Week 3 part 2 Flashcards
What kind of nerves are involved in pelvic floor muscle contraction e.g. during sneezing?
Somatic motor
Uterine cramping/menstruation and contraction involve what types of nerve?
Sympathetic/parasympathetic
What carries pain from pelvic part of vagina and from perineum?
Pelvic vagina - visceral afferents
Perineal vagina - somatic sensory
Pain runs alongside what fibres in inferior aspect of pelvic organs (not touching perititneum) and in what fibres when touching the peritoneum?
Inferior - parasympathetic fibres
Superior - sympathetic fibres
Name two structures crossing from pelvis to perineum?
Urethra
Vagina
What fibres deal with pain sensation above levator ani (pelvis)
Patasympathetic
What fibres deal with pain sensation below levator ani (perineum)?
Pudendal nerve
S2-4
Visceral afferents for pain travel back to T11-L2 from pelvic organs which touch the peritoneum. Give three of these structures? (sympathetic)
Uterine tubes
uTERUS
Ovaries
In the cervix and superior vagina where do pain sensation visceral afferents travel back to?
S2-S4
In relation to spinal and epidural anaesthetic: at what level does s[inal cord become cauda equina?
L2 vertebra
When does subarachnoid space end?
Level of S2
In relation to spinal and epidural anaesthetic: what region is anaesthetic injected into?
L3-L4 region (L4 spinous process at most superior point on iliac crest)
Where does needle pass through for spinal anaesthetic?
supraspinous ligament interspinous ligament ligamentum flavum epidural space (fat and veins) dura mater arachnoid mater finally reaches subarachnoid space (contains CSF)
What does needle pass through for epidural?
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space (fat and veins)
What do all spinal nerves and their named nerves contain?
Sympathetic fibres
How do you know if spinal anaesthetic is working?
Blockade of sympahtetic tone to all arterioles leading to vasodilation. Skin of lower limbs looks flushed, warm and reduced sweating
HYPOTENSION
The pudendal nerve exits pelvis via … It passes posterior to … ligament. It reenters via … It travels in pudendal canal (passageway within … with … artery and vein), also nerve to obturator internus
Greater sciatic foramen Sacrospinous ligament Lesses sciatic foramen Obturator fascia Internal pudendal artery
What landmark is used for administration of pudendal nerve block?
Ischial spines
During labour damage to what nerve and muscle could occur?
Pudendal nerve stretched
Excternal anal spincter muscle torn when weakened
Faecal incontinence
In an episiotomy - where is the mediolateral incision made into?
Ischioanal fossa (fat filled)
What triggers male/female differentiation?
Germ cells
What is the origin of male duct system?
Mesonephric
What is origin of female duct system?
Paramesonephric
What controls descent of the testis?
Gubernaculum
What do the paramesonephric ducts fuse to create?
Broad ligament of the uterus
Name three methods of doing a DNA or chromosome test on baby in utero?
Placenta - chorionic villus biopsy (good tissue)
Skin/urine cells - amniocentesis (poor tiossue)
Blood - fetal blood sampling (good tissue)
When can chorionic villus biopsy and amniocentesis be performed?
CVS - 12 weeks
Amniocentesis - 15 weeks
When can fetal blood samplimg be done?
18+ weeks
fetal blood sampling miscarriage risk?
2%
What fetal DNA method of testing has a risk of confined placental mosaicism?
CVS
When can fetal DNA from maternal blood test be done?
8+ weeks (stable tissue)
A method to analyse whole genome?
Array CGH
A method to analyse targeted genome?
FISH
If ther eis high risk of chromosomal trisomyt on screening, fetal abnormality on scanning, and balanced chromosomal rearrangement in parent what should be done?
Array CGH or chromosome analysis
Name a method of non-invasibe prenatal testing (currently - sex determination and trisomy testing)?
Free fetal DNA in maternal circulation
Trisomy 13
Patau syndrome
45 X
Neck webbing
Oedema
Turner syndrome
Bilateral cleft lip
Postaxial polydactyly
Patau syndrome trisomy 13
What is a robertsonian translocation?
Two acrocentric chromosomes stick end to end
Robertsian translocation trisomy 14
Misscarriage
What are the two broad catagoeries for the small baby?
- Pre term delivery
2. Small for gestational age (intra uterine growth restriction/constitutionally small)
Definition of preterm birht?
Delivery between 24 and 36.6 weeks
What are survival rates for pre-term borht at 24 weeks and 32 weeks?
24 - 20/30%
32 - greater than 95%
Give two causes of over distension that can lead to pre-term birht?
Multipel pregnanyc
Polyhydramnios
Give a vascular cause of pre-term birht?
Placental abruption
If you’ve had a pre term labour once before what is riks and what is risk if twice before?
Once - 20%
Twice - 40%
multiple pregnancies - 50% risk
What is a pregnant women who has uterine anomalies, is a teenager, smokes, does cocaine and is skinny have an increased risk of?
Pre term birth
Infant with a birthweight that is less than 10th centile for gestation corrected for maternal height, weight, fetal sex and birth order.
Small for Gestational Age
Give three fetal factors for poor growth?
- Infection e.g. rubella, CMV, toxoplasma
- Congenital anomalies e.g. absent kidneys
- Chromosomal abnormalities e.g. Downs
What are placental factors causing poor growth often secondary to?
Hypertension
describe symmetrical IUGR?
Small head
Small abdomen
describe asymmetrical IUGR
Normal head
Small abdomen
What four things are done to assess fetal wellbeing?
- Assessment of growth
- Cardiotocography
- Biophysical assessment
- Ultrasound (umbilical arterial dioppler)
Are accelerations on CTG good or bad?
Good - indicates good reflex reactivity of the fetal circulation
Normal doppler ultrasound in pregnancy will show what?
Continuous high forward flow at the end of diastole
Is IUGR a public health concern?
Yes
What can monochorionic twin pregnancy, fetal anomaly, maternal diabetes, hydrops fetalis all cause which leads to large for dates pregnancy?
Polyhydramnios
Discomfort
Labour
Membrane Rupture
Cord prolapse
Polyhydramnios
Diagnose with ultrasound
Are Monochorionic / monozygous twins at higher risk of pregnancy complications ?
Yes
Lamda sign on US?
Diachorionic twins
Exaggerated pregnancy symptoms e.g. excessive sickness
High AFP
Large for dates uterus
Multiple pregnancy
Give three consequences of maternal diabetes?
- Overgrowth of insulin sensitive tissues and macrosomia
- hYPOXIC STATE in utero
- Fetal metabolic reprogramming leading to long term diabetes and obesity risk
What is diagnosis of Gestation diabetes based on?
GTT at 28 weeks
Fasting greater than 5.1
2 hours greater than 8.5
In mother with diabetes in pregnancy what scan is offered at 18 weeks?
Fetal anomaly
What is the transformation zone of cervix?
Squamo-columnar junctioj between ectocervical squamous and endocervical columnar epithelia
Exposure of delicate endocervical epithelium to acid environment of vagina leads to physiological squamous metaplasia.
Cervical erosion or ectropion
What occurs sometimes when when stratified squamous epithelium of the ectocervix (toward the vagina) grows over the simple columnar epithelium of the endocervix (toward the uterus)?
Nabothian follicles
sub epithelial reactive lymphoid follicles present in cervix.
Follicular cervicitis
Is a cervical polyp pre malignant?
No
Give the two major types of cervical cancer?
Squamous carcinoma
Adenocarcinoma
What do HPV 16 and 18 cause?
Cervical cancer
What triples the risk of cervical cancer?
Smoking
Vulnerability of SC junction in early reproductive age can increase risk for cervical cancer - name three?
- Age at first intercourse
- Long term oral contraceptive use
- Non-use of barrier contraception
What types of HPV cause genital warts?
6 and 11
What causes condyloma acuminatum?
Thickened papillomatous squaous epithelium with cytoplasmic vacuolation (koilocytosis) - HPV
wHAT DOES HIGH RISK hpv TYPES 16 and 18 lead to?
Cervical Intraepithelial Neoplasia
What is detected in cervical smears to indicate cervical intraepithelial neoplasia?
Infected epithelium remains flat, but shows koilocytosis
What is the time line for HPV infection causing high grade CIN
6 months - 3 years
What is the time line for high grade CIN causing invasive cance?
5-20 years
What is the preinvasive stage of cervical cancer?
Cervical Intraepithelial Neoplasia
Where does CIN occur?
At transformation zone
What three things are assessed in histology of CIN?
- Delay in maturation/differentiation (immature basal cells occupy)
- Nuclear abnormalities (hyperchromasia, increased NC ration, pleomorphism)
- Excess mitotic activity (above basal layers, abnormal mitotic forms)
What stage of CIN is: basal 1/3 of epithelium occupied by abnormal cells, raised mitotic figures in lower 1/3, surface cells quite mature but nuclei slightly abnormal?
CIN I
What stage of CIN is: abnormal cells extend to middle 1/3, mitoses in middle 1/3, abnormal mitotic figures?
CIN II
What stage of CIN is: Abnormal cells occupy full thickness of epithelium, mitoses, often abnormal in upper 1/3?
CIN III
What are 75-95% of malignant cervica tumours? and the 2nd commonest female cancer worldside?
Invasive Squamous Carcinoma
What does invasive squamous carcinoma develop from ?
Pre-existing CIN, therefore most cases preventable by screening
Stage IB ISC?
Confined to cervix
Name some symptoms of invasive carcinoma of cervix?
- Abnormal bleeding
- Pelvic pain
- Haematuria/UTI
- Ureteric obstructin
Give some types of abnormal bleeding in Invasive carfcinoma of cervix?
Post coital
Post menopausal
Brownish or blood stained vaginal discharve
Contact bleeding - friable epithelium
Where does Cervical Glandular Intraepithelial Neoplasia (CGIN) originate from?
Endocervical epithelium
What is the preinvasive phase of endocervical adenocarcinoma?
Cervical Glandular Intraepithelial Neoplasia (CGIN)
5-25% of cervical cancers?
Endocervical adenocarcinoma - worse prognosis than squamopuse carcinoma
Higher S.E. Class
Later onset of sexual activity
Smoking
HPV again incriminated, particularly HPV18.
Adenocarcinoma
What disease is associated with vulvar intraepithelial neoplasia?
Pagets disease
Young women: often multifocal, recurrent or persistent causing treatment problems.
Vulvar Intraepithelial neoplasia
Older women: greater risk of progression to invasive squamous carcinoma.
Vulvar intraepithelial neoplasia
Who usually gets Vulvar Invasive Squamous Carcinoma
Elderly women, ulcer or exophytic mass
what are verrucous an extremely well differentiated type of?
Vulvar Invasive Squamous Carcinoma
Where does Vulvar Invasive Squamous Carcinoma spread to (nodes)?
Inguinal lymph nodes - most important prognostic factor
