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Repro/GU by Minnie: AH > 210/211/212: Normal and Abnormal Pregnancy, Anatomy and Pathology of Implantation > Flashcards

210/211/212: Normal and Abnormal Pregnancy, Anatomy and Pathology of Implantation Flashcards

1
Q

How will the following change during pregnancy?

  • D-Dimer:
  • Alk phos:
  • Albumin:
A
  • D-Dimer: increase
    • ​Does not indicate VTE - but pregnancy is a hypercoagulable state, so make sure not to miss?
  • Alk phos: increase
  • Albumin: decrease
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2
Q

In general, at what gestational age is it better to perform a preterm delivery than to manage expectantly?

(In situations like preeclampsia, PROM, etc)

A

34 weeks

Before 34 weeks, try to manage expectantly - usually delivery will occur within 1 week, but give a chance to administer antenatal steroids, give the baby a few extra days to grow

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3
Q

What defines fetal growth restriction?

Why is it important to diagnose?

A

Fetal growth below the 10th percentile

  • Counsel pts on prognosis, options
  • Start antenatal surveillance
  • Administer antenatal steroids if preterm birth is looking likely

Remember some babies are completely healthy and just small! This is a somewhat arbitrary screening cutoff.

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4
Q

What defines preeclampsia?

A

New onset HTN + proteinuria

Defined as severe if ANY of the following are present, even w/o proteinuria

  • BP > 160/110 on 2 occasions, at least 4 hours apart
  • Maternal symptoms (headache, visual changes, RUQ pain)
  • Hepatic injury
  • Renal dysfunction
  • Pulmonary edema
  • Coagulopathy
  • HELLP syndrome
  • Eclampsia (seizures)
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5
Q

How will the following change during pregnancy?

  • GFR:
  • Serum CR:
  • Ureter position:
  • Kidney size:
A
  • GFR: increase
  • Serum CR: decrease (since RPF increases more than GFR)
  • Ureter position: displacement, R>L
  • Kidney size: increase slightly, with mild/moderate hydronephrosis
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6
Q

List 3 important steps in the management of preterm labor

A
  • Give mom steroids -> accelerates fetal lung development
  • Give mom penicillin: GBS prophylaxis
    • Empirically, even if screening test has not been completed yet
  • Give mom magnesium: fetal neuroprotection
    • Reduces cerebral palsy risk
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7
Q

Describe the management of preeclampsia

A

Definitive treatment is delivery

If not severe and <34 weeks, may attempt expectant management

  • Control BP
  • MgSO4 to prevent seizure
    • Give antenatal steroids (baby is probably going to be preterm, get the lungs developed)
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8
Q

How is isoimmunization managed?

A

The pregnancy at risk is the second pregnancy, after Rh(-) mother develops antibodies to Rh during first pregnancy

(If mother was not given Rh immmunoglobulin during first pregnancy)

  • Look at serial antibody titers
  • 1:32 and above (so 1:16 and 1:8), fetus is at risk of anemia
  • Transfer adult RBCs to fetus to prolong gestation
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9
Q

What is the difference between spontaneous abortion and stillbirth?

A

Gestational age

  • Spontaneous abortion
    • Pregnancy loss < 20 weeks gestation
    • Vast majority <8 weeks
  • Stillbirth (aka intrauterine fetal demise)
    • Pregnancy loss ≥ 20 weeks gestation
    • MUCH less common than spontanteous abortion
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10
Q

List the causes of fetal vascular malperfusion (4)

A
  • Umbilical cord abnormalities:
    • Twisting
    • Velamentous insertion (cord inserts in membrances at side instead of in the disc)
    • Mechanical obstruction (knots or wrapped around the fetal body/neck)
  • Thrombus formation
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11
Q

What physiologic difference will be present in the chest x-ray of a pregnant person?

A

Enlarged cardiac silhouette due to elevation of the diaphragm

Heart will look too big, but it’s fine

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12
Q

How do estrogen and progesterone affect the uterus during pregnancy?

A

Estrogen -> Uterine hypertrophy (cells get bigger)

Progesterone -> Relaxation of uterine walls so fetus can grow

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13
Q

Which umbilical vessels deliver oxygenated blood to the fetus?

A

Umbilical vein (1)

Umbilical arteries (2) deliver deoxygenated blood from fetus to placenta

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14
Q

How will the following change during pregnancy?

  • HR:
  • CO:
  • BV:
  • SV:
  • BP:
A
  • HR: increase
  • CO: increase
  • BV: increase
  • SV: increase
  • SVR: decrease
  • BP:
    • 1st trimester: normal
    • 2nd trimester: may dip a bit
      • “normal BP” may actually be hypertension
    • 3rd trimester: back to normal
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15
Q

At what gestational age does the fetus begin to synthesize its own thyroid hormone?

A

10 weeks

Relies on maternal TH until then

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16
Q

How will the following change during pregnancy?

  • Clotting factors:
  • tPA:
  • Protein S:
  • Activated protein C:
A
  • Clotting factors: increase
  • tPA: increase
  • Protein S: decrease
  • Activated protein C: decrease

Also, RBCs and plasma volume both increase, but plasma volume increases more -> physiologic anemia, blood is more dilute, protective against hemorrhage

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17
Q

Onset of labor before what gestational age counts as preterm?

A

<37 weeks

37 weeks + 0 days = term

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18
Q

Does the umbillicl cord contain maternal blood or fetal blood?

List the vessels in the cord

A

Fetal blood only

  • 1 umbilical vein carries oxygenated blood from placenta to fetus
  • 2 umbillical arteries carry deoxygenated blood from fetus to placenta
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19
Q

What is the most common cause of spontaneous abortion?

A

Chromosomal abnormalities

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20
Q

Describe the management of placenta previa

A
  • Pelvic rest
  • Manage expectantly if <37 weeks
  • Planned C-section at 37 seeks
    • Labor is a risk factor for maternal hemorrhage
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21
Q

What is happening during stage 1 of labor?

A

Onset of labor -> full cervical dilation

  • Latent phase happens slowly
  • Active phase = acceleration
    • Usually at 4-6 cm
    • Usually happens more quickly in people who have delivered a baby before
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22
Q

List the stages of labor and what is happening at each stage

A
  • Stage 1
    • Onset of labor -> full cervical dilation
  • Stage 2 (pushing)
    • Full cervical dilation -> delivery of fetus
  • Stage 3
    • Delivery of neonate -> delivery of placenta
23
Q

Describe the pathophsyiology of isoimmunization

A

Rh (-) mother is exposed to Rh (+) fetal blood during pregnancy/delivery

  • -> Maternal production of antibodies
  • -> Next pregnancy = antibodies attack fetal RBCs, can cause fetal anemia, high volume congestive heart failure
  • Prevent by administering Rh immune globulin to all pregnant women who are Rh (-) at 28 weeks, after delivery, and any time there is concern for breakage of the feto-maternal barrier*
  • Manage by transfering adult RBCs to fetus to prolong gestation if fetal anemia is developing*
24
Q

Which two classes of drugs can be given to stop labor?

A
  • Beta-2 agonists (terbutaline)
    • Maintain relaxation of the myometrium
  • Calcium channel blockers (nifedipine)
    • Prevent depolarization of myometrial cells

Neither work very well. Buy a little time to administer steroids and develop fetal lungs.

25
Q

The corpus luteum supports pregnancy until __ weeks gestation

A

The corpus luteum supports pregnancy until 7 weeks gestation

Then placenta starts producing own progestrone

26
Q

How will the following change during pregnancy?

  • Minute ventilation:
  • Residual volume:
  • Tidal volume:
  • Functional residual capacity:
  • Acid/base balance:
A
  • Minute ventilation: Increase
  • Tidal volume: Increase
  • Residual volume: Decrease
  • Functional residual capacity: Decrease
  • Acid/base balance: Respiratory alkylosis
    • Due to decrease in maternal pCO2, compensated by excretion of bicarbonate

Most changes are compensatory 2/2 elevated diaphragm

27
Q

What is an “abnormally adherent placenta”?

What are the 3 different types?

A

The placenta implants into a layer of the uterus that is deeper than the decidua

  • Accreta = implantation on the myometrium
  • Increta = invasion into the myometrium
  • Percreta = invasion through uterine serosa into adjacent structures
28
Q

What protective structure is lost if a fetus has velamentous umbilical vessels?

A

Wharton’s jelly

  • Supposed to surround the umbilical vessels
  • If cords insert directly into the membrane (instead of the disk), they are at risk for rupture
29
Q

Which situation is more urgent:

  1. Bleeding from placenta previa
  2. Bleeding from vasa previa

How do you tell them apart on presentation?

A

b. Bleeding from vasa previa

More dangerous because fetal blood - fetus can bleed out very quickly - do an emergency c-section!! (within seconds-minutes)

Vasa previa will have worrisome fetal monitoring; placenta previa will have reassuring fetal monitoring

Also, Apt test: fetal hemoglobin is resistant to lysis by alkaline solutions (but realistically, you don’t have time to do this test)

30
Q

How is cervical insufficiency managed?

A

Cerclage

  • If CI is happening => emergent cerclage
    • Contraindications: contractions (implies labor), fetal demise, infection
  • If risk factors but has not happened yet => prophylactic cerclage

Cerclage = suture that gives structural integrity/closure of cervix

31
Q

What microscopic findings may be present in vaginal secretions in PROM (premature rupture of membranes)?

A

“ferning” pattern

Proves that the fluid is amniotic, not another vaginal secretion

  • Caused by salt in the amniotic fluid
32
Q

Which tumor of gestational trophoblastic tissue is large and hemorrhagic?

A

Choriocarcinoma

Highly malignant, rapidly invasive and widely metastasizing

Much less common than moles

Less hemorrhage in partial and complete moles

33
Q

What are the serious consequences of fetal vascular malperfusion?

A
  • Cerebral palsy
  • Intrauterine or neonatal fetal demise
34
Q

List the 3 membrandes of the placenta, from fetus to uterus

A
  • Amnion (fetal)
  • Chorion (fetal)
  • Parietal decidua (maternal layer)
    • Endometrium that is modified to support pregnancy

They are in alphabetical order

35
Q

List 3 tumor types that can arise from gestational trophoblastic tissue

A
  • Complete hydatidiform mole (no maternal DNA; 46XX or 46XY)
  • Partial hydatidiform mole (maternal DNA; 69XXX of 69XXY)
  • Choriocarcinoma
    • Pure trophoblastic proliferation; no chorionic vili
    • Large, malignant
    • More rare
36
Q

List 2 problems that can occur with twin vasculature

A
  • Twin-to-twin transfusion syndrome
    • Donor twin is anemic
    • Recipient twin is plethoric
    • Artery of donor to vein of recepient
  • Twin reversed arterial perfusion
    • Pump twin -> hydrops
      • Can have relatively normal gestation if acardic twin is removed
    • Other twin is acardiac (no heart at all)

May occur in monochorionic twin placentas

37
Q

How will blood sugar change during pregnancy?

A

Mild fasting hypoglycemia (increased insulin)

Mild post-prandial hyperglycemia (insulin resistance)

38
Q

If a twin pregnancy is diamniotic, what can you say about whether the twins are monozygous or dizygous?

A

May be either

  • Dizygous twins are ALWAYS diamniotic
  • Monozygous twins are usually diamniotic, but can be monoamniotic
39
Q

Describe the pathogenesis of preeclampsia

A

Failure of spiral artery to transform into a high-capacitance vessel

  • -> Cannot perfuse chorionic villi
  • -> Hypoperfusion
  • -> Placental ischemia
  • -> Immune reaction involving cytokines
  • -> Hypertension
40
Q

How does the cervix change during pregnancy?

A

Chadwick sign present (blueish tinge to tissue)

Due to hypertrophy and hyperplasia of cervical glands, eversion of proliferating columnar endocervical glands

41
Q

What is cervical insufficiency, in the context of preterm labor?

A

Painless cervical dilation with the absence of uterine contractions

  • Usually 16-24 weeks
  • May be related to collagen abnormalities (ex: Ehler’s Danlos)
  • Can lead to prolapse of amniotic sac→ miscarriage

If uterine contractions + cervical dilation = preterm labor; CI is NOT preterm labor

42
Q

What triggers labor?

(How do the mother and fetus know when it’s time?)

A

The placental clock determines the timing of labor

  • Cortisol releasing hormone (CRH) produced by the placenta
  • Stimulates maternal adrenals to produce DHEAS
  • Signals placenta to make estrogen
  • Contractions
  • Signals fetal pituitary, adrenals and lungs
    • Fetal adrenal and pituitary activity
    • Lung maturation, surfactant production
43
Q

Where in the fetus/placenta will we see inflammation in an ascending (vaginal) vs. hematogenous infection?

A
  • Ascending:
    • Maternal neutrophils in maternal arteries, move to amniotic fluid
    • -> Fetal neutrophils in the umbillical cord and on the chorionic plate
  • Hematogenous
    • Fetal inflammation in villi and intervillous space
    • Either chronic (lymphocytes) or acute (neutrophils) villitis
44
Q

If a twin pregnancy is monochorionic, are the twins monozygotic or dizygotic?

A

Monozygotic (identical)

Very rare (4%) and very risky

45
Q

Where does amniotic fluid come from…

  • <16 weeks:
  • >16 weeks:
A
  • <16 weeks: diffusion from maternal circulation
  • >16 weeks: fetal urine
46
Q

During gestation, where is the fetoplacental interface?

What are the boundaries of the fetal and maternal portions, respectively?

A

Chorionic villous = fetoplacental intervace

  • Fetal side: Chorionic villi
    • Cytotrophoblasts + syncytiotrophoblast
    • As the barrier thins later in pregnancy, syncytiotrophoblasts only
  • Maternal side:
    • Extravillous trophoblasts
    • Remodeled vessels
    • Basal plate

Basically, the villi/villous trees are fetal - the trophoblasts are maternal. They touch to exchange gas, nutrients, but blood does not mix!

47
Q

What is the etiology of fibrinoid necrosis in placental vessels?

A

Maternal vascular malperfusion

  • Caused by maternal HTN or preeclampsia
  • Results from failure of trophoblasts to remodel maternal spiral vessels into high-capacitance (high-flow vessels)
  • -> chronic hypoxia
  • -> fibrinoid necrosis
48
Q

What is considered “normal pregnancy weight gain”?

A

25-35 lbs, if normal pre-pregnancy weight

Obese/overweight pregnant people do not need to gain as much

  • Equates to ~300 extra calories/day*
  • But tbh if I’m every growing a baby inside of me I will eat as much as I please*
49
Q

List the 3 shunts in fetal circualtion and what they bypass

A
  • Ductus venosus
    • Portal vein -> IVC
    • Bypasses liver
  • Foramen ovale
    • Right atrium -> left atrium
    • One way valve, high to low pressure
    • Bypasses RV, lungs
  • Ductus arteriosus
    • Pulmonary artery -> aorta
    • Bypasses fetal lungs, LA, LV
50
Q

Describe the difference in presentation:

Placental abruption vs. placenta previa

A
  • Placental abruption
    • Vaginal bleeding + uterine contractions/pain
    • Pain does not stop when contraction ends
    • Caused by placenta separating from wall of uterus
  • Placenta previa
    • Painless vaginal bleeding
    • Caused by placenta covering cervical os
  • Placental abruption is a little bit more urgent - manage expectantly if mom and fetus are doing well, deliver if either is looking distressed*
  • Placenta previa = initiate pelvic rest, plan a c-section at 37 weeks*
51
Q

How can isoimmunization be prevented?

A

Administer Rh immune globulin to all pregnant women who are Rh (-) at 28 weeks, after delivery, and any time there is concern for breakage of the feto-maternal barrier

  • This prevents mom from developing atigens against Rh:*
  • The anti-Rh IgG neutralizes Rh-expressing fetal RBCs in maternal circulation before the maternal immune system can detect and become sensitized to fetal RBCs*
  • Thank you @Ben Gastevich!*
52
Q

Oxygenated blood is delivered to the fetus from the ____________

A

Umbilical vein (1)

There are 2 umbilical arteries with deoxygenated blood.

53
Q

A 33 year old G3P2 at 28 weeks presents for a flu shot. She appears well but her HR is 100bmp and her BP is 90/60. Chest x ray demonstrates a mildy enlarged cardiac silhouette. Elevated D-dimer and mild respiraroy alkalosis. What is the diagnosis?

A

NORMAL PREGNANCY

HR increases in pregnancy

BP decreases in 2nd trimester

Enlarged cardiac silhouette due to high diaphragm.

Normal elevation in D-dimer.

Normal respiratory aklalosis.

54
Q

A 38 year old G2P1 at 7 weeks is taken to the operating room for ovarian torsion. Left ovary is removed. There was a corpus luteum cyst on the ovary. What should be given to maintain pregnancy?

A

Progesterone!

Corpuse luteum makes progesterone for first 7 weeks before the placenta takes over.

Repro/GU by Minnie: AH (29 decks)

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