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128 Cards in this Set

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What are some statistics on reproductive events?
- 100 000 000 acts of sexual intercourse
- 910 000 conceptions (50% planned, 25% unwanted)
- 350 000 acquired STDs
- 150 000 abortions (50 000 illegal leading to 500 deaths)
- 1370 obstetric deaths
- 23 000 infant deaths
How often does one woman die because of pregnancy?
Every minute, 1 woman dies somewhere in the world because of pregnancy.
What is contraception?
The prevention of unplanned pregnancy is an important issue for society, the indivitual and caregivers.
What does an ideal contraceptive need to be?
- Safe
- Effective
- Immediately functional
- Easy to use
- Rapidly reversible
What is the efficacy to oral contraception?
Annual failure rate is 0.1%.
What is the mechanism of action of oral contraception?
- P supresses LH and prevents ovulation
- E suppresses FSH and prevents selection
- P causes atrophic endometrium
- P causes thick cervical mucus
- P decreases tubal motility
- E stabilizes the endometrium
List the generations of OCPs.
1st - NET and deribatives (estrane) (brevinor)
2nd - Norgetrel (Gonane) (Nordette, Microgynon)
3rd - Desogestrel, Norgestinate, Gestodene (Marvelon, Femoden, Minulet)
4th - CPA (Diane 35), Drosperinone (Yasmin)
What is the dose of OCP?
Depends on dose of EE
- ultra low does = 20ug
- low dose less than or equal to 50ug
- High doese > 50 ug
What are the phases of the OCP?
- Monophasic
- Biphasic
- Triphasic
How is the oral contraceptive pill administered?
- Active pill begun on CD1 - immediate protection
- The most important pills to miss are those that increase the pill free interval
- forgotten pills
What are the beneficial effects of oral contraception?
- Decreased menstrual flow and pain
- Alleviation of anemia
- Few simple ovarian cysts
- Less acne, hirsuitism
- Protection against endometriosis and fibroids
What is the cancer risk from oral contraceptiion?
Ovarian cancer - protective. Risk decreases with increasing duration of use and persists for 10-15 years after cessatio.

Endometrial cancer - protective. Use for 12 months decreases risk by 50%, greatest protection after 3 years, persists for 15 years after cessation.

Breast cancer - Recent trial has shown no increase in risk of breast cancer no matter the age at starting, the duration of use, the dose of E or the presence of a family history.

Trend for development of invasive cervical cancer with increasing duration of use. Studies not standardized for sexual activity.
What is the link between cardiovascular disease and oral contraception?
- Risk of AMI increases in women OLDER than 35 years who SMOKE
- related to thrombo-embolic events
What is the link between cerbrovascular disease and oral contraception?
- E dose dependent risk for thromboembolitic events
- No increase with low dose pills
- Risk of ischaemic and haemorrhagic stroke is low
What is the link between thromboembolic disease and oral contraception?
- Venous thrombosis is E dose related, limited to current users, risk disappears by 4-6 weeks
- Doubling with new P - ? real effect
What is the link between hypertension and oral contraception?
- no increase in incidence
- if hypertension is well controlled, OCP may be used.
What is the link between infections and oral contraception?
Risk of bacterial STD decreased by 50-60% after 12 months
What are the absolute contraindications for oral contraception?
Aboslute
- suspected pregnancy
- thrombo-embolic disorders
- cerebro or cardiovascular disease
- markedly impaired liver function
- cholestatic jaundice
- suspected E dependent cancer
- herpse gestationis
- abnormal vaginal bleeding
- smokers >35 years
- otosclerosis
What are the relative contraindications for oral contraception?
- migraine - E withdrawal vs E produced
- uncontrolled hypertension
- epilepsy
- sickle cell disease
- active gall bladder disease
At what age can the OCP be commenced?
- Menarche
At this time growth and reproductive development is essentially complete.
At what age should the OCP be ceased?
- smokers - aged 35 years
- non-smokers - at menopause
What causes pill failure for the OCP?
- physiological variation in absorption
- missed pills
- use of triphasics
- drug interactions
- interference with absorption
- high dose vitamin C
How do you manage pill failure for the OCP?
- improve compliance with counselling
- reduce pill free period to 4 days
- Higher dose
- Bi or tri cycle administration
- Alternative methods
What are some drug interactions with the OCP?
Decrease OCP - Rifampicin, anticonvulsants, broad spectrum antibiotics

Increas OCP - high dose vit C
Describe the progestagen only pill.
- 30mg LNG or 350mg NET
- given continuously within 3h
- action on cervical mucus
- irregular bleeding

- failure rate 2-3%
- no metabolic effects
- fertility immediate at cessation
- begun on CD1, backup for 7 days
- >3h elapsed - back up for 48h

- lactating women
- those with absolute contraindication to combined pill
List injectable progestogens.
- Depot provera
- Implanon
Describe depot provera (injectable progestogen).
- suppresses ovulation, thickens cervical mucus, causes endometrial atrophy
- Irregular bleeding, weight gain, PMS, mastalgia
- Antiepileptics, Rifampicin
- delay to conception of 9-12m. No difference at 24m.
- ? causes decrease in bone density
- beneficial effects - same as OCP
- failure rate 0.1%
Describe implanon (injectable progestogen).
- Rod that is place in the inside of the upper arm
- 3rd generation P only
- Efficacy for 3 years
- Stops ovulation
- Bleeding changes
- Immediate return of fertility
- No change in bone density
What is good about the IUD?
safe
effective
long-lasting
reversible
What kinds of IUDs are there?
- Unmedicated IUDs - plastic, stainless steel. Lifelong
- Copper IUDs - Cu T380A 10 y, multiload Cu 375 5 year
- Hormone relaseing - P coated and LNG coated for 5 y.
What is the mechanism of action for IUDs?
- Spermicidal intrauterine environment due to sterile inflammatory response
- Cu increases PG production
- P causes decidualization of endometrium and atrophy of glands. Inhibits implantation. Decrease in menstrual blood loss.
When can you insert an IUD?
- any time of the cycle
- 4-8 weeks after delivery
- after abortion
- prophylactic antibiotics of no value
- IUD check at 6 weeks
What are the contraindications for IUDs?
- contraindication to surgery
- congenital, acquired uterine defect
- Cu allergy or Wilson's disease
- Immunosuppressed
- Risk of endocarditis
- Mucopurulent discharge
What are some complications of IUDs?
- pain and bleeding
- pregnancy - failure 0.7/100 users for first year and cumulative rate of 2.1/100 users after 9 years
- intrauterine pregnancy
- ectopic pregnancy
- PID - first 20 days after insertion
How often does translocation of an IUD occur?
1:1000 insertions
IUD in POD or uterovesical pouch
Cu IUDs irritate peritoneal cavity
What are the side effects of IUDs?
- Increased bleeding and pain except with LNG containing
- Infection at insertion only
- spontaneous abortion
- septic abortion and premature labour
What is mirena?
Plain Nova T IUD with LNG around vertical stem (4.84mm) (6 Hegar)

Releases 20ug LNG over 24h. 4-13% of serum levels compared with 150ug COCP

Effective for 5 years.
? extend for 7 years
What are the side effects of mirena?
Irregular bleeding or amenorrhoea (20%)
Asymptomatic functional ovarian cysts (12%) - treated expectantly
Acne
Headache
Breast tenderness
Nausea
Mood changes
What are other benefits of minera?
Alternative to hysterectomy
After 6 months 64.3% of women cancelled operation versus 14.3% in control group.
How many people are sterilised?
Approximately 30% of all couples include at least one strilised partner, rising to about 50% of those over 40 years.
Describe sterilisation by Tubal ligation.
- Adequate counselling
- procedure can be reversed and most sucessful with clips
- pregnancy rates correlate with amount of tube left.
What kinds of emergency contraception is there?
- Postinor 0.75mg LNG 12h apart within 72h
- Yuzpe 100mg EE and 250microg LNG 12 h apart with antiemetic within 72 h
- Cu IUD within 5 days
- RU 486 within 72 h
Whar are some postpartum contraception methods?
- lactational amenorrhoea
- Progestagen only formulation
- IUD
- Barrier methods
Describe barrier methods.
- Most widely used throughout history
- protect against STDs and PID
- protect against cervical cancer
Describe condoms as a barrier method.
- greater efficacy with spermicides which inactivate sperm
- reduction in sensitivity
- latex allergy
- breakage rates 1-12/100 episodes of vaginal intercourse
Describe diaphragms as a barrier method.
- failure rate 2-23%
- safe
- inexpensive
- appropriately fitted
- vaginal irritation and UTIs

- must be removed after 24h and during menstruation
- inserted no longer than 6h before intercourse and can be removed after 6 h.
Describe periodic abstinence as a form of contraception.
- Rhythm or calender method - abstinence days 8-21
- cervical mucus
- symptothermal
What is gender?
- Defining category: "boy" or "girl"
- Entire system around which our very existence is organised.
> gendered roles/behaviours
> gendered attitudes
> gendered careers
> Feminism/anti-discrimination/equal opp..
- Gender as an 'independent variable'
What are the gender stereotypes of children (2 yrs)?
Girl/Female
- long hair
- cry's a lot
- slower
- shorter
- weaker
- soft
- not aggressive

Boy/Male
- short hair
- Cry's a little
- Faster
- Taller
- Stronger
- Hard
- Aggressive
What is gender identity?
- Gender identity is the understanding and acceptance that one is a boy or a girl
- Informed by:
> nature (XX/XY, hormones, male/female genitals)
> nurture (gender sterotypes - look, think, behave as a boy/girl)
What is the social learning theory of gender identity?
Bandura late 1960s - early 1970s

Gender identity is learned through
1) direct learning (operant conditioning)
- gender appropriate behaviours are rewarded and encouraged
- gender inappropriate behaviours are punished and discouraged
2) Observation of others (role models)
- gender roles learned through observing the behaviour of important others - parents, teacher, high profile identities
What is the cognitive theory of gender identity?
Kohlberg, late 1960s - early 1970s

- Focus is on the construction of cognitive (mental) representations of gender. Part of normal cognitive development.

Stage 1
Gender labeling: 0-30mths. Self-recognition as a boy or a girl.

Stage 2
Gender stability: by 3-4 years, development of awareness that gender does not change over time.

Stage 3
Gender consistency: By 4-5 years, development of an understanding that gender does not change, despite changes in appearance or activity.

Stage 2+3= gender constancy: understanding that gender is both stable and consistent.

Gender Identiy complete by 6 or 7 years of age.
What are biological theories of gender identity?
- Physiological or biochemical process that effect gender development (hormones)
- Androgens masculinise the brain as it develops, making it more sensitive to some types of environmental stimulation and less sensitive to others. As a result, males and females are predisposed to develop different skills, abilities and personalities.
- Accounts for gender differences across a range of aspects (e.g. male agression, female nurturing)
What are the gender differences in learning?
Mathematics
- No differences in early childhood. Males score higher from adolescence to adulthood.

Verbal ability
- No differences in childhood. Females score higher from adolescence to adulthood.

Visual-spatial ability
- No differences in early childhood. Males score higher from adolescence to adulthood.

Where there are differences, these differences are very small

There is as much within group variation as tehre is between groups

Difficult to tease out the Nature vs nurture aspect due to
- parental expectations
- teacher gender bias
What are some gender issues of adolescnce?
Puberty:
- development of primary/secondary sex characteristics confirm physical differences
- Gender differences reaffirmed

Emotions:
- sexual attractions and formation of intimate relationships

Friendships:
- shift from predominantly same gender to mixed gender friendship groups
Discuss self-concept and self-esteem of adolescents.
- Increased cognitive abilities mean adolescence are more capable of self-reflection and self-evaluation

Girls:
- increased importance of physical appearance, body image and peer acceptance - all of which influence self-concept and self-esteem
- Place more value on their social selves than do boys
- Emotions: more able to communicate & discuss problems

Boys:
- Have a stonger sense of self-confidence and competence about their appearance and physical abilities than do girls
- Place more value on what they do than what they look like
- Emotions: internalise problems & do not discuss.
What is John Money's Proposition?
- Gender identity is not established before 2 years of age.
- Gender identiy is established through socialisation and learning from age 2 to age 7
- Gender identity is mostly determined by nurture
- Therefore, gender can be surgically determiend or re-assigned prior to age 2 years.
What is Intersex condition?
A set of medical conditions that feature congenital anomaly of the reproductive and sexual system that are not standard for either male or female.
What are some intersex conditions?
- Androgen insensitivity syndrome (AIS)
- progestin induced virilisation
- Klinefelter syndrome (XXY)
- Other chromosome disorders
- Congenital adrenal hyperplasia (CAH)
- Ablatio Penis (trauma)
- ...ambiguous genitalia
What is ambiguous genitalia?
- Medically acceptable clitoris measures 0.02 to 0.09 cm. >0.9cm = ambiguity
- Medically acceptable penis measures 2.5 to 4.5cm. <2.5cm = ambiguity
- Estimated to occur in 1:20 000 births - but not confirmed
- 90% of intersexuals who undergo gender reassignment surgery are assigned a female gender.
Case 1: David Reimer (John/Joan Case)

- Biologically normal 46XY male Bruce born 1965 Monozygotic twin to Brian.
- Penis accidentally ablated during circumcision by electrocautery at 7 months (necrosed and sloughed off)
- Referall to Prof. Money: decision to reassign infant male to female gender at 17 months
- Surgical castration and initial genital reconstruction performed at 21 months.

What were the post-procedure evalution and Implications
Post Procedure evaluation
- Money's evaluation of Brenda at age 9 years - displayed 'tomboyish' traits such as abundant physical energy, high level of activity, dominant among a group of girls

Money wrote...
"Her behaviour is so normally that of an active little girl, and so clearly different by contrast from the boyis ways of her twin brother..."

Money concluded:
"gender identity is sufficiently incompletely differentiated at birth to permit successful assignment of a genetic male as a girl... and differentiates in keeping with the experiences of rearing".

Implications of the John/Joan Case
- Reported 'success' of this case received widespread exposure in professional journals and the media
- Case was used as proof of the importance of environmental influences on gender identity formation
- Case served as a precedent for many others.
Case 1 (John/Joan) revealed: Milton Diamond, 1997.
Professor of Anatomy & reproductive biology, University of Hawaii
- Diamond, skeptical & called for evidence in various publications
- 1994 - contacted the treating psychiatrist at John Hopkins University (Dr Keith Sigmundson)
- Discovered that Brenda had been living as a male since age of 14.
- At age 25 was married, adopted wife's children, grandfather.

What were the childhood experiences?
Case 1: Childhood experiences
David's recollection of 'her' childhood

Never felt comfortable as a girl (mother reported similar recollections)
- refusal to wear dresses, hated make-up
- preference of 'boy' type behaviours, fought like a boy
- banned from girl's toilets for standing to urinate

Often had thoughts of suicide.
What was the management for Case 1 (John/Joan)?

What were the conclusion for this case?
- placed on an estrogen regime at age 12
- breast development
- truth of gender reassignment revealed at age 14
- immediate return to living as a male
- testosterone replacement regime to induce masculisation at 14.
- mastectomy
- surgery for phallus construction at age 15 and 16.

Conclusion
- Female gender identity was not established despite surgical gender reassignment, feminising hormonal therapy and socialisation as a female
- Provides evidence for a biological eitiology for gender identity (i.e. nature)
Case 2: Bradley et al. (1998)
- Biologically normal 46XY male
- Penis accidentally ablated during circumcision at 2 months
- Surgical castration and inital genital reconstruction performed at 7 months
- Began regime of feminising hormone therapy (premarin) at 10 years, 10 months of age.

What was the post-procedure evaluation?
- Interviewed by psychiatrist at 16 and 26 years of age
- Was living 'comfortably' as a female at both occasions
- Denied any feeling of uncertainty about being a female in childhood and throughout adolescence
- Self-identified as 'tomboy' during childhood and enjoyed toys and games that are considered stereotypically masculine.
What was the Management for Case 2?

What was the post-procedure evaluation for this?
- Requested vaginoplasty at age 16 to repair her genitalia for suitability for sexual intercourse with males
- Additional vaginoplasty at age 26 after difficulty with intercourse (vaginal opening was too small, painful intercourse with male partner)

Post-procedure evalutation
- Was living with a woman in a sexual relationship
- Reported 3 other significant relationships with women, and reported greater physical attraction to females
- reported that male sexual relationships were better in terms of shared interests (worked in a 'blue collar' male occupation)
- female relationships were more sexually satisfying.
- self-identified as bisexual.
What were the conclusion for Case 2?
- report of no feelings of wanting to be male and comfort in female gender indicated successful establishment of female gender identity
- Evidence for a social/environmental etiology for gener identity (i.e. nurture)

"Our case suggests that it is possible for a female gender identity to differentiate in a biologically normal genetic male, which uspport the original conclusion of Money, that sex of rearing may be the most important determinant of a perosn's gender identity.
Describe the W. Reiner (2000) Conference paper.
- Tracked the development of 26 males with cloacal exstrophy (born without a penis, but otherwise normal - testicles, male genes and hormones)
- 24 underwent surgical gender reassignment and were raised as females
- 2 were not reassigned and raised as boys.

W. Reiner (2000) findings
- Of the 26 gender reassigned children (5 to 16 years)
> all exhibited the rough-and-tumble play of boyes
> 14 declared themselves to be boyes (one case as early as age 5) and have reassigned themselves to male (54%)
- The 2 children not reassigned fit in well with male peers, and are better adjusted psychologically than the gender reassigned children.
Minto et al. (2001, 2003) The lancet
- Mailed questionnaires to 81 gender reassigned cases (intersex)
- 44 returned questionnaire
- All reported sexual problems
- Those who underwent early vaginoplasty sill required major surgeries as adults.
The continuing debate
Cessation of surgical gender reassignment
- until further follow up studies can be undertaken
- call for the establishment of guidelines
- Intersex activists (www.isna.org)
Our mission: The Intersex Society of North America (ISNA) is devoted to systemic change to end shame, secrecy and unwanted genital surgeris for people born with an anatomy that someone decided is not standard for male or female.
ETHICS AND INTERSEX (journal)

Continuation of surgical gender reassignment
- Advancement in surgical procedures
- Silent majority (sucessful cases)
- guidelines published in 2001
What are the ethical considerations for infant gender reassignment surgery?
Questions for surgeons to consider (Lancet 2001 vol358, 2085)

- Is it ethical to do cosmetic surgery on infants?
- Do parents have the right to choose this surgery for their children?
- Does genital surgery really not damage sexual function?
- Should intersex even be deemed a medical condition requiring invasive treatment?
Closing quote on gender identity.
"Gender identity is very complicated..."

Alice Dreger
Assistant Professor of Science and Technology studies, Michigan State University, East Lansing, USA
What is menopause? What are the symptoms?
Menopause means decreased ovarian function

Signs/symptoms:
- loss of periods
- genital atrophy
- decreased libido; lack of energy
- vasomotor symptoms (e.g. hot flushes)
- loss of memory, mood swings, irritability
What are the long term consequences of menopause?
Increased risk of disease
- increased bone loss (decreased BMD(bone mineral density); osteoporosis)
- increased risk of coronary heart disease (myocardial infarction/fatal strokes)
- increased risk of Alzheimer's disease?
What are the effects of oestrogen?
Gruber et al. 2002 N Engl J Med 346:340-352
What are the aims of HRT/ERT?
- decrease everyday symptoms (i.e. hot flushes, sleeplessness, lethargy & depression, vaginal dryness)
- prevent long term complications due to oestrogen deficiency
> bone loss (ie osteoporosis)
> risk of CHD
> senile dementia
> colon cancer
What are the hormones used for HRT?
- Oe + Prog
- Oe alone
Does HRT reduce risk of CVD?
- Observational studies (e.g. NHS; 1985; 2000) - ERT associated with decresed incidence of ischaemic heart disease

cf (confer) other trials
- randomised controlled trial of HRT (women's health initiative 2002)
- secondary prevention trials of HRT (e.g. HERS; ERS)

- no reduction in heart disease or regression of atherosclerosis
- increased risk of stroke? (venous thrombosis & pulmonary embolism)
What does the stats on HRT mean?
HRT
- has a place in short term management of menopausal symptoms
- consider if high risk of osteoporosis? if other treatments inappropriate
- for long term disease prevention - can't be justified
What preparations need to be done for HRT?
No uterus (post hysterectomy) --> continuous oestrogen alone

Uterus
osetrogen vs oestrogen + progesterone
- sequential (continuous Oe; prog d14-28)
- continuous (fixed dose combination)

Progestins
- medroxyprogesterone
- norethisterone
- drospirenone

Oestrogens
- natural (oestrodiol)
- conjugated from preganat mare's urine
What are the routes of administration for HRT?
oral
transdermal patches/gels
sc implants
nasal sprays
vaginal preparations
What are some prescribing practice points?
- Titrate to lowest Oe dose required
- review regularly
- withdraw slowly
Raloxifene
"SERM" - selective oestrogen receptor modulator"

- breast & endometrial tissue - antioestrognic
- bone - oestrogenic
- no effect on vasomotor symptoms

Good effects
- strengthens bones
- lowers LDL cholesterol
- may reduce bresat cancer risk
- may reduce uterine cancer risk

Bad effects
- increases blood clot risk
- no relief for hot flushes
Tibolone
- oestrogen/progestogen
- mixed steroidal activity
> vagina, bone, thermoregulatory centres - estrogenic
> breast - antioestrogenic/progestogenic
> endometrium - progestogenic
- associated with increased risk of breast cancer (Oe only < tibolone < Oe + P
What are alternatives to HRT?
Phytoestrogens in diet
- weak oestrogenic activity
- ? no greater than placebo
- little effect on bone
- few risks

Black Cohosh
- promising results
- variability on preparation
- oestrogenic-activity?

Non-drug alernatives?
What is andropause?
Late-onset hypogonadism

Age-related decrease in serum testosterone

Signs and symptoms:
- decreased well being
- decreased energy levels
- decreased libido (mb erectile dysfuntion)
- decreased lean body mass, muscle strength
- changes in mood and cognition
What are the long term conditions associated with andropause?
- increased bone loss (--> osteoporosis)
What are some androgen preparations?
- Testosterone undecanoate - taken orally 2-3 times/day
- Testosterone sc implant - replace every 2-3 months
- Testosterone enanthate/testosterone proprionate - im every 2-3 weeks
- testosterone transdermal patch - change daily
What are the beneficial effects of androgens?
- increased libido; sexual function
- sense of well being
- increased muscle mass (lead to increased muscle strength?)
- increased bone density (lead to decreased risk of fracture)
- decreased body fat
What are the adverse effects of androgens?
- decreased sperm production
- liver injury (adenocarcinoma?)
- altered serum lipids (lead to atherosclerosis?)
- increased prostate cancer? exacerbate?
- sleep apnea
- increased haematocrit
What are the recommendations for hypoganadism?
- treatment reserved for symptomatic individuals with hypogonadism
- discuss risks and benefits
- follow up with PSA and haematocrit measurements

? long term effects?
What is puerperium?
6 weeks during which a woman returns to her non pregnant state - these changes are a result of withdrawal of pregnancy hormones.
List 3 care givers for puerperium.
midwife
GP
O&G specialist
What are the aims of postpartum care?
- monitor uterine involution
- establish breastfeeding
- assist the development of parenting skills
Describe the process of uterine involution.
- Gradual return of uterine to non-pregnant state.
- Contraction and reduction in size of the myometrial muscle.
- Shedding of the decidua
- Regeneration of the endometrium
Give a timeline of uterine involution.
Day after delivery - uterine fundus at the umbilicus

Day 7 - midway between umbilicus and pubis

Day 14 - no longer palpable abdominally

6 weeks - uterus return to about pre-pregnant size

Term uterus - 1000g
6 weeks - 50g
Day 14 - Internal os of the cervix closes
Day 28 - vaginal blood loss has usually stopped
What happens to ovarian function postpartum?
Lactating women - 6mths or longer for ovulation to return.

Non-lactating women - ovulation as early as 4 weeks postpartum.
What happens to the perineal area postpartum?
Trauma - second degree tear or episiotomies.

Lochia - blood, decidua and leukocytes continues for up to 4 weeks

Pelvic floor exercises restore muscles and reduce pain.
What happens to the cardiovascular system postpartum?
- pregnancy is a physiological, hypercoagulable state.
- hypercoagulable state persist up to 6 weeks postpartum
- This increases the risk of thromboembolic disease.
What is urinary and bowel function like postpartum?
- smooth muscle function of the urinary tract and bowel gradually increases over 6 weeks.
- Constipation - common in the early puerperium
- By 6 weeks most women will have typically lost 10kgs
Describe breastfeeding postpartum.
Breast milk protects against infections.

Breastfeeding aids involution, reduces the risk of breast and epithelial ovarian cancer

Breast milk meets infant's nutritional needs
What is Ejection?
let-down reflex

Sucking leads to oxytocin release from posterior pituitary, resulting in contraction of myoepithelial cells, forcing milk into the lactiferous ducts and leading to ejection of milk.
What are common problems with breastfeeding?
- Painful nipples - incorrect positioning of baby's mouth
- Engorgement - baby not removing enough milk
- Mastitis - breast becomes red, swollen, hot and painful
What kind of preparation needs to be done at home for postpartum care?
Support structure - partner, family, friends and community

Care-giver provides guidance advice and education towards the mother's need to care for baby physically and emotionally
- Mother is advised about uterine involution, lactation and contraception
What happens at the six-week postpartum visit?
- Referred to local child health community nurse.
- Referred to GP for 6 week check up.
- Baby growth and development is assessed.
What are common complications of caesarean section?
- risk of haemorrhage
- short term risks of wound and urinary tract sepsis, thromboembolism
What management of future pregnancies after caesarean section needs to be done?
Successful vaginal birth after caesarean section (VBAC) occurs in 30-70%.

Complications of attempted VBAC, include uterine rupture and fetal loss.
What is puerperal sepsis?
Where temperature of 38degreeC or more is maintained or recurs withing 14 days of birth.
What are risk factors?
- Prolonged rupture of membranes resulting in an ascending infection
- Frequent use of urinary catheters
- Prolonged labour, with increased intervention and more vaginal examinations
- Assisted birth (vacuum or forceps delivery with episiotomy)
- vaginal lacerations
- postpartum haemorrhage
- caesarean section
Wound infection and caesarean sections.
See in caesarean sections around day 4 or 5 post-delivery but also may occur at site of episiotomy and perineal tear.
Apart from wound infection, what other infections can occur postpartum?
Urinary tract infection.
Chest infections
Intravenous or epidural site
Thomboembolism postpartum.
- Venous thromboembolism should be considered with presentations of peurperal fever following caesarean section and with factors such as clotting disorders.
Describe transmission of drugs in breast milk.
- Generally agreed that medications penetrate milk during first 4 weeks than in mature milk, although there are exceptions.

- Antibiotics- less than 1% of maternal dose find its way into milk and transferred to infant.
Describe secondary postpartum haemorrhage
- excessive vaginal bleeding occuring between 24 hrs and 6 weeks post-delivery.

- Two primary risk factors - retained placental fragments and infections
What are the clinical signs and symptoms of postpartum haemorrhage?
postpartum haemorrhage occurs in second week post-delivery.
What are the 3 management strategies for PPH?
There are 3 basic strategies in the management of secondary PPH:
- ascertain the aetiology of the bleeding
- instigate a medical or surgical management plan to treat the bleeding
- resuscitate in cases of excessive blood loss
What can be found on examination in the case of PPH?
A full gynaecological history and examination is required. On examination, the following may be found:
- General and abdominal
> uterine enlargement and/or tenderness
> fever, tachycardia
> occasionally haemodynamic compromise
- Speculum examination
> blood and/or necrotic placenta in the cervical canal
> cervical dilataion
> purulent or offensive vaginal discharge
What is the management of PPH?
- intravenous line insertion (large-bore cannula)
- volume replacement with crystalloid/colloid
- blood transfusion if haemoglobin <80g/dL - fresh frozen plasma, cryoprecipitate and platelet infusion may be required.
- Intravenous oxytocin (10IU), followed by an infusion of oxytocin (30-40 units in 500mL crystalloid solution at 125mL/h)
- Ergometrine 250ug IV if there is continuing heavy bleeding
- Intravenous broad spectrum antibiotics
- operative exploration of the uterine cavity and lower genital tract under anaesthesia, once stabilised.
What is the surgical approach to PPH?
- Examination under anaesthesia is required to find evidence of retained placental tissue and heavy bleeding not responding to medical therapy
What are complications of surgical postpartum evacuation of the uterus?
Uterine perforation (3%)
Hysterectomy (1%)
Asherman syndrome (rare)
What is Asherman syndrome?
Asherman's syndrome, also called "uterine synechiae", presents a condition characterized by the presence of scars within the uterine cavity.
What trauma can happen postpartum?
Genital tract trauma
Describe the anatomy of the genital tract.
The uterus can be divided into:
> The upper uterine segment
> The lower uterine segment
> The cervix

Tree layers of muscles in the pelvic floor support the pelvic organs:
> superficial muscles
> Triangular ligament
> Deep muscles
What is the classification of Perineal lacerations.
First degree - laceration of the vaginal mucosa, perineal skin or fourchette only, but not of the underlying muscles of the perineal body.

Second degree - laceration of the vaginal epithelium, perineal skin and muscle of the perineal body, which may be slight or sever but does not include the external anal sphincter. The muscles involved are the superficial transverse perineal, bulbocavernosus, central perineal body, and posterior margin of the deep transverse muscle and urogenital diaphragm. A puborectalis and pubococcygeus muscles.

Third degree - the tear extends through the whole of the perineal body and involves any part of the external anal sphincter.

Fourth degree - the tear extends into the anal or rectal mucosa.
What is an episiotomy?
This is the surgical incision made to enlarge the vaginal outlet during childbirth. It involves:
- Perineal skin and subcutaneous tissue
- posterior vaginal wall
- Bulbocavernosus muscle
- Superficial transverse perineal muscle
- Pubococcygeus muscle
What are vaginal lacerations?
Tears of vaginal mucosa nd underlying tissue.
What is vulval trauma?
Grazes or tears of the internal surface of the labia minora, clitoris or urethral area.
What is cervical trauma?
Rare - but is suspected when bleeding is heavy and the uterus is firmly contracted.

Repair must be done as soon as possible.

Could also be caused by instrumental delivery before full dilation of the cervix.
What are vulval haematomas?
Develop following injury to blood vessel - associated with nulliparity, episiotomy and operative delivery.

Develop rapidly and readily diagnosed by excruciating pain.
What happens when there is a rupture of the uterus?
This mostly occurs during labour and may be attributed to:
- rupture of a previous classic or lower uterine caesarean section scar.
- spontaneous rupture following obstructed labour by cephalopelvic disproportion or malpresentation.
- trauma