Repro Revision Flashcards
1
Q
How does cystic fibrosis affect fertility
A
Mutations and congenital bilateral absence of vas deferens
2
Q
What does computed semen analysis assess
A
Volume Concentration Number Motility Normal morphologically
3
Q
Treatment for a women to help ovulation
A
Clomifine = anti-oestrogen, increases FSH and LH and follicle growth
Gonadotrophins - multifollicular response
GnRH - unifollicular response
4
Q
How does metabolism change in pregnancy
A
Increased insulin resistance – gestational diabetes
5
Q
Why are pregnant women more prone to GORD
A
Progesterone and prostaglandins slacken all smooth muscle hence LOS, slowed gastric emptying, constipation
6
Q
Why do pregnant women get goitre
A
Feotus uses lots of iodine so thyroid needs to increase uptake and increases the size for efficiency
7
Q
Why do crohn’s and rhuematoid arthritis improve during pregnancy
A
HCG decreases the immune response
8
Q
How much does the mother’s cardiac output increase during pregnancy
A
40%
Due to decreased vascular resistance, increased circulating volume and heart rate
9
Q
How does pregnancy affect peripheral resistance
A
Decreases
10
Q
How does pregnancy affect the urinary tract
A
Dramatic dilatation particularly on R due to relaxant effect of progesterone
In later pregnancy there may be ureteric obstruction due to uterine enlargement
May be glycosuria as proximal tubular ability to absorb is less
Increased urinary frequency due to increased renal blood flow and pressure of pregnant uterus on bladder
11
Q
Why are pregnant women at more risk for PE and DVT
A
They are hypercoagulable
12
Q
How do folate and iron needs change in pregnancy
A
Increased need
13
Q
What factor worsens morning sickness
A
When HCG is higher - multiple pregnancy and molar pregnancy
14
Q
Hyperemesis gravidarum
A
Persistent severe vomiting leading to weight loss and dehydration
15
Q
Why does the BP drop in the second trimester
A
Expansion of the uteroplacental circulation
A fall in sytemic vascular resistance
Decrease in blood viscosity
Decreased sensitivity to angiotensin
16
Q
Why is urine output increased during pregnancy
A
Bladder decreases capacity
Renal blood flow increases
GFR increases
17
Q
Effect of pregnancy on serum urea and creatinine
A
Decrease both due to increased GFR and dilutional effect of plasma volume
18
Q
Factors affecting egg supply; causing problems with infertility
A
Androgen xs - hirsutism (clinical) or xs testosterone (biochemical)
Infrequent periods - anovulation
Polycystic ovaries
19
Q
Name the 3 stages of labour
A
- Cervical dilation
- Expulsion of baby
- After birth - placenta delivery
20
Q
How to ovarian hormones change in the leadup to labour
A
Progesterone lowers so that oestrogen > progesterone and the uterus is more sensitive to other hormones like oxytocin
21
Q
Signs of labour
A
- The drop - baby goes lower into pelvis
(2. Braxton-hicks contraction increase) - Loss of mucous plug so canal not sealed - bloody show
- Spontaneous rupture of membranes
- Effacement and dilatation of the cervix
22
Q
Which is the longest stage of labour
A
Stage 1 - for cervix to dilate to 10cm
23
Q
How long does stage 1 of labour take
A
6-12 hours
24
Q
How long should the second stage of labour take
A
30-120 mins
25
How long should stage 3 of labour take
10-30 mins
26
When would you consider induction of labour
Haven't laboured spontaneously before 41-42 weeks
27
What is an amniotomy
Artificial rupture of foetal membranes using an amniohook
28
Complications associated with induction of labour
Longer, less efficient labour, needing more pain relief, more foetal distress and more likely to need operative or C-section
29
Length of labour in a primiparous woman
12-24 hour
30
Length of labour in a multiparous woman
6-12 hours
31
What would you do if the fetal heart rate is abnormal
Fetal scalp blood pH
32
How do you monitor the foetus during labour
Amniotic fluid appearance
Foetal heart rate monitoring - intermittent or continuous
Foetal scalp blood pH if abnormal fetal heart rate
33
How to assess uterine activity during labour
3-5 good tone contractions per 10 mins each lasting 40-60 seconds
34
What do you do if the placenta is not passed by 30mins
Manual removal under spinal or general anaesthesia
35
What are the criteria of the bishop score and why is it used
Cervical dilatation
Length of cervix
Station of presenting part In relation to ischial spines
Consistency of cervix (firm, medium, soft)
Position with regards to fornix of the vagina (posterior central anterior)
--- To assess the cervix when considering induction of labour
36
Forms of induction of labour
Prostaglandins to "ripen the cervix" (bishop 7) followed by oxytocin infusion
37
What is the name for when the head is too big for the pelvis during labour
Cephalopelvic disproportion
38
What determines progress of labour
Determined by combo of abdominal and vaginal examinations:
Cervical effacement - needs to be very thin
Cervical dilatation
Descent of fetal head through maternal pelvis
39
Effect of cephalopelvic disproportion when baby is born
Caput - cone shaped head due to scalp oedema
and moulding - skull bones overlap
40
Forms of malpresentation
Face
Brow
Breech
Shoulder
41
How could the strength and duration of contractions be improved
Giving artificial oxytocin (syntocinon) as an IV infusion
42
Indications for induction
Hypertension
Pre-eclampsia
Prolonged pregnancy
Rhesus disease
Diabetes, previous still birth, abruption, fetal death in utero and placental insufficiency
43
What would be the effect of stimulating an obstructed labour
Could result in a ruptured uterus which can result in severe maternal and fetal morbidity and even mortality
44
How to assess fetal well being during pregnancy
Intermittent auscultation of the fetal heart
Cardiotocography
Fetal blood sampling
45
Potential complications of C-section
Increased risk of infection, visceral injury and VTE compared to vaginal birth
46
Define miscarriage
Termination/loss of pregnancy
47
Threatened miscarriage is when
Pregnancy is viable
Vaginal bleeding +/- pain
Cervix is closed
48
Inevitable miscarriage is when
The pregnancy is viable
The cervix is open and bleeding (heavily)
49
Missed miscarriage is when
Gestational sac is seen but no clear fetus or a fetul pole with no fetal heart
Also known as early fetal demise
50
Incomplete miscarriage is when
Most of the pregnancyis expelled out with some products remaining in the uterus
Cervix is open and there may be vaginal bleeding
This can lead to a septic miscarriage
51
Where is the most common site for an ectopic pregnancy
The fallopian tube
The ampulla in particular
52
Name the the parts of the uterine tube
Fimbriae
Infundibulum
Ampulla
Isthmus
(Then onto uterus)
53
Presentation of ectopic pregnancy
Period of amenorrhoea and positive pregnancy test
PV bleeding +/- abdo pain
Tenderness on vaginal exam and cervical excitation (pain when move cervix)
May have hypovolaemic shock in acute presentation
54
Conservative management of ectopic
If stable wait and see if shrinks and serially measure bHCG
55
Medical management of ectopic
Methotrexate and serially measure bHCG
56
Surgical management of ectopic
Laparoscopic or open salpingectomy (tube and ectopic) or salpingotomy (remove ectopic)
57
Antepartum haemorrhage
Bleeding >24 weeks but before birth of the baby
58
Causes of antepartum haemorrhage
Vasa praevia (abnormal umbilical vessels)
Local lesion of genital tract
Unknown origin (50%)
Placenta praevia
59
What is placenta praevia
When all or part of the placenta implants on the lower uterine segment
60
What factors increase risk of placenta praevia
Multiparous
Old age
Multiple pregnancy
Previous C section
Scarring in uterus
61
Features of placenta praevia
Painless PV bleeding
Malpresentation of fetus on scan
Soft, non-tender uterus
62
Why must you not perform a vaginal exam in antepartum haemorrhage
If placenta praevia could disturb cervix and give bigger bleed
63
Management of placenta praevia
Depending on gestation and severity may want to deliver by C-section
Cross match blood because there usually lots of bleeding
Give steroids to help foetal lungs develop
64
Placenta abruption
Haemorrhage resulting from premature separation of placenta before baby birth
65
Presentation of placental abruption
Pain - constant and contractions
Vaginal bleeding
Increased uterine activity - hard, pain, tender and sometimes enlarged
66
What factors increase risk of placental abruption
Previous abruption
Pre-eclampsia/HT
Multiple pregnancy
Smoking and increased age
Cocaine use
67
Why are pregnant women more at risk for venous thromboembolism
They are in a hypercoagulable state - more clotting factors
68
Symptoms of VTE in pregnancy
Tender/pain in calf
SOB
Cough
increased HR
69
Management of VTE in pregnancy
Antiocoagulation if VT is confirmed using LMWH
Dalteparin if lots of risk factors (sickle cell, increased BMI, older mothers, less mobility)
Encourage movement and advise stockings
70
Preterm labour is classed as
Onset of labour
71
Predisposing factors for preterm labour
Multiple pregnancy
Antepartum haemorrhage
Infection
Pre-eclampsia
72
How do fetal fibronectin levels change during labour
They go up when women go into labour
Is the biological glue that bind the fetal sack to the uterine lining
73
Management of an extreme premature
Consider tocolysis (delay) to allow steroids for fetal lung maturity and transfer to a specialist unit
Aim for a vaginal delviery
74
Neonatal morbidity from prematurity
Visual impairment
Hearing loss
More infections
Jaundice
Nutrition
Cerebral palsy
Respiratory distress syndrome
75
Management of those with chronic HT who are pregnant
Monitor for superimposed pre-eclampsia
Aim to keep BP low
Decrease sodium in diet
Consider changing drugs (ACEi and ramipril cause birth defects and B-blockers impair growth)
76
How would you know if a lady has pregnancy induced hypertension
Begins >20 weeks
77
Pre-eclampsia
New HT >20 weeks in association with significant proteinuria (24h urinary protein collection >300mg/day)
78
Risk factors for pre-eclampsia
1st pregnancy
Maternal age extremes
Pregnancy interval > 10 yrs
BMI >35
Family history
Chronic HT, renal disease, diabetes, autoimmune conditions
79
Symptoms of pre-eclampsia
Vision blurring, headache, epigastric pain, vomiting and sudden swelling
Potentially convulsions
80
Signs of pre-eclampsia
High BP
Urine output decrease
Papiloedema
Clonus/brisk reflexes
Epigastric tenderness
81
Biochemical investigations for pre-eclampsia
Increased liver enzymes and bilirubin
Increased urea and creatinine
82
Haematological investigations for pre-eclampsia
Low platelets
Low Hg
Signs of haemolysis
83
Complications of pre-eclampsia for the baby
Impaired placental perfusion
IUGR, prematurity
84
What does HELLP stand for
Haemolysis
Elevated liver enzymes
Low platelets
85
Maternal complications of pre-eclampsia
```
Seizures
Stroke
DIC
Renal failure
Pulmonary oedema and heart failure
HELLP
```
86
Management of pre-eclampsia
BP and urine check frequently
Only cure is delivery - consider induction
Anti HT - labetolol
Steroids for fetal lung maturity
MONITOR POST DELIVERY
87
Effect of pre-existing diabetes on the fetus
Cause fetal hyper-insulinaemia - maternal glucose crosses placenta and induces increased insulin production
Greater risk of foetal hypoglycaemia
Babies often hypoglycaemic and chubby
MACROSOMIA
88
Effect of pre-existing diabetes in pregnancy for mother with regards to insulin requirments
Increased insulin requirements for mother
This is because human placental antigen, progesterone, HCG and cortisol from the placenta have anti-insulin actions
89
How can gestation complicate existing diabetes
Maternal nephropathy
Retinopathy
Hypoglycaemia
90
Physiology of gestational diabetes
HPL, cortisol, GH and progesterone all increase blood glucose and increase insulin resistance so there is more glucose available for baby
91
Screening for gestational diabetes
Oral glucose tolerance test
92
Treatment of gestational diabetes
Diet
Insulin
Keep an eye on HbA1c as prone to diabetes after pregnancy
93
How does management of existing diabetes change in pregnancy
More aware of hypoglcaemic risk, ketonuria and infection
Consider changing to injecting insulin from oral to optimise control
94
Aetiology of preterm labour
```
Idiopathic
Preterm rupture of membranes
Polyhydramnios (++amniotic fluid)
Multiple pregnancy
Cervical incompetence
Uterine abnormality
Antepartum haemorrhage
Maternal pyrexia
```
95
Aim of tocolysis
To suppress uterine contractions long enough to administer steroids and transfer somewhere with a neonatal unit
96
Complications of premature rupture of membranes
Ascending infection
97
Which anti-hypertensive agents are contra-indicated during pregnancy
Diuretics and ACE inhibitors
98
What is HELLP syndrome
Haemolysis
Elevated Liver enzymes (particularly transaminases)
Low platelets
Is a variant of pre-eclampsia
99
Categories of small infants
Born too small - normal size for gestation
Low birth weight -
100
Purpose of an epiostomy
Indicated when signs of tearing or excessive blanching of the perineum during labour
- avoids uncontrolled tearing in a downward direction which migh effect future bowel control
101
The 4 Ts of post partum haemorrhage
Tissue: delayed spontaneous expulsion of placenta; incomplete delivery
Thrombus: placental abruption and pre-eclampsia impair maternal coagulation
Tone: multiple pregnancy, polyhydarmnios, macrosomy, general anaesthetic, prolonged or rapid labour
Trauma: birth canal or uterine trauma
102
How do we test for trisomy 21
Maternal risk factors, b-HCG and pregnancy associated plasma protein and fetal nuchal translucency
103
Fetal heart rate parameters
110-160
104
Indications for operative delivery
Presence of fetal distress or "delay" or failed progress despite good contractions and maternal effort
105
Uterine inversion is usually caused by
Pulling on the cord before separation
106
Why are pregnant women prone to carpal tunnel syndrome
Swelling of soft tissues
107
What is given to a newborn slow to establish respiration thought to be due to narcotic analgesics being given
Naloxone - narcotic antagonist
108
Prematurity related problems
```
Respiratory distress syndrome
Periventricular haemorrhage
Cortical damage
Hydrocephalus
Necrotising enterocolitis
Sepsis
Retinopathy/hearing problems
```
109
Where is surfactant produced
Type 2 pneumocytes of the alveoli
110
Effect of meconium aspiration syndrome
Meconium is irritant to the neonatal lungs and may lead to a pneumonitis
111
Causes of seizures
```
Neonatal encephalopathy
Focal cerebral infarction
Cerebral malformation
Meningitis
Hypoglycaemia
Hypercalcaemia
Maternal drug abuse
Inborn errors of metabolism
```
112
Investigation for recurrent miscarriage
Karyotype from both parents
Maternal blood for lupus anticoagulant and anticardiolipin antibodies
Possible hysterosalpingogram and/or pelvic ultrasound to look for uterine abnormality
113
Causes of recurrent spontaneous miscarriage
```
Anti-phospholipid syndrome
Chromosomal abnormality
Cervical incompetence - suture may help
Thrombophilic defects
Anatomical uterine abnormalities
```
114
Options for termination of pregnancy
Suction evacuation
| Medical termination - mifepristone
115
Follow up of termination
After termination anti-D should be given to those who are rhesus negative
Give patient pregnancy test to use
Arrange appointment to check termination is complete
