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Obs & Gyn > Subfertility & Early Pregnancy > Flashcards

Subfertility & Early Pregnancy Flashcards

1
Q

What is sub fertility defined as?

What is the prevalence

A

Failed conception after 1yr regular unprotected intercouse

Affects 15% couples

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2
Q

What are the 4 main conditions / stages of conception and what causes of sub fertility may affect each one

A

Egg produced - anovulation (PCOS)
Adequate sperm release - male factor
Sperm reaches egg - tubal damage, sexual /cervical probs
Embryo implantation - unexplained subfertility

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3
Q

What are some causes for damaged fallopian tubes? (3)

A

Infection
Endometriosis
Hydrosalpinx
Surgery / adhesions

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4
Q

List the causes of anovulation (7)

A

COMMON:
Hypothalamic hypogonadism (stress, anorexia, idio)
Hyperprolactinaemia (pituitary damage/tumour)
PCOS

Uncommon:
Hypo/hyperthyroidism
Adrenal hyperplasia
Premature ovarian failure
Gonadal dysgenesis
Luteinised unruptured follicle syndrome
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5
Q

What investigations of ovulation can be done? (4)

A

Mid-luteal phase serum progesterone (elevated = ovulated)
LH-based urine predictors
USS follicular tracking
Temperature charts (unreliable)

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6
Q

What are the different fertility treatments for PCOS? (6)

A 
Wt loss
Clomifene (1st line)
Metformin (2nd line)
Gonadotrophin induction
Laparoscopic ovarian diathermy
IVF
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7
Q

What is clomifene, how does it work?
How is it given (in what regime)?
What are the risks with clomifene (2)

A

Anti-oestrogen, raises FSH+LH thus follicle maturation
Given on day 2-6 of cycle, for 6m

Risks: multiple pregnancy (multiple follicles) + endometrial thinning (assessed with transvag USS)

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8
Q

What is metformin, how does it work in sub fertility?

What are the advantages to using metformin > clomifene? (4)

A

Insulin-sensitising + oestrogen restoring

No risk multiple preg
Treats hirsutism
Reduce risk early miscarriage
Reduce risk gestational DM (common in PCOS)

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9
Q

How does gonadotrophin induction work in artificially causing ovulation?
What are the risks?

A

Recombinant/purified (menopausal urinary) FSH±LH
Follicle development monitored with USS
Follicle release stimulated by hCG injection (structurally similar to LH)

Risk: multiple preg (but reduced with low-dose step up)

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10
Q

How would laparoscopic ovarian diathermy help in sub fertility treatment? (2)

A

Treat adhesions / endometriosis

Test tubal patency (dye test)

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11
Q

How is hypothalamic-hypogonadism subfertility managed? (2)

A

Wt loss

Gonadotrophins if wt normal

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12
Q

How is hyperprolactinaemia subfertility managed? (2)

A

Bromocriptine
or
Cabergoline (blocks prolactin secretion)

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13
Q

What are some side effects of ovulation induction? (2)

A

Multiple pregnancy

Ovarian Hyperstimulation Syndrome (OHSS)

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14
Q

What are some RFs of OHSS? (3)

How can it be prevented?

A

Gonadotrophin induction
IVF (>ov induction)
<35yrs

Prevented by low-doses of induction

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15
Q

What types of infection can → PID? (3)

A

Chlamydia
post-IUD infection
Ruptured appendix

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16
Q

What anatomical changes occur in PID?

How can this be managed in sub fertility treatment?

A

Peritubal adhesions
Closed fibril ends (w. normal tubes)

Laparoscopic adhesiolysis + salpingostomy

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17
Q

What Ix can be done for tubal damage? (2)

A

Laparoscopy + dye test (w. hysteroscopy)

Hysterosalpingogram

18
Q

What cervical problems can cause subfertility? (2)

A

Antibody production against sperm

Vaginal/cervical infection

19
Q

What are the indications for assisted conception? (6)

A 
Any/all other methods failed
Unexplained sub fertility
Male factor subfertility (intracytoplasmic sperm injection)
Endometriosis
Tubal blockage (standard IVF)
Genetic disorders
20
Q

What are the processes of normal IVF?

A

Follicle production
Egg collection + mix with sperm
Transfer / implant into uterus

21
Q

What types of subfertility can intra-uterine semination be used for? (4)
+ not be used for? (1)

A

Used in: cervical, sexual, some male factor, unexplained

Not used in: tubal damage (still req patent tubes)

22
Q

How are FSH + LH involved in spermatogenesis?

A

LH acts of Leydig cells → testosterone production
FSH + testosterone → Sertoli cells → synthesis + transport of sperm
Testosterone + other steroids inhib LH release (-ve feedback)

23
Q

What is the normal concentration of sperm in semen?

And normal level of motility?

A

Normal: >15million sperm/ml
Motility: >32%

24
Q

What are the different ranges of low sperm count?

A

<15 million / ml = oligospermia
<5 million / ml = severe oligospermia
Zero = azoospermia

Absent/low motility = asthenospermia

25
Q

What are some causes of low sperm count? (7)

A 
Smoking
Alcohol
Drugs
Chemicals
Inadequate local cooling
Genetic factors
Antisperm Abs
Idiopathic
26
Q

What interventions can be done for:
Oligospermia
Mod-severe
Azoospermia

A 
Oligo = intra-uterine insemination
Mod-severe = IVF ± ICSI
Azoo = examine for presence of vas deferens + karyotype
27
Q

What is the incidence of ectopic pregnancy?

What are the RFs? (6)

A

1%+ of pregnancies

Older
Smoking
Endometriosis
PID
Previous ectopic
Previous surgery
28
Q

When / how will ectopic pregnancy present?

  1. Acute (4)
  2. Sub-Acute (6) (3S + 3S)
A

Presents at 4-10wks amenorrhoea

ACUTE:
Abdo pain + Shock (tachycardia + → hypotension)
Syncope + shoulder tip pain (= intraperitoneal blood loss)

SUBACUTE:
Abdo pain (colicky → constant)
Dark PV bleeding
Lower abdo tenderness
Cervical excitation
Adnexal tenderness
Smaller uterus than expected/os closed
29
Q

What investigations can be done regarding ectopic pregnancy? (6)

A

Urine hCG - for all repro women w. abdo pain / bleeding
Serum hCG (can detect earlier in gestation)
USS (transvag if serum hCG >1000; transabdo if >6000)
Speculum
Bloods: FBC / G&S / Cross-Match
Laparoscopy

30
Q

What is the immediate management of ectopic pregnancy if symptomatic? (4)

A 
→ Admit to hosp:
NBM
IV access
Anti-D if Rh-ve
Consider resuscitation + transfusion
31
Q

When is medical management of an ectopic carried out? What criteria (3)
What does it involve? (2)

A

if hCG <3000
Unruptured
No fetal cardiac activity

IM methotrexate w/o laparoscopy
Serial hCG to confirm trophoblastic tissue gone (may need 2nd dose)

32
Q

What happens in a molar pregnancy / gestational trophoblastic disease? (2)
What is the incidence
What are the RFs (2)

A

Aggressive trophoblastic proliferation
+ excess hCG secretion

0.1-0.2% pregancies
RFs: extreme repro age + asian

33
Q

What are the different classifications of molar pregnancy / gestational trophoblastic disease (4)

A

Hyatidiform mole (Complete/Partial) - localised non-invasive
Invasive mole - malignant tissue within uterus
Choriocarcinoma - metastasis occurred

34
Q

What are the features of a molar pregnancy ? (4)
What is a complication
How is it Dx? (2)

A

PV bleed (poss heavy)
Severe vomiting
Large uterus
Early pre-eclampsia + hyperparathyroidism

Complication: recurrence (1 in 60 subsequent pregs)

Dx confirmed histologically but serum hCG v high

35
Q

How is molar pregnancy managed? (3)

A 
Suction curettage (ERCP)
Avoid pregnancy + COC
Monitor any rising hCG levels (would suggest malignancy)
36
Q

What embryological events happen from fertilisation → implantation?

A

Fertilised in ampulla → zygote + peristalsis / ciliary action
Enters uterus by day 4 as multicellular morula
→ Becomes fluid filled blastocyst + trophoblast outer layer
Implants at day 6-12

37
Q

What does the trophoblastic tissue do upon invasion? (2)

A

Produces hCG → maintains CL (oestrogen/progesterone → keeping endometrium secretory with glycogen/lipids)

Trophoblast formation → chorionic villi formation

38
Q

What is miscarriage defined as?

What are the different types? (6)

A

= death <24wks

Threatened miscarriage
Inevitable
Incomplete
Complete
Septic
Missed
39
Q

What will be seen O/E with each type of miscarriage (6)

A

Threatened - Bleeding, FHR, uterus normal enlarged/ os closed
Inevitable - bleeding, os open
Incomplete - some fetal parts passed, os open
Complete - all fetal parts passed, uterus not enlarged/ os closed
Septic - foul discharge, tender uterus, fever, abdo pain/peritonism
Missed - no FHR only recognised until bleeding/USS, smaller uterus/ os closed

40
Q

What Ix can be done in the case of a miscarriage?

A

USS (less useful in ectopics)
hCG
FBC
RhGrp

41
Q

What are the 3 different options of management in a non-viable intrauterine miscarriage?

A

Expectant: for incomplete / missed - watch&wait
Women willing + no signs infection

Medical: prostaglandin ± anti-progesterone

Surgical: ERPC (GA + vacuum aspiration)
Indications: heavy bleeding/ signs infection

42
Q

What is the incidence/definition of recurrent miscarriage?

What are the different causes (6) + Tx

A

= >3 successive miscarriages → in 1% couples

Antiphospholipid Abs → Aspirin + LMWH
Chromosomal defects 
Anatomical factors 
Infection
PCOS
Lifestyle/other: obesity, smoking, caffeine, older

Obs & Gyn (4 decks)

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