Learning Outcomes (Non-CLIC) Flashcards
(182 cards)
1
Q
Define Oogenesis.
A
The process by which female gametes/Ova(um) are created
or
The steps/process a developing egg (oocyte) goes through to differentiate into a mature egg (ovum).
Each gamete = haploid = one copy of each chromosome)
2
Q
Describe Oogenesis.
A
Phase 1 (during foetal development and before birth):
1- Oogonia are created
2- undergo mitosis -> millions produced
3- Oogonia also begins to differentiate into primary oocytes
4- millions degenerate and die before birth
5- the remaining enter meiosis I
6- meiotic arrest occurs in prophase I
Phase 2 (occurs at ovulation hence it begins at puberty with menstrual cycle developing one primary oocyte into a secondary oocyte)
1- When menstrual cycle takes place primary oocyte finishes off meiosis I producing secondary oocyte and a polar body (this is stimulated by LH)
2- secondary oocyte begins meiosis II and meiotic arrest occurs in metaphase II
3- Secondary oocyte is ovulated
4- Sperm comes along and fertilizes it
5- On fertilisation meiosis II is completed and you have an ovum
Remember: Oogenesis begins before birth and finishes after secondary oocyte is ovulated
3
Q
What are oogonia?
A
Oogonia are germ cells. Germ cells are cells that create reproductive cells called gametes in humans.
4
Q
Describe Follicular Development.
A
Note: follicular development is independent from oogenesis but parallel to it.
1- Primordial Follicle - single layer of granulosa cells around the oogonium (This is a small follicle - most numerous at any one point, secrete anti-mullerian hormone)
2- Primary Follicle - this surrounds the primary oocyte, the oocyte size continues to increase, the layer of granulosa cells increase and three layers are created (this is occurring parallel to the increase in size of oocyte), separated from oocyte by zona pellucida but gap junctions allow nutrients to reach the oocyte
(GROWTH FROM SMALL TO MEDIUM IS INDEPENDENT OF HORMONES)
3- Early antral follicle - this is just before pre-ovulatory follicle, here the antrum began to form as fluid is secreted from granulosa cell, and there is granulaosa cells which have differentiated into theca cells
4- Pre-ovulatory (mature) follicle - this has the secondary oocyte in it arrested in meiosis II, and Antrum fully formed
(Primary Oocyte develops into secondary oocyte same time primary follicle becomes pre-antral -> early antral -> Pre-ovulatory (this also named graafian follicle which means follicle with developed antrum)
5
Q
Define small, medium, and large follicles.
A
Small = primordial follicles Medium = this is primary and pre-antral follicle Large = Graafian Follicle (rapid mitotic divison to get to this stage and antrum fills with fluid)
6
Q
Describe the difference between the growth of small follicles to medium, and medium to large.
A
- Small -> medium = independent of hormones
- medium -> large = stimulated by FSH and takes 14 days
7
Q
A) Which hormone stimulate Theca cells to produce androstenedione?
B) what is androstenedione the precursor to?
A
A) LH
B) precursor to the synthesis of estridol 17 Beta
8
Q
List the two gonadatropins and two gonadal sex hormones.
A
1) LH and FSH (Anterior Pituitary Gonadotropins)
2) Oestrogen and progesterone
9
Q
Describe how the corpus Luteum is created.
A
- Mature follicle releases it Antrum and egg
- Granulosa cells and theca cells enlarge and form gland-like structure ie the corprus luteum (if no fertilization will reach maximum development within 10 days and degenerate by apoptosis)
10
Q
Name the hormones secreted by Corpus Luteum.
A
- Oestrogen
- Progesterone
- Inhibin
11
Q
What is the role of LH in the ovulation process when it surges and triggers ovulation?
A
- Induces prostaglandins endoperoxide synthase in granulosa cells (setting up a pseudo-inflammatory response)
12
Q
What is the role of FSH in ovulation?
A
Stimulates plasminogen activator from granulosa cells (Plasminogen –> plasmin)
13
Q
Describe the role of Prostaglandins E and F in ovulation.
A
Release lysosomal enzymes which digest the follicular wall
14
Q
Describe the role of Stigma in Ovulation.
A
- Stigma is the area of the ovary surface where the follicle exits/burst out
- Forms on the surface of a follicle, balloons out, forms a vesicle then ruptures –> oocyte expelled
15
Q
Compare and contrast Spermatogenesis and oogenesis.
A
Spermatogenesis:
- Continuous Process
- Lower temperature is required
- Meiotic Spermatogonia proliferation begins after puberty (indirectly dependent on progesterone)
- The meiotic division of one primary spermatocyte produces 4 mature spermatozoa
- This process results in the production of an infinite number of sperm
- Results in the production of motile gametes
- Products of meiosis (spermatids) undergo considerable differentiation while maturing and becoming spermatozoa
Oogenesis:
- Discontinuous process
- Normal body temperature
- Meiotic proliferation of oogonia occurs prior to birth
- Meiotic division of oocyte produces one mature ovum
- second meiosis complete upon fertilisation
- results in the production of a finite number of oocytes
- Results in the production of immotile gametes
16
Q
Name the two stages of ovarian cycle.
A
- Follicular Phase
- Luteal Phase
17
Q
What are the phases of menstrual cycle.
A
- Menstrual Phase
- Proliferative phase
- Secretory Phase
18
Q
Following LH Peak, What happens on the following days: 1- 1 day 2- 2 days 3- 2-4 days 4- 5 days 5- 6-7 6- 9-10
A
1- ovulation
2- fertilisation.
3- cell division to 32 cells
4- Blastocyst enters the uterine cavity
5- implantation (attaches adjacent to the inner cell mass), here the blastocyst leaves the zona pellucida and is bathed in uterine secretions for 2 days, it is a limited attachment window
6 -Human Chorionic Gonadotropin Hormone (hCG) from implanted blastocyst (trophoblast cells) rescues corpus luteum (from the trophoblasts hCG goes to maternal ovary)
19
Q
The ovarian cycle involves a _________ phase, followed by a __________ phase. In the initial phase, GnRH released by the __________ causes the anterior _________ gland to release two hormones. Once released, the _________ hormone stimulates the development of the follicles in the ovaries. The maturing follicles release _________ leading to the growth of the lining of the uterus, and a spike in the concentration of ________, which triggers ovulation. In the second phase of the ovarian cycle, the corpus luteum forms releasing mainly __________, which increases the blood, supply to the uterus, and further thicken the uterus lining with additional fluids and nutrients ready to support a developing embryo.
A
Follicular Luteal Hypothalamus Pituitary FSH Oestrogen LH Progesterone
Notes: Oestrogen inhibits FSH in the follicular phase
Progesterone inhibits both LH and FSH in the luteal phase once the corpus lutem degenerates progesterone decreases allowing the increase of LH and FSH once more cycle repeats
20
Q
Describe how the fertilized egg under goes cell division.
A
1- Conceptus (Fertilized egg) is held in the fallopian tube dur to smooth muscle contraction induced by estrogen
2- Conceptus undergoes cleveage leading to the formation of the mourla (16 cells) which takes 3-4 days (could be up to 32 cells by day 4 (32-cell stage) but it would still be called the mourla)
3- All cells in the mourla totipotent
4- 4-5 days after fertilization the blastocyst is formed (Blastocyst has fluid-filled cavity, inner cell mass, and trophoblasts which is the layer that creates the round/ball structure all within the zona pellucida
21
Q
Explain the difference between the following cell types:
- Totipotent Cells
- Pluripotent
- Multipotent
A
1- Totipotent = can form all cell types in the body including the placenta
2- Pluripotent = can give rise to all cell types excluding the placenta
3- Multipotent = develop into a limited number of cell types in a particular lineage
22
Q
Describe the placenta.
A
Organ of exchange between the mother and fetus which develops during pregnancy
23
Q
Name the cells which are of totipotent origin which give rise to the placenta found in the blastocyst.
A
Trophoblasts
24
Q
Discuss the fate of the trophoblasts following implantation.
A
- They differentiate into inner cytotrophoblasts and outter layer of cells called the Syncytiotrophoblasts which invade the endometrium
- they end up creating extra embryonic tissue like the placenta and umbilical cord
25
What is the fate of the inner cell mass?
Fated to become the embryo, amnion, and yolk sac
26
In the earliest stages of the pregnancy the anatomical link between the mother, and the fetus develops through a series of phases. List those phase.
1- invasion - conceptus invades endometrium
2- Decidulisation - endometrial remodelling including secretory transformation of the uterine glands, influx of specialised uterine natural killer cells, and Vascular remodelling
3- Placentation - placenta formation
27
Why would a woman who has conceived with an implanted blastocyst think she is not pregnant?
- In implantation at around day 13 after fertilisation the synctiotrophoblasts of the implanted blastocyst in the wall of the endometrium erode through the walls of the large capillaries which then bleed into spaces (thi sis primitive placenta circulation) this blood bathes the synctiotrophoblasts
- This is the same time a woman expects her next period, and hence this bleed maybe thought to be the next period
28
Describe the process of formation of the placenta.
▪ We know that at implantation the trophoblasts differentiate into synctiotrophoblasts which erode through maternal endometrium and capillaries
▪ Digestive Enzymes break down cells and allow Trophoblasts/Synctiotrophoblasts to form villi that project into the blood filled spaces called chorionic villi (so this is bathed in maternal blood)
▪ In the core of the villus is a fetal capillary loop (this is blood vessels connected to the umbilical vein and artery)
▪ This develops over several weeks
▪ Villi become localised in the embryonic pole
▪ Huge surface area for O2 exchange
▪ Embryonic portion of the placenta is supplied from the outer most layers of trophoblast cells (ie the chorion)
▪ The maternal side of the circulation (the maternal arteries and veins that form to supply this pool of blood) is restricted and not functional until 10-12 weeks so first trimester is largely depends on uterine tissue and nutrients and O2
▪ Maternal portion is supplied by the endometrium underlying the chorion
▪ Endometrium around villi is changed by enzymes and paracrine agents so each villi is surrounded by a pool/sinus of maternal blood (Blood Sinuses)
▪ So we see that the placenta consists of chorion that forms the villi, blood sinuses bathe the chorion villi in blood, then there is the endometrium with maternal blood vessels
▪ Maternal and fetal blood are separated by The placental membrane and there is no mixing of the two bloods
29
List the functions of the placenta.
- Nutrition: provides nutrients (water and electrolytes (diffuse freely), glucose (facilitated diff), amino acids (active trans)) (Placental conductivity increases with weeks of gestation reaching max around 35/36 wks of gestations then declining just before parturition)
- Respiratory organ: gas exchange of O2 and CO2
- Endocrine Organ/Gland: releases hCG, Oestrogen, Progesterone
- Waste product removal: removes waste products such as CO2, Urea, and Uric Acid
- Provides Immunity: IgG immunoglobulins cross the placenta into the fetal circulation to protect them
30
Until the placenta can produce its own progesterone the uterus relies on the corpus luteum to produce progesterone (this is for about 13 weeks so the first trimester) to prepare and thicken uterine lining.
A) Name the hormone that ensures the corpus luteum does not degenerate and continues producing progesterone until placenta develops
B) Describe the function of that hormone
C) Name the cells that produce this hormone.
1) human Chorionic Gonadotropin Hormone
2) mimics LH, supports steroid synthesis by the CL --> prevents menstruation and any further follicular development (hCG is important in males too as it stimualtes Leydig cells to produce testesterone important for development of male duct system)
3) Synctiotrophoblast
31
At what point can hCG be detected by commercial kits in urine?
Sensitive kits can detect it as soon as 8 days after fertilisation
32
Which anatomical point reaches by the uterus during pregnancy usually marks 20 weeks of gestation?
umbilicus
33
Which anatomical point reached by the uterus during pregnancy usually marks 36 weeks of gestation?
xiphoid orocess
34
- Define the fundal height.
| - What is it used for?
- Distance measured from pubic symphysis pubis to top of uterus (fundus)
- Used to estimate gestational age(E.g. at 36 weeks near the xiphoid process you expect it to be close to 36 cm)
35
What stimulates release of FSH and LH, and where is it produced?
Where are LH and FSH produced from?
GnRH produced in the hypothalamus
Anterior Pituitary
36
Describe the physiological respiratory changes during pregnancy.
1- Increase in minute ventilation due to increase in tidal volume (as oxygen consumption and CO2 production increases) and high levels of serum progesterone stimulating the respiratory centre but the respiratory rate remains the same
2- Increase in intra abdominal pressure due to increase in uterus size leads to feeling of breathlessness and hyperventialtion insome cases which can lead to respiratory alkalosis
37
Describe the physiological cardiovascular changes during pregnancy.
- Increase in CO as there is increase in SV and HR as more blood is required to supply the placenta
- Slight decrease in BP as there is decrease in systemic vascular resistance due to relaxant effects of progesterone on smooth muscle
- relaxation of systemic resistance also to allow blood flow to the placenta
38
Describe the physiological haematological changes during pregnancy.
- 40% increase in the volume of blood plasma
- 25% increase in RBC count
- net loss in the number of RBCs per unit volume of plasma --> physiological anaemia
39
Describe the physiological renal changes during pregnancy.
- Increased CO -> Increased renal blood flow -> increase GFR -> increased urinary frequency
- Increase in Kidney size (increase in the size of the calyces and renal pelvis) as the kidney adapts to the increased blood flow --> physiological hydronephrosis + physiological hydroureter
- progesterone effect on ureter -> relaxation -> hypomotility -> increase risk of UTIs
40
Describe the physiological GI changes during pregnancy.
Hormonal changes --> reduced peristalsis -> constipation and bloating + relaxation of the lower oesophageal sphincter leading to reflux and heartburn
41
Describe the role of hCG.
- maintain CL and release of progesterone and oestrogen -> prevents menses and causes decidua-like cells to become swollen with nutrients for blastocyst
- Anything happens to the CL before 7 weeks of gestation the pregnancy will spontaneously abort
42
Describe the effects of oestrogen in pregnancy.
- Effects on uterus = thickens the lining and maintains the lining of the uterus stimulating endometrium proliferation and vascularisation for nutrient supply
- effects on the breast = stimulates breast growth by stimulating stromal tissue growth (connective tissue), fat deposition and growth of mammary glands and stimulates the development of the ductile system
- during labor, it induces it = induces myometrial excitability, increases oxytocin receptors and formation of gap junctions, and promotes synthesis of prostaglandins
43
Describe the effects of progesterone in pregnancy.
Effects on uterus =
- leads to the growth/thickening and maintenance of uterus lining
- promotes development of decidua in the endometrium which is thick layer of modified mucous membrane which lines uterus during pregnancy (decidulisation = process by which endometrial cells change in structure to form decidua which supports the attachment of the placenta and implantation of the embryo , these cells become swollen with nutrients for the embryo)
- progesterone inhibits uterine contractions by
1. Inhibiting production of prostaglandins
2. Decreasing sensitivity to oxytocin
stimulates development of lobules and alveoli
Effects on the breasts:
- prepares breasts for lactation as it stimulates the development of lobules and alveoli
44
Describe the effects of human somatomammotropin hormone in pregnancy.
- Begins production during 5th week of gestation and increases progressively throughout the pregnancy
- Contributes to the development of breasts and promotes lactation
- Causes metabolic changes:
- reduced insulin sensitivity = reduction in the amount of glucose utilised so more is available for the fetus
- Promotes the release of fatty acids = acts an an alternative energy source for the mother.
45
When diagnosing illness, choosing the right specimen for the following conditions:
```
1- UTI
2- Wound
3- Meningitis
4- Pyrexia of unknown origin
5- pneumonia
```
```
1- midstream urine
2- pus or swab
3- CSF and blood
4- Blood culture and serology
5- Sputum, lavage (tube into lung, some material pushed our slightly, then syringed back through the tube for assessment), serology
```
46
Name the 4 ways by which labs usually examine samples.
- Direct examination (E.g. Smear Diagnosis: Rapid, simple, cheap, not sensitive or specific so requires expertise)(Requires microscopy: light microscopy good for direct smear like when examining stool, and gram bacteria like in CSFm fluorescent is good for RSV)
- Culture (Slow, organisms can be rendered negative by antibiotics and you miss a diagnosis, more sensitive than smear and allows susceptibility testing (so tells you what antibiotic the bacteria is sensitive to), and allows rapid presumptive diagnosis and detailed identification)
- Serology (detect changes in the body in response to an infection that has taken place already: detect high IgG concentration, rising and falling of titres so when you take two sample at different times you get to see if it is acute or chronic as the antibodies would be rising or falling)
- Molecular (DNA hybridization and NAAT)
47
Name two examples of serological techniques.
- Agglutination
| - Precipitation
48
Define sensitivity.
The ability of a test to detect all of the true positives
49
Define specificity.
Ability of a test to identify the number of true negatives
50
- Name an example of a bacteria part of the normal flora.
| - Explain why it is always important to take test results in the context of the normal flora.
- Staph Aureus/epidermidis/haemolyticus
- because normal flora can contaminate a sample but not actually be colonisers. so for example staph aureus is found on the skin naturally but it may pop up on a blood culture when it is not a coloniser
51
Outline the principles that inform safe prescribing in pregnancy and when breastfeeding
1. Pre-conception counselling to all women who want to get pregnant and are prescribed drugs
2. Balance benefit to the mother against the risks to the foetus
3. Drugs that have been extensively used in pregnancies and appear to be usually safe should prescribed rather than new untried drug
4- Try and use the smallest effective dose
52
Define teratogencity/teratotoxicity.
The ability of a drug to cause fetal malformations (1st trimester)
53
Define fetotoxicity.
the ability of a drug to cause functional changes to the fetus (2nd and 3rd trimester)
54
Name classes of drugs that are teratogenic.
The A-Club:
- Anti-psychotics
- Anti coagulants
- Anti-convulsants/Anti-epileptic
- Anti-metabolites
- Acne drugs
- Alcohol
- Androgens
- Anti-biotics
55
Name a teratogenic cardiovascular drug in first trimester.
ACEi
56
Name GI drug that should be avoided in pregnancy.
PPI
57
Name an anti-coagulant that should be avoided in pregnancy.
Warfarin (Causes warfarin embryopathy)
58
A woman is severely epileptic with fits occuring frequently causes falls. Should she be on anti-epilepsy drugs or not?
- All anti-epilepsy drugs are teratogenic
- however in this situation (and others) uncontrolled epilepsy is more dangerous than taking no medication
- Use lamotrigine as it is more safe
59
Describe some of the risks associated with IVF for both the mother and the child.
- Ovarian Hyperstimulation syndrome (occurs due to superovulation as a response to the drugs used in IVF - more than one oocyte in the follicle)
- Transferral of several embryos (unintentionally) à multiple births
- Welfare of child - women cannot be provided with treatment unless the welfare of the child who would be born as a result of the treatment has been taken into account, but also any other child that could be affected by the birth - there needs to be supportive parenting.
60
What is the role of the HFEA in regulating assisted reproduction in the UK?
○ HFEA: Human Fertilisation and Embryology Authority
○ It regulates and provides information
○ Regulates treatment (inspects and licenses clinics)
○ Regulates Research (Licenses for human embryo research)
○ Human Fertilisation and Embryology Act 1990, 2008 deal with IVF
○ The 2008 act indicates the need for supportive parenting
61
Outline the Scottish Government's most recent (2016) recommendations for IVF on the NHS.
○ Guidelines for IVF In Scotland
- <40 yo: 3 cycles of IVF allowed
- 40-42: 1 cycle of funded IVF (need to discuss implications of IVF and pregnancy at this stage)
62
True or false. A surrogate mother is not the legal mother of a child
False.
+ In the UK surrogate mother is always the legal mother from birth (parental order or adoption is required for this to change)
63
Name one ethical issue arising with IVF at the stage of access (to IVF) on the NHS.
- Whether homosexual couples should be allowed
- NHS Greater Glasgow and Clyde (2009) - This case origianlly denied gay couples IVF. Here th NHS GGC refused IVF for a couple based on the basis that they do not meet the criteria that couple attempting should be able to conceive biologically. Ruling: the board reviewed HFEA 2008 and Equality act (Sexual Orientation) 2007 and overturned the decision
64
what organisation is responsible for regulating treatment and research of IVF
human fertilisation and embryology authority
human fertilisation and embryology act 1990
65
Other than homosexual couple, what other ethical issues are there relating to access to IVF.
- Whether single women are allowed to use IVF on the NHS
- Case: Elizabeth Pearce - miss pearce cited articles 8 and 14 of the european convention on human rights (rights to family and private life and prohibtion of discriminatiojn) - stated it is her right to be a mother doesnt matter she is single - allowed single women to access IVF
66
Name an ethical dilemma regarding IVF and Gametes.
If gametes are frozen then there is question as to how long they can be frozen and what happens in the scenario of death
or
is it okay to be a donor if they are donated? (they can in the UK - £750)
67
True or false. Surrogacy Agreements are legally enforceable.
False
They are not unlawful but they are not enforceable
68
Explain recent trends in the prevalence of vaginal births versus C-sections and relate these to the increasing professional dominance of obstetrics.
- Continuous increase in c-sections in last two decades
- Associated with increased institutionalised delivery (98% take place in hospital)
- C-section resulting from a domino-effect of medical interventions, these intervention are the results of dominant obstetric knowledge which produces a cascade of medical interventions (so obstetrician decides a woman should not stay in hospital long, this is probably due to targets and time constraints at hospital -> induce labor -> synthetic oxytocin -> epidural needed now because of pain -> this causes relaxation so more Synthetic oxytocin needed -> eventually leads to contractions that are too strong -> problems could occur to baby -> need a C-Section now! and saving the child is attributed to C-Section rather than the interventions)
- In addition to this dominance, the authrotative nature of obstetric knowledge means they direct birth and prefer to carry out c-section as they are quick and carry less responsibility as they can argue they done everything they can and women trust their advice and rely on it so go for c-section
69
Describe what is meant by authoritative knowledge.
Not the correct knowledge, nor exactly the knowledge of 'people in authoritative position' but it is the knowledge that carry's more weight and that is made to count in the particular setting in which it is used.
- usually made to count due to association structural superiority or its efficacy
70
The 'authority' of the knowledge is not forcefully given, but the authoritative status of the knowledge is 'negotiated' through specific interactions.
Name 4 factors that negotiate/lead to authoritative status (e.g. makes the knowledge of an obstetrician authoritative compared to patient). (Leads to vertically distributed knowledge)
1- technology : used to express power, expert status, and appreciated for their symbolic value as well as their use.
2- Medical staff as gatekeepers: only medical staff are sanctioned to interpret results
3- Staging a physician's performance: when an obstetrician walks in all attention is on them by the team and not on the woman
4- Participation structure:the room is set up, and everyone is set up in a way where obstetrician has eye contact with everyone in the room except the woman who is laying supine feeling marginalised.
71
Explain the difference between vertically and horizontally-distributed authoritative knowledge.
Vertical (Technologized america):
▪ In birth knowledge system is very vertical where the knowledge of the obstetrician is given more value than the rest
▪ Factors that play part*
- More instructions given to a woman
Horizontal: (Rural Yucatan, Mexico)
▪ Knowledge of birth, and knowledge gained from technology used, is continuously jointly produced and displayed for inspection by who ever is involved. This way the decisions of birth are made jointly, and in a collaborative manner with multiple inputs.
▪ No instructions are given to the woman, and she remains in control
▪ Mid-wife is trusted and valued as an observer and her reassurance is valued and found to be helpful
▪ Mid-wife knowledge is from experience and reputation in the community (So no all mid-wifes are valued the same)
▪ First birth is given more instructions.
72
Where was Ultrasound invented?
Glasgow
73
State whether the following imaging techniques have consequences during pregnancy:
1- X-ray
2- MRI
3- CTPA (important for women with risk of PE)
4- V/Q Scan (Also investigating PE)
1- Away from pelvis negligible harm, scan of uterus -> disputed increase in childhood cancer
2- No evidence of harm
3- Small (10%) increase in risk of breast cancer, lower risk of childhood cancer than V/Q scan
4- Higher childhood cancer risk but lower maternal breast cancer risk
(Up to the woman and the doctor to decide)
74
What is meant by the lower segment of the uterus?
Lower part of the uterus which develops from the upper part of the cervix (so not part of the uterus) this happens when the cervix dilates around 25 weeks into pregnancy (During labour the whole cervix becomes the lower segment of the uterus)
75
Through which part of the uterus are C-Sections done?
Lower Segment of The Uterus
76
When we are scanning the uterus with ultrasound, what are the things we are looking for?
- Uterine Anomalies (like double uterus)
- Uterine tumours (Fibroids)
- Check the cervix's length as it predicts onset of labor
- Check the uterine blood supply (If poor blood supply, then it can indicate increased chances of pre-eclampsia)
77
Name the imaging used to screen for pre-eclampsia.
Umbilical Artery Doppler
(Blood flows from placenta (oxygenated) --> umbilical vein --> liver --> upper IVC --> right atrium --> ductus venouses --> umbilical artery through placenta back to mother) - flow through umbilical artery during the systole of foetal heart results in big peaks, but even when the foetal heart is in diastole you can usually still observe the blood flow through the umbilical artery - if arteries/arterioles are damaged due to preeclampsia then the flow will be reduced.)
78
Describe what is meant by Absent End Diastolic Flow.
Blood flow through the umbilical artery during diastole of the fetal heart is absent due to damaged arteries/arterioles due to pre-eclampsia usually and observed on a umbilical artery doppler
(Reversed end diastolic flow when the damage is so severe that the blood flows back into the foetus)
79
What conditions are you looking for when using ultrasound to scan the placenta?
- Placenta Praevia - placenta inserts in the lower uterine segment
- Abnormal placentation (worst complication as it can cause death of both foetus and mother but very rare and requires c-section)
-
80
What is the difference between Major and minor placenta praevia?
Major - covers the internal cervical os (major can become minor later in pregnancy as the lower uterine segment develops)
Minor - doesn't cover the internal cervical OS AND SOMETIMES NORMAL BIRTH CAN OCCUR
81
What is vasa praevia?
the fetal blood veseels which join the ubillical cord with the placenta run near/across the internal cervical os (so they cover the opening where the baby meant to go through) so when the baby is delivery it causes rupture of the vessels which is disastrous
82
What is Placenta Accreta/Percerta?
trophoblasts invade through the endometrium and continues to grow into the myometrium (muscles) and sometimes grows into the bladder (this is more common as it associated with section and c-sections are more common)
Danger with this is that when the placenta is about to detach in stage 3 of labour, it will cause a post-partum haemorrhage (and premature birth could be a complication)
Placenta praveia and age are risk factors
Need C-section followed by hysterectomy
83
Discuss how ultrasound can be used in foetal imaging, including screening programs early on in the pregnancy.
By week 13:
1- Check if the fetus is alive or not (may not hear anything up to 7 weeks so imaging is good than listening)
2- working out baby location (is it intrauterine or ectopic)
3- Number of foetuses (if more than one do they have their own blood supply)
4- checking size of baby - working out the crown-rump size
5- structural abnormalites
84
Why is ultrasound more accurate at checking conception than using LMP?
Some women have longer periods and some have shorter (can have 5 weeks periods, while other have 3 weeks periods), so some will ovulate 1 weeks different to expected based on LMP
85
Discuss how ultrasound can be used in foetal imaging, including screening programs early on in the pregnancy.
1- A live or not - checking heart beat
2- Foetal anomaly screening (18-22weeks)
3- wellbeing (fluid volume around baby which is actually baby urine so if low volume --> baby not urinating --> dehydrated , you also check blood flow (if baby hypoxic or anaemic then blood flow is prioritised to the brain and there is increased blood flow through the middle cerebral artery which can be seen on scan)
4- Growth - abdominal and head circumference estimating the fetal weight
5- presentation (breech, transverse, cephalic)
5- Position of head in labour (e.g. occiput transverse so you know to use forceps)
86
List risk factors for conceiving a child with an NTD.
- partner has an NTD, previous pregnancy, or family history
- taking anti-epileptic medications
- Has coeliac disease, diabetes, other malabsorptive state sickle cell anaemia, thalassaemia
- Obesity (>30 BMI)
87
How much folic acid should a woman with normal risk of NTD take?
400 micrograms daily until 12th week
88
How much folic acid should a woman with high risk of NTD take?
5mg daily until 12th weeks of gestation
89
How much folic should a woman take who has sickle cell or thalassemia?
- 5mg
- daily
- through out pregnancy
90
Explain what happens to asthma treatment during pregnancy.
- No modification
- risk of uncontrolled outweighs any risk from medication
- Steroids used as normal
91
State the inheritance pattern of cystic fibrosis, and briefly describe the pathophysiology.
- Autosomal recessive disorder
- CFTR gene dysfunction regulates chloride channel
- requires counselling before conceiving and multidisciplinary management throughout
92
When can having epilepsy be dangerous during pregnancy?
- Status epilepticus (fits lasting more than 5 minutes or two or more seizures within 5 minutes without person returning to normal between them)
- baby can deal with short episodes of hypoxia but not long
93
Which epilepsy medications are safe, and which are a concern for its teratogenic effect?
Safe = lamotrigine and levetiracetam
Teratogenic = sodium valporate
94
What is the HbA1c target during pregnancy for a diabetic?
keep below 48 mmol/mol - prevent congenital malformation
95
What HbA1c level indicates that a woman should avoid pregnancy until better control is achieved?
above 86 mmol/mol
96
Which oral hypoglycaemic agent can be continued during pregnancy with insulin?
Metformin
97
What are the pregnancy risks which are associated with diabetes?
- miscarriage
- congenital malformation
- still birth
- Neonatal death
98
Which medications usually taken by someone with diabetes and blood pressure problems should be stopped?
ACEi
| ARBs
99
Describe management of Hypothyroidism during pregnancy.
- Increase thyroxine dose by 25mcg at +ve pregnancy test
| - Repeat TFTS every 12 weeks and postnatally 6-12 weeks TFT
100
Describe management of Hyperthyroidism during pregnancy.
- Grave's Disease
- Specialist review
- Anti-thyroid treatment
- Radioactive Iodine is contraindicated
101
Name risks associated with Hypertension during pregnancy.
- Pre-eclampsia
- Risk of placental abruption
- Neonatal morbidity and mortality
102
A women has a history of hypertension becomes pregnant. What should be done about medications?
1- Check if the woman is on ACEi or ARBs
2- if yes stop medications and use an alternative agent
3- Labetalol (first line)
103
List alternative antihypertensives used during pregnancy in place of ACEi/ARBs.
- Methyldopa (indirectly affects epinepherine reducing affects and acting on B2 receptors)
- BB (Labetalol, propranolol, metrprolol)
- Nifedipine
104
What are the target BP levels for uncomplicated hypertension during pregnancy.
140/90mm Hg
105
Describe steps that should be taken when a woman with Congenital Heart Disease is considering having a baby.
1- MDT
2- All women with congenital or acquired heart disease should discuss future pregnancies with cardiologist
3- Advise to continue contraception until decision is made
4- Risk of foetus having congenital heart disease is higher is the mother has it
5- Statins are contra-indicated in pregnancy and top them before conception
106
Describe overall management of diabetes if a woman is considering having a baby.
1- good glucose control prior to conception to reduce risks
2- structured educational programs should be offered where women have not previously attended one
3- advice on diet, exercise and weight loss
4- good glycemic control reduces but does not eliminate risks
107
Name three congenital heart defects
- ASD
- VSD
- PDA (Patent Ductus Arteriosus - ductus arteriosus fails to close after birth this is a duct between pulmonary artery and aorta pushing pressure back up the pulmonary artery)
108
What is Eisenmenger's Syndrome?
- A pulmonary obstructive vascular disease as a result of Long standing Congenital heart defect (ventricular septal defect, ASD, or PDA) causes a left to right shunt increasing the pressure within the lungs (Pulmonary Hypertension) eventually the shunt is reversed into cyanotic right to left
- High risk in pregnancy (risk of mortality, risk of clots, fainting spells)
- Cyanosis, clotting problems, iron deficiency anaemia, fatigue, dyspnea, chest pain and ejection murmur on auscultation
109
Why is pregnancy contraindicated/High risk for someone with Primary Pulmonary Hypertension.
- Normal Physiological changes during pregnancy = increased plasma volume and Cardiac Output
- Normally, systemic resistance is decreased
- In women with PPH there is no change in resistance of pulmonary arteries to accomodate increased CO -> RHF -> left shift decreases volume and filling ability of Left ventricle too -> worsen symptoms.
- High mortality rate and morbidity
110
Describe management of IBD during pregnancy.
- 5mg folic acid through out pregnancy
- Nutrition management
- Most medications can be continued throughout
- Immunomodulators infusions are stopped by 24 weeks
111
Describe management of SLE (connective tissue disease) during pregnancy.
- Flare-ups in pregnancy
| - Continue treatment in most cases
112
Rheumatoid Arthritis in pregnancy?
- Patients find improvement during pregnancy but many who have these remissions during pregnancy have postpartum exacerbations
- Disease modifying agents - chlorambucil, Gold salts are CI in pregnancy
113
Describe Antiphospholipid syndrome.
- Autoimmune disease which can cause clotting in the arteries due to the presence of antiphospholipid antibodies (aCL, LA) - unknown why exactly but could be triggered by infection in someone who is genetically predisposed
- Hx of thrombosis, recurrent pregnancy loss, presence of antiphospholipid antibodies
- Risk of pregnancy loss, thromboembolic disease and stroke
114
What do you treat Antiphospholipid syndrome with?
Aspirin
| LMWH
115
What condition is characterised by low maternal platelet count during pregnancy and requires regular monitoring of platelet count?
Autoimmune Thrombocytopenia
Risk of haemorrhage to the mother
116
Why are women more at risk of coagulation disorders during pregnancies?
Pregnancy is assocaited with changes in all aspects of the hemostatic mechanism - hypercoagulable state
117
What is the inheritance pattern of haemophilia?
What is haemophilia?
- X-Linked Recessive
- Deficiency in coagulation factor
- A = lack of factor VIII
- B = lack of factor IX
118
What is sickle cell disease?
Inherited abnormality of haemoglobin synthesis (produce haemoglobin S - this is what leads to the misshapen red blood cells) they produce both flawed and normal haemoglobin
119
What is a sickle cell crisis?
A sickle cell crisis is pain that can begin suddenly and last several hours to several days. It happens when sickled red blood cells block small blood vessels that carry blood to your bones. You might have pain in your back, knees, legs, arms, chest or stomach
120
What is Von Willebrand's disease?
Genetic disease where is defective/deficiency in VW factor (a glycoprotein) essential for normal platelet activity. You test the blood for this.
121
what are the risks associated with renal disease during pregnancy?
- Intrauterine growth restriction
- Prematurity
- deterioration in maternal renal function
122
Venous thromboembolism is a condition that needs to be treated/managed during pregnancy. Which common anticoagulants cannot be used for this?
- Warfarin
- Dabigatran
- Apixaban
- Rivaroxaban
123
Anti-depressants should be ideally stopped before pregnancy. However, if the risk of stopping is higher than the risk of continuing, then which class of antidepressants has no evidence of risk during pregnancy?
- Tricyclic Antidepressants
| However no recommendation exists by NICE, for example, that this should be use or any others as a matter of fact
124
Which antidepressants are associated with (particularly cardiac) malformations?
SSRI's but they are still generally safe to use during pregnancy
125
Name the bipolar medication that should be changed during pregnancy.
Lithium
126
Which medication class used as a painkiller/anti-inflammatory can lead to the premature closure of the ductus arteriosus (allows the most of the blood from the right ventricle to bypass fluid-filled non-functioning lungs) during first trimester?
- NSAID's
127
What is the Haemoglobin level cut off during 1st and 2nd trimester of pregnancy?
minimum 110g/dl
128
What is the haemoglobin level cut off during 3rd trimester to exclude anaemia?
105g/dl
129
List three symptoms of anaemia.
- Feeling tired and exhausted
- Breathlessness
- Palpitations
130
List investigations for anaemia.
- FBC
- Ferritin
- Folic Acid
- Vit B12
131
How do you treat anaemia in pregnancy?
oral/injectable iron/folic acid/B12
132
Why does urinary stasis occurs during pregnancy?
- bladder volume increases and detrusor tone decreases
- 90% develop ureteric dilation as the result of a combination of progesteronic relaxation of smooth muscle and pressure from expandind uterus
133
The physiological changes during pregnancy lead to which condition that facilitates bacterial colonisation?
Urinary stasis, compromised ureteric valves, and vesicoureteric reflux (valves will be relaxed and open from progesteronic effects and then urine will flow back up the ureters)
134
UTI's are very common during pregnancy. Which microorganism is responsible for 80-90% of infections?
Escherichia Coli
135
How do you test for UTI?
Mid-Stream Sample (culture and sensitivity) at booking
136
Why should you do a urine test to check for UTI if no symptoms?
You can have Asymptomatic Bacteriuria which has complications
137
A) List complications associated with Asymptomatic Bacteriuria.
B) How do you treat it?
C) Diagnosis?
- Preterm delivery and low birth weight
- Increased risk of preeclampsia
- Anaemia
- Chorioamnionitis
B)
- antibiotics for 7 days
C)
- Mid-Stream Urine Sample (positive culture of bacteria)
- No symptoms of UTI
138
List all the early and late complications in pregnancy that you can think of.
EARLY:
- Anaemia
- UTI symptomatic/and Asymptomatic Bacteriuria
- Acute cystities
- Pyelonephritis
- Recurrent UTI
- Hyperemesis Gravidarum
- Bleeding in Earyl pregnancy
- Miscarriage
- Rhesus Disease
- Ectopic pregnancy
- Hydatiform mole
LATE:
- Antepartum haemorrhage
- Placenta Praevia
- Placenta Abruption
- Preterm Labour
- Intra uterine growth retardation
- Obstetric Choestasis
- Pre-eclampsia and Eclampsia
139
List symptoms for Acute Cystities.
- Dysuria
- Frequency and urgency
- suprapubic pain in the absence of systemic illness
Tx = hydration and Antibiotics
140
List symptoms and treatment of pyelonephritis.
- 90% occurs in the last two trimester
- Sepsis (tachycardia, tachypnoea, pyrexia), loin pain, urinary symptoms (Dysuria, frequency and urgency, cloudy, smelly)
Ix = MSU, USS of renal tract, FBC, Renal Function tests, blood culture, CRP
Tx = Antibiotics for 10-14 days
141
A) Define Hyperemesis Gravidarum.
B) How does it differ form morning sickness
C) List Risk factors
D) Describe management
A) extreme, persistent nausea and vomiting during pregnancy (can cause weight loss of more than 5% of body weight)
B) Morning sickness is a mild nausea and vomiting during early pregnancy (common during first three months)
C) Twins, molar pregnancies, history of hyperemesis in previous pregnancies or motion sickness
D) Hydration, antiemetics, multivitamin supplements, in severe cases steroids
142
List causes of bleeding in early pregnancy.
- Implantation bleeding (physiological)
- Miscarriage
- Ectopic Pregnancy
- Cervical causes - Ectropion/Polyp, rarely cancer
- Molar pregnancy
143
A) Define a miscarriage.
B) Describe its symptoms and signs.
C) list causes
A) Loss of pregnancy during first 22 weeks
B) Vaginal bleeding, cramping and pain in the lower abdomen
C) unknown, chromosomal, placental problems, uterine anomalies, cervical incompetence, autoimmune conditions
144
List different types of miscarriages.
- Threatened miscarriage = bleeding but pregnancy remains viable
- Missed miscarriage = nonviable pregnancy where baby has died but not physically miscarried (but the placenta and embryonic tissue still in the uterus)
- Incomplete miscarriage = products of conception partly expelled
- Complete miscarriage = products of conception completely expelled
- Recurrent miscarriage = 3 or more consecutive miscarriages
145
List potential causes of a miscarriage.
- Smoking
- Drinking Alcohol
- Drugs
- Health conditions like diabetes, high blood pressure if not well controlled or treated
146
Describe the management of a miscarriage.
- Medical = Mifepristone (stops progesterone leading to the shedding of lining and also causes contractions ) and misopristol (prostaglandin analogue - binds to myometrial cells to cause strong myometrial contractions)
- Surgical = evacuation of the uterus by suction evacuation or curettage (removal of tissue from the wall of a cavity)
147
What should you give women with Rhesus Negative blood group?
- Anti-D Prophylaxis at around 28 wks of gestation
| - 500IU
148
What are the criteria for a woman who is Rh -ve to get Anti-D Immunoglobulin before 12 weeks?
- Ectopic pregnancy
- Molar Pregnancy
- Therapeutic termination of pregnancy
- Cases of heavy uterine bleeding with abdominal pain
you give 250IU
149
Sensitising events between 12-20 weeks of gestation require how much Anti-D immunoglobulin and when?
250IU
within 72 hours of the event
150
When would you give 500UI of Anti-D?
If there is a sensitising event after 20 weeks of gestation
Given within 72 hours of the event
151
What is meant by an ectopic pregnancy?
When the fertilised egg implants outside the uterus (usually in the fallopian tube)
152
Describe the symptoms/signs of ectopic pregnancy.
- Positive pregnancy test or other signs of pregnancy
- Lower abdominal pain (more on one side)
- Vaginal bleeding or a brown watery discharge
- Shoulder tip pain
- Discomfort while micturating or opening bowels
153
Describe the management of ectopic pregnancy.
- Medical = methotrexate (immunosuppressant - anti-metabolie)
- Surgical = salpingectomy (removal of one or both fallopian tubes)
154
What is a Hydatiform mole?
Growth of an abnormal fertilised egg or overgrowth of abnormal tissue from placenta. (Grape Clusters) - it can be partial with some fetal parts recognisable and abnormal placenta, or complete where there is no recognisable parts and abnormal placenta
155
Describe the symptoms of Hydatiform.
- Bleeding in early pregnancy
- can be profuse accompanied with expulsion of grape like tissues
- Pregnancy symptoms like nausea and vomiting can be occasionally profound
156
Describe the diagnosis of a Hydatiform mole.
- USS
- High levels of Beta-hcg
- Confirmed on histology
157
Discuss management of Mole pregnancy.
- Surgical evacuation
- Notify molar pregnancy register
- Follow-up until B-hCG is negative
158
List causes of abdominal pain.
- Heart burn
- Constipation
- Muscular
- Appendicitis
- Cholecystitis
- Renal Colic
- IBS
- Ovarian Cyst accidents
159
Define antepartum haemorrhage.
Bleeding from genital tract after 22nd weeks of gestation
160
List causes of antepartum haemorrhage.
- Placenta abruption
- Placenta previa
- Vasa previa
- Cervicitis
- Trauma
- Genital tumors and infection
161
How do you manage an antepartum haemorrhage?
- Depends on the cause and severity
- Admit to hospital
- Cannula and bloods taken (FBC, G and S, U and E's, Coagulation profile)
- Resuscitation (IV Fluids, blood transfusion)
- Ultrasound
- Women with Rh -VE need anti D immunoglobulin and Keilhauer test (to check the amount of haemoglobin that transfered from foetus to the mother's blood stream)
162
What are the grades of placenta Praevia?
1-4
4 = placenta completely inserted covering the internal os completely
163
List risk factors for Placenta Praevia.
- Previous C-section
- Previous Abortion
- Age >35
- Smoking
- Having multiple placentas
164
What is placenta abruption?
Bleeding following premature separation of normally situated placenta
165
List causes of placental abruption.
- Usually unknown
- trauma
- Polyhydramnios
- Hypertension
(clinical presentation, exam, and USS for diagnosis)
166
A) Define pre-term labour.
B) List risk factors.
C) Diagnosis?
A) Onset of labour before 37 weeks of gestation
B) Multiple pregnancies, history of preterm labour, polyhydramnios
C) Clinical grounds, and fetal fibronectin test (between 22-35 weeks, predicts the likelihood of a preterm labour in people who have preterm labour symptoms) and USS
167
What are causes of polyhydramnios?
- Baby not swallowing enough which means they could have duodenal atresia or oespphageal fistula
- or they are urinating too much which could be due to mother having diabetes and baby being hyperglycaemic
168
How do you manage preterm labour?
- Tocolysis - this is used to slow down labour so you can give steroids to protect lung maturity or time to transfer the woman to another unit
- Steroids for fetal lung maturation (Dexamethasone)
- Magnesium Sulphate - for neuro protection
169
What is Preterm Pre-labour rupture of membranes? (PPROM)
Spontaneous rupture of membranes before 37 weeks of gestation in the absence of regular painful uterine contractions
170
What are the risk groups for PPROM?
- Polyhydramnios
- Previous history of PROM
- Uterine anomalies
- Infections
171
Describe the management of PPROM.
- Tocolysis (Sub-cut terbutaline and salbutamol IV are examples of these drugs which prevent contractions of uterus)
- Antibiotics
- Steroids
- Delivery
(Diagnosis = examination, swabs, USS)
172
Define Intra uterine growth retardation.
- Failure of foetus to achieve the expected weight for a given gestational age
- Chromosomal, uteroplacental, environmental
(Small for gestational age (SGA) refers to foetus estimated birth weight (EFW) on USS is below 10th centile for given population)
173
A) Diagnosis of IUGR?
B) Management of IUGR?
A)
- Regular SFH
- Use of customised growth charts
- USS
B)
- Careful monitoring and appropriate intervention
174
Define Obstetric Choestasis.
- Multifactorial condition of pregnancy
- Characterised by pruritus in the absence of a skin rash with abnormal liver function tests (LFT's)
- Neither of which has an alternative cause
- both resolve after birth
175
How do you diagnose Obstetric Choestasis?
- Unexplained pruritus (Pruritus that involves the palms and soles of the feet is particularly suggestive)
- Abnormal LFT's
- Both resolve after pregnancy!!
176
What are risks associated with Obstetric Choestasis?
- Meconium passage
- Delivery by C-Section
- small risk of stillbirth
- Premature birth (Iatrogenic)
177
Treatment of Obstetric Choestasis?
- Symptomatic
178
Define Pre-eclampsia.
Condition that is a - combination of raised blood pressure (hypertension) and protein in your urine (proteinuria)
- Typically after 20 weeks of gestation
179
List symptoms of pre-eclampsia
- Can be asymptomatic
- Headaches
- Visual Disturbance
- Pain in the right hypochondriac region
- Oedema
180
List risk factors for Pre-eclampsia.
- Diabetes
- Hypertension
- Kidney disease
- Lupus
- Antiphospholipid syndrome
- Age >40
- High BMI
181
A) Describe investigations of Pre-eclampsia.
| B) Describe the management of Pre-eclampsia.
A) FBC, U&E's, Uric Acid, Coagulation profile
B)
- Regular BP monitoring, antihypertensives
- Fetal growth monitoring
- Delivery
182
List complications of pre-eclampsia.
- Eclampsia (life threatening seizures of coma - treat with magnesium sulphate)
- Intracranial haemorrhage
- Pulmonary Oedema
- HELLP Syndrome
- Placental Abruption
- Still birth
- IUGR
