Theme 7:
Reproduction
Summary
1
,Content
Week 25: Sex ........................................................................................................................................... 6
“Doctor, we have a sexual problem” .................................................................................................. 6
Case 1 .............................................................................................................................................. 6
Case 2 .............................................................................................................................................. 7
How sex works: sexology..................................................................................................................... 9
Why do we have sex ........................................................................................................................ 9
Models of sexual response .............................................................................................................. 9
Genital vasocongestion ................................................................................................................. 11
Sexual dysfunction......................................................................................................................... 12
Ejaculation problems ..................................................................................................................... 13
Erection problems ......................................................................................................................... 13
Low desire ..................................................................................................................................... 13
Genito-pelvic pain penetration disorder ....................................................................................... 13
Ageing ............................................................................................................................................ 14
Sexually transmitted diseases ........................................................................................................... 15
Organisation of sexual health care and STDs .................................................................................... 19
Epidemiology ................................................................................................................................. 19
Sexual problems ............................................................................................................................ 19
Sexual violence: a hidden pandemic ............................................................................................. 20
Sexology in the first line .................................................................................................................... 21
SOA in the second line: STD care in the hospital............................................................................... 24
When to think about syphilis and HIV ........................................................................................... 24
HIV ................................................................................................................................................. 26
Endometriosis and hormones ........................................................................................................... 27
Gender dysphoria .............................................................................................................................. 30
Male-to-female.............................................................................................................................. 30
Female-to-male ............................................................................................................................. 31
Week 26: Pregnancy, childbirth and the postnatal period ................................................................... 32
Introduction....................................................................................................................................... 32
Organisation of maternity care in the Netherlands ...................................................................... 32
Early pregnancy ............................................................................................................................. 33
First appointment: at the midwife or GP ...................................................................................... 33
Information and preparation for labour ....................................................................................... 35
Introduction to reproductive health ................................................................................................. 37
Safe motherhood........................................................................................................................... 37
2
, Maternal adaption............................................................................................................................. 38
Embryonic development and placentation ....................................................................................... 41
The placenta .................................................................................................................................. 41
Embryonic development ............................................................................................................... 43
Foetal monitoring .............................................................................................................................. 44
Ante partum (during pregnancy) ................................................................................................... 44
Foetal monitoring during labour ................................................................................................... 46
Complications during the first trimester ........................................................................................... 47
Miscarriage .................................................................................................................................... 47
Ectopic pregnancy ......................................................................................................................... 47
Trophoblast disease ...................................................................................................................... 48
Midwifery led care............................................................................................................................. 50
Pictures of birth ............................................................................................................................. 50
Normal labour and delivery............................................................................................................... 52
Anatomy ........................................................................................................................................ 52
Lie, presentation, attitude and position ........................................................................................ 53
The first stage of labour ................................................................................................................ 55
The second stage of labour ........................................................................................................... 57
The third stage of labour ............................................................................................................... 58
The fourth stage of labour............................................................................................................. 59
Induction and augmentation of labour ............................................................................................. 60
Induction of labour ........................................................................................................................ 60
Augmentation of labour ................................................................................................................ 60
Partogram: when to take action.................................................................................................... 61
Postnatal period and puerperium care ............................................................................................. 62
Lactation ........................................................................................................................................ 63
Postnatal care ................................................................................................................................ 63
Week 27: Foetal development: too small ............................................................................................. 65
Prenatal screening and diagnosis ...................................................................................................... 65
Screening for genetic disorders ..................................................................................................... 66
Gestational problems: Preterm birth ................................................................................................ 69
Foetal growth and monitoring .......................................................................................................... 71
Large for gestational age (LGA) ..................................................................................................... 71
Small for gestational age (SGA) ..................................................................................................... 71
Blood group antagonism and blood disorders .................................................................................. 75
Blood group ABO ........................................................................................................................... 75
3
, Rhesus D ........................................................................................................................................ 75
Blood disorders: Sickle cell ............................................................................................................ 77
Blood disorders: Thalassemia ........................................................................................................ 77
Vaginal bleeding during second and third trimester......................................................................... 78
Placenta previa .............................................................................................................................. 78
Placental abruption ....................................................................................................................... 79
Vasa previa .................................................................................................................................... 80
Uterine rupture ............................................................................................................................. 81
Genital embryology ........................................................................................................................... 82
Primordia and timeline .................................................................................................................. 82
Cloaca and urogenital sinus........................................................................................................... 85
Gonads and ducts indifferent ........................................................................................................ 86
Gonads and ducts differentiation.................................................................................................. 87
External genitalia ........................................................................................................................... 88
Anatomy ............................................................................................................................................ 92
Week 28: Abnormal pregnancy and delivery, Caesarean Section ...................................................... 103
Complicated pregnancy ................................................................................................................... 103
Appendicitis ................................................................................................................................. 103
Placental problems ...................................................................................................................... 103
COVID-19 ..................................................................................................................................... 103
Obesity......................................................................................................................................... 103
Complicated delivery ................................................................................................................... 104
Postnatal depression ................................................................................................................... 106
Postnatal psychosis ..................................................................................................................... 106
Maternal mortality ...................................................................................................................... 106
Perinatal morbidity and mortality ............................................................................................... 107
Operative delivery and caesarean section ...................................................................................... 108
Vacuum ........................................................................................................................................ 108
Forceps ........................................................................................................................................ 109
Caesarean section ....................................................................................................................... 109
Hypertensive disorders of pregnancy ............................................................................................. 111
Pregnancy induced hypertension: PIH ........................................................................................ 111
Pre-eclampsia: PE ........................................................................................................................ 111
Hemolysis, elevated liver enzymes and low platelets: HELLP ..................................................... 113
Complications during third stage of labour ..................................................................................... 114
Postpartum haemorrhage: PPH .................................................................................................. 114
4
, Uterine inversion ......................................................................................................................... 115
Complicated deliveries: shoulder dystocia and breech .................................................................. 116
Shoulder dystocia ........................................................................................................................ 116
Breech delivery ............................................................................................................................ 116
Chronic conditions and pregnancy: pregnancy and diabetes ......................................................... 119
Pre-existing diabetes ................................................................................................................... 119
Gestational diabetes.................................................................................................................... 119
Acute pathology in pathology in pregnancy, sepsis, pulmonary embolism and amniotic fluid
embolism ......................................................................................................................................... 121
Sepsis ........................................................................................................................................... 121
Pulmonary embolism................................................................................................................... 122
Amniotic fluid embolism ............................................................................................................. 123
5
,Week 25: Sex
“Doctor, we have a sexual problem”
Case 1
Details:
• Male, 30 years
• Married for 4 years
• He and his wife want children, but he is not able to have intercourse with his wife.
Questions:
• How long has this been happening: since a couple a months
• Why are you not able to have intercourse: he doesn’t know. He tries, but it doesn’t
work.
• What doesn’t work: he cannot get an erection. Sometimes it gets hard but then it
goes away.
• Are you experiencing stress in your personal life: yes, he has a busy job. Also the
situation in the world.
• Any other complaints: he is constipated.
• Medical history: no previous problems.
• Do you get along with you partner: yes.
• Do you already have children: two.
• Current medication: no.
Additions:
• Erectile function is good upon awakening.
• Masturbation without any problems.
• No micturition problems
• Intimacy and sexual activity is less frequent.
• Difficulties to conceive in the past: put pressure on the relation with his wife and
family.
• The patient does not feel “sexy” at the moment, because he cannot “make it work”.
He feels like he fails as a man. He does not enjoy sex.
• No psychiatric diagnoses
• Personality: active, religious, serious, somewhat neurotic
• No negative sexual experiences or physical abuse
• Good contact with family
• Relationship: second partner. Shy, she has experienced trouble conceiving in the
past.
Differential diagnosis:
Erectile dysfunction = the inability to achieve or maintain an erection long enough to engage
in sexual intercourse
6
, • Recurrent
• Suffering
Physical Psychological
Gradual onset + -
Stress - +
Relation problems - +
Normal libido + -
Morning erection - +
Ejaculation praecox - +
Masturbation erection - +
Organic/physical factors:
• Ageing
• Intoxications
• Cardiovascular disease
• Diabetes
• Spinal cord injury
• MS
• Radiation
• Surgery
Psychological factors:
• Relationship problems
• Grief
• Psychological disorders
• Stress
Sexual factors:
• Performance anxiety
• Limited erotic repertoire
• Spectators role
• Inadequate sexual stimulation
• Difference in desire
• Unrealistic expectations
In the absence of physical/organic problems: refer to sex therapy by sexologist
→ goal = reset the system
Case 2
Details :
• 29 year old female
• Married for 3 years
7
, • Wants to have children, but doesn’t get pregnant
Questions:
• How long have they been trying: since the beginning.
• Frequency: has dropped. At the beginning the tried a lot but it declined.
• Children already: no children.
• Have you already succeeded to have intercourse: no. It feels like there is a physical
wall. Each attempt is painful.
• Do you use tampons: yes. It is not pleasant, but she can insert the tampon.
• Have you every had intercourse with someone else: no.
• Do you have regular menstruations: yes.
• Are you on contraception: no.
• Medication: no.
• Sexual response = normal.
• Masturbation: yes. Masturbation is normal.
• Strong religion.
• The pain is superficial.
• Lubrication is normal.
• The patient is able to orgasm.
Additions:
• No psychiatric diagnosis
• Regular cycle
• Micturition: twice per hour, squeezes to void, cystitis
• Defection: twice a week, painful
• No negative sexual experiences or physical abuse
• Personality: perfectionist
• Family: both parents, one brother, good contact
• Relationship: first partner, 5 years, understanding partner
• No daily life troubles, works 32 hours a week as management secretary
Physical examination: only what is necessary
• Speculum examination
• Pelvic floor examination: overactive pelvic floor muscles
• External examination: positive touch test (redness at the perineum) + no anatomic
abnormalities
Differential diagnosis:
Vaginismus: it is nearly impossible to enter anything
Dyspareunia: persistent recurrent pain with vaginal entry = final diagnosis
→ due to overactive pelvic floor
8
Reproduction
Summary
1
,Content
Week 25: Sex ........................................................................................................................................... 6
“Doctor, we have a sexual problem” .................................................................................................. 6
Case 1 .............................................................................................................................................. 6
Case 2 .............................................................................................................................................. 7
How sex works: sexology..................................................................................................................... 9
Why do we have sex ........................................................................................................................ 9
Models of sexual response .............................................................................................................. 9
Genital vasocongestion ................................................................................................................. 11
Sexual dysfunction......................................................................................................................... 12
Ejaculation problems ..................................................................................................................... 13
Erection problems ......................................................................................................................... 13
Low desire ..................................................................................................................................... 13
Genito-pelvic pain penetration disorder ....................................................................................... 13
Ageing ............................................................................................................................................ 14
Sexually transmitted diseases ........................................................................................................... 15
Organisation of sexual health care and STDs .................................................................................... 19
Epidemiology ................................................................................................................................. 19
Sexual problems ............................................................................................................................ 19
Sexual violence: a hidden pandemic ............................................................................................. 20
Sexology in the first line .................................................................................................................... 21
SOA in the second line: STD care in the hospital............................................................................... 24
When to think about syphilis and HIV ........................................................................................... 24
HIV ................................................................................................................................................. 26
Endometriosis and hormones ........................................................................................................... 27
Gender dysphoria .............................................................................................................................. 30
Male-to-female.............................................................................................................................. 30
Female-to-male ............................................................................................................................. 31
Week 26: Pregnancy, childbirth and the postnatal period ................................................................... 32
Introduction....................................................................................................................................... 32
Organisation of maternity care in the Netherlands ...................................................................... 32
Early pregnancy ............................................................................................................................. 33
First appointment: at the midwife or GP ...................................................................................... 33
Information and preparation for labour ....................................................................................... 35
Introduction to reproductive health ................................................................................................. 37
Safe motherhood........................................................................................................................... 37
2
, Maternal adaption............................................................................................................................. 38
Embryonic development and placentation ....................................................................................... 41
The placenta .................................................................................................................................. 41
Embryonic development ............................................................................................................... 43
Foetal monitoring .............................................................................................................................. 44
Ante partum (during pregnancy) ................................................................................................... 44
Foetal monitoring during labour ................................................................................................... 46
Complications during the first trimester ........................................................................................... 47
Miscarriage .................................................................................................................................... 47
Ectopic pregnancy ......................................................................................................................... 47
Trophoblast disease ...................................................................................................................... 48
Midwifery led care............................................................................................................................. 50
Pictures of birth ............................................................................................................................. 50
Normal labour and delivery............................................................................................................... 52
Anatomy ........................................................................................................................................ 52
Lie, presentation, attitude and position ........................................................................................ 53
The first stage of labour ................................................................................................................ 55
The second stage of labour ........................................................................................................... 57
The third stage of labour ............................................................................................................... 58
The fourth stage of labour............................................................................................................. 59
Induction and augmentation of labour ............................................................................................. 60
Induction of labour ........................................................................................................................ 60
Augmentation of labour ................................................................................................................ 60
Partogram: when to take action.................................................................................................... 61
Postnatal period and puerperium care ............................................................................................. 62
Lactation ........................................................................................................................................ 63
Postnatal care ................................................................................................................................ 63
Week 27: Foetal development: too small ............................................................................................. 65
Prenatal screening and diagnosis ...................................................................................................... 65
Screening for genetic disorders ..................................................................................................... 66
Gestational problems: Preterm birth ................................................................................................ 69
Foetal growth and monitoring .......................................................................................................... 71
Large for gestational age (LGA) ..................................................................................................... 71
Small for gestational age (SGA) ..................................................................................................... 71
Blood group antagonism and blood disorders .................................................................................. 75
Blood group ABO ........................................................................................................................... 75
3
, Rhesus D ........................................................................................................................................ 75
Blood disorders: Sickle cell ............................................................................................................ 77
Blood disorders: Thalassemia ........................................................................................................ 77
Vaginal bleeding during second and third trimester......................................................................... 78
Placenta previa .............................................................................................................................. 78
Placental abruption ....................................................................................................................... 79
Vasa previa .................................................................................................................................... 80
Uterine rupture ............................................................................................................................. 81
Genital embryology ........................................................................................................................... 82
Primordia and timeline .................................................................................................................. 82
Cloaca and urogenital sinus........................................................................................................... 85
Gonads and ducts indifferent ........................................................................................................ 86
Gonads and ducts differentiation.................................................................................................. 87
External genitalia ........................................................................................................................... 88
Anatomy ............................................................................................................................................ 92
Week 28: Abnormal pregnancy and delivery, Caesarean Section ...................................................... 103
Complicated pregnancy ................................................................................................................... 103
Appendicitis ................................................................................................................................. 103
Placental problems ...................................................................................................................... 103
COVID-19 ..................................................................................................................................... 103
Obesity......................................................................................................................................... 103
Complicated delivery ................................................................................................................... 104
Postnatal depression ................................................................................................................... 106
Postnatal psychosis ..................................................................................................................... 106
Maternal mortality ...................................................................................................................... 106
Perinatal morbidity and mortality ............................................................................................... 107
Operative delivery and caesarean section ...................................................................................... 108
Vacuum ........................................................................................................................................ 108
Forceps ........................................................................................................................................ 109
Caesarean section ....................................................................................................................... 109
Hypertensive disorders of pregnancy ............................................................................................. 111
Pregnancy induced hypertension: PIH ........................................................................................ 111
Pre-eclampsia: PE ........................................................................................................................ 111
Hemolysis, elevated liver enzymes and low platelets: HELLP ..................................................... 113
Complications during third stage of labour ..................................................................................... 114
Postpartum haemorrhage: PPH .................................................................................................. 114
4
, Uterine inversion ......................................................................................................................... 115
Complicated deliveries: shoulder dystocia and breech .................................................................. 116
Shoulder dystocia ........................................................................................................................ 116
Breech delivery ............................................................................................................................ 116
Chronic conditions and pregnancy: pregnancy and diabetes ......................................................... 119
Pre-existing diabetes ................................................................................................................... 119
Gestational diabetes.................................................................................................................... 119
Acute pathology in pathology in pregnancy, sepsis, pulmonary embolism and amniotic fluid
embolism ......................................................................................................................................... 121
Sepsis ........................................................................................................................................... 121
Pulmonary embolism................................................................................................................... 122
Amniotic fluid embolism ............................................................................................................. 123
5
,Week 25: Sex
“Doctor, we have a sexual problem”
Case 1
Details:
• Male, 30 years
• Married for 4 years
• He and his wife want children, but he is not able to have intercourse with his wife.
Questions:
• How long has this been happening: since a couple a months
• Why are you not able to have intercourse: he doesn’t know. He tries, but it doesn’t
work.
• What doesn’t work: he cannot get an erection. Sometimes it gets hard but then it
goes away.
• Are you experiencing stress in your personal life: yes, he has a busy job. Also the
situation in the world.
• Any other complaints: he is constipated.
• Medical history: no previous problems.
• Do you get along with you partner: yes.
• Do you already have children: two.
• Current medication: no.
Additions:
• Erectile function is good upon awakening.
• Masturbation without any problems.
• No micturition problems
• Intimacy and sexual activity is less frequent.
• Difficulties to conceive in the past: put pressure on the relation with his wife and
family.
• The patient does not feel “sexy” at the moment, because he cannot “make it work”.
He feels like he fails as a man. He does not enjoy sex.
• No psychiatric diagnoses
• Personality: active, religious, serious, somewhat neurotic
• No negative sexual experiences or physical abuse
• Good contact with family
• Relationship: second partner. Shy, she has experienced trouble conceiving in the
past.
Differential diagnosis:
Erectile dysfunction = the inability to achieve or maintain an erection long enough to engage
in sexual intercourse
6
, • Recurrent
• Suffering
Physical Psychological
Gradual onset + -
Stress - +
Relation problems - +
Normal libido + -
Morning erection - +
Ejaculation praecox - +
Masturbation erection - +
Organic/physical factors:
• Ageing
• Intoxications
• Cardiovascular disease
• Diabetes
• Spinal cord injury
• MS
• Radiation
• Surgery
Psychological factors:
• Relationship problems
• Grief
• Psychological disorders
• Stress
Sexual factors:
• Performance anxiety
• Limited erotic repertoire
• Spectators role
• Inadequate sexual stimulation
• Difference in desire
• Unrealistic expectations
In the absence of physical/organic problems: refer to sex therapy by sexologist
→ goal = reset the system
Case 2
Details :
• 29 year old female
• Married for 3 years
7
, • Wants to have children, but doesn’t get pregnant
Questions:
• How long have they been trying: since the beginning.
• Frequency: has dropped. At the beginning the tried a lot but it declined.
• Children already: no children.
• Have you already succeeded to have intercourse: no. It feels like there is a physical
wall. Each attempt is painful.
• Do you use tampons: yes. It is not pleasant, but she can insert the tampon.
• Have you every had intercourse with someone else: no.
• Do you have regular menstruations: yes.
• Are you on contraception: no.
• Medication: no.
• Sexual response = normal.
• Masturbation: yes. Masturbation is normal.
• Strong religion.
• The pain is superficial.
• Lubrication is normal.
• The patient is able to orgasm.
Additions:
• No psychiatric diagnosis
• Regular cycle
• Micturition: twice per hour, squeezes to void, cystitis
• Defection: twice a week, painful
• No negative sexual experiences or physical abuse
• Personality: perfectionist
• Family: both parents, one brother, good contact
• Relationship: first partner, 5 years, understanding partner
• No daily life troubles, works 32 hours a week as management secretary
Physical examination: only what is necessary
• Speculum examination
• Pelvic floor examination: overactive pelvic floor muscles
• External examination: positive touch test (redness at the perineum) + no anatomic
abnormalities
Differential diagnosis:
Vaginismus: it is nearly impossible to enter anything
Dyspareunia: persistent recurrent pain with vaginal entry = final diagnosis
→ due to overactive pelvic floor
8
