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Reproduction/Sexual Health > Week 4 > Flashcards

Week 4 Flashcards

1
Q

When does blastocyst implant into uterus?

A

3-5 days: Transport of blastocyst into the uterus
5-8 days: blastocyst attaches to lining of uterus.

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2
Q

Function of trophoblastic cells

A

differentiate into multinucleate cells (syncytiotrophoblasts) which invade decidua and break down capillaries to form cavities filled with maternal blood

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3
Q

Contenst of placental villi

A

contains fetal capillaries separated from maternal blood by a thin layer of tissue – no direct contact between fetal & maternal blood

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4
Q

When is fetal heart and placenta functional?

A

5th week

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5
Q

How is corpus luteum stimulated?

A

Human chorionic gonadotropin (HCG) signals the corpus luteum to continue secreting progesterone

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6
Q

How does placenta act as fetal lungs?

A

Oxygen diffuses from the maternal into the fetal circulation system (PO2 maternal > PO2 fetal).
Carbon dioxide, (partial pressure is elevated in fetal blood) follows a reversed gradient.

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7
Q

3 factors facilitating O2 supply to foetus

A
  1. Fetal Hb
  2. Higher Hb concentration in fetal blood

3.Bohr effect

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8
Q

Describe HCG function

A
  • prevents involution of Corpus Luteum
    (CL: stimulates progesterone, estrogen)

*effect on the testes of male fetus - development of sex organs

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9
Q

Describe human placental lactogen function

A

produced from ~ week 5 of pregnancy
growth hormone-like effects
protein tissue formation.
decreases insulin sensitivity in mother
more glucose for the fetus
involved in breast development.

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10
Q

When do HCG levels start to fall?

A

12-14w
- this is when nausea, vomiting etc start to stop

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11
Q

Cardio changes in pregnancy

A

HR - incr to 90
- incr cardiac output need
BP - drops in 2nd trimester
- UP circulation expands

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12
Q

Why are pregnant women advised not to lie on back?

A

Uterus compresses vena cava

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13
Q

ECG changes in pregnancy

A

Relative sinus tachycardia
Slight left axis deviation
Inverted or flattened T-waves (Leads III, V1-V3)
Q-wave (Leads II, III, aVF)
Atrial and ventricular ectopic beats more common

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14
Q

Levels of Hb in anaemia in pregnancy

A

First trimester Hb <110g/L
2nd and 3rd trimester Hb <105g/L
Postnatal Hb <100 g/L

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15
Q

Postpartum haemorrhage is quantified by loss of how much blood?

A

> 500ml blood

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16
Q

Changes to maternal coagulation

A

Hypercoagulable state
Reduces risk of haemorrhage during and after delivery
Increased risk venous thromboembolism (Ddimer not used to test for PE)

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17
Q

Management of major haemorrhage in obstetrics

A

Tranexamic acid
Transfusion 4xRBC
THEN Consider FFP >2000ml or coagulopathy

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18
Q

Respiratory changes in pregnancy

A

Respiratory rate increases
Tidal and minute volume increases (50%)
pCO2 decreases slightly
Vital capacity and PO2 don’t change

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19
Q

Urinary system changes in pregnancy

A

GFR and renal plasma flow incr
Increased re-absorption of ions and water
Slight increase of urine formation
Postural changes affect renal function

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20
Q

Changes to metabolism/diet in pregnancy

A

200 extra kcal/day should be ingested by mother
85% fetal metabolism, 15% stored as maternal fat
Extra protein intake - 30g/day
End of pregnancy - fetal glucose need 5mg/kg/min

Fetus has really high metabolic demands
- accelerated starvation of mother
- reduced insulin sensitivity

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21
Q

Nutritional needs in pregnancy

A

Folic acid (folate) - reduces risk of neural tube defects
Vitamin D supplement
High protein diet, higher energy uptake
Iron supplements may be required
B vitamins - erythropoesis
- NO VITAMIN A

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22
Q

Hormonal changes at labour

A

Uterus becomes progressively more excitable
Estrogen:progesterone changes incr excitability
Prostaglandins inhibit contractility
Oxytocin incr contractions and excitability

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23
Q

Drugs used to induce labour

A

Prostaglandins to soften cervix
Oxytocin to induce contraction

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24
Q

Stages of labour

A

1st stage: cervical dilation
(8-24 hours)

2nd stage: passage of the fetus through birth canal
(few min to 120 mins, epidurl can make it a bit longer)

3rd stage: expulsion of placenta.

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25
Q

Hormonal changes affecting lactation

A

Estrogen - growth of ductile system
Prog - development of lob/alveolar
(these both inhibit milk production, sudden drop after birth)

Porlactin - stims milk prod, steady rise from week 5 to birth
Oxytocin - milk let down reflex

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26
Q

Why should you use POP as birth control is breastfeeding?

A

Progesterone is much less inhibiting of milk production than oestrogen

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27
Q

How to predict EDD?

A

Naegele’s Rule
Onset of LMP + 9 months + 7 days

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28
Q

Foetal meausurements to estimate due date

A

Crown rump length
AFTER 14 WEEKS
Head circumference

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29
Q

Main US scans in pregnancy

A

Initial after booking app
Anomaly scan at 20w

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30
Q

Define placenta praevia

A

the placenta is low lying in the uterusandcovers all or part of the cervix. Its site is identified at the anomaly scan

recheck at 32 weeks US (somtimes TVUS)

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31
Q

Trisomy risk assessment

A

Measure of skin thickness behind fetal neck using ultrasound (Nuchal thickness; NT)
+ HCG + PAPP-A

> 3.5mm is considered high risk

Second trimester T21 only:
Blood sample at 15-20 weeks
Assay of HCG and AFP

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32
Q

Low AFP + high HCG + high maternal age?

A

Higher chance of T21

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33
Q

What is NIPT?

A

Nn-invasive prenatal testing
Cell free fetal DNA (cffDNA) testing
- detectable from around 10 weeks of pregnancy
- screens for chance of DSS

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34
Q

Diagnostic tests in pregnancy

A

Amniocentesis:
Usually performed after 15 weeks
Carries a miscarriage rate of <1%
Chorionic villus sampling:
Usually performed after 12 weeks
Carries a miscarriage rate of <2%

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35
Q

IDing maternal anaemia

A

Iron deficiency
Folate deficicy
B12 deficiency
Screened at booking and 28 weeks
Aim to optimise Hb prior to birth

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36
Q

Why is anti-D given?

A

To prevent D antigens forming in Rh negative women
Given routinely at 28 w and after any sensitizing event
E.g.
(TOP, APH, invasive procedure, external cephalic version, fall, road traffic incident ect)
Given again after birth if baby Rh +ve

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37
Q

How is gestational diabetes tested for?

A

Use the 2‑hour 75g oral glucose tolerance test (OGTT) to test for gestational diabetes in women with risk factors

Diagnose gestational diabetes if the woman has either:
a fasting plasma glucose level of 5.6mmol/litre or aboveor
a 2‑hour plasma glucose level of 7.8mmol/litre or above.

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38
Q

How is foetal growth measured without USS?

A

Serial measurement of symphysis fundal height (SFH) is recommended at each antenatal appointment from 24 weeks of pregnancy as this improves prediction of a SGA neonate
- below 10th centile: ref to US
- high BMI, large fibroids: ref to US

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39
Q

Height changes in uterus fundus during pregnancy

A

12 weeks - just above pelvis
(16 weeks - in between)
20 weeks - umbilicus
(28 weeks - in between)
36 weeks - costal margin

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40
Q

Factors incr risk of preeclampsia

A

hypertensive disease during a previous pregnancy
chronic kidney disease
autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension.

take 150mg aspirin daily from 12-36weeks

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41
Q

Trend of BP changes in pregnancy

A

Reduction in 1st trimester
Stays low
Then increases as nearing term
Often overshooting after birth
Highest at day 3/4 post-birth

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42
Q

Defs of hypertension in pregnancy

A

≥140/90 mmHg on 2 occasions , 4 hours apart

> 160/110 mmHg once

Mild >150, >100
Mod 150-200, 100-109
Severe .160, >110

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43
Q

Management of chronic HT in pregnancy

A

ACEi/ARBs/thiazide contraindicated (stop within 2 days)
Lifestyle mods
Sometimes won’t need meds due to physiological changes in pregnancy

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44
Q

Describe gestational hypertension

A

2nd half of pregnancy, resolves 6 weeks after delivery
No proteinuria or systemic features
Better outcomes than pre-eclampsia
Can progress to PT depending on gestation

45
Q

Management of GH at birth and postnatally

A

Birth usually > 37 weeks unless poorly controlled hypertension
Daily BP monitoring
- <130/90 (140 if chronic)
Continue methyl dopa for 2 weeks then review (2 days if chronic)

46
Q

Describe preeclampsia

A

Multi-system disorder
Diffuse vascular endothelial dysfunction widespread circulatory disturbance
May be asymptomatic
Family history increases risk

47
Q

Triad of pre-eclampsia

A

Hypertension
Proteinuria (UPCR >30mg/mmol)
Oedema

Absence does not exclude diag

48
Q

Classificaton of pre-eclampsia

A

Early <34 weeks
- uncommon, assoc with lesions of placenta, higher risk of complications than late

Late >34 weeks
- majority of cases, minimal placental lesions, most deaths occur in late disease, maternal factors very important

49
Q

Pathogenesis of pre-eclampsia

A

Stage 1 - abnormal placental perfusion
- placental ischaemia
- trophoblasts don’t invade decidua, spiral arteries stay narrow and high pressure, less blood/nutrients to baby

Stage 2 - maternal syndrome
- an anti-angiogenic state associated with endothelial dysfunction
- leads to damage throughout body e.g. cardiac, renal, hepatic changes

50
Q

Pres of liver disease in pregnancy

A

Epigastric/ RUQ pain
Abnormal liver enzymes
- ALT > 150 assoc with increased morbidity
Hepatic capsule rupture

e.g. Haemolysis, Elevated Liver Enzymes, Low Platelets

51
Q

Pres of pre-eclampsia

A

Headache
Visual disturbance
Epigastric / RUQ pain
Nausea / vomiting
Rapidly progressive oedema

52
Q

Signs of pre-eclampsia

A

Hypertension
Proteinuria
Oedema
Abdominal tenderness
Disorientation
Small for Gestational Age (SGA) Fetus
Intra uterine fetal death (might be first pres)
Hyper-reflexia / involuntary movements / clonus (can develop into eclampsic seizure)

53
Q

Investigations for preeclampsia

A

Urea & Electrolytes
Serum Urate
Liver Function Tests
Full Blood Count
Coagulation Screen
Urine Protein Creatinine Ratio (UPCR)
Cardiotocography
Ultrasound - fetal assessment

54
Q

Management preeclampsia

A

Early antenatal assessment - identify risk factors
Hypertension < 20 weeks - look for secondary cause
Antenatal screening - BP, urine, symptoms, Uterine Artery Doppler
Treat hypertension
Maternal & fetal surveillance
Timing of Birth

55
Q

Medical prevention of those at risk of preeclampsia

A

75-150mg aspirin from 12 weeks (prevents thrombosis)
More than 1 mod risk
- 1st preg, >40, preg interval >10 years, BMI>35, FHx
High risk
- HT in prev preg, CKD, AI, diabetes/HT

56
Q

Notch sign on uterine artery doppler

A

Notch is sign of high resistance in the vessel
- placenta not dev normally
- risk of preeclampsia and fetal growth restriction

57
Q

When to offer antihypertensives in preeclampsia

A

Offer treatment to women not on treatment if
SBP>140 mmHG or DBP>90 mmHg
Target BP = 135/85 mmHg

UNLESS sys <110, symptomatic hypotension

58
Q

Medical management of hypertension in pregnancy

A

Methyl dopa
Labetalol
Nifedipine
Hydralazine
Doxazocin

59
Q

When to hospitalise in pre-eclampsia

A

SBP > 160 mmHg or higher
Abnormal blood tests (creatinine >90,
ALT >70, platelets <150)
signs of impending eclampsia
signs of impending pulmonary oedema
other signs of severe pre-eclampsia
suspected fetal compromise

Baby usually delivered within 2 weeks of diagnosis

60
Q

Magnesium sulfate

A

Used to treat eclamptic seizures (4g IV over 5 mins, maintain with 1g/hour)
Also in run up to pre-term birth
Improves neuro outcomes for baby

61
Q

Describe eclampsia

A

Tonic-clonic (grand mal) seizure occuring with features of pre-eclampsia
>1/3 will have seizure before onset of hypertension / proteinuria
More common in teenagers
Associated with ischaemia / vasospasm

Manage BP, prevent seizures, fluid balance, delivery

62
Q

What is large for dates?

A

Symphyseal-fundal height >2cm for Gestational age

63
Q

Causes of large for dtes

A

Wrong dating
- concealed, vulnerable, transfer of care from abroad
Multiple pregnancy
Polyhydraminos
Fetal macrosomia

64
Q

Diagnosis of macrosomia

A

USS EFW >90th centile, AC>97TH Centile

65
Q

Risks of fetal macrosomia

A

clinican & maternal anxiety
Labour dystocia
Shoulder dystocia- more with diabetes
Post-partum haemorrhage

66
Q

Management of large for dates

A

Exclude diabetes
Reassure
Conservative vs IOL vs C/S delivery
Don’t induce labour just because you think baby is big

67
Q

Diagnosis of polyhydraminos

A

Excess amniotic fluid
- Amniotic Fluid Index (AFI >25cm)
- Deepest Pool >8cm
- Subjective

68
Q

Causes of polyhydraminos

A

MATERNAL:
Diabetes
Red cell antibodies
FETAL:
Anomaly- GI atresia, cardiac, tumours
Monochorionic twin pregnancy
Hydrops fetalis – Rh isoimmunisation
Viral infection

69
Q

Symptoms of polyhdraminos

A

Abdominal discomfort
Pre-labour rupture of membranes
Pre-term labour
Cord prolapse

70
Q

Signs of polyhydraminos

A

Large for dates
Mal-presentation
Tense Shiny Abdomen
Inability To feel fetal parts

71
Q

Investigatiosn for polyhydraminos cause

A

Viral serology Toxoplasmosis, CMV, Parvovirus
Antibody Screen
USS- fetal survey- lips, stomach bubble

72
Q

Management polyhydraminos

A

Patient information- complications including preterm rupture of membranes
Serial USS- growth, LV, presentation
IOL by 40 weeks
Risk: malpresent, cord prolapse, PPH

May resolve spontaneously

73
Q

2 types zygosity in multiple pregnancy

A

Monozygotic : splitting of a single fertilised egg (30%)

Dizygotic: fertilisation of 2 ova by 2 spermatozoa(70%)

74
Q

Types of chorionicity in multiple pregnancy

A

Essetially no of placentas per foetus
(1 Placenta vs 2 Placentas)

Dizygous – always DCDA (own placenta, own sac)

Monozygous- MCMA, MCDA, DCDA, conjoined; depends on time of splittingof fertilised ovum

75
Q

Time of cleavage related to chorionicity

A

Day0-3: DCDA
Day 4-7: MCDA
Day 8-14: MCMA
Day 15: Conjoined twins

76
Q

Lambda sign suggests

A

Multiple pregnancy (twin peaks)
Can see 11-13+6 weeks

77
Q

Clin pres of multiple pregnancy

A

SYMPTOMS
Exaggerated pregnancy symptoms e.g. excessive sickness/ hyperemesis gravidarum

SIGNS
High AFP
Large for dates uterus
Mutiple fetal poles

USS confirmation at 12 weeks

78
Q

Complications of multiple pregnancy

A

Higher perinatal mortality
Congenital anomalies (acardiac twin)
Pre term
Growth restriction
IUD
CP
Twin to twin transfusion

Maternal: HG, anaemia, PET, APH

79
Q

AN management of twins

A

MC 2 weekly from 16/40
Anomaly USS 18-20 weeks
DC 4 weekly

Fe supp, low dose aspirin, folic acid

80
Q

Define SGA

A

Small for gestational age
Abdominal circumference (AC) or estimated fetal weight (EFW) less than the 10th centile (population or customised charts available)
Severe SGA = AC or EFW <3rd centile

81
Q

Define fetal growth restriction

A

Failure of the fetus to attain their growth potential
Difficult to identify in practice
All babies below 3rd centile
Below 10th centile with evidence of placental dysfunction

82
Q

Define low birth weight

A

Any baby born with a weight less than 2.5kg at any gestation

83
Q

Risks of FGR and SGA

A

Hypoxia
Stillbirth

Hypoglycaemia
Asphyxia
Hypothermia
Polycythaemia
Hyperbilirubinaemia
Abnormal neurodevelopment
Complications related to prematurity if preterm delivery

84
Q

Maternal causes SGA

A

Lifestyle: smoking, alcohol and drugs
Very low or high BMI
Age
Maternal disease eg hypertension, renal disease

85
Q

Placental causes SGA

A

Infarctions
Abruption (APH)
Association with hypertensive diseases

86
Q

Fetal causes SGA

A

Infection e.g. rubella, CMV, toxoplasmosis
Congenital anomalies
Chromosomal abnormalities

87
Q

Prevention of SGA

A

Aspirin if at risk PET
Vit D for all
Smoking cessation
Drugs service input
LMWH for APLS

88
Q

How often are FGR high risk pregnancies offered scans?

A

Growth scans every 4 weeks from 28 weeks (sometimes 24 weeks)

89
Q

Measurements needed for EFW

A

Abdo circumference + head circumference + femur length

90
Q

Liquor volume in FGR

A

Poor sign in context of FGR would be reduction in DVP as marker of reduced renal perfusion and urine output

(normal >2cm and <10cm)

91
Q

Pulsatility index parameters

A

Reduces as gestation advances
<1.4 always normal

92
Q

MCA doppler function

A

Indicates brain perfusion
Redistribution of blood to vital organs such as brain
Reduced PI in a compromised fetus
Increased peak systolic velocity in fetal anaemia
Useful additional marker in SGA/FGR after 32 weeks

93
Q

Ductus venosus doppler fucntioon

A

A direct reflection of fetal heart function
A-wave (atrial flow)
- Becomes progressively deeper as fetal condition worsens
Used to time delivery
Particularly useful in preterm FGR
Moderate predictive value of fetal acidaemia and adverse outcome

94
Q

Management SGA between 3rd and 10th centile

A

Fortnightly scans for fetal growth, DVP and dopplers
Ensure regular BP + urine check
Advice on symptoms of pre-eclampsia, increased risk of stillbirth and to report reduced movements immediately
Offer IOL at 39 weeks
- aim to deliver by 39+6 weeks

95
Q

Management SGA under 3rd centile

A

Once weekly dopplers plus liquor volume
Individual plan
Counsel on signs of preeclampsia, stillbirth, contact support
Delivery 37 weeks if no concerns
- no later than 37+6

96
Q

Planning for preterm birth

A

Steroids up to 33+6 weeks
Magnesium sulphate for fetal neuroprotection up to 29+6 weeks
Delivery with immediate availabiity in NICU
CS if abnormal dopplers or v premature
IOL less likely
IP antibios with benzylpenicillin up to 36+6 for vaginal births, risk of strep A

97
Q

When do pregnant people need more calories?

A

Last 12 weeks
200 extra per day

98
Q

How much caffeine allowed in pregnancy?

A

200mg
- 2 mugs instant
- 1 mug filter
- 3 mugs tea

99
Q

Supplements required in pregnancy

A

400ug folic acid pre-conception and during first trimester (13th week)
10ug vitamin D during pregnancy and continue to breastfeeding

100
Q

When may someone need extra folic acid in pregnancy?

A

5mg high dose

Previous pregnancy affected by spina bifida
Woman/ partner has spina bifida
Anticonvulsants for epilepsy
Coeliac disease
Diabetes
BMI is 30 or more
Sickle-cell anaemia or thalassaemia (higher dose of folic acid will also help to prevent and treat anaemia)
Folic Acid Deficiency

101
Q

Fetal risks of maternal vitamin D deficiency

A

SGA, Neonatal Hypocalcaemia, Asthma/Respiratory Infection, Rickets

102
Q

How can you avoid listeriosis in pregnancy?

A

UHT pasteruised milk
No ripened soft cheese e.g. brie
No pate or deli meat
No undercooked food
Avoid animals giving birth

103
Q

How to avoid salmonella in pregnancy?

A

Avoid raw/partially cooked eggs/fish/poultry

104
Q

Avoiding toxoplasmosis in pregnancy

A

Good hand hygiene with food
Washing fruit/veg/salad
Cook meat well
Gloves while gardening
Avoid contact with cat faeces

105
Q

Complications of iron deficiency in pregnancy

A

Tiredness
Shortness of breath
Preterm labour
Still birth
Intrauterine growth restriction / low birth weight
Placental Abruption
Post partum haemorrhage
Neonatal iron deficiency in their first 3 months of life
Neurodevelopmental delay in baby

106
Q

How does NIPT determine chance of trisomy 21 in pregnancy?

A

Blood test to test the free fetal DNA in maternal serum
If there’s too much chromosome 21 in mother’s serum = high chance pregnancy

107
Q

What drug is used first in TOP?

A

Potassium chloride

108
Q

Rh-ve pregnant woman with anti-D antibodies has partner who is Rh+ve, what is the most appropriate next test?

A

NIPD
- to ID foetus Rh status

109
Q
A

Reproduction/Sexual Health (9 decks)

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