfurls a bit and you see the columnar cells come out
Where’s the commonest site for ectopic pregnancies and where does fertilisation normally occur
Ampulla for both- but once its fertilised it should move down to uterine cavity
What cells in the ampulla nourish the egg?
Peg cells!
Name uterine and ovarian ligaments
Broad ligament is big sheet of peritoneum over them all
Round ligament is remnant of gubernaculum and connects uterus to labia majora
Suspensory ligament connects ovaries to lateral wall
Ovarian ligaments connect ovary to uterus
What are the three components of the broad ligament
Mesovarium (supports ovary), mesosalpinx (supports ovary and uterine tube), mesometrium (supports inferior rest of it)
What are the parts of the uterine tube
Infundibulum (wide to catch eggs), ampulla (fertilisation and ectopic site), isthmus
On a microscope looking at the vagina, what would you see?
White gaps are glycogen to feed lactobacilli for low pH, cells are stratified squamous epi
What components make an indifferent gonad
Primordial germ cells and intermediate mesoderm
What is the cloaca
Caudal opening shared by GI, uro and genital, closed by cloacal membrane
Where does the uterus come from
The paramesonephric duct (which is part of urogenital ridge)
What controls formation of the Mullerian and Wolffian ducts?
Mullerian duct forms if no MIH is made by testis
Wolffian duct forms if androgens are made
What cells make MIH and androgens?
MIH made by sertoli cells
Androgens made by leydig cells
What makes the prostate?
Urogenital sinus
What does the mullerian duct make?
Vagina, cervix, uterine tubes
What does the wolffian duct make?
Vas deferens, seminal vesicles, epididymis
What makes the external gentials?
The genital folds, tubercles and swellings
Genital tubercles: glans penis and clitoris
Genital folds: spongy urethra and labia minora
Genital swellings: scrotum and labia majora
When do mitosis, meiosis I and meiosis II happen with eggs
Mitosis happens before birth when PGCs proliferate and colonise ovary
Meiosis I happens at birth to form primordial follicles
Meiosis II happens post puberty pre ovulation
When do eggs enter meiosis II
Pre-ovulatory, induced by LH surge. THey freeze in meiosis II 3 hours before ovulation and only complete meiosis II if they are fertilised, ad die 24hrs later if not
What does the corpus luteum do
The remaining granulosa and theca interna cells become lutein cells and produce oestrogen and progesterone. Normally dies after 14 days but if HcG is present it will survive
What’s spermiogenesis
Spermatid –> spermatozoa
What type of cells make primary spermatocytes
Ap spermatogonia (the Ad are the resting reserve stock)
Where does mitosis, meiosis I and meiosis II occur in sperm
Mitosis is between spermatogonia and primary spermatocytes. Meiosis I is primary spermatocytes to secondary spermatocytes. Meisosi II is secondary spermatocytes to spermatids
What’s a spermatogenic cycle and wave
A cycle is the amount of time it takes for one bit of seminiferous tubule to see the same sperm stage again, and the wave is the distance in a tubule between one stage and the next
What is spermiation
Release of spermatids into lumen of seminferous tubule
Since spermatids are non motile until they get to the epididymis, how do they get there?
In sertoli cell secretions and peristaltic movements
What’s the final stage of sperm maturation?
Capacitation in the female genital tract. Removes glycoprotein and cholesterol from sperm membrane, activates sperm signalling (AC, PKA), and allows sperm to start acrosome reaction
WHen does puberty end?
With epiphyseal fusion
Give average puberty ages with stages
F- 11.5 (8-13), thelarche first sign (8-11), adrenarche (11-12), 9cm/yr growth, duration 2.4 years
M- 12.5 (9-14), first sign testicular vol up to 4ml, 104cm/yr growth for 3,2 years
What connects the hypothalamus and the anterior pituitary
The superior hypophyseal artery
When does LH increase
In the night
What does GHRH do
Released from hypothalamus, stimulates GH release from anterior pituitary which activates liver to produce IGF-1 which leads to
What does GH do
Released from anterior pituitary in response to GHRH from hypothalamus. Causes IGF-1 release from liver to cause bone growth plus GH by itself increases metabolic rate and increases muscle mass
What do LH and FSH do?
Fs- LH causes theca cells to release androgens, FSH causes granulosa cells to release oestrogens
Ms- LH causes leydig cells to release androgens, FSH causes sertoli cells to release inhibin
What does moderate oestrogen do to GnRH?
Decreases GnRH
What does high oestrogen do to GnRH?
Increase GnRH
What does high oestrogen + progesterone do to GnRH?
Decrease GnRH
Name layers of the endometrium
Myometrium is the muscle, basal layer stays there and produces functional layer, functional layer is hormone responsive and sheddable
How does clomiphene work?
Antagonist to oestrogen Rs in hypothalamus so the hypothalamus thinks oestrogen is low, increases GnRH and thus FSH and LH so increases fertility
Secondary causes of dysmenorrhea
HMB, imperforate hymen, vaginal septae, endometriosis
Define dysfunctional uterine bleeding
Heavy and irregular bleeding secondary to anovulation
Give chromosomal causes of primary amenorrhea
Turner’s syndrome (45 XO) and Swyer syndrome (46 XY but female externally with undeveloped streak gonads)
Define oligomenorrhea
4-9 periods/yr
Describe epididymal maturation
Nuclear condensation, membrane glycoproteins added, acrosomal shaping, rigid flageullum and stronger beat
What prevents retrograde movement of sperm into bladder?
Contraction of internal sphincter of bladder
Name the nerves involved in erection and ejaculation
Parasymp is pelvic N, symp is hypogastric N, somatic is pudendal (which contracts ischiocavernosus and bulbospongiosus)
What causes vasodilation in erection?
Activation of parasymp and inhibtion of symp. Parasym releases ACh which binds to M3R on endothelial cells, NO released and diffuses into vascular SM
Name causes of erectile dysfunction
Vascular probs (diabetes), psychogenic, tears in tunica albuginea, antidepressants, antihypertensives
How does viagra work
Slows rate of cGMP degradation to increase NO’s vasodilation
Describe the steps in sperm binding to egg
Sperm team effort to push through the corona radiata
Acrosomal reaction occurs in order to bind with zona pellucida
To bind with the zona pellucida its surface Rs bind with ZP3 glycoprotein of pellucida
Once it enters the pellucida the cortical reaction occurs to block polyspermy
Meiosis II in egg continues, F pronucleus forms, M and F pronucleus fuse
What do the oocyte and the spermatozoa uniquely hae
Egg has mitochondria, sperm has centriole
What’s the primary mechanism of depo provera and progesterone implant?
Inhibits ovulation
Which contraceptives will cause a delay to fertility returning
Depo provera
How does referral for subfertility work?
Subfertility is no conception in couple w regular 2-3day sex for a year. Early referral if F >36yrs or known reason for infertility
Give causes of M and F infertility
M: ED, diabetes, chlamydia, varicocele, torsion, hypothyroidism
F: PCOS, premature ovarian failure, endometriosis, chlamydia, ectopic pregnancy tubal damage, no GnRH, prolactinemia, fibroids
Prolactin inhibits ____
____ inhibits prolactin
Prolactin inhibits GnRH
Dopamine inhibits prolactin
How do we test if ovulation has occurred
Test for progesterone on day 21
What do we give bromocriptine for?
It’s a dopamine agonist, and dopamine inhibits prolactin which decreases GnRH so it’s a drug to treat hyperprolactinemia eg in infertility
Give physiological and non physiological causes of secondary amenorrhea
Physiological pregnancy and menopause
Non physiological primary ovarian failure, weight loss, stress, hyperprolactinemia
What test would you do to test for blocked uterine tubes?
Hysterosalpingogram (a contrast USS)
What happens in PCOS
Abnormal secretion of GnRH resulting in increased androgens made by theca cells and follicles arrest in antral stage so don’t secrete progesterone so unopposed action of oestrogen on endometrium causes endometrial hyperplasia and risk of endometrial cancer. Increased androgens result in hirsutism and androgenic alopecia.
What makes up the placenta
Embryo- trophoblast and extraembryonic mesoderm (chorionic plate)
Mumma endometrium
How do chorionic villi change
Primary villi are outgrowths of cytotrophoblast
Secondary have mesenchyme core
Tertiary have fetal blood vessels
How does the positioning of villi change
Early on all around embryo, in third month there is chorion frondosum at embryo end and chorion laeve at other end
What does endometrium become if a conceptus is there
Decidua
What’s the problem with ectopic pregnancies
Growing in a place without decidua so invasion isn’t controlled
What can cause preeclampsia
Placental insufficiency or shallow invasion
What are the lobes of the placenta called
Cotyledons
What hormones does the placenta secrete
Progesterone and oestrogen
hCG, hCS, hCT, hCC
What part of the placenta makes the hCG
Syncytiotrophoblast
Which ig can cross the placenta
IgG
What happens in haemolytic disease of the newborn
A rhesus negative Mother makes antibody against rhesus D present on a rhesus positive baby’s RBCs. The mother must have been sensitised to the antigen eg ABO incompatibility, childbirth, abortion, ectopic pregnancy
Which infectious disease can cross the placenta
Rubella, CMV, TB, listeria, syphilis
Describe circulation in the foetus
Oxygenated blood arrives via one umbilical vein. Goes to liver but shunted to pass it by ductus venosus. Goes up IVC and enters RA, some blood enters RV then PA to oxygenate lungs but not too much so have ductus arteriosus, shunted to LA via foramen ovale, goes LV, aorta, then body, exits through two umbilical arteries returning to mother
Name some teratogens
Thalidomide Alcohol Warfarin Anti epileptics ACEi Drugs of abuse
When is the baby most sensitive to teratogens
3-8 weeks
Describe metabolic changes in pregnancy
Gluconeogenesis increases
Response to insulin decreases
Insulin release post meal increases
Maternal blood glucose decreases
Increased use of FAs, TAGs, and ketones as fuel
Progesterone makes you hungry so more fat storage
Describe blood and heart changes in pregnancy
Plasma volume increases by fifty percent
Blood 6l/min
SV and BP increase
Increased blood flow to boobs, kidneys, GI
heart bigger and shifted upwards and left
St depression and t wave inversion
BP decreases in late pregnancy though which plus increase in plasma volume can cause venous distension so haemorrhoids and varicose veins
Define preeclampsia
Bp more than 140/90 and proteinuria
Papillodema and ischaemic optic neuropathy
Hyperreflexia from HTN affecting brain
How does pregnancy affect kidneys
More blood flow
Uterus presses on bladder so incontinence
Uterus presses on ureter so pyelonephritis
GFR increases by 160%
Progesterone means that kidneys and ureters dilate so loss of tone so increased urinary stasis and UTIs
What stimulates pregnancy breast growth
Prolactin and growth hormone
How does hCG affect maternal immune system
Decreases iga IgG Igm
Name three risk factors for preeclampsia
Autoimmune disease
Diabetes
HTN
If your BMI is more than forty, what should you have in pregnancy
Thromboprophylaxis
Name mechanisms for gas exchange in foetus
Increased haematocrit
Double Bohr effect
Double haldane effect
HbF has increased affinity for oxygen
Foetus has lower oxygen and higher CO2 than mother for diffusion gradients
Respiratory alkalosis in mother induces 2,3 BPG so gives up oxygen more easily
What can you give the mother to increase surfactant production in foetus
Glucocorticoids
Describe fetal formation of the lung
8-16 weeks is pseudoglandular stage where bronchioles form
16-26 is canalicular stage where respiratory bronchioles form
24-term is terminal sac stage where sacs bud off from bronchioles
What can you use to assess fetal growth
CRL before 13 weeks
At 20w USS for biparietal diameter, femur length, abdominal circumference
What ways could you see a fetal heart beat and in which weeks
Transvaginal USS 5-6 weeks
USS 10 weeks
Stethoscope 20weeks
What is BPP biophysical profile?
Assesses fetal tone, movements, breathing movements, amniotic fluid volume and HR in non stress test
What is the fetal non stress test
In fetal movements hr should go up, watch for 30mins. Reassuring or non reassuring
What two growth restriction types occur and when
In early pregnancy symmetrical growth restriction
In late pregnancy asymmetrical because this is when abdo grows
Causes of olighydramnios and polyhydramnios
Oligo from renal problem
Poly from duodenal atresia, swallowing problem, blind ending oesophagus, maternal hypertension
What might class a foetus as at risk
Cardiac anomaly
Chromosomal abnormality
Unexplained polyhydramnios
When might meconium be in amniotic fluid
In fetal stress or asphyxia
What controls breast growth at different stages
Oestrogen at start of puberty stimulates growth of lactiferous ducts
Progesterone at menarche for further duct growth
In pregnancy hCG stimulates rapid growth and branching of terminal lobules and lots of vascularisation
How does milk work
Prolactin steadily rises in pregnancy but oestrogen is inhibiting this
Once birth has occurred, source of placental oestrogen removed so prolactin no longer inhibited
Prolactin controls milk secretion
Oxytocin stimulated by nipple sucking controls milk let down
Why isn’t milk released until after birth
Placental oestrogen inhibits prolactin
Why is it unlikely you’ll get pregnant straight after birth
Sucking inhibits GnRH so no ovulation
Why does lactation stop
Prolactin levels gradually fall
What prevents uterine contractions earlier in pregnancy and how?
Progesterone by decreasing the uterine response to oxytocin and decreasing uterine prostaglandin release
What causes cervical ripening
Decidua and fetal membranes produce prostaglandins which decrease collagen and increase GAGs and hyalauronic acid
Describe fundal heights to estimate gestation
Three months pubic bone
Five months umbilicus
Eight nine months xiphisternum
Which levels does an epidural block
T10-L1
Define post partum haemorrhage
Blood loss of more than 500ml less than 24hrs after delivery
What Sheehan’s syndrome
Postpartum pituitary gland ischaemic necrosis from loss of blood and hypovolemia shock. Signs are agalactorrhea, loss of pubic and axillary hair, hypoglycaemia
Describe blood flow post partum
Initially red flow which is Lochia rubia to white flow lochia alba
Clot passed d3/4
Periods return week 6 if no lactation
When can you feel low after birth
Postnatal blues peak at d4/5
Postnatal depression is within 4 weeks
What is the contents of breast milk
IgA
Foremilk high water
Hindmilk high fat
Lactoferrin to bind iron to prevent E. coli proliferation
Risk factors for pelvic floor dysfunction
Obesity, chronic increase in intra abdo pressure eg constipation COPD, childbirth, ageing, marfans
What muscles make up levator ani
Puborectalis, pubococcygeus, ileococcygeus
What attaches to the perineal body
Ischiocavernosus, bulbospongiosus, levator ani, external anal sphincter, superficial and deep transverse perineal muscles
What symptoms might you have with POP
Stress urinary incontinence, sensation of bulge or something descending, dysparenuria, bladder doesn’t feel empty
Describe stages of FGM
- clitoridectomy
- labia major and or min
- infibulation (others plus sew vagina)
- anything else
How can you avoid tearing the perineal body in labour?
Perform an episiotomy: cut the perineum
What comprises the pelvic diaphragm
Levator ani + coccygeus
Which muscle maintains the ano-rectal angle and stops anus filling?
Puborectalis
Where is the deep perineal pouch found?
Between the pelvic diaphragm (superior) and perineal membrane
What is in the deep perineal pouch
Deep transverse perineal muscle, external urethral sphincter, bulbourethral glands
What’s the Ferguson reflex?
Positive feedback involving increased oxytocin caused by pressure on the cervix increasing uterine contractions
How should you manage post partum haemorrhage
Fluid, transfusion, A-E, manual fundal massage, oxytocin to increase contraction of uterus, intrauterine balloon tamponade
What is Fitz Hugh Curtis syndrome?
Complication of PID causing perihepatitis due to transabdominal spread (infects liver capsule and anterior peritoneum but not liver itself)
Neisseria gonorrhea is what type of bug
Gram negative diplococcus
Give complications/symptoms for chlamydia, gonorrhea and syphilis
Chlamydia- conjunctivitis, fitz hugh curtis syndrome, PID
Gonorrhea- PID, reactive arthritis
Syphilis- initially chancre, later rash and feverm then neuro and cardiac effects
Name respiratory effects in pregnancy
Increased tidal volume (ribs are relaxed due to relaxin), physiological hyperventilation
Name growth factors involved in pregnancy and at which stages
IGF II in trimester 1 which is nutrient-independent
IGF I in tri 2/3 which is nutrient dependent
Name the three stages of lung development
Pseudoglandular, canalicular, terminal sac
What is colposcopy?
Looking at the cervix
Define CIN
Dysplasia of squamous cells within cervical epithelium infected with high risk HPVs
What are the two types of endometrial adenocarcinoma?
Endometrioid and serous
What are the 4 types of ovarian cancer
- Epithelium (serous, mucinous, endometrioid)
- Germ cell (tissues from any 3 of germ layers)
- Sex cord-stromal (Sertoli-Leydig, or Granulosa)
- Mets
What are the types of testicular tumours
Germ cell tumours are either seminomatous or non-seminomatous (e.g. teratoma, chorioarcarcinoma, yolk sac tumours). Seminomatous met late and very responsive, non-seminomatous met early and need more aggressive chemo.
Or sex cord stromal tumours (Sertoli or Leydig)
What markers do testicular tumours release
Choriocarcinoma hCG
AFP yolk sac tumour
(both non-seminomatous germ cell tumours)
