RHCN Lecture Notes Flashcards
What is 2,3-DPG
It is a compound that inhibits the switch from deoxy to oxyhaemoglobin (shifting curve right)
This is helpful because it means blood doesn’t steal oxygen from cells that need it. It means blood only associates with oxygen in the lungs
Why does HbF have a stronger affinity to oxygen than HbA
Because it has a weaker affinity with 2,3-DPG (left shift for baby)
Also because in pregnancy the mum makes more DPG (right shift for mum)
what vessels lead from fetus to placenta
Semi-deox blood
aorta –> internal iliac –> umbilical arteries
Describe fetal circulation
blood into umbilical vein over lift via ductus venosus into RA 2/3 through FO and LA --> LV aorta and away 1/3 to RV Into pul artery Most through ductus arteriosus into aorta Small amount into lungs
What happens to fetal circulation at birth
Pul vascular resistance drops Blood from RV goes into lungs Arteriosis starts shutting down Increased return to LA from pul veins shuts FO Ductus venosus constricts
How is fluid in the baby’s lungs removed
- physical squeezing and spluttering
- adrenaline mediates change in respiratory epithelium - switch from secretory to resorbing (via Na+ transport) into pulmonary vessels and lymph
What happens if pul vascular resistance remains high after birth
persistent fetal circulation
blood not getting to lungs (hypoxia)
cells not getting oxygen (lactic acidosis)
How do you manage persistent fetal circulation (3)
- high flow oxygen
- inhaled NO (vasodilator to try bring down pul vascular resistance)
- inotropes (to force blood into lungs)
What is differential cyanosis
When feet are cyanosed but hands are not.
Something that can happen in babies with a PDA.
Happens because the brachiocephalic trunk, left common carotid trunk and the left subclavian trunk is given off proximal to the PDA.
Remember that as a general rule:
L2R shunt = breathless
R2L shunt = blue
How do you manage PDA
indomethacin (NSAID)
Why and how do we give vitamin K to newborns
breast milk contains insufficient vitamin K - risk of haemorrhagic disease of the newborn
why do babies get neonatal jaundice (4)
- immature liver enzymes
- they have all the HbF to break down
- breast milk beta-gluronidase interferes
- they are polycythaemic in utero
when is baby jaundice not normal
<24hrs
>10 days (term)
>14 days (preterm)
Benefits to baby of breast feeding
From top to toe: neurocognitive development IQ is 8.3 better less ear infection less lung infection lower BP later in life less obesity less gastroenteritis 10x less NEC less diabetes less obesity less SID
benefits of mum to breastfeeding
less postpartum uterine bleeding cheaper allows bonding burns calories less breast, ovarian, uterine cancer less osteoporosis less arthritis less heart disease
at what point in feeding session is fat content highest
end (because fat globules accumulate in lobules not in ducts in between feeds)
disadvantages of breast feeding
slower growth of baby
poorer bone mineralisation (less vit D compared to formula)
APGAR score
check elsewhere
preterm birth =
<37w
low birth weight
v low birth weight
extreme low birth weight
low = <2.5kg
v low = <1.5
extreme low = <1
perinatal vs neonatal death
perinatal = stillbirths + within 7 days neonatal = 7-28 days
what happens at 24 weeks in gestation in terms of lungs
You get canaiculi –> saccules in lungs
You get surfactant
What is apnoea of prematurity and Mx
When baby’s brain doesn’t tell it to breathe properly
Mx = caffeine (+ resp support if needed)
Acute and later in life worry with a PDA
Acute = heart failure Later = chronic lung disease
NEC appearance:
- Abdo film
- USS
- AXR = distended gut loops, air in portal veins, oedematous gut loops
- USS = pneumatosis intestinal = pearl like strong of bubbles in gut wall
Why does retinopathy of prematurity occur
Vessels grow from optic disc outwards
If premature this hasn’t completed and they complete in a tortuous fashion
prone to bleeding and therefore scarring in first 6 months of life
causing retinal detachment and blindness
Oxygen target with ROP and why
<95% because higher oxygen can increase neovascularisation and increase ROP
Also screening from 6-7 weeks with lasering of any badness
diving reflex
when oxygen is low
bradycardia and decreased BMR, blood shunts away from peripheries to brain
pathogenesis of brain damage in term infant
Mx
Hypoxic ischaemic encephalopathy (macroscopic and microscopic things after reoxygenation). Hypoxia, hypercarbia, cells anaerobically respire –> lactic acidosis (metabolic acidosis)
Occurs first in basal ganglia where demands are highest, hence the tendency for contralateral hemiplegia
Cooling 33.5 for 72hours
pathogenesis of brain damage in pre-term infant
Mx
intraventricular haemorrhage
liquefaction
CSF disruption and hydrocephalus
–> periventricular leukomalacia
Maternal corticosteroids reduces chance of IVH Ventriclar washout to prevent disability after IVH has occurred
Magnesium sulphate protect white matter
VP shunt if hydrocephalus present
TORCH syndrome cause and symptoms
caused by in utero infection by certain bugs
growth restriction, hepatosplenomegaly, thrombocytopaenia, rash
Toxoplasmosis (protozoan parasite - treat with spiramycin) Other Rubella CMV Herpes simplex
% mums carrier of GBS
Chance of colonising baby
Chance of baby infection if colonised
20-40%
50%
2%
RFs for GBS infection
prematurity
prolonged rupture of membranes
previous GBS pregnancy
paternal pyrexia
opisthotonos
position in meningism arched back and neck to relieve pressure eon meninges
Empirical Abx for: early infection (<48hrs) late infection (>48hrs)
Where do early infections and late infections come from respectively
early = benzyl pen + gent + cefotaxime (if meningitis)
late = fluclox + gent
early = from mum or from PROM
late = nosocomial
Hep B screening programme
Screening at booking visit for HBsAg
If + –> test for HBeAg and HBeAb
If Ag+/Ab+ –> 4 doses vaccine
If Ag+/Ab- –> 4 doses vaccine + Hep B immunoglobulin now
Mum has Hep B surface antigen –> Baby gets:
1) Within 12 hours of birth = Hep B vaccine + HBIG
2) Future = Hep B vaccine @ 2 & 6 months
vertical transmission risk of HIV and Hep B
HIV = 25% (from placenta, labour or breast milk)
Hep B = 40% (all from placenta, none from breast milk)
transient tachypnoea of newborn:
- Cause
- Mx
- Prognosis
- CXR appearance
- delayed resorption of fluid from lungs
- CPAP and oxygen
- Resolves within a day
- coarse streaking and fluid in interlobar fissures ‘wet lung’
why is meconium bad for lungs (3)
- mechanical obstruction
- chemical pneumonitis
- inactivated surfactant
cause of granuloma as cause of stridor
cause of sub-glottic stenosis as cause of stridor
granuloma = follows ET suction
sub-glottic stenosis = follow ET tube placement
stress test
pad test
q-tip test
stress test = fill bladder and ask to jump or cough and observe fluid leakage
pad test = same as stress test but weigh pad before and after
q-tip - put q tip in urethra and if it moves a lot when coughing or jumping it indicates weak pelvic floor
stress incontinence
C
M
S
C = pelvic floor exercises and bladder diary M = duloxetine (SNRI) S = urethral bulking, mid-urethral slings
urge incontinence
C
M
S
C = bladder diary and bladder retraining M = antimuscrinics (oxybutnin/tolterodine for less detrusor activity) or sympathetics (mirabegron for more detrusor inhibition) S = botulinum, detrusor myomectomy
how does menopause increase chance of prolapse
reduce elasticity of pelvic floor
% women affected by prolapse at some point
% chance relapse
50%
30%
prolapse
C
(no M)
S
L = loose weight, stop smoking C = pessary, pelvic floor exercises S = surgical repair or last line is colpcleisis
PID Abx
doxy + met + IM ceftriaxone
PID follow up schpiel (5)
- contact tracing (3m)
- treat partner
- no sex in 2 week treatment period
- follow up in 14 days for re-swab
- counselling re pelvic pain, infertility, ectopic, adhesions
OHS Sx
mild = enlarged ovaries, ascites, abdo pain
severe = thrombosis, oliguria, pleural effusions, respiratory distress
OHS Mx
- analgesia
- thromboprophylaxis
- fluid management
PUL defintion
Mx
bHCG 1000-1500 with an empty uterus
conservative (most just fail and resorb)
surgical management of menorrhagia
only if fertility not needed:
- endometrial ablation
- transcervical resection of endometrium
- ?hysterectomy
when is surgery needed for firboids
> 3cm
surgical options for fibroids
uterine artery embolisation
myomectomy
definition of oligomenrohoea
> 35 days in between
advice for people with PCOS re. periods
have at least 3 a year
gardasil protects against
HPV 6, 11, 18, 18
limitations of cervical screening programme
rest detect adenocarcinomas well (which are 20%)
typical age for cervical cancer
late 20s to early 40s
what is lichen sclerosus
pre-cancer stage of vulva
squamous cell hyperplasia
process at colposcopy
visualisation of cervix
addition of acetic acid (white bits are bad)
addition of iodine (bits that don’t take up iodine are bad
biopsies may be taken
chemotherapy type in ovarian cancer
carboplatin
how does cell free fetal DNA work
trophoblastic cells (DNA of fetus) leak into mums blood
This DNA is examined by NIPT or NIPD
What is NIPT
What is NIPD
How many blood samples how often are needed?
non invasive prenatal testing. is not diagnostic. used to see if free fetal DNA has any trisomies
non invasive prenatal diagnosis. can be used to detect single gene disorders (Achondroplasia, Duchenne’s). needs two blood samples 1 week apart from 10 weeks
combined screening at 10-14 weeks. why is it called combine?
because its blood test and USS
double check you know the results of the combined and quad testing
yes
what result does triple testing give you in terms of downs
high risk (>1 in 150) or low risk. if you want a diagnosis, need invasive testing (amnio or CVS)
what is QFPCR
amplification of whatever sample you’ve taken through PCR
replacing karyotyping
what is microarray CGH
comparative genomic hybridisation. can see extra or fewer bits of DNA compared to known sample.
can’t see single base pair mutations that sequencing can
what happens to a sample after CVS or amniocentesis
QFPCR to detect trisomies
CGH to detect anything else
how long after a sexual assault can forensic sample be retrieved
7 days in adults
3 days in children
if a patient comes into A&E having been raped, what do you do
- Hep B and HIV post-exposure prophylaxis
- 1g azithromycin (chla) and 500g ceftriaxone IM (gon)
- emergency contraception
- psychological coucnelling
- call forensic people
- collect evidence like clothing, underwear, bedding
3 absolute drug CI
lithium
methotrexate
radioactive iodine
do you usually need a higher or lower drug dose in pregnancy and why
higher
increased plasma volume
increase renal clearance
increase metabolism
chylamydia
% asymptotic men
% asymticamc women
men = 50% no Sx women = 70% no Sx
types of chylamdial diseases
A-C = trachoma D-K = STI L1-3 = lymphogranuloma venereum
Mx for lymphogranuloma venereum
doxycycline 3 weeks BD
testing for chylmydia
endocervical swab for women –> NAAT
first catch urine for men –> NAAT
length of contact tracing for chylamydia
Sx = 1 month tracing
No Sx = 6 month tracing
Abx for epididymis-orchitis
same as PID but without metronidazole:
IM ceftriaxone + doxycycline BD 2 weeks
urethral strictures STI?
gonorrhoea
how often if PID bug negative
60%
most common 3 bugs for PID
- chylamydia
- mycoplasma genitalia
- gonorrhoea
legal limit for abortion
24 weeks
cutoff in weeks when you have to do surgical and not just medical
14 weeks
medical drugs for termination
mifepristone (anti-progesterone to ripen cervix)
misoprostol 48 hours later (stimulates min labour)
what is hyaline membrane disease
aka for RDS (surfactant baby problem)
what is erythema toxicum
common finding at first NIPE. central papule surrounded by erythema all over. caused by eosinophils,
main cause of facial asymmetry after difficult birth
facial nerve palsy secondary to forceps. usually resolves
choledocal cysts
- what are they
- presentation
Choledochal cysts (a.k.a. bile duct cyst) are congenital conditions involving cystic dilatation of bile ducts. They are uncommon in western countries but not as rare in East Asian nations like Japan and China
presents as prolonged neonatal jaundice (conjugated hyperbili)
biliary atresia presentation and Mx
> 2w jaundice (conj hyperbili)
needs op before 6w
complications of kernicterus
CP
Cerebral deafness
learning difficulties
death
how is dose of Anti-D in a sensitising event calculated
Kleihauer test - checks for amount of fetal blood din mums blood to see how much extra anti-D is required
how do you manage a rhesus -ve baby in a previously sensitised rhesus +ve woman
Monitor antibody levels every 2-4 weeks
If rises, check baby for anaemia (by looking at MCA peak systolic velocity)
If baby is becoming anaemic, must do bi-weekly Rh-ve, CMV-ve blood transfusions in to the umbilical vein
direct vs indirect coombs test and uses
direct = tests for antibodies or complement ON THE SURFACE OF RBCs
- warm or cold AIHA
- drug induced haemolytic anaemia
- alloimmune haemolysis (testing babies blood for haemolytic disease of newborn, transfusion reaction)
indirect = tests for antibodies IN THE SERUM
- pre-transfusion testing
- pre-natal testing (For IgG in mums blood that can cross placenta and cause haemolytic disease of newborn)
appearance of baby at birth if haemolytic disease of newborn has occured
Anaemia
hepatosplenomegaly
severe jaundice
diagnosis of periventricular leukomalacia in preterm infant
USS through fontanelle
–> echo dense area around ventricles followed later by cystic lesions a few weeks later
HIV +ve mum, management:
- antenatally
- intrapartum
- postpartum
- start or continue HAART. test viral load once every trimester, at 36w and at delivery
- if viral load low and CD4 high, can do vaginal delivery at 36w WITH DOSE of ZIDOVUDINE. Otherwise, plan elective caesarean with intrapartum zidovudine
- no breastfeeding. give neonatal post-exposure prophylaxis
what time is ben pen given for intrapartum prophylaxis of GBS
2 hours before delivery
average age of:
menarche
menopause
12.5
51
how is GnRH released
in a pulsatile manner to trigger LH/FSH release
staging system for breast development
Tanner
is the follicular phase or luteal phase of a woman menstrual cycle fixed?
The luteal phase is fixed (1 week)
the follicular phase varies between women
what is gastrulation and neurulation and when do they occur
gastrulation = formation of the endoderm, ectoderm and mesoderm = beginning of week 3
neurulation = lateral edges of ectoderm fold to form neural fold and plate = end of week 3
by what week have most organs formed and can you call the embryo a fetus
week 7
Hormones in pregnancy:
- increases blood to uterus
- causes muscle and ligament relaxation
- maintains corpus luteum
- breast development
- oestorgen
- progesterone
- hCG
- placental lactogen
Changes in pregnancy:
- thyroid hormones
- T3/T4 increase, but so does the binding protein
low and high doses of folate
low = 400ug high = 5mg
how many antenatal appointments for uncomplicated:
- nulliparous
- parous
10 appointments
7 appointments
What is the Barker hypothesis
a hypothesis that says that specific set of conditions during pregnancy will have long tern effect on adult health and risk of associated diseases
What foods to avoid during pregnancy
excess vitamin A (liver) Uncooked foods: - soft cheese - raw fish - honey
when is sex CI in pregnancy
placenta praevia
ruptured membranes
how long is maternity leave
do you have to take it
how long is paternity leave
52 weeks total:
26 week ordinary leave
26 weeks additional leave
you must take the first 2 weeks (or 4 if in a factory), but don’t have to take any more
paternity leave is 1-2 weeks
time in pregnancy for CVS and amniocentesis
CVS = 11-14 weeks Amnio = 15+ weeks
chance of having a down syndrome baby at:
30y
40y
45y
30y = 1 in 1000 40y = 1 in 100 45y = 1 in 30
Do you give anti-D in miscarriage?
if >12w, yes
If <12w, only if evac was performed of if it was an ectopic
Investigations for recurrent miscarriage
Mums blood:
thyroid function
FBC, metabolic screen
antiphospholipid antibodies
Mums anatomy:
Pelvic exam
TV-USS
MRI hysterosalpingogram
Genetics:
parental karyotyping
hCG rise in:
- normal pregnancy
- ectopic
- miscarriage
- doubles every 48 hours
- <66% every 48 hours
- falls
complete vs partial mole
partial = normal egg fertilised by 2 sperm - 69 chromosomes from mum and dad
complete mole = egg with no maternal DNA fertilised by 2 sperm - 46 chromosomes all from dad
treatment for full blown choriocarcinoma
prognosis
chemotherapy
almost 100% cure
when does hyperemesis usually start and stop (Estimate)
starts around 6 weeks
ends around 14 weeks (can linger)
Investigations for hyperemesis
urine dip (ketones) FBC U/E (?renal failure) LFT (?liver failure) USS (?molar preg)
Management of mild vs severe hyperemesis
Mild (conservative)
- eat frequent meals
- drink fluid between meals
Severe because not tolerating fluid and dehydrated
- admit and IV rehydrate
- NBM for 24hours
- Antiemetic (cyclizine, promethazine)
- Pabrinex (risk of Wernickes)
best laxative for constipation of pregnancy
Osmotic laxative = lactulose
What condition is carpal tunnel syndrome in pregnancy linked to
gestational diabetes
what do you do for a woman with essential hypertension on ACEi and a diuretic who is now pregnant
Take her off the ACEi (?renal agenesis in baby) and put her on labetolol
Take her off diuretic (reduces plasma volume)
Increase antenatal visits
Gestational hypertension management:
- > 140/90
- > 160/110
labetolol
> 160 = admit to DAU to treat
What kills you in pre-eclampsia
hypertension –> seizure –> stroke
5 high risk factors for pre-eclampsia
4 moderate risk factors
PMHx of PET (7x) Kidney problems Chronic hypertension diabetes Antiphospholipid syndrome
Nulliparity (or not parous for >10yrs, or new partner)
FHx of PET
BMI >35
Multiple gestation
What is the prophylaxis for PET based on RFs
1 high or 2 moderates
Aspirin 75mg OD started between 12-16w
where is the oedema in PET most likely to occur
face
Management of PET in terms of delivery
Get to 35w –> Deliver
If it gets worse –> deliver
If already 35w+ –> deliver asap
Think about steroids if coming early
Give MgSO4 if severe to prevent seizure
Remember: can’t give ergometrine in hypertension so give just oxytocin if required
How long do you keep someone in hospital for after PET
5 days to monitor BP and urine
Tx of eclampsia AND HELLP
MgSO4
ABCDE
What happens if you are high risk for gestational diabetes
GTT at 26-28w
Why can’t you use urinary glucose as a test for gestational diabetes
Because the renal threshold for glucose changes and some leaks out anyways
Process of GTT? and result that means GDM?
Starve over night
Glucose measured
75g glucose drink
Glucose measured again at 2 hours
If baseline >5.6 or if post-drink glucose >7.8 = GDM
3 steps of GDM management
- lifestyle and diet
- recheck in 2 weeks then give metformin
- recheck in 2 weeks and then insulin
ASPIRIN FOR PET RISK
Delivery with GDM
IOL at 38w
Caesarean if macrosomia
Normal Hb in 1st, 2nd, 3rd trimester
1st = 110+ 2nd/3rd = 100+
Mx for high, medium and low risk for VTE
How does this Mx change in labour itself?
High = LMWH antenatally and for 6 weeks postnatally
Medium = LMWH from 28w to 6 wks postnatally
Low = avoid dehydration
In labour, stop LMWH. If high risk, continue with unfractionated heparin because you can reverse it quicker with protamine sulphate
Tx for simple UTI in pregnancy:
- symptomatic
- asymptomatic
Amoxicillin
Sx = 7d
No Sx = 3d
SGA vs IUGR
SGA is simply in bottom 10% of size
IUGR is failure of fetus to achieve genetic potential of size
Main cause of IUGR
compromised uteroplacental flow
1
2
3
stages of labour
1 = onset to 10cm dilated
2 = delivery of baby
3 = delivery of placenta and membranes
During labour frequency of:
- Obs
- VE
- Temp measurement
- Obs = every hour (apart from temp which is 4 hourly)
- VE = every 4 hours
Opioid in labour and route?
Pethidine IM (takes 15mins)
Acidosis cutoff in fetal blood sampling
<7.25
time lag in a late decel
> 15s
late vs variable decelerations
late = happens with every contraction = always bad
variable = happens with some contractions = sometimes bad
when are variable contractions bad
when occurring in >50% contractions for >30min
what does attitude refer to in baby presentation
the amount the neck is flexed
a brow presentation has greatest diameter
What two things does a face presentation contraindicate
fetal blood sampling
ventouse delivery
when do you do ECV
36w in nulliparous
37w in multiparous
how long should 2nd stage of labour last (10cm-baby delivered)
<2hrs in primip
<1hr in multip
way to think about failure to progress
Power - uterus contracting properly?
Passenger - presentation and lie of baby?
Passage - type of pelvis? android causes failure to progress.
Method and escalation steps to induce labour
- Membrane stretch and sweep
```
2. Vaginal PGE2
6hrs later
3. ARM
(2hrs later)
4. Syntocinon
~~~
If you want to do ventouse, can the head be palpable?
Yes, but no more than 1/5th palpable
definition of puerperium
6 weeks following delivery
timeline of:
- postnatal blues
- postnatal depression
- postnatal psychosis
blues = 0-2 wk depression = 6 wk + psychosis = 1-4 wk +
Can you do VE or speculum in placenta praevia
Dont do VE
Can do speculum
classic presentation of vasa praevia
Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen
4 major causes of post-partum haemorrhage in order (4 T’s)
tone (uterine atony)
tear
thrombin (clotting abnormality)
tissue (retained tissue)
Main investigation for:
?PROM
?Preterm labour
PROM:
- speculum to look at cervix
- AMNIsure/actinPROM test for placental alpha microglobulin
preterm labour:
- TV-USS for cervical length
- fetal firbonectin (if negative you can send them home - high NPV)
teenage pregnancies increases risk of
PET
anaemia
low birth weight
Legal obligation for pre-term infants: 24w + 23w 22w 21w
24w+ = full ICU required 23w = parental preference 22w = comfort care unless research project available, in which case parental preference 21w = comfort care
3 Mx for pruritus vulvae
Vulval care
Hydrocortisone
Antihistamine
Hirsutism in PCOS Tx
In combo with COCP = Cyproterone acetate
Topical for face: eflornithine
endometriosis medical management
adenomyosis management
endometriosis = NSAIDs + para + COCP
adenomyosis = none really. can wait for menopause. can try normal management of menorrhagia
what is a nabothian cyst
a retention cyst of the cervix - mucus filled lesion considered normal part of adult cervix. occur as a result ofmetaplastic change. asymptomatic.
histology of dyskaryosis:
mild
moderate
severe
mild = <1/3 of thickness shows dyskaryosis (hyperchromic nuclei and irregular chromatin). confined too basal 1/3rd
moderate = basal 2/3rds show dyskaryosis
severe = >2/3rds show dyskaryosis
FIGO staging
staging for ovarian cancer: 1 = ovary 2 = true pelvis 3 = beyond true pelvis 4 = mets
staging for endometrial cancer
1 = endometrium 2 = and cervix 3 = and pelvis 4 = beyond pelvis
staging for vulval cancer
1 = vulva 2 = local spread to vagina, anus etc 3 = and lymph nodes 4 = mets
When is abortion legal (5 categories)
A = risk of life to mother B = risk of permanent injury to mother C = <24wks AND injury to mother mental or physical D = <24wks AND injury to other siblings E = substantial risk of child being born with serious disability
most fall under section C
what type of TOP is more common
Surgical (90%) compared to only 10% medical (mifi+miso)
surgical TOP technique:
<14w
>14w
>22w
<14w = suction >14w = dilation and curettage >22w = foeticide
Rokitansky syndrome
agenesis/hypoplasia of uterus and top 2/3rds of vagina
presents with short vagina and infertility
Criteria for diagnosing PCOS
Rotterdam criteria:
Need 2/3 for diagnosis:
- oligomenorrhoea
- evidence of hyperandrogenism (acne, hirsuitism, alopecia)
- 12+ follicles on USS
definition:
- oligospermia
- asthenospermia
oligo = <20 million per ml astheno = poor motility
when is IVF offered on NHS
Women under 40 get 2 cycles
women over 40 get 1 cycle
IF
- trying for 2 years
- tried 12 cycles of IUI
success rate of IVF
under 35 = 32%
over 40 = 13%
IVF process
COCP suppresses natural cycle FSH daily injection for 10 days hCG given to trigger oocyte maturation USS guided oocyte retrieval Semen collected IVF cultured for 3-5 days 1-2 embryos implanted
what does clomifene do
Increases fertility in PCOS
Clomifene is a nonsteroidal
SERM that inhibits estrogen receptors in the hypothalamus, inhibiting negative feedback of estrogen on gonadotropin release, leading to up-regulation of the hypothalamic–pituitary–gonadal axis.
pessary ring advice and follow up
We’ll do a VE and size you up. Put it in and wait 30 mins so you can walk around and go tot he toilet with no problems. Then we’ll call you back in 6m to change it and follow up.
