fetal / neonatal Flashcards
Complications in the fetus from indomethacin in pregnancy include:
a. renal insufficiency
b. oligohydramnios
c. premature closure of the ductus arteriosus
d. all of the above
e. none of the above
d. all of the above
Its an NSAID
Cardiovascular changes at birth
A - the brain is the organ that receives the most dramatic increase in blood flow
B - pulmonary vascular resistance and pulmonary blood flow decrease
C - foramen ovale is a flap valve that becomes functionally closed when L atrial pressure exceeds R atrial pressure
D - prostaglandins have a minor role in physiological closure of ductus arteriosus
C - foramen ovale is a flap valve that becomes functionally closed when L atrial pressure exceeds R atrial pressure
Occurs in the first few minutes of life
DUCTUS ARTERIOSUS - closes over course of a few hours
Pulmonary artery goes from high pressure to low pressure
Fall in prostaglandin (from placenta being removed) –> closure of ductus arteriosus
Also get constriction of smooth muscle in ductus arteriosus from high oxygen levels
What is the blood volume of a newborn baby weighing 3500gm?
A. 150 ml B. 250 ml C. 300 ml D. 350 ml E. 400 ml
D. 350 ml
Another set on answers say 300ml
BV of a child is around 85-105 ml/kg (WHO)
An ultrasound examination reveals that your patient has a fetus with gastroschisis. You advise her that:
A - The fetus has >30% chance of an associated chromosomal abnormality
B - Surgical repair is successful in <20% of cases
C - It is uncertain whether LUSCS confers any advantages over NVD
D - The infant is likely to have severe mental retardation
C - It is uncertain whether LUSCS confers any advantages over NVD
Surgical repair is often successful Neonatal mortality low (5-10%) Increased risk of FGR and PTB Neonatal bowel complications The opening is near the umbilicus but towards to right and not directly over it - no increase in incidence of chromosomal abnormalities - only contains small bowel usually - a/w oligo
Omphalocele - membrane covered herniation, inserts into the apex of the sac (of cord insertion)
- high incidence with associated abnormalities / genetic syndromes / chromosomal abnormalities (T13, 18)
- Can contain stomach, liver, spleen
- a/w poly
What is the fetal PaO2 at term?
A - 22 mmHg B - 32 mmHg C - 42 mmHg D - 52 mmHg E - 62 mmHg
B - 32 mmHg
32-35mmHg in the fetal umbilical vein
Compared to 90-100mmHg in mum
What is the cord pH at term immediately after a normal labour and delivery?
A - Vein 7.3, artery 7.27
B - Vein 7.27, artery 7.3
c - Vein 7.5, artery 7.2
d - Vein 7.2, artery 7.5
A - Vein 7.3, artery 7.27
Median artery pH - 7.27
Median vein pH - 7.35
Which of these crosses the placenta the least?
A - TSH
B - T4
C - TRH
D - Propylthiouracil
A - TSH
Don’t cross
- TSH
Does cross
- TRH
Which of the following drugs will affect the fetus adversely if used during pregnancy?
A - Flagyl
B - Heparin
C - Thiazide diuretics
D - Azothiaprine
C - Thiazide diuretics
Increase risk of malformations, fetal/neonatal electrolyte abnormalities, jaundice and thrombocytopenia
The most common cause of term infant mortality is:
A - congenital abnormalities B - infection C - NEC D - Bronchopulmonary dysplasia E - IVH
B - infection
You see a patient with bipolar disease on Lithium 900mg /day. The risks to the fetus include:
A - CNS abnormalities
B - Cardiac abnormalities
C - Renal anomalies
D- Postmaturity
B - Cardiac abnormalities
Ebstein’s anomaly - septal and posterior leaflets of tricuspid valve are displaced towards the apex of the right ventricle –> tricuspid regurgitation –> RA dilatation
Foramen ovale doesn’t close sometimes
Rx: valve replacement and closure of the foramen ovale
Phenytoin is associated with all of the following except:
A - IUGR B - Mental retardation C - Spina bifida D - Cardiac anomalies D - Cleft palate
C - Spina bifida
"Fetal dilantin syndrome" Growth deficiency Developmental delay Characteristic facies GU abnormalities Cleft palate
Neonatal thyroid function which are true:
a - increase in thyroxine after birth in preterm but not term infants
b - neonatal rise in T4 due to TSH increase
c - thyroxine is involved in shivering but not non-shivering thermogenesis
b - neonatal rise in T4 due to TSH increase
Serum TSH concentrations rise abruptly A/w exposure to cold Initial surge in TSH --> stimulates T4 secretion T4 peaks 24-36h of life Serum T3 also rises at same time
serum TSH levels rise rapidly in the first minutes after birth and peak at 30 minutes of postnatal life
A woman with bipolar affective disorder on lithium presents at 11/40. Serum lithium is 1.0 (0.9-1.4). She should be told:
a - lithium is suspected of causing heart defect
b - to cease lithium now will reduce risk to the baby
c - to reduce dose will reduce risk to baby
d - she should have CVS
e - should have amniocentesis at 16/40
a - lithium is suspected of causing heart defect
Which drug should not be used in lactation
a - Amiodarone
b - Warfarin
c - Digoxin
d - Propylthiouracil
a - Amiodarone
Secreted in high amounts in breastmilk
Contraindicated in breastfeeding
Rare cases of hypothyroidism in baby
PTU - safe 1st trimester, later in pregnancy risk of maternal liver disease, safe in breastfeeding
Warfarin - avoid in 1st trimester, 2nd and 3rd can give, safe in breastfeeding
Digoxin - minimal amounts in breastmilk, in pregnancy crosses placenta but not known to be harmful - lacking data
Which of the following is the most common cause of neonatal hyperthyroidism?
a - previous thyroidectomy on thyroxine b - Graves disease treated with PTU c - Maternal exposure to Iodine 131 during pregnancy d - Iodine deficiency goitre e - Maternal Hashimoto’s thyroiditis
b - Graves disease treated with PTU
TSH receptor stimulating antibodies (TSI)
PTU doesn’t reduce TSI
TSI can cross the placenta
Most likely cause of perinatal mortality with diabetes?
a - fetal hypoglycaemia b - congenital abnormality c - APH d - Fetal hyperinsulinaemia e - PIH
d - Fetal hyperinsulinaemia
PEDERSON HYPOTHESIS
Maternal high glucose –> fetal hyperinsulinaemia –> high rates of fetal growth and subcut fat and glycogen deposition in liver –> increased fetal metabolic rate which can provoke fetal hypoxia
Congenital abnormality - 2-4 fold increased risk
- T1DM 2.9-7.5%
- T2DM 2.1-12.3%
Management in suspected fetal hypothyroidism?
a - give mother thyroxine
b - intraamniotic thyroxine
c - do nothing in utero but give thyroxine to neonate
d - none of the above
c - do nothing in utero but give thyroxine to neonate
Usually due to TSH receptor blocking antibodies crossing the placenta
- More common in women with atrophic thyroiditis rather than Hashimoto’s
2% of congenital hypothyroidism
Refer MFM for serial USS
To pick up most no. of causes of neonatal hypothyroidism
a - TSH only
b - TSH first and if elevated do T4
c - Both TSH and T4
d - T3
b - TSH first and if elevated do T4
TSH on guthrie card
Screening for congenital hypothyroidism
Primip with no antenatal care delivers 1000 gm baby at 28/40. What is most likely cause of death?
A - sepsis
B - temp instability
C - intracranial haemorrhage
D - RDS
D - RDS
as per Lancet article
What features are suggestive of neonatal hypothyroidism – except?
a - hypotonia
b - atypical facies
c - open posterior fontanelle
d - slow heart rate in labour
b - atypical facies
swollen eyes, but no other atypical facies
Which one crosses the placenta
a - heparin only
b - warfarin only
c - heparin and warfarin
d - none of the above
B - warfarin only
Which one causes stipling of the epiphysis?
a - heparin only
b - warfarin only
c - heparin and warfarin
d - none of the above
b - warfarin only
stipling = pattern of focal bone calcification
- caused by warfarin, hypothyroidism, alcohol
What is the risk of congenital heart block with anti Ro + La antibodies?
A - 5%
B - 10%
C - 20%
A - 5%
most likely to be assoc with oligohydramnios:
A - VSD- isolated
B - posterior urethral valves
C - PUJO – unilateral
D - duodenal atresia
B - posterior urethral valves
Keyhole sign on USS - distended bladder, oligo
PUJO = pelvic ureteric junction obstruction
most likely to be assoc with abnormal karyotype
A - VSD- isolated
B - posterior urethral valves
C - PUJO – unilateral
D - duodenal atresia
D - duodenal atresia
30% of duodenal atresia with have T21
3% of those with T21 will have duodenal atresia
Vactryl association
Which of the following cannot be detected on routine US scanning?
a - hydrocephalus
b - exomphalos
c - cystic fibrosis
d - cleft palate
c - cystic fibrosis
A previously healthy 4 day old infant becomes hypotensive and dehydrated, low Na and high K. Which definitive Ix likely to be positive next?
raised 17-OH progesterone (>200)
CAH
- salt-wasting crisis
Predominant Hb type in neonate?
a - HbA
b - HbA2
c - HbF
d - HbH
c - HbF
US (picture given) at 17/40 shows ‘frog’s eyes’ and maternal serum AFP 4 times above normal range. Following options in counselling parents?
a - defect unclear as not often seen at 17/40
b - neonatal survival is poor (<48hrs)
c - prompt termination required to avoid serious maternal complications
d - fetus will survive, but with significant morbidity
b - neonatal survival is poor (<48hrs)
frog eyes = anencephaly
What has the least effect on the fetus when given to the mother?
a - TSH
b - TRH
c - Thyroxine
a - TSH
Doesn’t cross
With respect to the fetal auditory system, which statement is correct?
a - high pitched sounds are heard best
b - depends on movement of ossicles in the air-filled middle ear
c - has completed myelination by the time of birth
d - the cochlear membrane develops from the basilar end to the apical end
c - has completed myelination by the time of birth
Auditory system becomes functional at around 25/40
Regarding AVP, which is true? (AVP = arginine vasopressin, or ADH)
a - the main determinant of fetal heart rate variability
b - causes increased fetal urine output to protect umbilical cord with amniotic fluid
c - is produced in the right atrium under the influence of stretch receptors
d - causes fetal tachycardia secondary to peripheral vasoconstriction
e - is released in response to haemorrhage
e - is released in response to haemorrhage
Made by the hypothalamus and stored in the posterior pituitary gland
Concentrates urine and preserves water
Of placentation, which is true?
A - complete feto-placental circulation is established by 5-6 weeks post-conception
B - 2 waves of endothelial cytotrophoblast invasion is finished by 10/40
C - of uterine blood flow, 55% is to placenta, the rest to myometrium / endometrium / decidua
D - blood leaves fetus to go to placenta via 2 veins and 1 artery, and flow is 350ml/minute
E - flow in cord is 150ml/min
TRICK QUESTION - none right
flow in cord is 110-125ml/min/kg - relatively constant in the third trimester
Feto-placental circulation is not fully established until the end of the first trimester
2 waves of endothelial cytotrophoblast invasion
- first wave at 8-10weeks
- second at 16-18weeks
Of uterine blood flow, 55% is to placenta, the rest to myometrium / endometrium / decidua
- 85% goes to the placenta
Regarding fetal circulation, which is true?
A - 1/3 of cardiac output goes to brain B - 40% of CO goes to placenta C - RV and LV output is similar D - 1/2 RV output traverses the ductus arteriosus E - 50% RV outflow is to the lungs
B - 40% of CO goes to placenta
1/3 of combined CO perfuses the placenta
<10% of the output of the RV reaches the lungs
What level of fetal Hb is associated with fetal hydrops
A - 2 B - 4 C - 6 D - 8 D - 10
B - 4
Fetal blood with the highest PO2 is in;
A - SVC
B - IVC
C - Ductus arteriosus
D - Umbilical arteries
B - IVC
Fetal tachycardia, confirmed as SVT. Evidence of pericardial effusion and ascites on scan. Incorrect option:
A - steroids B - digoxin C - amiodarone D - flecanide E - delivery
E - Delivery????
Digoxin and flecanide definitely can be used
Amiodarone often not used first line, but can be used
Steroids would be helpful in preparation for delivery
Male baby has just been delivered by elective LUSCS, weight 3000gm, Apgars 7(1), 9(5). After a couple of hours he develops grunting and intercostal recession and RR 80 which is all better by 18 hrs. Mechanism?
A- surfactant deficiency
B - delayed resorption of lung liquid
C - acidosis
D - neonatal pneumonia
B - delayed resorption of lung liquid
Assuming term
All are causes of haemolytic disease of newborn except:
A - Kell
B - Duffy
C - Lewis
D - ABO
C - Lewis
Which ultrasound features are the least accurate assessment of gestational age?
A - BPD
B - FL
C - AC
D - BPD/FL ratio
C - AC
The expected weight of a 28 week fetus to deliver is:
A - 600 gms B - 800 gms C - 1100 gms D - 1300 gms E - 1600 gms
C - 1100 gms
Streaming of blood in the fetal IVC result in:
a - more oxygenated blood being directed through the foramen ovale to the left atrium
b - deoxygenated blood from the coronary sinuses being directed to the aorta
c - deoxygenated blood being directed to the left lobe of the liver
d - oxygenated blood travelling in the right ventral portion of the IVC
a - more oxygenated blood being directed through the foramen ovale to the left atrium
The fetal kidney:
a - is just as responsive to aldosterone as the adult kidney
b - produces hyperosmolar urine
c - responds to hyperosmolar mannitol by increasing GFR to excrete the osmotic load
c - responds to hyperosmolar mannitol by increasing GFR to excrete the osmotic load
Can’t concentrate urine until the first year of life
- therefore yellow urine in newborn is abnormal –> easy to diagnose jaundice
hyperosmolar urine = concentration urine
Fetal lungs:
A - are 80% of the volume that they will be immediately after birth
B - lung movement is required for the production of surfactant
C - the pressure in the trachea is less than that in amniotic fluid
D - none of the above
D - none of the above
Lung movement isn’t required for surfactant production
Pressure in trachea will be equal to that in the amniotic fluid
Uncertain about A
Fetal urine amount related to?
A - fetal weight
B - gestational age
A - fetal weight
Can calculate neonatal expected UO based on weight
Which is not produced by the fetus?
A - oestrogen
B - insulin
C - ACTH
D - TSH
A - oestrogen
Made by mum and placenta
ACTH - detected from 12/40
Make insulin by 20/40
Thyroid function starts ~20/40, under influence of fetal TSH
What contributes most to AFI in late gestation?
A- fetal swallowing
B - fetal urination
C - transudation across membranes
B - fetal urination
Regarding cerebral palsy and birth asphyxia
A - 50% of affected infants will have apgars less than 3 at 5 minutes
B - most affected infants will have normal apgars
C - early neonatal fitting does not indicate a poor prognosis
A - 50% of affected infants will have apgars less than 3 at 5 minutes
HIE is the pathogenesis for CP due to birth asphyxia
CRITERIA FOR HIE:
0-3 for >5 mins
Significant hypoxic event before or during labour and delivery
Profound acidaemia (pH <7 of umbilical cord artery)
Neonatal neuro manifestations - seizures, hypotonia, coma
Multisystem organ dysfunction
Only 10% of CP in term or near term infants is due to birth asphyxia
- Usually spastic quadraplegia or dyskinetic CP
An elective CS was performed at 38/40 for grade 4 placenta praevia under GA. Infant was delivered with Apgars of 9 and 9. The infant develops increasing respiratory effort 1 hr after birth. What is the most likely diagnosis?
A - hyaline membrane disease B - pneumonitis C - transient tachypnoea of newborn D - prolonged effects of newborn E - birth asphyxia
C - transient tachypnoea of newborn
How many babies with cerebral palsy have normal apgars?
75% of CP have normal Apgars
Baby’s born < 32 weeks are most likely to die from?
A - HMD (hyaline membrane disease)
B - NEC
C - Subdural haemorrhage
D - Infection
D - Infection
Which is the most likely chromosomal abnormality in 3rd trimester FDIU (fetal death in utero)?
A - T21 b - T18 c - T13 d - Triploidy e - Turners syndrome
b - T18
US at 28/40 shows ventriculomegaly with a cortical mantle thickness of 8mm. You advise:
A - prognosis bleak – TOP advised
B - prognosis is uncertain and await spontaneous labour
C - ventriculocentesis will causes brain damage
D - could be prevented by preconceptual folate
C - ventriculocentesis will causes brain damage
Up to date says that it is nearly always fatal
Rarely, used to decompress the fetal head to allow vaginal delivery to reduce maternal morbidity
Suggest to use where neurological prognosis is so bad that is the baby dies it doesn’t make a difference
A term infant has just been delivered with Apgar 1 at 1. Airway cleared. Next most appropriate step?
a - IM Konakion
b - Intraumbilical glucose and bicarb
c- Continue to bag and mask
d - Intubate
c- Continue to bag and mask
Cerebral palsy, incorrect option:
a - 20 times more likely if Apgars <4 at 5 mins
b - 5% will develop CP if Apgars <4 at 5 mins
c - triplets 45 per 1000 develop CP
d - twins 15 per 1000 develop CP
e - singleton 2 per 1000 develop CP
f - 25% infants with grade 3 IVH develop CP
b - 5% will develop CP if Apgars <4 at 5 mins
By process of elimination
Shoulder dystocia – most likely injury?
a - Nerve
b - fractured clavicle
c - fractured humerus
a - Nerve
Transient nerve injury up to 16%
Permanent nerve injury 1%
# clavicle (up to 9.5%) - double rate of humeral # (up to 4.2%)
HIE 0.3%
Death 0.35%
PPH 11%
3rd or 4th degree - 4%
Advantages of rooming in: all except?
a - baby gets colonised with mum’s bugs, not others b - decreased SIDS later c - facilitates 4 hrly feeds d - increase uterine involution e - improves let down
a - baby gets colonised with mum’s bugs, not others
Para 3, all SVD at term weighing > 3600gm. Now 36 weeks gestation with a 31 cm fundus. US BPD = 7.9 cm, BPP normal. Mx?
a - delivery by CS
b - karyotype the fetus
c- biweekly US to assess fetal growth
d - amniocentesis for L:S ratio
c- biweekly US to assess fetal growth
Regarding placental sulfatase deficiency, which statement is correct?
A- premature labour is a feature
B - equal sex distribution with fetal effects
C - inheritance is X-linked recessive
D - associated with neonatal dermatitis
C - inheritance is X-linked recessive
Results in lack of cervical dilatation
In the newborn infant, normal circulation changes associated with neonatal life include all EXCEPT
a. Increase pulmonary venous flow
b. Increase in left atrial pressure
c. Increase in pulmonary venous resistance
d. Increase in renal blood flow
c. Increase in pulmonary venous resistance
The blood volume of a 3.5kg infant at term is approximately
a. 200mL
b. 250mL
c. 300mL
d. 350mL
c. 300mL
85ml/kg
You are called to Delivery Suite to attend a recently delivered baby with ambiguous genitalia. You cannot assign a gender to the baby. After 24 hours, your NEXT step should be;
a. Order immediate serum electrolytes
b. Order serum 17-OH progesterone levels
c. Arrange for serum testosterone and 17-oxosteroids the following day
d. Order an USS to check for presence/absence of uterus or testicles
e. Organise blood to be taken for chromosome analysis the next day
b. Order serum 17-OH progesterone levels
Congenital adrenal hyperplasia
Most common cause of ambiguous genitalia
Wait 24h to allow 17-OH progesterone produced by the placenta to disappear
17-oxosteroids - metabolite found in urine
- confirms 11 b hydroxylase deficiency
Which is LEAST CORRECT regarding cerebral palsy
a. Around 5% of those with Apgar < 4 at 10 minutes will develop CP
b. Around 25% of babies with grade 3 HIE will develop CP
c. Around 50/1000 surviving triplets will develop CP
d. Around 10/1000 surviving twins will develop CP
b. Around 25% of babies with grade 3 HIE will develop CP
2 cases per 1000 live births - live births
HIE grade 3
- High mortality (75%) and neurologic disability (80% of survivors)
A 4 day old neonate suddenly becomes unwell, dehydrated and hypotensive. There is clitoromegaly with rugosity of the labia. She is hyponatraemic, hyperkalaemic, urea 8.0mmol. What is the most likely additional laboratory finding?
a. Karyotype XY
b. Elevated Testosterone
c. Markedly elevated 17OH progesterone
d. Markedly elevated blood glucose level
c. Markedly elevated 17OH progesterone
In a full term neonate with omphalocele, which factor is MOST important to determine prognosis
a. Size of the defect
b. Presence of other anomalies
c. Mode of delivery
d. Method of surgical repair
b. Presence of other anomalies
Which best describes the relationship between Apgar scores and neurologic outcomes?
a. A 10 minute apgar of 0-3 and neonatal convulsions is not predictive of poor neurological outcome
b. 75% of children with Cerebral palsy had normal Apgar scores
c. 1/3 of infants with a 5 minute score 0-3 will have poor long term neurological outcomes
d. The 1 minute score correlates well with long term neurological outcomes
b. 75% of children with Cerebral palsy had normal Apgar scores
A full term infant has an Apgar score of 2 at 1 minute. The MOST appropriate statement is
a. The infant will develop seizures
b. The infant needs immediate transfer to Special Care
c. The infant has significant hypoxia
d. The infant needs resuscitation
d. The infant needs resuscitation
A 4 day old neonate develops vaginal bleeding. You should:
a. Test for haemoglobin in the next stool specimen
b. Reassure the family
c. Arrange EUA to exclude vaginal tumour
d. Arrange pelvic ultrasound to exclude uterine tumour
b. Reassure the family
A woman has a 46XX child born with Congenital Adrenal Hyperplasia and virilisation requiring surgical correction and steroid therapy. In the next pregnancy you would recommend:
a. Commence dexamethasone at the diagnosis of pregnancy
b. Commence prednisolone at the diagnosis of pregnancy
c. Amniocentesis to diagnose fetal sex and commence dexamethasone if female
d. Amniocentesis to diagnose fetal sex and commence prednisolone if female
a. Commence dexamethasone at the diagnosis of pregnancy
If fetus at risk of CAH, treat with dexamethasone 20mcg/kg daily to avoid virilisation of an affected female ideally <5/40
- Suppresses fetal ACTH and reduce fetal adrenal hyperandrogenism
- Continue until sex determined and paternal status is known
- If female and partner carrier –> CVS
- If fetus affected, continue dexamethasone or offer TOP
Which statement about neonatal circulatory changes at birth is CORRECT
a. Gaseous expansion of the lungs causes an increase in pulmonary vascular resistance and increase in pulmonary blood flow
b. Pulmonary venous return doubles
c. Prostaglandin E1 causes closure of the Ductus Arteriosus
d. Ductus venosus oxygen tension falls
e. When the umbilical cord is occluded, the flow of blood to the placenta is interrupted, causing a decrease in systemic blood pressure
d. Ductus venosus oxygen tension falls
Neonatal hyperthyroidism is most likely to be caused associated with
a. Maternal Graves disease controlled by previous surgery
b. Untreated maternal toxic thyroid adenoma
c. DiGeorge syndrome
d. Carbimazole therapy
a. Maternal Graves disease controlled by previous surgery
Carbimazole therapy
