Gynaecology Pg No 41 -50
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Questions and Answers

What is a disadvantage of Jones metroplasty?

  • It has no associated complications.
  • It increases the likelihood of normal childbirth.
  • It may lead to pelvic adhesions causing infertility. (correct)
  • It requires the patient to have vaginal delivery.

    • Patients who undergo Jones metroplasty can safely deliver vaginally without complications.

    False

    List one complication in male fetuses exposed to DES.

    Cryptorchidism, testicular hypoplasia, hypospadias, microphallus, or renal anomalies.

    One of the disadvantages of metroplasty is the need for __________ delivery.

    <p>C-section</p> Signup and view all the answers

    Match the following male fetal complications caused by DES exposure:

    <p>Cryptorchidism = Undescended testicles Hypospadias = Abnormal urethral opening Testicular hypoplasia = Underdeveloped testicles Microphallus = Small-sized penis Renal anomalies = Kidney disorders</p> Signup and view all the answers

    What hormone is released by the hypothalamus to initiate the menstrual cycle?

    <p>GnRH</p> Signup and view all the answers

    The primary oocyte is in the diplotene stage of prophase during childhood.

    <p>True</p> Signup and view all the answers

    What is the initiating hormone of the ovarian cycle?

    <p>FSH</p> Signup and view all the answers

    During folliculogenesis, a single layer of flat follicular cells surrounding the primary oocyte transforms into a single layer of ______ cells.

    <p>cuboidal</p> Signup and view all the answers

    Match the following stages of follicular development with their descriptions:

    <p>Primordial follicle = First stage with flat follicular cells Primary follicle = Single layer of cuboidal cells Secondary/Pre-antral follicle = Antral cavity begins to develop Tertiary/Antral follicle = Fully developed follicle ready for ovulation</p> Signup and view all the answers

    What is the primary hormone produced by granulosa cells that is crucial for uterine health?

    <p>Estrogen</p> Signup and view all the answers

    The growth of follicles during the pre-antral stage is dependent on FSH.

    <p>False</p> Signup and view all the answers

    What is the function of AMH in relation to follicles?

    <p>AMH regulates follicle development and is a marker for pre-antral and small antral follicles.</p> Signup and view all the answers

    The ______ hormone triggers a surge that leads to ovulation.

    <p>luteinizing</p> Signup and view all the answers

    Match the following follicle stages with their duration:

    <p>Till early pre-antral = 70 days Late pre-antral = 84 - 85 days</p> Signup and view all the answers

    What triggers ovulation within the menstrual cycle?

    <p>LH surge</p> Signup and view all the answers

    The corpus luteum has a lifespan of 20-24 days.

    <p>False</p> Signup and view all the answers

    What hormone primarily supports the growth and maintenance of the endometrium?

    <p>Progesterone</p> Signup and view all the answers

    The _____ is formed on day 14 of the menstrual cycle.

    <p>corpus luteum</p> Signup and view all the answers

    Match the hormone with its function:

    <p>LH = Stimulates ovulation FSH = Promotes follicle development Estrogen = Negative feedback on LH and FSH Inhibin A = Inhibits FSH secretion</p> Signup and view all the answers

    Which of the following hormones has a positive feedback effect on LH and FSH?

    <p>Estrogen</p> Signup and view all the answers

    Progesterone is released in large amounts before ovulation.

    <p>False</p> Signup and view all the answers

    What effect does decreasing progesterone have on the endometrium?

    <p>It leads to shedding and the onset of menstruation.</p> Signup and view all the answers

    What is a characteristic appearance of an imperforate hymen?

    <p>Tense, bulging hymen possibly bluish</p> Signup and view all the answers

    Transvaginal sonography typically shows a bulging hymen.

    <p>False</p> Signup and view all the answers

    What is the management procedure for an imperforate hymen?

    <p>Cruciate incision on hymen</p> Signup and view all the answers

    The presence of _______ is typically associated with imperforate hymen.

    <p>blood</p> Signup and view all the answers

    Match the investigational techniques with their purposes:

    <p>USG Pelvis = Assesses hematometra and hematocolpos MRI = Differentiates between imperforate hymen and TVS Hormonal Profile = Not needed to assess conditions</p> Signup and view all the answers

    Which of the following is the most common cause of cryptomenorrhea?

    <p>Imperforate hymen</p> Signup and view all the answers

    Retrograde menstruation increases the risk of developing endometriosis.

    <p>True</p> Signup and view all the answers

    What genotype is typically associated with individuals suffering from cryptomenorrhea?

    <p>46 XX</p> Signup and view all the answers

    Hematocolpos refers to the collection of blood in the ______.

    <p>vagina</p> Signup and view all the answers

    Match the presentation of cryptomenorrhea with the associated symptom:

    <p>Cyclical pain = Pain associated with menstruation Urinary retention = Inability to pass urine Retrograde menstruation = Menstrual flow that goes backward Supra pubic bulge = Bulging in the lower abdomen</p> Signup and view all the answers

    What is the primary hormone produced during the first half of the menstrual cycle?

    <p>Estrogen</p> Signup and view all the answers

    Menstruation begins during the first half of the menstrual cycle.

    <p>False</p> Signup and view all the answers

    On which day of the menstrual cycle does ovulation typically occur?

    <p>14</p> Signup and view all the answers

    The corpus luteum produces _____ during the second half of the menstrual cycle.

    <p>progesterone</p> Signup and view all the answers

    What happens to the corpus luteum if pregnancy does not occur?

    <p>It degenerates.</p> Signup and view all the answers

    Match the day of the menstrual cycle with the corresponding event:

    <p>Day 14 = Ovulation occurs Day 22 = Max size of corpus luteum Day 1 = Menstruation begins Day 28 = Start of a new cycle</p> Signup and view all the answers

    The peak of estrogen occurs during the luteal phase.

    <p>False</p> Signup and view all the answers

    What syndrome is associated with mid-cycle pain during ovulation?

    <p>Mittelschmerz syndrome</p> Signup and view all the answers

    What embryological origin is responsible for the upper one-third of the vagina?

    <p>Mesodermal origin</p> Signup and view all the answers

    Vaginal agenesis is a common condition characterized by the complete absence of the vagina.

    <p>False</p> Signup and view all the answers

    What symptom is commonly associated with an imperforate hymen?

    <p>Outflow tract obstruction</p> Signup and view all the answers

    The lower two-thirds of the vagina develop from the ___________ and are of endodermal origin.

    <p>sinovaginal bulb</p> Signup and view all the answers

    Match the vaginal anomalies with their characteristics:

    <p>Vaginal Agenesis = Absence of complete vagina Longitudinal Vaginal Septum = Associated with uterus didelphys Transverse Vaginal Septum = Failure in resolution of transverse septum Imperforate Hymen = No opening in hymen</p> Signup and view all the answers

    Which uterine anomaly is associated with the highest rate of recurrent abortions?

    <p>Septate uterus</p> Signup and view all the answers

    Unicornuate uterus is the most common uterine anomaly associated with renal anomalies.

    <p>True</p> Signup and view all the answers

    What is the best outcome related to uterine shape?

    <p>Arcuate uterus</p> Signup and view all the answers

    The most common cause of recurrent breech presentation is __________.

    <p>Mullerian malformations</p> Signup and view all the answers

    Match the following uterine anomalies with their associated complications:

    <p>Septate uterus = Recurrent abortions Unicornuate uterus = Ectopic pregnancy Bicornuate uterus = Pre-term labor Uterus didelphys = Malpresentations</p> Signup and view all the answers

    What is considered the gold standard investigation for gynecological complications?

    <p>MRI</p> Signup and view all the answers

    Increasing renal anomalies is common in all types of uterine anomalies.

    <p>False</p> Signup and view all the answers

    Name the most common anomaly associated with infertility.

    <p>Septate uterus</p> Signup and view all the answers

    The procedure performed to unify a bicornuate uterus is called __________.

    <p>metroplasty</p> Signup and view all the answers

    Match the following uterine complications with their descriptions:

    <p>Endometriosis = Presence of endometrial-like tissue outside the uterus Hematometra = Accumulation of blood in the uterus Dysmenorrhea = Painful menstruation AUB = Abnormal uterine bleeding</p> Signup and view all the answers

    Study Notes

    Development of Female Internal Genitalia

    • Most common Mullerian Anomaly: Septate uterus
    • Most common presentation: Recurrent abortions
    • Best reproductive outcome: Arcuate uterus, followed by Uterus didelphys
    • Worst reproductive outcome: Septate uterus
    • Most common anomaly associated with renal anomalies: Unicornuate uterus
    • Unicornuate uterus is associated with unilateral renal agenesis

    Clinical Features

    • Recurrent abortions:
      • Most common complication/presentation
      • Most common time: First trimester
      • Most common anomaly associated: Septate uterus
      • First trimester abortions are associated with a Septate uterus
    • Ectopic Pregnancy: Associated with Unicornuate uterus.
    • Pre-term labor: Due to altered shape of the uterus; Associated with Bicornuate uterus
    • IUGR (Intrauterine Growth Restriction)
    • Malpresentations:
      • Breech is associated with: Uterus didelphys, Septate uterus, Bicornuate uterus.
      • Most common cause of recurrent breech: Mullerian malformations
    • Increased risk of Cesarean section
    • PIH (Pregnancy induced Hypertension )
    • Transverse lie:
      • Septate uterus
      • Bicornuate uterus
      • Not seen in Unicornuate uterus or Uterus didelphys

    Growth of Follicles

    • Till early pre-antral: Primordial follicle (70 days)
    • Late pre-antral: Graafian follicle (84-85 days)

    FSH

    • Growth of follicles is independent of FSH in the pre-antral stages
    • Follicle development is dependent on FSH in the late pre-antral stage (14 days) until mature Graafian follicle

    Hormone regulation

    • Estrogen (main hormone of Granulosa cells): Promotes proliferation of the uterine endometrium. Note: Estrogen should not be administered alone to females with an intact uterus.
    • Granulosa cells of follicles produce estrogen, a key hormone for uterine health.
    • LH: Luteinizing hormone. LH ≥ 200 picogram x 48 hours triggers ovulation.
    • Negative feedback on FSH: Regulates FSH levels.
    • Positive feedback: Triggers LH surge.
    • Inhibin B: Inhibits FSH release.
    • AMH (Anti-Mullerian Hormone):
      • Released by granulosa cells.
      • A marker for pre-antral and small antral follicles.
      • Levels are elevated from puberty onwards, correlated with follicle number.
      • Factors contributing to increased risk of Endometrial Hyperplasia and Cancer.

    Granulosa Cell Tumors

    • Feminizing tumor: Causes elevated estrogen levels.
    • Tumor markers: Elevated Inhibin B and AMH levels.
    • New tumor marker: AMH, a protein that regulates follicle development.

    Other important considerations

    • Atresia of stimulated follicles: Apoptosis (programmed death) of all stimulated follicles except the dominant follicle.

    Development of Vagina and Transverse Vaginal Septum

    • Caudal Fused Part of Mullerian Duct: Upper 1/3rd of vagina, mesodermal origin → Fibromuscular wall of vagina.
    • Sinovaginal Bulb → Urogenital Sinus (UGS): Lower 2/3rd of vagina, endodermal origin → Epithelium of vagina..
    • Fusion occurs when the upper and lower parts meet → Transverse vaginal septum.
    • The septum dissolves around week 20.
    • Canalization is complete except the distal end.
    • Sinovaginal bulb meets UGS properly.
    • Hymen: Has opening for menstrual blood outflow.
    • Lining of Hymen and vagina: Non-keratinized stratified squamous epithelium.

    Anomalies of Vagina

    • Vaginal Agenesis: Rare condition, absence of complete vagina, associated with Mullerian agenesis.
      • Symptoms: Hidden menstruation (cryptomenorrhea), outflow tract obstruction, cyclical abdominal pain without menstruation.
      • Signs: Absent vaginal opening (introitus).
    • Longitudinal Vaginal Septum (Hemivagina): Associated with Uterus didelphys.
    • Transverse Vaginal Septum: Failure in the resolution of transverse septum, leading to outflow tract obstruction.
    • Imperforate Hymen: No opening in hymen, leading to outflow tract obstruction.

    General Gynecology

    • Gynaecological complications: Outflow tract obstruction, Hematometra, Endometriosis, Dysmenorrhea (Unilateral in unicornuate uterus), AUB (Atypical Uterine Bleeding), Increased risk of renal anomalies (except in arcuate uterus), Infertility (rare, most common anomaly associated with infertility: Septate uterus)
    • Investigations:
      • Clinical examination is not useful, expect in Uterus didelphys (2 vaginas).
      • First investigation (Screening): Co-incidental findings on:
        • TVS: Recurrent abortions.
        • HSG: Infertility
      • IOC: 3D USG
      • Gold Standard: MRI
      • Last resort:
        • Laparoscopy + Hysteroscopy (visualise uterus from the outside and inside).

    Management

    • Indication for a procedure: Recurrent abortion.
    • Bicornuate uterus: Unification Sx/metroplasty.
      • Resection (Diagram showing this)
      • Suture (Diagram showing this):
        • Strassman metroplasty
        • Tompkins’ metroplasty
    • Same procedure can be done for Uterus didelphys.

    Imperforate Hymen vs TVS

    • Imperforate Hymen: Located at the level of the introitus, appears as a tense, bulging hymen, possibly bluish due to retained blood.
    • TVS: Located at the upper part of the vagina, typically appears as a thick fibrous septum without bulging of the hymen.
    Feature Imperforate Hymen TVS
    Vaginal Bulge Present Absent
    Hymen Color Possibly blue Not Applicable
    Presence of Blood Possible Usually not associated with blood
    Association with Other Issues Common Less common (but possible)
    Lower Vagina + (in lower vagina) -
    Upper Vagina + (in upper vagina) +

    Management

    • Imperforate Hymen: Cruciate incision on hymen.
    • TVS: Resection/excision of the septum.

    Investigations

    • Hormonal Profile: Not needed (FSH, LH, estrogen: Normal)
    • USG Pelvis: First investigation, confirms the presence/absence of the uterus, assesses hematometra and hematocolpos.
    • MRI: Differentiates between Imperforate Hymen and TVS, useful for determining the site/location, thickness, and ruling out other abnormalities (e.g., renal).

    Timeline of the Menstrual Cycle

    • Divided into two main phases:
      • First Half of the Cycle (Follicular/Proliferative Phase):
        • Hormone: Estrogen
        • Duration: Variable, 14-24 hours
        • Key Events:
          • Follicle development
          • Estrogen production leading to endometrial proliferation
          • LH surge at day 14
          • Ovulation occurring at this time
          • Follicle becomes the corpus luteum
        • Estrogen Peak: Occurs within this stage
        • Follicle size just before ovulation: 18-20 mm or 217 mm
      • Second Half of the Cycle (Secretory/Luteal Phase):
        • Hormone: Progesterone
        • Duration: 14 days
        • Key Events:
          • Corpus luteum activity
          • Maximum size and activity of the corpus luteum is at day 22 of the cycle
          • Progesterone production
          • Endometrial changes support pregnancy.
          • Degeneration of corpus luteum if pregnancy does not occur.
          • Menstruation begins.

    Other Important Observations:

    • Ovulation: Occurs around day 14.
    • Max Progesterone (D22/1 WK before menstruation): 15 ng/ml
    • Day of ovulation: 14 days before next menstrual period (or) Length of cycle 14 days.
    • Day 22 of cycle: Maximum size and activity of the corpus luteum.
    • Mid-cycle/Ovulatory pain: Pain at ovulation sometimes experienced.
    • Miteslschmerz syndrome: Pain at ovulation.
    • Pathophysiology: Rupture of antral cavity.
    • Fluid collection: Fluid collection in Pouch of Douglas (Ovulatory finding on US6)
    • Irritation of peritoneum: c/o Pain
    • Corpus Luteum of pregnancy: Maintained by HCG (Human Chorionic Gonadotropin) up to 10 weeks to protect from luteolysis

    Cryptomenorrhea

    • Causes: Transverse vaginal septum, Imperforate hymen (Hematocolpos >> Hematometra, Hematosalpinx) - most common cause, Vaginal agenesis.
    • Presentation: Young female with primary amenorrhea/hidden menstruation, Cyclical pain, Urinary retention, Retrograde menstruation: ↑ Risk d/t outflow obstruction. Leads to Endometriosis
    • Collection of blood:
      • Vagina: Hematocolpos
      • Uterus: Hematometra
      • Fallopian Tubes: Hematosalpinx.
    • Genotype & phenotype:
      • Karyotype: 46 XX.
      • Gonads: Ovary.
      • Breast: (+)
      • Axillary & pubic hair: (+)
    • 0/e:
      • Per abdominal: Supra pubic bulge.
      • Per vaginal: C/I in virgin female.
      • Per rectal: Anterior swelling.
      • Local Examination: Interoitus (Absent/Present)

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    Description

    This quiz explores the development and anomalies of female internal genitalia, focusing on conditions like septate uterus and unicornuate uterus. It covers clinical features such as recurrent abortions, ectopic pregnancies, and malpresentations. Test your knowledge on reproductive outcomes and associated complications.

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