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MFM Flashcards

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1
Q

CV ∆ in pregnancy

A
  1. HR ↑ 10-15 BPM
  2. Blood volume ↑30-50% (most during 2nd trimester) causing ↑preload
  3. BP ↓ during 1st trimester and lowest in 2nd associated with widened PP and ↓ SVR
  4. CO ↑ 30-50% with↑ blood flow to kidneys and uterus
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2
Q

Pulmonary ∆ in pregnancy

A
  1. Minimal Change in RR
  2. ↑in TV w/ ↑ in MV associated with ↑ GA (TV * RR = MV)
  3. ↓ RV
  4. Progesterone induces a chronic hyperventilated state (↓ paCO2)
  5. ↑ O2 uptake and sensitivity to hypoxemia
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3
Q

Renal ∆ in Pregnancy

A
  1. Renal Hypertrophy
  2. ↑ GFR and RBF by 50%; ↓BUN and Cr
  3. ↓ Renal bicarb threshold; ↑ protein filtration
  4. ↑ ADH, renin Ang II and aldosterone secretion; ↑fluid volume and Na retention
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4
Q

Heme ∆ in Pregnancy

A
  1. RBCs ↑ by 30% (↑ need for Iron leading to ↑production, ↑MCV, ↑ Plasma volume - dilutional anemia)
  2. ↑ WBCs assoc w/ ↑ estrogen (greatest in labor) but ↓ function
  3. ↑ width and volume of platelets but minimal ∆ in count
  4. ↓ Hgb/Hct (due to ↑ Blood Volume despite erythropoiesis)
  5. ↑ Coagulation factors (↑ Fibrinogen 30-50%) and ↓ anti-coagulation factors (↓ Fibrinolysis)
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5
Q

GI ∆ in Pregnancy

A
  1. Uterus displaces stomach and intestines
  2. ↓ Gastric emptying time, ↓LES tone leading to reflux
  3. Hemorrhoids d/t constipation and ↑ Venous Pressure
  4. Impaired Gall Bladder contraction
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6
Q

Endocrine ∆ in Pregnancy

A
  1. Pituitary gland ↑ 135% assoc w/ PRL
  2. ↑TBG; ↑ Total T4 with ↓ TSH
  3. ↑ PTHr peptide leading to ↑ Calcitriol leading to maternal intestinal absorption of Ca (protects mom while transferring Ca to fetus)
  4. ↑ Insulin (Estrogen stimulates pancreas) leading to ↑ tissue glucose utilization and ↑ lipogenesis/fat storage
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7
Q

hCG in pregnancy

A
  1. Produced by syncytiotrophoblasts
  2. Highest in 1st trimester - detectable by 8-9 days following ovulation
  3. Prevents corpus luteum involution, TSH like effect, Suppresses maternal immune fxn
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8
Q

hPL in Pregnancy

A
  1. Produced by syncytiotrophoblasts
  2. ↑ w/ GA
  3. ↑ lipid utilization; has an anti-Insulin effect
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9
Q

Progesterone in Pregnancy

A
  1. Smooth muscle relaxation on uterus
  2. Withdrawal of fxn during labor - functional suppression
  3. Anti inflammatory and immonosuppressive fxns
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10
Q

Estrogen in Pregnancy

A
  1. Regulates progesterone, assists with maturation of fetal organs and proliferation of uterine endometrium
  2. Increases strength of Uterine Contractions
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11
Q

Maternal Portion of Placenta = Decidua Basalis

A
  1. Uterine Surface has 10-38 lobes or cotyledons
  2. O2 maternal blood enters from endometrial arteries into intervillous space
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12
Q

Fetal Portion of Placenta = Villous and Chorion and fetal blood flow

A
  1. UTERINE A. sends O2 blood into intervillous space where it mixes with deO2 blood and travels on gradient to capillaries within villi to form UMBILICAL V. that provides O2 and nutrients to fetus
  2. 2 UMBILICAL A. return blood to intervillous space and UTERINE V. then collects waste for maternal excretion
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13
Q

Transplacental Transfer

A
  1. Simple Diffusion (O2, CO2, H2O, Na, Cl, Lipids, Fat sol vits, Most meds)
  2. Facilitated Diffusion (Glucose, Cephalexin)
  3. Active Transport - Against Gradient (Amino Acids, Ca, Phos, Mg, Fe, Iodide and water soluble vits)
  4. Bulk Flow (H20, dissolved electrolytes)
  5. Pinocytosis (IgG Ab - starts in 2nd trim with most in 3rd, other proteins)
  6. Breaks (maternal or fetal cells)
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14
Q

Compounds that cross Placenta

A

Bilirubin
Aspirin, Coumadin
Dilantin, Valproate
Alcohol
Small Amount of T4 & T3 (also converted to T2 by placenta)
TRH and Iodine
IgG

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15
Q

Compounds that do NOT cross Placenta

A

Biliverdin
Heparin
Glucagon, HGH, Insulin
PTU (only small amounts cross)
TSH
IgM

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16
Q

Placenta Previa = C/s delivery

A
  1. Complete, Partial, Marginal, low-lying and varies with cervical dilation
  2. 1 in 200 deliveries; ↓ with ↑ GA, ↑ risk with AMA, ↑ parity, previous c/s, smoking, hx of abortion
  3. ↑ risk preterm delivery, ↑ risk fetal anomalies, ↑ bleeding
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17
Q

Placental Abruption

A
  1. total or partial separation of placenta leading to bleeding into decidua basalis
  2. Assoc w/ HTN, prior abruption, AMA, ↑ parity, Cigarettes, Cocaine, trauma, leiomyoma, ↑ thrombotic state
  3. Vaginal bleeding, uterine tenderness, fetal distress
  4. ↑ risk preterm delivery, ↑ risk stillbirth, ↑ risk growth restriction if chronic, ↑ risk neurological deficits
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18
Q

Abnormal Placental Adherence = planned early delivery

A
  1. Accreta (to myometrium), Increta (in myometrium), Percreta (past myometrium)
  2. May have ↑ AFP in early pregnancy
  3. may lead to severe hemorrhage, uterine perforation or infection
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19
Q

Placental Tumors

A
  1. Hydatidiform Mole
  2. Gest Trophoblastic Dz
  3. Chorioangioma - benign placental tumor
  4. Placental Mets - assoc with malignant melanoma, leukemia, lymphoma, breast CA, Lung CA or Sarcoma
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20
Q

Hydatidiform Mole = D&C and follow for malignancy

A
  1. 1 in 1000 (↑ risk AMA and previous hx of mole)
  2. Types: Complete (46, XX - paternal origin, no fetus or amnion, uterus large for GA and ~20% develop trophoblastic tumors, frequent medical comp.) Partial (69 XXX, XXY, XYY, nonviable fetus and amnion present, less likely to develop trophoblastic tumors, rare to have medical comp)
  3. Presents with bleeding, no fetus, rapidly developing uterus, preE in 2nd tri, ↑ BHCG for GA, ↑ trophoblastic tissue embolization
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21
Q

Gestational Trophoblastic Dz

A
  1. Invasive mole (excessive trophoblastic growth with severe invasion, usually no mets) and Choriocarcinoma (Malignant trophoblastic tumor that rapidly grows and invades uterine muscle and blood vessels with frequent mets to lungs and vagina)
  2. Irregular bleeding and persistently elevated BHCG
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22
Q

Single Umbilical A.

A
  1. 0.4-0.6% all infants
  2. 3-4 x more common with twins
  3. urogenital tract, GI and Cardiac anomalies associated
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23
Q

Velamentous Insertion of Cord

A
  1. 0.5-1% singletons, 9% twins, almost all triplets
  2. ↑ risk of labor intolerance
  3. ↑ risk prematurity and LBW
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24
Q

Vasa Previa = covering cervical Os

A
  1. 1 in 2,000-5,000 pregnancies
  2. ↑ risk low lying placenta or multiple gestation
  3. Frequently occurs with Velamentous insertion
  4. If unknown high mortality (40-90%)
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25
Ompahlomesenteric remnant
1. 2-3% all infants 2. Persistent ompahlomesenteric duct leading to cyst, sinus, polyp, meckel diverticulum or fistula
26
Urachal Remnant = Failed obliteration at 20 weeks
1. Complete 2. Partial patent urachus at umbilical end = urachal sinus 3. patent central part = urachal cyst 4. patent urachus ant bladder end = bladder diverticulum 5. Mucosal remnant at umbilical end = umbilical polyp
27
Lupus & Pregnancy
1. ↑ incidence of 1st tri abortions, IUGR and fetal death 2. Assoc w/ Lupus anticoag Ab and Anticardiolipin Ab that inhibit prostacyclin (fxn as vasodilator and inhibits platelet aggregation 3. ↑ risk heart block leading to hydrops independent of maternal dz severity but ↑ if Anti-Ro or Anti-La 4. Tx with Heparin and low dose Aspirin +/- steroids and monitoring for fetal heart block
28
MG & Pregnancy
1. Autoimmune Ab directed at NMJ - 90% Ab to adult ACh receptors and 10% to fetal ACh receptors 2. Possible maternal exacerbation with limited fetal effects but may lead to fetal arthrogryposis 3. Tx with AChE inhib, steroids, immunosuppressants, IVIG, plasmapharesis 4. 10-20% develop neonatal MG presenting 12-18 h after birth lasting ~ 18 days and 90% recovered by 2 mo
29
DM effects on Fetus
1. Overall - stillbirth, polyhydramnios, preterm delivery, perinatal depression, LGA, SGA, Organomegaly 2. Endo - Transient hyperinsulinism and neonatal hypoglycemia, ↓ neonatal Ca 3. Pulm - surfactant deficiency 4. Cardiac - HOCM, VSD, TGA, ASD, hypoplastic LV, DORV, TA 5. Neuro - NTD, anencephaly 6. Heme - polycythemia assoc w/ ↑ indirect hyperbili risk 7. GI - Duodenal Atresia, imperforate anus, anal atresia, Situs Inversus, Small Colon syndrome 8. GU - Ureteral Duplication, Renal Agenesis, Hydronephrosis, Renal V. Thrombosis 9 Skeletal - Caudal regression syndrome, hemivertabrae
30
Thrombosis in Pregnancy
1. Resistance of activated protein C 2. Decreased protein S activity 3. Increased Fibrinogen and factors II, VII, VIII and X 4. Increased levels and activity of fibrinolytic inhibitors Factor V Leiden (most common thrombophilia in pregnancy) protein C deficiency, antithrombin deficiency, prothrombin gene mutation
31
Antiphospholipid Ab Syndrome
1. Assoc w/ recurrent pregnancy loss (High levels of IgG cardiolipin and Lupus Anticoagulant) thrombophilia, pre E (10-50%), placental insuffic (30%), IUGR (30%), preterm delivery 2. ↑ maternal complications = ↑ neonatal complications 3. Tx with Heparin to ↑ live birth rates
32
ITP
1. IgG Ab binding to plt leading to plt<100 k in both mom and possibly baby 2. Tx with steroids or possibly high dose IVIG
33
AFP
1. Produced by Yolk Sace then fetal liver and GI tract 2. Can diffuse across placenta to maternal circulation 3. Fetal AFP peaks at 13 w, MSAFP detected after 12 w and peaks at 32 w and most sensitive btw 16-18w
34
Elevated MSAFP (>2.0-2.5 MOM)
1. Neuro: Open NTD 2. GI: Liver necrosis, esophageal or intestinal obstruction, omphalocele, gastroschisis 3. Renal: urinary obstruction, PCKD, renal aplasia, congenital nephrotic syndrome, cloacal exstrophy 4. Masses: pilonidal cyst, cystic hygroma, sacrococcygeal teratoma 5. Other: LBW, ↓ maternal weight, oligohydramnios, multiple gest, underestimation of GA, OI, placental chorioangioma Increased risk of IUGR or fetal death if unexplained
35
Low AFP
1. Genetics: trisomies 2. Fetal Death, ↑ Maternal weight, overestimated GA, gestational trophoblastic dz
36
1st trimester Maternal Screening (10-13w)
1. PAPP-A & BHCG 2. ↓ PAPP-A in T 18/21 (combined w/ maternal age can detect 65% T21)
37
NT Test (10-14 w)
1. 0.5 to 2.0 mm; If >3 mm 1/6 risk aneuploidy; if cystic hygroma 50% fetal aneuploidy and if euploid 50% with MAJOR fetal malformation 2. Assoc with anomalies especially cardiac 3. Detects 78-89% T21 when combined w/ maternal age; 91% when combined w/ maternal age + 1st trimester screen
38
Quad Screen (14-20 w)
1. MSAFP (least sens), Maternal estriol (produced by placenta from fetal adrenal and liver precursors), BHCG (T21 Most sens), Inhibin A (produced by placenta and ovaries) 2. T21:↓ AFP, ↑ BHCG, ↓ Estriol, ↑ Inhibin 3. T18: ↓ AFP, ↓ BHCG, ↓ Estriol, Inhibin unaffected 4. T13: not helpful other than slightly low Estriol 5. Turner : ↓ AFP, ↑ BHCG, ↓ Estriol, ↑ Inhibin (hydropic) ↓ Inhibin (non-hydropic) 6. SLO: ↓ AFP, ↓ BHCG, ↓ Estriol, Inhibin unaffected 7. Triploidy: ↓ Estriol
39
cell free DNA (after 9 weeks GA)
1. ↓ early GA, maternal obesity, abnormal karyotype, poor sample 2. T21 99%, T18 95%, T13 91% 3. False + (Demised twin, paternal mosaicism, maternal CA)
40
Dandy Walker abnormality
1. Malformation: cystic dilatation of 4th ventricle, enlarged or normal post fossa and cerebellar vermis aplasia, often assoc with obstructive hydrocephalus 2. Variant: Direct communication btw 4th ventricle and cisterna magna without enlargement of post fossa, mild cerebellar vermis hypoplasia, ↑ Chromosomal Abnormalities
41
Encephalocele (Mass + Skull Defect)
1. 75% occipital (assoc w/ Meckel Gruber) 2. ↑ Assoc with renal cystic dz, NTD, microcephaly 3. Differentiate btw hygroma or soft tissue edema by identifying bony defect
42
Meningomyelocele
1. Splaying of post ossification centers of spinal bones 2. +/- fluid filled sac over skin 3. "Banana" sign elongated cerebellum on transaxial views, "Lemon" sign skull shape with concave frontal bones, microcephaly, ventriculomegaly
43
Hormonal Regulation of Fetal Growth
1. Insulin: Major hormone for growth produced by fetus 2. IGF-I&II: mice knockouts have ↓ growth 3. EGF: Important for ectodermal and mesodermal tissue development 4. GH: no involvement of fetal or maternal GH; fetal tissues do not have GH receptors until late gestation
44
Ponderal Index
1. (Weight (g) x 100)/(crown - heel)^3. Length in cm 2. Low PI if asymmetric growth
45
NIFH
1. Abnormal fluid accumulation in at least 2 compartments including general skin thickening, cystic hygroma, polyhydramnios and thick placenta (> 6 mm) 2. Etiologies: Most common is disorders assoc w/ CHF, anemia, obstructed lymph flow, ↓ plasma osmotic pressure with increased capillary permeability 3. 40-90% perinatal mortality, prognosis worse with oligo and/or structual heart dz
46
TOPS (Twin Oligo Poly Seq) v TAPS (Twin Anemia Polycythemia Seq)
1. Both have Hct differences 2. TOPS has amniotic fluid volume differences 3. Dichorionic twins are not at risk for TOPS or TAPS - so only occurs with single placenta 4. If large ∆ in Hcts yet similar weights, transfusion likely near time of delivery
47
BPP
1. 10 Well Fetus 2. 8 w/ normal AFV - well fetus 3. 8 w/ ↓ AFV - likely chronic asphyxia; deliver if at least 37 w 4. 6 - possible asphyxia; deliver if abnormal AFV or normal and > 36 w; if not repeat in 24 h 5. 4 - probable asphyxia; repeat same day 6. 0-2 - almost certain asphyxia; deliver
48
Tocolytics
1. Terbutaline causes tachycardia: β2 agonist→adrenyl cyclase→ATP converted to cAMP→↓intracellular Ca→↓uterine contractility 2. Magnesium: ↓uterine contractility by ↓ ACh at NMJ and acting as Ca antagonist; decreases CP risk 3. Indomethacin: PG synthetase inhibitor 4. Ca Ch Blocking Agent: ↓uterine contractility by inhibiting transmembrane Ca influx
49
ACE - I Teratogenic Effects
1. Greater risk if exposure during 2nd or 3rd tri 2. ↑risk Oligohydramnios 3. ↑ risk postnatally hypotension, oliguria 4. skull hypoplasia, fetal compression syndrome with limb deformations and pulm hypoplasia, renal tubule dysgenesis
50
Cannabis - Teratogen Effects
1. Association with preterm birth 2. ↓ fetal growth and worse neurodevelopmental outcomes
51
Carbamazepine - Teratogen Effects
1. Craniofacial Defects, fingernail hypoplasia, GR 2. NTD (meningomyelocele), DD 3. ↓ Vit K placental transfer→↑ risk hemorrhagic Dz newborn
52
Cocaine - Teratogen Effects
1. Stillbirth, Abruption 2. Skull Abnormalities, Cutis Aplasia, Porencephaly 3. Ileal Atresia, Cardiac Anomalies, Urinary tract anomalies
53
Cyclophosphamide - Teratogen Effects
1. Imperforate Anus 2. Small Brain - Microcephaly 3. Cleft Palate, Single Coronary 4. Missing or hypoplastic digits 5. Exposure worse during early preg 5. FGR
54
Phenytoin - Teratogen Effects
1. Cleft Lip/Palate 2. IUGR, FTT, mild MR, wide AF 3. Digit/Nail Hypoplasia 4. ↓ Vit K placental transfer→↑ risk hemorrhagic Dz newborn 5. Cardiac Defects (VSD, Valve defects)
55
Isoretinoin - Teratogen Effects
1. △ Facies: (↓ slanting palpebral fissures, anterolateral hair whorl, malformed ear, narrow sloping forehead, Facial n. paralysis) 2. Cardiac: TGA, TA, TOF, VSD, DORV, hypoplastic or interrupted aortic arch, retroesophageal subclavian 3. Neuro: Hydrocephalus, Microcephaly, MR, cerebellar hypoplasia 4. Thymic or parathyroid abnormalities 5. Limb reduction
56
Lithium - Teratogen Effects
1. Ebstein's Anomaly 2. Fetal Goiter, hypotonia, arrythmia, seizure, DI, preterm
57
Methotrexate
1. 6-8 w is critical time 2. Facial: Cranial dysplasia, broad nasal bridge, low set ears, synostosis lambdoid or coronal sutures 3. Microcephaly 4. IUGR, short, Talipes equinovarus, Syndactyly
58
Phenobarbital - Teratogen Exposure
1. Cleft lip and palate 2. Cardiac 3. ↓ Vit K placental transfer→↑ risk hemorrhagic Dz newborn
59
Valproic Acid - Teratogen Exposure
1. Facial Anomalies 2. Cardiac 3. Long thin fingers] 4. NTD (meningomyelocele), DD, MR 5. Hypospadias
60
Warfarin
1. Fetal Effects 6 -12 w (25%), after 12 w risk ↓ 2. Nasal hypoplasia with deep groove btw alae and tip 3. Severe MR, Seizures, Microcephaly, hydrocephalus 4. Stippled Bone Epiphysis 5. LBW, mild nail hypoplasia
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