Rep Flashcards

Question

Explain the action of gonadotrophins on the testes and ovaries

Answer 1

Ovaries FSH - follicular development from 1st day of menstruation in order to nurture and sustain the development of the gamete. The follicles also produce oestrogen and inhibin. LH - ovulation

Answer 2

Female Oestrogen The effect of oestrogen on the reproductive tract is intended to promote fertilisation: • Proliferation of endometrium • Proliferation of myometrium • Fallopian tube motility • Thin, alkaline cervical mucus Progesterone The effect of progesterone on the reproductive tract is intended to sustain a viable pregnancy • Secretory function of endometrium • Reduction of motility of myometrium (assumes fertilisation has occurred) • Thick, acidic cervical mucus to prevent further entry of sperm

Answer 3

Ovarain cycle Follicular phase Day 0-5 Granulosa cell secrete activin which inc FSH production. Inc follicle growth, theca interna appears, inc oestrogen. Then switch to inhibin (from activin)-dec FSH and inc oestrogen Days 5-14 Oestrogen Inc LH receptors on granulosa cells Day 14 LH surge - oestrogen rises Ovulation- Mature oocyte (meiosis 2 not completed) travels through the capsule of the ovary into the fallopian tube 14-28 LH stimulates the remaining follicle (granulosa and theca cells) to develop into the corpus luteum. Secretes oestrogen and progesterone in large quantities. Set lifespan of 14 days. After this, it regresses so levels of oestrogen, progesterone, and inhibin drop, allowing the cycle to start again. Endometrium = epithelium + stroma • Functional layer responsive to hormones, shed in menstruation Early proliferative - Sparse glands, straight Late proliferative - Thicker functional layer, glands coiled. In response to oestrogen produced by the ovary. After ovulation Secretory - Endometrial thickness at maximum, very coiled glands. Coiled arterioles. Under the influence of progesterone.

Answer 4

1. FSH and LH from granulosa and theca interna cells 2. LH means oestrogen produced. Oestrogen sends signal to stop FSH at low levels. 3. Oestrogen inc to high levels and sends signal to release surge of FSH and LH 4. Oocyte breaks off 5. Menstruation - drop in inhibin, progesterone and oestrogen. Less neg feedback so rising FSH.

Answer 5

Amenorrhoea an absence of menstruation. Primary - the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics or by 13 years of age in girls with no secondary sexual characteristics. Secondary - The cessation of menstruation for 3–6 months in women with previously normal menses, or for 6–12 months in women with previous oligomenorrhoea. Oligomenorrhoea Infrequent menstruation defined by a cycle length between 6 weeks and 6 months. Menorrhagia heavy menstrual bleeding, either by objective volume >80ml and/or the subjective opinion of the patient that periods have become heavier or that she is passing clots. More than 7 days. Affects quality of life. Dysmenorrhoea This is defined as painful periods, to the point where it is interfering with quality of life. It often leads to chronic pelvic pain. Primary - absence of any identifiable underlying pelvic pathology. • 6–12 months after the menarche • production of uterine prostaglandins during menstruation Secondary: • often starts after several years of painless periods • caused by an underlying pelvic pathology

Answer 6

Amenorrhoea - primary/secondary Sexual history- pregnancy Age - menopause or pre-pubertal Weight loss,/anxiety/stress 1st - Look for other secondary sexual characteristics, if present then blockage of outflow tract 2nd - if none look at FSH/LH and GnRH 3rd - if low then hypo-gonadotropin hypogonadism If high then hyper-gonadotropin hypogonadism - then karyotype analysis Menorrhagia - quantity of blood loss, anaemia, Medication history (anticoagulants) Dysmenorrhea -Location and timing of pain e.g. pelvic, cyclical, during intercourse?

Answer 7

Hormonal - HPG axis Defect in hypothalamus release of GnRH. Defect in pituitary release of FSH and LH. Or problem with ovary’s response. Structural - structural problem of uterus or vagina. Investigated by USS, MRI or other imaging. System review - thyroid disorders can cause menorrhagia or oligomenorrhoea so it is important to consider thyroid function tests.

Answer 8

Menopause = Age = 45-55 Pre-menopause- oestrogen levels fall so -ve feedback removed and LH+FSH rise. FSH rises more as inhibin removed. Menstrual cycle shortens, ovulation is either early or absent so problems with fertility. Peri-menopause - transition phase, greater infrequency of menstruation. Menopause - complete cessation of menstrual periods for 12 months. Post-menopause - women who have experienced the changes above are now deemed as post-menopausal. No primary follicles left so no reproduction.

Answer 9

Peri hot flushes and sweating. insomnia and mood swings or depression. Intermediate further decreasing levels of oestrogen, so affects tissues reliant on oestrogen - vaginal atrophy leading to dyspareunia. Tissues lining the urethra and bladder, which can lead to increased frequency of UTIs and stress incontinence. Ovaries will atrophy, thinning of the uterus, loss of vaginal rugae, reduction of pubic hair due to testosterone decline later in menopause, breast tissue reduce in size. skin elasticity, fat storage bloating, related to reduced motor activity of the GI activity and can also cause constipation. and fracture healing Post Dec oestrogen = inc osteoclast activity = osteoporosis NOF fractures after a fall Dec height due to dec bone mass Low oestrogen + progesterone = inc circulating lipid levels = inc risk of atherosclerosis = inc risk of MI + stroke.

Answer 10

Non-hormonal management General lifestyle advice eg light weight clothing, avoid triggers Dietary advice to reduce weight gain and cardiovascular risk. Hormonal management Vasomotor or mood disorders Offer HRT with oestrogen and progesterone (p protects the endometrium from hyperplasia) Urogenital - vaginal oestrogen Also dec risk of osteoporosis and colorectal cancer and muscle mass Risk = DVT (oral), breast cancer(l with pro), CHD and stroke(over 60 and tablets), endometrial cancer (only o).

Answer 11

Polycystic ovarian syndrome- Triad = hyperandrogenism, menstrual irregularity, obesity (insulin resistance). Diagnosis due to inc androgens + polycystic ovaries (ovaries become enlarged and contain many follicles that are unable to release an egg) on ultrasound. Symptoms- secondary amenorrhoea, infertility, hirsutism and obesity. Management = lifestyle, type 2 diabetes, cyclical progesterone Fibroids benign tumours of smooth muscle occurring in the myometrium. Can lead to very heavy menstrual bleeding. Risk factors - increasing age (until the menopause) -early menarche -older age at first pregnancy -black and Asian ethnicity -family history Endometrial carcinoma - bleeding in menopause. in menopause ovulation is not occurring so no corpus luteum so no progesterone so unopposed oestrogen. Ovarian cancer - present with symptoms as vague as bloating, so an important differential in post-menopausal women.

Answer 12

Amenorrhoea causes = hormonal disorders or structural disorders: Imperforate Hymen - thin layer of connective tissue (hymen) covers the vaginal entrance, and this has not perforated at the onset of menstruation. This can lead to a collection of blood behind the hymen, and progress to an infection. Cervical Stenosis – where the os of the cervix is not open meaning blood cannot flow from the uterus into the vaginal canal. Vaginal Septae – where a wall of tissue forms during the development of the vagina, separating the upper vagina into two parts, one of which forms a pouch where blood can collect. Agenesis or Hypoplasia of the Genital Tract Asherman’s Syndrome – an acquired condition where scar tissue forms in the uterus, often following IUS insertion or surgical termination, blocking the flow of blood. Uterine Fibroids – can cause the blockage of blood in the uterus. Physiological- pregnancy, menopause in older women Other - weight loss, stress Menhoragia Causes Uterine/ovarian problems = endometrial cancer, fibroids, adenomyosis, polyps Systemic = clotting disorders, Hypothyroidism, bleeding tendency Iatrogenic = anticoagulation therapy, intrauterine contraceptive Oligomenorrhoea cause - PCOS (irregular ovulation so to irregular periods), PID, Hyperthyroidism, High levels of prolactin Dysmenorrhoea Cause = endometriosis- ectopic endometrial tissue that responds in the same way to hormonal stimulation as the endometrial lining of the uterus. This can irritate the peritoneum leading to chronic pain, intra-abdominal adhesions, infertility, bowel obstruction. Test is laparoscopy. Risk - early menarche, white, late menopause. Adenomyosis: endometrial tissue found deep within myometrium ➢ Fibroids, endometrial polyps can obstruct menses. ➢ pelvic inflammatory disease ➢ Intrauterine device (IUD) insertion. Inter-menstrual bleeding- STIs/PID Cervical ectropion – the evolution of the cells of the internal cervical canal to the outer surface of the cervix which can cause them to bleed. Cervical cancer Endometrial polyps or cancer Ovarian cysts

Answer 13

Seminal vesicles - clotting factors Prostate - proteolytic enzymes that break down coagulation Coppers glands - alkaline fluid, a mucous that lubricates the end of the penis and urethral lining, (pre ejaculate) Semen acts as nutrition source for the spermatozoa, transport medium and neutralises the acidic environment of the vagina.

Answer 14

Erection: 1. Stimulants - Psychogenic, tactile(sensory afferent of penis and perineum) 2. Spinal reflex 3. Efferent - activation of pelvic nerve (PNS) 4. Post-ganglionic fibres release ACh 5. Ach binds to M3 receptor on endothelial cells 6.. A rise in [Ca2+] , activation of NOS and formation of NO 7. NO causes vasodilation Ejaculation - sympathetic Emission - semen is moved into prostatic urethra which requires smooth muscle contraction from the prostate, vas deferens and seminal vesicles. Expulsion - contraction of glands, ducts and internal sphincter(prevent retrograde). Also contraction of pelvic floor.

Answer 15

Capacitation (6-8hrs) - sperm is deposited at cervix - The sperm cell membrane changes to allow fusion with oocyte cell surface, and the tail movement changes - fully mature. Acrosome - enzymes in the acrosome are released to remove the outer granulosa cells that surround ovum as the corona radiata. sperm then interacts with the zona pellucida and digests it.

Answer 16

Ampulla of uterine tube One sperm head fuses with membrane A cortical reaction happens in the oocyte which prevents further sperm from entering. Triggers meiosis II to finish - Pronuclei move together. Mitotic spindle forms leading to cleavage.

Answer 17

The character of cervical mucus changes over the course of the menstrual cycle • Oestrogen - Thin, stretchy • Oestrogen and progesterone - Thick, sticky - forms a plug

Answer 18

Oocytes are fertilised in vitro and allowed to divide to the 4- or 8-cell stage • The morula is then transferred into the uterus • Pre-implantation Genetic Diagnosis (PGD)

Answer 19

sperm deposition up to 3 days prior to ovulation or day of ovulation. Sperm - 72hr Oocyte - 24hr

Answer 20

CHLAMYDIA TRACHOMATIS - Obligate intracellular bacterium. Unique cell wall, inhibits phagolysosome fusion (virulence factor). NEISSERIA GONORRHOEAE - Gram -ve Diplococci, unencapsulated + pilated TRICHOMONIASIS - Protozoa Herpes - HSV-1 (oral and genital warts + cold sores) & HSV- 2 (genital warts + more likely to have HIV) - DNA virus (enveloped) SYPHILIS - TREPONEMA PALLIDUM - Spirochete bacteria Anogenital warts - HPV 6 and 11 - DNA virus (non-enveloped) 16 and 18 have the highest association with cervical cancer

Answer 21

GENITAL LESIONS Syphillis Herpes Anogenital warts - HPV PELV I C / L OW E R A B D O M I N A L PA I N : Ectopic pregnancy Appendicitis Endometriosis Ovarian cyst UTI PID Discharge: Chlamydia +Gonorrhoea - normal but with pelvic pain, bleeding Trichomoniasis - fishy, yellow, frothy, irritating to the vulva BV - thin, grey, smell Candidiasis - thick, white, non-offensive, irritating to the vulva

Answer 22

Chlamydia Female - typically asymptomatic, inc or purulent vaginal discharge, bleeding, dyspareunia, dysuria Endocervical or vulvovaginal swab Male - Urethral discharge, Dysuria, Epididymitis NAATs - most sensitive and specific Both treatment - doxycycline (or azithromycin), except in pregnancy/allergy where erythromycin is used. Gonorrhoea Men - 90% symptomatic, Causes thick, yellow discharge, dysuria, epididymo-orchitis Women - 50% asymptomatic, Dysuria, inc or altered discharge, Lower abdominal pain, Dyspareunia, PID Both treatment - ceftriaxone and azithromycin to ‘boost’ the effect, reduce the risk of resistance, treat chlamydia as a common co-infection.

Answer 23

SYPHILIS - can be co-infected with HIV Primary - Typically painless ulcers Secondary syphilis - 4 to 10 weeks after initial infection, rash, symptoms disappear, can enter a latent phase Tertiary - reactivated eg in pregnancy Swabs can be taken, and blood tests to confirm the infection. Trichomonas - due to inc pH Symptoms- copious, yellow, odourous discharge, Vulval itching/ soreness or ulceration Treatment - Metronidazole NON-GONOCOCCAL URETHRITIS IN MEN - Inflammation of the urethra with associated discharge, other STIs

Answer 24

PID - A general term for infection of the upper genital tract - almost always a STI Ascending infection from the endocervix causing: • Endometritis. • Salpingitis. • Parametritis. • Oophoritis • Tubo-ovarian abscess. • Pelvic peritonitis Symptoms - Pelvic pain/ lower abdominal pain, discharge, bleeding, Fever, Dyspareunia, secondary dysmenorrhea Signs - Lower abdominal tenderness, cervical motion tenderness, or uterine tenderness (on bimanual vaginal examination), discharge, Fever >38°C Complications- Early - Sepsis, Peritonitis Late - • Chronic pelvic pain, Pelvic abscess, infertility, Ectopic pregnancy, Fitz-Hugh Curtis Syndrome (peri-hepatitis so RUQ pain) Management - admit if signs of peritonitis, fever etc. • Start empirical antibiotics eg Oral ofloxacin plus oral metronidazole • Screen for other STIs • Contact tracing • ADVISE- complete course, potential complications, barrier contraceptive

Answer 25

Bacterial Vaginosis (BV) - Gardnerella vaginalis - anaerobe Gram staining- clue cells, Vaginal pH >4.5 Risk factors - washing the vagina, smoking, Receiving oral sex Symptoms: fishy-smelling, thin, grey discharge Candidiasis Candida albicans - yeast normal vaginal flora Risk factors - Activated in immunocompromised states, diabetes or post antibiotics. Favours high oestrogen (can be associated with COCP) Symptoms- Vulval or vaginal itching • Vulval or vaginal soreness and irritation. • Vaginal discharge (usually white, 'cheese-like', and non-malodorous). • Superficial dyspareunia. • Dysuria

Answer 26

Genital herpes Initial then recurrent infection with painful ulcers, dysuria or discharge, or asymptomatic. Swabs - PCR/NAATs Management - Antivirals e.g. aciclovir Genital warts - painless genital warts on the penis, vulva, vagina, cervix and perianal skin. Warts typically regress without treatment, although topical treatments are available. PCR to identify high risk types (biopsy/swab), vaccination

Answer 27

Female - urinanalysis only to rule out UTIs Men - • ‘First catch’ urine for gonorrhoea/chlamydia • ‘Mid-stream’ urine for culture & sensitivities rectal and pharyngeal sampling for men who have sex with men

Answer 28

Abstinence Withdrawal method This is where ‘withdrawal’ occurs before ejaculation. Not reliable. Some sperm can be released in the pre-ejaculate, no protection against STIs. Fertility awareness method - This includes monitoring basal body temperature, avoiding intercourse around the time of ovulation, and monitoring of cervical mucus. This can be unreliable, requires a lot of education, no preventing STIs. Lactational amenorrhoea Lactation delays onset of ovulation, hypothalamus lowers release of GnRH due to high prolactin due to the suckling response. However, only effective for about 6 months, and is reliant upon exclusive breastfeeding. Unreliable and no STI cover. Barrier contraception Barrier to sperm entering the cervix. Male condoms, female condoms and diaphragm/caps can also be used. Preventing STIs. Requires interruption of intercourse. Hormonal contraception This method of contraception can be broken down into short acting and long acting reversible hormonal contraception. Sterilisation

Answer 29

Short acting: Progesterone only pill (POP) - effect on the cervical mucus, take every day Does not inhibit ovulation Does not control periods Higher risk of ectopic pregnancy due to effect on cilia. Combined Oral Contraceptive Pill (COCP): containing oestrogen and progesterone - main aim to prevent ovulation by ‘tricking’ the hypothalamus into thinking it is in the luteal phase. Secondary aims include reducing the endometrial receptivity to prevent implantation, and also thickening of cervical mucus. Advantages - Also used to alleviate symptoms such as menorrhagia, irregular periods and dysmenorrhea. It is taken every day, with a break to allow bleeding to occur. Reducing ovulation can reduce risk of ovarian cancer, and preventing proliferation of endometrium can reduce risk of endometrial cancer. Disadvantages - interaction with other medication via CYP450 Contraindicated in those who are at higher risk of stroke and MI as oestrogen is thromboembolic. It therefore also needs to be stopped prior to surgery. Increased risk of breast cancer because of effect of oestrogen on breast tissue. Longer: Progesterone injection Intramuscular injection of high dose progesterone - prevent ovulation, thicken cervical mucus and thin the lining of the endometrium. Injections taken every 12 weeks. Can be used where COCP is contra- indicated. Injection may be unpleasant, and there can be a delay in fertility returning. Progesterone implant Small subcutaneous tube inserted in the arm, releasing high dose progesterone Same function and benefits as the injection. Up to three years, and fertility can return much quicker than the injection. It can cause amenorrhoea, irregularity of bleeding/spotting, or cause heavy periods.

Answer 30

Coil There are two types of intrauterine coil contraception. The intrauterine system (IUS): This coil contains progesterone, which is released locally but not into the systemic circulation. It provides a physical barrier to implantation as well as thinning of the endometrial lining. This is useful for those with menorrhagia. The intrauterine device (IUD) This coil is made of copper - provides a physical barrier Toxic to sperm and ova. No effect on reducing the endometrial lining. These devices can be technically difficult to insert, they can displace or cause perforation, and no protection for STIs.

Answer 31

Vasectomy Clips the vas deferens to prevent entry of sperm into the ejaculate. High success rate Samples must be provided afterwards to ensure it has been effective. Tubal ligation Aims to clip the fallopian tubes to prevent the ovum entering the uterus. It requires general or local anesthetic and can have a slightly higher failure rate than vasectomy. Emergency Contraception - IUD up to five days after the event or ovulation or hormonal pills Levonorgestrel- high dose progesterone - 72hrs Ulipristal acetate (EllaOne) – selective progesterone receptor modulator: • inhibits ovulation. • Upto 120 hours post

Answer 32

Infertility - a couple who are having regular, unprotected sex (approximately every 2-3 days), who have been unable to conceive within 1 or 2 years. Subfertility- generally describes any form of reduced fertility that results in a prolonged duration of unwanted lack of conception Primary infertility = never been pregnant Secondary infertility = have been pregnant in the past (including ectopic pregnancy and termination of pregnancy) and are struggling to conceive again. Causes of Infertility In about 25% of cases, no cause is identified. It is important to ask a full sexual history, including menstrual history, and past medical history.

Answer 33

Factors affecting men 1. Pre-testicular Hypogonadotropic hypogonadism Thyroid disorders 2. Testicular a. Chromosomal or congenital abnormalities meaning that sperm production is decreased - Klinefelter syndrome (XXY), Cryptorchidism b. STIs, Mumps c. Vascular - testicular torsion, Varicocele d. Drugs such as chemotherapy 3. Post-testicular Congenital – CBAVD (absent vas) Acquired – Infective, Vasectomy Coital Problems - Sexual Dysfunction, Hypospadias

Answer 34

Factors affecting women 1. Ovulatory disorders It can be divided into: a. Failure of GnRH to act on the pituitary (hypothalamic- pituitary failure) b. Failure of the axis to respond appropriately to stimulation (hypothalamic-pituitary-ovarian dysfunction). Eg: PCOS, and high levels of prolactin. c. Failure of the ovary to respond appropriately (ovarian failure) eg: Turner’s syndrome, or early menopause. 2. Uterine and peritoneal disorders - physical reasons why implantation is not possible. a. Uterine fibroids b. Conditions where scarring/adhesions have occurred i. PID ii. Asherman’s syndrome iii. Endometriosis iv. Abdominal surgery c. Abnormal structure of the uterus from issues of the Mullerian duct developing incorrectly e.g. septate or bicornate uterus 3. Tubal damage - disruption of transport of the ovum from the ovary to uterus. a. Endometriosis b. Iatrogenic from pelvic surgery c. Infection e.g. chlamydia d. Ectopic pregnancy

Answer 35

History - Past medical history, Social history- smoking, alcohol, occupation, Past pregnancies, Sexual health, Sexual dysfunction In men: 1. Semen analysis - Sperm count, motility, liquification studies 2. Hormone levels - LH, FSH, testosterone 3. Ultrasound scan of testes, Examine Penis for structural abnormalities, Scrotal exam, Secondary sexual characteristics 5. Karyotyping In women: 1. Hormone levels to assess whether ovulation is occurring; these have to be timed a. LH, FSH (day 2) b. Progesterone (day 21) c. Androgens 2. Systemic blood tests - Prolactin, Thyroid function 3. Pelvic USS, Hysterosalpingogram, Laparoscopy 4. BMI, Secondary sexual characteristics, Hirsutism, Acne, Pelvic /abdominal exam and swabs Management • Smoking cessation, dec Alcohol intake • Lifestyle changes – dec stress, weight loss • Regular intercourse Consider referral if normal in both partners, and not conceived after 1 year. Consider early if Woman is >35 Or Known cause. Medical Treatment – ovulation induction e.g. Clomifene Surgical Treatment – to dec tubal occlusions e.g. laparoscopy Assisted Reproductive Technology (ART) = e.g. intrauterine insemination, IVF etc.

Answer 36

Implantation begins at day 6 - trophoblast cells interact with the endometrial lining once it has ‘hatched’ and lost the zona pellucida. The blastocyst then embedded within the endometrium, to interact with vasculature and secretory glands of the endometrium.

Answer 37

The placenta begins to develop in the second week of the pregnancy. placenta develops from trophoblast cells. amniotic membrane fuses with the chorionic membrane to produce a single amniotic cavity. Projections around the outer surface of the membrane are concentrated into a single disc-like space, which goes on to become the placenta. initial unit of exchange- villi

Answer 38

Days 13-15 Primary Cytotrophoblast sends off projections through the syncytiotrophoblasts. Forms a cytotrophoblastic shell Intervillus spaces Days 16-21 Extra Embryonic mesoderm (somatic layer) invades into the primary villi = secondary villus (3 layers) Days 17-22 Chorionic vessels grow up into the villus - Branches of umbilical vein and artery - waste products to the villi through the umbilical arteries (paired), oxygen and nutrients to the fetus via the umbilical vein (singular). Maternal blood vessels then surround villi - endometrial arteries and veins Barrier becomes progressively less by reducing the number of cytotrophoblast cells so more optimised for transport. 4-5th month Decidua form septae which separate tertiary villi into groups called cotyledons.

Answer 39

Transport: 1. Simple diffusion across a concentration gradient e.g. water, electrolytes, gases Rate of gas exchange is flow limited, not diffusion limited. Therefore adequate uteroplacental circulation is required. 2. Facilitated diffusion e.g. glucose 3. Active transport - specific “transporters” expressed by the syncytiotrophoblast e.g. amino acids, iron, vitamins

Answer 40

The immune system of the fetus is very immature. Antibodies transported across the placenta into the fetal circulation so at birth the fetus has some defence against infection. Only certain immunoglobulins can cross placenta - IgG.

Answer 41

Endocrine function The placenta produces protein hormones - human chorionic gonadotrophin (hCG) - first 2 months Produced by syncytiotrophoblasts and is therefore pregnancy specific and excreted in maternal urine. Supports the secretory function of corpus luteum. Human placental lactogen (hPL) causes insulin resistance, inc the glucose availability to the fetus. Placental growth hormone (PGH) Corticotropin-releasing hormone (CRH) Steroid hormones - allows placenta to take on the role of the corpus luteum after first trimester. Also, oestrogen and progesterone keep the HPG axis in a ‘pregnant state’. Progesterone promotes an increase in appetite so increased fat deposition to support fetus and breastfeeding.

Answer 42

Decidua - endometrium cells that become specialized to modulate degree of invasion of conceptus. Balanced by factors that promote and inhibit decidualisation. If implantation in a location with no decidua or suboptimal decidual reaction then get defects. Defects: Incorrect site: – Ectopic pregnancy – Placenta praevia Incorrect depth: Too shallow: – placental insufficiency – pre-eclampsia Too Deep: – Placenta accrete – Placenta increta – Placenta percreta

Answer 43

Transfer across the placenta can also lead to harmful substances (‘teratogens’) being transferred. Blood group incompatibilities can also occur - Rhesus disease of the new-born - maternal antigens cross into the fetal circulation and attack fetal blood cells. Teratogens have greatest effect in embryonic stage (3-8 weeks) - body system development. Also pre-embryonic can have lethal effects. Harmful substances: • thalidomide – Limb defects • Alcohol – FAS and ARND • therapeutic drugs – Anti-epileptic drugs, Warfarin, ACE inhibitors • drugs of abuse – Dependency in the fetus and newborn • maternal smoking INFECTION IN PREGNANCY T O R C H Toxoplasmosis Other- syphillus, HIV, varicella Rubella Cytomegalovirus (CMV) Herpes Simplex (HSV)

Answer 44

Oxygen transport in fetal blood: The fetal blood has lower partial pressure of oxygen to allow gradient of transfer from mother to fetus. Progesterone causes maternal hyperventilation which causes inc pH which inc Hb affinity and dec CO2 To dec affinity maternal 2,3-BPG produced Release of O2 to foetus HbF - week 12 - alpha and 2 gamma subunits - greater affinity as it does not bind 2,3-BPG. Double Bohr effect During exchange in placenta CO2 passes into intervillous blood so pH dec so dec affinity in mother. Foetus give up CO2 down gradient so inc pH so inc affinity Double haldane effect Mother - gives up O2 so Hb accept more CO2 Foetus- gives up CO2 so accepts more O2

Answer 45

longest period of development, from 9 weeks to term. Prepares for independent life after birth.

Answer 46

Size Weight gain in the early fetal period, the tissue contributing to the weight is protein e.g. due to muscle development. Later on during the fetal period, adipose tissue is developed for metabolic purposes and for regulation of heat. Proportion of growth Initially, the head forms approximately 50% of the length of the fetus Then limbs and trunk elongate, so that the head is approximately ¼ of the overall length. Assessment - Symphysis-fundal height - assess growth by measuring the length from the pubic symphysis to the top of the fundus of the uterus. 20 weeks = umbilicus 12 week and 20 week ultrasound scan to measure fetal growth.

Answer 47

Resp system Embryonic - lungs outpocuhing of foregut to create bronchopulmonary tree. Fetal - Budding and branching of the bronchioles starts in week 8-16; the pseudoglandular stage. Canalicular stage - Further branching to form respiratory bronchioles in weeks 16-26. Differentiation of cuboidal cells to pneumocytes. Saccular stage - The terminal sacs develop at week 26 to term. Type 1 and 2 pneumocytes develop to produce surfactant. Alveolar stage - 36 weeks+ The Cardiovascular System average fetal heart rate is between 110-160 beats per minute - fetal bradycardia is a sign of fetal distress. The Urinary System Starts producing urine - removal by placenta Fetal kidney function begins in week 10. Fetal urine forms most of amniotic fluid from 20 weeks. The Nervous System No movement until the 8th week. Then “practising” for post- natal life e.g. suckling, breathing. 4th month = corticospinal tract for co-ordinated movements, myelination incomplete until after 1 year. Myelination of brain starts at 9th month.

Answer 48

Viability is only a possibility once the lungs have entered the terminal sac stage - 24 weeks RESPIRATORY DISTRESS SYNDROME - Due to insufficient surfactant production Management: Antenatal - Glucocorticoid Neonate - Nasal continuous positive airway pressure (nCPAP) • Surfactant replacement therapy • Mechanical ventilation Infants born preterm are at high risk for neurodevelopmental disorders, cerebral palsy, Interventricular haemorrhage (blood vessels not well developed). Magnesium sulphate for neuro protection when between 24-29 weeks.

Answer 49

MEASURING GROWTH AND WELLBEING LMP- last menstrual period Mother senses Fetal movements - quickening’ from approximately 17 weeks. Symphysis-fundal height (20weeks = umbilicus) Ultrasound scan - 12 week Scan (dating Scan), rule out ectopic (if it is done transvaginally), identify multiple pregnancy, screening for chromosomal abnormalities (Nuchal Translucency scan) 20 week to detect foetal abnormalities - most structures developed and big enough to be seen on USS. Crown Rump Length - length of the fetus; i.e. from ‘head to tail’. Only early on at 7-13 weeks. Biparietal diameter - The distance between the parietal bones of the fetal skull. date pregnancies in 2nd and 3rd trimesters ABDOMINAL CIRCUMFERENCE & FEMUR LENGTH - Used in combination for dating and growth monitoring in 2nd and 3rd trimesters

Answer 50

•low birth weight: <2.5 kg •very low birth weight: 1.0 -1.5 kg •extremely low birth weight, <1.0 kg • Macrosomia > 4kg Reasons Premature, small or growth restriction, maternal malnutrition 2 types Symmetrical - abdominal circumference, biparietal diameter and fetal length all proportionally reduced. Genetic and TORCH infections Asymmetrical- abdominal circumference smaller. biparietal diameter and femur length normal. Placental insufficiency.

Answer 51

Amniotic fluid volume 8 weeks - 10ml 38 weeks - 1l offers an element of mechanical protection but also contains substances that are critical for lung development. Production - urine production by 9 weeks. Kidney function is to produce urine for amniotic fluid. Excretion by placenta. Recycling - inhaling amniotic fluid by the fetus ‘practicing’ breathing movements. This helps with production of the lung - surfactant. fetus swallowing the fluid, and so it enters the fetal GI tract. Composition - 98% water, and electrolytes, bile, hormones, fetal skin etc. AMNIOCENTESIS - Sampling of amniotic fluid, collects foetal cells, diagnostic test eg karyotyping. 1% Risk of miscarriage Oligohydramnios-too little • Placental insufficiency • fetal renal impairment • Premature rupture of membranes • Pre-eclampsia • Polyhydramnios- too much indicate an issue in the recycling of amniotic fluid. Issues co-ordinating the swallowing movement (i.e. CNS defect) or congenital abnormalities (e.g. trachea-oesophageal fistula) • Gestational diabetes • Fetal anaemia • Multiple pregnancy

Answer 52

Maternal malnutrition can cause symmetrical or asymmetrical growth restriction. Gas exchange through placenta not lungs so oxy blood shunted away. Summary: Placenta Umbilical vein Liver - small amount Ductus venosus shunts so from umbilical vein to IVC Liver and IVC drain into RA Foramen ovale so mostly LA Left ventricle and some into right Aorta and some into pulmonary trunk Ductus arteriosus shunts from pulmonary trunk to aorta Body At birth - shunts close and lungs for gas exchange

Answer 53

meconium stained liquor - meconium released prematurely from GI tract. Can lead to meconium aspiration. Can happen in pregnancies longer than 40 weeks. Chronic Hypoxaemia: • Growth restriction • Reduced fetal movement Hypoxia - Fetal chemoreceptors detect dec pO2 or inc pCO2 - Bradycardia by vagal stimulation (unlike adults) - dec oxygen demand of heart • HbF and increased [Hb] • Redistribution of flow to protect supply to heart and brain

Answer 54

Glucose Metabolism • reduction in maternal blood glucose and amino acid concentrations • maternal insulin resistance in the 2nd half of pregnancy - by Human Placental Lactogen (hPL) and prolactin. Oestrogen inc prolactin • increase in maternal free fatty acid, ketone and triglyceride levels - progesterone inc appetite in 1st half of pregnancy and diverts glucose into fat synthesis. • increased insulin release in response to a normal meal Cardiovascular Changes maternal vascular-neogenesis Dec systemic vascular resistance by oestrogen and progesterone - activation of RAAS (can cause peripheral oedema)- inc cardiac output by 40%. Inc plasma vol - can cause dilutional anaemia. Haematological changes - prepare for blood loss during delivery Clotting - inc procoagulants, dec anticoagulants and dec fibrinolysis. Can lead to thromboembolic disease. Renal Inc vasodilation = inc GFR by 55% Dec serum urea and creatinine Dec PCT absorption so glucosuria Smooth muscle relaxation + obstruction so inc size of kidney and dec speed of urine passage Inc risk of infection

Answer 55

GI Gravid uterus so displaces bowel - mechanical obstruction Progesterone: Dec LES tone so GORD Dec small + large bowel motility - dec mineral + water absorption Dec gallbladder contractility - gallstones Smooth muscle relaxation so slow gastric emptying - nausea, constipation Endocrine: Euthyroid state Oestrogen inc liver production of TBG Inc in TSH And thyroxine So same free levels for mother More Ca and phosphate absorption as inc calcitriol by kidneys but also inc phosphate excretion Resp Progesterone - tidal volume and oxygen uptake increase PCO2 dec - compensated resp alkalosis. ERV and TLC dec. Changes in MSK and skin Change in center of gravity → Increased lordosis and kyphosis → Forward flexion of neck Stretching of abdominal muscles → Impede posture → Strain paraspinal muscles This causes back+shoulder pain and tension headaches Increased mobility of sacroiliac joints and pubic symphysis, anterior tilt of pelvis This causes pelvic pain Fluid retention can compress structures such as median nerve -carpal tunnel Chloasma More melanin - linea nigra- pigmentation of where rectus muscles join Palmar erythema Vascular spiders

Answer 56

Iron deficiency anaemia is common. Complications are inc morbidity, preterm delivery, maternal fatigue and infant IDA Gestational Diabetes - glucose intolerance first recognised in pregnancy but does not persist after delivery. diagnosed using oral glucose tolerance test Associated with macrosomia, congenital defects, hypoxia and sudden death in baby. In neonate - hypoglycaemia (high insulin as adaptation but sugar suddenly gone), resp distress, jaundice. In mother - pre-eclampsia, polyhydraminos, premature, shoulder dystocia Risk factors. BMI above 30, previous macrosomia baby or gestational diabetes, family history of diabetes and ethnicity associated with diabetes.

Answer 57

pregnancy-induced hypertension, with proteinuria +/- maternal organ dysfunction after 20 weeks Severe - severe hypertension and does not respond to treatment Risk Factors: •40 years or older •Nulliparity •pregnancy interval of more than 10 years •family history/previous history •BMI •vascular disease eg hypertension renal disease multiple pregnancy Pathogensis: Impaired invasion of trophoblast so shallow invasion of spiral arteries - high resistance - dec blood flow • Leads to hypoperfusion and ischemia Symptoms: • Headache • Vision disturbance • Epigastric pain • Swelling of hands, feet, face • Vomiting • SOB Complications maternal: • Seizure • Cerebral hemorrhage • Renal failure • Pulmonary oedema • HELLP syndrome: Haemolysis, Elevated Liver enzymes, Low Platelets • DIC Fetal: • Growth restriction •Oligohydramnios • Placental infarct or abruption • Fetal distress • Premature delivery • Stillbirth

Answer 58

Dyspnea of Pregnancy - Increase in wakefulness drive Could be: • Anemia • DVT/PE • Pneumonia/ARDS • Pulmonary oedema

Answer 59

Labour (parturition) process by which fetus and supporting placenta and membranes pass from the uterus to the outside world. 1st stage = regular uterine contractions and cervical dilatation till 10cm 2nd = from full dilatation until the fetus is born. 3rd = from the birth of the fetus until delivery of the placenta and membranes.

Answer 60

1. Softening of the pelvic ligaments may allow some expansion to occur. 2. Increase in myometrial activity- contractions 3. Cervical dilatation and effacement:

Answer 61

Triggered by prostaglandins: • Marked reduction in collagen and increase in glycosaminoglycans (GAGs) • Decreases the aggregation of collagen fibres. •collagen bundles ‘loosen’. • Influx of inflammatory cells, and an increase in nitric oxide output.

Answer 62

During pregnancy, the myometrium gets much thicker due primarily to increased cell size and glycogen deposition. Early pregnancy: contractions may occur every 30 minutes or so, but are of low amplitude Braxton-Hicks’ contractions Noticeable contractions later - reduced frequency but increased amplitude - no effect on cervix. Prostaglandins - enhance release of calcium from intracellular stores Oxytocin: • Peptide hormone secreted from posterior pituitary gland (under control of neurons in the hypothalamus) - lower threshold for triggering action potentials.

Answer 63

Cervical dilatation and effacement Umbilical cord stop pulsating and then cut and then passive delivery of placenta. Oxytocin or ergometrine injection can be give to cause contraction of uterus.

Answer 64

Passage: The birth canal diameter cannot extend beyond pelvis diameter - 11cm Passenger: Molding: -The changes in fetal head shape from external compressive forces. -Reduces diameter Fetal lie - longitudinal, transverse, oblique Fetal presentation- cephalic, breech Determine fetal position by Obstetric abdominal examination, Vaginal examination to feel sutures of baby’s head

Answer 65

Shoulder dystocia - vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus after the head has delivered and gentle traction has failed. Occurs when either the anterior, or less commonly the posterior, fetal shoulder impacts on the maternal symphysis, or sacral promontory, respectively. Pre-labour risk factors Previous SD Macrosomia Diabetes mellitus Greater than 30 BMI Induction of labour Intrapartum: Prolonged 1st or 2nd stage of labour Assisted vaginal delivery Complications: • Brachial plexus injury- Erb’s palsy • Neurological dysfunction/ disability • Neonatal mortality • PPH (post-partum haemorrhage) • Tears

Answer 66

Intermittent monitoring: • Doppler/ pinard stethoscope • Every 15minutes in 1st stage and 5 minutes in 2nd stage Continuous electronic fetal monitoring: • CTG (Cardiotocography) • Fetal scalp electrode Fetal blood sampling- to check pH

Answer 67

Membrane sweep- 39+ weeks • Prostaglandins (prostin vaginally) - starts contractions • IV Oxytocin -regular contractions • Artificial rupture of membranes (ARM)

Answer 68

Assisted delivery - forceps, suction cup Indicatons: Fully dilated cervix - 2nd stage • Failure to progress - in 2nd stage baby should be delivered within 2hrs • Maternal exhaustion • Maternal conditions (ie heart disease) • Fetal compromise in 2nd stage - HR drop etc Caesarean section - can do in 1st stage Indications: • Malpresentation • Macrosomia • Failure to progress • Fetal compromise • Fetal malformations • Previous caesarean

Answer 69

Lack of acceleration on CTG Meconium Lack of movements Ante partum haemorrhage NORMAL = deceleration of heart rate due to pressure on brainstem during labour

Answer 70

Commonly squamous cell carcinomas. Clinical Features - Lumps Ulceration Skin changes Epidemiology - older women - 80+ In older women - associated with longstanding inflammatory conditions (e.g. lichen sclerosus) In women in their 60s associated with HPV 16 Can have precursor to squamous cell carcinoma which is vulval intraepithelial neoplasia - atypical cells but no invasion of basement membrane Spread: Direct extension - Anus Vagina Bladder Lymph Nodes - Inguinal, Iliac, Para-aortic Distant Metastases - Lungs Liver Definitive surgery would include removing the primary tumour and nodes.

Answer 71

The inner part of the cervix (endocervix) is made of simple columnar epilthelium. Outer part (ectocervix) is covered by squamous epithelium. Oestrogen everts cervix Simple columnar in contact with acidic environment of vagina - becomes irritated - ectropion Metaplasia occurs to change it to squamous in the transformation zone but inc risk of dysplasia. Cause - HPV 16 & 18 - Infect transformation zone. Produce viral proteins E6 & E7. Inactivate tumour suppressor genes p53 & Rb. Uncontrolled cellular proliferation of squamous cells in transformation zone. Leads to CIN - dysplasia Confined to Cervical epithelium - divided into CIN 1 / 2 / 3. 1 = bottom 1/3 of epithelial cells are abnormal. 2=2/3. 3=full length. SCC = when CIN invades basement membrane. Risk factors: • Sexual partner with HPV • Multiple partners • Early age of first intercourse • Early first pregnancy • Multiple births • Smoking • Immunosuppression Invasive Cervical Cancer (includes SCC and adenocarcinoma of endocervical glands) Presentation Bleeding (Post coital, Inter menstrual, Post menopausal) Abdominal Mass Local spread can involve the ureters, bladder, rectum and is extremely distressing with pain and fistula formation. Treatment: CIN1 • Often regresses spontaneously • Follow up cervical smear in 1 year CIN 2 & 3 • Needs treatment: • Colposcopy +/- • Large Loop Excision of Transformation zone (LLETZ) Invasive Cervical Cancer Hysterectomy and Lymph Node Dissection (iliac and aortic) +/- Chemoradiotherapy

Answer 72

Cervical Cancer Screening - detect pre-invasive lesion and to excise area completely before invasive malignancy develop - Brush used to scrape cells from transformation zone. Detects cells with abnormally enlarged nuclei possessing abnormal chromatin (dyskaryotic cells). Tested for HPV If positive – cells looked at under microscope Then referral for colposcopy where abnormal areas are excised by diathermy (loop biopsy). • Aged 25 – 49 = every 3 years • Aged 50 – 64 = every 5 years • Over 65 – only if recent abnormality Vaccination against HPV • Gardasil • Recombinant • Against HPV (6/11/16/18) • Protects from cervical, vulval, oral, anal cancers • Given aged 12-13

Answer 73

Endometrial cancer Presentation - Inter-menstrual/post- menopausal bleeding, mass 60-70yrs Can get endometriod (from endometrial hyperplasia and look like normal glands) or serous adenocarcinoma (more aggressive, abnormal glands). Endometriod spread by direct invasion - cervix (stage 2), vagina, ovaries (3), bladder, bowel (4). Serous - Exfoliates, Travels through Fallopian tubes, Deposits on peritoneal surface ( Transcoelomic spread) Associated with collections of calcium (Psammoma bodies) Treatment: Hysterectomy Bilateral salpingo- oophorectomy +/- lymph node dissection +/- chemo radiotherapy Risk factor = endometrial hyperplasia which is caused by excessive oestrogen Endogenous - Obesity (androgens -> oestrogens) - Early menarche/late menopause - Oestrogen secreting tumours Irregular cycle - Polycystic Ovary Syndrome Exogenous - Unopposed oestrogen hormone replacement therapy for menopause - Tamoxifen - for breast cancer - blocks oestrogen receptors in breast but stimulates in endometrium HNPCC Endometrial hyperplasia diagnosis - Thickened endometrium >7mm detected by ultrasound. Then biopsy taken and shows increased gland:stroma ratio

Answer 74

Fibroids are benign tumours of uterine smooth muscle - leiomyomas Pale, homogenous, well circumscribed mass oestrogen dependant so regresses after menopause. Presentation Pelvic pain Heavy periods - menorrhagia infertility. Urinary frequency (bladder compression) Uterine enlargement Histology - Whorled, intersecting fascicles of benign smooth muscle cells Malignant -leiomyosarcoma Atypical cells Doesn’t arise from a leiomyoma similar symptoms infiltrate locally with metastasis by the blood stream to the lungs

Answer 75

Tumours of the ovary may arise from the surface epithelium, germ cells or sex cord-stromal elements. Presentation: Later symptoms due to tumour mass Abdominal pain, distension, ascites, intestinal obstruction Urinary symptoms Gastrointestinal symptoms Hormonal disturbances Diagnosis: Ca -125 - Serum marker – diagnosis/monitoring recurrence - then do scan BRCA1/2 - Tumour suppressor genes - familial ovarian epithelial carcinoma - high grade serous cancers - Prophylactic salpingo-oophrectomy Epithelial Tumours - majority serous, mucinous or endometrioid - present as cystic masses Further classified as benign, borderline or malignant depending on histological appearance. Malignant epithelial tumours present late and prognosis poor Ovarian Serous Adenocarcinoma - Often show Psammoma Bodies, Often spreads to peritoneal surface by exfoliates. Ovarian Mucinous Adenocarcinoma - epithelial cells Secreting mucin Ovarian Endometrioid Adenocarcinoma - Glands resembling endometrium, May arise in endometriosis, May have synchronous endometrial endometrioid adenocarcinoma Germ Cell - most common is teratoma - mature (benign), immature or monodermal. Mature can have any of the 3 germ layers so skin, hair, teeth, bone, muscle, cartilage, neural tissue and epithelia. Presence of immature tissue such as primitive neuroepithelium indicates malignancy, a risk for intra-abdominal spread and can cause death. Other malignant germ cell tumours include yolk sac tumour, choriocarcinoma and embryonal carcinomas. All malignant. Tumour markers - alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (hCG).

Answer 76

Sex-cord Stromal Tumours - derived from the ovarian stroma, which is derived from the sex cords of the embryonic gonad. 1. Granulosa/theca cell tumours - resemble cells lining the ovarian follicle. Produce oestrogens and may be responsible for endometrial hyperplasia and breast cancer or precocious puberty. 2. Sertoli-Leydig cell tumours - sex-cord stromal tumours that produce androgens and cause masculinisation, amenorrhoea and infertility, Hirsuitism, Breast atrophy. Metastases to the ovary: tumours derived from Müllerian epithelium, i.e., from the uterus, Fallopian tubes, contralateral ovary or pelvic peritoneum. Also gi and breast carcinomas.

Answer 77

Tumours of the testis are commonest in men aged 15-34. Presentation- Painless testicular mass. Classified as germ cell tumours and sex cord- stromal tumours. Non-Germ Cell Tumours Eg Sertoli or Leydig cell tumours - benign. Lymphoma common. Germ Cell Tumours -(precursor = intratubular germ cell neoplasia) In postpubertal, 95% of tumours arise from germ cell tumours - malignant. 2 groups: seminomas and nonseminomatous (NSGCTs). Seminomas The peak age is 40-50 years. Confined to the testis for long periods of time. Metastasise by the lymphatics, most commonly to the iliac and paraortic lymph nodes. Further spread is rare. NSGCT - Many are mixed tumours - at least 2. 1. Yolk sac tumours occur in young children, good prognosis. Produce alpha fetoprotein (AFP). 2.Choriocarcinomas (elevated serum conc of beta- hCG) - occur in young adults. 3. Teratomas occur in men of all ages. Prepubertal men = benign, postpubertal men = malignant. NSGCTs tend to metastasise early via lymphatics and blood vessels. Can present with metastases and primary testicular tumour being non-palpable. Risk factor for both: Familial predisposition Cancer in one testis so inc risk of cancer in other testis 3-5x inc risk in cryptorchidism (failure of testicular descent into the scrotum). Orchiopexy (surgical placement of the undescended testis into the scrotum) before puberty decreases this risk of cancer. Management: Testicular tumours are treated by radical orchiectomy. Seminomas are radiosensitive so radiotherapy gives best prognosis. After surgery, NSGCTS are treated with aggressive chemotherapy.

Answer 78

period from the delivery of the placenta to six weeks after this. During this time the body returns to a pre-pregnancy state - Low oestrogen levels so: Lower genital tract - Reduction in size of vulva, vagina and cervix Poor lubrication of the vagina Transformation zone of the cervix withdraws into the endocervix Internal os is closed haematological - Bleeding- initial heavy flow (lochia rubra) Changes from red-brown/red-pink-heavy white (lochia alba). Passage of clots not normal. Menstruation returns (new endometrium by week 3 and menses by week 6) unless nursing cardiovascular function - reversal of pregnancy changes skeletal - ligament laxity resolves

Answer 79

Haemorrhage (>500ml) o Primary (up to 24hrs after birth). Postpartum H (PPH) if inadequate uterine contraction after delivery. o Secondary (24h – 6 weeks later). Prolonged or excessive bleeding once mother is at home. Causes of PPH: Tone (atony) Tissue (Retained placental tissue) Thrombin (clotting disorder) Trauma Uterine inversion o The uterus turns inside out – occurs when delivering the placenta. emergency. Perineal trauma o Bruises/tears o Sequelae (e.g. involving perineal body and anal sphincter) • Maternal collapse/cardiac arrest o Amniotic fluid embolism o Hypoglycaemia o Hypotension/hypovolemia Thromboembolic disease - can lead to PE Managed by assessing risk factors, taking preventative measures and then prompt diagnosis. Treatment is with anti coagulation - heparin, warfarin, new anti-coagulants • Pyrexia/sepsis focus in - Genital tract, urinary tract or lactation ducts. Am,e sure to examine.

Answer 80

Postnatal blues - more tearful or anxious - normal up to 2 weeks - reassurance Post-partum depression- within 4 weeks - if greater than 1 month then pharmacological treatment Puerperal psychosis - within 4 weeks - anxiety, mania, paranoid thoughts, delusions - esp in mothers with pre-existing mental health conditions- suicide and infanticide risk - pharmacological. PTSD- psychological therapies.

Answer 81

During pregnancy high levels of these hormones cause full development of breasts: oestradiol + progesterone prolactin (PRL) + human placental lactogen (hPL)

Answer 82

Hormones which affect the breast are: • Mammogenic (promote proliferation of alveolar & duct cells) • Lactogenic (promote milk production) - PRL - Released when suckling which stimulates neurons from the spinal cord to inhibit dopamine release which maintains milk production. • Galactokinetic (promote contraction of myoepithelial cells) - oxytocin - Neurons from the spinal cord stimulate oxytocin release, which causes myoepithelial cells to contract and eject milk – the “let-down” reflex. • Galactopoietic (maintain milk production).

Answer 83

Once lactation ceases, milk accumulates in the alveoli of the breast causing distention and atrophy of the glandular epithelium. mechanical factors suppress milk secretion, not hormonal changes. Dopamine agonists e.g. bromocriptine can be given to artificially supress lactation

Answer 84

milk accumulation in the in the lactiferous ducts of the breast can lead to inflammation, with or without infection. Typically occurs if the mother does not breastfeed with both breasts so one unused. Staph aureus Can lead to abscess Continue feeding and inc frequency on affected side. Antibiotics.

Answer 85

The breast consists of a series of secretory lobules, which empty into ductules. These ductules from 15 to 20 lobules combine into a duct, which widens at the ampulla—a small reservoir. The lactiferous duct carries the secretions to the outside.

Answer 86

support of the pelvic organs, namely the vagina, uterus, ovaries, bladder and rectum. 1. Suspension- strong vertical support. cardinal ligaments (holding the cervix and upper vagina in place) & the uterosacral ligaments (holding the back of the cervix and upper vagina laterally) and round ligament ( maintain the anteverted position of the uterus). 2. Attachment - Arcus tendinosus fascia pelvis (ATFP) (“white line” ) Endopelvic fascia- stretches from the white line laterally to the vaginal wall medially. Urethra lies anterior and above it so gets compressed against it during inc intra-abdo pressure. Maintains urinary continence 3. Fusion - involves urogenital diaphragm and the perineal body. Lower half of the vagina is supported by fusion of the vaginal endopelvic fascia to the perineal body posteriorly, the levator ani laterally and the urethra anteriorly. Continence Maintain high Intra-abdominal pressure Childbirth - contributes to the birth canal

Answer 87

Deep muscles pelvic floor is made up predominantly by the levator ani muscles: Pubococcygeus Puborectalis Iliococcygeus midpoint of these attachments is the perineal body - central point between the vagina and the rectum. U-shaped encircle the urethra, vagina, and rectum Superficial muscles: Bulbospongiosus Ischiocavernosus Superficial transverse perineal 1 and 3 can undergo iatrogenic damage during medio-lateral episiotomy which is done to prevent 2nd or 3rd degree tear. Complications = infection, haemorrhage, dyspareunia, and damage to the anal sphincter. Urogenital diaphragm sheet of dense fibrous tissue that spans the anterior half of the pelvic floor. Arises from the inferior ischiopubic ramus. Attaches medially to the urethra, vagina and perineal body.

Answer 88

Pelvic Organ Prolapse Loss of support so prolapse of structures into vagina. Anterior compartment bladder and/or urethra: o Cystocele = bladder Urethrocele = urethra o Cystourethrocele = both Middle Uterus into vagina Vault’ (apex of vagina) prolapse can occur after hysterectomy as the supportive ligaments have to be cut when removing the uterus. Posterior bowel or surrounding structures: Rectocele = rectum Enterocele = loops of bowel involved entering the rectouterine pouch (Pouch of Douglas) Urinary Incontinence - stress increased abdominal pressure causes ‘leaks’ of urine, as the support to the urethral sphincter (via the pelvic floor) is inadequate. Vulval problems related to tension of the levator ani muscles. Posterior Compartment Pelvic Floor Dysfunction - constipation/incomplete evacuation and anal incontinence due to anal sphincter injury - attached to levator ani muscles.

Answer 89

age, vaginal delivery, oestrogen deficiency e.g. post-menopausal, chronic increased abdominal pressure, connective tissue or neurological disorders. Prolapse lump down below, or something ‘coming down’. symptoms relating to where the prolapse is occurring, e.g. constipation. Then do examination For stress incontinence - passing urine on coughing, laughing, or other activities that increase abdominal pressure. Not much to see on examination, other than obvious injury to the pelvic floor. Urodynamic studies Management 1. Non-surgical options Use of pessaries e.g. ring pessaries as additional support 2. Surgical options many, depending on type of prolapse. might involve hysterectomy or using ‘mesh’ support in a vault prolapse. For stress incontinence - pelvic floor muscle training. Surgical intervention to create ‘slings’ to support the urethral sphincter.

Answer 90

Breast milk protects the baby from infection in a variety of ways: 1. Lactoferrin - binds iron, preventing the proliferation of E.coli 2. Populates neonatal gut with non-pathogenic flora 3. Presence of bacteriocidal enzymes 4. Contains specific immunoglobulins 5. Contains lymphocytes (mainly T-cells) and granulocytes that play a role in cell-mediated immunity.

Answer 91

family planning following childbirth helps reduce both maternal and typically occurs if the mother does not breastfeed with both infant deaths, reduces the risk of pre-term birth, low birthweight and breasts, and therefore milk can build up in the lactiferous ducts small-for-gestational age babies.

Answer 92

Female Genital Mutilation practice of damaging the female external genitalia. severe pain, potential sepsis, or haemorrhage. complications include psychological effects, sexual dysfunction, and difficulty conceiving, as well as chronic pain and menstrual disorders.

Answer 93

Blood supply – the internal and the external pudendal arteries and drains through corresponding veins. Lymphatic drainage- via the inguinal lymph nodes. Nerve supply- branches of the pudendal nerve, which derives its fibres from the ventral branches of the second, third and fourth sacral nerve

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