Case 17 Flashcards
Metabolic abnormalities secondary to alcohol consumption
Hypertriglyceridaemia
Ketoacidosis
Fasting hypoglycaemia
Hyperuricaemia
Alcohol metabolism
Ethanol to acetaldehyde via ADH and MEOS
Acetaldehyde to acetic acid via ALD
Acetic acid to acetyl CoA
First two steps confined to the liver
How is osmolarity calculated?
2Na + glucose + urea
Biochemical markers of alcohol abuse
Gamma GT
Carbohydrate deficient transferrin
Increased MCV
Intimate partner violence
A pattern of assaultive and coercive behaviour including physical, sexual, psychological and economic aspects.
Blastocyst attachment and implantation
Zona pellucida hatches
Apposition of blastocyst and endometrium
Decidual cells become epithelial-like and form the primary decidual zone
Local vascular permeability
Reduction in the number of desmosomes and apoptosis of endometrial epithelial cells facilitates trophoectodermal invasion of the secondary decidual zone
What makes up the chorionic sac?
Trophoblast and extra embryonic mesoderm
Functions of the syncytiotrophoblast
Invasion of endometrium and 1/3 of myometrium to form secure attachment
Proteolytic breakdown of spiral arteries to form lacunae which will later form the intervillous spaces
Secretion of hCG
Syncytiotrophoblasts express Fas ligand and do not express MHC
Development of chorionic villi
Under the influence of extraembryonic mesoderm, cytotrophoblastic cells invade the syncytioteophoblast cell mass and form primary villi.
Secondary villi are formed when extraembryonic mesoderm invades the cytotrophoblast layer to form an inner mesodermal core.
Tertiary villi are formed when the extraembryonic mesoderm becomes vascularised with capillaries.
Cytotrophoblastic cells extend beyond the syncytiotrophoblasts to form the cytotrophoblastic shell
Some villi become attach to the cytotrophoblastic shell and become anchoring villi
Branch or terminal grow into the intervillous space
Regions of the decidua
Basalis
Parietalis
Capsularis
Fetal components of the placenta
Chorion frondosum - chorionic plate and villi
Chorion laeve
Macrophages present in the placenta
Hoffbauer cells
Placental circulation
Closed fetal circulation
Open maternal circulation
Maternal blood enters the intervillous space, regulated by cytotrophoblastic cell plugs.
Exchange between maternal and fetal blood occurs
Maternal blood is drained to the uterine veins
2 umbilical arteries, 1 umbilical vein. Umbilical vein has an internal elastic lamina
What makes up the placental barrier?
Endothelial cells and their basal lamina
Cytotrophoblast and syncytiotrophoblast cells and their basal lamina
Fetoplacental estrogen synthesis
The placenta synthesises progesterone which the fetal adrenal cortex converts to DHEA, DHEAS and cortisol. The placenta uses DHEA/S to form estrogens
Placental hormones
Progesterone Estrogen Placental lactogen Relaxin Placental PTH-RP
Role of the decidua in immunotolerance
Infiltrating leukocytes secrete IL-2
Prostaglandin secretion inhibits activation of NK cells
Effects of pregnancy on maternal physiology
Increased tidal volume Increased maternal blood volume Increased GFR Increased mammary gland growth and development Increased nutrient requirements Increased uterine size
Mammary gland development
In utero: the nipple forms first, followed by the mammary bud, an ectodermal downgrowth. The buds give rise to solid mammary cords which later develop into lactiferous ducts.
Birth to puberty: few lactiferous ducts, no glands, fibrocollagenous tissue
Puberty: epithelial downgrowth and increased complexity of ductal system. Adipose tissue is laid down.
Protective factors in breast milk
IgA Lactoferrin Lysozyme Oligosaccharides Mucins
Inactive mammary gland
Sparse glandular component
Mainly duct elements lined by low columnar epithelium
Sparse myoepithelial cells
Pregnant mammary gland
Epithelial hypertrophy, lobules enlarge
Protein, sugar and fat containing vacuoles within glandular epithelium
Lymphocytes and plasma cells in the stroma
Colostrum may be present in glandular lumen later in pregnancy
Initiation of lactation after parturition
Rise in cortisol during birth induces enzymes needed for milk production
Rapid decline in estrogen levels overcomes dopamine inhibition to stimulate maternal prolactin secretion
Control of prolactin secretion
Dopamine secreted by the hypothalamus inhibits prolactin secretion
Suckling inhibits dopamine release via a neural reflex allowing prolactin release
Cessation of suckling stimulates to be released again, blocking prolactin release
Milk ejection
Suckling stimulates neurons in the hypothalamus to cause release of oxytocin from the neurohypophysis
Oxytocin stimulates myoepithelial cell contraction
Facial anomalies in FASD
Short palpebral fissures Ptosis, strabismus Epicanthal folds Short upturned nose Depressed nasal bridge Smooth philtrum Thin upper lip
CNS anomalies in FASD
Microcephaly Mental retardation Hypotonia Poor coordinaton Hyperactivity Sleep disorders Seizures Hydrocephalus
Palliative care definition
An approach that improves the quality of life of patients and their families facing life-threatening illness through the relief and prevention of suffering by means of early identification and treatment of pain and physical, psychosocial and spiritual problems
Aspects of palliative care
Provides relief from pain and distressing symptoms
Affirms life and regards dying as a normal process
Integrates spiritual and psychological aspects of patient care
Offers support to help patients to live as actively as possible
Offers a support system to help the family cope
Uses a team approach
Enhances QOL
Applicable early in the course of illness
WHO analgesic ladder
- Non-opioid +/- adjuvants
- Weak opioids +/- non-opioids +/- adjuvants
- Strong opioids +/– non-opioids +/- adjuvants
Analgesics
Step 1: paracetamol, aspirin
Step 2: tramadol
Step 3: morphine
FASD spectrum
FAS
Partial Fetal Alcohol Syndrome
Alcohol Related Neurodevelopmental Disorder
Alcohol Related Birth Defect
Fetal alcohol syndrome definition
Specific pattern of facial features with pre/post natal growth deficit and CNS dysfunction with a positive history of maternal drinking during pregnancy
Risk factors for FASD
Higher age, gravidity, parity Lower SES and income. Rural residence Timing - daily drinking, binge drinking Partner consumes alcohol Tobacco use Poor nutrition Metabolism
