Reproduction Exam 1

Describe the development of the female reproductive system

1. Development of the sexually indifferent gonad: At week 5 of development, the intermediate mesoderm thickens to form the urogenital ridge. The urogenital ridge will form into the nephrogenic cord (posterior) and the gonadal ridge (anterior). Primordial germ cells will migrate along the dorsal mesentery and invade the gonadal ridge, and form the primitive sex cords. 2. Development of the genital ducts: In the absence of testis determining factor (TDF), in females, a female gonad develops. The primitive sex cords degenerates and the surface epithelium incorporates the primordial germ cells and forms the cortical cords. 3. Development of genital ducts: derived from the paramesonephric ducts (laterally along posterior body wall). In the absence of MIS, these ducts enlarge and fuse in the midline, held by the broad ligament of the uterus. These ducts will give rise to the uterine tube and uterus. 4. Development of the external genitalia: The vagina is formed from the paramesonephric ducts (superior vagina) and the urogenital sinus (distal vagina)

What are the layers of the uterus?

1. Endometrium: inner mucous coat, epithelium 2. Myometrium: forms most of the wall; smooth muscle 3. Perimetrium: peritoneum and a thin layer of areolar tissue

Laceration of the Vagina/Birth Canal

1. First degree: small tear in which the vaginal mucous membrane can be seen but not the underlying fascial and muscle. 2. Second Degree: Fascia and muscles of the Perineal body but not the anal sphincter are torn. 3. Third Degree: extends farther to involve the anal sphincter 4. Fourth Degree: Extends through the rectum to expose its lumen.

List the 3 important procedures that should be performed during the obstetric pelvic examination.

1. Inspection of the external genitalia, vagina, and cervix 2. Collection of cytologic specimens from the exocervix and superficial endocervical canal 3. Palpation of the cervix, uterus, and adnexa

Describe the four ethical principles that need to be taken into account in health care.

1. Nonmaleficence: "first, do no harm." 2. Beneficence: put the welfare of the patient first 3. Autonomy: The right of self-determination, which in order to exercise, a patient must be capable of effective deliberation and be neither coerced into a particular course of action nor limited by an external constraint 4. Justice: the manner in which benefits and burdens of society are distributed

What holds the ovaries in place?

1. Ovarian Ligament 2. Suspensory ligament of the ovary 3. Mesovarium

List the 2 most common causes of amenorrhea

1. Pregnancy 2. Normal menopause

What are the cardinal movements of labor?

"Every Descent Family In Europe Eats Eggs" 1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External Rotation 7. Expulsion

List the major points the physician should cover during the obstetric history and relevant points for each. a. List the relevant points to cover for the history regarding previous pregnancies.

1. Previous Pregnancies: date & location of delivery, duration of gestation, type of delivery, duration of labor, type of anesthesia, maternal complications, newborn weight, newborn gender, fetal & neonatal complications 2. Menstrual History: used to determine expected date of confinement (EDC) -- add 9 months and 7 days to FDLNP 3. Contraceptive History: hormonal contraceptives taken during early pregnancy have been associated with birth defects, and retained IUDs can cause early pregnancy loss, infection, and premature delivery 4. Medical History: obtain information about common disorders (DM, HTN, etc.) as well as serious medical conditions 5. Surgical History: recorded chronologically, including date, hospital, surgeon, and complications 6. Social History: smoking, alcohol use, and other substance abuse, contact with domesticated animals, work and lifestyle

What are the routine tests and their timing in a normal pregnancy?

1. Rh: if patient is Rh-, rhogam should be administered within 72 hours of screening which prevents the formation of antibodies and gives the patient passive immunity (gives the patient the antibodies) 2. Blood Type 3. Antibody Screen

Identify the four basic principles and guidelines for practicing and improving health care

1. Safety: emphasize teamwork and implement practices proven to be effective in the airline industry 2. Adhere to Ethical Practices 3. Use Value-Based system of Healthcare Delivery: be open to a more cost effective multidisciplinary approach to diagnostic and therapeutic practices 4. Prevention and Early Mitigation: should occur in a patient centered manner

What are the fetal surveillance tests used in the monitoring of high risk pregnancies?

A. Non-Stress Test (NST): mother hooked up to fetal monitor to monitor fetal HR, and mother hits a button when she feels the fetus move; look for rise in fetal HR >15 BPM for at least 15 seconds in a 20 minute period -- this is normal (reactive), and indicates good fetal health B. Contraction Stress Test (CST): mother hooked up to the fetal monitor for contractions and fetal HR. Mother is given stimulation to cause contractions- nipple stimulation or oxytocin- to cause 3 contractions lasting 40-60 seconds in 10 minutes; look for late decelerations; 0 is a reassuring test C. Biophysical profile (BPP): 10 point system that performs a non-stress test and an ultrasound that looks for specific behaviors of the fetus (i.e.- breathing movement, fetal movements, fetal tone, amniotic fluid index) - best score is 10 D. Cord Doppler Velocimetry: used in pregnancies at risk for fetal growth restriction; it measures blood flow and normal doppler studies indicate forward motion of blood flow both in systole and diastole.

Define Labor

Contractions that cause cervical dilatation. Contractions are regular, with gradually shortening intervals and gradually increasing intensity. Patients typically have back and abdominal pain.

Hysterosalpingogram

Contrast is injected into the cervical canal in an attempt to opacify the cervical canal and the fallopian tubes. Frequently utilized in infertility evaluation or recurrent abortions.

Histology of the ovary

Covered with a mesothelial layer of cuboidal or squamous cells. Just under this epithelium is the tunica albuginea which is a dense connective tissue layer, followed by the cortex below this.

Identify guidelines and recommendation of major medical societies on preimplantation sex selection and Posthumous Assisted Reproduction (PAR)

American Society for Reproductive Medicine (ASRM) Ethics Committee: PAR is ethically justifiable if written documentation from the deceased authorizing it is available. If documents are not available, requests should only be fulfilled when initiated by the surviving spouse or life partner, as long as adequate time for grieving and counseling has been allowed. European Society of Human Reproduction and Embryology (ESHRE): PAR is acceptable when the request is from a surviving partner who was part of the original project, written consent was given by the deceased, a minimum of 1 year waiting period has been imposed, and the surviving partner is appropriately counseled.

What is the normal positioning of the uterus?

Anteverted and Anteflexed

Preterm Labor Define and include the incidence, which patients are at highest risk, etiologies, and treatment

Any birth that occurs prior to 37 weeks Incidence: Higher in those living in the deep south, those of lower socioeconomic status High Risk: Prior pre-term delivery, smoking, substance abuse, uterine malformations, fibroids Etiology: Activation of maternal/fetal HPA axis (i.e.-maternal/ fetal stress), inflammation/infection, decidual hemorrhage, pathological uterine distention (multi-fetal pregnancy, polyhydramnios, uterine abnormalities) Treatment: ∙ Cerclage: stitch through the cervix to clamp it down

List the causes of vaginal bleeding in the prepubertal child

In Newborns., the most common cause is maternal estrogen withdrawal. Precocious puberty may present with vaginal bleeding. Along with these causes, functional ovarian cysts, exogenous hormonal exposure (ingestion of birth control), or ovarian tumors

List the common issues encountered in the geriatric patient gynecologic assessment

Elderly women tends to underreport their symptoms either due to the belief that they are normal due to the aging process or for fear of loss of their independence The more common gynecologic conditions include atrophic vaginitis, uterine and vaginal prolapse, and genital tract malignancies

Explain the changes that occur in the endometrium during the stages of the endometrial cycle and the hormone alterations that lead to these changes.

Endometrial Cycle A. Menses (days 0-4): When estrogen and progesterone levels fall following death of the corpus luteum there is nothing to cause proliferation of the endometrium or glycogen, resulting in sloughing off of the endometrial tissue B. Proliferative Phase (days 4-14): estrogen causes proliferation of the endometrial cells C. Secretory Phase (days 14-28): with production of the corpus luteum, there are high levels of progesterone which secretes glycogen, preparing the endometrium for implantation of an ovum, and preventing the uterine myometrial contractions.

Describe the role(s) of hormones (estrogen, progesterone, & hCG) in pregnancy.

Estrogen: Levels increase and stay elevated following fertilization (produced at first by the corpus luteum, followed by the placenta). It is responsible for stimulating growth of the myometrium, contributes to increasing blood flow to the uterus, increases LDL receptors on syncytiotrophoblasts, and increases prostaglandin synthesis and oxytocin receptors in the uterus. Progesterone: Levels increase and stay elevated following fertilization (produced at first by the corpus luteum, followed by the placenta). It is responsible for implantation and maintenance of pregnancy through uterine quiescence (inhibits prostaglandin release to prevent uterine contractions). It will also promote formation of the cervical plug, and suppression of the maternal immune response to fetal antigens Human Chorionic Gonadotropin (hCG): Secreted by syncytiotrophoblasts, it is similar to LH in structure/ function, and is responsible for maintaining the corpus luteum. This is detected 6-8 days after ovulation (right after implantation)

Identify the mechanisms of action and biological functions of estrogen and progesterone.

Estrogen: Pre-menopausal, it is critical for breast growth & development and endometrial/ myometrial growth and vascularization in preparation for pregnancy Progesterone: inhibition of further endometrial proliferation and stimulation of secretion of nourishing glycoproteins & proteins by glandular epithelium.

Post Partum Hemorrhage Etiologies and Treatment

Etiology: "The 5 T's" 1. Tone: uterine atony 2. Trauma: surgical or instrumental delivery 3. Tissue: retained placenta 4. Thrombosis: congenital/ acquired abnormal clotting abnormalities 5. Traction: uterine inversion Treatment: ∙ Bimanual compression: fist in the vagina with pressure over the abdomen on the uterus ∙ Bakri Balloon: insertion of balloon and inflation with air to provide pressure ∙ B-Lynch "Brace" Suture: suture placed into the uterus that clamps it down ∙ Uterine Artery ligation ∙ Hysterectomy: last ditch effort

Gestational Hypertension

Hypertension after 20 weeks gestation without proteinuria. Blood pressure returns to normal by 12 weeks postpartum, and does not put the patient in as much risk as pre-eclampsia (proteinuria indicated developing pre-eclampsia) and eclampsia Hypertension is considered BP > 140/90 mmHg

What can sonogram of the testicles determine about a palpable abnormality?

If it is intra-testicular or extra-testicular

How can you estimate how far a patient is along in her pregnancy using the fundal height?

If the fundal height is at the umbilicus, she is around 20 weeks. The closer the fundal height is to the ribs, the loser the patient is to term.

Preimplantation Sex Selection Define and Identify the reasons couples may desire to use it as well as the ethical concerns

Definition: Preimplantation selection of genetically desired embryos, followed by transfer of only those embryos Use: The major reasons for sex selection include- ∙ Personal preference for a child of a specific sex ∙ To achieve "balanced" family with children of both sexes ∙ To avoid sex-linked genetic disease ∙ To avoid diseases with unequal sex incidence Ethical Concerns: Preconception and preimplantation sex selection for medical reasons has broad approval, whereas sex selection for nonmedical reasons is more controversial ∙ May reinforce sex bias or lead to sex ratio imbalances ∙ Creation and destruction of excess embryos for the sole purpose of selecting an embryo of a particular sex

Chronic Hyptertension

Individuals who have known hypertension (BP > 140/90 mmHg) prior to pregnancy, develop hypertension prior to 20 weeks, or those with hypertension lasting beyond 12 weeks post-partum

Endometrial Hyperplasia

Increased proliferation of the endometrial glands relative to the stroma with malignant potential. It is divided into (4) main categories: 1. Simple Hyperplasia ∙ With Atypia: uncommon, cells becomes rounded and lose perpendicular orientation to the basement membrane ∙ Without Atypia: glands of various sizes with irregular shape and cystic dilation 2. Complex Hyperplasia ∙ With Atypia: morphologic overlap with well-differentiation endometrial adenocarcinoma ∙ Without Atypia: increase in the number and size of endometrial glands with marked crowding and branching

Discuss the synthesis of estrogens and progesterone, including the producing cells, steps and enzymes involved.

LH binds theca cells in the ovary, which brings cholesterol into the cell and stimulates the synthesis of weak androgens (progesterone, Androstenedione) which are converted to testosterone which can then be converted to estradiol in the granulosa cells. FSH binds Granulosa cells in the ovary. Within the Granulosa cell, Androstenedione and testosterone made in the Theca cells are converted to Estradiol In the Luteal cell, cholesterol is converted into progesterone.

Placental site trophoblastic tumor (PSTT) Include etiology, morphology, and prognosis

Neoplastic proliferation of extra-villous trophoblasts with presence of syncytiotrophoblasts and cytotrophoblasts. Presents as a uterine mass (smaller than choriocarcinoma) Morphology: Trophoblastic cells diffusely infiltrating the endomyometrium

What is the epithelium type of the uterine tube?

Simple Columnar

What is the imaging modality of choice for evaluation of the pelvis?

Sonogram (ultrasound)

What is the prime imaging modality for evaluation of the scrotum, testicles and epididymis?

Sonogram (ultrasound)

What is the Imaging modality of choice for the evaluation of scrotal pain?

Sonogram (ultrasound) Can be used to determine testicular torsion vs. epididymitis or undescended testicles

Evaluate the consequences of testosterone deficiency in males at different life stages.

• Fetal (2-3 mos): genital ambiguity, pseudo-hermaphroditism • Fetal (3rd trimester): cryptorchidism, micro-penis • Prepubertal: altered skeletal proportions, poor development of 2° characteristics • Post-pubertal: Erectile Dysfunction, low libido and energy, decreased facial hair growth

List the gynecological issues that are associated with abdominal pain

∙ Salpingo-oophoritis with peritoneal inflammation ∙ Torsion and infarction of ovarian cyst ∙ Endometriosis ∙ Ectopic pregnancy rupture

List the normal baseline levels that should be established during a general obstetric physical exam

∙ Weight ∙ Blood Pressure ∙ Funduscopic (retina) appearance ∙ Cardiac status

Endocervical Polyps

Benign exophytic growths of the cervix that results in irregular vaginal "spotting" or bleeding Typically soft, almost mucoid lesions which are composed of loosely cellular material

Identify the importance of androgen binding protein (ABP)

Binds testosterone to keep locally elevated levels within the testes

Discuss the implications of vaginal bleeding before the age of 9 and after the age of 52

Bleeding before age 9 or after age 52 is cause for concern and required investigation. ∙ Uterine Cancer ∙ Exogenous estrogens

What is the standard way in which results of a mammogram are reported??

Breast imaging reporting and database system (BI-RADS)

What is the lymphatic drainage of the vagina?

upper 2/3: Internal & external iliac lower 1/3: superficial inguinal

What is the innervation of the vagina?

upper 2/3: autonomic (visceral) → no pain lower 1/3: somatic from deep perineal branch of the pudenal n. → sensitive to touch and temperature

Chorionic Villus Sampling (CVS) Define and include its use, advantages, and disadvantages

Prenatal genetic tests that is done by taking a sample of the placental tissue, performed between 10-11 weeks. May require follow-up amniocentesis

List the pertinent points to consider during the following histories: A. Menstrual B. Contraceptive C. Obstetric D. Sexual E. Past F. Systemic

A. Menstrual: age at menarche, interval between periods, duration of menses, & character of flow B. Contraceptive: type and duration used along with complications C. Obstetric: number of pregnancies, delivery, and associated complications D. Sexual: pain, bleeding, or dysuria, as well as sexual satisfaction E. Past: Any significant past medical, surgical, or family history F. Systemic: review of all other organ systems

When should a cesarean section be considered?

>6cm with ruptured membranes who fail vaginal delivery despite 4 hours of adequate or 6 hours of inadequate contractions

Klinefelter Syndrome Define and predict hormone levels

A chromosomal disorder in which males have an extra X chromosome, making them XXY instead of XY. This is the most common genetic cause of hypogonadism (47, XXY) and results in tall stature, breast development, osteoporosis, small testes, and female-type pubic hair pattern. Patients are typically infertile Testosterone: Low Sex Hormone Binding Globulin (SHBG): Increased LH: Increased Estradiol: Increased

Interpret the validity of genetic tests based on sensitivity and specificity

Sensitivity: the ability of a test to correctly identify individuals who are positive for a disease (true positives) True Positive/ (True positive + False negative) Specificity: the ability of a test to correctly identify individuals who are negative for a disease (true negatives) True negative/ (True negative + False positive)

Explain the physiological responses of the mother's body during pregnancy. Include changes in the following: A. Hematological B. Cardiac C. Renal anatomy/vasculature D. Body water E. Respiratory F. Endocrine G. Metabolism

A. Hematological: ∙ Increased plasma volume -- uterus needs increased blood volume ∙ Altered coagulation system (increased VIII, IX, X, and Fibrinogen) which favors clotting -- risk of venous thrombosis B. Cardiac: ∙ Decreased systemic vascular resistance ∙ Increased cardiac output ∙ Decreased mean arterial pressure C. Renal anatomy/vasculature: ∙ Vasodilation of renal arteries caused by relaxin which produced nitric oxide ∙ Increased renal blood flow ∙ Increased GFR D. Body water: ∙ ADH release causes hypervolemia (increased plasma volume) ∙ Decreased plasma sodium concentrations E. Respiratory: ∙ Increased tidal volume ∙ Increased pO2, decreased pCO2, compensatory fall in serum bicarbonate ∙ Mild, compensated respiratory alkalosis F. Endocrine: ∙ Undetectable FSH/LH due to increased Estrogen and progesterone ∙ Increased RAAS ∙ Enlarged pituitary gland G. Metabolism: ∙ Increased insulin resistance, resulting in hyperplasia of beta-cells ∙ Gestational diabetes (insulin secretion insufficient to overcome insulin resistance causing hyperglycemia)

Explain the intricacies of ethical practice for the following: A. Autonomy of the maternal-fetal relationship B. Multidisciplinary interactions in the hospital C. Relationships to all parties within the health-care delivery system

A. Autonomy of the maternal-fetal relationship: management of the mother, inevitably affects the baby. In addition, procedures performed on behalf of the fetus, may violate the personal integrity and autonomy of the mother B. Multidisciplinary interactions in the hospital: Historically, the physician has been the only decision maker; but there is increasing recognition that other clinicians (i.e.- nurses) involved in health care have a right to participate in the decision making process. C. Relationships to all parties within the health-care delivery system: hospitals, health insurance companies, and governments all claim an interest in what services are made available or paid for which may prevent a patient from receiving what their physician considers optimal care

Classification of Cervical Precancerous Lesions

A. Cervical Intraepithelial Neoplasia (CIN) ∙ CIN I: Mild Dysplasia ∙ CIN II: Moderate Dysplasia ∙ CIN III: Severe dysplasia B. Two-Tiered System ∙ Low-Grade squamous intraepithelial Lesion (LSIL): AKA CIN I; typically regress spontaneously and does not progress directly to invasive carcinoma; nuclear enlargement with hyperchromasia (dark staining) and the presence of coarse chromatin granules ∙ High-Grade squamous intraepithelial lesion (HSIL): AKA CIN II and CIN III; increased cellular proliferation; atypical immature squamous cells that are confined to the lower 1/3 of the epithelium; cells expand to two third of the epithelial thickness

Define the following terms: A. Chadwick's sign B. Piskacek's sign C. Hegar's sign

A. Chadwick's sign: dark discoloration and cyanosis of the vulva and vaginal walls B. Piskacek's sign: when one cornu of the uterus is slightly larger from asymmetric implantation of the ovum C. Hegar's sign: Uterus becomes softer, making it possible to palpate or compress the connection between the cervix and the fundus

Define the following terms: A. Epigenetics B. Barker Hypothesis C. Developmental Programming

A. Epigenetics: the study of environmental influences (i.e.- poverty, nutrition, smoking) on gene expression without a change in the DNA sequence B. Barker Hypothesis: the idea that prenatal exposure to adversity may influence the development of adult diseases (i.e.- obesity, diabetes, stroke) thought to occur through re-programming of gene expression C. Developmental Programming: A stimulus or insult, at a sensitive or critical period of fetal development, induces permanent alterations in the structure and function of the baby's vital organs

Assess the mechanism of action for testosterone and its biological outcomes in males.

A. Fetus: Differentiation internal, external genitalia B. Puberty: Growth of male reproductive tissues; skeletal muscle and larynx; epiphyseal cartilage plates; development of 2° sex characteristics (hair growth on the face, chest, genitals); stimulates erythropoiesis C. Adult males: Stimulate sperm production; maintenance of 2° sex characteristics; libido and potency

Intra-testicular masses are most often A. Malignant or Benign, while extra-testicular masses are most often B. Malignant or Benign

A. Malignant B. Benign

What are the components of prenatal care and how can they help identify complications of pregnancy?

A. Preconception Consultation: identify risk factors (pre-term labor, low birth weight, pre-eclampsia, stillbirth, congenital anomalies, gestational diabetes), personal, or in the family to optimize medical status to reduce risks B. 1st Trimester Screening: performed between 10-13 weeks ∙ Bloodwork: PAPP-A (low in fetal Down's), Inhibin A + free beta subunit HCG + total HCG (higher in fetal Down's) ∙ Nuchal Translucency Ultrasound: looks for a naturally occurring fluid space at the back of the neck (thickening is associated with Down's) C. 2nd Trimester Screening: Mothers > 35 years at the expected delivery date are at increased risk of trisomies ∙ Serum Alpha Fetoprotein: performed at 15-20 weeks; < 0.5 there is an increased risk of trisomy, and if > 2.5 there is an increased risk of open neural tube defects ∙ Quad Screen: Performed at 15-20 weeks, it is a combination of Alpha fetoprotein, HCG, Estriol, & Inhibin A ∙ Cell Free DNA: non-invasive blood test for trisomies, which is negative, does not require amniocentesis ∙ Amniocentesis: performed at 15-20 weeks, it is a diagnostic test for Trisomies ∙ Chorionic Villi Sampling: performed at 12-14 weeks, it is diagnostic test where tissue is sampled from the placenta D. Third Trimester ∙ Glucola Test: 1 hr. 50 gm, to screen for gestational diabetes ∙ Group B Beta Strep: cultured from lower 1/3 of vagina and rectum and treated in labor (Ampicillin or Penicillin G)

Aromatase Deficiency Include the clinical findings in both males and females

Aromatase is responsible for converting androstenedione and estrone to estrogen. If deficient, it can lead to: Females (46, XX) ∙ Ambiguous genitalia ∙ Early ovarian cysts ∙ No breast growth or menses ∙ Acne & Hirsutism Males (46,XY) ∙ Small Testes ∙ Decreased sex drive Both ∙ Tall ∙ Slowed mineralization of bones and osteoporosis ∙ Hyperglycemia ∙ Weight gain

Distinguish between the roles of aromatase, C17 dehydrogenase, and 5α-reductase in hormone synthesis.

Aromatase: converts androstenedione and estrone to estrogen C17 Dehydrogenase: Enzyme that is used in the final step of testosterone synthesis (Androstenedione to Testosterone) 5α-reductase: converts testosterone to dihydrotestosterone (DHT) which is more biologically active; responsible for the formation of primary sex characteristics and most secondary sex characteristics (i.e.- muscle growth, facial & body hair growth, deepening voice)

Pelvic Inflammatory Disease (PID)

Ascending infection, most commonly caused by Gonococcus or Chlamydia, it begins in the vulva and vagina then spreads upward to involve the most structures in the female genital system Results in pelvic pain, adnexal tenderness, fever, and vaginal discharge

List the four steps that should be avoided to minimize adverse drug reactions

Avoid: 1. Prescribing unnecessary medications 2. Treating mild side effects of one drug with a second, more toxic drug 3. Misinterpreting a drug's side effect for a new medical problem and prescribing a new medication 4. Prescribing a medication when there is any uncertainty about dosing

Early Decelerations

Baby's HR drops during each contraction (uniform, mirror the contraction) due to head compression (vagal response) ∙ These are not associated with fetal distress

Late Decelerations

Baby's HR drops after the contraction. This is a sign of uteroplacental insufficiency (hypoxia) Treatment: Stop pitocin, change maternal position left to right, administer 100% oxygen, scalp stimulation, tocolytics, delivery

What is the lymphatic drainage of the uterus?

Cervical region: internal & external iliac Fundus: lumbar nodes Round ligament attachment: Superficial inguinal nodes

Posthumous Assisted Reproduction (PAR) Define and identify when it may be used, ethical concerns (and the differences between planned vs. unplanned)

Definition: The process by which assisted reproductive technologies- i.e. In vitro, cryopreservation- is used to establish pregnancy and produce genetic offspring after the death of the parent Use: Intended to fulfill a couple's desire to reproduce, considered within the context of the untimely death or imminent demise of at least one genetic parent and assuming that at least one invested party desired children through PAR. Ethical Concerns: the clinician's decision to fulfill the request should depend on the presence of absence of informed consent from the deceased gamete provider, the relationship of the requester to the deceased, and the perceived benefit vs. harm ∙ Respect for autonomy: both clinicians and survivors should strive to act in accordance with expressed or presumed wishes of the deceased ∙ Beneficence: desire to reproduce is considered by many a central human drive and may provide peace of mind and ease suffering ∙ Non-maleficence: benefits should outweigh the potential adverse outcomes ∙ Social Justice: fair distribution of health care resources to provide the greatest benefit to society as a whole A. Planned: Ideally, the use of gametes for postmortem conception, when the possibility of death is anticipated, has been decided on and consent given B. Unplanned: the question becomes whether the deceased wanted a child to be born using his/her genetic material

Gestational Diabetes Include definition, diagnosis, classification, & treatment

Diabetes that typically presents in the last half of pregnancy, and places the fetus at risk of macrosomia, delayed organ maturation, as well as cardiac/ neural tube/ sacral mutations Test ∙ Screening Test: 1 hour 50 gram glucola test, if > 135 diagnostic test ∙ Diagnostic Test: 3 hour glucose tolerance test (100g loading dose); diagnosis of gestational diabetes is if there are >2 abnormal values on the 3 hour GTT → Normal values: F:95, 1hr:180, 2hr:155, 3hr:140 White Classification ∙ A1: Abnormal GTT, normal values with diet & exercise, no insulin needed A2: Abnormal GTT, abnormal values with diet & exercise, insulin needed Treatment ∙ Diet ∙ Exercise ∙ If fasting or post-prandial values remain elevated, treat with insulin A. Antepartum (before labor): serial ultrasounds, serial tests for fetal well being, maintain normal glucose levels B. Intrapartum (during labor): those requiring insulin, should get IV insulin @ 0.5-2.0 units/hr to maintain glucose 80-120mg/dL C. Post-partum (after labor): most do not require insulin for the first 48-72 hours post delivery; monitor glucose q 6 hr, and treat with insulin if glucose > 150mg/dL

Polycystic Ovarian Syndrome (PCOS) Define and include clinical findings

Disorder of androgen excess, there is a baseline elevation in LH without the LH and FSH surge, causing cyst development in the ovaries. This results in irregular, heavy, and long menstrual periods. Symptoms ∙ Hyperandrogenism: Hirsutism, Acne ∙ Oligo-Ovulation: unpredictable menstrual cycles, subfertility ∙ PCO morphology: reduced egg quality, increased rate of miscarriage ∙ Insulin resistance ∙ Obesity ∙ Risk of Type II DM, CVD ∙ Metabolic Dysfunction ∙ Muscle changes ∙ Depression ∙ Anxiety

Choriocarcinoma Include morphology, prognosis, signs/symptoms, & diagnosis

Malignant neoplasm of the trophoblastic cells, which is derived from a previously normal or abnormal pregnancy (can include ectopic pregnancy). This is a rapidly invasive cancer which metastasizes widely, but responds well to chemotherapy (good prognosis) Morphology: Do not produce chorionic villi, but a mixed proliferation of syncytiotrophoblasts and cytotrophoblasts Signs/Symptoms ∙ Vaginal bleeding ∙ Hemoptysis ∙ Headaches, dizzy spells, blacking out ∙ Uterine enlargement Diagnosis: persistently elevated B-hCG

Restate the effects of gonadotropic hormones on the ovaries and explain the two-cell, two-gonadotropin hypothesis of ovarian hormone synthesis.

FSH binds granulosa cells, LH binds theca cells Theca cells will convert cholesterol to androgens (i.e.- testosterone, progesterone) Granulosa cells produce progestins and estrogens from testosterone produced by the theca cells using aromatase

Cervical Carcinoma

Malignant tumor of the cervix which are most often caused by HPV 16 and HPV 18. Risk Factors: ∙ Male partner with multiple previous or current sexual partners ∙ Young age at first intercourse ∙ Immunosuppression ∙ Oral Contraceptives Signs/Symptoms: ∙ Typically asymptomatic

What is the imaging modality of choice for evaluation of the breast?

Mammography

Describe the synthesis of testosterone in the testis, including producing cells, hormonal regulation, and steps and enzymes involved.

GnRH is released from the hypothalamus, acts on the anterior pituitary, which released LH that acts on Leydig cells in the testes (converts cholesterol to testosterone) and FSH which acts on Sertoli cells along with testosterone to produce androgen binding protein (ABP), allowing for testosterone to keep locally elevated levels within the testes. LH binds GPCR which increased Adenylate cyclase, which increases cAMP, stimulating the synthesis of testosterone from cholesterol

Compare and contrast linkage analysis and direct mutation analysis, including methods; interpret the results of analysis in conjunction with a family pedigree

Linkage Analysis: used for when a gene is not known but it is localized. It will follow a linked marker among multiple family members to determine which allele is carrying the disorder Direct Mutation Analysis: molecular basis for the mutation is known, and a gel is run of the genetic material to determine if the individual is positive for a genetic disorder (i.e.- running a gel to determine if a patient has sickle cell disease)

Percutaneous Umbilical Blood Sampling (PUBS) Define and include its use, advantages, and disadvantages

Prenatal genetic test is which there is removal of blood from the umbilical cord in-utero. Performed after the 16th week of gestation. This test is able to diagnose hematologic disorders, and has rapid cytogenetic results.

Explain the hormonal and cellular changes that occur during the follicular and luteal phases of the ovarian cycle and the mechanisms behind each.

Ovarian Cycle: A. Follicular Phase (days 0-14): Low levels of estrogen and progesterone leads to elevated levels of FSH and LH. Rising FSH recruits 15-20 antral follicles, resulting in their development and the production of a dominant follicle. As the follicles grow, they increase estrogen levels. The dominant follicle will produce maximum amounts of estrogen, decreasing FSH levels from negative feedback. Estrogen levels will peak 24-36 hours, which switches feedback from negative to positive, resulting in a LH surge. With an increase in LH and prostaglandins, there is production of proteolytic enzymes which results in the rupture of the follicle which will release the oocyte. B. Luteal Phase (days 14-28): Following ovulation, there is a rapid decline in LH and FSH. When the follicle meets its demise at ovulation, it results in decreased estrogen. Theca and granulosa cells left over will produce the corpus luteum. This occurs by the breakdown of the basement membrane and angiogenesis. The Granulosa cells becomes granulosa-lutein cells which are hypertrophied with a high capacity to produce progesterone/ estradiol. The Theca cells become theca-lutein cells which express enzymes that produce androgens and progesterone. This results in elevation of progesterone and estrogen (progesterone > estradiol). Over time, the corpus luteum becomes less sensitive to LH and results in luteolysis which causes degeneration and apoptosis of the corpus luteum, producing the corpus Albicans (nodule of dense connective tissue). As LH and FSH levels fall, luteal cell production of estrogen and progesterone rapidly decline, leading to an increase in FSH and LH and the beginning of the next cycle.

Amniocentesis Define and include its use, advantages, and disadvantages

Prenatal genetic test that is done by sampling the amniotic fluid and amniocytes which is usually performed between 15 to 17 weeks. The cells that are obtained are grown in the lab for karyotyping. Cytogenetic tests take 10-12 days. Disadvantages ∙ Cannot be done early in pregnancy ∙ Long wait for cytogenetic results ∙ Cytogenetic changes can occur during culture

Ultrasonography Define and include its use, advantages, and disadvantages

Prenatal genetic test which is a non-invasive method of fetal imaging, mainly used in the second trimester. It required no X-ray exposure Malformations can be detected visually (specificity is high, sensitivity is low). Can node nuchal translucency which is fluid behind the fetal neck in the first trimester of pregnancy.

Explain how a feed-forward mechanism leads to labor.

Parturition is the initiation of labor. Oxytocin stimulated distention of the cervix, which results in increased pituitary gland release of oxytocin (feed-forward), which stimulates the uterus to contract as well as the release of prostaglandins which stimulate uterine contractions.

Using the PREPARED system, identify the key points that expand on the minimum information required for informed consent.

Plan: the course of action being considered Reason: indication or rationale Expectation: chances of benefit and failure Preferences: patient-centered priorities and cultural preferences Alternatives: all other reasonable options Risks: potential of harm from treatment Expenses: direct and indirect costs Decision: fully informed, collaborative choice and consent

Eclampsia

Pre-eclampsia that is associated with convulsions

Describe the process of maturation, fertilization, and implantation of the ovum. Include capacitation and the acrosome reaction, and the movement of the blastocyst to the uterus.

Preparation: Functional sperm will mature in the epididymis, in the female reproductive tract, sperm undergoes capacitation stimulating hyperactivation -- membrane becomes more permeable to Ca2+ ions and Ca2+ enters to sperm to change the activity of the flagella to propel them forward-- and the acrosome reaction -- modification of the sperm head membrane to allow the acrosome reaction to take place (dissolution and release of enzymes upon binding the zona pellucida) Fertilization: 1. Sperm weaves past follicular cells and bind to zona pellucida 2. Acrosome reaction breaks down the zona pellucida 3. Sperm head binds to the egg 4. Microvilli on the oocyte surround the sperm head and the two membranes fuse, allowing the contents of the sperm to enter the oocyte 5. A rise in Ca2+ inside of the oocyte triggers a cortical reaction in which enzymes are released leading to the hardening of the zona pellucida, preventing the entry of other sperm cells. 6. Male and female pro-nuclei fuse to form the zygote Implantation: The zygote will remain in the fallopian tube for 3-4 days, where it will divide and form the morula (spherical shape). Morula will move into the uterus where it differentiates into the blastocyst. 6-8 days post LH surge is the best window period for implantation, due to progesterone levels being highest at this time. Progesterone is extremely important for preparing the uterus for implantation. Progesterone increases pinopods that help attach the blastocyst to the endometrium and increases adhesive proteins which decreasing anti-adhesive proteins.

Endometriosis

Presence of endometrial tissue outside of the uterus, consisting of both endometrial glands and stroma. Can see it in many different site, including: ovaries, large/small bowel, cervix, vagina, etc. Signs/Symptoms: ∙ Infertility ∙ Dysmenorrhea ∙ Pelvic Pain Morphology: nodules with red-blue to yellow-brown appearance on or just beneath the mucosal surfaces

List and differentiate between the presumptive, probable and positive signs of pregnancy

Presumptive: those primarily associated with skin and mucous membrane changes. Chadwick sign is dark discoloration and cyanosis of the vulva and vaginal walls. Pigmentation over the bridge of the nose and under the eyes (Chloasma/ AKA mask of pregnancy) Probable: those primarily related to the detectable physical changes in the uterus. Uterus becomes globular, and one cornu of the uterus may enlarge slightly (Pskacek sign). Uterus becomes softer, making it possible to palpate or compress the connection between the cervix and the fundus (Hegar sign) Positive: detection of a fetal heartbeat and recognition of fetal movements

What type of epithelium is found on the vagina?

Stratified squamous

What is the innervation of the ovary?

Sympathetic: IML, T10-L1 Parasympathetic: Vagus

Recognize the signs and symptoms of pregnancy

Symptoms • Amenorrhea • Abnormal Uterine Bleeding • Urinary frequency • Fatigue • Nausea and vomiting • Breast tenderness • Quickening: sense movement of the baby Signs • Chadwick's sign: skin (vagina & cervix) become purple-blue • Chloasma: Hyperpigmentation of the skin, in particular over the cheeks and nose (mask region) • Uterine Enlargement: uterus palpable above the pubic bone at ~12 weeks, above the umbilicus at ~ 20 weeks • Fetal heart tones: heard starting around 10 weeks

Discuss the psychological well being and the assessment of evaluating a child with ambiguous genitalia

The family's psychological well-being must be address because they may feel confident in the gender identity of their child

Pre-eclampsia Define and include types, risk factors, clinical findings, morphology, and complications

Systemic syndrome identified by Hypertension (BP > 140/90 mmHg), Proteinuria, & Edema Types A. Mild ∙ BP > 140/90 ∙ Proteinuria > 0.3g/24 hr ∙ Mild edema B. Severe ∙ BP > 160/110 ∙ Proteinuria > 5g/24 hr ∙ Oliguria < 500mL/24 hr ∙ Visual changes ∙ Pulmonary edema ∙ Epigastric pain (due to liver swelling) ∙ Elevated liver enzymes ∙ Thrombocytopenia C. HELLP Syndrome: severe form of pre-eclampsia which is much more progressive and is associated with ∙ Hemolysis ∙ ELevated liver enzymes ∙ LP Low platelets Risk Factors ∙ Nulliparity ∙ Maternal age (< 20 or > 35) ∙ Family history ∙ Hydatidiform mole (abnormal pregnancy that turns into tumor) ∙ Chronic HTN ∙ DM ∙ Renal Disease ∙ Multiple gestation (twins, triplets, etc.) Clinical Findings ∙ HTN ∙ Weight gain ∙ Proteinuria ∙ Hyperreflexia ∙ Headaches ∙ Epigastric pain ∙ Visual changes Morphology ∙ Placenta malperfusion, ischemia, & vascular injury ∙ Placental infarcts ∙ Increased syncytial knots ∙ Fibrinoid necrosis of vessels Complications A. Maternal ∙ Placental abruption ∙ DIC ∙ Renal failure ∙ Hepatic failure ∙ CNS hemorrhage & stroke ∙ Eclampsia B. Fetal ∙ Fetal growth restriction ∙ Prematurity ∙ Acute & chronic fetal distress (d/t placenta not working properly because of fibrosis) Treatment A. Mild ∙ Rest and observation ∙ Assure fetal well-being ∙ Deliver if: 38 weeks gestation, progression in signs/symptoms, or evidence of fetal compromise B. Severe ∙ Remain hospitalized until delivery ∙ Before 32 weeks: bed rest, control of BP to mild pre-eclampsia levels, steroids for lung maturation ∙ After 32 weeks: stabilize and deliver ∙ Deterioration requires delivery (i.e.- uncontrolled BP, oliguria, pulmonary edema, HELLP, coagulopathy, abruption, evidence of fetal compromise)

What is the imaging modality of choice for the prostate?

TRUS (trans rectal sonogram) Patient supine on the table and rectal sonogram probe is entered to the level of the prostate

Identify what the Institute of Medicine (IOM) recommends for reporting errors.

The IOM recommends that health care providers be required to report errors that result in serious harm, and that the information collected should be made available to the public.

When assessing the descent of the fetal head by vaginal examination, how is it explained?

The Ischial spine is 0cm, with -5cm being high, and +5 being almost out

Identify the position of the National Patient Safety Foundation on health care injuries.

The NPSF believes that when a health care injury occurs, the patient and the family or representatives are entitled to a prompt explanation of how the injury occurred, and its short- and long-term effects. In addition, if an error contributed to the injury, truthful and compassionate explanation about the error and the remedies available to the patient should be explained.

Secondary amenorrhea

The absence of menstruation for > 3 months, after a period of normal menses

What is the most common cause of trauma to the genitals of a young girl? A. What else should be considered?

The most common cause of trauma to the genitals of a young girl are straddle injuries which have a seasonal peak when bicycles are being ridden A. Always consider sexual assault

Variable Decelerations

The most frequently encountered decertation, it is when the baby's HR drops at times which are not correlated to contractions The HR rapidly declines and then rapidly increases ∙ Associated with umbilical cord compression Treatment: Stop pitocin, change maternal position left to right, administer 100% oxygen, amnioinfusion (injection of sterile saline), delivery

Describe the process of folliculogenesis, including the timing of receptor acquisition and the characteristics of each follicle stage.

The ovarian follicle is the basic unit of female reproductive biology. The growth and development of the follicle is what cumulates in ovulation. Folliculogenesis is the progression of primordial follicles towards large preovulatory follicles. Preantral Phase 1. Primordial Follicle: contains an oocyte and one layer of pregranulosa cells. These cells have no receptors and produce no hormones 2. Primary Follicle: Enlargement o the ovum with cuboidal granulosa cells and presence of zona pellucida. These cells have no receptors and produce no hormones 3. Secondary Follicle: Proliferation of the granulosa cells with stromal cells differentiation into theca externa and interna. Capillaries will form between the thecal layers. FSH receptors are acquired by granulosa cells and LH receptors are acquired by theca cells. The granulosa cells will produce a small amount of estradiol. Antral Phase 4. Tertiary Follicle: FSH stimulates the proliferation of granulosa cells resulting in increased estradiol production and increased antral volume/ follicle size. The theca internal cell will produce androgens 5. Graafian Follicle: Proliferation of granulosa cells results in changes in hormone concentrations of the follicular fluid (↑LH, ↑estradiol, ↑progesterone, ↓PRL)

How should a breech presentation be delivered?

Via C-section is the recommended delivery method, however, if the patient is already in labor or if it is an emergency situation, vaginal delivery is possible.

Discuss the development and the major physiological functions of the placenta.

With the blastocyst completely inside of the endometrium, syncytiotrophoblast cells cover the entire surface of the villous trees and are in direct contact with the maternal blood. These syncytiotrophoblasts are what will exchange nutrients between the mother and fetus. Cytotrophoblasts will proliferate and invade into the syncytiotrophoblasts. At the same time, there is free communication between the lacunae and maternal blood vessels Functions ∙ Pulmonary, Alimentary, and excretory systems ∙ "immunological insulation" ∙ produced pregnancy hormones

What are the proper tests to confirm pregnancy?

• Βeta Human Chorionic Gonadotropin → Qualitative: present or not → Quantitative: numerical value of how much is present (doubles in number ever 2-3 days); drop by 50% is typically indicative of miscarriage • Serum Progesterone → Less than 5: failed pregnancy → Greater than 25: rules out ectopic pregnancy • Ultrasound • Doppler