Flashcards in repro LO Deck (327)
describe the production of sperm
Germ cells known as spermatogonia undergo mitosis, some continue mitosis others undergo meiosis and become primary spermatocytes. This divides into two secondary spermatocytes and undergoes further division into two spermatids each with 23 chromosomes.
Leydig cell produce
Leydig cells in the testis produce testosterone and androgens that also stimulate sustencular cells in the seminiferous tubules
Sertoli cells role
support sperm producing cells and produce inhibin
LH and FSH and produced in the
which hormone stimulate the production of LH and FSH in the anterior pituitary and where from?
GnRH produced in the hypothalamus
endocrine cells to produce steroid and peptide hormones which then can target the anterior pituitary and hypothalamus in a long loop positive/negative feedback. it also stimulates Leydig cells.
gamete production in the testes
role of inhibins
inhibits FSH secretion
stimulate FSH secretion as well as spermatogenesis
factors affecting spermatogenesis
problems with hormonal control (genetics, tumours, medications, functional)
problems at the site of production (genetics, cancer, surgery, trauma, infection)
skin for hair growth, balding, sebum production, liver for synthesis of serum proteins, male sexual organs for penile growth, spermatogenesis, prostate growth and function, brain for libido, mood, muscle for increase in strength and volume, kidney for stimulation of erythropoietin production, bone marrow for stimulation of stem cells, bone for accelerated linear growth and closure of epiphyses.
GnRH action in female
stimulate LH and FSH secretions from anterior pituitary
FSH action in female
stimulate follicular recruitment and development
LH action in female
maintain dominant follicle, induce follicular maturation and ovulation, stimulate CL function
oestradiol is produced from
oestradiol role in females
support secondary sexual characteristics and reproductive organs
negative feedback control of LH, GnRH and oestrogen for most of the cycle
except for late follicular phase – positive control of LH surge during day 12-14
stimulates proliferative endometrium
progesterone from corpus Luteum role
maintenance of secretory endometrium
negative feedback control of HPO
targets of oestrogen
targets of oestrogens are central nervous system, anterior pituitary, hypothalamus, fat distribution, ovary, mammary gland, bone maturation and turnover, cervix, vagina, fallopian tube, uterus. Its systemic effects include protein metabolism, carbohydrates, lipids, water and electrolyte balance, blood clotting.
production of eggs description
Oogonia the ovary germ cell complete mitosis and meosis by the firth month of female development resulting in primary oocytes resulting in ovaries containing half a million primary oocytes. Upon puberty meiosis resumes, with the primary diving into two sells a large egg (secondary oocyte) and a tiny first polar body which disintegrates. If the secondary is chosen for ovulation it undergoes meosis as the sister chromatids separate, and the final step occurs with fertilisation
ovaries hormone produce
. The ovaries also produce inhibins that inhibit FSH secretion and activins that stimulate FSH secretion as well as oogenesis.
the ovarian cycle
luteal phase description
ruptured follicle forms the corpus luteum, secretes hormones in preparation for pregnancy. If not it will cease function and the ovarian cycle continues.
follicular growth lasts for
endometrial cycle stages
endometrial cycle post ovulation description
after ovulation corpus luteum hormones convert the thick endometrium into a secretory phase, if not pregnancy occurs the superficial layer is lost during menstruation.
early follicular phase hormonal control
GNRH stimulates FSH and LF which stimulate the follicle to produce androgens and AMH, androgens stimulate further production of oestrogens as stimulated by FSH, this generates a positive feedback as it also inhibits FSH, LH, and GnRH.
late follicular phase and ovulation hormonal control
GnRH stimulate FSH and LH. FSH stimulates the follicle to produce inhibin which inhibits FSH, but also lots of oestrogen which now stimulates the hypothalamus to produce GnRH. LH stimulates the production of androgens which stimulate more follicular production of oestrogen as well as a small amount of progesterone which stimulates LH and GnRH production.
early luteal phase hormonal control
GnRH, FSH and LH levels decrease in response to increased oestrogen, progesterone and inhibin from the corpus luteum
late luteal phase hormonal control
tonic secretion of GnRH stimulates increased FSH to develop a new follicle and LH. The corpus luteum disintegrates reducing levels of oestrogen and progesterone.
factors affecting oogenesis
stress, nutritional status
changes in the day and night cycle
problems with hormonal control (genetics, tumours, medications, functional) problems at the site of production (genetics, cancer, surgery, trauma, infection)
morning sickness affects what percentage of women?
morning sickness can develop into
pregnancy Cardiac output increases to
blood pressure drops in which trimester?
during pregnancy renal plasma flow increases by
during pregnancy GFR increases by
pyelonephritis is associated with what in pregnancy?
plasma volume increases by what during pregnancy?
RBC mass increases by what during pregnancy?
iron requirements increase by how many grams?
progesterone effect on respiratory system?
reducing C02 consumption and oxygen consumption increases by 20% with hyperaemia of respiratory mucous membranes.
GI affects during pregnancy
peristalsis is reduced, gastric emptying slows, the cardiac sphincter relaxes and overall GI motility reduced due to increased progesterone and reduced motilin. Acid reflux
focus of pre-pregnancy counselling?
It should focus on general health measures such as improving diet, optimising BMI, reducing alcohol consumption, smoking cessation and folic acid. A risk assessment should be conducted considering socioeconomic factors, parity (Pre-eclampsia), occupation, substance misuse.
goal of pre-pregnancy counselling?
ensure optimum maternal and psychiatric health, stopping unsuitable drugs and advice complications and sometimes against pregnancy. With attempts made to reduce any fetal or maternal risks.
what should an antenatal exam focus on?
(wellness, foetal movement), blood pressure, urinalysis, abdominal palpation (estimated size, liquor volume, and symphyseal fundal height). Determine foetal position and foetal heart.
what infection screens are offered to a pregnant women?
what blood/immunological screens are available for pregnant women ?
anaemia and (rhesus disease, anti C, anti Kell)
when does the first scan occur?
what does the first scan look at?
(viability, multiple pregnancy, abnormalities, down syndrome screening
what maternal risk factors during pregnancy can be examined?
Beta CG, PAPP-A and fetal nuchal translucency
second trimester US for
neural tube defects, if no Nuchal translucency possible alpha fetoprotein screen.
amniocentesis miscarriage percentage risk?
down syndrome screening issues
cut off high risk is 1/150, overall is 1/700 but isn’t an exact yes or no answer)
mechanical changes during pregnancy
spine curvature increases
metabolic changes during pregnancy
the body enters a starvation like mode with increased ketone production
thyroid issues during pregnancy
TSH reduces but binding globulins increase but there is then iodine deficiency often with temporary hyperthyroidism in the first semester,
issue with a supine position If pregnant
25% reduction in CO
intrapartum CV changes
pain results in increased catecholamines and CO increases 10% in labour and 80% in 1st post-delivery. However there is also an effective ½L of blood added.
how long post partum before CV returns to normal
what increase in folate during pregnancy
10-20 fold folate requirements
how might human placenta lactogen affect insulin resistance?
increased insulin resistance
Hg during pregnancy
WCC during pregnancy
platelets during pregnancy
CRP during pregnancy
ESR during pregnancy
urea during pregnancy
creatinine during pregnancy
urate during pregnancy
reduced but increases during gestation - uric acid marker for renal dysfunction and marker for pre-eclampsia
24hr protein during pregnancy
total protein during pregnancy
albumin during pregnancy
AST/ALT/GGT during pregnancy
Alk Phos during pregnancy
bile acids during pregnancy
D dimer during pregnancy
HBA1c during pregnancy
Combined hormonal contraception method
ethinyl oestradiol and synthetic progesterone. Stop ovulation and affects cervical mucus and endometrium (21 days and a hormone free week)
Combined hormonal contraception options
pill taken daily
patch EVRA (changed weekly)
Ring Nuvaring - changed every 3 weeks
take same time every day without free trial can be desogestrel pill or traditional LNG NET pill
injectable progestogen method
injection every 13 weeks that prevents ovulation, alters cervical mucous making it hostile to sperm, makes endometrium unsuitable for implantation
subdermal progestogen implant method
inhibition of ovulation and effects cervical mucous, can last 3 years.
intrauterine contraception options
copper or levonorgestrel
intrauterine contraception copper method
toxic to sperm, stop sperm reaching egg, may sometimes prevent implantation of fertilised egg. Can last 5-10 years.
intrauterine contraception levonorgestrel method
affect cervical mucus and endometrium but still ovulate it stops fertilisation and implantation, slow release progestogen.
combined hormonal contraception general side effects
breast tenderness, nausea, headache, irregular bleeding first 3 months, mood changes, weight gain. Serious include venous thrombosis, increased arterial thrombosis (MI/stroke), avoid if active gall bladder or previous liver tumour, increased risk of cercial cancer or breast cancer.
EVRA patch side effect
<5% skin reaction
progestogen pill side effects
appetite increase, hair loss, mood change, bloating, headache, acne, still avoid if current breast cancer or liver tumour.
injectable progestogen side effects
delay in return to fertility, reversible reduction in bone density, problematic bleeding, weight gain.
subdermal progestogen implant side effects
30% have prolonged frequent bleeding, may cause mood changes
intrauterine contraception general risk
1:100 perforation risk, 5:100 expulsion risk, <1:1000 small infection risk.
copper intrauterine contraception risk
may make periods heavier
female sterilisation procedure
laparoscopic sterilisation – Filshie clips applied across tube to block tube lumen
may do a salpingectomy at planned caesarean section if discussed in advance
laparoscopic sterilisation failure risk
male sterilisation procedure
vans deferens divided and ends cauterised small incision midline scrotum.
failure risk for vasectomy
is 1 in 2000 lifetime.
issues with reversing with a vasectomy
describe the abortion act
2 drs must sign and under
Under 24 weeks and continuation of pregnancy involves risk greater than if the pregnancy were terminated of injury to the physical or mental health of the pregnant woman or of the existing child (ren) of the pregnant. risk that if the child were born it would suffer physical or mental abnormalities as to be seriously handicapped
surgical abortion method
cervical priming misoprostol 3 hrs preop. Transcervical suction catheter. (5-12 weeks) 1
medical abortion method
mifepristone oral antiprogestogen tablet, 36-48hrs later misoprostol expels pregnancy (5-24 weeks).
can be done at home.
physiology of the initiation of labour description
the cervix softens, myometrial tone changes to allow for coordinated contractions, progesterone decreases whilst oxytocin and prostaglandins increase to allow for labour to initiate.
stage 1 of labour description
dilation of 0.5cm-1.0cm per hour and is completed once the cervix is fully dilated.
stage 2 part 1 of labour description
passive stage, important to position for gravity to assist
stage 2 part 2 labour description
active second stage expulsive contractions prima expect crowning within two hours, multi within an hour.
stage 3 of labour
from the birth of the baby to the expulsion of the placenta and membranes
mechanisms part of labour
A) before engagement
B) engagement, flexion and descent
C) descent, rotation
D) complete rotation, early extension
E) complete extension
G) anterior shoulder delivery
H) posterior shoulder delivery
methods of assessing labour
abdominal palpation (assessing orientation, engagement and position)
vaginal examination (for cervix dilation but important for high risk)
monitoring of liquor (colour, smell, consistency)
auscultation of the foetal heart (stage 1 HR every 15 minutes, stage 2 every 5 minutes)
palpation of uterine muscle contractions
external signs (rhomboid of michaelis and anal cleft line)
methods of analgesia
breathing, message, TENs, paracetamol, dihydrocodeine
remifentanil patient controlled analgesia (might overdo it making pushing harder)
pharmacokinetics in pregnancy refers to
the process of Administration, Distribution, Metabolism and Excretion.
pharmacodynamics of pregnancy refers to
affect of site of action and receptor response to drugs. Altering the efficacy.
issue with absorption in pregnancy
morning sickness, increased gastric emptying and gut motility, increased blood flow and for inhalation there is increased cardiac output and decreased tidal volume may increase absorption of drugs. In general, there is increased absorption.
issue with distribution in pregnancy
: increased plasma volume and fat will alter distribution and greater dilution of plasma will decrease relative amount of plasma proteins resulting in more free drugs
issues with metabolism in pregnancy
oestrogen and progestogens can induce or inhibit P450 enzymes, increasing or reducing metabolism.
issues with excretion in pregnancy
GFR is increased by 50%, reduced plasma concentration
pharmacodynamic issues with pregnancy
changes in blood flow
changes in receptor
issues with medication in breast feeding
most drugs will be present at lower doses. Avoid immunosuppressants, anti-convulsant, drugs of abuse, amiodarone, lithium, radio-iodine, cytotoxic.
guidelines for medication and breast feeding
Avoid unnecessary drug use, check on up to date information. If licensed and safe in paediatrics use likely to be safe in pregnancy. Choose drugs with pharmacokinetic properties that reduce infant exposure (high protein bound).
principles for prescribing in pregnancy
safe to assume all drugs will cross the placenta
try non-pharma logical treatment first
avoid new drugs unless proven safe
use lowest effective dose
use the drug for shortest time, intermittent if possible
consider stopping or reducing dose before delivery
don’t under treat disease harmful to the foetus
common reasons for abnormal labour
failure to start labour, inadequate progress, malposition, foetal distress
failure to start labour treatment
induction and amniotomy with I.V oxytocin to achieve adequate contractions.
cephalopelvic disproportion refers to
(foetal head in correct position but too big to negotiate pelvis)
in pregnancy malposition refers to
(foetal head being in an incorrect position)
foetal distress may arise from
excessive contractions reducing placental blood flow
the 4 T's of post partum haemorrhage
tone, Trauma, Tissue, Thrombin
primary post partum haemorrhage is
secondary post partum haemorrhage refers to
post partum to 6 weeks
venous thromboembolism in pregnancy investigation and treatment
hypercoagulability treat with thromboprophylaxis. D-Dimer unreliable in pregnancy treat with heparin.
1 maternal death occurs how many minutes along?
maternal mortality refers to
death of a woman while pregnancy or within 42 days of termination of pregnancy. Any cause related to the pregnancy/management.
maternal mortality ratio refers to
No. of death during given time per 100,00 livebirths during the same period. Risk each pregnancy.
maternal mortality rate refers to
No. of death in given time period per 100,000 women of reproductive age or woman-years of risk exposure in same time period. Frequency of exposure to the risk
proportionate mortality ratio : (maternal)
: maternal deaths as proportion of all female deaths of those of reproductive age in a given time period. Measure of women’s risk of becoming pregnant and well as the risk of dying pregnant
still birth is defined as
birth of a death baby after 20/24/28 weeks
early neonatal death is defined as
first week of life
late neonatal death is defined as
death within 28 days of life
perinatal refer to
still birth and neonatal
infant mortality refers to
death of an infant within the first year
child mortality refers to
death of a child within 5 years
measuring global maternal and neonatal mortality facility
health information systems, registries, confidential enquiries, maternal death review, audit
measuring global maternal and neonatal mortality facility population
law, vital registration, census, surveys or surveillance (sisterhood or verbal autopsy).
what are the three areas responsible for perinatal and maternal death
addressing the delay in decisions to seek care
addressing the delays in reaching care
addressing the delays in receiving care
methods for reducing global maternal and perinatal death
better antenatal care (monitoring weight, B.P. proteinuria, folic acid, malaria prophylaxis), skilled attendant at birth, emergency obstetric care.
ensure the baby is breathing, exclusive breastfeeding right away, warmth and handwashing before baby contact.
vulvovaginal candidosis symptoms
itch, discharge, thick ‘cottage cheese’ but usually asymptomatic carriage
bacterial vaginosis symptoms
watery/yellow fishy discharge, sore itch from dampness, asymptomatic, worse after sex
vulvovaginal candidosis signs
fissuring, erythema with satellite lesions, characteristic discharge
bacterial vaginosis signs
thin homogenous discharge
list the types of miscarriage
• List the types of miscarriages
initial management of a threatened miscarriage
initial management of a inevitable miscarriage
– if heavy bleeding then may need evacuation
initial management of a missed miscarriage
either conservative, medical (prostaglandins (misoprostol)) or surgical
initial managment of a septic miscarriage
antibiotics and evacuate uterus
definition of a antepartum Haemorrhage
Haemorrhage from the genital tract after the 24th week of pregnancy but before the delivery of the baby.
antepartum haemorrhage can be caused by
Placenta Praevia, placental abruption, unknown, local lesions or vasa praevia.
initial managment of APH
vary from expectant treatment to attempt a vaginal delivery to caesarean depending on amount of bleeding, general condition of mother and gestation.
list common STI's
gonorrhoea Male presentation
asymptomatic, thick profuse yellow discharge, dysuria.
Gonorrhoea Female presentation
vaginal discharge, dysuria, post-coital bleeding
Chlamydia male presentation
asymptomatic, slight watery discharge, dysuria
chlamydia female presentation
vaginal discharge, dysuria, post-coital bleeding
chlamydia presentation for both sexes
80% have no symptoms. The rest have recurring symptoms – monthly, annually. Burning/itching then blistering then tender ulceration. Tender inguinal lymphadenopathy. Flu-like symptoms. Dysuria, Neuralgic pain in back, pelvis and legs,
Trichomoniasis presentation males
trichomoniasis female presentation
profuse, thin vaginal discharge, greenish, frothy and foul smelling, vulvitis
anogenital warts presentation
Lumps with a surface texture of a small cauliflower. Occasionally itching or bleeding especially if perianal or intraurethral.
syphilis primary presentation
syphilis secondary presentation
Rash, mucosal ulceration, neuro symptoms, patchy alopecia, other symptoms
syphilis tertiary presentation
Neurological, cardiovascular or gummatous – skin lesions, (all v rare).
Nucleic Acid Amplification Test (NAAT) on urine or swab from an exposed site, Gram stained smear from urethra/cervix/rectum in symptomatic people. Culture of swab-obtained specimen from an exposed site using highly selective lysed blood agar in a 5% CO2 environment.
First void urine in men. Self-taken or clinician-taken swab from cervix, urethra, rectum as appropriate. All specimens tested using a NAAT
– clinical impression, swab from lesion tested using PCR.
urogenital warts diagnosis
PCR on a vaginal swab
Clinical signs Serology for TP IgGEIA, TPPA and RPR PCR on sample from an ulcer
gonorrhoea treatment and follow up
Blind treatment with ceftriaxone 1g im. Test of cure at 2 weeks and test of reinfection at 3 months.
chlamydia treatment and follow up
Doxycycline 100mg bd 1 week. Test for reinfection at 3-12 months. Earlier test of cure not needed unless symptoms persist.
herpes primary treatment
Aciclovir: various regimens – eg 400mg tds for 5 days, Lidocaine ointment
herpes infrequent recurrences treatment
Lidocaine ointment. Aciclovir 1.2g once daily until symptoms gone (1-3 days)
herpes frequent recurrences
Aciclovir 400bd long-term as suppression
Metronidazole 400mg po bd for 5 days or 2g single dose.
anogenital warts at home treatment
Podophyllotoxin (brands warticon and condyline), imiquimod (brand Aldara). Both home treatments.
anogenital warts other treatments
Others – cryotherapy Bulky warts – diathermy, scissor removal.
syphilis early stage Tx
- Benzathine penicillin 2.4 MU im once Or Doxycycline 100mg bd po 2 weeks
syphilis late stage Tx
Benzathine penicillin 2.4MU im weekly for 3 doses Doxycycline 100mg bd po 28 days
male complications for gonorrhoea
female complications for gonorrhoea
pelvic inflammatory disease, Bartholin's abscess
complications for gonorrhoea both
Acute monoarthritis usually elbow or shoulder. Disseminated Gonococcal Infection: skin lesions - pustular with halo
chlamydia male complications
chlamydia female complications
PID and hence ectopic pregnancy, pelvic pain and infertility. Probably only ~1% of women who get chlamydia will develop a problem with their fertility
complications for both sexes chlamydia
Reactive arthritis/ Reiter’s syndrome – urethritis/cervicitis + conjunctivitis + arthritis
Autonomic neuropathy (urinary retention), neonatal infection, secondary infection.
trichomoniasis complication s
miscarriage and preterm labour
cranial nerve palsies are commonest, cardiac or aortal involvement.
blood test assessment of ovulation
blood test to measure serum progesterone in the mid luteal phase of their cycle day 21 of a 28 cycle to confirm ovulation
when to refer to a fertility clinic?
Refer after 1 year of trying or if period irregularity, past medical issues, testicular issues, abnormal tests, HIV/Hep B, anxiety
female history fertility points
duration of infertility, previous contraception, fertility in past relationships, previous pregnancies and complications, menstrual history, medical and surgical history, sexual history, previous investigations, psychological assessments.
female fertility examination
weight, height, BMI, fat and hair distribution, galactorrhoea, abdominal examination, pelvic examination.
investigations for female fertility
Testing for ovulation, pelvic ultrasound, ovulation assessment, if irregular menstrual cycles then measure serum gonadotrophins
baseline assessment of what for female fertility
rubella immunity, chlamydia, TSH, mid luteal progesterone, PRL, TSH, testosterone
screening for female fertility
hysterosalpingography (HSG), HyCoSy (combined contrast and US) for tubal patency
tubal patency: laparoscopy
male history fertility
developmental (testicular descent, change in shaving frequency, loss of body hair), infections (STD, mumps), surgical (varicocele repair, vasectomy), previous fertility. Drugs/environment (alcohol, smoking, anabolic steroids, chemo, radiation, drugs), sexual history (libido, frequency and prior fertility assessments, chronic illness
male fertility examination
weight, height, BMI, fat and hair distribution, abdominal and inguinal examination, genital examination (epididymis, testes, vas deferens, varicoele), testicular size
male baseline assessments for fertility
semen analysis (volume, concentration, number, progressive motility, total motility, morphologically normal)
female group 1 ovulation disorders (anovulatory infertility) treatment
increase body weight, moderate exercise, offer pulsatile administration of gonadotrophin releasing hormone or gonadotrophins with LH to induce ovulation.
PCOS treatment of infertility
treat underlying cause, weight loss/gain, BMI >18 and <35, ovulation induction clomifene, gonadotrophins
tubal factors and endometriosis treatment for infertility
surgery for hydro salpinges before IVF, ideally offered a salpingectomy via laparoscopy
male infertility treatment options
IVF, sperm retrieval, urology, donor insemination
explanation of IVF
eggs harvested, then fertilised in lab with sperm, undergo divisions before being transferred to womb. Via intracytoplasmic sperm injection, ideally, we wait for 5 days if possible but if necessary 2 or 3 days. Spare embryos are kept in cryopreservation.
Gillick competence refers too
child under the age of 16 can consent if they fully understand and can communicated what is involved in the treatment, purpose, effects, risks, chances of success and availability of other options. If they do not pass, then the consent of a guardian is required.
gynae history for an adolescent
age of menarche
examination in an adolescent gynae examination
(never in a first visit and should only be conducted on consenting adolescents who are sexually active and when necessary)
Primary amenorrhoea refers too
failure of menstruation by the age of 16 In presence of normal secondary sexual characteristics, or 14 years in the absence of other evidence of puberty.
secondary amenorrhoea refers too
absent periods for at least 6 months in a women who previously had regular periods or 12 months if she previously had oligomenorrhoea
puberty induction in young women may be achieved through
oestrogen induction, once maximum height reached add progesterone
investigations in amenorrhoea
FSH, LH, PRL, TSH, testosterone, oestrogen. Pelvic USS, progesterone withdrawal bleed (pregnancy test).
secondary further investigations in amenorrhoea
weight, PCOS, pregnancy, fluctuating LH/oestrogens
polycystic ovaries investigations
USS-TAS, FSH, LH, oligo/anovulation, hyperandrogenism, US/direct inspection findings.
Fraser guideline -
– a doctor can proceed to give contraceptive advice and treatment to a girl under 16 if; they understand, doesn’t force her to tell her parents, is sexually active, her health is at risk, and it is in her best interests
persistent vulval irritation/discharge. yellow-green offensive discharge, vaginal soreness, itching.
red flush around vulva and anus
: Poor perineal hygiene, lack of oestrogen, chemical irritation.
foreign body presentation and examination
vaginal bleeding or foul-smelling refractory discharge. Examination under anaesthetic is required.
labial adhesions presentation
Clearly visible thin membranous line in the mid-line where the tissues fuse, the urethra may just be a pinhole. Most children are asymptomatic.
labial adhesions management
Surgical separation is rarely needed unless urinary symptoms are persistent and oestrogen therapy has failed
: frequent troublesome, irregular and heavy periods.
Diary may be helpful and irregular periods are common, and somewhat normal for the first 2 years. Haematological conditions must be ruled out, main treatment is POP or combined oral pill. If severe bleeding than tranexamic acid.
Dysmenorrhoea refers too
pain during menstruation
managment of dysmenorrhoea
Attributed to higher levels of prostaglandins, so anti-prostaglandin drugs such as mefenamic acid can be helpful as well as suppression of ovulation with the combined oral contraceptive pill.
if refractory then NSAIDS and oral contraceptive, a diagnostic laparoscopy.
risk with uterine cysts
can tort, become gangrenous and rupture threatening ovaries. Usually tender and mass present.
the anatomical support of the pelvic floor
endo-pelvic fascia refers too
: network of fibro-muscular connective tissue/ surrounds the various visceral structures. Fibromuscular components stretch but connective tissue breaks.
pelvic diaphragm refers too
layer of striated muscles with its fascial coverings
urogenital diaphragm refers too
superficial and deep transverse perineal muscles with their fascial coverings.
level 1 of the female pelvic floor consists of
level 2 of the female pelvic floor consists of
para-vagina to arcus tendinous fascia: pubocervical/rectovaginal fascia
level 3 of the female pelvic floor consists of
predisposing factors for uterovaginal prolapse
forceps delivery, large baby, prolonged second stage, advancing age, obesity, continence procedures ,hysterectomy
different types of prolapse
urethrocele refers too
prolapse of lower anterior vaginal wall involving urethra
cystocele refers too
prolapse of upper anterior vaginal wall involving the bladder
uterovaginal prolapse refers too
prolapse of uterus, cervix and upper vagina
enterocele refers too
prolapse of upper posterior wall of the vagina containing loops of small bowel
rectocele refers too
prolapse of the lower posterior wall of the vagina involving the rectum
examinations for pelvic organ prolapse
exclude pelvic mass, record position of examination, QoL. Objective Baden-Walker-Halfawy grading, POPQ score (gold standard).
investigations for pelvic organ prolapse
investigations: USS/MRI, urodynamics, renal USS/IVU
effects of pelvic organ prolapse on women's quality of life
sensation of bulge, pressure, protrusion, heaviness, difficulty inserting tampons. Urinary incontinence, frequency, weak stream, incomplete emptying, hesitancy, manual reduction of prolapse to start complete voiding. Urgency with bowel, splinting around bowel to aid defecation.
prevention of pelvic organ prolapse
avoid constipation, management of chronic chest pathology, small family size, improving antenatal and intrapartum care.
Physiotherapy for Pelvic organ prolapse
pelvic floor muscle training, increase pelvic floor strength and bulk to relieve the tension of the ligaments. Supplemented with perineometer, biofeedback, vaginal cones and electrical stimulation
surgery for pelvic organ prolapse
relieve symptoms, restore function both sexually and continence. Remember prophylactic antibiotics, thrombo-embolic prophylaxis, post-operative urinary Vs. SPC.
chronic hypertension during pregnancy is only evident earlier than how many weeks?
gestational hypertension is evident after how many weeks?
severe hypertension in pregnancy
mild hypertension in pregnancy
moderate hypertension in pregnancy
Pre-Eclampsia refers too
>20 weeks in association with significant proteinuria
symptoms of Pre-Eclampsia
headaches, blurring vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands and face, clonus, papilloedema, epigastric tenderness, reduced urine output, convulsion.
biochemical signs of Pre-Eclampsia
raised liver enzymes, bilirubin, raised urea, creatinine and urate, low platelets, low haemoglobin, signs of haemolysis, features of DIC.
management for Pre-eclampsia
check protein, BP., FBC, renal function, LFT’s, scan for growth, CTG. Only ‘cure’ is delivery of baby and placenta. Conservatively looking as anti-hypertensive (labetolol, methyldopa, nifedipine) and steroids for foetal lung maturity if <36weeks.
post delivery care for pre-eclampsia
Continue monitoring post-delivery. In case of seizure than Mg + sulphate bolus IV infusion, I.V. labetolol and hydralazine whilst avoiding fluid overload. Prophylaxis for PET in subsequent pregnancy is low dose aspiring from 12 weeks till delivery.
chronic management for pre-eclampsia
Drug review, pre-pregnancy care and control (<150/100), use of labetolol, nifedipine, methyldopa and continue monitoring of mother and foetus.
complications of hypertensive disorders
risk of placental abruption
multisystem multi-organ disorder
seizures, cerebral haemorrhage, stroke, HELLP (Haemolysis, elevated liver enzymes, low platelets), DIC (disseminated intravascular coagulation), renal failure, pulmonary oedema, cardiac failure.
foetal impaired placental perfusion leading to foetal distress, prematurity and increased PN mortality and intrauterine growth restriction.
HELLP refers too
(Haemolysis, elevated liver enzymes, low platelets)
DIC refers too
disseminated intravascular coagulation),
complications associated with diabetes in pregnancy
insulin requirements of mother increase
foetal hyper-insulinemia occurs causing macrosomia and more risk of neonatal hypoglycaemia and respiratory distress, jaundice
increased risks of diabetes in pregnancy
increased risk of foetal congenital abnormalities, miscarriage, polyhydramnios, shoulder dystocia, still birth and increase perinatal mortality, pre-eclampsia, worsening of maternal nephropathy, retinopathy, hypoglycaemia’s, infections.
signs/symptoms of VTE
pain in calf, unilateral increased girth of calf, muscle tenderness, breathlessness, pain on breathing, cough, tachycardia, hypoxia, pleural rub.
risks for developing a VTE
; older mothers, increase parity, smokers, BMI, IV drug users, PET, dehydration, reduced mobility, infection, operative delivery, prolonger labour, haemorrhage, prior VTE, thrombophilia, sickle cell disease
symptoms of a pelvic mass related to the ovaries
vague, IBS like symptoms, poor appetite, bloating, weight gain, pelvic mass, pressure
diagnosis of ovarian cancer
surgical/pathological, US scan abdomen and pelvis, CT scan, CA125, surgery
CA125 refers too
glycol protein antigen, however is not specific as produced in various malignant and benign conditions not all related to ovarian cancer
treatment for ovarian cancer
surgical, chemotherapy adjuvant or neo-adjuvant, CA 125 used in detecting and monitoring epithelial ovarian tumours.
surgical treatment in ovarian cancer is
laparotomy – obtain tissue diagnosis, stage disease, disease clearance and debulk disease.
chemotherapy treatment in ovarian cancer is
first line platinum and taxane, complete/partial response, cure unlikely, average response 2 years
prophylaxis for ovarian cancer is
investigation of pest menopausal bleeding
pelvic and speculum examination
transvaginal ultrasound scan to measure her endometrial thickness, contour.
if >4mm or irregular then biopsy (pipelle)
presentation of endometrial cancer
include abnormal vaginal bleeding and post-menopausal bleeding, post menopausal women, high circulating oestrogen, atypical endometrial hyperplasia, HNPCC/Lynch type 2 familial cancer syndrome.
causes for high circulating oestrogen
(obesity, unopposed E2 therapy/tamoxifen, polycystic ovarian syndrome, early menarche/late menopause
treatment for endometrial cancer
often Total laparoscopic hysterectomy and bilateral salpingoophorectomy plus peritoneal washings.
high risk histology of endometrial cancer calls for
advanced stages of endometrial cancer calls for
palliation of endometrial cancer calls for
type 1 of histological endometrial cancer
endometrioid adenocarcinoma, common. Hyperplasia with atypia precursor
type 2 histological endometrial cancer
uterine serous and clear cell carcinoma, aggressive and worse. Serous intraepithelial carcinoma precursor.
upper urinary tract mechanical description
low pressure, distensible conduit with intrinsic peristalsis
lower urinary tract mechanical description
low pressure storage of urine
vesico-ureteric mechanism refers too
protects the nephrons from any damage secondary to retrograde transmission of back pressure or infection from the bladder
cortical influence for bladder control
pontine micturition centre) activation and parasympathetic and inhibition of sympathetic pathways. (sympathetic hypogastric for storage), (parasympathetic for voiding and pudendal for voluntary control.)
both stress and urge incontinence arise from the same anatomical defect which is
defect in the anterior vaginal wall and pubo-urethral ligament
suburethral hammock laxity may result In
stimulation of bladder neck stretch receptors provoking a premature micturition reflex and urge incontinence
stress urinary incontinence refers too
involuntary leakage on effort or exertion, on sneezing/ coughing
urge urinary incontinence refers too
involuntary leakage accompanied by or immediately preceded by urgency
mixed urinary incontinence
involuntary leakage accompanied by or immediately preceded by urgency and on effort or exertion.
history for female incontinence
age, parity, delivery, baby weight, smoking, HRT. Medical conditions (DM, glaucoma, liver/kidney, cognitive, anti-depressants), prior PFMT, surgical treatment.
presentation for female incontinence
urgency, increased daytime frequency (>7), nocturia, dysuria, haematuria, coital, severity
assessments for female incontinence
urinary diary, urine dipstick
examination for female incontinence
general, abdominal, neuro if indicated, gynaecological, pelvic floor assessment
investigations for female incontinence
urinalysis, post voiding residual volume assessment, urodynamics
lifestyle changes for female incontinence
stop smoking, eat healthily, stop drinking alcohol and caffeine, low weight), medical treatments, physiotherapy, surgery
pharmacological treatment for female incontinence
Yentreve (Duloxetine) – in combination with pelvic floor muscle training
surgery for female incontinence
colosuspension, mid-urethral slings retropubic TVT
overactive bladder conservative management
fluid intake, reduce caffeine, fizzy drinks, chocolate, stop smoking, weight loss, bladder training, continence nurse
pharmacological treatment for overactive bladder
antimuscarinic, tricyclic antidepressants
recent advances in treatment for overactive bladder
natural process of menopause
Ovarian insufficiency, oestradiol falls, FSH rises, still some oestriol from peripheral, conversion of adrenal androgens in fat.
symptoms of menopause
hot flushes’, vaginal dryness, low libido, muscle and joint aches, mood changes/poor memory. Osteoporosis (fractures).
management of menopause
DEXA scan, prevention of fractures with exercise, calcium and Vit D, HRT, bisphosphonates, denosumab, teriparatide
general symptomatic treatment of menopause
General symptoms treated with HRT (systemic, oestrogen if no uterus, oestrogen and progesterone if uterus present) local vaginal oestrogen only. Selectiv oestrogen modulators, SSRI SNRI antidepressants (Venlafaxine), natural (phytoestrogen, hypnotherapy, CBT), lubricants.
causes of secondary amenorrhoea
pregnancy, breast feeding, contraceptive, polycystic ovaries, early menopause, thyroid disease, chronic disease, cushings, prolactinoma, edication, hypothalamic stress, androgen secreting tumour, sheehan’s syndrome, Asherman’s syndrome
examinations for secondary amenorrhoea
BMI, androgen signs, abdominal, bimanual vaginal, urine pregnancy test, bloods (FSH, oestradiol, thyroid function, prolactin, testosterone), pelvic US
management for secondary amenorrhoea
treat cause, assume fertile (unless 2 years post menopause) then contraception, if premature ovarian insufficneyc offer HRT till 50.
weight loss, increase SHBG, antiandrogens (combined hormonal contraception, spironolactone, eflornithine). Endometrial protection (CHC, progestogens, mirena IUS), fertility clomiphene/metformin.
normal blood loss during a period is
normal loss less then 80ml over 7 days
average duration of menstruation
average age of menopause
PALMCOEIN causes of heavy menstrual bleeding
Not yet classified
Polyps diagnosis is by
diagnosis by US or hysteroscopy, management is polypectomy
adenomyosis treatment is
partially responds to hormone but definitively surgery
small Leiomyoma treatment is
POP, mirena, COCP
large Leiomyoma treatment is
fertility preservation, embolization, and myomectomy
submucosal Leiomyoma treatment
then hysteroscopic fibroid resection, if failed then hysterectomy
investigations for endometriosis
pelvic examination, US, diagnostic laparoscopy
managment for endometriosis
analgesia, medical COCP, POP, mirena IUS, depot provera, GnRH analogues, surgical ablation, hysterectomy, endometrioma excision, pelvic clearance, hysterectomy
hormonal options in general for heavy menstrual bleeding
mirena IUS, COCP, POP, depot provera
medical non hormonal options for heavy menstrual bleeding
mefenamic acid, tranexamic acid, GnRh analogues
surgical options for heavy menstrual bleeding
endometrial ablation, fibroid embolization, hysterectomy.