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Med 3 > Menstrual Disorders And Early Pregnancy Problems > Flashcards

Menstrual Disorders And Early Pregnancy Problems Flashcards

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1
Q

Sympathetic division of nervous system

A

Function is to prepare the body for an emergency

  • increase heart rate
  • redistribution of blood
    Arterioles of skin and intestine are constricted
    Arteriole of skeletal muscle dilated
  • increase BP

Consists of efferent outflow from the SC, sympathetic trunk, branches, plexuses and ganglia

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2
Q

Sympathetic chain

A

2 ganglionic nerve trunks that extend the while length of the vertebral column

Neck - 3 ganglia
Thorax - 11/12
Abdomen - 4/5
Pelvis - 4/5

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3
Q

Splanchic nerves

A

Lower thoracic
Greater - T5-T9 (T10)
Lesser - T10-T11
Least - T12

Origin: thoracic sympathetic trunk

Target: abdominal
Prevertebral
Ganglia
Preganglionic fibres

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4
Q

Parasympathetic division

A

Function is to conserve and restore energy

  • decrease heart rate
  • peristalsis and glandular activity increased
  • sphincters are opened
  • bladder wall is contracted
  • pupils are constricted
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5
Q

Functions of autonomic nervous system in digestion

A

Sympathetic: inhibits peristalsis, constricts blood vessels to react so blood available for skeletal muscles, contracts internal anal sphincter

Parasympathetic:: stimulates peristalsis and secretions of digestive juices, contracts rectum, inhibits internal anal sphincter

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6
Q

Functions of autonomic nervous system in urinary

A

Sympathetic: Vasoconstriction of renal vessels, contraction of internal sphincter of bladder

Parasympathetic: inhibits contraction of bladder internal sphincter, contract detrusor muscle of bladder wall (urination)

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7
Q

Functions of autonomic nervous system (genital)

A

Sympathetic: ejaculation and vasoconstriction leading to remission of erection

Parasympathetic: erection of erectile tissue of external genitals

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8
Q

What is the enteric nervous system

A

Two important plexuses of nerve cells and fibres extend along / around GI tract

Meissner plexus (submucosal plexus) - controls glandular secretion of mucosa

Auerbach plexus (myenteric plexus) - controls peristalsis

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9
Q

Function of enteric nervous system

A

Second brain
Contains a variety of functional types of neurones and a plethora of neurotransmitters

Controls motility and secretory functions

Complete reflex circuit
- afferent sensory neurones, interneurones and efferent secretomotor neurones

Functions autonomously but modified by sympathetic and parasympathetic nervous systems

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10
Q

Pathology of the enteric nervous system

A

Hirschsprung’s disease

  • congenital birth defect
  • enteric neurones absent from variable lengths of the distal gut

Symptoms: intestinal obstruction or severe constipation

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11
Q

Key events in first trimester

A

Embryo 0.5-24g, placenta 5-80g
Formation of chorionic villi
Development of maternal circulation
Development of fetal circulation

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12
Q

Key events of 2nd trimester

A 
Gets 11-800g
Placenta 28-300g 
Arborization of chorionic villi 
Fetal vessels identity and maturation 
Regulation of blood flow (no nervous system, no lymphatic system) 
Formation of cotyledons
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13
Q

Key events of 3rd trimester

A

Foetus 1000-3000g (larger increase in growth due to fat deposition)
Placenta 500-700g
Angiogenesis: formation of terminal villi and terminal capillaries

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14
Q

Nutritional function of placenta

A

Allows essential nutrients to get across from mum to baby (waste back)

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15
Q

Respiratory function of placenta

A

Allows oxygen to get across and carbon dioxide to return (so acts as lung oxygen gradient)

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16
Q

Barrier function of placenta

A

Main barrier between mother and embryo / fetus (protects from maternal immune system, maternal infection, discriminates solute transport, phagocytosis of unwanted material)

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17
Q

Endocrine function of placenta

A

Produces hormones- progesterone, prolactin etc to influence maternal physiology; for efficient placental function

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18
Q

Alteration in placental fetal vessel identity and endothelial junctional maturity

A

1) artery- vein specification (flow mediated)
2) smooth muscle and pericyte wrapping of endothelial cells
3) maturation of junctions at endothelial - endothelial contacts - tight junctions and adherens junctions

Result: mature blood vessels that are not leaky

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19
Q

Function of terminal villous capillaries

A

Bringing fetal blood close to maternal blood without intermingling

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20
Q

Features of terminal villous capillaries

A

Dilated lumen (more blood flowing through at slower rate; fetal flow = 5ml/min; maternal flow = 20ml/min)

Abutting of endothelium (e) with syncitium (syn) and creating thin exchange area to minimise diffusion distance

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21
Q

Umbilical blood supply

A

Umbilical arteries: takes de oxygenated blood from fetus to placenta

Umbilical vein takes oxygenated blood back to fetus

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22
Q

Maternal fetal transport

A

Simple diffusion: blood glasses, sodium, water, electrolytes, urea, fatty acids, non conjugated steroids and bilirubin

Active transport: hexose sugars, amino acids, water, soluble vitamins, nucleotides, cholesterol, calcium, glucose (fetus has little capacity of gluconeogenesis)

Receptor mediated endocytosis and transcytosis: eg maternal IgG; iron concentration 2-3 times more than in maternal blood

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23
Q

Obstetric problems of umbilical cord

A

Coiling around the fetus
True knots - stops fetal circulation
1 artery - cardiovascular malformations

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24
Q

Mechanisms for efficient materno fetal transport in placenta

A

Branching of chorionic villi and extensive vascular network

1) increase in SA of exchange
- microvilli on syncytiotrophoblast (ST)
- expression of receptors and transporters
- endocytosis: clathrin coated pits and vesicle, endosomes, lysosomes
- synthesis and storage in ST: increased ER

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25
How is diffusion distance decreased in placenta
Extrusion of the excess accumulated nuclei in the syncytiotrophoblast - aggregation and pinching off nuclei within syncytial knots into the maternal circulation - these syncytial debris is phagocytoses by maternal immune cells
26
Barrier formation process
Possession of a syncytial layer (no cell - cell borders of inter cellular spaces; has to go through the syncytium) A continuous endothelium (no fenestra) with restrictive inter cellular tight and adherens junctions ie most nutrients have to go through endothelial cells Endothelial inter cellular junctions are size and charge selective to hydrophilic solutes Presence of macrophages in stromal core of villi Placenta is freely permeable to alcohol and drugs Barrier to most viruses except toxoplasmosis, cytomegalovirus, herpes, rubella, HIV Maternal smoking causes hypoxia and heavy metal poisoning
27
Volume of amniotic fluid
8 weeks: 15ml | 20 weeks: 450ml
28
What is oligohydraminos
Insufficient amniotic fluid (renal agenesis) fetal kidney is principal source of amniotic fluid
29
What is polyhydramnios
Excessive fluid (no swallowing, oesophageal atresia)
30
What is pre eclampsia
Mother presents with high BP and protenuria Reduced invasion of spiral arteries so reduced maternal blood flow to placenta, hypoxia
31
Way to determine a pregnancy is ectopic
If the HCG levels don’t double
32
Development of blastocyst
1) trophoectoderm (will form placenta) - a layer of trophoblast cells 2) inner cell mass (will form embryo) 3) blastocoel cavity
33
What are the 3 phases of implantation
Attachment (apposition), adherence (stable adhesion) and invasion
34
What does high oestrogen and progesterone in the luteal phase cause
The epithelial cells lining the endometrium of the uterus: - lose surface glycocalyx - lose anionic charges - flatten their microvilli - have a thin mucin coat This is called primary decidualisation (occurs at luteal stage of every cycle)
35
Decidualisation of the endometrium
Secondary decidualisation spreads to create 3 decidual layers Decidua basalis: endometrium underlying the conceptus. This shows the highest changes as this is where the conceptus needs to burrow into. This is also called the basal plate of the placenta Decidua capsularis: superficial portion overlying the conceptus Decidua parietalis : remaining uterine mucosa
36
Function of female reproductive system
Produces haploid female gametes Receives haploid male gametes prior to fertilisation Provides environment for fertilisation Accommodates and nourishes the embryo and fetus during pregnancy Expels the mature fetus at the end of pregnancy Protects against pathogens Production of steroid hormones
37
Histology of clitoris
2 corpora cavernosa erectile vascular tissue Corpora cavernosa can be engorged with blood upon arousal the equivalent of the male penis
38
Structure of vagina
Fibromuscular tube 7-9cm Capable of marked distension and elongation >90 degree angle with normal anteverted uterus At inner end, vaginal tube forms a cuff around protruding cervix of uterus creating anterior, posterior, lateral cornices At outer end it opens into vestibule
39
Histology of vagina
1) epithelial mucosa - non keratinised stratified squamous epithelia 2) lamina propria 3) sub mucosa highly vascularised, has elastic fibres - allows distension 4) adventitia elastic fibres and irregular smooth muscle
40
Epithelial mucosal layer of vagina
Non keratinised stratified layer of squamous epithelial cells Glycogen rich (involved in maintenance of pH) Under influence of oestrogen Before puberty and after menopause this layer is thin At ovulation there is increased glycogen production by vaginal epithelium Breakdown of glycogen by commensal lactobacilli leads to production of lactic acid and a pH of 5.7-3.0 PH restricts vaginal flora to acid loving bacteria nad deters pathogens such as Candida albicans (thrush)
41
Describe the cervix
Cylindrical tube 3-4cm long and 2.5cm wide partly protruding into vagina Ectocervix: portion projecting into vagina (lower pH) Endocervix: passageway between the eternal OS and uterine cavity (neutral pH) terminates at internal OS Can distend to 10cm diameter during childbirth
42
Histology of endocervix
Single layer of tall columnar mucus secreting epithelial cells Basal layer of reserve cells Stroma composed of a matrix of fibre muscular tissue, elastin and collagen fibres Important for cervical distension during childbirth due to softening of stroma- hydration of matrix; alterations in collagen and elastin fibres There is a rapid reversal to normal dimensions after childbirth
43
Function of mucin produced by endocervix
Lubrication during sex Protection against bacterial ascent into uterus Allows ascent of sperm into uterus at correct time
44
Consequences of squamous metaplasia
Blocking of endocervical glands - mucus filled nabothian cysts / follicles Development of abnormal epithelium - lose regular stratified pattern, high nucleus to cytoplasm ratio, increased mitotic activity Progression to cancer: these cells can breach the basement membrane and invade cervical stoma
45
Where are cervical smears taken
At transformation zones to ensure early diagnosis of cancer if present. NHS cervical screening age 24-64 every 3 years HPV testing occurs with cervical screening
46
What is HPV
Infection with HPV is a major causative agent for cervical cancer Of 100 types, 40 are transmitted by sexual contact Low risk types 6, 11 can cause genital warts but not cervical cancer Types 16-18 are high risk that cause cervical cancer
47
What is uterus wall composed of
External serosa covered with peritoneum of the pelvic cavity, the perimetrium
48
What is the endometrium
Internal mucosa lawyer which lines the entire uterus and is under influence of the menstrual cycle. Fertilised egg will implant in the endometrium of the uterus
49
What does oestrogen stimulate
Mitotic activity in glands, proliferation of stromal cells Increases thickness of endometrium Increased length of spiral arteries
50
What happens if pregnancy does not occur
Degeneration of corpus luteum that leads to cessation of progesterone and oestrogen. This results in - involution of functional layer of endometrium - rise in endothelin and thromboxane - vasoconstriction of spiral arteries, cessation of blood flow and ischaemia of functional endometrium - rupture of arteries and shedding of blood into uterus
51
Describe the uterine tubes
10-12cm long Open at infundibulum which is surrounded by fimbrae, finger like projections into the peritoneal cavity. Released ovum from ovary is wafted into and lodges at the ampulla region of the tube Sperm swims up to and stays at the isthmus (neck of tube) until ovulation draws near, they then travel to the ampulla where fertilisation occurs
52
Histology of ampulla
2 layers of smooth muscle in the wall of the tube: the inner being a tight spiral the outer a loose spiral which makes them appear circular and longitudinal respectively
53
Histology of isthmus
Mucosa consists of longitudinal folds lined with ciliated and non ciliated columnar epithelium Muscularis consists of a circular and a longitudinal layer
54
What occurs at the isthmus
Capacitation of sperm (where sperm is resting so not really doing anything) Sperm movement alters here once ovulation draws near and sperm can swim to ampulla.
55
Role of ciliated and non ciliated cells in epithelial mucosa of uterine tube
Epithelial mucosa do the entire uterine tube has ciliated and non ciliated cells. Cells are more numerous near ovarian end - cilia beat towards the uterus, creating flow in that direction (this is where you want implantation to occur) - ciliary height is cycle dependent; highest at time of ovulation, the subsequent decrease in length is progesterone mediated - non ciliated cells secrete mucus to aid motion of cells
56
Make up of tubal fluid
Watery fluid rich in potassium and chloride ions, immunoglobulins, serum proteins Provides nutrients to egg during its migration
57
Disorders of uterine tube
Tubal ectopic pregnancy (implantation of fertilised ovum) Acute and chronic Salpingitis (bacterial infection, acute inflammation, pus formation, abscess, scarring, blocked tube)
58
Define fertilisation.
Sequence of co-ordinated events that begins with contact between a sperm and an oocyte and ends with intermingling of maternal and paternal chromosomes
59
Site of fertilisation
Ovulated oocyte enters Fallopian tube and waits in the ampulla where fertilisation usually occurs
60
Roles of differnt parts of ovulated oocyte
Granulosa cells suspended in hyaluron rich matrix produces progesterone and chemo attractants (aromatic aldehydes) Secondary oocyte continues to obtain nutrients from the cytoplasm, the first polar body Zona pellucida remains as a protective shell
61
Features of spermatozoa
Acrosome: contains the enzyme acrosin Haploid nucleus Mid piece: mitochondria (powerhouse) Plasma membrane of sperm head: odorant receptors (similar to olfactory receptors) that can react to the chemo attractants from oocyte 3 surface binding molecules- ADAM family: fertilin a, B and cyritestin ADAM: a disintegrin and metalloprotinease membrane
62
Spermatozooal movement from vagina to oviduct
Spermatozoa has to undergo capacitation in female tract Starts in vaginal environment when it is oestrogen primed, pH <5.7 Full capacity is reached by the time the spermatozoa travels through the isthmus to the ampulla region of the oviduct
63
What is capacitation
Release of chemo attractants by the oocyte, now in ampulla is received by the odorant receptors on sperm Changes in movement characteristics to hyper activated motility pattern: regular wave like changes to wide amplitude whiplash beats needed to swim upstream from isthmus to ampulla
64
1st step of fertilisation (penetration of corona radiata)
Secretion of hyaluronidase Digestion of extra cellular matrix Active movement to reach zona pellucida
65
2nd stage of fertilisation (penetration of zona pellucida)
4 sulphated glycoproteins in humans. 3rd one has the dominant binding role but only if its in conjunction with 2nd (ZP2). The ZP2/3 three dimensional framework is species specific and blocks cross species fertilisation
66
Process of attachment to zona pellucida
The receptors for ZP proteins (ZP2R and ZP3R) are present on different membrane components for the spermatozoa The receptor fro ZP3, ZP3R is on the surface of the sperm head The receptor for ZP2, ZP2R is on the inner acrosomal membrane
67
Step 3 of fertilisation (the acrosome reaction)
Binding of ZP3 to its receptor on sperm head plasma membrane leads to: - calcium influx which causes depolymerisation of the F actin present between the acrosome and sperm head plasma membrane Obstruction gone: acrosome has room to expand and does so Increased calcium also leads to increased cAMP and increase in pH from 7.1-7.5
68
Steps of gamete fusion
1) after penetration of zona pellucida, spermatozoon lies tangential to oocyte surface. Oocyte microvilli envelop sperm head 2) sperm oocyte binding (binding involved adhesion molecules) 3) specific areas on egg surface are rich in integrins to allow binding in correct areas 4) spermatozoon sinks into oocyte - a zygote formed
69
Post fusion events
1) at fertilisation, oocyte is still arrested in second meiotic metaphase (M phase) 2) a rise in Ca++ after fusion leads to exit from M phase 3) one set of chromosomes is dispatched as the 2nd polar Body 4) the other half set of 23 unpaired chromosomes remain behind in the female pro nucleus and can unite with the 23 paternal chromosomes of the penetrating sperm Gynogenic triploidy is avoided by dispatching the second polar body
70
Avoidance of triploidy
If the exiting second polar body encounters the entering spermatozoon there can be mutual interference and all 3 haploid sets of chromosomes remain inside. This triploidy results in fetal death To avoid this: Spermatozoa do not bind to oocyte membrane immediately overlying the second metaphase spindle This ensures avoidance of encounter between the exiting second polar body and the entering sperm
71
Prevention of polyspermy
``` 1) changes in electrical activity or membrane potential of zygote leads to a Ca++ wave from point of sperm entry. Ca++ released from internal stores (lasts 2-3 mins) Ca spikes (1-2 min duration, every 15 min) ``` Leads to cortisol reaction - release of cortisol granules into perivitelline space - enzyme cleaves ZP2 and hydrolyses binding region of ZP3 ZP2 and 3 no longer available for further sperm binding
72
What is aneuploidy
An abnormality in number of chromosomes by loss of duplication Loss: lethal Extra: trisomy Trisomy 21 = Down’s syndrome
73
What is parental imprinting
Packaging of chromosomes in egg or sperm can influence the organisation of genes and their ability to become transcriptionally active. This epigenetic imprinting is important Genes affected in spermatogenic lineage may differ from oogenetic lineage To be fully functional some genes require both parental imprints
74
Function of cervix
Fibrous ring that holds the baby in during the pregnancy
75
Mechanism of cervical dilation
``` Upper segment (smooth muscle) contracts Lower segment (collagen) passively dilates ```
76
Mechanisms of labour
``` Flexion Descent in the transverse position Internal rotation (shoulders enter inlet) Delivery by extension External rotation / restitution (shoulders enter outlet) Anterior shoulder Posterior shoulder Body delivers like a fish ```
77
Influence of pregnancy hormones on maternal physiology and anatomy
Progesterone (corpus luteum and then placenta) 200mg / day by late pregnancy Oestrogen : cooperation of placenta + fetus
78
What are the pregnancy hormones
Placental prolactin : for breast changes and behavioural changes Placental lactogens for maternal insulin and glucose metabolism, lipolysis and erythropioesis Corticotropin releasing hormone from placenta leads to increased secretion of cortisol in mother. Stress response Aldosterone (plasma volume) Erythropoietin (red blood cells)
79
What is aortocaval compression
From mid pregnancy the enlarging uterus compresses both the inferior vena cava and the abdominal aorta when the patient lies supine Compression of inferior vena cava: reduces venous return to the heart, resultant fall in BP may be severe enough for mother to lose consciousness Compression of the aorta: reduction in uteroplacental and renal blood flow During last trimester maternal kidney function is lower in supine than lateral position No women should lie supine in late pregnancy
80
Anatomical changes to kidneys
Enlarge due to increased vasculature Renal parenchymal volume increase in pregnancy, glomerular diameters are greater There is dilatation of the calyces, renal pelvic and ureter (caused by progesterone and local pressure effect) increases chances of urinary tract infection Bladder loses tone: increased urinary frequency
81
Changes in handling of glucose in pregnancy
Amount of glucose in urine = amount of glucose filtered through the glomerulus minus the amount re absorbed by the proximal tubule In non pregnancy: glucose can move freely across glomerular filter. Is reabsorbed leading to almost glucose free urine In pregnancy: filtration fraction declines but increased renal flow means at any one time there is mroe glucose in the filtrate. The filtered load of glucose rises in pregnancy and exceeds maximal rate of reabsorption so urine is not glucose free
82
Risk for pregnant women of having excess glucose in the urine
Increases chances of UTIs
83
Maternal glucose homeostasis
Fetus has little capacity for glucoenogenesis, gets all glucose from mother Glucose readily crosses placenta This + increased glucose excretion should create a glucose deficit in mother.
84
How do glucose levels revert from normal to mid pregnancy
Progesterone increases maternal appetite and stimulates deposition of glucose in fat stores. There is increased insulin secretion which favours lipogenesis Mid pregnancy onwards: - increased absorption of glucose from gut - increased maternal gluconeogenesis - mobilisation of free fatty acids and lipolysis - enhanced lipolysis
85
How does fetus avoid maternal rejection
Placenta is a structural barrier stopping direct contact of maternal blood with the fetus Fetus has major histocompatibility antigens, but placenta, specifically the surface of the syncytiotrophoblast does not so acts as immunological barrier
86
What is the next step if a smear test sample tests positive for high risk human papillomavirus
Examine the sample cytologically | To look for any signs of dyskaryosis (cells with abnormal nuclear changes)
87
Why does GFR increase in pregnancy by 30-60%
Hormonal changes during pregnancy cause increased blood flow to the kidneys and altered autoregulation, causing GFR to increase through reductions in net glomerular oncotic pressure and increased renal size
88
What is a common risk factor for ectopic pregnancy
Pelvic inflammatory disease due to damage of the tubes Previous ectopic pregnancy Endometriosis IUD IVF
89
What is a threatened miscarriage
The fetus is alive but bleeding has occurred | Uterus is the size expected from the dates given and the cervical os is closed only 25% of cases will go on to miscarry
90
Why does multiple gestation lead to hyperemesis gravidarum
``` Intractable vomiting Dehydration Weight loss Ketonuria Multiple gestations cause increased levels of BhCG, this leads to hormone imbalances which increase vomitting ```

Med 3 (10 decks)

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