1
Q
What is the process of decidualisation?
A
transformation of endomterial stromal cells into specialised secretory cells. mediated by estrogen, prog, endrogens and factors from the blastocyst
2
Q
What are the three layers of the decidua?
A
basalis, capsularis, parietalis
3
Q
What hormone does the decidua make and what is the function?
A
prolactin, to create insulin resistance, increased glucose for fetal growth
4
Q
Which decidual layer is in contact with the embryo?
A
capsularis
5
Q
What are the three layers that make up the decidua parietalis and basalis?
A
zona compacta
zona spongiosa
zona basalis
6
Q
Which layers of the decidua are the zona functionalis?
A
compacta and spongiosa
7
Q
Which layer of the decidual is left behind after delivery and why?
A
zona basalis, to regenerate the endometrium
8
Q
When does most fertilisation occur?
A
when intercourse occurs 2 days prior or on the day of ovulation
9
Q
What is the zona pellucida?
A
a thick glycoprotein layer surrounding the oocyte
10
Q
What are the two kinds of cells in an early embryo?
A
blastomeres (totipotent cells) and polar bodies
11
Q
How many cells are present at the start of the morula stage?
A
12-16 cells until the blastocyst forms at about 50-60 blastomeres
12
Q
Which cell stage enters the uterine cavity and what stage after fertilsation?
A
the morula, day 3
13
Q
What differentiates the morula from the blastocyst?
A
accumulation of fluid filled cavity (blastocyst cavity)
14
Q
at what stage does the blastocyst form?
A
day 4-5
15
Q
What occurs at day 4-5 at around 58 cells?
A
formation of a inner cell mass and trophectoderm
loss of zona pellucida
16
Q
What does the trophectoderm become?
A
the trophoblast
17
Q
What day does the embryo implant?
A
day 6-7
18
Q
What are the three stages of implantation?
A
apposition
adhesions
invasion
19
Q
What is involved in invasion of implantation?
A
penetration of the syncytiotrophoblast and cytotrophoblast into the decidua, inner 1/3 myometrium and uterine vasculature
20
Q
when is uterine receptivity restricted to?
A
day 2-24 of endometrial cycle
21
Q
What are the two layers of the trophoblast? inner and outer?
A
Synciotrophoblast outer and cytotrophoblast inner
22
Q
What is the layer which makers HCG of the trophoblast?
A
until week 5 it is both trophoblast cell types then the syncytiotrophblast
23
Q
What is the function of HCG?
A
to stimulate the corpus to make progesterone
24
Q
what are the villous trophoblasts?
A
they generate chorionic villi
25
What are extra villous trophoblasts?
migrate into the decidua and myometrium surrounding the spiral arteries
26
How does the syncytiotrophoblast invade the stromal tissue?
releasing hyodrolytic enzymes
27
How do lacunae in the early placenta form?
with syncytiotrophoblast invasion of the superficial decidual capillaries
28
What is the first wave of uteroplacental development?
up to 12/40 spiral arteries are invaded up to the boder of the decuidua and myometrium, low estradiol levels are important for this
29
What is the second wave of uteroplacental development?
12-16 weeks invasion of the intramyometrial segments of the spiral arteries creating low resistance uteroplacental vessels
30
When are the placenta and the fetus equal weights?
17 weeks
31
How big id the placenta compared to the fetus at term?
1/6 weight
32
When does a fetus develop positive EDF in the UAPI?
10 weeks
33
Explain the exchange of oxygen between the fetus and the mother
Maternal blood flows into the intervillous spaces and the umbilical arteries carry deoxygenated fetal bloods to the placenta, exchanges between the systems occur as maternal blood flows around the villi. Inflowing arterial blood pushes maternal venous blood into the endometrial veins which are scattered over the entire surface of the decidua basalis
34
What is beta HCG?
the degredation product of HCG hormone
35
When does HCG peak and nadir?
week 9 ,16
36
what is HCG made up of ?
beta and alpha subunit
37
When does beta HCG peak?
week 10
38
What do urine pregnancy tests pick up?
HCG and beta HCG
39
What does human placental lactogen do?
lipolysis and increase circulating free fatty acids in maternal system for energy and increase maternal insulin resistance to ensure nutrient flow to the fetus
40
Where is relaxin made?
in the placenta and corpus
41
When does the placenta take over making progesteron?
8 weeks
42
When does resection of the corpus luteum cause a miscarriage?
prior to 7 weeks
43
How much progesterone is made in a term pregnancy by the placenta?
250mg/day
44
What makes estrogens in the first trimester?
corpus luteum and then the placental takes over at week 7
45
What is the main source of maternal estrogens in pregnancy?
the fetus adrenals make DHEAS which the placenta converts into estrogens and releases into the maternal circulation
46
What fetal conditions cause low maternal estrogens and why?
* Anencephaly
* Fetal demise
* T21
Complete molar
as they don't have malfunctioning adrenals or enzymes to make estrogen precursors
47
when does amniotic fluid levels peak?
week 34
48
approximately how much amniotic fluid is present by term?
1 litre
49
how many cell layers in the amnion?
5
50
What is the recommended IM dose of vitamin K for infants?
1mg or 0.1ml of konakion MM at birth
51
If less than 1.5kg at birth what dose of vitamin K should be given?
0.5mg, 0.05ml IM konakion MM at birth
52
What is the oral dose of vitamin K advised IM declined?
3x 2mg doses of oral konakion MM.
one at birth
one at time fo newborn screening (usually day 3-5)
one at the forth week
53
What are the provisos to oral vitamin K dose
1. parents must be willing to take responsibility with clinicians support and advise for the last dose.
2. if they vomit within an hour of the doses it should be repeated
3. if at any time the baby is too sick to take the dose by mouth, medical advice should be sought for if it should be given IM
4. if they are formula fed they don't need the last dose
54
What is the placental gradient of vitamin K to fetus?
1:30
55
What is the amount of vitamin K in breast milk vs formula?
1-2mg/L vs 30mg/L
56
How is vitamin K source by the infant after birth?
dietary
57
What are the two kinds of vitamin K and how is it acquired?
K1 - oral intake
K2 - bacteria in the gut
58
When does a neonate accumulate enough K2 for adequate stores and protection?
the first few months
59
What is in the formulation of konakion to allow the vitamin K to be in an aqueous solution?
bile salts and lethicin
60
What is the definition of vitamin K deficient bleeding?
spontaneous of excessive induced bleeding at any site associated with decreased activity of the vitamin K dependent clotting factors and and normal activity of vitamin K independent factors, fibrinogen and platelets
61
How do you confirm the diagnosis of VKDB?
the coagulation disorders is rapidly reverse following vitamin K administration and other causes are excluded
62
what are the classifications of VKDB?
early
classical
late
63
What is the time frame for early VKDB?
within the first day
64
Who is early VKDB confined to?
fetuses of women on medication which interfere with vitamin K metabolism eg phenytoin, barbituates, carbemazepine, rifampicin, warfarin
65
What is the time frame for classical VKDB?
day 1-7
66
What are the high risk groups of VKDM classical?
unwell infants at birth or delayed onset of feeding
67
Where are common sites to bleeding from for VKDB?
umbilicus, GIT, skin punctures, surgical sites
68
What is the incidence of VKDB in well babies?
difficult to know, maybe 0-0.44%
69
What is the timeframe for late VKDB?
day 8 to 6 months. mostly 1-3 months
70
What are the infants most commonly effected by late VKDB?
exclusively breastfed infants
infants with liver (50%) or malabsorption issues
71
What is the common site of bleeding in late onset VKDB?
intracranial 30-50%
72
What is a warning bleeding in VKDB?
minor bruising , bleeding or black stools or other signs of coagulopathy prior to a large bleed
73
what is the estimated rate of late VKDB when n o prophylaxis given?
5-20 in 100 000
74
What is the mortality rate of late VKDB?
30%
75
Why is vitamin K IM method preferred?
reliability of admininstration
76
what is the rate of early VKDB in women taking vitamin K effecting meds if no supplementation taken on the last 2 weeks?
6-12%
77
What can be done to prevent early VKDB?
maternal supplemtation of 20mg vitamin K OD for at least 2/52 prior to delivery and fetal IM vitamin K
78
How do you reduce classical VKDB?
virtually eliminated by one dose of any route at birth
79
what is the rate of late VKDB with no vitamin K, one oral dose, 3 oral doses and IM dose
none 34
one 20
3 oral 4.1
IM 0.2
per 100 000
80
What is the issue with data for late VKDB?
the newer medication (konakion) isn't well studied on efficacy of rates
81
Factors which can predispose the newborn to VKDB?
* Anticoagulants
* Anticonvulsants
* Tuberculosis medications
* Some antibiotics eg cephalosporins,
* Birth asphyxia
* Prolonged labour
* Prematurity
Delayed oral feeding
82
Who is the oral vitamin K not advised for?
* Anti convulsant
* Anticoags
* TB meds
* Prematurity
* Birth asphyxia
Delayed oral feeding
83
What are the down sides of vitamin K oral?
relying on people giving the other two doses
variable oral absorption
relys on liver and bowel working
84
What are the side effects of the vitamin K injection?
Usually confined to the local effects of the injection - infection, irritation, nerve or muscle damage as given as deep IM injection very rare
85
What is the definition of resuscitation?
the preservation or restoration of life by the establishment and or maintenance of ABC and related emergency care
86
what neonatal resus trained practitioners hsould be at high risk births?
a registered HP with advanced neonatal resus training PLUS a HP trained in neonatal resus
87
What coordination is required for respiratory adaptation?
fluid clearance
surfactant secretion
commencement of breathing
88
What are the 5 embryonic phases of lung development?
1. embryonic
2. psuedoglandular
3. canalicular
4. saccular
5. alveolar
89
When and what is the embryonic phase of lung development?
week 3-6.
Lung bud formation from the ventral foregut
branching into the primary bronchial buds.
establishes the basic structure
90
When and what is the pseudoglandular phase of lung development?
week 6-17
Branching morphogenesis continues, forming bronchial tree
Differentiation of epithelial cells begins to ciliated cells and early type 2 pneumocytes
lays ground owrk of strcutres and epithelial differentiation
91
When and what is the canalicular phase of lung development?
Week 17-26
Formation of the respiratory bronchioles, increased vascularisation, thinning of the airway epithelium, appearance of type 1 pneumocytes and lamellar bodies in type 2
Critical for the development of air blood barrier essential for gas exchange
92
When and what is the saccular phase of lung development?
Week 26 to term
Terminal saccules form and begin to septate into alveoli. Extensive capillary network develops around the saccules
Prepares for effective gas exchange at birth
93
When and what is the alveolar phase of lung development?
Week 32 to childhood
Formation of mature alveoli continues postnatally, with significant development in the first two years
Increase the surface area for gas exchange
94
What cells make surfactant?
type 2 pneumocytes
95
what endocrine adaptations occur to stimulate fluid clearance in the fetal lungs in the neonata?
cortisol and adrenaline stimulate absorption of fluid into the interstitial spaces reducing pulmonary resistance and facilitating initiation of breathing
96
which layer in embryonic development does the respiratory system develop from?
the endoderm with the mesoderm (bronchi, trachea and lungs) contributing the the structure
97
When do infants have adequate surfacatant?
34-36 weeks
98
what change occurs before birth to facilitate fetal breathing?
reduced lung fluid
99
what stimulates breathing at birth?
internal - chemoreceptors respond to oxygen, CO2, pH stimulates the medulla to initiate breathing
external - mechanical compression of birth, tactile stimulation activates resp centre
100
why do preterm infants have a hard time breathing at birth?
weak muscles, reduced surfactant, making fluid clearance hard
101
what % of babies will cry at birth within 30 seconds?
85%
102
what % neonates need intubation at birth?
2%
103
what % neonates need CPR or adrenaline at birth?
0.1%
104
what % neonates need pos pressure at birth?
3%
105
what stops blood flowing to the lungs in the neonatal lung circulation?
high pulmonary pressures
106
where does blood flow to avoid the lung pressure lungs in the neonatal lung circulation?
through the ductus arteriosus which comes in after the L carotid and the brachiocephalic artery so oxygen deplete blood goes to the body not the brain
107
Where does the oxygen rich blood go in the fetal heart?
into the right artium and across the foramen ovale to the brain out the LV
108
what changes occur in the respiratory and heart system at birth?
1. inhaled oxygen reaches lungs
2. pulm A dilates and pressures reduces increasing blood flow
3. umbilical artery is tied off
4. blood from the lungs fills the left atrium, increasing pressures and stops blood across the FO
5. Oxygen rich blood flows through the ductus arteriosus causing it to contract
109
how does blood enter the fetal circulation form the umbilical vein?
via the ductus venosus is bypasses the immature liver into the IVC
110
what does the FO allow in fetal circulation?
oxygen rich blood to shunt from the RA to LA
111
where does blood flow through the Ductus arteriosus from?
the high pressure pulmonary artery to the descending aorta
112
Where do the umbilical arteries branch off?
internal iliacs
113
What changes after birth in the neonatal circulation?
1. umbilical clamping and removal of placental circulation
2. lung aeration and reduction in pulmonary pressures
3. closure of the foramen ovale
4. closure of the ductus arteriosus
The umbilical vein and DV clot off and the umbilical arteries vasoconstrict
114
what occurs physiologically with umbilical clamping?
eliminates placenta circulation and increased systemic vascular resistance and LV workload.
115
What does wortons jelly do at birth?
contracts the vessels when the temperature around baby reduces at birth.
116
What occurs when the lungs fill with air in the RHS?
pressures drop in the right heart
117
what occurs to close the foramen ovale?
increased pressure int he left heart and reduced in the right heart stop flow across the FO and closure within minutes
118
what occurs to close the ductus arteriosus?
increased oxygenation of blood and a drop in prostaglandins (made by the placenta) leads to constriction and closure, redirecting blood to pulmonary system. Over hours this starts to constrict.
119
what does cortisol act to do to prepare the fetus for birth?
1. lung maturation
2. CVS maturation
3. GI maturation
4. metabolic maturation
120
when does cortisol rise in pregnancy?
late gestation peaking just before labour
121
what does cortisol do in the lungs in the fetus?
stimulates surfactant, lung maturation and prepares them for efficient gas exchange
122
what does cortisol do in the CVS in the fetus?
enhances the sensitivity to catecholamines allowing for blood pressure maintenance
123
what does cortisol do in the GI system in the fetus?
maturation of the gut, motility, and digestive enzyme development
124
what does cortisol do in the metabolism in the fetus?
induces the liver enzymes which help with gluconeogenesis and glycogenolysis to allow blood sugar control at birth
125
What does thyroid hormone do for the newborn?
Plays a role in metabolic rate, heat production, brain and lung maturation
126
What occurs with the cortisol surge pre labour and removal of the placenta to thyroid hormone?
conversion of T4 to T3 (active) temp control and metabolism
127
what do catecholamines do to help in the CVS and resp system?
Increase HR and CO
Enhance contraction of the diaphragm for breathing
Mobilise glucose and fatty acids
Promote fetal lung fluid absorption
128
What are the main difference in energy supply in the fetus and neonate?
go from a constant supple of glucose via the placenta to relying on intermittent feeds and storing glycogen and gluconeogenesis to maintain sugar levels
129
What is the ideal core temperature of a neonate?
36.5-37.5
130
Why is keeping a baby war important?
reduces the energy and oxygen requirements for thermoregulation
131
what can occur when a baby gets cold?
hypoxemic, acidotic, hypoglycaemia, and reduce their growth.
132
What can occur when a baby is hypothermic?
IVH, DIC, sinus bradycardia, hypotension, shock, death
133
Why are babies susceptible to heat loss?
* Immature thermoregulation centre in the brain
* Large surface area to body weight ratio
* Decreased brown fat stores
* Extended posture
Minimal subcutaneous fat
134
How do babies make heat?
brown fat metabolism and heat production from the brain metabolism
135
how does brown fat make heat?
Specialised fatty tissue which is rich in mitochondria and found in neck, thorax, around kidneys
Removal of placenta prostaglandin E2, catecholamines and thyroid hormones activates brown fat metabolism --> heat
136
Why do babies need brown fat for thermoregulation?
they can't shiver
need non shivering thermogenesis
137
What are the four ways babies lose heat?
radiation
convention
conduction
evaporation
138
What temperature should the delivery room be?
25-28 degrees to stop convection
139
Why are preterm infants more susceptible to cold?
higher surface area to body
thinner skin
lower fat stores
140
What are the basics of kidney development in the fetus?
start at week 5
nephrogenesis from week 9 to week 36
141
When is the most of nephrogenesis ocurring?
the formation of nephrons. Primarily occurs in T3 to 36 weeks
142
What occurs with GFR at birth onwards?
low at birth with increases over the next few weeks
143
What fluid losses occur after birth?
ECF losses, about 10% of body weight
144
What occurs with sodium excretion after birth?
high as tubules are not able to retain sodium effectively. this improves over days
145
How do you monitor neonatal renal function?
UO should be 1-3ml/hr
creatinine not accurate as reflects maternal
146
What do you need to be cautious of with electrolytes and preterm babies?
* Immature kidneys - difficulty with fluid and electrolyte balance
* Higher fluid requirements
* Need careful administration of parenteral feeding, electrolyte monitoring and UO
* Need feeding progression to avoid NEC
147
Where does fetal erythropoiesis occur?
in the yolk sac, then the liver from week 8 then the bone marrow from T3
148
What regulates erythropoiesis int he fetus?
EPO from hypoxia
149
What is physiological anaemia of the neonate?
from week 6-12 as the HbF is replaced by HbA and a reduction temporarily of erythropoiesis you get an anaemia
150
Over what time period if HbF replaced by HbA?
6 months
151
Where does bilirubin conjugation occur?
in the liver
152
How does bili conjugation occur?
addition of a glucuronic acid
153
what is the effect of bilirubin conjugation?
makes it water soluble to be excreted int he bile
154
When does physiological jaundice occur?
usually after 24 hours and resolves by 1-2 weeks
155
How long can physiological jaundice last in the preterm infant?
2-3 weeks
156
When does pathological jaundice occur?
within the first 24 hours
157
What causes pathological jaundice?
haemolytic disease
infection
genetic disorders in bili metabolism
Biliary atresia
158
What causes physiological jaundice?
RBC turnover and an immature liver
159
How does phototherapy work?
it uses photoisomerisation to make the unconjugated bilirubin soluble without the liver
160
What is assessed in APGAR score?
A ppearance (colour)
P pulse
G grimace (reflex irritability)
A activity (tone)
R respiration
161
what scores 0 points in apgars?
A - cyanotic
P - 0
G - no response to stimulation
A - floppy
R - apnoea
162
What scores one point on APGARS?
A - peripheral cyanosis
P - HR <100
G - grimace or weak cry to stimulation
A - some flexion
R - slow irregular breathing
163
What scores 2 points in APGARS?
A - pink
P - HR >100
G - cries with stim
A - well flexed and resisting extension
R - strong cry
164
what is the transitional period and what should be done?
4-6 hours
assessment every 30-60 minutes
165
What is normal HR for a new born?
120-160bpm
166
What is a normal RR for a newborn?
40-60
167
What does the RES do to blood cells?
macrophages engulf the cells and break them down to haem and globin
168
What is haem broken down into?
bilirubin and iron
169
Where does UCG get conjugated and how?
in the heaptocytes by glucuronidation
170
Where is urobiliogen made?
from conjugated bili in the large intestine
171
What happens to urobilingoen?
it can be reabsorbed and excreted in urine
or remain in bowel and made into stercobliin which colours stool
172
What is kernicterus?
severe form of permanent brain damage is used to describe clinical features of acute or chronic bilirubin encephalopathy and yellow staining in the brain.
173
What are signs of kernicterus?
○ Muscle spasm
○ Respiratory
○ Hypotonia
○ Unusual eye movements
○ Seizures
○ High pitched cry
Back arching
174
What are long. term complications o fkernicterus
○ Hearing problems
○ Speech issues
○ Cerebral palsy
Dental staining
175
What are atypical features of jaundice?
* Early onset
* Rapid rise in SBR
* Prolonged
* Late onset
176
What features of jaundice would make you refer to paeds?
* Present before 24 hours
* Other signs of illness
* SBR >200micrmol/L on the 2nd day of life
* When jaundice is late onset - 7-10 days of later
When jaundice is prolonged SBR >200 after 7-10 days
177
What is the approach to the infant with jaundice?
1. Review maternal blood group and antibodies
2. Request neonates group and coombs is the mothers group is O
3. Check SBR
4. Hb, WBC and differential and reticulocytes if suspect HL
5. Urine MC+S if suspicion of UTI
6. If galactosaemia is suspected send sample
7. Is there a FHx of G6PD
178
What is the difference between the direct coombs and indirect coombs?
direct detected antibodies on RBC surface
indirect is to detect antibodies in serum
179
For jaudice do you use direct or indirect coombs?
direct
180
What are causes of pathological anemia?
ABO incompatibiltiy
rehsus incomp
sepsis
G6PD deficiency
galactosaemia
liver disease
haemolysis
181
What is G6PD deficiency?
RBCs lack enough G6PD enzyme which protects them from oxidative stress and HL
182
What is galactosaemia?
when the body cannot break down galactose (found in milk and dairy) leading to jaundice, cataracts, vomiting, developmental delays
Galactose is a simple sugar which makes up the building blocks for lactose
183
What is ABO incompatibility?
antibodies from the maternal system enter the fetal circulation and cause HL of the fetal cells. most common in maternal O group.
normally mild and doesn't always cause anaemia
184
What kind of antibodies cross the placenta?
igG
185
What coombs test would you use to detect ABO incomp?
direct coombs
186
When should you use serum bili not TC?
getstaion <35 weeks,
jaundice in first 24 hours
TC is >250
187
How does phototherapy work?
uses light to convert UCB to lumibilirubin which is water soluble
188
What is the phototherapy cut off for 24 hours, 48 hours and 72?
200, 250, 300
189
what is classed as prolonged jaundice?
>14 days term
>21 days PT
190
What proportion of BF babies are still jaundiced at 28 days?
at least 9%
191
What is an exchange transfusion for jaundice?
replaces the fetal blood for donor blood
192
What is the level os SBR high risk for kernicterus?
>340
193
What is the definition of neonatal hypoglycemia?
BSL <2.6
194
hat are the causes of neonatal hypoglycemia?
transient - due to reduced stores or increased needs eg hypoxia, IUGR, preterm, hypothermia
hyperinsulinaemia
endocrine issues
inborn metabolic error
other problems eg maternal meds (beta blockers stop glycogen breakdown)
195
What are the symptoms of hypoglycemia in the infant?
50% are asymptomatic *Abnormal cry
* Poor feeding
* Jitteriness
* Apnoea
* Convulsions
* Hypotonia
* Pallor
* Sweating
* Tachycardia (from catecholamines)
* Bradycardia (effect on heart from low BSL)
* Hypotension
* Heart failure
Cardiac arrest
196
What infants need BSL monitoring?
* Infants weight <10 or >95%
* Signs of growth restriction
* Diabetic mothers
* Preterm
* Stressed infants eg birth asphyxia
* If symptomatic
Some brain anomalies
197
When do you monitor neonatal BSLs?
At 60-120 minutes
then 3 hourly before feeds
continue until 12 hours since last abnormal reading
198
What level of neonatal BSL needs NICU admission?
<1.2
199
What levels of neonatal BSL needs oral dextrose and when would you repeat it reading?
1.2-2.5
check in 30 minutes
200
Why do we care about low BSL in infants?
can lead to motor developmental delay, cerebral palsy an if severe brain atropy and loss of occipital cortex
201
what is the purpose of type on pneumocytes?
gas exchange
202
what are risk factors for RDS?
○ Diabetes - high levels of insulin inhibits the production of surfactant
○ low birth weight
○ low gestation
○ Caesarean section - don't get cortisol surge from labour
Rapid delivery
202
What is RDS?
Almost always due to prematurity due to lack of surfactant.
203
What is the duration of onset of symptoms in RDS?
minutes
204
What are the signs of RDS?
- early onset of tachypnoea (in minutes), blue lips, rapid shallow breathing, nostril flaring, grunting, hypoxia, acidemia, fine respiratory crackles. Progressive and worsening.
205
What might you see on CXR in RDS?
small volume lungs, homogenous ground glass opacity, air bronchograms
206
What are the microscopic findings in RDS?
collapsed alveoli, damaged pulmonary vessels, leakage of protein
207
What is the prevalence of RDS in all newborns?
1%
208
What is the prevalence of RDS in 26-28 weeks?
50%
209
What is the prevalence of RDS in30-31 weeks?
25%
210
What is TTN?
* Caused by excessive fluid being retained in the baby's lungs, leading to reduced lung compliance and gas exchange
usually onset by 2 hours and resolves by 24 hours
211
What are signs of TTN?
increased RR, grunting, flaring, indrawing, cyanosis, normally are not severely hypoxic, diffuse crackles, reduced breath sounds
212
What are CXR signs of TTN?
cardiomegaly, prominent interlobar fissures, interstitial or pleural fluid, increased central vascular markings, hyperation (too much air)
213
what are risks for TTN?
c section, delivery <39 weeks, macrosomia, male fetus, SGA
214
When do babies start to make meconium in fluid?
about 38 weeks
215
what complications can occur with meconium aspiration?
penumothorax
pulmonary hypertension
216
How does meconium cause problems when aspirated?
chemical pneumonitis
mechanical obstruction
217
What can be seen on a CXR with meconium aspiration?
coarse infiltrates, widespread consolidation, hyperinflation, pleural effusions, pneumothorax, pneumomediastinum
218
What is persistent pulmonary hypertension of the newborn?
pulmonary vasoconstriction exacerbated by hypoxia and acidosis
219
What can cause PPHN?
* MAS
* Hypoplastic lungs
* TTN
* Congenital pneumonia
* RDS
* Myocardial failure
* Polycythaemia
* Structural lung abnormalities - congenital diaphragmatic hernia, CPAM
* GBS sepsis
Maternal medications NSAIDs, SSRIs
220
What is done to manage PPHN?
they are really tricky to manage.
oxygen, pulmonary vasodilators eg NO or MgSO4, ECMO, sedation, muscle relaxation, normotension
221
which surface on the placenta is the chorionic plate?
fetal side
222
What is placentomegaly?
>40mm thickness
223
What is a chorioangioma and what is it's incidence?
a benign placental tumour
1% incidence
224
What is the appearance of the chorioangioma?
welcircumscribes, rounded, hypoechoic lesion near the chionic plate, protrucing into the amniotic cavity
225
what is the basal plate of the placenta?
maternal cells, lies against the uterine wall
226
What complications can occur from chorioangioma?
PTB, PPROM, IUGR, hydrops, haemolysis
227
Can cancers metastasise to fetus?
yes but rare, most common in melanoma
228
What is fetal vascular malperfusion?
from small thrombi in fetal vessels in the placental vessels branching off from the fetal umbilical arteries, making them non functional. Occurs in PET
229
What is placental chorangiosis?
increased number of capillaries in the terminal villi, caused by longstanding hypoperfusion, hypoxia.
230
What is funisitis?
inflammation of the umbilical cord
231
What is a normal cord length?
40-70cm
232
What is the umbilical coiling index and is it important?
number of coils per cm on cord.
unclear if significant. can be linked to FGR, PTB, intrapartum FHR abnormalities
233
What occurs in the umbilical vessels in t1?
you have two veins and one atrophies
234
What are the links with single umbilical artery?
twins, FGR, IUFD, congential anomaly
235
How common in marginal cord and what are the risks?
6%, 11% in twins.
minimal, cord avulsion
236
What are the risks of a velamentous cord?
Vessels are vulnerable to compression leading to hypoperfusion and acidemia. Risks of low APGARs, IUFD, PTB, SGA. Growth scans are reasonable
237
how common is a velamtentous cord?
1% in singles 6% in twins
238
How common in vasa praveia?
1 in 350
239
What are the types of vasa praveia?
1. with velamentous cord
2. with succ or bilobed
3. with previously LLP which moved
240
What is a umbilical vein varix and what should be considered?
cystic dilation of the umbilical vein, can be intra-amniotic or intra-abdominal. Can cause constriction and thromboses of artery. 10% have other anomalies.
241
When do two the epiblast and the hypoblast develop in the embryo?
day 9
242
What is the other name for wolffian ducts?
mesonepheric ducts
243
What is the other name of the paramesonepheric ducts?
mullerian ducts
244
What structures do the mullerian ducts beceom?
the upper 1/3 vagina, cervix, uterus, broad ligaments and fallopian tubes
245
What hormones from the male fetus stimulate development of male wolffian ducts?
AMH, testosterone, and DHT
246
What is DHT?
dihydrotestesterone
247
When do the paramesoneprhic ducts fuse?
7-9 weeks
248
When does the septum from the fusion of paramesoneprhic ducts resolve?
usually 22 weeks
249
What gene on the male Y chromosome causes testicular development and paramesonephric duct regression?
SRY gene
250
what is the remanent of the mesonephric ducts left in the female?
the gartners duct
251
what is the chance of antiD formation in a rh -ve mum if rh +ve mother and no anti D?
16%
252
Why does Kell antibodies cause severe fetal anaemia?
because they also attach to precursor cells for erythropoiesis. Cause severe anaemia without a huge amount of haemolysis
253
what is different about disease with kell antibodies?
disease severity not predicted by titres or previous pregnancy history
254
why do anti B and A antibodies only cause anaemia of the newborn not fetus?
they are IgM and can't cross the placenta
255
How do women O blood group women have A and B antibodies already?
from exposure to bacteria with similar antigens
256
Which babies should be screened for ABO incompatibility?
to mothers of type O mothers
257
What % of D -ve women carry a D -ve fetus?
40%
258
in response to doppler findings when do you cord sample for anaemia?
when MCA PSV >1.5MoM
259
at what haematocrit would you for a intrauterine transfusion?
<30%
260
In the white population what proportion of males are Rh +ve?
85%
261
How much can reduce Anti D sensitisation by with prophylactic anti D?
<0.2%
262
What % of anti D alloimmunisation is from sensitisation at delivery?
90%
263
How does the Kleihauer work?
it adds a acid test to maternal blood. HbF doesn't break down while maternal Hb does. Fetal cells red and maternal cells ghost cells
264
What does kleihauer assume?
maternal blood volume is 5L
Hct 35%
265
What is the minimum volume a kleihauer can detect of fetal blood?
5ml
266
What can make a kleihauer inaccurate?
maternal haemglobinopathies where mum have HbF
a near term fetus making HbA
267
What are causes of fetal anaemia?
alloimmunisation
infection eg parvo virus
haemoglobinopathies,
FMH
genetic - fanconi anaemia
268
What is immune hydrops and the signs on imaging?
from alloimmunisation of the fetus and newborn
enlarged liver and spleen
269
What reduces the oncotic pressure in immune hyrops?
portal hypertension causing impaired hepatic protein synthesis
270
What is hyrdops?
two or more effusions
271
What proportion of hydrops is non immune?
90%
272
When hydrops is seen in the first trimester what is the most likely cause?
aneuploidy, commonly turners
273
What are common causes of fetal hydrops?
cardiovascular
idiopathic
chromosomal
hematological - thalassaemia, FMH
lymphatics
infections
274
What is thought to be the origin for the raised UAPI?
poorly vascularised placental villi
275
What does the s wave correlate to in DV doppler?
ventricular contraction (largest peak)
276
What does the D wave correlate to in DV doppler?
early ventricular diastole (2nd lastest peak)
277
What does the A wave correlate to in DV doppler?
fetal atrial contraction (lowest peak, but should have forward flow)
278
How many rhesus antigen systems are there and how many are capable of causing HDFN?
45, all of them technically
279
Which rhesus antigens regularly cause HDFN?
D and c
280
how many antigens in the Kell system?
26
281
Where is K antigen found in fetuses?
bone marrow in early development
282
Which antibodies can cross the placenta? IgG or IgM
IgG
283
What antibodies can cause severe HDFN?
K, D, c, c+E
284
What are the other red cell antigen that cause HDFN?
MNS system - anti M, S, s, U
Duffy - anti Fya and b
Kidd - anti JK
Diego
Colton
285
What the moderate risk antibodies for HDFN?
anti Fya, E, C, Ce, Jka, MNS, ABO
286
What antibodies have no risk to the fetus?
Lewis, I, P1
IgMs
287
Which antigen causes the most alloimmune thrombocytopenia?
HPA-1a
288
why can you develop NAIT in your first pregnancy?
platelets are more immunogenic, may be able to cross the placenta at 14 weeks when throphoblastic invasion occurs
289
When is rhesus antigen expressed from?
day 30 gestation
290
How does anaemia evolve to show in on USS?
1. hepatosplenomegaly from erythropoiesis in extra medullary sites
2. Cardiac failure, tricuspid regurg, dilated ventricles from increased CO requirement
3. tissue damage from hypoxia
4. pericardial effusion from myocardial stress
5. third spacing and skin edema from endothelial effect and protein loss
291
How does NAIT present in utero?
CNS haemorrhage
292
How does NAIT present in the neonate?
petechial rash, rectal bleeding, excessive bleeding from puncture sites, bruising, CNS bleeding
293
when is prophylactic ant D given?
28 and 34 weeks
294
What history should be taken for women with red cell antibodies?
* Find out when the sensitising event took place (if possible)
* Effect on any subsequent pregnancies, alloimmunisation to D antigen typically gets progressively worse with each pregnancy
New partner or same
295
What investigations should be done for red cell isoimmunisation?
titre
is fetus at risk? NIPT or paternal genotype
does fetus need treatment? MCA PSV
296
When should you refer to MFM in RBCalloimmunisation?
titre rising
titre over critical treshold
signs of fetal anaemia on USS
297
At what gestation in fetal anaemia is it safer to delivery baby and give extra uterine blood tranfusion?
35 weeks
298
What is a significant titre of antibodies? what is the excpetion?
1 in 32, anti K any positive result needs referral
299
What international units for anti D are used for HDFN?
<4 iu/ml low risk
>15 high risk
300
What international units for anti c are used for HDFN?
<7.5iu/ml low risk
>30 high risk
301
when can you used cfDNA for antigens ?
11 weeks
302
when can you amniocentesis for anti K antibody?
20 weeks
303
How often should you do titres for high risk antibodies?
4 weekly until 28 weeks then 2 weekly
if rising increase to fortnightly
304
How often should you do titres for non high risk antibodies?
at 28 weeks
305
What test used to be done to detect fetal anaemia
delta OD450 - which used light to analyze if bilirubin present in amniotic fluid is high levels
306
When do you do MCAPSV in RBC alloimmunisation?
when titre reaches critical levels
previous pregnancy with HDFN
do once weekly
307
when do you refer to MFM for fetal blood sampling in RBC alloimmunisation?
if evidence of fetal hydrops
MCA PSV reaches 1.5 MoM
308
What is the MCA PSV false positive and sensitivity for anaemia
12% FPV
100% sens for mod to severe anaemia
309
When is MCAPSV less accurate?
after 35 weeks, or IUT
310
What is fetal loss rate with fetal blood sampling?
1-2%
311
What are risks with fetal blood IUT?
cord haematoma, vasospasm, bradycardia, infection, ROM
312
Where do they do cord blood sampling or IUT?
intrahepatic vein or umbilical vein at cord insertion of placenta
313
when do you delivery in alloimmunisation RBC if no IUT and normal MCAPSV?
37-38 weeks
314
If previous IUT in fetal alloimmunisation when should you deliver?
about 2-3 weeks after IUT to aviod anaemia
315
How should the newborn be cared for after birth alloimmunisation?
* Cord bloods for - ABO status, antibodies, Hb, DAT/coombs, bilirubin levels
* Monitor for jaundice and anaemia
* 80% will need further transfusion
* Feed regularly
* Treat any jaundice
316
How should you care for women with subsequent pregnancies after HDFN?
* Anti D - usually more severe and onset 10 weeks earlier
* MCAPSV from 16 weeks
* If previously severe will likely be again
Anti K - previous pregnancies do not predict future
317
What is the role of IVIg in HDFN?
can delay severe anaemia by 15-25 days
318
When can you do fetal blood sampling?
18-35 weeks
319
Are c antigen dominant or recessive?
dominant, only need one to display c antigen
320
When should you refer anti K positive women to MFM for USS monitoring?
16 weeks
321
What are the difference in effect on fetus of anti K vs anti D?
anti K:
produced HL
suppressed EPO
immune destruction of erythriod progenitor cells
hyper bili not a feature
Anti D
HL and high bili a feature
322
How do you usually get anti K antibodies?
blood transfusion
323
What does the fetal umbilical vein branch into?
the left portal vein 40%
ductus venosus 60% blood flow
324
What investigation should be done for non immune fetal hydrops?
Blood group and antibody screen + titre
Kleihauer
PET screen (mirror syndrome)
FBC
Haemoglobinopathy screen
Consider G6PD
TORCH screen
syphilis
Anti Ro and La
TSH and TSH Rab
USS - anatomy, echo, MCA PSV max
Consider fetal bloos sampling
Amiocentesis can be done for PCR for infections, microarray and OD450
CTG
325
What are the four main pathophysiology of hydrops?
1. Obstruction of lymphatic drainage in the thorax and abdomen eg congenital anomaly, neoplasm
2. Increased vascular permeability
3. Increased central venous pressure eg high CO failure, obstructed venous return to heart
4. Decreased osmotic pressure -
326
When does the neural tube close after LMP?
cranial day 38, caudal day 40
327
During what week are there five vesicles of the brain and what becomes the cerebral hemispheres?
week 7, telencephalon
328
When does brain gryal formation start?
second half of pregnancy
329
When does neuronal proliferation and differentiation peak and what impact does this have?
3-4 months, if infection during this time, it can impact brain development eg zika
330
Where is the spinal cord at birth?
L3
(fills the entire length during development)
331
When is the cardiac tube present?
day 23
332
what layer forms the heart?
visceral mesoderm
333
when does the heart undergo looping?
week 4
334
When does the heart undergo growth & modification to form partially septated four-chambered heart with primitive set of valves?
4-7
335
When is the heart structurally complete?
week 10
336
What is the initial 'heart beat' we see?
myocardial cells in the sinus venosus start to produce a rhythmic electrical discharge a fetal heart beat is seen by week 6
337
What does the newborn heart working in series not paralell mean?
the right and left heart are supplying seperate circuits
338
What structure was the ligamentum teres?
umbilical vein
339
What structure was the ligamentum venosum?
ductus venosus
340
What is the newborn blood volume?
78ml/kg after immediate cord clamping
341
What is the order of fetal erythropoiesis location?
* Begins in the yolk sac and endothelium
* Liver
* Spleen
Bone marrow
342
What changes occur with RBCs during pregnancy?
Start as macrocytic nucleated cells with a short life span and then as gestation progresses become smaller and non nucleated with a longer lifespan
343
Where is fetal EPO made and what drives it?
liver then kidneys.
mainly hypoxia but other hormones
344
WHat makes up fetal haemoglobin?
2 alpha and 2 gamma
345
Where does the lung grow from in the embryo and when?
foregut endoderm, day 20
346
when does the lung bud arise?
day 25
347
At birth what % of your total adult alveoli do you have?
15%
348
when have you gorwn all your lung alveoli?
age 8 y
349
When can you see breathing movements in a fetus?
11/40
350
What chromosome gene is the beta Hb gene on?
11
351
What chromosome gene is the alpha Hb gene on?
16
352
What is the primordial gut?
yolk sac
353
What is made form the foregut?
pharynx, lower respiratory system, esophagus, stomach, proximal duodenum, liver, pancreas, biliary tree
354
what is made form the mid gut?
distal duodenum, jejunum, ileum, caecum, appendix, right colon
355
What is made from the hind gut?
left colon, rectum, superior part of anal canal
356
What are the causes of meconium passage?
normal bowel peristalsis of a mature fetus
vagal response
AVP release in response to hypoxia from the pituituary gland
357
what forms the kidney?
the metanephros
358
what makes up the primitive urinary system?
pronephros and mesonephros
urine produced by week 5
359
What embryonic layer is the kidney and ureter from?
mesoderm
360
What embryonic layer is the bladder and urethra from?
endoderm, urogenital sinus
361
When is the mesonephros made?
week 9-12
362
When do gloemruli develop and start to filter?
week 9
363
When do you make nephrons until?
36 weeks
364
When do kidneys make urine from?
week 12
365
When do you transition from embryo to fetsu?
week 9
366
When do limb buds appear?
week 5
367
When is the circulation between the embryo and the chorionic villi establish?
week 4
368
What is Naegeles rule
Due date = LMP + 7 days - 3 months
369
When does the blastocyst begin implantation>
day 6-7
370
When should you be able to see an embryo?
week 5
371
When is surfactant production started?
week 24
372
When do you make vernix?
week 28
373
What is the vitelline duct?
connects the yolk sac to the gut week 3-4. this regresses week 8-9
374
When does the gut rotation occur and how?
* From week 5-10 the mid gut herniates into the umbilical cord/vitellius duct
Rotates 90 degree anticlockwise, then reenters the abdominal cavity and does a further 180degree rotation
375
What are the principles of cool? eg who is eligible?
>36/40, less than 6 hours old, who fulfill specific criteria related to condition at birth and neurological status -> eligible for cooling
Involves lowering body temperature to 33-34 degrees for 72 hours then slow rewarming to normothermia
376
What are the side effects of phototherapy?
eyes need to covered, skin rash, loose stools,
377
What are pathologic causes of neonatal jaundice in the first 24 hours?
haemolysis - Rh, ABO
G6PD def
hereditary spherocytosis
congenital infection
378
What are pathologic causes of neonatal jaundice age 24 hours - 2 weeks?
physiologic, haemolysis, bruising, GI obstruction, polycythemia, metabolic disorders, crigler najjar syndrome
379
What are the causes of prolonged jaundice?
unconjugated hypothyroidism, breast milk
conjugated >20% - biliary atresia, hepatitis syndrome
380
Ellen's flashcards
flashcards
Decks in class (27)
# Cards
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Week 419
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Week 585
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Autoimmune medications and pregnancy11
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Landmark trials to date13
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Week 6253
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Week 7259
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Week 8232
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Week 9206
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Week 10364
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Week 258
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week 371
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Week one136
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Week 11237
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Week 12314
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Week 13381
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GONC 1395
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GONC 2259
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Week 16134
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Week 17410
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Week 18266
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Week 19347
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Week 20307
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Week 21430
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Week 22370
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Week 23298
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Week 24325
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Week 261
