Week 1 Tutorial - Bleeding, Male infertility, amenorrhea, acute abdomen (ectopic)

Question 1

Mrs Alice Bain is 27 year old and this is her first pregnancy. Her last menstrual period (LMP) was two months ago, having stopped the contraceptive pill six months ago. For the past twelve hours she has experienced lower abdominal pain and some vaginal bleeding. What should be the first investigation carried out?

Answer 1

She should take a pregnancy test

Question 2

What hormone does the pregnancy test measure in the urine? How many weeks post-coitus must be waited before exclude a pregnancy with a pregnancy test?

Answer 2

bHCG hormone is measured in the urine

Have to wait 3 weeks post coitus to exclude a pregnancy with a pregnancy test

Question 3

Most urine pregnancy tests have a “control” window and another window that is the “results” window. When a line appears in the control window what does this ,mean? (usually a blue line) When a blue line appears in both the control and results window, what does this mean?

Answer 3

When the line or symbol appears in the control window, this ensures the test is working properly If the control window is working properly, and a line, plus sign, or other symbol as directed by the package instructions appears in the results window, this means the test is positive and the woman is pregnant.

Question 4

Question 2: In the event of a positive test, possible diagnoses are given. a) What do you understand these terms to mean? i. Threatened miscarriage ii. Incomplete miscarriage iii. Ectopic pregnancy iv. Hydatidiform mole

Answer 4

Threatened miscarriage - this is where there is some bleeding and potentially cramping but the amniotic sac remains intact and the pregnancy goes on Incomplete miscarriage - this is where there is bleeding and passage of some of the foetus but not all of it Ectopic pregnancy - fertilised ovum implants anywhere outside of the uterus (usually ampulla of fallopian tube) Hydaitiform mole - this is where there is gestation trophoblastic disease - collection of fluid filled sacs

Question 5

What are the two different types of hydatidiform mole? Describe the difference in chromosomal arrangement?

Answer 5

Partial and complete molar pregnancies Complete - this is where there is a diploidy egg (both sets off DNA from 1 (reduplication can occur) or2 sperm and no maternal DNA) - there is no foetus and only growth of abnormal placental tissue Partial - the egg supplies half the DNA and 1 (can reduplicate inside) or 2 sperm cause the zygote to be triploidy - foetus can form with abnormal placental tissue

Question 6

Transvaginal Ultrasound Scan: The images are all consistent with Mrs Bain’s history. Either Incomplete, ectopic, threatened or hydatidiform mole

Answer 6

• i)This is a threatened miscarriage - can see the bleeding on ultrasound but feotus is still on USS
• ii) Incomplete miscarriage - can see remnants of foetus in the uterus and some bleeding
• iii) Unsure how to tell but is an ectopic pregnancy
• iv) collection of fluid filled sacs (cysts/vesciels) so hydatidiform mole

Question 7

Define a miscarriage?

Answer 7

A miscarriage i ss defined as a loss of pregnancy during the first 23 weeks

Question 8

If there’s no pregnancy tissue left in your womb, no treatment is required. However, if there’s still some pregnancy tissue in your womb, what are the options?

Answer 8

Conservative management Medical management Surgical management

Question 9

Describe the advantages and disadvantages of conservative management? How long can conservative management take up to?

Answer 9

Advantages - this lets the body decide when it is naturally ready to expel the pregnancy - may be days to a couple of weeks Disadvantage - Conservative management can take up to as long as six weeks if extremely slow Also can have severe pain/heavy bleeding

Question 10

What are the advantages and disadvantages of medical management?

Answer 10

Advantaes - more controlled and speeds up the pregnancy process, also avoids surgery Disadvanatges - can have side effects from the tablets such as nausea/vomiting, needs 2 hospital appointments and may cause severe pain/heavy bleeding

Question 11

What is the drug used in the medical management of miscarriage ?

Answer 11

Misoprostolol

Question 12

What are the advantages and disadvantages of surgical miscarriage?

Answer 12

Advantages - procedure is quick and avoids severe pain and heavy bleeding Disadvantages- risk of procedure (utrine perforation, anesthetic) and small risk of infection after

Question 13

b) Mrs Bain has the following questions for you to answer before she is discharged home. i) Why did the miscarriage happen?

Answer 13

In most cases, it is found to be that it is not related to anything the patient did

Question 14

ii) Will I become pregnant again and, if so how long should I wait and will I have another miscarriage?

Answer 14

It is likely that she will become pregnant again, the risk of further miscarriage is not increased Recommended that the patient waits at least one period before trying to conceive again

Question 15

b) What protective injection should be given?

Answer 15

As Mrs Brain has tested Rhesus negative, she should be given an Anti-D immunoglobulin injection for protection

Question 16

What is the aim of the Anti-D immunoglobulin? What happens in rhesus disease?

Answer 16

Most people are rhesus positive Therefore if the mother tests as rhesus negative, this means that if her unborn baby was rhesus positive, then antbodies would have formed so come her next pregnancy, her own immune system may have preformed antibodies that will attack the babies red blood cells The Anti-D immunoglobulin aims to prevent these antibodies from forming

Question 17

What factors determines the sex of a person?(which part of the Y chromosome and what does it cause to be secreted)

Answer 17

• The Y chromosome in a male determines the sex of a person - the sex determining region (SDR) of the Y chromosome causes testicular development - Phenotypic sex - The SDR directs secretion of mullerian inhibiting substance from the testis that causes MUllerian duct to degenerate (no female reproductive system) The SDR also promotes the development of the testis - Psychological sex: related to upbringing of child and other psychological conditions

Question 18

When the testis are formed, what does this cause secretion of? What does the wolffian duct differentiate into? What cells produce tesosterone? What cells produce the anti-mullerian hormone?

Answer 18

Testis produce tesosterone which promotes the formation of the Wolffian duct Wolffian duct becomes the vas deferens, epididymis and seminal vesicles Sertoli cells produce the anti-mullerian hormone Leydig cells produce testosterone

Question 19

What happens in the absence of testosterone? (what will the mullerian ducts form)

Answer 19

. In the absence of testosterone, the Mullerian ducts will form the fallopian tubes, uterus and upper third of the vaginal

Question 20

Testosterone and other androgens cause the development of male external genitalia. In their absence female external genitalia develop. What hormones do secondary sexual characteristics form under?

Answer 20

Secondary sexual characteristics form under the role of testosterone and oestrogen

Question 21

What will the mullerian duct go on to form? What will the wollfian duct go on to form?

Answer 21

Mulelrian duct - goes on to form the fallopian tubes, uterus and upper third of the vagina Wollfian duct - goes on to form the vas defernes, epididymis and seminal vesicles

Question 22

Descent of the Testes Descent of the testes from the abdomen into the scrotum is an androgen dependent event, when the testes are pulled downwards by a fibrous cord anchored to the developing scrotum What is this embryological fibrous cord that pulls the testis down known as? (also pulls the ovaries down in females)

Answer 22

This cord is known as the gubernaculum - attaches to caudal end of gonads to pull them down

Question 23

Mr Edward Christie is a 28 year old man, who attends an infertility clinic with his wife with a 3 year history of primary infertility. He had bilateral cryptorchidism diagnosed as a teenager and underwent bilateral orchidopexy at the age of 16. Otherwise he is fit and healthy. What is cryptoorchidism and orchidopexy?

Answer 23

Cryoptorchidism is an increasingly common condition in which the testes fails to descend Orchidopexy is the surgical correction of undescended testis

Question 24

What is the most common cause of male factor infertility?

Answer 24

Most male factor infertility is idiopathic (60%)

Question 25

What are obstructive causes of male factor infertility? What condition is congenital bilateral absence of vas deferens related to?

Answer 25

Vasectomy, infection (ie chlamydia or gonorrhea) CBAVD (Congenital bilateral absence of vas deferens) CBAVD - this is related to cystic fibrosis

Question 26

What is the mutated gene in cystic fobrosis? What chromosome is it found on? Which ion channel is affected when there is a mutation in the gene?

Answer 26

This is the cystic fibrosis transmembrane regulator (CFTR) gene found on chromsome 7 - mutations with this gene affect chloride ion channel function

Question 27

What is a chromsomal cause of male infertility? What is a hormonal cause?

Answer 27

Chromosomal Kleinfelter’s - 47XXY Hormonal - Hypogonadotrophic hypogonadism (Kallman’s syndrome) or hyperprolactinaemia These are both non-obstructuve causes f male-infertility

Question 28

What is seen when Kleinfelter’s syndrome affects females?

Answer 28

The condition can only affect males As there is 2 X chromosomes and a Y chromsome (Y chromosome makes the person male)

Question 29

Question 3. Insert the missing labels in the correct positions on the diagram of normal male anatomy. (start at the top left corner of the picture and work clockwise to name the structures)

Answer 29

Bladder - ureteral orifice - seminal vesicle - vas deferens (ductus deferens) - rectum - prostate gland - anus - bulbourethral gland - bulb of penis - external urethral meatus - prepuce - glans of penis - membranous urethra - pubic symphysis - retropubic pad of fat

Question 30

What is the fucntion of the bulbourethral gland?

Answer 30

Bulbourethral gland lubricates the urethra and helps to neutralise the acid in the urethra

Question 31

WHat is the other name for the bulbourethral glands? What is the homologous glands in the femaleand what is their function? (give both names)

Answer 31

Cowper’s gland Homologous glands in the female are known as Bartholin’s glands (Greater vestibule glands) - they lubricate the opening of the vagina

Question 32

4a) What is the normal size of adult testes? What is the normal size of prepubertal testis? What is the normal size of pubertal testes? What is used to measure the size of testis? (what volume does this measurmement measure from)

Answer 32

Prepubertal testis - 1-3 mls Pubertal testes - 4mls and up Adult testes - 12-25mls Orchidometer is used to measure the size =- The orchidometer consists of a string of twelve numbered wooden or plastic beads of increasing size from about 1 to 25 mls

Question 33

Testicular size varies greatly amongst men from different backgrounds What does testicular size correspond to?

Answer 33

Testicular size corresponds to sperm production

Question 34

Any condition that causes testicular failure (i.e. non-obstructive causes) can reduce testicular volume Give examples of these?

Answer 34

Kleinfelter’s syndrome, undescended testis (cryptorchidism), testicular torison

Question 35

Which hormone from the pituitary gland innervates the sertoli and leydig cells of the testis? What do the sertoli and leydig cells do?

Answer 35

FSH causes setoli cells to secrete inhibin and stimulate spermatogenesis (it is also the sertoli cells that produce anti-mullerian hormone during development) LH causes the Leydig cells to secrete tesosterone

Question 36

Question 5. What investigations should you perform on a man to help decide the cause of azoospermia? (why do endocrine, why do chromsome analysis)

Answer 36

Phsyical examination of genitalia Endocrine tests to understand if it could be due to low LH/FSH, hyperprolactinaemia, hypothyoridism Chromosme analysis - for CF or 47 XXY testicular biopsy to see if any sperm production and rule out testicular carcinoma

Question 37

In the man with cryptorchidsm, a surgical sperm aspiration was carried out If spermatazoa are obtained here, then what assissted reprodution technique can be used?

Answer 37

If spermatozoa are obtained here, can use intracytoplasmic sperm injection (ICSI)

Question 38

WHat happens in ICSI?

Answer 38

Intracytoplasmic sperm injection is an in vitro fertilization procedure in which a single sperm is injected directly into an egg.

Question 39

The nucleus of a sperm or an egg cell during the process of fertilization, after the sperm enters the ovum, but before the genetic material of the sperm and egg fuse. What is this stage in fertilisation known as?

Answer 39

This is known as the pronuclear stage in fertilisation

Question 40

Question 8. a) Name the stages of embryo development shown. b) How many days after fertilisation does each of the stages shown occur? (how many blastomeres make up the morula, what forms the blastomere)

Answer 40

A - Pronuclear stage - occurs within a few hours of fertilisation before the genetic material of egg and sperm fuse B - 4 cell stage - approx 48 hours after fertilisation C - Morula stage - formed by 8-16 blastomeres 72-96 hours ferilisation D - Blactocyst stage - formed 5-6 days after fertilisation Blastomere is formed by the cleavage of the zygote after fertilisation

Question 41

Station 3 Question 1. a) When does menstruation normally start? b) How do you define primary amenorrhoea? (in presence of secondary sexual characteristics) When does puberty in females normally start?

Answer 41

Menstruation normally begins at roughly age 13 in females Primary amenorrhea is the failure of menses to occur by age 16 years, in the presence of normal growth and secondary sexual characteristics. Puberty normally begins around age 11 with the development of normal secondary sexual characteristics

Question 42

What is breast budding known as? What is the onset of menstruation known as? What is the onset of androgen dependent body changes such as armpit hair and body odour known as?

Answer 42

Breast budding - thelarche Onset of menstruation - menarche (usually occurs 1-5 years after onset of puberty (on average 2 years) Onset of andorgen dependent body chanegs - adrenarche

Question 43

What does A,B,C,D,E denote?

Answer 43

A - hymen B - labia minora C - Posterior forchette D - external urethral orifice E - clitoris

Question 44

What is the procedure during pregnancy where an incision is made into the posterior forchette to prevent tearing from extending into the anus and causing faecal incontinence?

Answer 44

This is known as an episiotomy - Episiotomy is done in an effort to prevent against soft-tissue tearing which may involve the anal sphincter and rectum.

Question 45

What is collection of blood in the uterus known as?

Answer 45

Collection of blood in the uterus is known as haematometra

Question 46

Sarah Milne is a 16 year old girl, who attends her GP surgery with her mother. This is here tranabdominal USS Stae what A,B and C are

Answer 46

A - rectum B - haematometra - uterus is sitting on top of bladder but has blood in it C - bladder

Question 47

What is the most common cause of haematometra?

Answer 47

Most common cause is an imperforate hymen

Question 48

Sarah Milne is a 16 year old girl, who attends her GP surgery with her mother. She is concerned that her periods have not started. She is also increasingly aware of some intermittent lower abdominal discomfort. Otherwise her pubertal development has been normal, starting pubic hair and breasts growth two years ago. She is fit and healthy and of normal height and weight. What is the most likely diagnosis after seeing her USS?

Answer 48

Most likely an imperforate hymen is the cause An imperforate hymen is a congenital disorder where a hymen without an opening completely obstructs the vagina. It is caused by a failure of the hymen to perforate during fetal development. It is most often diagnosed in adolescent girls when menstrual blood accumulates in the vagina and sometimes also in the uterus

Question 49

What is the management of an imperforate hymen?

Answer 49

Management: incision into hymen in order to create a passage to expell blood

Question 50

Due to back flow of blood from the uterus into the pelvic, what are the possible long term consequences of an imperofate hymen?

Answer 50

Endometriosis can occur

Question 51

What are physiological causes of aemnorrhea?

Answer 51

Premenarche Pregnancy Post- menopausal Breast feeding

Question 52

Describe the symptoms and signs of hypovolaemic shock.

Answer 52

Symptoms - light headedness, confused, sweaty, dizzy Signs - tachycardic, hypotensive, oliguria, decreased cap refill

Question 53

When looking for a pregnancy, a urine pregnancy test should be carried out to ensure the person is pregnant and then a transvaginal ultrasound scan to see if the pregnancy can be located If the TVUS cannot confirm a viable intrauterine pregnancy, what test is carried out? (measures hormone)

Answer 53

Measure the bHCG levels twice 48 hours apart - in normal pregnancy the levels would double but in ectopic the levels will not double in 48 hours This can be a useful way of identifying ectopic pregnancies that aren’t found during an ultrasound scan, as the level of hCG tends to be lower and rise more slowly over time than in a normal pregnancy.

Question 54

a) What management of tubal pregnancy would you recommend in this case and why?

Answer 54

Diagnostic laparotomy - enables a look into the abdominal cavity And proceed possibly to salpingectomy - reomoves the ruptured fallopian tube Since the fallopian tube has ruptured, probably carry out the salpingectomy via laparotomy since haemoodynamically unstable

Question 55

What are the different ways to manage an ectopic pregnancy? If patient is haemodynamiccaly stable and unstable for surgical method

Answer 55

Expectant management - close monitoring and see if dissolves itself naturally Medication - give methotrexate to stop the growth of the baby and see if it dissolves naturally Sugical - laparoscopy if haemodynapically stable - minimally invasive to carry out salpingectomy Laparotomy - more invasive if haemodynamiccaly unstable - usually when tube has ruptured

Question 56

If the ectopic pregnancy hadnt ruptured, what drug could be given to treat the ectopic pregnancy? What surgical procedure could have been carried out if the patient was haemodynamically stable?

Answer 56

Could have given methotrexate to treat the ectopic pregnancy - will stop the growth of the foetus Laproscopy could be carried out if the patient was haemaodynamically stable - Laparoscopy is a type of surgical procedure that allows a surgeon to access the inside of the abdomen (tummy) and pelvis without having to make large incisions in the skin. This procedure is also known as keyhole surgery or minimally invasive surgery.

Question 57

Again what is the management of an ectopic tubal pregnancy in a patient who is haemodynamically unstable?

Answer 57

Laparotomy guided salpingectomy

Question 58

Question 4. a)What are A, B, B, D & E? b) Why is E abnormal and what should it look like?

Answer 58

A - ovary B - uterus C - surgeons finger D - ovary E - fallopian tube

The fallopian tube looks abnromal as it is swollen and engorged (contains foetus) and should look thin and pale

Question 59

One day post-operatively her haemoglobin is 5.2g/dl. She looks very pale. It is decided that she should receive a blood transfusion of 3 units of red cells. ) What is the most common error that can occur when administering a blood transfusion and what can be done to minimise the risk of this occurring?

Answer 59

administrative error resulting in blood being given to the wrong patient (either receive wrong blood component, not supposed to receive blood or receive a component not intended for them). - all staff contributing to blood transfusion should be trained in the procedures they carry out. In particular: forms fully completed by writing (not labels) name, date of birth and CHI number.