Miscellaneous Flashcards
(164 cards)
1
Q
What are the different types of assisted conception?
A
IUI - Intrauterine insemination
IVF - In vitro fertilisation
ICSI - Intracytoplasmic sperm injection
Donated sperm
Donated eggs or embryos
Surrogacy
2
Q
In people with mild infertility, mild endometriosis or unexplained infertility how long until they are offered assissted conception?
A
2 years
3
Q
What are the basic investigations for when a couple can’t concieve?
A
Semen analysis
Serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
4
Q
What are the causes for infetility?
A
male factor 30%
unexplained 20%
ovulation failure 20%
tubal damage 15%
other causes 15%
5
Q
What do the different levels of progesterone mean?
A
< 16 nmol/l
Repeat, if consistently low refer to specialist
16 - 30 nmol/l
Repeat
> 30 nmol/l
Indicates ovulation
6
Q
What is intrauterine insemination (IUI)?
A
Intrauterine insemination (IUI) is a fertility treatment where sperm are placed directly into a woman’s uterus.
7
Q
When is IUI used?
A
- unexplained infertility
- mild endometriosis
- issues with the cervix or cervical mucus
- low sperm count
- decreased sperm motility
- issues with ejaculation or erection
- same-sex couples wishing to conceive
- a single woman wishing to conceive
- a couple wanting to avoid passing on a genetic defect from the male partner to the child
8
Q
How does IUI work?
What medications can be used to stimulate the release of an egg?
A
IUI is a relatively painless and noninvasive procedure. IUI is sometimes done in what is called the “natural cycle,” which means no medications are given. A woman ovulates naturally and has the sperm placed at a doctor’s office around the time of ovulation.
Medications such as clomiphene citrate (Clomid), hCG (human Chorionic Gonadotropin), and FSH (follicle stimulating hormone) may be used to prompt the ovaries to mature and release an egg or multiple eggs.
9
Q
What factors affect the success rate of IUI?
A
age
underlying infertility diagnosis
whether fertility drugs are used
other underlying fertility concerns
10
Q
What are the risks with IUI?
A
Small risk of infection
Possibility of overstimulation of the eggs
11
Q
What is in vitro fertilisation?
A
IVF is the process by which eggs are removed from your ovaries and mixed with sperm in a laboratory culture dish. Fertilisation takes place in this dish, “in vitro”, which means “in glass”.
12
Q
Who will benefit from IVF?
A
IVF is likely to be recommended for the following fertility problems:
- If you have blocked or damaged fallopian tubes
- If your partner has a minor problem with his sperm. Major problems are better treated using ICSI.
- If you have tried fertility drugs, such as clomifene, or another fertility treatment such as IUI, without success.
- If you have been trying to conceive for at least two years and a cause hasn’t been found.
13
Q
How is IVF done?
A
Fertility drugs - develop mature eggs for fertilisation, done by taking GnRH
Hormone injections - stimulate ovaries to release a greater number of eggs than normal, ovulation induction, done by taking FSH and LH
Egg retrieval and sperm collection
Fertilisation and embryo transfer
14
Q
What are the complications associated with IVF?
A
- Multiple birth
- Side-effects from th fertility drugs
- Increased risk of ectopic pregnancy
- Slighty higher risk of being born with a birth defect
15
Q
What are the chances of success with IVF?
A
30%
16
Q
What is intracytoplasmic sperm injection?
A
Intracytoplasmic sperm injection (ICSI) can be used as part of an in vitro fertilisation (IVF) treatment to help you and your partner conceive a child
ICSI only needs one sperm, which is injected directly into the egg. The fertilised egg (embryo) is then transferred to your womb (uterus)
17
Q
When is ICSI used?
A
- A very low sperm count.
- A high percentage of abnormally shaped or slow sperm.
- Sperm that does not show in the fresh sample but can be collected from the testicles.
- Problems with getting an erection and ejaculating, due to spinal cord injuries or diabetes, for example.
- A need to use frozen sperm that is not of the best quality.
- A need to test the embryos to avoid passing on a genetic abnormality.
18
Q
What are the procedures called to extract sperm?
A
Percutaneous epididymal sperm aspiration (PESA)
Testicular sperm aspiration (TESA)
19
Q
What is the process of ICSI?
A
Same as IVF
20
Q
What is the success rate of ICSI?
A
45%
21
Q
What is donor conception?
A
Donor conception means having a baby using donated sperm, or donated eggs or embryos.
22
Q
At what age can the child find out about the donor?
What type of identificaiton data can you find out?
A
Once he or she reaches 16, your child will have access to identifying information about their genetic donor. He or she will also be able to find out if she has any donor siblings.
Non-identifiable data
Identifiable data
23
Q
What networks are available for doners?
A
Donor conception network - gorup of couples concieved by donor
British Infertility Counselling Association
National Gamete Donation Trust
Fertility Network UK
24
Q
What are important factors to consider when thinking about donor conception?
A
Mental health status
How to cope when the baby is older
Strain on relationship
25
What is donor insemination?
Donor insemination (DI) is the process of conceiving a baby using donated sperm. Many people who use DI are same-sex female couples or women who want to conceive without a partner.
26
What are the reasons for using sperm insemination?
1. If you’re in a same-sex relationship and want to conceive.
2. If you’re a single woman
3. A low sperm count OR no sperm, or sperm that is unlikely to result in conception.
4. A known genetic disorder or infection that may be passed on to your baby.
5. A severe rhesus problem
27
How does a parent become legal guardian of the child?
f you’re married or in a civil partnership, your partner will automatically become the legal father
If you’re in a relationship, but not married or in a civil partnership, your partner needs to give consent to be the legal parent
The legal situation for a man who wants to donate sperm and be involved in co-parenting the child can be more complex
28
How is donor isemination carried out?
Donated sperm is commonly used as part of an intrauterine insemination (IUI) procedure. Or it can be used for in vitro fertilisation (IVF) if necessary. During donor-IUI, your doctor places a concentrated dose of the donated sperm in your womb (uterus) when you’re ovulating.
29
What are the advantages of using sperm donor?
1. Screen for diseases
2. Screened for lots of infections
3. Man who donates sperm has no legal rights over the child
30
What is egg and embryo donation?
Egg and embryo donation are ways to help you conceive, using donors.
Egg donation is when eggs from another woman are fertilised with your partner’s sperm in a laboratory. The resulting embryos are then transferred to your womb (uterus).
31
When is egg and embryo donation used?
f you have no ovaries, produce low-quality eggs, or no eggs at all.
If you and your partner have been unsuccessful with other treatments, such as IVF.
If you’re at risk of passing on an inherited disorder or chromosomal abnormality.
You and your partner are unlikely to conceive using your own eggs and/or sperm for fertility treatment.
You’re single and have gone through the menopause.
32
How does egg and embryo donation work?
Egg donors are women who are not receiving fertility treatment themselves, but who choose to donate their eggs to help other women, or a particular woman they know.
Egg sharers are women undergoing fertility treatment, who donate some of their eggs as part of their IVF cycle.
33
How is egg and embryo donation done?
Embryo donation
Egg donation - need to sync their cycles
34
What are some disadvantages of egg and embryo donation?
more likely to develop pre-eclampsia
35
What is surrogacy?
Surrogacy is when another woman carries and gives birth to a child for you. Though it can be an emotionally intense and legally complex arrangement, it is growing in popularity with couples, as a way of having children.
36
Why choose surrogacy?
You have had recurrent miscarriages.
You have a condition that makes pregnancy and birth dangerous.
You’ve had a hysterectomy or you have a serious uterine abnormality.
Fertility treatments such as in vitro fertilisation (IVF) haven’t been successful.
37
What are the different types of surrogacy?
**_Straight surrogacy_**
A surrogate mum typically conceives after being artificially inseminated though IUI with the intended dad’s sperm. This can be done through a fertility clinic. This is called partial, straight, or traditional surrogacy because the surrogate’s eggs and womb are used.
**_Host surrogacy_**
A surrogate mum carries a donated embryo to term. This is called full, host, or gestational surrogacy because the woman has no genetic connection to the baby. The embryo is conceived through IVF or ICSI. This means the baby can be:
38
Who is in charge of surrogacy?
Surrogacy arrangements are not regulated by the Human Fertilisation and Embryology Authority. They are usually set up through agencies or by private arrangement with a friend or family member. You can meet potential surrogate mums and access support through unregulated, not-for-profit organisations such as:
## Footnote
Brilliant Beginnings
Childlessness Overcome Through Surrogacy (COTS)
Surrogacy UK
39
What are the disadvantages to surrogacy?
Mental health
Expensive
40
What are the names for the different progesterone only pills?
**3 hour pills**
Micronor
Noriday
Nogeston
Fumulen
**12 hour pill**
Cerazette (desogestrel)
41
What should you do when you are late for either the progesterone only pill or the combined pill?
**POP**
Less than 3 hours - no action required
Over 3 hours - take the misssed pill as soon as possible, take the next pill at usual time, also use condoms for 48 hours
**Combined pill**
Less than 12 hours - no action needed
Over 12 hours - take the misssed pill as soon as possible, take the next pill at usual time, also use condoms for 48 hours
42
WHAT IS OVARIAN HYPERSTIMULATION?
Ovarian hyperstimulation syndrome is an exaggerated response to excess hormones
43
Who is at particular risk of ovarian hyperstimulation in IVF?
PCOS
44
What are the symptoms of ovarian hyperstimulation?
1. Abdo pain
2. Ascites
3. Vomiting
4. Diarrhoea
5. High haematocrit
45
What medications can be used to conduct ovarian induction?
1. Clomiphene citrate
2. Raloxifene
3. Letrozole
4. Anastrozole
46
HOW FAST SHOULD A FETAL HEARTBEAT BE?
HOW MUCH SHOULD IT VARY?
Between 100 and 160
5-25 beats per minute
47
What is fetal tachycardia?
Heart rate above 140 bpm
48
How long should decreased variability in a fetus last?
Less than 40 minutes
49
What are the causes of fetal decreased variability?
**Drugs**
Benzodiazipenes
Opoids
Methyldopa
Fetal acidosis
Fetal tachycardia
Cogential heart abnormalities
Prematurity \<28 weeks
50
What is the cause of early deceleration?
1. Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
2. Usually an innocuous feature and indicates head compression
51
What is the cause of late deceleration?
Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction
Indicates fetal distress e.g. asphyxia or placental insufficiency
52
What is the cause of baseline bradycardia?
Increased fetal vagal tone
Maternal beta-blocker use
53
At what weeks of pregnancy if movements are not felt is it concerning?
24 weeks
54
WHEN IS CERVICAL SMEAR TEST OFFERED?
25 to 64 years
55
What is the normal recall rate of smear test?
Every 3 years
56
What is the management of a negative hrHPV?
**Return to normal recall, unless**
The test of cure (TOC) pathway
Should be invited 6 months after treatment
The untreated CIN1 pathway
Follow-up for incompletely excised cervical glandular intraepithelial neoplasia
Follow-up for borderline changes in endocervical cells
57
What is the management of a postive hrHPV?
**Samples are examined cytologically**
1. If the cytology is abnormal → colposcop
**If the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months**
1. If the repeat test is now hrHPV -ve → return to normal recall
2. If the repeat test is still hrHPV +ve and cytology still normal → further repeat test 12 months later:
3. If hrHPV -ve at 24 months → return to normal recall
4. If hrHPV +ve at 24 months → colposcopy
58
What is the managment of an inadequate hrHPV sample?
Repeat the sample within 3 months
If two consecutive inadequate samples then → colposcopy
59
What happens if a pregnant woman is called for a smear test?
Wait until at least 12 weeks after delivery
60
How often does a HIV patient need a repeat smear?
Every year
61
WHAT ARE THE DIFFERENT TYPES OF CONTRACEPTION?
**Long-acting reversible contraception**, such as the implant or intra uterine device (IUD)
**Hormonal contraception**, such the pill or the Depo Provera injection
**Barrier methods**, such as condoms
**Emergency contraception**
**Fertility awareness**
**Permanent contraception**, such as vasectomy and tubal ligation.
62
How long does the IUD, IUS and implant last?
IUD - 5-10 years
IUS - 3-5 years
Implant - 3 years
63
When should non-hormonal methods of conctraception be stopped \<50 and \>50?
**\<50**
Stop contraception after 2 years of amenorrhoea
**\>50**
Stop contraception after 1 year of amenorrhoea
64
How long does it take for each contraceptive to be effective?
Instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
65
When can hormonal contraceptives be taken after taking emergency contraception?
Immediately
66
When can hormone contraceptives be taken to 50 and over 50?
67
HOW DOES THE COPPER COIL WORK?
Decreases sperm motility and survival
68
What is the Intrauterine device primary mechanism of action?
TOXIC ENVIRONMENT WHICH
## Footnote
**Decreases sperm motility and survival**
69
What is a contraindication to the IUD?
Pelvic inflammatory disease
70
WHAT IS THE IUS AND HOW DOES IT WORK?
Secrets **progesterone** in the uterus
Primary: **Prevents endometrial proliferation**
Also: **Thickens cervical mucus**
71
What is the most common symptom 6 months after inserting the IUS?
Irregular bleeding
72
WHAT ARE THE NAMES FOR THE IMPLANT?
Where is it inserted?
Implanon - old
Nexplanon - new
Subdermal non-dominant arm
73
What is the implantable contraceptive (etonogestrel) primary mechaism of action?
Primary: Inhibits ovulation
Also: thickens cervical mucus
74
What are the main side effects of the implant?
irregular or heavier bleeding
75
WHAT ARE THE DIFFERENT TYPES OF PROGESTERONE-ONLY PILL?
There are 2 different types of progestogen-only pill:
3-hour progestogen-only pill (traditional progestogen-only pill) – must be taken within 3 hours of the same time each day
12-hour progestogen-only pill (desogestrel progestogen-only pill) – must be taken within 12 hours of the same time each day
76
What is the progestogen-only pill (excluding desogestrel) primary mechanism of action?
Thickens cervical mucus
77
What happens if you miss a pill of the progesterone only pill?
1. Take a pill as soon as you remember
2. Take the next pill at the usual time
3. Carry on taking your remaining pills each day at the usual time
4. Use extra contraception such as condoms for the next 2 days (48 hours) after you remember to take your missed pill, or don't have sex
78
What is the most common complication of taking the POP?
Irregular bleeding
79
What class of medicaitons interact with the COCP but not the POP?
Antibiotics
80
WHAT IS THE NAME FOR THE COMBINED ORAL CONTRACEPTIVE PILL?
Cerazette
81
What is the pill and how does it work?
1. **The pill prevents the ovaries** from releasing an egg each month (ovulation). It also:
2. **Thickens the mucus** in the neck of the womb, so it is harder for sperm to penetrate the womb and reach an egg
3. **Thins the lining of the womb**, so there is less chance of a fertilised egg implanting into the womb and being able to grow
82
What happens if you miss pills on the pill?
**1 pill**
You should:
Take the last pill you missed now, even if this means taking 2 pills in 1 day
Carry on taking the rest of the pack as normal
You do not need to use extra contraception.
**2 pills**
You should:
Take the last pill you missed now, even if this means taking 2 pills in 1 day
Leave any earlier missed pills
Carry on taking the rest of the pack as normal
Use extra contraception, such as condoms, for the next 7 days
83
What should a woman do if she has missed one dose of the COCP?
AT ANY TIME IN THE CYCLE
1. Take the last pill even if it means taking two pills in one day and then continue taking pills daily, one each day
2. No additional contraceptive protection needed
84
What should a woman do if she misses 2 or more pills of the COCP?
1. Take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
2. The women should use condoms or abstain from sex until she has taken pills for 7 days in a row. FSRH: 'This advice may be overcautious in the second and third weeks, but the advice is a backup in the event that further pills are missed'
3. If pills are missed in **week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1**
4. if pills are missed in w**eek 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception\***
5. if pills are missed in w**eek 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval**
85
When should COCP of conctraception be stopped \<50 and \>50?
**\<50**
Can be continued to 50 years
**\>50**
Switch to non-hormonal or progestogen-only method
86
What does the combined oral contraceptive protect and increase the risk of?
1. **Increased** risk of breast and cervical cancer
2. **Protective** against ovarian and endometrial cancer
87
Which method of contraception is contraindicated in breast feeding?
Until what week?
Combined oral contraceptive pill
Week 6
88
What are the contraindications for the combined oral contraceptive pill?
1. More than 35 years old and smoking more than 15 cigarettes/day
2. Migraine with aura
3. History of thromboembolic disease or thrombogenic mutation
4. History of stroke or ischaemic heart disease
5. Breast feeding \< 6 weeks post-partum
6. Uncontrolled hypertension
7. Current breast cancer
8. Wheelchair use
9. BMI \>35 kg/m2
10. Antiphospholipid syndrome
89
HOW OFTEN IS THE DEPO INJECTIONS ADMINISTERED?
Every 12 weeks
90
What is the injectable contraceptive (medroxyprogesterone acetate) primary mechanism of action?
Primary: Inhibits ovulation
Also: thickens cervical mucus
91
When should Depo-Provera of conctraception be stopped \<50 and \>50?
**\<50**
Can be continued to 50 years
**\>50**
Switch to either a non-hormonal method and stop after 2 years of amenorrhoea OR switch to a progestogen-only method and follow advice below
92
What class of medicaitons is the depo inject unaffected by?
Enzyme inducers
93
What are the adverse effects of the depo injection?
1. irregular bleeding
2. weight gain
3. may potentially increased risk of osteoporosis: should only be used in adolescents if no other method of contraception is suitable
4. not quickly reversible and fertility may return after a varying time
94
What is the contraindication to the progesterone only depot injection?
Current breast cancer
95
When should implant, POP, IUS of contraception be stopped \<50 and \>50?
**\<50**
Can be continued beyond 50 years
**\>50**
Continue
If amenorrhoeic check FSH and stop after 1 year if FSH \>= 30u/l or stop at 55 years
If not amenorrhoeic consider investigating abnormal bleeding pattern
96
WHAT PATCH IS THE ONLY PATCH FOR LICENCED USE WITHIN THE UK?
The Evra patch is the only combined contraceptive patch licensed for use in the UK.
97
How do you use the evra patch?
The patch cycle lasts 4 weeks.
For the first 3 weeks, the patch is worn everyday and needs to be changed each week.
During the 4th week, the patch is not worn and during this time there will be a withdrawal bleed.
98
What happens if there is a delay in changing the evra patch within the first two weeks?
1. If the delay in changing the patch is **less than 48 hours,** it should be changed immediately and no further precautions are needed.
2. If the delay is **greater than 48 hours**, the patch should be changed immediately and a barrier method of contraception used for the next 7 days. If the woman has had sexual intercourse during this extended patch-free interval or if unprotected sexual intercourse has occurred in the last 5 days, then emergency contraception needs to be considered.
99
What happens if there is a delay in changing the patch in the third week?
The patch should be removed as soon as possible and the new patch applied on the usual cycle start day for the next cycle, even if withdrawal bleeding is occurring. No additional contraception is needed.
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.
100
What happens if there is a delay in changing the patch at the end of the patch-free week?
If patch application is delayed at the end of a patch-free week, additional barrier contraception should be used for 7 days following any delay at the start of a new patch cycle.
101
WHAT IS THE APGAR SCORE?
A method to quickly summarize the health of newborn children against infant mortality
102
What does each part of the APGAR score represent?
1. Appearance
2. Pulse
3. Grimace
4. Activity
5. Respiration
103
What are the points for appearance on the APGAR score?
Normal - 2
Normal but blue hands and feet - 1
Blue all over - 0
104
What are the points for **pulse** on the APGAR score?
2 - \>100
1 - \<100
0 - absent
105
What are the points for **grimace** on the APGAR score?
2 - pulls away, coughs, sneezes, cries with stimualtion
1 - facial movement only with stimulation
0 - absent
106
What are the points for **activity** on the APGAR score?
2 - active spontaneous movement
1 - arms and legs flexed with little movement
0 - no movement 'floppy tone'
107
What are the points for **respiration** on the APGAR score?
2 - normal rate and effort
1 - slow or irregular breathing
0 - absent
108
When is APGAR score measured?
1, 5, and 10 minutes after birth
109
What is the newborn resusitation rate ratio, compression to breaths?
3:1
110
WHAT IS THE BISHOP'S SCORE?
The Bishop score is a system used by medical professionals to decide how likely it is that you will go into labor soon.
They use it to determine whether they should recommend induction, and how likely it is that an induction will result in a vaginal birth.
111
What are the parts of the Bishop's score?
**I -** Effacement
**S -** Station
**H**ard or soft - Consistency
**O**pening - Dilation
**P**resenting part - Position
112
What points are given for the position in Bishop's scoring?
2 - Anterior
1 - Mid position
0 -
113
What points are given for consistency in Bishop's scoring?
2 - Soft
1 - Medium
0 - Firm
114
What points are given for effacement in Bishop's scoring?
3 - \>80%
2 - 60 - 70%
1 - 30 - 50%
0 - 0 -30%
115
What are the points given for dilation in Bishop's scoring?
3 - \>5cm
2 - 3-4cm
1 - 1-2cm
0 - closed
116
What are the points given for station in Bishop's scoring?
* **0** - -3
* **1** - -2
* **2** - -1, 0
* **3** - +1, +2
117
What should you do if a woman has a Bishop's score of \<5 or \>8?
\<5
1. Induction
2. Prostoglandins
\>8
1. Cervix is ripe or favourable - high chance of spontaneous labour
118
WHAT METHODS CAN BE DONE TO INDUCE LABOUR?
SPORR
1. Membrane **S**weep
2. Vaginal **P**rostaglandin
3. Maternal **O**xytocin infusion
4. Amniotomy/**R**upture of membranes (breaking of waters)
5. Cervical **R**ipening balloon
119
What are the three stages of labour?
**Stage 1**
From the onset of true labour to when the cervix is fully dilated
Latent - 0-3cm, normally takes 6 hours
Active 3-10cm, 1 cm/hour
**Stage 2**
From full dilation to delivery of the fetus
**Stage 3**
From delivery of fetus to when the placenta and membranes have been completely delivered
120
What monitoring is done in labour?
FHR monitored every 15min (or continuously via CTG)
Contractions assessed every 30min
Maternal pulse rate assessed every 60min
Maternal BP and temp should be checked every 4 hours
VE should be offered every 4 hours to check progression of labour
Maternal urine should be checked for ketones and protein every 4 hours
121
What is involved in active management in the third stage of labour?
1. **Uterotonic drugs**
* Oxytocin
2. **Deferred clamping and cutting of cord**
* Over 1 minute after delivery but less then 5 minutes
* Controlled cord traction after signs of placental separation
122
WHAT ARE THE DIFFERENT MECHANISMS OF ACTION OF EMERGENCY CONTRACEPTION?
**LevonorgestrelI -72 hours**
Inhibits ovulation
**Ulipristal - 120 hours**
Inhibits ovulation
**Intrauterine contraceptive device**
Primary: Toxic to sperm and ovum
Also: Inhibits implantation
123
What emergency contraception is used after 21 days postpartum?
After day 21 postpartum, progesterone only EC (Levonelle and ellaOne) can be used in both breastfeeding and non-breastfeeding woman.
124
When must Levonorgestrel be taken for emergency contraception?
What happens if the patinet vomits within 3 hours of taking it?
72 hours
Take another dose
125
When must Ulipristal (ellaOne) taken for emergency congraception?
120 hours = 5 days
126
In what condition is Ulipristal (ellaOne) used with caution?
Severe asthma on steroids
Has an anti glucocorticoid effect
127
When is emergency contraception not required postpartum?
up to 21 days
128
When can women restart their normal hormonal contraception after ulipristal acetate?
5 days
129
WHAT IS EACH PHASE OF THE MENSTURAL CYCLE CALLED?
1. Follicular phase
2. Luteal phase
130
What does FSH and LH act on?
What does this release?
1. FSH on oocytes
2. LH on receptors on theca cells
1. FSH converts androgens in granulosa cells to estrogens
2. Theca cells release androgens
131
What is the action of oestrogen?
**_Day 7_**
1. Causes endometrium to grow thicker
2. Supresses hypothalamus stopping production of FSH and LH
**_Day 14 - Really high Oestrogen_**
1. Increase LH LOADS and FSH A BIT
132
What is the action of progesterone?
1. Maintains uterine lining
2. Produce fluids for potential embryo
3. Secretes thick mucus as barrier to sperm
133
When should you measure mid-luteal progesterone level?
7 days before the end of the cycle
134
What does the corpeus luteum produce?
What do they have an effect on?
1. Progesterone
2. Low levels of oestrogen
1. Negative feedback on hypothalamus
2. Less FSH and LH
135
What is an egg called after it is fertilised?
1. Zygote
2. 16 cells - blastocyst
136
WHAT DAY OF THE CYCLE DOES A WOMAN OVULATE?
14
137
Where are FSH and LH produced?
Anterior pituitary
138
What does FSH and LH cause?
The dominant follicle to turn into the corpus luteum
139
What day of the cycle is there a surge in progesterone?
21
140
WHAT IS A PARTOGRAM?
Used in assessment of labour
1. Maternal - BP (hourly)
2. Heart rate (¬ hourly)
3. Temperature (once unless abnormal)
4. Contractions - length, frequency, strength
5. Baby - heart rate (¬ hourly), liquor.
6. Also - maternal state of mind, drugs administered etc.
141
What is defined as baseline bradycarida and what are the causes?
Heart rate \< 100 /min
Increased fetal vagal tone, maternal beta-blocker use
142
What is defined as baseline tachycardia on a CTG and what are the causes?
Heart rate \> 160 /min
Maternal pyrexia, chorioamnionitis, hypoxia, prematurity
143
What is defined as loss of baseline variability and what are the causes?
\< 5 beats / min
Prematurity, hypoxia
144
What are early decelerations and what causes this?
Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction
Usually an innocuous feature and indicates head compression
145
What are late decelerations and what causes this?
1. Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after **30 seconds** following the end of the contraction
2. Indicates fetal distress e.g. **asphyxia or placental insufficiency**
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What are variable decelerations and what causes this?
1. Heart rate changes independent of contractions
1. Indicates cord comporession
147
What is the management for late declerations on CTG?
Urgent fetal blood sampling is needed to assess for fetal hypoxia and acidosis
148
What pH is considered normal in fetal sampling?
What happens if this is abnormal?
A pH of \>7.2 in labour is considered normal
Urgent delivery of the fetus
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What should you be looking for on a CTG?
**This mnemonic is helpful in interpreting CTGs; DR C BRA VADO:**
1. **DR- define risk:** why is this patient on a CTG monitor? e.g. pre-eclampsia, antepartum haemorrhage, maternal obesity, maternal ill health
2. **C- contractions**. Look at the bottom of the trace, each contraction is shown by a peak. In established labour you would expect 5 contractions in 10 minutes. Each large square = 1 minute duration, so count the number of contractions in 10 squares.
3. **BRA- baseline rate.** The fetal baseline rate should be approximately 110-160 beats per minute. Each large square = 10 beats and each small square = 5 beats. A fetal bradycardia is below 110 beats per minute and a fetal tachycardia is above 160 beats per minute.
4. **V- baseline variability.** The fetal heart rate should vary between 5 to 25 beats per minute. Below 5 beats per minute, the variability is said to be reduced.
5. **A- accelerations**. Are there accelerations in fetal heart rate? Accelerations are a rise in fetal heart rate of at least 15 beats lasting for 15 seconds or more. There should be 2 separate accelerations every 15 minutes. Accelerations typically occur with contractions.
6. **D- decelerations.** Are there decelerations in fetal heart rate? These are a reduction in fetal heart rate by 15 beats or more for at least 15 seconds. Decelerations are generally abnormal and should prompt senior review. In particular, late decelerations, which are slow to recover are indicative of fetal hypoxia.
7. **O- overall impression/diagnosis.** As a medical student it is important to be aware of two features- terminal bradycardia and terminal decelerations. A terminal bradycardia is when the baseline fetal heart rate drops to below 100 beats per minute for more than 10 minutes. A terminal deceleration is when the heart rate drops and does not recover for more than 3 minutes. These make up a 'pre-terminal' CTG and are indicators for Emergency Caesarean section.
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What parameters will cause you to constantly use a CTG whilst in labour?
1. Suspected **chorioamnionitis** or **sepsis**, or a temperature of 38°C or above
2. **Severe hypertension** 160/110 mmHg or above
3. **Oxytocin** use
4. The presence of **significant meconium**
5. **Fresh vaginal bleeding that develops in labour** - this was a new point added to the guidelines in 2014
151
How does a placenta attach onto the endometrium?
https://www.youtube.com/watch?v=bped-RVWsLk
WATCH THIS
1. Trophoblast
2. Primary/secondary chorionic villi
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WHAT ARE THE RISKS OF AMNIOCENTESIS?
1. Damage of one eye, causing blindness
2. Damage to the brachial plexus
3. Pneumothorax
4. Puncture of a fetal vessel
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What are the indication for amniocentesis?
**_Karyotyping_**
1. Down's
**_Haemolytic disease_**
1. Rhesus disease
**_Maturity of newborn lungs_**
**_Biochemical studies_**
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WHAT IS CHORIONIC VILLUS SAMPLING?
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What are the advantages and disadvantages of chorionic villus sampling over amniocentesis?
**_Advantages_**
1. Can be done before pregnancy
2. Results are available earlier
**_Disadvantages_**
1. Can cause an abnormality in the baby e.g. limb agenesis syndrome by disrupting blood supply
156
What gene defects can chorionic villus sampling detect?
1. Cystic fibrosis
2. Huntington's disease
3. Haemophillia
4. Myotonic dystrophy
5. Phenylketonuria
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WHAT ARE THE NORMAL RANGES FOR SPERM ANALYSIS?
1. **_Semen volume:_** 1.5 ml or more
2. **_pH:_** 7.2 or more
3. **_Sperm concentration:_** 15 million spermatozoa per ml or more total
4. **_Sperm number:_** 39 million spermatozoa per ejaculate or more
5. **_Total motility:_** 40% or more motile or 32% or more with progressive motility
6. **_Vitality:_** 58% or more
7. **_Live spermatozoa sperm morphology_** (percentage of normal forms): 4% or more
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WHAT ARE THE CAUSES OF POSTCOITAL BLEEDING?
1. No identifiable pathology is found in around 50% of cases
2. **Cervical ectropion** is the most common identifiable causes, causing around 33% of cases. This is more common in women on the combined oral contraceptive pill
3. Cervicitis e.g. secondary to Chlamydia
4. Cervical cancer
5. Polyps
6. Trauma
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WHAT IS HRT?
Hormone replacement therapy (HRT) involves the use of a small dose of oestrogen (combined with a progestogen in women with a uterus) to help alleviate menopausal symptoms.
160
What are the complications with giving HRT?
1. **Increased risk of breast cancer**
* Increased by the addition of a progestogen
2. **increased risk of endometrial cancer**
* Oestrogen by itself should not be given as HRT to women with a womb
3. **Increased risk of venous thromboembolism**
* Increased by the addition of a progestogen
161
Which is the safest HRT to use to prevent VTE?
Transdermal
162
What are some management options for non-HRT?
1. **Vasomotor symptoms**
* Fluoxetine, citalopram or venlafaxine
2. **Vaginal dryness**
* Vaginal lubricant or moisturiser
3. **Psychological symptoms**
* Self-help groups, cognitive behaviour therapy or antidepressants
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WHAT IS FIBRONECTIN?
1. Protein that is released from the gestational sac
2. High levels indicate early labour
164
What are examples of muscarinic antagonists?
1. Oxybutynin
2. Tolterodine
3. Solifenacin
