Workbook Questions

Question 1

Define phenotype

Answer 1

The observable physical characteristics of an individual as determined by their genes.

Question 2

Should the external genitalia be ambiguous at birth, suggest what types of investigations could be carried out to determine sex

Answer 2

Information on karyotype, gonadal sex, hormonal tests, and anatomy

(e.g., palpation of gonads, length and diameter of any phallus, position of urethral meatus,
degree of labio-scrotal fold fusion, presence of vagina/pouch/urogenital sinus) (including ultrasound study).

Question 3

Why are germ cells separated from somatic cells so early in development?

Answer 3

Germ cells need to remain undifferentiated and protected from influences arising during development of the rest of the body

Question 4

Which tissue forms the matrix of the gonads into which

the primordial germ cells migrate.

Answer 4

Somatic mesenchymal tissue

Question 5

An individual has a genotype of XXY. Will they have ovaries or testis? Explain your answer.

Answer 5

Testis

Y chromosome determines gonadal sex

Question 6

Which gene on the short arm of the Y chromosome determines formation of the testes?

Answer 6

SRY gene (sex determining region of Y gene) also called TDF gene (testis determining factor)

Question 7

In Turner’s syndrome (45,XO), the ovaries develop normally until the15th week of gestation, but then the ova begin to degenerate and disappear such that at birth the ovaries are mere streaks. Sometimes, the diagnosis will only occur at puberty. What
will be the presenting signs at puberty?

Answer 7

Primary amenorrhoea (failure to menstruate for the first time).

Failure of secondary sexual characteristics such as poor breast development as 2° sexual characteristics are dependent on ovarian hormones.

Also short stature.

Diagnosis is more usually made earlier if to peripheral lymphodema, redundant neck skin
and congenital heart disease are present.

Question 8

Predict the gonads in an individual with a sex chromosome mosaic of XY, XX (or XO) cells?

Answer 8

Both ovarian and testicular tissue is present (sometimes in one gonad); this is true/primary hermaphroditism.

Question 9

If, experimentally, the ovaries are removed from a fetus (castration) which internal genitalia develop?

Answer 9

Female

Question 10

Which hormones prevent the spontaneous development of the female genitalia in the male and from which cells are they secreted?

Answer 10

Interstitial cells of Leydig in the testes secrete androgens, principally testosterone, from 9 weeks gestation.

Sertoli cells lie within the walls of the seminiferous tubules and secrete MIH (Müllerian inhibitory hormone; MIS Müllerian inhibitory substance).

Question 11

What structures do the Müllerian ducts develop into?

Answer 11

uterine tubes
uterus
cervix
(upper vagina)

Question 12

Which structures do the Wolffian ducts develop into?

Answer 12

epididymis
vas deferens
seminal vesicles

Question 13

The prostate develops from the urogenital sinus in the male (under the influence of testosterone), but what does the urogenital sinus form in the female?

Answer 13

Lower part of the vagina

Question 14

What do the following precursors develop into in the male & female respectively?
labioscrotal swelling
urethral folds

Answer 14

Male:
Labioscrotal swelling = scrotum
Urethral folds = ventral aspect of shaft of penis, incl spongy urethra

Female:
Labioscrotal swelling = labia majora
Urethral folds = labia minora

Question 15

what is the homologous structure to the male glans penis in the female (both derived from the genital tubercle)?

Answer 15

Clitoris

Question 16

Consider an individual with genotype XY, testicular development and normal secretion of testosterone and MIH. However, the fetal genitalia is insensitive to testosterone or DHT. Predict the consequences to

Wolffian ducts:
External genitalia:
Müllerian ducts:

Hence, summarize you findings with regards to internal and external genitalia.

Answer 16

Wolffian ducts: regress (these are androgen dependent)
External genitalia: female
Müllerian ducts: regress (since MIH secreted from testes)

The phenotype is female as labia, clitoris and vagina are present but no other internal
genitalia but remember the genotype is male. (testicular feminisation)

Question 17

consider a female fetus (XX), who has excessive secretion of androgens from the adrenal glands.
What would be the affect on the following:

Wolffian ducts:
External genitalia:
Müllerian ducts:

Summarize your findings with regards to internal and external genitalia:

Answer 17

Wolffian ducts: promoted by the presence of the androgens

External genitalia: masculinised to a variable extent, since androgens cause the urethral fold to fuse

Müllerian ducts: present (as no MIH secreted)

External appearance male but genetically female with internal genitalia of both sexes.

Question 18

What would occur in a male (XY) with low levels of MIH or resistance to MIH?

Where will you find the testes in such an individual & why

Answer 18

The presence of testicular testosterone will promotes male external genitalia and Wolffian ducts, but the Müllerian ducts are also retained. Hence, genetically and gonadally male but with internal genitalia of both sexes.

In the abdomen. They cannot descend. Failure to fully descend can be caused by mechanical obstruction by fibrous adhesions, shortened spermatic cord and narrowing of inguinal canal.

Question 19

True or false:

Germ cells arise 3 weeks after conception

Answer 19

True

Question 20

True or false:

Germ cells are haploid

Answer 20

False

Question 21

True or false:

The para-mesonephric duct gives rise to the vas deferens

Answer 21

False

Question 22

True or false:

The mesonephric duct is supported by MIH

Answer 22

False

Question 23

What connects the seminiferous tubules to the epididymis.

Answer 23

Rete testis

Question 24

True or false:

The vas deferens is c35 cm long in the adult human

Answer 24

False

Approx 24cm

Question 25

True or false:
The gubernaculum connects the developing testis to the
posterior abdominal wall

Answer 25

False

Testes to scrotum

Question 26

True or false:

The cervix arises from the Müllerian duct

Answer 26

True

Question 27

True or false:
Testosterone causes the genital swellings (labioscrotal)
to develop into the shaft of the penis

Answer 27

False

Shaft of penis from urethral folds

Question 28

True or false:

The primordial gonads arise ventral to the gut

Answer 28

False

Question 29

True or false:

In the adult female human one ovum is normally produced

Answer 29

True

Question 30

True or false:

Primary oocytes increase in number following puberty

Answer 30

False

Question 31

True or false:

Oogonia are diploid cells

Answer 31

True

Question 32

True or false:

Primordial follicles are surrounded by a theca

Answer 32

False

Question 33

True or false:

In antral follicles thecal cells produce androgens

Answer 33

True

Question 34

In the antral phase what do granulosa & thecal cells have receptors for respectively?

Answer 34

In the antral phase granulosa cells have receptors for_FSH_, thecal cells for_LH_.

Question 35

True or false:

Ovulation is preceded by the completion of meiosis II

Answer 35

False

Only completed after fertilisation

Question 36

True or false:
One type A spermatogonium produces up to 64 primary
spermatocytes

Answer 36

False
Each spermatogonium gives rise to 64 spermatozoa.
Also, it is the type B spermatogonium which gives rise to the daughter spermatocytes, with some type A remaining as resting cells to serve as an ancestor for later generations. (Be aware that classification of the spermatogonia varies in different texts but it is not necessary for you to
learn these).

Question 37

True or false:

One primary spermatocyte normally produces 4 spermatids

Answer 37

True

Question 38

True or false:

Sperm spend 12 days in the epididymis

Answer 38

True

between 6-12 days. They can be stored for much longer (weeks) in the vas deferens.

Question 39

What hormone(s) does the corpus luteum secrete & under the influence of what

Answer 39

The corpus luteum secretes_progesterone__ and_oestrogen (oestradiol)_ under the control of__LH_

Question 40

True or false:

Ovulation is stimulated by the LH surge

Answer 40

True

Question 41

True or false:

One primary oocyte produces 4 ova

Answer 41

False
Whilst a primary oocyte goes through two meiotic division to produce an ovum
(including an ovulation and fertilization), non-functional first and second polar bodies are
formed at each stage.

Question 42

True or false:
2% of sperm deposited in the vagina reach the site of
fertilisation in the ampulla of the fallopian tube

Answer 42

False
It is lower than 2%. Each ml of sperm (usually 1-4 mls ejaculated) contain tens of million sperm and only 200-300 of these will reach the site of fertilization in the ampulla of the uterine tube.

Question 43

True or false:

The vas deferens passes anterior to the pubic bone

Answer 43

True

Question 44

True or false:

The tunica vaginalis is a remnant of peritoneum

Answer 44

True

It is a peritoneal sac derived from the embryonic tunica vaginalis.

Question 45

True or false:
The largest proportion of the volume of semen is from
the seminal vesicles

Answer 45

True

Up to 60% comes from the seminal vesicle and 1/3 from the prostate.

Question 46

True or false:

The arterial supply of the testis is from the iliac arteries

Answer 46

False

It is from the testicular artery which has its origin in the aorta (remember the embryological origin of the testes).

Question 47

discriminate between the roles of oestrogen in the early follicular phase and its role at ovulation.

Answer 47

In the early follicular phase, oestrogen at low levels exerts a negative (inhibitory) feedback on gonadotrophin release.

At ovulation, rising levels of oestrogen produces a positive (stimulatory) feedback, enhancing LH release thus promoting ovulation. (In fact the oestrogen enhances the LH releasing
mechanism to GnRH.)

Question 48

At the menopause the ovary secretes dramatically less oestrogen. What will happen
initially to:
o plasma levels of FSH
o plasma levels of LH
o the secretion of GnRH from the hypothalamus?

Answer 48

FSH levels will rise considerably
LH levels will rise
GnRH levels will rise
Feedback from gonadal steroids much reduced

NB Several years after the menopause, these hormones return to lower levels.

Question 49

Why are the changes in LH and FSH secretion at the menopause different?

Answer 49

No Inhibin secreted from ovary, so selective inhibition of FSH by Inhibin acting on pituitary gland no longer occurs and FSH levels rise more than LH

Question 50

In pregnancy, once the placenta has developed it begins to secrete oestrogen and progesterone.  The secretion is independent of LH and FSH.  What will happen to: 
o plasma levels of FSH 
o plasma levels of LH 
o hypothalamic secretion of GnRH 
in a pregnant woman?

Answer 50

FSH levels will fall
LH levels will fall
GnRH levels will fall
Because placental oestrogen & progesterone exert negative feedback inhibition at both hypothalamus and pituitary

Question 51

The drug clomiphene is an “anti-oestrogen” used in the treatment of infertility.
Clomiphene exerts a weak oestrogenic effect, sufficient to achieve uptake and binding
by to oestrogen receptors. It then reduces the concentration of oestrogen receptors
inhibition of the process of receptor replenishment. Thus, the hypothalamic-pituitary axis
blinded to the endogenous oestrogen level in the circulation. It is given for 5 days at the
start of the menstrual cycle. What will be the effects on:
o GnRH secretion
o plasma levels of FSH and LH
of treatment with clomiphene?

Answer 51

GnRH secretion will rise as the true oestrogen signal is falsely lowered and negative feedback inhibition is diminished.
LH & FSH secretion will also rise, with a larger increase in LH levels

Question 52

What would be the effects on gonadotrophin secretion of a constant moderate dose of a progesterone like drug?

How might these effects be different if the dose is much lower? In this case which parts
of the reproductive system might still be affected?

Answer 52

Progesterone enhances negative feedback of natural oestrogen
At moderate doses this will reduce LH and FSH secretion
And inhibit positive feedback of oestrogen, so no LH surges
And ovulation is suppressed

At lower doses, there is no inhibition of LH surges
Ovulation will probably still occur
But progestogens will affect cervical mucus, inhibiting sperm transport

Question 53

If the anterior pituitary gland is transplanted to another site in the body the secretion of
LH, FSH, TSH, GH and ACTH falls to negligible levels. Why?

The transplanted anterior pituitary, however, hypersecretes prolactin. Why?

A major part of control of prolactin secretion is inhibition by dopamine.

Answer 53

Releasing hormones are diluted to ineffective concentrations in the general circulation.
The portal nature of the hypophyseal vessels normally ensures that releasing hormones reach
the pituitary at relatively high concentration

Prolactin secretion control is removed if the anterior pituitary is transplanted and the dopamine is diluted in the
general circulation

Question 54

The major hypothalamic hormone inhibiting prolactin secretion is dopamine (prolactin
inhibitory hormone). The actions of dopamine are mimicked by the drug bromocriptine
and antagonised by drugs like haloperidol, metoclopramide and domperidone. What will
happen to prolactin levels if a woman is given bromocriptine?

Answer 54

They should fall, as it mimics the inhibitory effect of dopamine on lactotrophs

Question 55

Prolactin and, particularly, hyperprolactinaemia, suppresses fertility by disturbing the pulsatile release of GnRH. What do you think might happen to the fertility of a woman given metoclopramide?

Answer 55

Fertility may be reduced, as prolactin levels rise because the inhibitory effects of dopamine are themselves inhibited since metoclopramide inhibits dopamine

Increasing levels of prolactin will produce a spectrum ranging from inadequate luteal phase function to anovulation and amenorrhoea with complete GnRH suppression. Fertility will be
affected at all points..

Question 56

In some women, impaired fertility is associated with a loss of the normal daytime fall in prolactin levels. Which drug would you choose to lower prolactin levels and restore fertility?

Answer 56

Bromocriptine; mimics dopamine

Question 57

What are the normal age ranges for the following in girls:
Thelarche
Adrenarche
Growth Spurt
Menarche

Answer 57

Thelarche – breast enlargement 8-11 years
Adrenarche – pubic hair 11-12 years
Growth Spurt 10-14 years
Menarche 11-15 years

Question 58

Precocious puberty is defined as physical signs of sexual maturation before 8 years or menarche before 10 years old. Why might precocious puberty be stimulated by meningitis?

Answer 58

Irritation and inflammation stimulating early rises in GnRH secretion
True precocious puberty is caused by premature secretion of gonadotrophins - mostly idiopathic, but can be caused by CNS lesions (hypothalamic tumours, post-encephalitis neurofibromas etc.).
Hence, irritation and inflammation such as meningitis can stimulate early rises in GnRH secretion.

Question 59

What are the effects of precocious puberty on a bone growth? Would you expect a girl to be shorter or taller as an adult because of precocious puberty?

Answer 59

The growth spurt begins earlier and is terminated earlier, so that epiphyses may close at an earlier stage of growth, making the individual shorter.

Question 60

Delayed puberty commonly present as primary amenorrhoea, which is failure to
menstruate by the age of 16 years. What possible explanations might you consider if:
(i) plasma LH and FSH levels are in the normal range?
(ii) plasma LH and FSH levels are very low?

Answer 60

(i) If gonadotrophin levels are normal, then either the ovary is not responding to them so no steroids are produced, or if the tissues are not responding to the steroids that are produced. If no steroids are produced, however FSH & LH levels should be raised. Another possibility is that menstruation is occurring, but the products are not shed because of a vaginal or cervical problem

(Also, consider some forms of androgen insensitivity syndrome - these XY individuals will have external female genitalia as their tissues do not respond to androgen - but their male gonad will produce MIH so they will not have internal female ducts and will present with primary
amenorrhoea. Breast development is often normal or enhanced as the small amount of gonadal oestrogen and adrenal oestrogen is not opposed by androgen. Body hair is normal to scanty.)

(ii) If gonadotrophin levels are low, then the problem is likely of pituitary or hypothalamic origin. Some examples are pituitary tumours. Anorexia nervosa, malnutrition and psychogenic causes also lead to hypo gonadotropic hypogonadism. Check serum prolactin and consider imaging for a cranial lesion.

Question 61

If plasma LH & FSH are in the normal range & other secondary sexual characteristics were present what possible explanation would you consider for primary amenorrhoea?

Answer 61

The ovary may not be responding, so ovulation does not occur and a cycle of steroid secretion is not properly established.

Question 62

A boy is brought to you by his parents, concerned that he is behind his classmates in pubertal development.
What would you examine to assess his stage of puberty?

Answer 62

To assess stage of puberty check height, weight, body hair, genitalia, bone age.
Also ask about medical history and medications.
Delayed puberty is lack of sexual maturation by age 15 - majority have constitutional delay - which is quite benign - and which represents normal variation - often familial. Such boys will eventually undergo a normal puberty and attain normal height.
Constitutional delay is most probable in a healthy boy with delayed growth and bone age.

Question 63

Consider a 14 year old boy with query delayed puberty. What proportion of normal 14 year olds would be expected not yet to be exhibiting signs of puberty? What factors in his history might
make you feel that he is in this group?

Answer 63

The proportion would be very low (3-5%) since puberty in boys visibly begins between 9 and 14 years with scrotum and testicular development, however, full maturity may not be complete until
early 20’s (e.g., facial hair).
If he has good general health and nutrition, also if a brother was a “late developer”, you would suspect constitutional delay of puberty and would give reassurance.
Serious systemic illness (e.g. diabetes, malabsorption) can delay puberty

Question 64

Explain what is meant by ‘bone age’. How will this help in establishing puberty delay?

Answer 64

Accelerated growth is one of the earliest signs of precocious puberty and bone age can be determined with hand-wrist films and compared with standards for the patient’s chronologic age.
If his bone age is inconsistent with (behind) his chronologic age then constitutional delay is likely.

Question 65

What is the normal growth spurt for boys in puberty?

How is this measured?

Answer 65

Growth spurt in boys is approx 10cm/year

height comparisons over time are useful.

Question 66

When does the growth spurt occur in relation to other events in pubertal development in boys?

Answer 66

The growth spurt starts about 12 months after the first signs of puberty (increase in testicle size due to FSH induced increase in seminiferous tubules).

Question 67

Why may parents not notice the early signs of puberty in boys?

Answer 67

Early signs of puberty in boys are the increase size of testes followed by reddening of scrotal skin and elongation of penis-his parents may not be aware that these changes are occurring.

Question 68

Is a boy with delayed puberty likely to be producing sperm?

Answer 68

High intra-testicular levels of testosterone are needed for spermatogenesis-so it is doubtful.

Question 69

If there is a problem of delayed puberty, what test would you use to distinguish between defects in the gonads and defects primarily in the hypothalamus/pituitary?

Answer 69

If FSH is low, suspect hypothalamic/pituitary.

If testosterone is low, suspect hypogonadism.

Question 70

What is the lower age limit of normal puberty in boys?

Answer 70

10 yrs

Question 71

How would you clinically assess the stage of puberty?

Answer 71

Height, weight, genitals, body hair, bone age.

Question 72

What are the possible consequences of early puberty

Answer 72

Short stature-premature growth spurt - epiphyseal closure

Question 73

What are the common causes of early puberty in boys?

Answer 73

True precocious puberty - premature secretion of gonadotrophins - leads to testicular androgen production and sperm production and virilisation - mostly idiopathic.
Can be caused by CNS
lesions, thus evaluation and follow-up is needed. Precocious pseudopuberty results from secretion of androgens from adrenal glands or testis, virilisation occurs but not sperm
production (most commonly caused by adrenal hyperfunction-congenital adrenal hyperplasia).

Question 74

A patient has isosexual precocity, which is manifest in males as virilisation, but no more. What disorders of the adrenal gland may cause these signs?
How might you differentiate between them?

Answer 74

He may have adrenal hyperfunction - congenital adrenal hyperplasia (from 21-hydroxylase
or Il-hydroxylase deficiency)
or an adrenocortical tumour.

Congenital adrenal hyperplasia: Biochemical tests of enzyme levels (patients have elevated
serum 17-hydroxyprogesterone levels).
Adrenal tumours can be seen by imaging studies - sonography, CT, NMR.

Question 75

There is a gradual depletion of ovarian follicles as a woman proceeds toward the menopause such that the secretion of oestrogen declines dramatically. What will happen to plasma levels of the following hormones?
FSH
LH
GnRH

Why do these changes occur?

Answer 75

FSH: rises considerably
LH: rises
GnRH: rises

As gonadal steroid production falls there is loss of negative feedback to the pituitary and hypothalamus.

Question 76

Why are the changes in LH and FSH secretion different in menopause?

Answer 76

No inhibin from ovary so selective inhibition of FSH no longer occurs and it thus rises more than LH.

Question 77

List at least 5 effects of oestrogen depletion that menopausal women may experience.

Answer 77

hot flushes
poor sleep
vaginal/urethral atrophy dysparunia/dysuria
breast atrophy
mood change/depression
osteoporosis/posture & height change/increased fracture risk
changing cholesterol/lipid profile & possible increased risk of CHD

Question 78

What treatments or preventive measures might you consider for menopause problems?

Answer 78

Oestrogen HRT Calcium

(HRT is comprised usually of a mixture of oestrogens and progesterone, which are either
synthetic or extracted from pregnant mares’ urine.)

Question 79

What are the disadvantages of using HRT

Answer 79

Increased risk of thromboembolism, breast cancer.

Question 80

Why are oestrogen-only preparations not given to women who have not had a hysterectomy

Answer 80

Unopposed oestrogens cause proliferation of uterine lining with a risk of endometrial cancer. Progesterone inhibits this.

Question 81

How are fibroids diagnosed?

Answer 81

Most fibroids are asymptomatic.
The most common symptom is abnormal bleeding, typically menorrhagia and the women is usually in her 40s.
Large fibroids may be palpable on bimanual examination (irregularly shaped uterus) examination by anaesthesia and curettage or by laparoscopy.
ultrasound may show the presence of a mass but may not distinguish other ovarian tumours.

Question 82

How would you assess whether menstrual blood loss is sufficiently great to have
adverse effects?

Answer 82

Menorrhagia is usually defined as menstrual loss greater than 80ml which will produce
anaemia. Assess by pad and tampon counts and measuring haemoglobin/haematocrit levels.

Question 83

What options are there for treating fibroids (i) in a woman under 35, (ii) in a woman
nearing the menopause?

Answer 83

Treatment options

Question 84

It is common for women in their forties to have a hysterectomy, which usually involves removal of both uterus and ovaries. What might be the advantages and disadvantages of removing the ovaries as well as the uterus? What evidence bases would you quote in
helping a woman to decide whether to have her ovaries removed?

Answer 84

Strictly speaking a hysterectomy is the removal of the uterus.
Women in their forties may be counselled on the risks and benefits of bilateral oophorectomy in
conjunction with hysterectomy.
Potential benefits include, avoidance of ovarian pathology in the future(although some ovarian
type tumours can arise from the peritoneum de novo)
Potential disadvantage, sudden onset of menopause as the albeit aging ovary is removed and
loss of ovarian androgen.

Question 85

Define genotype

Answer 85

The genetic makeup of an individual as defined by the particular sets of genes they possess.

Question 86

What are the main public health messages required to limit STIs?

Answer 86

Practice safer sexual behaviour 
Age at first intercourse 
Total number of partners 
Number of concurrent partners 
Frequency of partner switching 
Sexual orientation 
Specific at-risk sexual practices 
Use correct barrier contraception techniques consistently 
Seek better sexual health education 
Seek early treatment for suspected STI 
Attend for regular screening if at risk 
Avoid teenage pregnancy 
Avoid alcohol abuse and illicit drug use

Question 87

What factors influence the effectiveness of public health campaigns for STIs?

Answer 87

Changing societal norms
Targeted advertising and education
Peer group pressure and social activities
Socio-economic factors
Poverty
Educational and social disadvantage
Unemployment
Teenage conception and pregnancy
Ready and confidential access to GUM clinics and other health practitioners
Awareness of serious risks associated with some STIs

Question 88

Colin aged 19, presents to you somewhat embarrassed. For the past two days he has
experienced pain on passing urine, and a urethral discharge. He has no previous history
of genital urinary problems and is normally fit and healthy. On examination he has no
fever, the discharge from his urethra is creamy, and there is a slight reddening of the
surrounding glans penis.

What key things will you need to know about his history?

Answer 88

Details of recent sexual contacts
Timing
Partner(s)
Nature of sexual activity and sexual orientation
Have partners sought advice or treatment?
Are partners symptomatic?
Previous STIs and complications
Overseas travel and place of residence
Underlying diseases, including HIV, HBV and HCV status
Participation in commercial sex
Recent antibiotic use and history of allergies

Question 89

Colin aged 19, presents to you somewhat embarrassed. For the past two days he has
experienced pain on passing urine, and a urethral discharge. He has no previous history
of genital urinary problems and is normally fit and healthy. On examination he has no
fever, the discharge from his urethra is creamy, and there is a slight reddening of the
surrounding glans penis.

What possible infections will you consider?

Answer 89

Chlamydial urethritis
Gonococcal urethritis
Non-specific urethritis (NSU)

Question 90

A Gram stain of the urethral discharge shows intracellular Gram negative diplococci (ie. cocci in pairs).

What is your diagnosis?

Answer 90

Gonococcal urethritis

Question 91

For Gonococcal urethritis, What antibiotics will you consider, and why?

Answer 91

Ceftriaxone 500 mg IM single dose (many gonococci resistant to other agents)

PLUS

Azithromycin (single large oral dose 1g) (co-treatment for chlamydia and enhances treatment for gonorrhoea)

Question 92

Subsequent investigation of the urethral discharge from a patient with Gonococcal urethritis reports the specimen as positive for Chlamydia trachomatis as well.

Why do you think such mixed infections are common?

Answer 92

Common at risk behaviours and associated factors
Long-term asymptomatic infection
High prevalence rates of Chlamydia trachomatis infection
Identical mode of transmission

Question 93

What is the likelihood of the partner of a patient with Chlamydia/Gonococcal urethritis being infected?

Answer 93

Depending on the following factors the risk of her being infected with Chlamydia trachomatis and/or Neisseria gonorrhoeae, though not necessarily symptomatic, may be anywhere upwards
of 50 %!

Adherence to strict barrier contraception
Frequency of intercourse
Duration of sexual relationship
Time of acquisition of the STI by her partner
Concurrent genital inflammation or ulcers?

Question 94

How would you manage the asymptomatic partner of a patient with Chlamydia/Gonococcal urethritis

Answer 94

Detailed history
Physical Examination
Diagnostic investigations
Endocervical smear and swab for microscopy and culture of N. gonorrhoeae
First-void urine and/or endocervical smear for C. trachomatis (+/- N. gonorrhoeae) detection by
nucleic acid amplification (NAA) test
Pharyngeal and/or rectal swabs for culture of N. gonorrhoeae

Screening investigations
Syphilis serology
pap smear cytology
cervical swabs for HPV detection by hybrid capture?
serology for blood and body-fluid borne viruses – HIV, HBV, HCV

If positive treat for Chlamydia +/- gonorrhoea
Advice regarding need to abstain until treated or cleared of infection – potentially infectious
despite being completely asymptomatic!

Advice regarding need for return visit

Counselling, advice, and basic sexual health education

Question 95

Julie, aged 27 comes to see you. She has noticed a slight increase in vaginal discharge but is otherwise well. On questioning you establish that she had unprotected sex with a casual partner 5 days ago. She has no steady sexual partner.

What possible infecting organisms will you consider?

Answer 95

Normal physiological variation! 
Candida spp. – fungus 
Bacterial vaginosis – Perturbed normal flora including Gardnerella vaginalis and Mycoplasma 
hominis 
Trichomonas vaginalis – protozoa 
Chlamydia trachomatis 
Neisseria gonorrhoeae

Question 96

Julie, aged 27 comes to see you. She has noticed a slight increase in vaginal discharge but is otherwise well. On questioning you establish that she had unprotected sex with a casual partner 5 days ago. She has no steady sexual partner.

You examine Julie and find that she is tender in the right upper quadrant of her
abdomen.

What structures will you be considering as the reasons for this tenderness?
How might tenderness in these structures be linked to her other symptoms?

Answer 96

Liver 
Gall bladder 
Right kidney 
Stomach, pancreas, small or large intestine 
Lung or pleura 

Fitz-Hugh Curtis syndrome due to perihepatitis – C. trachomatis or less commonly N. gonorrhoeae

Question 97

Julie, aged 27 comes to see you. She has noticed a slight increase in vaginal discharge but is otherwise well. On questioning you establish that she had unprotected sex with a casual partner 5 days ago. She has no steady sexual partner.

You decide to perform a pelvic examination and decide to undertake some investigations for infections.

From where will you take swabs?

Answer 97

Endocervical smear and swab for microscopy and culture of N. gonorrhoeae
Endocervical swab for detection of C. trachomatis by NAAT
Urethral swab for culture of N. gonorrhoeae
Throat and/or rectal swabs for culture of N. gonorrhoeae
First-void urine for detection of C. trachomatis(+/- N. gonorrhoeae) by NAAT
Mid stream urine (MSU) for microscopy and culture of UTI pathogens
Cervical smear for cytology
Cervical swab for HPV detection
High vaginal smear and swab – Candida, Trichomonas, bacterial vaginosis (BV)

Question 98

Julie, aged 27 comes to see you. She has noticed a slight increase in vaginal discharge but is otherwise well. On questioning you establish that she had unprotected sex with a casual partner 5 days ago. She has no steady sexual partner.

You decide that Julie does indeed have a sexually transmitted infection.

Apart from offering her treatment with appropriate antibiotics, what other advice
should you give her?

Answer 98

Abstain until both partner and herself, and any other sexual contacts, have been treated
effectively
Measures to minimise risk of future STI
Advice on correct use of barrier methods of contraception
Need to attend for a return visit – ‘test of cure’ investigations?
Basic sexual health education and advice regarding regular screening option

Question 99

What is the ‘illness iceberg’? How does this concept apply in the case of sexually transmitted infections?

Answer 99

Only a small percentage of those infected with a pathogen may manifest symptoms and/or
signs of illness
Many STIs exhibit this phenomenon – Chlamydia, HPV, HSV, even syphilis may only manifest
with transient and minor evidence of primary disease
Potential large infectious reservoir – needs to be identified and treated promptly – CONTACT TRACING

Question 100

Helena attended the family planning clinic a few weeks ago and elected to start taking
oral contraceptives. She has come to you now because she has developed genital
itching and a white discharge.

What organism will you consider in this case?
Why might the organism have grown at this particular time?

Answer 100

Candida spp. – fungus which can be part of the normal vaginal flora
Trichomonas vaginalis – sexually transmitted protozoan pathogen
Bacterial vaginosis – perturbed vaginal flora

Oral contraceptive use is associated with increased incidence of vulvo-vaginal thrush
Overgrowth of the yeasts is favoured by high oestrogen levels

Question 101

Helena attended the family planning clinic a few weeks ago and elected to start taking
oral contraceptives. She has come to you now because she has developed genital
itching and a white discharge.

What conditions in the vagina will promote organism growth

Answer 101

Perturbed normal flora – broad spectrum antibiotic use
Warmth and humidity – climate, clothing, obesity
Oral contraceptives and pregnancy – oestrogen levels
Glucose levels – diabete mellitus
Steroid therapy
Menstrual cycle-associated changes – pre-period symptoms
Colonisation with a recalcitrant Candida species or strain

Question 102

Helena attended the family planning clinic a few weeks ago and elected to start taking
oral contraceptives. She has come to you now because she has developed genital
itching and a white discharge.

What are the principles of treatment of this condition?

Does it constitute a sexually transmitted infection

Answer 102

Withdraw or control risk-factors
Obtain high vaginal smear and swab for microscopy and culture – many diagnoses may be
made clinically without laboratory investigation
Treat only if significantly symptomatic
Use first-line topical azoles (e.g. clotrimazole)
Consider oral fluconazole for more problematic cases
If recurrent or unusually severe investigate for resistant yeast and/or other unidentified risk
factors
Consider treating partner to reduce frequency of ‘re-infection’

No, as the aetiological agent is typically part of the normal vaginal flora

Question 103

Jane aged 18, presents with a two day history of painful genital ulcers, mild fevers and a
painful swelling in her left groin. During the past few hours she has experienced marked
dysuria.

What other aspects of the history are you going to seek?

Answer 103

Sexual history – partner(s), timing, symptoms in partner(s)
History of previous STIs
History of previous genital ulcers, vesicle, or rashes
History of cold sores or primary gingivostomatitis
History of recent drug or antibiotic use and known allergies

Etc

Question 104

Jane aged 18, presents with a two day history of painful genital ulcers, mild fevers and a
painful swelling in her left groin. During the past few hours she has experienced marked
dysuria.

What are the possible aetiological agents?

How would you confirm your diagnosis?

Answer 104

Herpes simplex virus typically type 2 (but may be HSV1)
Haemophilus ducreyi – tropical STI (chancroid)
Klebsiella granulomatis– tropical STI (granuloma inguinale)
Treponema pallidum – syphilis but lesions rarely multiple
Behcet’s syndrome or erythema multiforme – non-infectious aetiology

Smear and swab of vesicle fluid or ulcer base – herpes PCR
Syphilis serology and other investigations as per normal GUM assessment

Question 105

Jane aged 18, presents with a two day history of painful genital ulcers, mild fevers and a
painful swelling in her left groin. During the past few hours she has experienced marked
dysuria.

How would you manager her illness?

Answer 105

A diagnosis of primary genital herpes warrants immediate aciclovir treatment
Oral aciclovir if outpatient management appropriate
Otherwise consider hospitalisation and IV aciclovir
Features of primary genital herpes
Mild fever and systemic symptoms
Inguinal lymphadenopathy
Extensive genital ulceration including spread to adjacent skin
Prolonged illness – up to two or more weeks!
Marked dysuria and possible acute urinary retention
Consider use of indwelling urinary catheter
Analgesia and other supportive measures
Advise regarding risk of recurrence
HSV2 (90 % patients experience recurrence within 1 year)
HSV1 (25 % patients experience recurrence within 1 year)
If recurrences persist for > 1 year, frequency unlikely to decline
Advise regarding possible transmission to others even whilst asymptomatic
Advise regarding issues related to current or future pregnancies
Frequent recurrences
Patients may recognise trigger factors and/or herald symptoms
Long-term continuous or periodic suppressive aciclovir therapy

Question 106

What is inflammation of the Fallopian (uterine ) tubes called?

If the surrounding structures are involved, what is this called?

Answer 106

salpingitis

PID- if abscess develops may be called tubo-ovarian abscess

Question 107

List the symptoms of PID

Answer 107

Lower abdominal pain, dyspareunia (+/- vaginal discharge) fever,(+/- menstrual abnormalities)

Question 108

What is the differential diagnosis from PID (listed by anatomical structures affected) of:
bladder conditions
bowel conditions
gynaecological conditions

Answer 108

bladder conditions
cystitis, bladder stones

bowel conditions
irritable bowel syndrome, inflammatory bowel disease, appendicitis

gynaecological conditions:
ovarian cysts, endometriosis, ectopic pregnancy, torsion

Question 109

What investigations would you perform to confirm a diagnosis of PID?

Answer 109

ultrasound, laparoscopy, swabs from endocervix, swabs from peritoneum if laparoscopy is done

Question 110

What organisms are involved in PID?

Answer 110

Most episodes of PID will be polymicrobial, including organisms such as Chlamydia trachomatis, Neisseria gonorrhoeae, mycoplasmas, bacteriodes + other anaerobes

Question 111

How would you manage a patient with PID?

Answer 111

medication:
analgesia, antibiotic / antimicrobial against specific organism, and broad spectrum antibiotics with good anaerobic coverage.

advice:
bed rest, if hospitalised, Semi-Fowler position to drain pus into pelvis
Aggressive antibiotic Treatment, particularly in young nulliparous patients.

Question 112

What are the potential sequelae of PID?

Answer 112

chronic recurring infection, increased risk of ectopic pregnancy, impaired fertility, chronic pelvic pain

Question 113

How can patients prevent PID & associated complications?

Answer 113

barrier contraceptives, STD screening, screening of partner, early treatment of STIs, avoidance of promiscuity

Question 114

The uterine tubes lie in the free edge of which ligament?

Answer 114

Broad

Question 115

List the mechanisms, which facilitate movement of an ovum along the duct?

Answer 115

Cilia & smooth muscle contraction (peristalsis)

Question 116

Explain how infection may spread to the peritoneum from the female reproductive tract

Answer 116

The opening of the uterine tube at the infundibulum into the peritoneal cavity allows infection such as gonorrhea to spread from the vagina and cervix, via the uterus and uterine tubes into the peritoneal cavity.

Question 117

What may be the consequence of infection in the uterine tubes?

Answer 117

Adhesions, which do not allow an ovum to pass through to the uterus. Hence, this may cause infertility or an ectopic pregnancy.

Question 118

List some common & very rare sites of implantation in ectopic pregnancy

Answer 118

Common: fimbrial, ampullary, isthmic or interstitial (of the uterine tubes); ovary

Rare: Pouch of Douglas, abdominal viscera.

Question 119

Where would pain be felt with an ectopic pregnancy implanted in the ampulla of the uterine tubes?
Explain why pain may be felt at the shoulder tip following rupture of an
ectopic pregnancy?

Answer 119

Pain from an ectopic pregnancy is felt in the lower abdominal quadrants

If lying down blood in the peritoneal cavity may collect beneath the diaphragm irritating the phrenic nerve.
Since this nerve originates with cutaneous nerves from C3, 4 and 5, pain may be referred to the dermatomes for these segments; i.e. shoulders.
Pain felt in the lower quadrants is due to stretching and tearing of the peritoneum.
Blood passing from the vagina is usually withdrawal bleeding (not a result of bleeding at the site of the rupture), caused by reduction in the hormone hCG which maintains the corpus luteum and hence prepares the endometrium for implantation.

Question 120

A ruptured ectopic pregnancy at this site may cause a dangerous haemorrhage.
Describe the arterial blood supply to the uterine tubes?

Answer 120

It is an anastomotic system of the ovarian and uterine arteries.

Question 121

The lateral reflection of the peritoneum off the body of the uterus forms which ligament?

Answer 121

Broad ligaments (which also contain uterine vessels)

The broad ligament may be subdivided. The mesentery of uterus is also called the mesometrium.
The mesosalpinx is mesentery of the uterine tube, whilst the mesovarium is that part of the broad ligament that suspends the ovary.

Question 122

Histologically, what are the three layers of the uterus and which of these layers is shed during menstruation?

Answer 122

Perimetrium (outer)

Myometrium (consisting of three muscle layers)

Endometrium (inner)
consisting of the stratum functionalis - shed during menstruation
and the stratum basalis (which produces new stratum functionalis after each menstruation)

Question 123

The endometrial lining of the uterus is of which type of epithelial cells?

How does this compare to the cervical canal epithelium?

Answer 123

Simple columnar epithelium (either are ciliated or have microvilli) with glycogen producing glands changing from simple to highly coiled over the course of the uterine cycle.

Tall columnar cells, with branched glandular cells, which form an alkaline mucus.

Question 124

How does the epithelium of the body of the uterus change during the uterine cycle

Answer 124

menses days 1 – 4 :
desquamation of 2/3, bleeding

days 5 – 7 :
rapid re-growth from remaining epithelial cells

days 7 – 14 :
endometrial re-growth is completed
This concludes the proliferative phase

days 14 – 28 :
Secretary phase includes endometrial thickening, enlargement of
glandular cells, oedematous, proliferation of white cells.

3 layers : compact superficial zone spongy middle zone (glandules) inactive basal layer

As menses approach the arteries go in to spasm, retracting back to the deeper layers evoking ischaemia.

Question 125

Explain why the ureter is in danger of being damaged during hysterectomy

Answer 125

In clamping off the uterine artery, the ureter may be accidentally damaged (remember : water (urine) under the (arterial) bridge).

Question 126

List the lymphatic drainage of the following structures:
Fundus of uterus
Body of uterus
Cervix

Answer 126

Fundus of uterus - aortic nodes (lesser to inguinal lymph nodes)
Body of uterus - external iliac nodes
Cervix - external and internal iliac nodes, sacral nodes.

Question 127

In what position does the uterus usually lie

Answer 127

anteverted in relation to vagina

anteflexed in relation to cervix

Question 128

What is assessed in a bimanual examination

Answer 128

Insertion of one or two fingers into the vagina to examine the cervix. The external hand palpates the uterus (and ovaries if enlarged) from the anterior surface of the body to assess for pregnancy or irregularity.

The uterus is assessed for mobility, consistency, pain, regularity, position, size (usually of a plum, 10weeks pregnancy it is the size of an orange), etc

Question 129

If the uterus is retroverted, which structure would be the presenting part on a speculum or vaginal examination?

Answer 129

Os or the posterior lip (rather than the anterior lip) of the cervix.

Question 130

Secretory cells of the cervix produce a cervical mucus. Comment on how the mucus changes during the uterine cycle.

Answer 130

The mucus is a mixture of water, glycoprotein, lipids, other proteins, enzymes and inorganic salts.

Production of mucus is greatest during the follicular phase, in readiness for ovulation.

It changes from cloudy to clear. At ovulation it is a clear, acellular mucus with high stretchability (spinnbarkeit). (Such characteristics may enable a women to self-assess the time of ovulation - it dries in a glass slide with a characteristics fern-patterning).

Following ovulation (as progesterone increases), the mucus again becomes cloudy and more sticky but in diminishing quantities.

A thick cervical mucus -plug forms during pregnancy - the loss of which may indicate labour.

Question 131

From what cells of the cervix do Nabothian cysts develop?

Answer 131

From the cervical glandular ducts.

Infection of the endocervical glands (as in chronic cervicitis) can result in blockage of the ducts and hence cyst formation (between 2mm to 1cm).

There presence, especially if infected, can reduce chances of pregnancy by making the cervix inhospitable to sperm.

Question 132

What are the anatomical relations of the vagina

Answer 132

Anteriorly – base of bladder and urethra (embedded in anterior vaginal wall)

Posteriorly – anal canal, rectum and most superiorly pouch of Douglas

Laterally – levator ani and ureters (lying just superior to lateral fornices) (A ureteric stone can sometimes be palpated from the vagina)

Question 133

What structures may be palpated in a vaginal examination

Answer 133

Anteriorly – bladder, urethra and pubic symphysis
Posteriorly – rectum (prolapsed uterine tubes and ovary)
Laterally – ovary and uterine tube, sidewall of pelvis (ischial spines)
Apex – cervix (ante or retro-verted)

Question 134

In bimanual / pelvic examination, which of the cervical fornices is the usually largest and why? What structures can be palpated from each fornix?

Answer 134

Since the uterus is usually anteverted and anteflexed, the posterior fornix is the deepest (more of the posterior part of the cervix enters the vagina compared to anteriorly).

The fornices form a continuous recess around the cervix.

During bimanual examination, examination of the pelvis, the vaginal fingers should pass through each of the four fornices.

Palpation of the posterior fornix is used to assess posterior fundus, uterosacral ligaments, posterior broad ligaments/ovaries and Pouch of Douglas.

Palpation of the anterior fornix might address bladder, recto-pubic space

Palpation of the lateral fornices might address broad ligaments and associated structures.

The Fallopian tubes and ovaries cannot normally be felt.

Question 135

Generally, which lymph nodes drain the vagina?

Answer 135

Inguinal lymph nodes

Question 136

How does the epithelial lining of the vagina reflect its function?

Answer 136

Stratified squamous epithelia, hence external layers are shed with friction.

Cells are swollen due to glycogen production.

Lubrication is via cervical mucus, shed vaginal cells.

Question 137

Which bony & fibrous structures form the boundaries of the perineum

Answer 137

Pubic symphysis, inferior pubic rami, ischial rami, ischial tuberosity, sacrotuberous ligaments, coccyx

Question 138

which structures are found within the urogenital and anal triangles in the female and male perineum?

Answer 138

Female:
UT triangle - external genitalia
Anal triangle - Anus

Male:
UT triangle - root of scrotum & penis
Anal triangle - Anus

Question 139

Which structure is found mid-point of the line joining the ischial tuberosities?

Answer 139

Perineal body

Question 140

How is the bony pelvis assessed in early pregnancy

Answer 140

Bimanual exam, palpate ischial spines, assess intertuberous distance, assess subpubic arch, assess diagonal conjugate.

Question 141

What might a narrow pubic arch signify?

Answer 141

Possible small pelvic outlet.

Question 142

Why is it important for the fetal head to rotate after it delivers

Answer 142

Allows the fetal shoulders to move into the long axis of pelvic outlet.

Question 143

An elderly lady finds that she feels a lump in her anus after a bowel action, but it disappears when she wipes herself. Over the past few months the lump appears even when she’s up and about. She feels very uncomfortable and has to lie down and push it back by
hand, but it soon reappears. During PR examination, the lady is asked to squeeze the doctors finger as hard as possible. This is a ‘full thickness rectal prolapse’ when all the layers of the rectal wall have prolapsed through the anus. Such a prolapse looks like ‘a big
red sausage’.

Which two muscles would you feel contracting when the patient squeezes on the examining finger?

Answer 143

The external anal sphincter muscle tube squeezes and the puborectalis pulls the finger anteriorly.

Question 144

What important role does the perineal body play in pelvic floor support?

Answer 144

In women, the fibro-muscular perineal body supports the lower posterior part of the vaginal wall against prolapse and forms a dense attachment for the two halves of the levator muscles in the midline. It acts as a tear-resistant body between the vagina and external anal
sphincter muscle tube during childbirth, but is now considerably stressed by the evolution of large fetal head size.

(A median episiotomy divides or partly divides the perineal body, which ‘encourages’ perineal tearing posteriorly into the anal sphincter. It was abandoned in favour of a postero-lateral episiotomy that passes to the lateral side of the body and anal sphincter tube.)

Question 145

Which part of levator ani muscles can be torn or stretched during childbirth and with what consequences?

Answer 145

Fibres of pubococcygeus can be damaged which may lead to prolapse or herniation of bladder and / or urethra with subsequent incontinence. The medial fibres of pubo-rectalis (which inserts into the perineal body as a pubo-vaginalis muscle) may be torn together with
the perineal body allowing herniation of the rectum to occur (the tear extending into the external anal sphincter) leading to difficulty with defecation or faecal incontinence.

Question 146

What is an episiotomy?

Answer 146

A surgical cut in the perineum during childbirth to avoid tearing and damage to the perineal body

Question 147

In general, what tissues need to be repaired after episiotomy?

Answer 147

Vaginal mucosa and submucosa, perineal skin, muscles and fascia of perineum

Question 148

What checks should you carry out after repair of an episiotomy?

Answer 148

Vaginal and rectal exam.

Question 149

Which structure lies on the postero-lateral border of the testis?

Answer 149

Epididymis

Question 150

The seminiferous tubules anastomose to form what posteriorly?

Answer 150

Rete testis

Question 151

A fluid layer in what cavity allows the testis to move freely in the scrotum.

Answer 151

Tunica vaginalis

Question 152

Where is the origin of the testicular arteries?

Answer 152

Aorta, just inferior to the renal vessels.

Question 153

The testicular veins arise from what plexus?

What do they drain into on the right and left?

Answer 153

pampiniform plexus
IVC on the right
left renal vein

Question 154

How may the cremasteric reflex be evoked and what does it demonstrate?

Answer 154

Stroking the superior part medial thigh evokes elevation of the testis on that side. This part of the thigh is innervated by the ilioinguinal nerve (L1); the genital branch of the genitofemoral nerve (L1, L2) innervates the cremaster muscle. Hence, a spinal reflex arc is demonstrated.

Question 155

Which smooth muscle layer causes the scrotal skin to wrinkle when exposed to cold temperatures?

Answer 155

Dartos muscle

Question 156

Distinguish between the lymphatic drainage of the scrotum & testis

Answer 156

The scrotal skin (fascia and tunica vaginalis) drains to the superficial inguinal lymph nodes
whereas lymphatic drainage of the testis is via the spermatic cord to the para-aortic (or lumber) glands at the transpyloric plane, LI (hence, upper abdomen must be palpated).

Further spread may be to mediastinal and cervical nodes.

Question 157

Explain why spread of malignancy from the testis to the cervical nodes of the neck is not uncommon.

Answer 157

Lymphatic drainage to para-aortic nodes, which anastomose with intra-thoracic and in turn cervical lymph nodes.

Question 158

The efferent ductules transmit sperm from where to where?

Answer 158

Rete testis to head of epididymis

Question 159

Describe the course of the vas deferens

Answer 159

Tail of epididymis, inguinal canal, side wall of pelvis close to ischial spine, then travels medially and joins with ducts from the seminal vesicle to form ejaculatory duct which joins the prostatic urethra, inferior to the bladder. (Hence, bladder, urethral and prostate infection
may spread to the vas deferens here.)

It is typically 45 cm long

Question 160

The spermatic cord commences superiorly at the deep inguinal ring lateral to what artery?
Passing through the inguinal canal it terminates at the posterior border of what?

Answer 160

Inferior epigastric artery

Testis

Question 161

During vasectomy, the vasa deferentia are sectioned and ligated bilaterally from the superoanterior scrotal wall. What are the consequences to (a) the sperm and (b) the
composition of the ejaculate (generally) after vasectomy?

Answer 161

(a) Sperm degenerate in the epididymis and proximal ductus deferens, debris is removed by phagocytosis
(b) The ejaculate is composed of secretions form the prostate, seminal vesicle, and bulbourethral glands only.

Question 162

From which layers of the anterior abdominal wall are the fascial coverings of the spermatic cord derived?

Answer 162

The double layer of the tunica vaginalis is surrounded by:

Internal spermatic fascia (from transversalis fascia)

Cremasteric fascia (from fascial covering of the internal oblique)

External spermatic fascia (from the external oblique aponeurosis)

These are followed by a layer of superficial fascia lying directly beneath the scrotal skin

Question 163

During descent of the testes, at what fetal month do they usually:
reach the iliac fossa  
travel through the inguinal canal  
reach the external ring   
enter the scrotum

Answer 163

3rd month
7th month
8th month
9th month

Question 164

What are the consequences of undescended testis?

Answer 164

Infertility & potentially malignancy

testicular torsion, which remains elevated even after orchiopexy

Question 165

What are the contents of the spermatic cord?

Answer 165

Ducts: vas deferens (and its artery)

Vessels: testicular artery, cremasteric artery, pampiniform plexus of veins (surrounding the testicular artery), testicular lymphatic vessels

Nerves: autonomic nerves, genital branch of the genitofemoral nerve,

Question 166

The smooth muscle of which structures contract in peristaltic waves during emission?

How is this controlled?

Answer 166

Prostate
Vas deferens
Seminal vesicles

Sympathetic: hypogastric nerve (L1, L2)

Question 167

List the accessory glands of the male reproductive system, identifying the substances they secrete, the functions of such and the percentage volume of secretion the glands contribute to the semen (seminal fluid).

Answer 167

Seminal vesicles:
secrete an alkaline fluid that contains-
fructose (used in ATP production by the sperm)
prostaglandins (facilitate sperm motility and may promote smooth muscle contraction in the female tract)
clotting factors, particularly semenogelin, (are proteins which help temporarily coagulate semen after ejaculation).

Its alkalinity helps to neutralize the acid in the male urethra and female reproductive tract.

60% of volume of semen.

The prostate:
secretes a milky, slightly acidic fluid containing-
proteolytic enzymes (such as PSA, prostate-specific antigen, pepsinogen etc), which breakdown clotting proteins from the seminal vesicles, hence re-liquefying semen about 10-20 minutes after ejaculation
citric acid, used by sperm in the Krebs cycle for ATP production
acid phosphotase (unknown function)

25% volume of semen

Bulbourethral glands (Cowper's glands):
secrete an alkaline fluid to the urethra for acid neutralization (particularly neutralization of acid in the vagina), and a mucous that lubricates the end of the penis and urethral lining. 

These glands contribute a very small amount to the ejaculate.

Question 168

A prostate can grow to the size of an orange when enlarged but what is its usual size?

Answer 168

Chestnut or golf ball (3cm round)

Question 169

Which part of the prostate gland is felt on rectal examination?

Answer 169

Posterior (median groove)

Question 170

Enlargement of which lobe of the prostate causes urethral obstruction?

Answer 170

Median (This may not be detected on rectal examination; the lateral lobes, however, are readily detected on rectal examination).

Question 171

The arterial supply to the prostate, the inferior vesical artery, is a branch of which artery?

Answer 171

Internal iliac

Question 172

Why is it that cancer of the prostate often presents later than benign prostatic hyperplasia (BPH)?

Answer 172

The cells that enlarge in BPH are close to the urethra, therefore causing a blockage of the urethra. Cancerous cells are more peripheral and therefore only occlude the urethra at a later, more advanced stage.

Question 173

How do levels of PSA vary in BPH and carcinoma of the prostate?

Answer 173

BPH PSA normal/ slightly raised, carcinoma PSA markedly raised

Question 174

Explain why carcinomas of the prostate spread readily to the pelvis and vertebrae. (Hint : consider venous drainage)

Answer 174

Veins from prostatic venous plexus with dorsal vein of penis, drains into internal iliac vein.
Some of the veins pass to a plexus in front of vertebral bodies and are valve-less, (valve-less vertebral veins of Batson) hence spread of malignancy.

Question 175

List the three parts of the male urethra.

Answer 175

Prostatic
Membranous
Spongy

Question 176

Which part of the male urethra is least distensible?

Answer 176

Membranous, due to the surrounding sphincter urethrae muscle and perineal membrane

Question 177

Name the erectile tissue in the penis

Answer 177

Corpora cavernosa
Corpus spongiosum
(glans penis is continuous with corpus spongiosum)

Question 178

Describe the arterial supply to the penis

Answer 178

Branches of the internal pudendal artery form :

(1) the deep arteries
(2) the dorsal arteries
(3) the arteries of the bulb

(1) and (2) supply the crura and corpus cavernosa. (2) and (3) supply the bulb and the corpus spongiosum

Question 179

Which fibrous capsule surrounds the corpora cavernosa?

Answer 179

Tunica albuginea

Question 180

During erection of the penis, venous engorgement occurs through vasodilation of the coiled (helicine) arterioles to the corpora cavernosa, hence increasing blood flow.
What is the effect of the tunica albuginea and fascial sheaths?

Answer 180

These resist expansion, such that internal pressure rises and occludes venous drainage.
Blood from the cavernous spaces drains into a venous plexus (which
are compressed during erection), then into the deep dorsal vein. This, along with increased arterial flow, maintains rigidity of the penis for intercourse.

(Venous return is also restricted by contraction of the bulbospongiosus and ischiocavernsosus muscles.)

Question 181

Whist the corpus spongiosum swells with blood, it does not become rigid. Why not?

Answer 181

Whilst the tunica albuginea does surround the corpus spongiosum it is not as fibrous or restrictive as that which surrounds the corpora cavernosa.
High pressure in the corpus spongiosum would occlude the urethra and hence prevent ejaculation of the semen.

Question 182

Predict what may happen, if the neck of the bladder (vesical sphincter) does not close during ejaculation?

Answer 182

Retrograde ejaculation into the bladder

Question 183

The pudendal nerves carry afferent, sensory information from the glans penis to the CNS but which efferent outflow is involved in erection?

Answer 183

Pelvic nerve, parasympathetic (S2 - S4) , via inferior hypogastic plexuses promotes erection in erectile tissue, through relaxation of smooth muscle in the fibrous trabeculae and cooled arteries

Emission is sympathetically controlled. Ejaculation occurs via sympathetic outflow (L1 – L2)

Hypogastric, sympathetic, involved mostly in depression of erection, by increasing myogenic tone in arterial smooth muscle.

Question 184

Identify some common causes of erectile dysfunction

Answer 184

psychological problems

tears in fibrous capsule of corpora cavernosa

obstruction of blood flow to corpora cavernosa

pharmacological

Question 185

Which part of the penis is removed in circumcision

Answer 185

prepuce (foreskin)

Question 186

Discriminate between the obstetric conjugate and the diagonal conjugate, which are assessments of the female bony pelvis made during pregnancy prior to labour.

Answer 186

The OBSTETRIC conjugate is measured from the midpoint (i.e. thickest ) part of the pubis (posterior surface) to sacral promontory. This is obstetrically the most important AP diameter (as it is the narrowest AP diameter that the fetus passes through) and is usually about 10cm.
This diameter can only be assessed with imaging

therefore clinicians use the DIAGONAL CONJUGATE measured from inferior border of pubis to sacral promontory as an
assessment tool.
This is measured by introducing two fingers into the vagina and palpating the sacral promontory and noting where on one’s hand the under edge of pubis is. Most clinicians do this so often that they immediately know by how far in the fingers go whether
this measurement is adequate. It usually needs to be about 11.5 cm.

Question 187

List the causes of scrotal swelling

Answer 187

Testicular torsion*; hernia, hydrocoele, epididymal cyst, epididymitis, orchitis, spermatocoele, varicocoele, a testicular mass and a cyst of the cord.

A testicular torsion is the most important diagnosis, followed by testicular mass.

• the maximum time window from torsion to surgery is 12h. Thereafter most testes are unsalvageable and infertility occurs (other testes destroyed due to break down of blood testes barrier). So any scrotal swelling needs to be considered as torsion till proven otherwise.

Question 188

Why does a lump in the testis of a 22 year old man need follow up?

Answer 188

Any lump in the testis must be a suspected tumour.
Testicular cancer is the commonest cancer that affects young men between the ages of 19 to 44 years old.
Almost half of all testicular cancers occur in men under 35 years old

Question 189

In very general terms, how might you discriminate between a hernia and a swelling associated with the testis?

Answer 189

A hernia can be reduced then feel for normal scrotal contents

Question 190

Which veins are dilated in a varicocœle? What does it feel like upon palpation?

Answer 190

The veins of the pampiniform plexus become dilated in the standing position. For reasons that are postulated rather than known; it occurs, almost invariably, on the left side and a right-sided varicocœle should always suggest malignant obstruction of the right testicular vein. On palpation it feels like a bag of worms.

Question 191

Predict why is a varicoceole almost always on the left?
Why is a right sided varicocoele potentially worrying?
Hint: think about the venous drainage.

Answer 191

The left testicular vein empties vertically into the renal vein. much higher than the right drainage.
The varicosities form when the valve system between these two veins fails and blood falls backwards under the pull of gravity.
The right testicular vein drains directly into the inferior vena cava at an oblique angle, further down. Its valves do not have to support the
same weight of blood as those in the left testicular vein and are therefore much less likely to fail.
A right sided varicocoele is very uncommon and is suggestive of other, potentially more serious problems such raised IVC pressure - e.g. due to obstruction.

Question 192

What is a hydrocœle? Explain why hydrocœles in young boys often get bigger when they cough (or cry)”

Answer 192

A hydrocœles is usually a painless enlargement of the testis caused by accumulation of watery fluid, in a persistent processus vaginalis (tunica vaginalis) surrounding the testis. It can grow as large as a grapefruit!

Hydrocœles at this age are usually still connected to the peritoneal cavity by some persisting patency of the processus. The patency is limited so raised intra-abdominal pressure is required to send i.p. fluid through into the hydrocœle.

Question 193

Explain why trans-illumination with a small bright torch can distinguish an epididymal cyst from a spermatocœle.

Answer 193

An epididymal cyst contains clear fluid and transilluminates ‘brilliantly’, while a spermatocœle contains turbid fluid that inhibits transillumination. Epididymal cysts arise from unconnected segments of the efferent tubules that sprouted from the mesonephric duct hence the clear fluid content.
Spermatocœles arise similarly, but the segment is marginally connected to the rete testis and contains degenerate products of spermatogenesis. There is no important clinical difference between them, other than embryological origin.

Question 194

What is a haematoceole of the testis?

Answer 194

An accumulation of the blood in the tunica vaginalis (e.g., traumatic rupture of the testicular artery). If therefore does not transilluminate.

Question 195

Why is a NMR very good and palpation very poor at assessing lymphatic spread from a testicular tumour?

Answer 195

Malignant spread from some testicular malignancies is primarily via lymphatics, which reflect the embryological origin of the testis from the posterior abdominal wall and drain into para-aortic lymph nodes. Para-aortic nodes only become palpable when they are massively enlarged i.e. the patient already has a large tumour burden. NMR/ CT can detect nodal
enlargement of 2cm or less and indicate that XRT or surgical ablation may be beneficial..

Question 196

Suggest what proportion of young couples have regular unprotected sex might be expected to conceive within a year?

Answer 196

75%

Question 197

In Western European populations, what proportion of primary infertility is due to problems with the male partner?

Answer 197

Approx 30%

Question 198

List the possible points in the female reproductive system where problems may lead to infertility.
Write beside each the approximate proportions of women in which each type of problem is identified as the cause

Answer 198

Failure to ovulate 28%
Fallopian tube problems 22%
Uterine problems 11%
Cervical problems 3%

Question 199

What is the normal range of volume in a single ejaculate?

Answer 199

2-4ml

Question 200

What is the normal range of sperm count (millions/ml)?

Answer 200

20-200 millions/ml

Question 201

What other factors, apart from sperm count and vol, are assessed in semen analysis?

Answer 201

Sperm Motility & morphology

Question 202

what are the likeliest causes of erectile dysfunction in young men?

Answer 202

Psychological
Endocrine (e.g., diabetes)
Neurological
Alcohol

Question 203

What is the physiological basis of drugs designed to improve erectile function?

Answer 203

Increase penile blood flow

Question 204

What is the normal range of length of menstrual cycle?

Answer 204

21-35 days

Question 205

If you know the date that a menstrual bleed began, how would you most accurately calculate when the previous ovulation had occurred?

Answer 205

14 days before;

Life of corpus luteum

Question 206

Which hormone provides evidence that ovulation has occurred? When, relative to the onset of a menstrual bleed should you measure it, and in what body fluid?

Answer 206

Day 21; at peak of progesterone curve

In blood

Question 207

Why is it useful to keep a daily record of body temperature on rising in the morning?
Why does the temperature have to be taken at the same time each day?

Answer 207

Progesterone elevates basal temperature

Circadian rhythm of body temp will confuse results if not taken at same time

Question 208

What is the difference between primary & secondary amenorrhoea?

Answer 208

Primary – never had periods

Secondary – cessation of periods after they have begun (after a 3 month cessations of menses)

Question 209

What are the two commonest causes of secondary amenorrhoea and what hormone tests will you use to distinguish them?

Answer 209

Pregnancy – Human chorionic gonadotrophin

Fall in body weight – Gonadotrophin levels

Question 210

Hyperprolactinaemia may lead to infertility.

What clinical sign may indicate a diagnosis of hyperprolactinaemia?

Answer 210

Production of small quantities of milk

Question 211

what drug could be used to treat hyperprolactinaemia.

How does it work?

Answer 211

Bromocryptine

Dopamine agonist – mimics effects of prolactin inhibitory hormone

Question 212

How, in principle, might you test whether uterine tubes are patent?

Answer 212

Passage of radio-opaque dye from uterine cavity, hysterosalpingography

Question 213

What particular feature in a patient’s history might lead you to suspect that the uterine tubes could be blocked?

Answer 213

Previous pelvic infection

Question 214

What properties of cervical mucus facilitate sperm survival and transport?

Answer 214

Alkalinity

Lowered viscosity

Question 215

How might you establish whether cervical sperm transport is disturbed?

Answer 215

Post coital test; collect cervical mucus soon after copulation

Question 216

How in principle would you set about inducing ovulation in a woman whose cycles are anovulatory? Suggest which types of drugs or hormones might be used and why.

Answer 216

Use an anti-oestrogen to reduce inhibition of FSH & LH e.g., clomiphene given for a few days prior to expected time of ovulation

Question 217

In polycystic ovarian syndrome (PCOS), exposure of follicles to androgens may lead to inhibition of FSH, but not LH secretion.
From what you know of the control of gonadotrophin secretion, by what mechanism might FSH secretion be inhibited
selectively?
Why might there be no LH surges in this condition?

Answer 217

Follicles may still secrete inhibin which selectively inhibits FSH, thus reducing FSH in respect to LH (hence, ratio changed)

Androgens may suppress LH surges (consider the role of testosterone in the male which inhibits LH release from the pituitary).

Question 218

What features of excess androgens may be present?

Answer 218

hirsutism (which can be blocked by anti-androgen therapy)

oily skin / acne

Question 219

Why is there an increased risk of endometrial malignancy in prolonged and untreated PCOS?

Answer 219

Due to sustained oestrogen stimulation of the endometrium

Biochemically, this is a very complex condition, which is poorly understood

Question 220

What tissues constitute the placental barrier:
In the first trimester?
In the third trimester?

Answer 220

First trimester:
syncytiotrophoblast 
cytotrophoblast 
connective tissue 
Fetal capillary 

Third trimester
syncytiotrophoblast
Fetal capillary endothelium

Question 221

Describe the blood supply from mother to fetus

How many are there of each?

Answer 221

A single umbilical vein carries oxygen-rich blood from the placenta to the fetus.

Two umbilical arteries carry oxygen-poor blood from the fetus to the placenta.

Question 222

What effects would you expect maternal smoking to have upon the placenta?
What effect may this have upon the baby?

Answer 222

May reduce placental blood flow and growth. Poorer fetal nutrition will reduce birth weight, by on average, 200g.

Question 223

How does alcohol cross the placenta?

What implications does this have for the development of a baby whose mother drinks significantly during pregnancy?

Answer 223

By diffusion – lipid soluble

Possible cause of Fetal Alcohol Syndrome in which the maternal (mis)use of alcohol leads to a fetus of low weight and with growth retarded (potentially with mental retardation, head and facial abnormalities).

Question 224

Why might cytomegalovirus, which normally just causes a mild flu-like illness in infected adults, be a significant health hazard in pregnancy?

Answer 224

Can cause teratogenesis

Question 225

Following the birth of a rhesus positive baby to a rhesus negative mother it is customary to administer ‘anti-D therapy’ in the form of anti-D antibody. Why is this done?

Answer 225

Mother may have made antibodies to fetal Rhesus antigens if fetal blood has entered the maternal circulation.
The anti-D antibody neutralises these antigens.
The presence of maternal anti-Rh antibodies in the fetal circulation causes rapid haemolysis when they bind to the fetal red blood cells. (The Kleihauer test is used to demonstrate the presence or
absence of fetal cells in the mother’s circulation (which is especially important in Rh isoimmunization). If the foetal cells contain antigens which the mother’s cells lack then the mother could raise antibodies against these antigens.)

Question 226

In the third stage of labour, what tissue of maternal genetic origin is shed with the afterbirth?

Answer 226

The decidua

Question 227

At what gestational age is the concentration of IgG higher in fetal than maternal blood

Answer 227

approx. 35 weeks

Question 228

Where does IgG in fetal blood come from?

Answer 228

Mother’s blood

Question 229

Could, in principle, a neonatal immune disease be mediated by IgM? If not, why not?

Answer 229

No, because the IgM class of antibodies does not cross the placenta

Question 230

hCG is released from trophoblastic cells (syncytiotrophoblasts) of the blastocyst peaking at 10 weeks gestation

hCG mimics the action of LH on the corpus luteum, hence preventing degeneration of the latter

Oestrogen and especially progesterone secretion is important in maintaining pregnancy

Use this information to explain how early pregnancy ‘supports itself’.

Answer 230

hCG is released from cells of the developing fertilized ovum.
By stimulating the corpus luteum, hCG maintains (and indeed increases) the release of progesterone and oestrogen
characteristic of the luteal phase of the menstrual cycle.
Hence, oestrogen and progesterone maintains the endometrium and hence the pregnancy.

Question 231

hCG reduces maternal IgA, lgG and IgM. Speculate:

(i) why may this benefit the fetal-placental unit?
(ii) what consequence may it have on the mother?

Answer 231

i) Humeral immunity is depressed and is probably necessary to stop rejection of the placenta by the mother and vice-versa.
ii) The mother is more susceptible to viral infections

Question 232

Progesterone relaxes smooth muscle. Identify two effects increasing progesterone levels may therefore have on GI tract function that the mother may complain of?

Answer 232

Reducing motility may lead to heart burn & comstipation

Question 233

Three oestrogens are synthesized from DHEA-S (dihydro epiandrosterone sulphate);
oestrone (El), oestradiol (E2) and oestriol (E3).
Which oestrogen level in maternal serum/urine would best indicate fetal progress and explain why.

Answer 233

Oestriol (E3); this hormone is dependent on fetal adrenal and liver metabolism as well as placental function.
Low levels of oestriol can indicate fetal distress such that earlier
delivery may be desirable.

Question 234

Oestrogen and progesterone both stimulate breast growth, along with which other hormone from the anterior pituitary?

Answer 234

Prolactin

Question 235

Explain how inhibin (from the corpus luteum and placenta) prevents further pregnancies occurring?

Answer 235

Suppresses FSH, hence blocking follicular growth

Question 236

In early pregnancy, progesterone stimulates appetite and promotes maternal deposition of fat (on average 3 kg of fat are accumulated by the mother; i.e. 25% of her weight gain). How is this beneficial to the mother in later pregnancy and after the birth of the baby?

Answer 236

Maternal preparation e.g. breast growth, and also may provide a reserve for later pregnancy when fetal demands are greater. In later pregnancy fat rather than glucose is the primary source of energy for the mother.

Question 237

The transport of glucose across the placenta is limited by the maternal supply. Adaptations during pregnancy reduce uptake of glucose into maternal cells to favour fetal supply. This is achieved through the action of hPL (hCS), which is low in early pregnancy but later increases as the placenta grows. hPL contributes to the increases the maternal peripheral insulin resistance (i.e., it has a diabetogenic effect).

This can lead to maternal hypoglycaemia between meals. However,
hPL (hCS) also promotes lipolysis. How is this of value?

Answer 237

Lipids and ketones released are available for energy. In early pregnancy, progesterone increases maternal appetite and promotes the storage of glucose in fat stores. hPL (hCS) promotes lipolysis of these fat stores.

Question 238

In pregnancy, Plasma volume increases by about 50%, (red cell mass by about 20%). Cardiac output increases from 4.5 to 6 L/min. This is achieved mainly through increase in stroke volume as compared to heart rate (18%). What change in mother’s blood pressure do these adjustments induce?

Answer 238

Mean BP remains the same, but the increased stroke volume raises systolic BP a little and the stroke volume, flowing so rapidly into additional tissue, reduces diastolic BP a bit.

Question 239

what changes in the heart during pregnancy may be apparent on examination?

Answer 239

Upward displacement, hypertrophy, flow murmurs are common.

Question 240

remembering that progesterone levels are continually increasing in pregnancy, and also considering its effect on smooth muscle, how may mean arterial blood pressure be affected by progesterone? What may the mother notice due to those changes?

Answer 240

Peripheral vasodilation which may cause hypotension.(mean arterial blood pressure = total peripheral resistance x cardiac output, vasodilation cases a fall in TPR)

Peripheral vasodilation may be experienced as:
‘feeling the heat’
easy to sweat
nasal congestion

Question 241

Late pregnancy is associated with venous distension and engorgement. What factors contribute to it?

What are the 2 long term sequelae associated with this period of venous distension?

Answer 241

smooth muscle relaxation by progesterone.

Mechanical pressure from the uterus compressing the IVC may increase lower limb venous pressure, but only when mother is recumbent.

Varicose veins and haemorrhoids

(consider also raised circulating blood volume)

Question 242

During pregnancy, What anatomical / mechanical affect will the expanding uterus have on the maternal respiratory system?

Answer 242

Diaphragm rises and intercostal angle widens, the uterus exerting a mechanical limitation to inspiration

Question 243

After the gravid uterus rises from the pelvis it rests upon the ureters compressing them above the pelvic brim. What possible effects might this have?

Answer 243

Increased intraureteral tone, urethral dilatation, hydro-ureter, hydronephrosis.

This may also be caused by the smooth muscle relaxation effect of progesterone.

Question 244

Pregnancy may be associated with an increase in urinary incontinence. Why do you think this might occur?

Answer 244

Pressure on the bladder from enlarged uterus. Engagement of the fetal head towards the end of pregnancy

Question 245

Progesterone dilates smooth muscle in the nephrons of the kidneys (collecting duct) and ureters. Why might this increase the likelihood of urinary tract infections?

Answer 245

Dilation slows the excretion of urine, making UTI’s more common.

Question 246

The placenta also contributes to the maternal synthesis of DHCC (1,25
dihyroxycholecalciferol P3 or calcitriol). How does this active form of vitamin D3 contribute to fetal growth?

Answer 246

It increases uptake of calcium from the maternal gut. The increased availability of calcium to the fetus facilitates skeletal formation and growth, etc.

(Expectant mothers are encouraged to increase their dietary calcium by up to 70%. PTH (parathyroid hormone) also rises in the third trimester, enhancing calcium mobilisation from maternal bone and increasing availability to the fetus.)

Question 247

Explain why blood pressure should not be measured with the expectant mother lying down, particularly in late pregnancy?

Answer 247

The uterus can compress the inferior vena cava, reducing venous return and hence, lowering blood pressure (supine hypotensive syndrome)

Question 248

How will the following physiological parameters change during pregnancy? 
Cardiac output
Heart rate
O2 consumption
Tidal volume

Answer 248

Cardiac output: Increases by 40%

Heart rate: Increases to 80-90 bts per minute

O2 consumption: Increases by 15%

Tidal Volume Increased by 40%

Question 249

A women attends an antenatal clinic at 25 weeks gestation. A routine urine test showed raised glucose. A subsequent random blood glucose test recorded 12 mmol/l (4 hours post prandial). You suspect diabetes mellitus and confirm with appropriate blood glucose tests.
This pregnancy will require close monitoring.

If this diabetes is not controlled, how will sustained hyperglycaemia effect fetal glucose levels and what will be the consequences to the fetus?

How may such changes cause problems:
During childbirth?
In the neonate?

Answer 249

Fetal hyperglycaemia also occurs.
The fetus increases insulin secretion (but is not exposed to same levels of hPL as mother).
As there is increased glucose available, it is stored as fat (fetal macrosomia). In particular, the fetal liver enlarges (due to glycogen storage).

during childbirth:
Difficult delivery due to large size of fetus, birth trauma such as brachial plexus injury; caesarean section may be required.

in the neonate:
Once isolated from the maternal supply of glucose, the neonate may experience a reflex hypoglycaemia due to its high circulating levels of insulin. The brain is particularly at risk of damage from hypoglycaemia as it does not have glycogen storage.

Question 250

What other complications, to the fetus, are also associated with poorly controlled maternal diabetes?

Answer 250

prematurity
Impaired lung maturation
respiratory disorders of newborn

cardiac, neural tube defects and other congenital malformations, may occur if conception occurs during a period of maternal hyperglycaemia
polycythemia etc.

Question 251

During pregnancy:
Why does the mother herself need more iron?
How else is iron turnover changed in pregnancy?

Answer 251

For the Hb in her expanded blood volume.

Menstrual losses have stopped.

Question 252

A pregnant woman is diagnosed with anaemia. What symptoms may she present with & how would you treat her?

Answer 252

May be asymptomatic or easy fatigability or breathlessness

Oral iron sulphate or gluconate

Question 253

Predict the consequences of poor fetal-placental perfusion associated with anaemia in pregnancy?

Answer 253

Fetal growth retardation.

Anaemic women have 3-5 times higher mortality rate in pregnancy than non-anaemic women and a still birth rate up to 6 times higher

Question 254

A mother admits smoking continually during her pregnancy. How will this affect O2 flow to the fetus and by what mechanism?

Answer 254

Carbon monoxide in maternal blood shifts her Hb-O2 curve to the left, so the fetus suffers a reduced pO2 in extracting its O2 requirement, which may not be fulfilled.

Question 255

What are the diagnostic criteria for pre-clampsia?

Answer 255

Hypertension and proteinuria

Oedema may or may not be present and therefore is not included in the diagnostic signs.

Question 256

What signs and symptoms may suggest that a mild pre-eclampsia is worsening in severity?

Answer 256

Increasing diastolic BP Lack of fetal growth
Persistent and worsening albuminuria Oligohydramnios
Oliguria Pulmonary oedema
Thrombocytopenia Headache
Elevated liver enzymes Visual complaints

Eclampsia is the onset of convulsions in a pregnancy complicated by pre-eclampsia.

Question 257

If a pregnant woman with pre-eclampsia suffers increased blood pressure and the patient has an eclamptic fit,
what would you do?

Answer 257

Initial management of eclamptic fit is to maintain maternal airway, administer oxygen, place her on left side (enhance uterine perfusion) and maintain her safety during the convulsion.

Magnesium is given by intravenous bolus then continuous infusion to relieve vasospasm and stop the fitting.

Sometimes thiopentone or diazepam are needed for recurrent fits.

Blood pressure control usually requires hydralazine.

Once stable assess fetus and maintain optimum fluid/oxygen/positioning.

Delivery is the definitive treatment for eclampsia.
Caesarean delivery will often be required unless the cervix is extremely favourable.

Question 258

What complications are associated with multiple pregnancies?

Answer 258

Increased incidence of pregnancy induced hypertension 
anaemia 
polyhydramnios 
preterm labour 
perinatal mortality 
antepartum haemorrhage

Question 259

why are the following observations are done in order to assess a 
patient with potential pre-eclampsia: 
BP
Oedema
Optic fundi
Tendon reflexes
Uterine size estimation
Fetal size estimation
Fetal heart sounds

Answer 259

BP: Looking for evidence of worsening pre-eclampsia

Examination for oedema: Oedema is common in pregnancy; however a sudden increase in oedema and facial oedema is suggestive of pre-eclampsia

Examination of optic fundi: Assessing the potential for CNS involvement

Examination of tendon reflexes: Hyperreflexia is an indication of the effect of worsening vasospasm on CNS function; therefore increased risk of eclampsia (seizure in pregnancy)

Uterine size estimation:
Fetal size estimation:
Fetal heart sounds:
Assessment of effect of maternal syndrome on fetal well-being

Question 260

List some factors that have an impact on fetal growth

Answer 260

Maternal nutrition and health
Efficiency of placenta
Adequate utero-placental blood flow
Genetic factors
Maternal parity (primaparous mothers have smaller babies than multiparous)
Maternal habits (smoking, drug abuse etc)
Also, race, maternal height, weight,

Question 261

If a fetal growth restriction is caused by compromise of the uteroplacental circulation
(e.g., due to blood clots or hypertension), how may uteroplacental or fetoplacental circulations be investigated?

Answer 261

Doppler ultrasound

Question 262

An expectant women has her first (and sometimes only) ultrasound scan at 20 weeks. How are these measurements used at a later date?

Answer 262

The measurements are used to confirm earlier dating and form a reference point for later investigations.
Some but not all fetal anomalies may be excluded at this stage.

Question 263

Suggest three reasons why 20 weeks is a good time in pregnancy to have an anomaly scan?

Answer 263

i. At this stage of pregnancy the organ systems are developed and can be visualised and anomalies can be identified.
ii. If anomalies are seen, the pregnancy is still early enough for possible intervention or termination if appropriate.
iii. The inherent error in these measurements increases with gestational age such that as a dating tool ultrasound becomes less accurate as the pregnancy proceeds.

Ultrasound errors:
1st Trimester ± 1 week
2nd Trimester ± 2 weeks
3rd Trimester ± 3 weeks

Question 264

List some further uses of ultrasound in obstetrics

Answer 264

Determine presence or absence of intrauterine pregnancy (or ectopic pregnancy)

Determine gestational age and measure fetal growth  (when compared against standard tables) 
e.g., abdominal circumference (AC) 
biparietal diameter (BPD) 
crown-rump length (CRL) 
femur length (FL) 
head circumference (HC) 

Estimate fetal weight

Identify multiple pregnancies

Detect fetal anomalies (e.g., neural tube defects), placental anomalies (e.g., placenta praevia)

Measurement of amniotic fluid

(Identify maternal pelvic anomalies)

(Guide for needle in amniocentesis)

Question 265

A 26 year old woman has had several early pregnancy losses and now comes for in assessment at about 8 weeks.

At this early stage, why is transvaginal ultrasound used to reassure the mother that the pregnancy is well established?

Answer 265

Transvaginal ultrasound to see fetal cardiac activity in the uterus is very reassuring .
It rules out ectopic pregnancy and early causes of loss such as blighted ovum.

Question 266

Why are dietary supplements of folic acid recommended in pregnancy?

Answer 266

Folic acid supplements may reduce the risk of neural tube defects.

Routine blood tests for alpha-fetoprotein are taken between 15-19 weeks gestation (when levels are at their highest).
If elevated, it can be indicative of an open neural tube defect.

Ultrasound study with optional amniocentesis is indicated. Raised alpha-fetoprotein levels, however, may ‘simply’ indicate a multiple pregnancy.

Question 267

Identification of fetal cardiac activity is an assurance of the diagnosis of pregnancy. (The fetal heart beat can be seen with transvaginal ultrasound as early as 5-6 weeks).

Predict when you can you hear the fetal heartbeat with

(i) a Doppler stethoscope
(ii) a plain stethoscope?

Answer 267

Doppler: 10-12 weeks
Plain: 18-20 weeks

Question 268

What is the average fetal heart rate at term?

Answer 268

140 - 160 beats per minute

Question 269

At what stage are fetal respiratory movement detectable on sonography?

Answer 269

From about 12 weeks fetal respiratory movements are seen by sonographic evaluation.

By 34 weeks they occur in irregular bursts, with rates up to 40-60/min, punctuated with periods of apnoea (including hiccups).

Fetal respiratory movements are diaphragmatic and cause movement of amniotic fluid into and out of the lungs.

Question 270

Which cells secrete surfactant?

At what gestational age does surfactant production begin and how is this significant in prematurity?

Answer 270

Type II ALVEOLAR CELLS produce surfactant
beginning at about 20 weeks but increases dramatically after 30mwekks, reaching significant levels at about 34weeks.

A deficiency of surfactant leads to respiratory distress syndrome of the newborn – a high risk in prematurity.

Steroid therapy, given antenatally to women at risk of pre-term delivery, may reduce the risk of RDS by 50%, by promoting the production of surfactant.

Question 271

The symphysis-fundal is a simple but very common method of monitoring fetal growth is height. What is this and how is it measured?

Predict the sources of error for this measurement

Answer 271

The uterus becomes an abdominal organ at about 12 weeks so the fundus is now palpable.

The height from top of symphysis pubis to top of fundus (in cm) correlates with the number of weeks of gestation.
Distance between symphysis pubis to top of uterus (i.e., fundus).
It can be measured with a tape measure (e.g., 20cm at 20 weeks, 36 cm at 36weeks then, plateaus).
Alternatively, the height of the fundus is assessed in relation to other structures such as the umbilicus or xiphisternum.
The uterus is palpable above the pelvis after gestational week 12.
A lag of 4 cm or more of the fundal height is suggestive of intrauterine growth restriction/fetal growth restriction.

Measurements are dependent on the number of fetus, volume of amniotic fluid, extent of engagement of head and the lie of the fetus.

Question 272

At her 20 week visit, what question will you ask an expactant mother which will be an indication of fetal well-being?

Answer 272

As about fetal movements; the mother should be noticing fetal movements (also called ‘quickening’), which feel like fluttering.

A multiparous woman may detect fetal movements earlier

Question 273

An expectant mother presents at 30 weeks, she has previously been doing well. Her symphysis-fundal height today shows a lag and is only measuring 25cm. An ultrasound is ordered. Fetal abdominal circumference is measured below that which is predicted for gestational age (head circumference and biparietal diameter are
normal).

What sort of pattern of growth restriction would you expect to be occurring at this stage in a pregnancy?

Answer 273

Asymmetric growth retardation in which there is “brain sparing”. The head (and indeed femur) continues to grow but abdominal fat and glycogen is diminished as fetus is compromised.

Asymmetrical growth retardation is associated with poor maternal nutrition or decline in nutrient delivery to the fetus in the latter stages of pregnancy.
This may be due to maternal or fetal factors but most often reflects compromise to the utero-placental unit.
The growth restriction shows up mainly in the third trimester when nutritional demands and fetal growth are most rapid

Growth retardation earlier in pregnancy is more often related to genetic, or congenital problems or isolated insults to the development of the fetus.

Question 274

Why is fetal abdominal circumference a valuable measurement?

Answer 274

Measurement of fetal waist (at level of the umbilical vein) provides assessment of growth of fetal liver and amount of sub-cutaneous fat etc.
Glycogen laid down in the fetal liver accounts for much of this growth.

Question 275

The BioPhysical Profile (BPP) uses ultrasound and electrocardiography to document 5 parameters of fetal well-being relating to development and function of fetal organ systems and used to determine whether early delivery is required

Which organ systems are being assessed by each test?

Answer 275

fetal movement:
Musculoskeletal, CNS

fetal breathing movement:
musculoskeletal /respiratory, CNS

fetal tone:
Musculoskeletal, CNS

amniotic fluid volume:
Renal, uteroplacental, (GI)

fetal heart rate response to movement in the NON-STRESS TEST:
Cardiovascular, Autonomic nervous system

The first four are assessed by ultrasound. Many factors may cause a reduction in the scores
achieved including fetal sleep cycles, maternal dehydration or hunger, maternal sedation
and fetal alcohol syndrome, as well as fetal compromise due to hypoxemia. The results have
to be viewed in context of risk factors, earlier studies and sometimes repeat evaluations to
determine whether urgent and /or early delivery is required.

Question 276

Normal CNS development is dependent on the production of which fetal hormone(s) which if deficient cause cretinism in children?

Answer 276

Thyroid hormones (secreted from 12 weeks onwards, very little is derived from the mother)

Question 277

In a woman at 34 weeks of pregnancy, the fundal height is only 29cm. An ultrasound study shows asymmetrical growth restriction with reduced amniotic fluid (AF) volume (oligohydramnios). Uteroplacental circulation is compromised (Doppler ultrasound).

Why is oligohydramnios associated with this pattern of growth restriction?

Answer 277

Nutritional deprivation / utero-placental insufficiency leads to decreased fetal urine production.

Question 278

What factors must you consider in deciding whether to allow a compromised fetus to remain in utero?

Answer 278

Risks of compromise v risks of prematurity, particularly respiratory problems.

Question 279

Prior to week 8, how is amniotic fluid produced?

Answer 279

Passage of fluid across the amnion and non-keratinised fetal skin (transudation)

Question 280

Fetal urine contributes to the volume of amniotic fluid. At what stage is urine first produced?

Answer 280

Week 10

Question 281

Amniotic fluid volume increases proportionately with fetal growth until late pregnancy when it begins to decline. Most of the amniotic fluid in the last half of pregnancy consists of fetal urine and amniotic fluid volume is a reflection of fetal renal function and hence fetal metabolism.

Consider how amniotic fluid volume might be altered in the following situations: 
• Fetal kidney malfunction 
• Maternal hypertensive disorders 
• Premature rupture of membranes 
• Fetal bladder outlet obstruction 
• Premature leakage of amniotic fluid

Answer 281

All would lead to oligohydraminos (abnormally low amniotic fluid vol)

Amniotic fluid is a dynamic state of flux; the water component
being exchanged every 3 hours or so. It is a dialysate of maternal and/or fetal fluid. The fetal lungs also contribute to the amniotic fluid volume

Question 282

As the fetus swallows and digests amniotic fluid. Identify a fetal GI tract defects that might lead to excessive amniotic fluid volume (polyhydramnios)

Answer 282

Oesophageal atresia
Duodenal atresia

(Also, diaphragmatic hernia, anencephaly, inencephaly, hydrocephaly)

Question 283

At 36 weeks, the fetal abdominal circumference reading is high in relation to head circumference. What maternal condition might cause these abnormal readings?

Answer 283

Poorly controlled maternal diabetes. A rise in maternal blood glucose levels raises the availability of glucose to the fetus. Much of this glucose will be laid down as glycogen in the fetal liver (hence increase in fetal abdominal measurement).

Question 284

What term is used to describe an abnormally large a fetus?

Answer 284

Fetal macrosomia; birth weight >4000 or 4500g

There are other causes of fetal macrosomia including post-term pregnancy and maternal diabetes

Question 285

In certain pregnancies, especially near to term, a fetus may be classified as ‘at-risk’, and will require special monitoring such as a non-stress tests and biophysical profile.

In what instances might the fetus be classified as at-risk?

Answer 285

• maternal hypertension
• maternal heart or liver disease
• multiple gestation
• maternal diabetes
• where there is evidence of fetal growth retardation
• suspected oligohydramnios
• presence of placental abnormality
• post-dated pregnancy

Question 286

In a non-stress test, 3 or more fetal movements should be accompanied by a rise in fetal heart rate. Over a 30-minute period you record neither fetal movement nor change in heart rate. Should you be concerned?

Answer 286

Fetus may be sleeping;

Repeat later e.g. After a meal

Question 287

The presence of meconium in the amniotic fluid is a sign of fetal stress and asphyxia.

What is meconium and how is it formed?

Answer 287

Typically, meconium are the first stools of a newborn baby – green, dark and sticky and composed of cellular debris, mucous and bile pigments.
It is formed from the digestion products of amniotic fluid (cells and protein) the fetus has swallowed.
The presence of meconium in the amniotic fluid is an indicator that the fetus has had an episode of distress.

Question 288

Apart from ultrasound, how can you decide on the lie and presentation of a fetus in early labour?

Answer 288

Abdominal palpation

Question 289

What are the advantages of using a scalp electrode in monitoring fetal heart rate?

Answer 289

Allows for continuous close monitoring of fetal heart rate regardless of maternal position.

Question 290

Oestrogen stimulates oxytocin receptor production in the myometrium. Progesterone depresses the responsiveness of the uterus to oxytocin and reduces uterine prostaglandin release.

Explain the importance of this interrelationship during pregnancy.

Answer 290

An increase in the number of oxytocin receptors is in preparation for labour since oxytocin stimulates uterine contraction (via a positive feedback mechanism).

However progesterone prevents oxytocin from evoking contractions during pregnancy, so avoiding spontaneous abortion.
Progesterone also reduces uterine prostaglandin release thus again reducing myometrial activity.

Question 291

Identify the oestrogen mediated changes in the cervix and pelvis occurring in advancing pregnancy that will facilitate birth?

Answer 291

Cervical softening

Relaxation pelvic ligaments

Question 292

Relaxin (placental) contributes to this effect via a collagenase activity.

What postural change may ensue from these effects during advancing pregnancy and for what reasons?

Answer 292

It may cause lordosis (due to relaxation of vertebral ligaments and the additional weight of the fetus).

Question 293

What anatomical landmark gives an estimate for 20 weeks of gestation?

Answer 293

Mother’s umbilicus

Question 294

What fetal landmark is used to assess fetal head position in the birth canal?

Answer 294

Fetal fontanelles

Question 295

What fetal structures might be at particular risk during delivery of the shoulders?

Answer 295

Brachial plexus

Question 296

If an epidural is used for pain relief, what spinal segments are blocked?

Answer 296

T9 - S4

Question 297

Why is the patient with an epidural at risk for hypotension?

Answer 297

Lumbar sympathetic outflow blockade prevents vasoconstriction

Question 298

Define post-partum haemorrhage

Answer 298

Blood loss of > 500 ml after vaginal delivery

Question 299

What is the most common cause of post-partum haemorrhage?

Answer 299

Uterine atony

Question 300

What physiological mechanism exists to prevent post-partum haemorrhage?

Answer 300

Strong contractions after the 3rd stage of labour contract the uterus down, achieving closure of the “living ligature” (the unusual criss-cross arrangement of myometrial fibres) clamping the arterial supply to the placental bed in the endometrium.

Question 301

Following delivery, If the uterus is firm on palpation with continuous bleeding, what other cause should you consider?

Answer 301

Laceration or trauma to the genital tract / Retained placenta

Question 302

Sheehan’s syndrome is a very rare complication of post-partum haemorrhage and is pituitary failure as a result of necrosis of the anterior pituitary gland. Describe the aetiology of this condition.

Why is the Posterior pituitary unaffected

Answer 302

Thrombosis of vessels supplying the anterior lobe secondary to severe haemorrhage, leading to necrosis of the anterior pituitary gland which increases in size during pregnancy increasing its susceptibility to necrosis.

Posterior pituitary is unaffected because It has a relatively rich arterial blood supply.

Question 303

The patient has lost 1.5 L of blood. What state will result from this degree of blood loss.

What would you expect systolic arterial blood pressure to be?

What additional signs/symptoms would you expect?

Answer 303

Hypovolaemic shock

Question 304

A 44-year-old woman finds a lump in her breast when undertaking self-examination. She sees her G.P. who confirms the presence of a lump.

What are the possible diagnoses?

Answer 304

cyst 
fibroadenoma 
inflammatory (fat necrosis etc.) 
phyllodes tumour 
carcinoma

Question 305

A woman finds a lump in her breast. The G.P. puts a needle into the lump, aspirates fluid and reassures the patient. Three
months later the lump re-appears and this time the G.P. sends her to the Breast Clinic.

How would the clinic doctor make a diagnosis?

Answer 305

clinical history + examination

investigations e.g. ultrasound, mammogram, FNA and/or core

Question 306

25 year old woman finds a mobile lump in her breast.

What is the most likely diagnosis?
Describe its most likely histological appearance

Answer 306

Fibroadenoma

smooth surfaced lobulated mass;
histology = large amount of stroma with compression of elongated ducts.

Question 307

What changes do radiologists look for in mammograms?

What breast diseases can cause these changes?

Answer 307

parenchymal deformity, ASD, masses, calcification

malignant - ductal carcinoma in situ & invasive carcinoma
benign - cysts, sclerosing adenosis, columnar cell change

Question 308

What type of breast lesion presents as ducts expanded by malignant cells with central necrosis & calcification

What would happen in the lesion is left in the breast

What is the most likely treatment

Answer 308

Ductal carcinoma in situ

Invasion

Wide local excision or mastectomy - depends on location, size relative to breast, multifocality & patient choice

Question 309

What type of breast lesion presents as discohesive pleomorphic malignant epithelial cells

Answer 309

malignant breast aspirate (carcinoma)

Question 310

What will a pathologist examining removed breast tissue look for & measure?

Answer 310

size + weight of specimen, size of tumour, distance to margins, any other abnormalities

Question 311

What histological features can be used to help determine prognosis of a malignancy

Answer 311

(size), histological type, grade, lymphovascular invasion, margins

Question 312

A woman presents with primary carcinoma of the breast
Two years later she presents with abdominal discomfort and her eyes are noticed to be yellow

What do you think the underlying problem could be and how would you investigate her?

Why may she be at risk of bone fracture?

What other complications could occur that relate to her breast cancer?

Answer 312

metastases to liver
liver function tests
ultrasound / CT scan
liver biopsy if necessary

metastasis to bone resulting in pathological fracture

metastasis to lung and pleura – pleural effusions
metastasis to brain – stroke