Second and Third Trimester Complications - Cruz

Question 1

Define:

• First trimester
• Second trimester
• Third trimester

Answer 1

• First: last missed menses to 13 weeks
• Second: 13-25 weeks
• Third: 26 weeks to estimated due date

Question 2

Name the diseases that make up TORCH

Answer 2

• Toxoplasmosis
• ‘Other’ (syphilis and Parvovirus B19)
• Rubella
• CMV
• HSV

Question 3

What organism is impicated in toxoplasmosis?

What is the essential reservoir for this disease? Why is this important for pregnant women?

Answer 3

toxoplasma gondii (coccidian parasite)

Cats. Pregnant women should not handle cat feces (fecal->oral->transplacental transmission)

Question 4

Describe the effects of toxoplasmosis in:

• First trimester
• Second trimester
• Third trimester

How is this diagnosed?

Answer 4

• First: often results in death
• Second: hydrocephalus (ventriculomegaly), intracranial calcifications, chorioretinitis
• Third: often asymptomatic at birth

Dx: maternal +IgM and +IgG, fetal amniotic fluid PCR

Question 6

Treponema pallidum causes what disease?

Describe its morphology and gram-staining

Answer 6

Syphilis

G(-) spirochete

Question 7

When does congenital syphilis have the greatest chance of causing spontaneous abortion?

Give some other clinical manifestations

Answer 7

First trimester

• Stillbirth
• non-immune hydrops
• preterm birth
• hepatomegaly
• ascites
• anemia, thrombocytopenia

Question 8

What screening tests are used to detect syphilis?

What confirmatory tests are used?

Answer 8

Screening: RPR and VDRL

Confirm dx: FTA-ABS, MHA, dark-field microscopy, DFA

Question 9

Name the TORCH organism that is most closely associated with hemolysis and transient aplastic crisis

How is it transmitted?

Give some (fetal) clinical manifestations

Diagnostic tests?

Answer 9

Parvovirus B19

Tx: respiratory droplets with transplacental transfer

• anemia
• acute myocarditis
• edema/hydrops
• intrauterine fetal demise

Dx: maternal +IgM and +IgG, PCR of amniotic fluid

Question 10

Increased blood flow velocity in the fetal brain is worrisome for which TORCH bug?

Answer 10

Parvovirus B19

Question 11

What family of viruses does Rubella belong to?

How is it transmitted to the fetus?

Why (theoretically) should we be less concerned about this virus these days?

Answer 11

Togaviridae family of RNA viruses

Tx: respiratory droplets and transplacental transfer

Vaccine available

Question 12

What congenital defects are associated with Rubella?

How is it diagnosed?

Answer 12

• Deafness
• Eye defects (cataracts and retinopathy)
• CNS defects
• Cardiac malformations
• microcephaly, mental retardation, pneumonia, growth restriction, hepatosplenomegaly, hemolytic anemia, thrombocytopenia

Dx: increased IgM and IgG titers and PCR of amniotic fluid

Question 13

Give (3) possible transmission modes for CMV to the fetus/infant

Answer 13

1. Transplacental
2. Perinatal (inoculation in vagina or breast milk)
3. Bodily fluid contact (Don’t kiss the baby, grandma)

Question 14

Periventricular calcifications are a common finding with which TORCH bug?

Describe the characteristic histologic finding seen?

Answer 14

CMV

“Owl’s Eye” = enlarged (cytomegalic) cells with large basophilic nuclear inclusions

Question 15

Is transplacental infection common with HSV?

Give some other transmission modes

Answer 15

No. Transplacental infection is rare.

Other modes:

• Perinatal (contact with vagina)
• Contact after membrane rupture
• Direct contact with other affected areas

Question 16

Describe the clinical manifestation of fetal HSV infections

Answer 16

Microcephaly

ventriculomegaly

spasticity, echogenic bowel, hepatosplenomegaly, flexed extremities

Question 17

What organism is identified with a Tzanck Smear?

What other diagnostic tools might be used in the identification of this organism?

Answer 17

HSV

Others: culture, PCR, serology

Question 18

Define cervical insufficiency

Give some risk factors

Answer 18

painless cervical shortening or dilation leading to pregnancy loss

Risk factors:

• collagen abnormalities
• uterine abnormalities
• prior obstetric trauma
• mechanical dilation
• prior 2nd trimester loss

Question 19

What is cervical cerclage?

Answer 19

A suture technique used to reinforce closure of the cervix in cases of cervical insiffiency

Question 20

How are gross fetal anomalies usually identified?

Answer 20

fetal ultrasound

Question 21

What is Preterm Premature Rupture of Membranes (PPROM)?

What are its risk factors?

How is it diagnosed?

Answer 21

chorioamniotic membrane rupture before the onset of labor in pregnancies at less than 37 weeks of gestation

Risk factors: preterm labor, short cervix, advanced cervical dilation

Diagnosis: direct visualization of fluid with ferning on microscopy

Question 22

Define preterm labor

Answer 22

Labor/birth between 20 weeks and <37 weeks

Question 23

What is the #1 cause of perinatal morbidity and mortality in developed countries?

Give some risk factors

Answer 23

preterm labor/birth

Risk factors:

• premature activation of the maternal or fetal HPA axis
• exaggerated inflammatory response or infection
• placental abruption
• pathological uterine distension

Question 24

What is placenta previa?

Is it painful?

Answer 24

• Placenta located near (marginal) or over (complete) the internal cervical os
• Painless with no contractions

Question 25

Give some risk factors for placenta previa

Answer 25

* Smoking * Advanced maternal age * Multiple gestation * Uterine anomalies * Scarring from previous pregnancies

Question 26

# Define **placenta accreta** Why is this a problem?

Answer 26

Implantation extends into the basal zone of the endometrium It increases difficulty in removing the entire placenta during delivery, leading to higher risk of hemorrhage and hysterectomy following delivery

Question 27

What is **placenta percreta**? What are its risk factors?

Answer 27

implantation that extends into the uterine serosa and/or adjacent organs Risk factors: * multiple cesarean sections * placentra previa

Question 28

What is **placenta increta**?

Answer 28

Implantation that extends into the myometrium

Question 29

What is **placental abruption**? Give some sumptoms/clinical features Give some key risk factors

Answer 29

Placental separation due to hemorrhage into the decidual basalis before birth * Vaginal bleeding * uterine tenderness * May or may not show uterine heart tones Risk factors: * prior abruption * trauma * PPROM * HTN * Smoking and cocaine abuse

Question 30

What is **velamentous cord insertion**?

Answer 30

The umbilical cord attaches to the chorion and amnion rather than the placenta. The umbilical vessels continue on to the placenta between these two membranes. This arrangement makes the umbilical vessels prone to tearing. Serious fetal blood loss may occur

Question 31

Define **macrosomia** Define **intrauterine growth restriction**

Answer 31

Estimated fetal weight \>4500 grams (~9.9 lbs) Estimated (via ultrasound) fetal weight \<10th percentile

Question 32

Which maternal anatomical measrement should be a part of a normal 20wks gestation ultrasound scan?

Answer 32

Cervical length (screen for cervical insufficiency)