reproductive Flashcards
describe the HP-GA axis
hypothalamus releases GnRH which stimulates anterior pituitary to secrete LH and FSH.
LH and FSH stimulate the follicle and in return oestrogen is secreted that inhibits the axis.
Theca granulosa cells around the follicle secrete
oestrogen
physiological role of oestrogen is for
development of female sex organs, uterine blood vessels and endometrial development
physiological role of progesterone
thickens both the cervical mucous and maintains endometrium and increases body temp.
age of puberty in females
8-14
age of puberty in males
9-15
average length of puberty
4 years
why may girls with low weight have a delayed puberty
lack of aromatase due to reduced adipose deposits
female puberty starts with development of
breast buds, then pubic hair and then menarche
scale for measuring puberty development is
tanner scale
during puberty FSH levels plateau how long before menarche?
a year
a follicle develops receptors for FSH in which stage?
secondary follicle stage
ovulation occurs what day of the cycle?
day 14
what hormone maintains the corpeus luteum and where does this originate?
HCG from the syncytiotrophoblast
during menstruation what does the stromal cells release
prostaglandins
primary oocyte is contained within
pregranulosa cells surrounded by outer basal lamina layer
three layers of the primary follicle
primary oocyte, zona pellucida and the granulosa cells
as the follicle grows id develops a further surrounding layer called the
theca folliculi
the inner theca folliculi name and function
theca interna secretes androgen hormones
theca externa consists of
connective tissue, smooth muscle and collagen
development of the secondary follicle involves
growth of the antrum within the granulosa. the granulosa cells surrounding the follicle as referred to as the corona radiata.
role of LH in ovulation
surge of LH triggers the theca externa to squeeze releasing the ovum.
primary oocyte meiosis creates
a polar body and a haploid cell called the secondary oocyte.
development of the fertilised cell as it migrated along the fallopian tube
zygote->morula->blastocyst which contains the embryoblast and surrounding this is the trophoblast.
the cells of the trophoblast undergo adhesion with the
stroma of the endometrium
endometrial stroma cells in contact with the trophoblast convert into the
decidua
a week after fertilisation the embryoblast forms into
yolk sac and the amniotic cavity
the choroin surrounds the embryonic complex and has two sides called
cytotrophoblast (inner) and the syncytiotrophoblast (outer)
the outer ectoderm layer forms
skin, hair, nails, teeth, CNS
the middle mesoderm layer forms
heart, muscle, bone, connective tissue, blood and kidneys
inner endoderm layers forms
GI tract, lungs, liver, pancreas, thyroid and reproductive system
at how many weeks does the heart form and start to beat?
6 weeks
the myometrium sends of arteries into the endometrium called
spiral arteries
the placenta originates from the
chorion frondosum
spiral arteries degenerate int
lacunae (lakes of blood)
lacunae form around what week?
week 20
if spiral arteries maintain vascular resistance this runs the risk of
pre-eclampsia
functions of the placenta are
respiration, nutrition, excretion, endocrine and immunity
HCG plateus around what week of gestation?
ten weeks
placental oestrogen role
softens tissue and increases flexibility to expand pelvis and soften cervix.
which has a higher affinity for oxygen foetal or adult haemoglobin
foetal
placental progesterone role
maintain pregnancy through muscle relaxation
hormonal changes during pregnancy include
raised ACTH, prolactin, progesterone, oestrogen, HCG, T3 and t4 and melanocyte stimulating hormone
consequences of increased ACTH during pregnancy are
rise in cortisol and aldosterone (steroids) improving autoimmune conditions but increased risk of diabetes.
consequences of increased melanocyte stimulating hormone are
linea nigra and melasma
role of prostaglandins prior to delivery
breakdown collagen in cervix enabling dilation
CV changes during pregnancy
increase: blood volume, cardiac output and decreased peripheral vascular resistance and blood pressure in early pregnancy
respiratory changes during pregnancy
increased tidal volume and respiratory rate
renal changes during pregnancy
increased blood flow, GFR, aldosterone, protein excretion and hydronephrosis
haematological and biochem changes during pregnancy
raised ESR, d-dimer, Alk P, WBC and platelets but reduced albumin.
stage one of labour is
onset of contractions until 10cm cervical dilation
stage two of labour is
delivery of baby
third stage of labour is
placental delivery
braxton hicks contractions are
irregular contractions of the uterus during second and third trimester
three phases of the first stage of labour
latent phase (o.5 cm per hour, irregular contractions) active phase (1cm per hour) Transition phase (strong regular contractions)
stage 2 depends upon the three P’s
Power - uterine contractions
Passenger (size, attitude (position), Lie, presentation
Passage
different presentations of the passenger include
cephalic, shoulder, breech
three different types of breech include
complete (hips and knees flexed)
frank (hips flexed but knees extended)
footling (foot hanging through cervix)
cardinal movements of labour are
Engagement Descent Flexion Internal Rotation Extension Restitution and external rotation Expulsion
active management of the third stage of labour may involve
an intramuscular injection of oxytocin.
what fraction of couples struggle to conceive naturally?
1/7
investigation for infertility should occur after
12 months, or six months if >35yrs
commonest causes for infertility
mixed (40%) sperm problems (30%) tubal problems (15%)
general advice for infertility
The woman should be taking 400mcg folic acid daily
Aim for a healthy BMI
Avoid smoking and drinking excessive alcohol
Reduce stress as this may negatively affect libido and the relationship
Aim for intercourse every 2 – 3 days
Avoid timing intercourse
initial investigations for infertility
Body mass index (BMI) (low could indicate anovulation, high could indicate PCOS) Chlamydia screening Semen analysis Female hormonal testing (see below) Rubella immunity in the mother
female hormone testing for infertility involves
Serum LH and FSH on day 2 to 5 of the cycle
Serum progesterone on day 21 of the cycle (or 7 days before the end of the cycle if not a 28-day cycle).
Anti-Mullerian hormone
Thyroid function tests when symptoms are suggestive
Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea
high FSH in infertility indicates
poor ovarian reserve
high LH in infertility indicates
PCOS
high Anti-mullerian hormone in infertility indicates
high ovarian reserve
further investigations for infertility include
US, hysterosalpingogram, laparoscopy, and dye test.
management of anovulation in infertility includes
clomifene, ovarian drilling, metfromin, weight loss and gonadotrophins
clomifene is a
selective oestrogen receptor modulator (anti oestrogen)
management of tubal factors for infertility include
Tubal cannulation during a hysterosalpingogram
Laparoscopy to remove adhesions or endometriosis
In vitro fertilisation (IVF)
management of sperm problems for infertility include
surgical sperm retrieval, surgical correction, intra-uterine insemination, intracytoplasmic sperm injection and donor insemination
sperm sample analysis looks at
volume, semen pH, concentration, total number, motility, vitality, and percentage
pre-testicular causes of infertility include
Pathology of the pituitary gland or hypothalamus
Suppression due to stress, chronic conditions or hyperprolactinaemia
Kallman syndrome
testicular causes of infertility
Mumps Undescended testes Trauma Radiotherapy Chemotherapy Cancer genetic congenital
investigations into infertility for men include
LH, FSH, testosterone, geentic testing, MRI, US, vasography and testicular biopsy
post testicular causes of infertility
Damage to the testicle or vas deferens from trauma, surgery or cancer
Ejaculatory duct obstruction
Retrograde ejaculation
Scarring from epididymitis, for example, caused by chlamydia
Absence of the vas deferens (may be associated with cystic fibrosis)
Young’ syndrome is
(obstructive azoospermia, bronchiectasis and rhinosinusitis)
success rate of IVF
25-30%
IVF process
Suppressing the natural menstrual cycle Ovarian stimulation Oocyte collection Insemination / intracytoplasmic sperm injection (ICSI) Embryo culture Embryo transfe
methods for suppression of natural menstruation cycle
GnRH agonists or GnRH antagonists
ovarian stimulation is through
injections of FSH, once follicles have developed then injection of HCG 36 hours before collection
fertilised eggs in IVF are observed until the
blastocyst stage (day 5)
complication of IVF treatment is
ovarian hyperstimulation syndrome
pathology of ovarian hyperstimulation syndrome
increase in VEGF (vascular endothelial growth factor), fluid leaks to the extravascular space causing oedema, ascites and hypovolaemia
OHSS is specifically triggered by
HCG injection 36 hours prior to oocyte collection
monitoring for OHSS risk is through
serum oestrogen and US
risk reduction for OHSS is through
lower doses of hCG and GnRH antagonist
symptoms of OHSS
Abdominal pain and bloating Nausea and vomiting Diarrhoea Hypotension Hypovolaemia Ascites Pleural effusions Renal failure Peritonitis from rupturing follicles releasing blood Prothrombotic state (risk of DVT and PE)
management of OHSS is through
Oral fluids
Monitoring of urine output
Low molecular weight heparin (to prevent thromboembolism)
Ascitic fluid removal (paracentesis) if required
IV colloids (e.g. human albumin solution
haematocrit may be monitored to assess
volume of fluid in the intravascular space
folic acid 400mcg should be started in pregnancy from
12 weeks
why is folic acid taken in pregnancy?
reduces risk of neural tube defects
why should unpasturised dairy or blue cheese be avoided in pregnancy?
listeriosis
typically what weeks does ectopic pregnancies present?
6-8 weeks
presentation of an ectopic
Female patient with delayed menstruation and a history of sexual intercourse
Lower abdominal pain – constant and in the iliac fossa
Vaginal bleeding
Lower abdominal tenderness
Cervical excitation
criteria for methotrexate in an ectopic pregnancy
Unruptured Adnexal mass < 35mm No visible heart beat No significant pain hCG level <1500 IU / l Confirmed absence of intrauterine pregnancy on ultrasound
criteria for surgery in ectopic pregnancy
anything that doesn’t meet methotrexate criteria
miscarriage occurs in what fraction of pregnancies
1/5
missed miscarriage definition
foetus has died <20 weeks but inside uterus
threatened miscarriage definition
vaginal bleeding with closed cervix but foetus alive
incomplete miscarriage definition
retained products of conception
inevitable miscarriage
bleeding with open cervix
complete miscarriage
full miscarriage with no products of conception left
anembryonic pregnancy refers too
gestational sac present but n embryo
treatment for incomplete miscarriage
misoprostol vaginal pessary or evacuation of retained products of conception via surgery
recurrent miscarriage is referred to as
> 3 miscarriages in a row
causes of recurrent miscarriage
idiopathic, antiphospholipid syndrome, uterine abnormalities, genetic factors or chronic histiocytic intervillositis
investigations for recurrent miscarriage
antiphospholipid antibodies, pelvic US or genetic testing
diagnosis of chronic histiocytic intervillositis is made by
histology showing mononuclear infiltrate in the intervillous spaces of the placenta
medical abortion procedure
mifepristone followed 1-2 days by misoprostol
mifepristone is what type of drug?
anti-progestogen
misoprostol is what kind of drug
prostaglandin
two types of surgical abortion
cervical dilatation and suction of contents (15 weeks) or evacuation (15-24 weeks)
nausea vomiting in pregnancy peaks around
8-12 weeks gestation
correlation between high bHCG levels and
morning sickness due to molar pregnancies and multiple pregnancies
criteria for diagnosis of hyperemesis gravidarum
> 5% weight loss, dehydration and electrolyte imbalance
measuring severity of morning sickness is out of
pregnancy unique quantification of emesis score (PUQE) (15)
antiemetics for hyperemesis gravidarum
prochlorperazine or cyclizine
admission for hypermesis gravidarum should be considered for
unable to tolerate fluid.
Ketones on dipstix.
electrolyte imbalances and other medical conditions.
severe hypermesis gravidarum Tx
IV fluids, IV antiemetics, thiamine supplements and thromboprophylaxis.
complete mole pregnancy is caused by
two sperm fertilising an ovum with no genetic material
partial mole pregnancy occurs when
two sperm fertilise a normal ovum
presentation of molar pregnancy
More severe morning sickness. Vaginal bleeding Increased enlargement of the uterus Abnormally high bHCG Thyrotoxicosis
US appearance of molar pregnancy
snowstorm appearance
diagnosis confirmation of molar pregnancy is by
histology