Repro wk3 Flashcards
What is infertility?
Infertility is the inability to conceive with active intercourse (with no contraception) for a period of at least 12 months
What is primary infertility?
Being infertile without having had a previous pregnancy
What are irregular periods?
Where the time between the first day of each period changes between cycles
How do you diagnose PCOS?
2 of the following 3: Androgen access (Clinical vs biochemical) Infrequent periods (anovulation) Polycystic ovaries
When no other cause can be identified!
How do polycystic ovaries (PCO) and polycystic ovary syndrome (PCOS) differ?
PCOS is a diagnosis of exclusion over set criteria.
There are 3 criteria with PCO being one, 2 are needed for a diagnosis of PCOS
PCO is a common occurance in many women
What are the biochemical investigations into androgen access?
Testosterone
DHEAS (If over 700 CT adrenal to check for ovarian vs adrenal cause)
17-OH progesterone
What is pre-eclampsia?
New hypertension developed at or over 20 weeks with significant proteinuria
What is significant proteinuria?
Regent strip urinalysis 1+
Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol
24 hours urine protein collection > 300mg/ day
What are the different types of fibroids?
Submucosal
Subserosal
Intermural
What are you looking for in a pelvic exam for infertility?
Masses Pelvic distortition Tenderness Vaginal septum Cervical abnormalities
What are teh baseline investigations into infertility?
Rubella immunity Chlamydia TSH Biochemical tests Male semen analysis
What biochemical tests are used to investigate regular periods?
Mid-luteal progesterone
Taken 7 days before expected periods
What biochemical tests are used to investigate irregular periods?
Day 1-5: FSH LH PRL TSH Testosterone
How do you investigate suspected tubual and uterine abnormalities?
Hysterosalpinogram (falling out of favour)
HyCoSy (becoming more prevelant
Laparoscopy if indicated by test above
What are the important questions for fertility in a male history?
Development -
Testicular descent
Change in shaving frequency? (change in T levels)
Loss of body hair
Infections - Mumps/STIs
Surgical - variocele repair? Vasectomy
Drugs (smoking.alcohol etc)
Sexual history (libido, fertility)
What side is a variocele more common on?
Left side, due to drainage into renal vein
What is klinefelter syndrome?
Primary hypergonadism (small testis) caused by XXY Impaired spermiogensis (azoospermia) Testosterone deficiency
What is congenital bilateral absence of vas deferens associated with?
Cystic fibrosis
What are the types of ovulatory disorders?
3 types
1: Hypothalamic pituitary failure
2: Hypothalamic pituitary ovarian failure
3: ovarian failure
How do you manage type 1 ovulatory disorders?
Encourage to have BMI of 19-29 Treat underlying cause Potentially HRT to modulate ovulation: >Clomifene >Gonadotrophins
What is clomifene?
Selective oestrogen receptor modulator
Taken as lowest dose first, and graudally increase if ineffective
Usuable for 6 cycles
What are the side-effects of clomifene?
Vaso-motor
Visual disturbances
Multiple pregnancies
When do you use gonadotrophins?
No ovulation with clomifene
Ovulation but no pregnancy
FSH used
How do you treat hydrosalpinges?
Surgery - salpingectomy
BEFORE IVF
What are the causes of azzospermia?
Testicular (hormones levels off) Post testicular (congeinital, ineffective)
How do you investigate azoospermia?
History/examination
FSH/LH/Testosterone
Karyotype
CF screen
What are the classifications of azzospermia?
Transportation problem
Production problem
How do you manage transportation problems of azoospermia?
Surgical sperm retreival
How do you manage unexplained fertility?
No ovarian stimulation agents
2 years of unprotected sex before IVF
What is the difference between IVF and intracytoplasmic sperm injection?
IVF sperm is placed with eggs to fertilise
ICSI injection of eggs with sperm - individual
What is gestational hypertension?
New hypertension develped at or over 20 weeks
What is pre-eclampsia?
New hypertension developed at or over 20 weeks with significant proteinuria
What is significant proteinuria?
Regent strip urinalysis 1+
Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol
24 hours urine protein collection > 300mg/ day
What can cause spontaneous miscarriages?
Abnormal conception (genetic, structural, chromosomal) Uterine abnormality (fibroids/genetic) Cervical incompetence Maternal (age/diabetes) Unkown factors
How do you manage an inevitable miscarriage?
If bleeding is very heavy consider evacuation
How do yu manage a threatened miscarriage?
Conservatively
How do you manage a missed miscarriage?
Conservatively
Medically - prostaglandins
Surgical management of miscarriage
How do you manage a septic miscarriage?
Antibiotics and evacuate uterus
How common are ectopic pregnancies?
1 in 90
What are the risk factors of an ectopic pregnancy?
Pelvic inflammatory disease
Previous tubual surgery
Previous ectopic
Assisted conception
How does an ectopic pregnancy present?
Period of ammenorhea with positive pregnancy test \+/- the following Vaginal bleeding Abdominal pain GI/urinary symptoms
How do you investigate an ectopic pregnnacy?
US (no intrauterine signs
Serum beta HCG levels (do not rise as steeply as normal)
Serum progesterone levels
How do you manage an ectopic pregnancy?
Medially - methotrexate
Surgical - laparosciopical
Conservatively (sit and wait to see if it solves itself)
What is an antepartum haemorrhage?
Haemorrhage from genital tract after 24th week of pregnancy but before birth of baby
Obstetric emergency - high mortality and morbidity for mother and child
What can cause atepartum haemotrrhage?
Placenta praevia Placental abruption Unkown origin Local lesions of genital tract Vasa praevia (rare)
What is placenta praevia?
Where placenta is attached to lower segment of uterus (all or part)
What is placenta abruption?
Where placenta has started to separate from uterine wall before birth of baby
Who is likely to get placenta praevia?
Multiparous women
Multiple pregnancies
Previous C section
What is the incidence of placenta praevia?
1/200
What are the classifications of placenta praevia?
1: placenta encroaching on lower segment, but not in internal cervical os
2: placenta reaches internal os
3: placenta eccentrically covers internal os
4: central placenta praevia
How does placentae praveia present?
Painless PV bleeding
Soft, non tender uterus +/- Malpresentation of foetus
Incidental
How do you diagnose placenta praevia?
Ultra sound
MRI if inconclusive
DO NOT do a vaginal exam
How do you manage placenta praevia?
Depends on gestation + severity
Although C section most common - post partum haemorrhage common
How do you manage a post partum haemorrhage?
Medically - ocytocin, egometrine, carbaprost, tranexemic acid
Balloon tamponade
Surgical - B lynch cutre, ligation of uterine/illiac vessels
Hysterectomy
(in increaseing order)
What factors are assocated with placental abruption?
Pre-eclampsia/chronic hypertension Multiple pregnancies Polyhydramnios Smoking Increasing age Parity Previous abortion Cocaine use
What are teh types of placental abruption?
Revealed (apparent externally as escapes through cervical os)
Concealed (between uterine wal and placenta)
>Increased uterine contents + larger fundal height than would otherwise be expected for gestation
>Uterus may appear bruised
Mixed (both of above)
What is the presentation of placental abruption?
Pain (abdominal)
Vaginal pleeding
Increased uteruine activity (tone + contractions)
How do you manage APH?
Depends on:
Amount of bleeding
General condition of mother/baby
Gestation
Expectant treatment
Vaginal delivery
Immediate C section
What are the complications of placental abruption?
Maternal shock/collapse
Foetal death
Maternal DIC, renal failure
Postpartum haemorrhage
What is preterm labour?
Onset of labour before 37 weeks of gestation
Can be spontaneous of induced
Varies in severity - from 24 weeks being extremely to mild at 32 weeks
How common is preterm labour?
5-7% of singletons
30-40 in multipl pregnancnies
What are the predisposing factors of preterm labour?
Multiple pregnancues Polyhydramnios APH Pre-eclampsia Infection Prelabour premature rupture of membranes
How do you manage a preterm delivery?
All cases variable
In 24-26 weeks prognosis poor and discuss with parents/neonatologists
Consider toclyosis to allow steroids/transfer
Steroids unless contraindicated
Transfer to unit with neonate intensive care
Aim for vaginal delivery
What are the risks of a severe preterm labour?
Poor mortality rates
High chance of disability in newborn, increasing the earlier preterm they are
What are the morbiditys resulting from being preterm??
Respiratory distress syndrome Intraventicular haemorrhage Cerebral palsy Nutrition Temperature control Jaundice Infections Visual impairment Hearing loss
In patients with chronic hypertension, what is the ideal pre-pregnancy care?
Change ACEI/ARBs to beta blockers (labetolol), CCB (nifedipine) or metyldopa
Lower dietary sodium
Aim to keep BP below 150/100
Monitor during pregnancy + foetal growth
How do you diagnose pre-eclampsia?
Mild hypertension on 2 occasions (more than 4 hrs apart)
Or one instance of moderate - severe hypertension
PLUS significant proteinuria
What is the pathophysiology preeclampsia?
Immunological
Genetic predisposition
Due to either secondary invasion of maternal spiral arterioles being impaired leading to poor perfusion
Or inbalance of vasodilators/constrictors in pregnancy
What are the risk factors of pre-eclampsia?
First pregnancy Extremes of maternal age Pre-eclampsia in previous pregnancy BMI Family history of PET Multiple pregnancy Underlying medical disorders (HT, renal, diabetes, autoimmune) Long interval between last pregnancy
What are the complications of PET?
Eclampsia (seizures)
Severe hypertension - leads to haemorrhage (cerebral)/stroke
HELLP (haemolysis, elevated liver enzymes, low platlets)
Disseminated intravascular coagulation
Renal failure
Pulmonary oedem/cardiac failure
Can also impair foetal placental perfusion leading to distress or prematurity
What are the clinical features of severe PET?
Headache/visual disturbances Epigastric pain/ pain below ribs Vomitting Sudden swelling of hands/face Severe hypertension Clonus/brisk reflexes Reduced urine output Convulsions (eclampsia)
What are the biochemical abnormalities in preeclampsia?
Raised liver enzymes
Raised billirubin if HELLP present
Raised urea + creatinine + urate
What are the haemtological abnormalities of PET?
Low platlets
Low haemoglobin
Signs of haemolysis
Features of disseminated intravascular coagulation
How do you manage PET?
Only “cure” is delivery
Manage conservatively - diet etc to bring blood pressure down
Then drugs
Monitor closely with BP + urine protein + symptoms
Check with blood tests + check for distress in baby
Consider induction if starting to get severe
Continue to monitor post delivery
How do you treat PET seizures /impending seizures?
Magnesium suphate bolus + IV infusion
Control blood pressure
Avoid fluid overload (perihperal oedema often already present)
What is the prophylaxis for PET?
Aspirin low dose from 12 weeks until delivery
What is gestational diabetes?
Carboydrate intolerance with onset in pregnancy
Abnormal glucose tolerance returns to normal after delivery
More at risk of type 2 later in life
What happens in pre-existing diabetes and pregnancy?
Insulin requirements of mother increases (hormones from diabetes have anti-insulin action)
Foetal hyper-insulinaemia occurs (maternal glucose crosses placenta and increases insulin production.
Causes macrosomina, polhydramnios
What are the potential risks with children born to mothers with preexisting diabetes?
Higher risk of neonatal hypoglycaemia Increased risk of respiratory distress Foetal congeital abnormalities (cardiac abnormalities, sacral agenesis) Impaired lung matuiry Jaundice
What are the risks to the mother in preexisting diabetes?
Increased risk of preeclamsia Worsening of maternal neprhopathy, retinopathy + hypoglycaemia Decreasesd awareness of hypoglycaemia Infections Can result in miscarriage/still birth
How do you manage diabetes pre-conception?
Try to encourage better glycaemic control
Give folic acid
Dietary advice
Retinal + renal assessment
How do you manage preexisting diabetes during pregnancy?
Optimise glucose control as insulin requirements increase
Continue most dugs, but stop sulfonureas
Give glucose solution/glucagon injections and school on risk of hypos
Watch for infection
Watch foetal growth
Retinal assessments
Observe for PET
How do you manage labour in those with preexisting diabetes?
Usually induce it at 38-40, although maybe earlier depending on concerns
C section if significant macrosmnia
Give mother insulin/dextrose infusion during labour
Foetal monitoring in labour CTG continous
Feed baby early to reduce hypoglycaemia
What are the risk factors of gestational diabetes?
BMI > 30
Previous macromic baby
Previous gestation diabetes
FH of dibates
Women at high risk of diabetes
Polyhydramnios or macrosmnia in current pregnancy
Recurrent glycosuria in current pregnancy
How do you screen for gestational diabetes?
Offer HbA1C if risk factors present
>6% then do an oral glucose tolerance test
Repeat at 24-48 (OGTT)
How do you manage gestational diabetes?
Control blood sugars - det often enough, metformin if remain high
Gect oral glucose test post term
Yearly check as higher risk of diabeties
Why are pregnant women at greater risk of thromboembolism?
Hypercoaguable state >Increased fibrinogen + clotting factors + platlets >Increase in fibrinolysis >Decrease in natural anticoagulants Increased stasis
Who is at increased risk of thromboembolism in pregnancy?
Older mothers/high parity Increased BMI Smoking/IV drugs/alcohol PET Dehydration Decreased mobility Infections Operative delay or prolonged labour Haemorrhage Sickle cell disease
What are the signs of VTE /symptoms?
Calf pain
Increased girth in one leg
Calf muscle tenderness
Breathlessness/pain on breathing Cough Tachycardia Hypoxic Pleural rub
What is Duchenne muscular dystrophy?
X linked disease
Fatal in early adult life
Characterised by way boys get up onto their feet
What are the symptoms of sickle cell disorders?
Pain (lots) Cold Dehydration Infections Jaundice Stroke Leg ulcers Anaethestia issues
What is tay-sachs disease?
Progressive lyosomal storage disease
Deficency in an enzyme leads to build up of lipids in cells, especially nerve cells of brain
Neurological deteriation
Usually fatal by 3-5 years
What is pehynlketonuria?
Recessive condition unable to break down phenylalanine
Untreated babies develp serious mental disability
Early treatment with dtrict diet prevents disability
What is congenital hypothyroidism?
Not enough thyroixine produced
Untreated babies develop serious physical + mental disability
Treatment by 21 days with thyroxine tablets prevents disability
What is mediam change Acytl-COA dehydogenase deficency
Recessive condition
Cannot break down fat to make energy fr baby
Life threatening
Mean age of presentation 14 months
Treatment - avoid fasting + monitor frequency of meals to prevent metabolic crisis
In imergency give IV dextrose
What are the common sexually transmitted organisms in the UK?
Bacteria
Chlamydia trachomatis
Klebsiella granulomatis
Mycoplasma genitalium
Viruses HSV HIV HPV Molluscum contagiosum virus
parasites
Pthrius pubis
Sarcoptes scabei
Trichomonas vaginalis
What conditions only need genital contact?
Pubic lice (pthirus pubis)
Scabies (sarcoptes scabeii)
Warts (HPV 6 + 11)
Herpes (HSV 1/2)
What are the systemic symptoms from STIs?
Fever Rash Lymphadenopathy Malaise Infertility
What are the important questions in STI management?
When did you last have sexual contact? Was it casual or with a regular partner (how long with regular?) Male/female? Nature of sex? Condoms? Contraception? Nationality
What are the questions for risk assessment for a man?
Ever had sex with a man? Ever injected drugs? Ever had sexual contact with someone from outside of UK/injected drugs Medical treatment outside of UK? Involvement with sex industry?
What is the process of STI testing?
History/consultation
Test + offer further testing - always think HIV
Partner notification
Promote health - condoms
What STIs are condoms good at preventing + bad?
Good - HIV, chlamydia, gonorrhoea
Bad - herpes/warts
What are the presenting complaints of genital symptoms?
Discharge from orifice Pain Rashes Lumps/swellings Cuts, sores, ulcers Itching Change in appearance Vague sense of something not being right
What microbial conditions are not regarded as STDs?
Vulvovaginal candidosis Bacterial vaginosis Balanopothitis Tinea cruris Erythrasma Infected sebacous gland Impetigo Cellulitis
What is vulvovaginal candiosis?
Very common and usually trivial Usually acquired from bowel Often asymptomatic "Thrush" is symptomatic Itchy with discharge
What bacteria causes thrush/vulvovaginal candidosis?
90% candida albicans
Who is at risk of vulvovaginal candidosis?
Diabetes/oral steroids
Immune suprresion
Pregnancy
Reproductive age group (oestrogen leading to glycogen)
How do you diagnose vulvovaginal candidosis?
Characteristic history Examination: >Fissuring >Erythema with satellite lesions >Characteristic discharge Investigations - not very sensitive >gram stain - low sensitivity >Culture - low specificity
How do you treat thrush?
Azole antifungals >clotrimazole 500mg >Fluconazole 150mg If recurrent - reinfection or reistance? Other management - maintain skin + aoid irritants
What is bacterial vaginosis?
Most common cause of abnormal vaginal discharge
Symptoms:
>Most asymptomatic
>Watery grey/yellow “fishy” discharge (worse after sex)
>Sometimes sore/itch from dampness
Due to imbalance of bacteria rather than infection with biofilm
What are the problems associated with bacterial vaginosis?
Endometritis if uterine instrumentation/delivery
Premature labour
Increased HIV acquistion
How do you diagnose bacterial vaginosis?
Characteristic history Examination findings (not normally done) Would find thin, homogenous discharge
Gram stained smear of vaginal discharge
How do you treat bacterial vaginosis?
Metronidazole (oral - avoid alcohol)
>Vaginal gel
Clindamycin
What is zoons balanitis?
Chronic inflammation secondary to overgrowth of commensal organisms
+ foreskin malfunctiojn
Not pathogenic
