Workbook Questions Flashcards

Question

True or false: The gubernaculum connects the developing testis to the posterior abdominal wall

Answer 1

False | Testes to scrotum

Answer 2

False | Shaft of penis from urethral folds

Answer 3

In the antral phase granulosa cells have receptors for_FSH_, thecal cells for_LH_.

Answer 4

False | Only completed after fertilisation

Answer 5

False Each spermatogonium gives rise to 64 spermatozoa. Also, it is the type B spermatogonium which gives rise to the daughter spermatocytes, with some type A remaining as resting cells to serve as an ancestor for later generations. (Be aware that classification of the spermatogonia varies in different texts but it is not necessary for you to learn these).

Answer 6

True | between 6-12 days. They can be stored for much longer (weeks) in the vas deferens.

Answer 7

The corpus luteum secretes_progesterone__ and_oestrogen (oestradiol)_ under the control of__LH_

Answer 8

False Whilst a primary oocyte goes through two meiotic division to produce an ovum (including an ovulation and fertilization), non-functional first and second polar bodies are formed at each stage.

Answer 9

False It is lower than 2%. Each ml of sperm (usually 1-4 mls ejaculated) contain tens of million sperm and only 200-300 of these will reach the site of fertilization in the ampulla of the uterine tube.

Answer 10

True | It is a peritoneal sac derived from the embryonic tunica vaginalis.

Answer 11

True | Up to 60% comes from the seminal vesicle and 1/3 from the prostate.

Answer 12

False | It is from the testicular artery which has its origin in the aorta (remember the embryological origin of the testes).

Answer 13

In the early follicular phase, oestrogen at low levels exerts a negative (inhibitory) feedback on gonadotrophin release. At ovulation, rising levels of oestrogen produces a positive (stimulatory) feedback, enhancing LH release thus promoting ovulation. (In fact the oestrogen enhances the LH releasing mechanism to GnRH.)

Answer 14

FSH levels will rise considerably LH levels will rise GnRH levels will rise Feedback from gonadal steroids much reduced NB Several years after the menopause, these hormones return to lower levels.

Answer 15

No Inhibin secreted from ovary, so selective inhibition of FSH by Inhibin acting on pituitary gland no longer occurs and FSH levels rise more than LH

Answer 16

FSH levels will fall LH levels will fall GnRH levels will fall Because placental oestrogen & progesterone exert negative feedback inhibition at both hypothalamus and pituitary

Answer 17

GnRH secretion will rise as the true oestrogen signal is falsely lowered and negative feedback inhibition is diminished. LH & FSH secretion will also rise, with a larger increase in LH levels

Answer 18

Progesterone enhances negative feedback of natural oestrogen At moderate doses this will reduce LH and FSH secretion And inhibit positive feedback of oestrogen, so no LH surges And ovulation is suppressed At lower doses, there is no inhibition of LH surges Ovulation will probably still occur But progestogens will affect cervical mucus, inhibiting sperm transport

Answer 19

Releasing hormones are diluted to ineffective concentrations in the general circulation. The portal nature of the hypophyseal vessels normally ensures that releasing hormones reach the pituitary at relatively high concentration Prolactin secretion control is removed if the anterior pituitary is transplanted and the dopamine is diluted in the general circulation

Answer 20

They should fall, as it mimics the inhibitory effect of dopamine on lactotrophs

Answer 21

Fertility may be reduced, as prolactin levels rise because the inhibitory effects of dopamine are themselves inhibited since metoclopramide inhibits dopamine Increasing levels of prolactin will produce a spectrum ranging from inadequate luteal phase function to anovulation and amenorrhoea with complete GnRH suppression. Fertility will be affected at all points..

Answer 22

Bromocriptine; mimics dopamine

Answer 23

Thelarche – breast enlargement 8-11 years Adrenarche – pubic hair 11-12 years Growth Spurt 10-14 years Menarche 11-15 years

Answer 24

Irritation and inflammation stimulating early rises in GnRH secretion True precocious puberty is caused by premature secretion of gonadotrophins - mostly idiopathic, but can be caused by CNS lesions (hypothalamic tumours, post-encephalitis neurofibromas etc.). Hence, irritation and inflammation such as meningitis can stimulate early rises in GnRH secretion.

Answer 25

The growth spurt begins earlier and is terminated earlier, so that epiphyses may close at an earlier stage of growth, making the individual shorter.

Answer 26

(i) If gonadotrophin levels are normal, then either the ovary is not responding to them so no steroids are produced, or if the tissues are not responding to the steroids that are produced. If no steroids are produced, however FSH & LH levels should be raised. Another possibility is that menstruation is occurring, but the products are not shed because of a vaginal or cervical problem (Also, consider some forms of androgen insensitivity syndrome - these XY individuals will have external female genitalia as their tissues do not respond to androgen - but their male gonad will produce MIH so they will not have internal female ducts and will present with primary amenorrhoea. Breast development is often normal or enhanced as the small amount of gonadal oestrogen and adrenal oestrogen is not opposed by androgen. Body hair is normal to scanty.) (ii) If gonadotrophin levels are low, then the problem is likely of pituitary or hypothalamic origin. Some examples are pituitary tumours. Anorexia nervosa, malnutrition and psychogenic causes also lead to hypo gonadotropic hypogonadism. Check serum prolactin and consider imaging for a cranial lesion.

Answer 27

The ovary may not be responding, so ovulation does not occur and a cycle of steroid secretion is not properly established.

Answer 28

To assess stage of puberty check height, weight, body hair, genitalia, bone age. Also ask about medical history and medications. Delayed puberty is lack of sexual maturation by age 15 - majority have constitutional delay - which is quite benign - and which represents normal variation - often familial. Such boys will eventually undergo a normal puberty and attain normal height. Constitutional delay is most probable in a healthy boy with delayed growth and bone age.

Answer 29

The proportion would be very low (3-5%) since puberty in boys visibly begins between 9 and 14 years with scrotum and testicular development, however, full maturity may not be complete until early 20's (e.g., facial hair). If he has good general health and nutrition, also if a brother was a "late developer", you would suspect constitutional delay of puberty and would give reassurance. Serious systemic illness (e.g. diabetes, malabsorption) can delay puberty

Answer 30

Accelerated growth is one of the earliest signs of precocious puberty and bone age can be determined with hand-wrist films and compared with standards for the patient's chronologic age. If his bone age is inconsistent with (behind) his chronologic age then constitutional delay is likely.

Answer 31

Growth spurt in boys is approx 10cm/year | height comparisons over time are useful.

Answer 32

The growth spurt starts about 12 months after the first signs of puberty (increase in testicle size due to FSH induced increase in seminiferous tubules).

Answer 33

Early signs of puberty in boys are the increase size of testes followed by reddening of scrotal skin and elongation of penis-his parents may not be aware that these changes are occurring.

Answer 34

High intra-testicular levels of testosterone are needed for spermatogenesis-so it is doubtful.

Answer 35

If FSH is low, suspect hypothalamic/pituitary. | If testosterone is low, suspect hypogonadism.

Answer 36

Height, weight, genitals, body hair, bone age.

Answer 37

Short stature-premature growth spurt - epiphyseal closure

Answer 38

True precocious puberty - premature secretion of gonadotrophins - leads to testicular androgen production and sperm production and virilisation - mostly idiopathic. Can be caused by CNS lesions, thus evaluation and follow-up is needed. Precocious pseudopuberty results from secretion of androgens from adrenal glands or testis, virilisation occurs but not sperm production (most commonly caused by adrenal hyperfunction-congenital adrenal hyperplasia).

Answer 39

He may have adrenal hyperfunction - congenital adrenal hyperplasia (from 21-hydroxylase or Il-hydroxylase deficiency) or an adrenocortical tumour. Congenital adrenal hyperplasia: Biochemical tests of enzyme levels (patients have elevated serum 17-hydroxyprogesterone levels). Adrenal tumours can be seen by imaging studies - sonography, CT, NMR.

Answer 40

FSH: rises considerably LH: rises GnRH: rises As gonadal steroid production falls there is loss of negative feedback to the pituitary and hypothalamus.

Answer 41

No inhibin from ovary so selective inhibition of FSH no longer occurs and it thus rises more than LH.

Answer 42

hot flushes poor sleep vaginal/urethral atrophy dysparunia/dysuria breast atrophy mood change/depression osteoporosis/posture & height change/increased fracture risk changing cholesterol/lipid profile & possible increased risk of CHD

Answer 43

Oestrogen HRT Calcium (HRT is comprised usually of a mixture of oestrogens and progesterone, which are either synthetic or extracted from pregnant mares’ urine.)

Answer 44

Increased risk of thromboembolism, breast cancer.

Answer 45

Unopposed oestrogens cause proliferation of uterine lining with a risk of endometrial cancer. Progesterone inhibits this.

Answer 46

Most fibroids are asymptomatic. The most common symptom is abnormal bleeding, typically menorrhagia and the women is usually in her 40s. Large fibroids may be palpable on bimanual examination (irregularly shaped uterus) examination by anaesthesia and curettage or by laparoscopy. ultrasound may show the presence of a mass but may not distinguish other ovarian tumours.

Answer 47

Menorrhagia is usually defined as menstrual loss greater than 80ml which will produce anaemia. Assess by pad and tampon counts and measuring haemoglobin/haematocrit levels.

Answer 48

Treatment options

Answer 49

Strictly speaking a hysterectomy is the removal of the uterus. Women in their forties may be counselled on the risks and benefits of bilateral oophorectomy in conjunction with hysterectomy. Potential benefits include, avoidance of ovarian pathology in the future(although some ovarian type tumours can arise from the peritoneum de novo) Potential disadvantage, sudden onset of menopause as the albeit aging ovary is removed and loss of ovarian androgen.

Answer 50

The genetic makeup of an individual as defined by the particular sets of genes they possess.

Answer 51

``` Practice safer sexual behaviour Age at first intercourse Total number of partners Number of concurrent partners Frequency of partner switching Sexual orientation Specific at-risk sexual practices Use correct barrier contraception techniques consistently Seek better sexual health education Seek early treatment for suspected STI Attend for regular screening if at risk Avoid teenage pregnancy Avoid alcohol abuse and illicit drug use ```

Answer 52

Changing societal norms Targeted advertising and education Peer group pressure and social activities Socio-economic factors Poverty Educational and social disadvantage Unemployment Teenage conception and pregnancy Ready and confidential access to GUM clinics and other health practitioners Awareness of serious risks associated with some STIs

Answer 53

Details of recent sexual contacts Timing Partner(s) Nature of sexual activity and sexual orientation Have partners sought advice or treatment? Are partners symptomatic? Previous STIs and complications Overseas travel and place of residence Underlying diseases, including HIV, HBV and HCV status Participation in commercial sex Recent antibiotic use and history of allergies

Answer 54

Chlamydial urethritis Gonococcal urethritis Non-specific urethritis (NSU)

Answer 55

Gonococcal urethritis

Answer 56

Ceftriaxone 500 mg IM single dose (many gonococci resistant to other agents) PLUS Azithromycin (single large oral dose 1g) (co-treatment for chlamydia and enhances treatment for gonorrhoea)

Answer 57

Common at risk behaviours and associated factors Long-term asymptomatic infection High prevalence rates of Chlamydia trachomatis infection Identical mode of transmission

Answer 58

Depending on the following factors the risk of her being infected with Chlamydia trachomatis and/or Neisseria gonorrhoeae, though not necessarily symptomatic, may be anywhere upwards of 50 %! Adherence to strict barrier contraception Frequency of intercourse Duration of sexual relationship Time of acquisition of the STI by her partner Concurrent genital inflammation or ulcers?

Answer 59

Detailed history Physical Examination Diagnostic investigations Endocervical smear and swab for microscopy and culture of N. gonorrhoeae First-void urine and/or endocervical smear for C. trachomatis (+/- N. gonorrhoeae) detection by nucleic acid amplification (NAA) test Pharyngeal and/or rectal swabs for culture of N. gonorrhoeae Screening investigations Syphilis serology pap smear cytology cervical swabs for HPV detection by hybrid capture? serology for blood and body-fluid borne viruses – HIV, HBV, HCV If positive treat for Chlamydia +/- gonorrhoea Advice regarding need to abstain until treated or cleared of infection – potentially infectious despite being completely asymptomatic! Advice regarding need for return visit Counselling, advice, and basic sexual health education

Answer 60

``` Normal physiological variation! Candida spp. – fungus Bacterial vaginosis – Perturbed normal flora including Gardnerella vaginalis and Mycoplasma hominis Trichomonas vaginalis – protozoa Chlamydia trachomatis Neisseria gonorrhoeae ```

Answer 61

``` Liver Gall bladder Right kidney Stomach, pancreas, small or large intestine Lung or pleura ``` Fitz-Hugh Curtis syndrome due to perihepatitis – C. trachomatis or less commonly N. gonorrhoeae

Answer 62

Endocervical smear and swab for microscopy and culture of N. gonorrhoeae Endocervical swab for detection of C. trachomatis by NAAT Urethral swab for culture of N. gonorrhoeae Throat and/or rectal swabs for culture of N. gonorrhoeae First-void urine for detection of C. trachomatis(+/- N. gonorrhoeae) by NAAT Mid stream urine (MSU) for microscopy and culture of UTI pathogens Cervical smear for cytology Cervical swab for HPV detection High vaginal smear and swab – Candida, Trichomonas, bacterial vaginosis (BV)

Answer 63

Abstain until both partner and herself, and any other sexual contacts, have been treated effectively Measures to minimise risk of future STI Advice on correct use of barrier methods of contraception Need to attend for a return visit – ‘test of cure’ investigations? Basic sexual health education and advice regarding regular screening option

Answer 64

Only a small percentage of those infected with a pathogen may manifest symptoms and/or signs of illness Many STIs exhibit this phenomenon – Chlamydia, HPV, HSV, even syphilis may only manifest with transient and minor evidence of primary disease Potential large infectious reservoir – needs to be identified and treated promptly – CONTACT TRACING

Answer 65

Candida spp. – fungus which can be part of the normal vaginal flora Trichomonas vaginalis – sexually transmitted protozoan pathogen Bacterial vaginosis – perturbed vaginal flora Oral contraceptive use is associated with increased incidence of vulvo-vaginal thrush Overgrowth of the yeasts is favoured by high oestrogen levels

Answer 66

Perturbed normal flora – broad spectrum antibiotic use Warmth and humidity – climate, clothing, obesity Oral contraceptives and pregnancy – oestrogen levels Glucose levels – diabete mellitus Steroid therapy Menstrual cycle-associated changes – pre-period symptoms Colonisation with a recalcitrant Candida species or strain

Answer 67

Withdraw or control risk-factors Obtain high vaginal smear and swab for microscopy and culture – many diagnoses may be made clinically without laboratory investigation Treat only if significantly symptomatic Use first-line topical azoles (e.g. clotrimazole) Consider oral fluconazole for more problematic cases If recurrent or unusually severe investigate for resistant yeast and/or other unidentified risk factors Consider treating partner to reduce frequency of ‘re-infection’ No, as the aetiological agent is typically part of the normal vaginal flora

Answer 68

Sexual history – partner(s), timing, symptoms in partner(s) History of previous STIs History of previous genital ulcers, vesicle, or rashes History of cold sores or primary gingivostomatitis History of recent drug or antibiotic use and known allergies Etc

Answer 69

Herpes simplex virus typically type 2 (but may be HSV1) Haemophilus ducreyi – tropical STI (chancroid) Klebsiella granulomatis– tropical STI (granuloma inguinale) Treponema pallidum – syphilis but lesions rarely multiple Behcet’s syndrome or erythema multiforme – non-infectious aetiology Smear and swab of vesicle fluid or ulcer base – herpes PCR Syphilis serology and other investigations as per normal GUM assessment

Answer 70

A diagnosis of primary genital herpes warrants immediate aciclovir treatment Oral aciclovir if outpatient management appropriate Otherwise consider hospitalisation and IV aciclovir Features of primary genital herpes Mild fever and systemic symptoms Inguinal lymphadenopathy Extensive genital ulceration including spread to adjacent skin Prolonged illness – up to two or more weeks! Marked dysuria and possible acute urinary retention Consider use of indwelling urinary catheter Analgesia and other supportive measures Advise regarding risk of recurrence HSV2 (90 % patients experience recurrence within 1 year) HSV1 (25 % patients experience recurrence within 1 year) If recurrences persist for > 1 year, frequency unlikely to decline Advise regarding possible transmission to others even whilst asymptomatic Advise regarding issues related to current or future pregnancies Frequent recurrences Patients may recognise trigger factors and/or herald symptoms Long-term continuous or periodic suppressive aciclovir therapy

Answer 71

salpingitis PID- if abscess develops may be called tubo-ovarian abscess

Answer 72

Lower abdominal pain, dyspareunia (+/- vaginal discharge) fever,(+/- menstrual abnormalities)

Answer 73

bladder conditions cystitis, bladder stones bowel conditions irritable bowel syndrome, inflammatory bowel disease, appendicitis gynaecological conditions: ovarian cysts, endometriosis, ectopic pregnancy, torsion

Answer 74

ultrasound, laparoscopy, swabs from endocervix, swabs from peritoneum if laparoscopy is done

Answer 75

Most episodes of PID will be polymicrobial, including organisms such as Chlamydia trachomatis, Neisseria gonorrhoeae, mycoplasmas, bacteriodes + other anaerobes

Answer 76

medication: analgesia, antibiotic / antimicrobial against specific organism, and broad spectrum antibiotics with good anaerobic coverage. advice: bed rest, if hospitalised, Semi-Fowler position to drain pus into pelvis Aggressive antibiotic Treatment, particularly in young nulliparous patients.

Answer 77

chronic recurring infection, increased risk of ectopic pregnancy, impaired fertility, chronic pelvic pain

Answer 78

barrier contraceptives, STD screening, screening of partner, early treatment of STIs, avoidance of promiscuity

Answer 79

Cilia & smooth muscle contraction (peristalsis)

Answer 80

The opening of the uterine tube at the infundibulum into the peritoneal cavity allows infection such as gonorrhea to spread from the vagina and cervix, via the uterus and uterine tubes into the peritoneal cavity.

Answer 81

Adhesions, which do not allow an ovum to pass through to the uterus. Hence, this may cause infertility or an ectopic pregnancy.

Answer 82

Common: fimbrial, ampullary, isthmic or interstitial (of the uterine tubes); ovary Rare: Pouch of Douglas, abdominal viscera.

Answer 83

Pain from an ectopic pregnancy is felt in the lower abdominal quadrants If lying down blood in the peritoneal cavity may collect beneath the diaphragm irritating the phrenic nerve. Since this nerve originates with cutaneous nerves from C3, 4 and 5, pain may be referred to the dermatomes for these segments; i.e. shoulders. Pain felt in the lower quadrants is due to stretching and tearing of the peritoneum. Blood passing from the vagina is usually withdrawal bleeding (not a result of bleeding at the site of the rupture), caused by reduction in the hormone hCG which maintains the corpus luteum and hence prepares the endometrium for implantation.

Answer 84

It is an anastomotic system of the ovarian and uterine arteries.

Answer 85

Broad ligaments (which also contain uterine vessels) The broad ligament may be subdivided. The mesentery of uterus is also called the mesometrium. The mesosalpinx is mesentery of the uterine tube, whilst the mesovarium is that part of the broad ligament that suspends the ovary.

Answer 86

Perimetrium (outer) Myometrium (consisting of three muscle layers) Endometrium (inner) consisting of the stratum functionalis - shed during menstruation and the stratum basalis (which produces new stratum functionalis after each menstruation)

Answer 87

Simple columnar epithelium (either are ciliated or have microvilli) with glycogen producing glands changing from simple to highly coiled over the course of the uterine cycle. Tall columnar cells, with branched glandular cells, which form an alkaline mucus.

Answer 88

menses days 1 – 4 : desquamation of 2/3, bleeding days 5 – 7 : rapid re-growth from remaining epithelial cells days 7 – 14 : endometrial re-growth is completed This concludes the proliferative phase days 14 – 28 : Secretary phase includes endometrial thickening, enlargement of glandular cells, oedematous, proliferation of white cells. 3 layers : compact superficial zone spongy middle zone (glandules) inactive basal layer As menses approach the arteries go in to spasm, retracting back to the deeper layers evoking ischaemia.

Answer 89

In clamping off the uterine artery, the ureter may be accidentally damaged (remember : water (urine) under the (arterial) bridge).

Answer 90

Fundus of uterus - aortic nodes (lesser to inguinal lymph nodes) Body of uterus - external iliac nodes Cervix - external and internal iliac nodes, sacral nodes.

Answer 91

anteverted in relation to vagina | anteflexed in relation to cervix

Answer 92

Insertion of one or two fingers into the vagina to examine the cervix. The external hand palpates the uterus (and ovaries if enlarged) from the anterior surface of the body to assess for pregnancy or irregularity. The uterus is assessed for mobility, consistency, pain, regularity, position, size (usually of a plum, 10weeks pregnancy it is the size of an orange), etc

Answer 93

Os or the posterior lip (rather than the anterior lip) of the cervix.

Answer 94

The mucus is a mixture of water, glycoprotein, lipids, other proteins, enzymes and inorganic salts. Production of mucus is greatest during the follicular phase, in readiness for ovulation. It changes from cloudy to clear. At ovulation it is a clear, acellular mucus with high stretchability (spinnbarkeit). (Such characteristics may enable a women to self-assess the time of ovulation - it dries in a glass slide with a characteristics fern-patterning). Following ovulation (as progesterone increases), the mucus again becomes cloudy and more sticky but in diminishing quantities. A thick cervical mucus -plug forms during pregnancy - the loss of which may indicate labour.

Answer 95

From the cervical glandular ducts. Infection of the endocervical glands (as in chronic cervicitis) can result in blockage of the ducts and hence cyst formation (between 2mm to 1cm). There presence, especially if infected, can reduce chances of pregnancy by making the cervix inhospitable to sperm.

Answer 96

Anteriorly – base of bladder and urethra (embedded in anterior vaginal wall) Posteriorly – anal canal, rectum and most superiorly pouch of Douglas Laterally – levator ani and ureters (lying just superior to lateral fornices) (A ureteric stone can sometimes be palpated from the vagina)

Answer 97

Anteriorly – bladder, urethra and pubic symphysis Posteriorly – rectum (prolapsed uterine tubes and ovary) Laterally – ovary and uterine tube, sidewall of pelvis (ischial spines) Apex – cervix (ante or retro-verted)

Answer 98

Since the uterus is usually anteverted and anteflexed, the posterior fornix is the deepest (more of the posterior part of the cervix enters the vagina compared to anteriorly). The fornices form a continuous recess around the cervix. During bimanual examination, examination of the pelvis, the vaginal fingers should pass through each of the four fornices. Palpation of the posterior fornix is used to assess posterior fundus, uterosacral ligaments, posterior broad ligaments/ovaries and Pouch of Douglas. Palpation of the anterior fornix might address bladder, recto-pubic space Palpation of the lateral fornices might address broad ligaments and associated structures. The Fallopian tubes and ovaries cannot normally be felt.

Answer 99

Inguinal lymph nodes

Answer 100

Stratified squamous epithelia, hence external layers are shed with friction. Cells are swollen due to glycogen production. Lubrication is via cervical mucus, shed vaginal cells.

Answer 101

Pubic symphysis, inferior pubic rami, ischial rami, ischial tuberosity, sacrotuberous ligaments, coccyx

Answer 102

Female: UT triangle - external genitalia Anal triangle - Anus Male: UT triangle - root of scrotum & penis Anal triangle - Anus

Answer 103

Perineal body

Answer 104

Bimanual exam, palpate ischial spines, assess intertuberous distance, assess subpubic arch, assess diagonal conjugate.

Answer 105

Possible small pelvic outlet.

Answer 106

Allows the fetal shoulders to move into the long axis of pelvic outlet.

Answer 107

The external anal sphincter muscle tube squeezes and the puborectalis pulls the finger anteriorly.

Answer 108

In women, the fibro-muscular perineal body supports the lower posterior part of the vaginal wall against prolapse and forms a dense attachment for the two halves of the levator muscles in the midline. It acts as a tear-resistant body between the vagina and external anal sphincter muscle tube during childbirth, but is now considerably stressed by the evolution of large fetal head size. (A median episiotomy divides or partly divides the perineal body, which ‘encourages’ perineal tearing posteriorly into the anal sphincter. It was abandoned in favour of a postero-lateral episiotomy that passes to the lateral side of the body and anal sphincter tube.)

Answer 109

Fibres of pubococcygeus can be damaged which may lead to prolapse or herniation of bladder and / or urethra with subsequent incontinence. The medial fibres of pubo-rectalis (which inserts into the perineal body as a pubo-vaginalis muscle) may be torn together with the perineal body allowing herniation of the rectum to occur (the tear extending into the external anal sphincter) leading to difficulty with defecation or faecal incontinence.

Answer 110

A surgical cut in the perineum during childbirth to avoid tearing and damage to the perineal body

Answer 111

Vaginal mucosa and submucosa, perineal skin, muscles and fascia of perineum

Answer 112

Vaginal and rectal exam.

Answer 113

Epididymis

Answer 114

Rete testis

Answer 115

Tunica vaginalis

Answer 116

Aorta, just inferior to the renal vessels.

Answer 117

pampiniform plexus IVC on the right left renal vein

Answer 118

Stroking the superior part medial thigh evokes elevation of the testis on that side. This part of the thigh is innervated by the ilioinguinal nerve (L1); the genital branch of the genitofemoral nerve (L1, L2) innervates the cremaster muscle. Hence, a spinal reflex arc is demonstrated.

Answer 119

Dartos muscle

Answer 120

The scrotal skin (fascia and tunica vaginalis) drains to the superficial inguinal lymph nodes whereas lymphatic drainage of the testis is via the spermatic cord to the para-aortic (or lumber) glands at the transpyloric plane, LI (hence, upper abdomen must be palpated). Further spread may be to mediastinal and cervical nodes.

Answer 121

Lymphatic drainage to para-aortic nodes, which anastomose with intra-thoracic and in turn cervical lymph nodes.

Answer 122

Rete testis to head of epididymis

Answer 123

Tail of epididymis, inguinal canal, side wall of pelvis close to ischial spine, then travels medially and joins with ducts from the seminal vesicle to form ejaculatory duct which joins the prostatic urethra, inferior to the bladder. (Hence, bladder, urethral and prostate infection may spread to the vas deferens here.) It is typically 45 cm long

Answer 124

Inferior epigastric artery | Testis

Answer 125

(a) Sperm degenerate in the epididymis and proximal ductus deferens, debris is removed by phagocytosis (b) The ejaculate is composed of secretions form the prostate, seminal vesicle, and bulbourethral glands only.

Answer 126

The double layer of the tunica vaginalis is surrounded by: Internal spermatic fascia (from transversalis fascia) Cremasteric fascia (from fascial covering of the internal oblique) External spermatic fascia (from the external oblique aponeurosis) These are followed by a layer of superficial fascia lying directly beneath the scrotal skin

Answer 127

3rd month 7th month 8th month 9th month

Answer 128

Infertility & potentially malignancy | testicular torsion, which remains elevated even after orchiopexy

Answer 129

Ducts: vas deferens (and its artery) Vessels: testicular artery, cremasteric artery, pampiniform plexus of veins (surrounding the testicular artery), testicular lymphatic vessels Nerves: autonomic nerves, genital branch of the genitofemoral nerve,

Answer 130

Prostate Vas deferens Seminal vesicles Sympathetic: hypogastric nerve (L1, L2)

Answer 131

Seminal vesicles: secrete an alkaline fluid that contains- fructose (used in ATP production by the sperm) prostaglandins (facilitate sperm motility and may promote smooth muscle contraction in the female tract) clotting factors, particularly semenogelin, (are proteins which help temporarily coagulate semen after ejaculation). Its alkalinity helps to neutralize the acid in the male urethra and female reproductive tract. 60% of volume of semen. The prostate: secretes a milky, slightly acidic fluid containing- proteolytic enzymes (such as PSA, prostate-specific antigen, pepsinogen etc), which breakdown clotting proteins from the seminal vesicles, hence re-liquefying semen about 10-20 minutes after ejaculation citric acid, used by sperm in the Krebs cycle for ATP production acid phosphotase (unknown function) 25% volume of semen ``` Bulbourethral glands (Cowper's glands): secrete an alkaline fluid to the urethra for acid neutralization (particularly neutralization of acid in the vagina), and a mucous that lubricates the end of the penis and urethral lining. ``` These glands contribute a very small amount to the ejaculate.

Answer 132

Chestnut or golf ball (3cm round)

Answer 133

Posterior (median groove)

Answer 134

Median (This may not be detected on rectal examination; the lateral lobes, however, are readily detected on rectal examination).

Answer 135

Internal iliac

Answer 136

The cells that enlarge in BPH are close to the urethra, therefore causing a blockage of the urethra. Cancerous cells are more peripheral and therefore only occlude the urethra at a later, more advanced stage.

Answer 137

BPH PSA normal/ slightly raised, carcinoma PSA markedly raised

Answer 138

Veins from prostatic venous plexus with dorsal vein of penis, drains into internal iliac vein. Some of the veins pass to a plexus in front of vertebral bodies and are valve-less, (valve-less vertebral veins of Batson) hence spread of malignancy.

Answer 139

Prostatic Membranous Spongy

Answer 140

Membranous, due to the surrounding sphincter urethrae muscle and perineal membrane

Answer 141

Corpora cavernosa Corpus spongiosum (glans penis is continuous with corpus spongiosum)

Answer 142

Branches of the internal pudendal artery form : (1) the deep arteries (2) the dorsal arteries (3) the arteries of the bulb (1) and (2) supply the crura and corpus cavernosa. (2) and (3) supply the bulb and the corpus spongiosum

Answer 143

Tunica albuginea

Answer 144

These resist expansion, such that internal pressure rises and occludes venous drainage. Blood from the cavernous spaces drains into a venous plexus (which are compressed during erection), then into the deep dorsal vein. This, along with increased arterial flow, maintains rigidity of the penis for intercourse. (Venous return is also restricted by contraction of the bulbospongiosus and ischiocavernsosus muscles.)

Answer 145

Whilst the tunica albuginea does surround the corpus spongiosum it is not as fibrous or restrictive as that which surrounds the corpora cavernosa. High pressure in the corpus spongiosum would occlude the urethra and hence prevent ejaculation of the semen.

Answer 146

Retrograde ejaculation into the bladder

Answer 147

Pelvic nerve, parasympathetic (S2 - S4) , via inferior hypogastic plexuses promotes erection in erectile tissue, through relaxation of smooth muscle in the fibrous trabeculae and cooled arteries Emission is sympathetically controlled. Ejaculation occurs via sympathetic outflow (L1 – L2) Hypogastric, sympathetic, involved mostly in depression of erection, by increasing myogenic tone in arterial smooth muscle.

Answer 148

psychological problems tears in fibrous capsule of corpora cavernosa obstruction of blood flow to corpora cavernosa pharmacological

Answer 149

prepuce (foreskin)

Answer 150

The OBSTETRIC conjugate is measured from the midpoint (i.e. thickest ) part of the pubis (posterior surface) to sacral promontory. This is obstetrically the most important AP diameter (as it is the narrowest AP diameter that the fetus passes through) and is usually about 10cm. This diameter can only be assessed with imaging therefore clinicians use the DIAGONAL CONJUGATE measured from inferior border of pubis to sacral promontory as an assessment tool. This is measured by introducing two fingers into the vagina and palpating the sacral promontory and noting where on one's hand the under edge of pubis is. Most clinicians do this so often that they immediately know by how far in the fingers go whether this measurement is adequate. It usually needs to be about 11.5 cm.

Answer 151

Testicular torsion*; hernia, hydrocoele, epididymal cyst, epididymitis, orchitis, spermatocoele, varicocoele, a testicular mass and a cyst of the cord. A testicular torsion is the most important diagnosis, followed by testicular mass. * the maximum time window from torsion to surgery is 12h. Thereafter most testes are unsalvageable and infertility occurs (other testes destroyed due to break down of blood testes barrier). So any scrotal swelling needs to be considered as torsion till proven otherwise.

Answer 152

Any lump in the testis must be a suspected tumour. Testicular cancer is the commonest cancer that affects young men between the ages of 19 to 44 years old. Almost half of all testicular cancers occur in men under 35 years old

Answer 153

A hernia can be reduced then feel for normal scrotal contents

Answer 154

The veins of the pampiniform plexus become dilated in the standing position. For reasons that are postulated rather than known; it occurs, almost invariably, on the left side and a right-sided varicocœle should always suggest malignant obstruction of the right testicular vein. On palpation it feels like a bag of worms.

Answer 155

The left testicular vein empties vertically into the renal vein. much higher than the right drainage. The varicosities form when the valve system between these two veins fails and blood falls backwards under the pull of gravity. The right testicular vein drains directly into the inferior vena cava at an oblique angle, further down. Its valves do not have to support the same weight of blood as those in the left testicular vein and are therefore much less likely to fail. A right sided varicocoele is very uncommon and is suggestive of other, potentially more serious problems such raised IVC pressure - e.g. due to obstruction.

Answer 156

A hydrocœles is usually a painless enlargement of the testis caused by accumulation of watery fluid, in a persistent processus vaginalis (tunica vaginalis) surrounding the testis. It can grow as large as a grapefruit! Hydrocœles at this age are usually still connected to the peritoneal cavity by some persisting patency of the processus. The patency is limited so raised intra-abdominal pressure is required to send i.p. fluid through into the hydrocœle.

Answer 157

An epididymal cyst contains clear fluid and transilluminates ‘brilliantly’, while a spermatocœle contains turbid fluid that inhibits transillumination. Epididymal cysts arise from unconnected segments of the efferent tubules that sprouted from the mesonephric duct hence the clear fluid content. Spermatocœles arise similarly, but the segment is marginally connected to the rete testis and contains degenerate products of spermatogenesis. There is no important clinical difference between them, other than embryological origin.

Answer 158

An accumulation of the blood in the tunica vaginalis (e.g., traumatic rupture of the testicular artery). If therefore does not transilluminate.

Answer 159

Malignant spread from some testicular malignancies is primarily via lymphatics, which reflect the embryological origin of the testis from the posterior abdominal wall and drain into para-aortic lymph nodes. Para-aortic nodes only become palpable when they are massively enlarged i.e. the patient already has a large tumour burden. NMR/ CT can detect nodal enlargement of 2cm or less and indicate that XRT or surgical ablation may be beneficial..

Answer 160

Approx 30%

Answer 161

Failure to ovulate 28% Fallopian tube problems 22% Uterine problems 11% Cervical problems 3%

Answer 162

20-200 millions/ml

Answer 163

Sperm Motility & morphology

Answer 164

Psychological Endocrine (e.g., diabetes) Neurological Alcohol

Answer 165

Increase penile blood flow

Answer 166

21-35 days

Answer 167

14 days before; | Life of corpus luteum

Answer 168

Day 21; at peak of progesterone curve | In blood

Answer 169

Progesterone elevates basal temperature Circadian rhythm of body temp will confuse results if not taken at same time

Answer 170

Primary – never had periods | Secondary – cessation of periods after they have begun (after a 3 month cessations of menses)

Answer 171

Pregnancy – Human chorionic gonadotrophin | Fall in body weight – Gonadotrophin levels

Answer 172

Production of small quantities of milk

Answer 173

Bromocryptine | Dopamine agonist – mimics effects of prolactin inhibitory hormone

Answer 174

Passage of radio-opaque dye from uterine cavity, hysterosalpingography

Answer 175

Previous pelvic infection

Answer 176

Alkalinity | Lowered viscosity

Answer 177

Post coital test; collect cervical mucus soon after copulation

Answer 178

Use an anti-oestrogen to reduce inhibition of FSH & LH e.g., clomiphene given for a few days prior to expected time of ovulation

Answer 179

Follicles may still secrete inhibin which selectively inhibits FSH, thus reducing FSH in respect to LH (hence, ratio changed) Androgens may suppress LH surges (consider the role of testosterone in the male which inhibits LH release from the pituitary).

Answer 180

hirsutism (which can be blocked by anti-androgen therapy) | oily skin / acne

Answer 181

Due to sustained oestrogen stimulation of the endometrium | Biochemically, this is a very complex condition, which is poorly understood

Answer 182

``` First trimester: syncytiotrophoblast cytotrophoblast connective tissue Fetal capillary ``` Third trimester syncytiotrophoblast Fetal capillary endothelium

Answer 183

A single umbilical vein carries oxygen-rich blood from the placenta to the fetus. Two umbilical arteries carry oxygen-poor blood from the fetus to the placenta.

Answer 184

May reduce placental blood flow and growth. Poorer fetal nutrition will reduce birth weight, by on average, 200g.

Answer 185

By diffusion – lipid soluble Possible cause of Fetal Alcohol Syndrome in which the maternal (mis)use of alcohol leads to a fetus of low weight and with growth retarded (potentially with mental retardation, head and facial abnormalities).

Answer 186

Can cause teratogenesis

Answer 187

Mother may have made antibodies to fetal Rhesus antigens if fetal blood has entered the maternal circulation. The anti-D antibody neutralises these antigens. The presence of maternal anti-Rh antibodies in the fetal circulation causes rapid haemolysis when they bind to the fetal red blood cells. (The Kleihauer test is used to demonstrate the presence or absence of fetal cells in the mother's circulation (which is especially important in Rh isoimmunization). If the foetal cells contain antigens which the mother's cells lack then the mother could raise antibodies against these antigens.)

Answer 188

The decidua

Answer 189

approx. 35 weeks

Answer 190

Mother's blood

Answer 191

No, because the IgM class of antibodies does not cross the placenta

Answer 192

hCG is released from cells of the developing fertilized ovum. By stimulating the corpus luteum, hCG maintains (and indeed increases) the release of progesterone and oestrogen characteristic of the luteal phase of the menstrual cycle. Hence, oestrogen and progesterone maintains the endometrium and hence the pregnancy.

Answer 193

i) Humeral immunity is depressed and is probably necessary to stop rejection of the placenta by the mother and vice-versa. ii) The mother is more susceptible to viral infections

Answer 194

Reducing motility may lead to heart burn & comstipation

Answer 195

Oestriol (E3); this hormone is dependent on fetal adrenal and liver metabolism as well as placental function. Low levels of oestriol can indicate fetal distress such that earlier delivery may be desirable.

Answer 196

Suppresses FSH, hence blocking follicular growth

Answer 197

Maternal preparation e.g. breast growth, and also may provide a reserve for later pregnancy when fetal demands are greater. In later pregnancy fat rather than glucose is the primary source of energy for the mother.

Answer 198

Lipids and ketones released are available for energy. In early pregnancy, progesterone increases maternal appetite and promotes the storage of glucose in fat stores. hPL (hCS) promotes lipolysis of these fat stores.

Answer 199

Mean BP remains the same, but the increased stroke volume raises systolic BP a little and the stroke volume, flowing so rapidly into additional tissue, reduces diastolic BP a bit.

Answer 200

Upward displacement, hypertrophy, flow murmurs are common.

Answer 201

Peripheral vasodilation which may cause hypotension.(mean arterial blood pressure = total peripheral resistance x cardiac output, vasodilation cases a fall in TPR) Peripheral vasodilation may be experienced as: ‘feeling the heat' easy to sweat nasal congestion

Answer 202

smooth muscle relaxation by progesterone. Mechanical pressure from the uterus compressing the IVC may increase lower limb venous pressure, but only when mother is recumbent. Varicose veins and haemorrhoids (consider also raised circulating blood volume)

Answer 203

Diaphragm rises and intercostal angle widens, the uterus exerting a mechanical limitation to inspiration

Answer 204

Increased intraureteral tone, urethral dilatation, hydro-ureter, hydronephrosis. This may also be caused by the smooth muscle relaxation effect of progesterone.

Answer 205

Pressure on the bladder from enlarged uterus. Engagement of the fetal head towards the end of pregnancy

Answer 206

Dilation slows the excretion of urine, making UTI’s more common.

Answer 207

It increases uptake of calcium from the maternal gut. The increased availability of calcium to the fetus facilitates skeletal formation and growth, etc. (Expectant mothers are encouraged to increase their dietary calcium by up to 70%. PTH (parathyroid hormone) also rises in the third trimester, enhancing calcium mobilisation from maternal bone and increasing availability to the fetus.)

Answer 208

The uterus can compress the inferior vena cava, reducing venous return and hence, lowering blood pressure (supine hypotensive syndrome)

Answer 209

Cardiac output: Increases by 40% Heart rate: Increases to 80-90 bts per minute O2 consumption: Increases by 15% Tidal Volume Increased by 40%

Answer 210

Fetal hyperglycaemia also occurs. The fetus increases insulin secretion (but is not exposed to same levels of hPL as mother). As there is increased glucose available, it is stored as fat (fetal macrosomia). In particular, the fetal liver enlarges (due to glycogen storage). during childbirth: Difficult delivery due to large size of fetus, birth trauma such as brachial plexus injury; caesarean section may be required. in the neonate: Once isolated from the maternal supply of glucose, the neonate may experience a reflex hypoglycaemia due to its high circulating levels of insulin. The brain is particularly at risk of damage from hypoglycaemia as it does not have glycogen storage.

Answer 211

prematurity Impaired lung maturation respiratory disorders of newborn cardiac, neural tube defects and other congenital malformations, may occur if conception occurs during a period of maternal hyperglycaemia polycythemia etc.

Answer 212

For the Hb in her expanded blood volume. Menstrual losses have stopped.

Answer 213

May be asymptomatic or easy fatigability or breathlessness Oral iron sulphate or gluconate

Answer 214

Fetal growth retardation. Anaemic women have 3-5 times higher mortality rate in pregnancy than non-anaemic women and a still birth rate up to 6 times higher

Answer 215

Carbon monoxide in maternal blood shifts her Hb-O2 curve to the left, so the fetus suffers a reduced pO2 in extracting its O2 requirement, which may not be fulfilled.

Answer 216

Hypertension and proteinuria Oedema may or may not be present and therefore is not included in the diagnostic signs.

Answer 217

Increasing diastolic BP Lack of fetal growth Persistent and worsening albuminuria Oligohydramnios Oliguria Pulmonary oedema Thrombocytopenia Headache Elevated liver enzymes Visual complaints Eclampsia is the onset of convulsions in a pregnancy complicated by pre-eclampsia.

Answer 218

Initial management of eclamptic fit is to maintain maternal airway, administer oxygen, place her on left side (enhance uterine perfusion) and maintain her safety during the convulsion. Magnesium is given by intravenous bolus then continuous infusion to relieve vasospasm and stop the fitting. Sometimes thiopentone or diazepam are needed for recurrent fits. Blood pressure control usually requires hydralazine. Once stable assess fetus and maintain optimum fluid/oxygen/positioning. Delivery is the definitive treatment for eclampsia. Caesarean delivery will often be required unless the cervix is extremely favourable.

Answer 219

``` Increased incidence of pregnancy induced hypertension anaemia polyhydramnios preterm labour perinatal mortality antepartum haemorrhage ```

Answer 220

BP: Looking for evidence of worsening pre-eclampsia Examination for oedema: Oedema is common in pregnancy; however a sudden increase in oedema and facial oedema is suggestive of pre-eclampsia Examination of optic fundi: Assessing the potential for CNS involvement Examination of tendon reflexes: Hyperreflexia is an indication of the effect of worsening vasospasm on CNS function; therefore increased risk of eclampsia (seizure in pregnancy) Uterine size estimation: Fetal size estimation: Fetal heart sounds: Assessment of effect of maternal syndrome on fetal well-being

Answer 221

Maternal nutrition and health Efficiency of placenta Adequate utero-placental blood flow Genetic factors Maternal parity (primaparous mothers have smaller babies than multiparous) Maternal habits (smoking, drug abuse etc) Also, race, maternal height, weight,

Answer 222

Doppler ultrasound

Answer 223

The measurements are used to confirm earlier dating and form a reference point for later investigations. Some but not all fetal anomalies may be excluded at this stage.

Answer 224

i. At this stage of pregnancy the organ systems are developed and can be visualised and anomalies can be identified. ii. If anomalies are seen, the pregnancy is still early enough for possible intervention or termination if appropriate. iii. The inherent error in these measurements increases with gestational age such that as a dating tool ultrasound becomes less accurate as the pregnancy proceeds. Ultrasound errors: 1st Trimester ± 1 week 2nd Trimester ± 2 weeks 3rd Trimester ± 3 weeks

Answer 225

Determine presence or absence of intrauterine pregnancy (or ectopic pregnancy) ``` Determine gestational age and measure fetal growth (when compared against standard tables) e.g., abdominal circumference (AC) biparietal diameter (BPD) crown-rump length (CRL) femur length (FL) head circumference (HC) ``` Estimate fetal weight Identify multiple pregnancies Detect fetal anomalies (e.g., neural tube defects), placental anomalies (e.g., placenta praevia) Measurement of amniotic fluid (Identify maternal pelvic anomalies) (Guide for needle in amniocentesis)

Answer 226

Transvaginal ultrasound to see fetal cardiac activity in the uterus is very reassuring . It rules out ectopic pregnancy and early causes of loss such as blighted ovum.

Answer 227

Folic acid supplements may reduce the risk of neural tube defects. Routine blood tests for alpha-fetoprotein are taken between 15-19 weeks gestation (when levels are at their highest). If elevated, it can be indicative of an open neural tube defect. Ultrasound study with optional amniocentesis is indicated. Raised alpha-fetoprotein levels, however, may 'simply' indicate a multiple pregnancy.

Answer 228

Doppler: 10-12 weeks Plain: 18-20 weeks

Answer 229

140 - 160 beats per minute

Answer 230

From about 12 weeks fetal respiratory movements are seen by sonographic evaluation. By 34 weeks they occur in irregular bursts, with rates up to 40-60/min, punctuated with periods of apnoea (including hiccups). Fetal respiratory movements are diaphragmatic and cause movement of amniotic fluid into and out of the lungs.

Answer 231

Type II ALVEOLAR CELLS produce surfactant beginning at about 20 weeks but increases dramatically after 30mwekks, reaching significant levels at about 34weeks. A deficiency of surfactant leads to respiratory distress syndrome of the newborn – a high risk in prematurity. Steroid therapy, given antenatally to women at risk of pre-term delivery, may reduce the risk of RDS by 50%, by promoting the production of surfactant.

Answer 232

The uterus becomes an abdominal organ at about 12 weeks so the fundus is now palpable. The height from top of symphysis pubis to top of fundus (in cm) correlates with the number of weeks of gestation. Distance between symphysis pubis to top of uterus (i.e., fundus). It can be measured with a tape measure (e.g., 20cm at 20 weeks, 36 cm at 36weeks then, plateaus). Alternatively, the height of the fundus is assessed in relation to other structures such as the umbilicus or xiphisternum. The uterus is palpable above the pelvis after gestational week 12. A lag of 4 cm or more of the fundal height is suggestive of intrauterine growth restriction/fetal growth restriction. Measurements are dependent on the number of fetus, volume of amniotic fluid, extent of engagement of head and the lie of the fetus.

Answer 233

As about fetal movements; the mother should be noticing fetal movements (also called 'quickening’), which feel like fluttering. A multiparous woman may detect fetal movements earlier

Answer 234

Asymmetric growth retardation in which there is "brain sparing". The head (and indeed femur) continues to grow but abdominal fat and glycogen is diminished as fetus is compromised. Asymmetrical growth retardation is associated with poor maternal nutrition or decline in nutrient delivery to the fetus in the latter stages of pregnancy. This may be due to maternal or fetal factors but most often reflects compromise to the utero-placental unit. The growth restriction shows up mainly in the third trimester when nutritional demands and fetal growth are most rapid Growth retardation earlier in pregnancy is more often related to genetic, or congenital problems or isolated insults to the development of the fetus.

Answer 235

Measurement of fetal waist (at level of the umbilical vein) provides assessment of growth of fetal liver and amount of sub-cutaneous fat etc. Glycogen laid down in the fetal liver accounts for much of this growth.

Answer 236

fetal movement: Musculoskeletal, CNS fetal breathing movement: musculoskeletal /respiratory, CNS fetal tone: Musculoskeletal, CNS amniotic fluid volume: Renal, uteroplacental, (GI) fetal heart rate response to movement in the NON-STRESS TEST: Cardiovascular, Autonomic nervous system The first four are assessed by ultrasound. Many factors may cause a reduction in the scores achieved including fetal sleep cycles, maternal dehydration or hunger, maternal sedation and fetal alcohol syndrome, as well as fetal compromise due to hypoxemia. The results have to be viewed in context of risk factors, earlier studies and sometimes repeat evaluations to determine whether urgent and /or early delivery is required.

Answer 237

Thyroid hormones (secreted from 12 weeks onwards, very little is derived from the mother)

Answer 238

Nutritional deprivation / utero-placental insufficiency leads to decreased fetal urine production.

Answer 239

Risks of compromise v risks of prematurity, particularly respiratory problems.

Answer 240

Passage of fluid across the amnion and non-keratinised fetal skin (transudation)

Answer 241

All would lead to oligohydraminos (abnormally low amniotic fluid vol) Amniotic fluid is a dynamic state of flux; the water component being exchanged every 3 hours or so. It is a dialysate of maternal and/or fetal fluid. The fetal lungs also contribute to the amniotic fluid volume

Answer 242

Oesophageal atresia Duodenal atresia (Also, diaphragmatic hernia, anencephaly, inencephaly, hydrocephaly)

Answer 243

Poorly controlled maternal diabetes. A rise in maternal blood glucose levels raises the availability of glucose to the fetus. Much of this glucose will be laid down as glycogen in the fetal liver (hence increase in fetal abdominal measurement).

Answer 244

Fetal macrosomia; birth weight >4000 or 4500g | There are other causes of fetal macrosomia including post-term pregnancy and maternal diabetes

Answer 245

* maternal hypertension * maternal heart or liver disease * multiple gestation * maternal diabetes * where there is evidence of fetal growth retardation * suspected oligohydramnios * presence of placental abnormality * post-dated pregnancy

Answer 246

Fetus may be sleeping; | Repeat later e.g. After a meal

Answer 247

Typically, meconium are the first stools of a newborn baby – green, dark and sticky and composed of cellular debris, mucous and bile pigments. It is formed from the digestion products of amniotic fluid (cells and protein) the fetus has swallowed. The presence of meconium in the amniotic fluid is an indicator that the fetus has had an episode of distress.

Answer 248

Abdominal palpation

Answer 249

Allows for continuous close monitoring of fetal heart rate regardless of maternal position.

Answer 250

An increase in the number of oxytocin receptors is in preparation for labour since oxytocin stimulates uterine contraction (via a positive feedback mechanism). However progesterone prevents oxytocin from evoking contractions during pregnancy, so avoiding spontaneous abortion. Progesterone also reduces uterine prostaglandin release thus again reducing myometrial activity.

Answer 251

Cervical softening | Relaxation pelvic ligaments

Answer 252

It may cause lordosis (due to relaxation of vertebral ligaments and the additional weight of the fetus).

Answer 253

Mother's umbilicus

Answer 254

Fetal fontanelles

Answer 255

Brachial plexus

Answer 256

Lumbar sympathetic outflow blockade prevents vasoconstriction

Answer 257

Blood loss of > 500 ml after vaginal delivery

Answer 258

Uterine atony

Answer 259

Strong contractions after the 3rd stage of labour contract the uterus down, achieving closure of the “living ligature” (the unusual criss-cross arrangement of myometrial fibres) clamping the arterial supply to the placental bed in the endometrium.

Answer 260

Laceration or trauma to the genital tract / Retained placenta

Answer 261

Thrombosis of vessels supplying the anterior lobe secondary to severe haemorrhage, leading to necrosis of the anterior pituitary gland which increases in size during pregnancy increasing its susceptibility to necrosis. Posterior pituitary is unaffected because It has a relatively rich arterial blood supply.

Answer 262

Hypovolaemic shock

Answer 263

``` cyst fibroadenoma inflammatory (fat necrosis etc.) phyllodes tumour carcinoma ```

Answer 264

clinical history + examination | investigations e.g. ultrasound, mammogram, FNA and/or core

Answer 265

Fibroadenoma smooth surfaced lobulated mass; histology = large amount of stroma with compression of elongated ducts.

Answer 266

parenchymal deformity, ASD, masses, calcification malignant - ductal carcinoma in situ & invasive carcinoma benign - cysts, sclerosing adenosis, columnar cell change

Answer 267

Ductal carcinoma in situ Invasion Wide local excision or mastectomy - depends on location, size relative to breast, multifocality & patient choice

Answer 268

malignant breast aspirate (carcinoma)

Answer 269

size + weight of specimen, size of tumour, distance to margins, any other abnormalities

Answer 270

(size), histological type, grade, lymphovascular invasion, margins

Answer 271

metastases to liver liver function tests ultrasound / CT scan liver biopsy if necessary metastasis to bone resulting in pathological fracture metastasis to lung and pleura – pleural effusions metastasis to brain – stroke