Biochemistry Pregnancy and Fertility Flashcards Preview

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Flashcards in Biochemistry Pregnancy and Fertility Deck (42):
1


Definition of sub-fertility →
Cumulative conception rates:

1. 4 Months 65%
2. 9 Months 82%
3. 12 Months 85%

2

Causes of Subfertility →

1. Ovulatory failure 21%
2. Tubal damage 14%
3. Endometriosis 6%
4. Mucus defect 3%
5. Sperm defects 24%
6. Other male 2%
7. Coital failure 6%
8. Unexplained 28%
9. Others 11%

3

Assessment of Ovulation →Progesterone (nmol/L)

>30 ovulation (not sub-fertile)
<30 reduced conception rate
Low level repeat next cycle

4

“day 21” progesterone
7 days before menses

Note → Variability in period together → change in follicular phase not luteal phase.
Timing

“day 21” progesterone
7 days before menses

Note → Variability in period together → change in follicular phase not luteal phase.

5

Primary Ovarian Failure →

1. Impaired follicular development >
a. Low oestradiol
b. High LH/FSH (better marker) – PCOS or irregular ovulation – can alter LH levels.

→ No negative feedback to hypothalamus.

6

Causes of Ovarian Failure

➢ Premature ovarian Failure
➢ Post menopausal
➢ Autoimmune damage
➢ Surgery
➢ Irradiation (late effects of childhood or early adult cancer)
➢ Dysgenesis (Turners Syndrome)

7

Secondary Ovarian Failure

➢ Impaired LH/FSH production
➢ Low LH/FSH – not completely suppressed *
➢ Impaired follicular development > low estradiol

8

Causes of secondary Ovarian Failure

• LHRH deficiency (Kalmann’s syndrome)
• Pituitary tumours (prolactinoma)
• Secondary hypopituitarism e.g. irradiation, infiltrative and vascular disorders
• Function – weight loss, stress, exercise, starvation
• Systemic disease – e.g. thyroid, adrenal

9

Kallmann’s Syndrome:

1. Absent sense of smell
2. Won’t go into puberty

10

Polycystic Ovarian Syndrome → Epi

87-90% oligomenorrhea, 26-37% amenorrhoea

11

Polycystic Ovarian Syndrome → Diagnosis

1. Ultrasound → 15 cysts arranged around cortex, echogenic stromal compartment.
2. Or Endocrine studies (less time consuming)

12

Polycystic Ovarian Syndrome → Characteristic features of PCOS

3. Obesity
4. Insulin resistance – independent from obesity contribution
5. Increased cardiovascular risk
6. Hirsutism
7. Oestrogenisation – from multiple follicles

13

Polycystic Ovarian Syndrome → Serum Levels

LH increased
FSH normal
LH:FSH ratio abnormal
Testosterone increased (free testosterone is a better discrimination

14

Polycystic Ovarian Syndrome → Abnormal

Not all patients show the pattern
LH 12.6 93.1-26.0) 1-10 iu/L
• Sensitivity (positivety in disease)-60%
• Specificity (negativity in health)-94%

15

Hormonal Assessment of the infertile male:

Semen Analysis
Abnormal
Testicular Problem

16

Semen Analysis

Normal – no endocrine tests
Abnormal

17

Abnormal

LH/FSH, prolactin testosterone
• Testicular problem
• Hypothalamic pituitary

18

Testicular Problem

Normal endocrinology
Abnormal endocrinology

19

Hypergonadotrophic hypogonadism (testicular failure)

serum levels

Low Testosterone
High LH
High FSH

20

Isolated germinal compartment failure serum levels

Normal testosterone
Normal LH (acting on Leydig)
High FSH (abnormal sertoli cell function)

21

Non-Endocrine – impaired sperm serum levels

Obstructive azoospermia
Retrograde ejaculation
→ Normal Testosterone
→ Normal LH
→ Normal FSH

22

Hypogonadotrophic hypogonadism → serum levels


Low Testosterone, LH, FSH

23

Chemical

Increases – Alk phos, hormone binding proteins
Decreases – Albumin, creatinine, urea

24

Physiological

Increases – plasma volume, cardiac output, weight gain, GFR early pregnancy
Deceases – Fasting BG early pregnancy, renal threshold for glucose

25

Endocrine

Increase – Oestrogen, progesterone, prolactin, hCG
Decrease – LH and FSH

26

Gestational diabetes → Epi

1-2% women develop gestational diabetes

27

Gestational diabetes → Diagnostic problem

15% women develop g;ycosuria
No accepted reference ranges

28

Gestational diabetes → Diagnostic tests

Blood glucose, random/fasting
GTT (glucose tolerance)

29

Gestational diabetes → Risk Factors for gestational diabetes

• BMI >30 kg/m2
• Previous macrosomic baby weighing >4.5 kg
• Previous gestational diabetes
• Family history diabetes (first degree relative)
• Family origin with a high prevalence of diabetes

30

Gestational diabetes → Diagnostic tests

Blood tests: U and E, urate, urine protein, clotting, LFT
HELLP

31

Gestational diabetes → HELLP

Haemolysis, Elevated Liver enzymes, low Platelets

32

Gestational diabetes → HELLP diagnosis

Abnormality seen with raised ALT/AST

33

Gestational diabetes → Urate in gestational diabetes

Independent raise in pregnancy not explained by the change in renal function associated with pregnancy
Increase urate = worse prognosis

34

Pregnancy related liver disease “Big 5”

1. Pre-eclampsia
2. HELLP
3. Hyperemesis Gravidarum
4. Acute Fatty Liver of Pregnancy
5. Obstetric Cholestasis

35

Pregnancy Unrelated Liver Disease

6. Pre-existing liver disease
7. Liver disease co-incident with pregnancy

36

Obstetric Cholestasis → Definition

Usually occurs in the 3rd trimester
Significant peri-natal mortality and maternal morbidity

37

Obstetric Cholestasis → Cardinal feature

Generalised puritis (not specific)

38

Obstetric Cholestasis → Biochemical tests

Serum bile acids (sensitive but not specific)
ALT and AST often raised
Alkaline phosphatase and bilirubin – no significant contribution

39

Second Trimester

Triple or quadruple test which provides the current standard of a detection rate above 75% and a false-positive rate of less than 3%

40

New Guidance First trimester

The “combined test” (nucal translucency, hCG, pregnancy associated plasma protein A) should be offered between 11-13 weeks 6 days

41

Down’s Syndrome Screening Markers – 2nd Trimester

AFP
hCG
Free-beta hCG
Alpha hCG
Unconjugated estriol (uE3)
Inhibin – A

42

Down’s Syndrome Screening Markers – 1st Trimester

Pregnancy associated plasma protein A nuchal translucency

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