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NICU Board Review > MFM > Flashcards

MFM Flashcards

1
Q

MCC of infant death in 🇺🇸

A

Congenital anomalies/ chromosomal (21%)
Disorders related to Prematurity (17%)
SIDS (6.5%)

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2
Q

MC presentation of acute chorio

A

Absent clinical manifestation
*Placental pathology is required to confirm
Associated with preterm birth

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3
Q

Primary marker for detection of fetal aneuploidy

A

Nuchal translucency
> 3mm - has 1 out of 6 risk for aneuploidy
Obtained between 10-15 weeks

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4
Q

Term IUGR - what is MC neurodevelopmental deficit?

A

ADHD is higher in term IUGR infants

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5
Q

MC perinatal complications in late preemies compared to term

A

Jaundice is the MC complication (50%)

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6
Q

Wedge shaped mass in lung with systemic arterial supply on fetal MRI. Dx?

A

Bronchopulmonary sequestration (doesn’t communicate w tracheobronchial tree)

CPAM can be macrocystic (MC) or microcystic and located anywhere in lung. Communicates w tracheobronchial tree w pulmonary circulation

CLE hyper inflated lung tissue w predisposition for upper lobes. Can appear similar to microcystic CPAM

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7
Q

Which plasma protein is associated with thrombotic features of antiphospholid syndrome?

A

Beta 2 glycoprotein 1

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8
Q

In TTTS which twin has chorionic magistral blood vessel pattern?

A

Donor twin (large size vessels w minimal branching extending from cord insertion to placental periphery)

They are more at risk of anemia, hypovolemia, to be wrapped in cord, and “stuck twin syndrome” bc oligohydramnios

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9
Q

What is the goal Hct during PUBS?

A

Transfusion volume goal is high hematocrit to minimize fluid overload (O negative hct 75-80%)

= hgb goal- hgb fetal/hgb donor-hgb goal (fetal placental blood volume 90-120ml/kg)

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10
Q 
How does the following change in pregnant women? 
HR
Blood volume 
CO/SV 
SVR
A

HR increases 10-20%
Blood volume increases 30% (ie relative anemia)
CO increases 30-50%
SVR decreases by 20%

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11
Q

Which enzyme correlates best with serum bile acid levels in a pregnant woman w Intrahepatic cholestasis of pregnancy?

A

Gluthathione S transferase alpha

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12
Q

Clinical finding most commonly seen in neonate born to mother with intrahepatic cholestasis of pregnancy?

A

Surfactant deficiency

They too will have elevated bile acids
Increased risk bile acid pneumonia and mec aspiration syndrome

No risk for cholestasis rash hepatitis or sepsis

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13
Q

Women with intrahepatic cholestasis of pregnancy are deficient in which trace element?

A

Selenium

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14
Q

Characteristics of placentas of obese women

A
  1. Hyper mature with increased # of terminal villi or accelerated villose maturation
  2. Acute inflammation -with > oxidative stress
  3. Larger than avg
  4. Decreased perfusion - infarction risk
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15
Q

Role of progesterone

A

Progesterone maintains uterus in relaxed state (down regulating gap junctions, decreasing oxytocin receptors, inc the threshold of contractions and inhibiting cervical ripening)

Highest levels at the end of pregnancy

IOL requires withdrawal of progesterone receptor function (functional suppression) despite the levels being high

Decline in steroid receptor coaactivator (SRC)

Progesterone Receptor A (PR-A) increases during labor which impairs receptor responsiveness

Estrogen contributes to labor by increasing uterine contraction
(Allowed by functional suppression of progesterone)

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16
Q

The greatest risk of congenital malformations in a diabetic mother occur with poor glucose control ____ of pregnancy

A

Prior to conception and 1st trimester

Fetal malformations are 2-4x higher in 🤰🏽 with diabetes compared to population

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17
Q

Risk of congenital anomalies with diabetes

A

If 👩🏽 achieves glycemic control PRIOR to pregnancy- risk of fetal anomalies is 2.5%

If 👩🏽 achieves glycemic control AFTER becoming pregnant, risk of fetal anomalies is 7.8%

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18
Q

How do you diagnose antiphospholipid syndrome?

A

Elevated IgM or IgG anticardiolipin Ab, anti-B2 glycoprotein 1 or lupus anticoagulant on 2 ocassion 12 weeks apart.

If all 3 elevated, higher risk of thrombotic events and pregnancy related morbidity

Preferential transport capacity for IgG1

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19
Q

Most common congenital anomaly with gestational diabetes

A

Caudal regression syndrome

impaired development of lower half of body

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20
Q

Maternal risk factor with Highest likelihood ratio for the development of preeclampsia

A

Chronic hypertension

Then APS

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21
Q

What are lacunae on ultrasound used to diagnose

A

The presence of Lacunae lakes is used to diagnose abnormalities in placental implantation (ie - placental accreta)

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22
Q

What is the greatest risk factor for demise of recipient twin in TTTS?

A

Evidence of cardiomyopathy

Cardiac function of recipient twin

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23
Q

Which factors are associated with worse maternal fetal outcomes in preeclampsia ?

A

Elevated ratio of fms-like tyrosine kinase 1 (Flt-1) [antiangiogenic] to
placental growth factor (PIGF, angiogenic)

(A low ratio between 24-37 weeks gestation can predict absence of preeclampsia within one week)

Remember Other antiangionenic factors are endoglin which is also increased and angiogenic like VEGF is decreased

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24
Q

What are the risk factors for late preterm birth ?

A 
AMA
Multiple gestations
Obesity
Prior preterm delivery (OR 7.5)
Short (<12 months) interpregnancy 🤰🏽 interval (OR 4)
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25
Q

Describe changes in immunity during pregnancy relating to helper T cells

A

Downregulation of maternal immunity

Switch from TH1 cellular immunity to TH2 antibody mediated immunity

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26
Q

How is glucose and cephalexin transplacentally transferred?

A

Facilitated diffusion

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27
Q

How are lipids and fat soluble vitamins transplacentally transferred?

A

Simple diffusion

Similar to O2 CO2 Na Cl and most meds

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28
Q

How are amino acids and H2O-soluble vitamins transferred?

A

Active transport

Similar to Ca Ph Mg Iron and Iodide

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29
Q

How is water and dissolved electrolytes transplacentally transferred?

A

Bulk flow

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30
Q

How are immunoglobulin G antibodies transferred?

A

Pinocytosis

Similar to other proteins

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31
Q

Marfan syndrome characteristics

A

AD
Gêne: fibrillin 15q21.1
Dilated aortic root, MVP
Lens subluxation (upward)

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32
Q

Highest risk to the fetus with IVF

A

Multiple gestation

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33
Q

What are non thrombotic complications of anti phospholipid syndrome (APS)

A

♥️ valvular disease
Hemolytic anemia
Livedo reticularis
Thrombocytopenia

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34
Q

Risk factors for abnormal placentation (accreta, increta, percreta)

A

MCC Uterine surgery (includes C/S)
Fibroids
Multiparity
AMA

Accreta - implantation of the placenta that is deeper into the uterus than usual

Increta -Invades

Percreta - pénétrâtes

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35
Q

What are Hofbauer cells?

A

Stromae histiocytes found in placental villi of a normal placenta

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36
Q

Describe Quintero stages of TTTS

A

Stage I- oligo/polyhydramnios, visible donor bladder
Stage 2- oligo/poly, non-visible donor bladder
Stage 3-oligo/poly, abnl umbilical artery flow
Stage 4-oligo/poly, hydrops
Stage 5- oligo/poly, impending or actual demise in 1 or both twins

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37
Q

Which growth pattern puts babies at risk for CAD in adulthood?

Remember metabolic syndrome….

A

Low BW
Slow growth in infancy
Excessive growth in childhood

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38
Q

Risks with gestational diabetes

A

Poor control preconception and in 1st trimester = increase risk for congenital anomalies

Poor control in pregnancy= increase risk for Neonatal morbidities

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39
Q

Common Neonatal findings in baby’s born to preeclamptic mothers

A

Thrombocytopenia
Neutropenia

*Usually seen with growth restricted

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40
Q

MC valvular problem in pregnancy

A

Mitral stenosis

Most of acquired valvular disease is 2/2 rheumatic fever

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41
Q

What imaging modality is best for early detection of gastrointestinal obstruction?

A

Fetal MRI

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42
Q

Describe findings of placentas of GDM mother

A 
Large
Chorangiosis (vascular change from low grade hypoxia-seen in DM, IUGR and gestational HTN)
43
Q

What is the MCC of chronic infectious villositis (hint: intranuclear/cytoplasmic inclusion)?

A

CMV

Treponema pallidum

44
Q

What is the MCC of fetal overgrowth in pregnancies with diabetes

A

Fetal hyperinsulinemia

45
Q

Neonates born to mothers with APS are at high risk of?

A

Preterm birth
SGA
Autism/NDI with persistent APS-associated antibodies
Anticardiolipin and antibB 2 glycoprotein abs may persist for 6 mo

46
Q

Difference between pre gestational DM placenta (Type 1) and gestational diabetes placenta?

A

Pre gestational dm placentas have:

immature chorionic villi
Increased proliferation index
Villose necrosis

47
Q

MC complication associated with PUBS

Precutaneous villous sampling

A

Risk of fetal bradycardia (7-52%)
Spontaneously resolves
Severe in 3-4% of cases

48
Q

Magnesium sulfate in preeclampsia reduces which maternal morbidities?

A

Progression to eclampsia 60%

May decrease risk placental abruption

49
Q

Relative risk of morbidities in late preterm V’s term

A

Cerebral palsy (RR 2.7)
Cognitive deficits (RR 1.6)
Disorders of psychological development, behavior + emotional issues
Impaired work capacity

50
Q

MC reason for preterm delivery with preeclampsia

A 
Stillbirth (15-20%)
HELLP (6-10%)
Abruption 
Pulmonary edema (2-4%)
Eclampsia (1-2%)
51
Q

MC pregnancy specific complication of APS?

A

Preeclampsia (50%)
preterm birth (30%)
IUGR (30%)

52
Q

What is a long term neonatal adverse outcome for Fetal thrombotic vasculopathy ?

A
  • Neurologic stroke
    Encephalopathy
    CP
53
Q

Teratogen exposure during which period is most likely to lead to deleterious effects?

A

0-12 weeks during organogenesis

54
Q

Mother with Maculopapular rash starting in face, posterior auricular lymphadenopathy and prodromal symptoms. What is the neonate affected with and clinical features?

A

Rubella

Neonate clinical features:
Cataracts
PDA, Peropheral pulmonary artery stenosis
Microcephaly

Highest risk in first 12 weeks (most develop cardiac defects)
Sensorineural hearing loss

55
Q

Common neonatal presentation of Cosackieviruses

A 
Maculopapular rash (viral exanthem)
Myocarditis

Type B associated with cardiac issues

56
Q

Which torch infection can lead to hypertrophic cardiomyopathy?

A

Parvovirus B19

Viremia (fever, flu like symptoms)
Althralgia/rash (immune mediated)
Suppression of erythropoiesis leading to anemia and hydrops if severe

In some fetuses it can lead to hypertrophic cardiomyopathy

Highest risk for hydrops is 1st trimester

57
Q

Highest sensitivity of maternal serum AFP occurs at what gestational age?

A

Greatest sensitivity between 16-18 weeks

Fetal AFP: peaks at ~13 weeks’
gestation

Maternal serum AFP (MSAFP):
detected after 12 weeks' gestation;
peaks ~32 weeks' gestation
usually check level between 15 and 22
weeks' gestation
greatest sensitivity between 16 and 18
weeks' gestation

Amniotic fluid AFP:
peaks at ~13 weeks’ gestation
correlates with fetal serum AFP

58
Q

Complications of nifedipine as a tocolytic?

A

Fetal hypotension

59
Q

What are the characteristics of amniotic fluid (AF)?

A

Osmolality decreases with increasing gestational age (2nd trimester - due to increased fetal urine production)

AF volume + AFI (index) with bell shaped curve

60
Q

What are the sources of AFV Production and Clearance During the 3rd Trimester?

A
  • majority of AFV production is from fetal urine.
  • small amount of
    fetal lung fluid exits the lungs.
  • majority of AFV clearance is due to fetal swallowing
  • 2nd most important clearance mechanism is direct absorption of AF from the amniotic sac into fetal blood vessels within the placenta (i.e., intramembranous).
61
Q

Types of Decelerations of FHR

A

Early —-> head compression

Variable —-> umbilical cord compression (u, v, w pattern)

Late —-> utero placental insufficiency

Sinusoïdal pattern —-> ominous
assocd with severe anemia

62
Q

What is associated with fetal tachycardia ?

A

Fetal anemia
Maternal anemia
Maternal fever
Terbutaline treatment

(Magnesium is NOT associated)

63
Q

What are predictors of preterm labor

A

Fibronectin > 50 (produced by amniocytes + cytotrophoblast)
IL- > 400
Cervical length <30 mm

64
Q

Role of hPL

A

Promotes fetal growth

65
Q

How does CO, SVR and BP change in pregnant woman?

A 
Increased CO (30% CO goes to uterus)
Decreased SVR and 3rd trimester BP decrease to maximize blood flow to uterus and placenta
66
Q

How does red cell mass, pro and anticoagulants change in pregnancy?

A

Increase in red cell mass 30%
Increase in procoagulant and decrease in anticoagulant
Increase in vascular stasis

Increase risk for thromboembolic disease (likely so she doesn’t bleed to death at delivery lol)

67
Q

How does minute ventilation, RR and FRC?

A

Increase in minute ventilation
Deeper breaths not change in RR
Fall in FRC

68
Q

Maternal TSH can change in early pregnancy, why does this happen?

A

Cross reaction with hcg making it low TSH but no actual change in hormone levels

69
Q

What treatment should u avoid in mothers with hypothyroidism

A

Radioactive iodide (can concentrate and damage fetal thyroid)

70
Q

TTTS

A

10-15% of monochorionic diamniotic twins
80-100% mortality if untreated

Large placental AV anastomoses result in uneven blood flow

Donor and recipient twin
- Donor with decreased blood volume, growth restricted, poor urine
output (oligohydramnios); recipient is hypervolemic, polyhydramnios and hydrops

Stages 1-5 (2-4 are candidates for treatment with laser ablation)

71
Q

Which twins get affected by TRAP?

A

Twin reversed arterial perfusion

Seen in mono mono twins

Normally formed donor (pump) twin and a cardiac recipient twin

Treat by cord occlusion of a cardiac twin

72
Q

At what GA do you screen for gestational diabetes?

A

24-28 weeks

73
Q

Gestational diabetes in mother is associated w increased congenital anomalies (T/F)

A

False

74
Q

Neonates born to mothers with GDM are at risk for what?

A

Metabolic syndrome in the future

Serial and ♥️ hypertrophy

  • resolves in a few months
  • treat poor cardiac output with b blockers (NOT pressors)
75
Q

What is the most significant factor that affects risk of fetal malformations in mothers w gestational diabetes?

A

Preconceptual HgbA1c

If elevated cardiac dx, caudal regression syndrome, small left colon

76
Q

Name some Neonatal metabolic derangements seen with maternal diabetes

A

• Polycythemia-(due to insulin increasing metabolic rate and
increased oxygen demand)
Hypocalcemia-inadequate (PTH, excess calcitonin)
Hypoglycemia
• Hyperbilirubinemia
• Increased thrombotic events due to hyperviscosity
• Neonatal RDS
• Fetal hyperinsulinemia also retards production of surfactant
Prematurity
• Fetal death

77
Q

Fetal and Neonatal Risk factors of maternal diabetes

A

Polyhydramnions 2/2 osmotic diuresis w fetal hyperglycemia

Polycythemia 
hypoCa 
Hyperbili
Thrombotic events for hyperviscosity 
Neonatal RDS
78
Q

Diagnosis of Gestational Hypertension?

A

Elevated BP >140 systolic or 90 diastolic in a previously normotensive mother

79
Q

How does preeclampsia lead to placental insufficiency

A

Inadequate remodeling of maternal spiral arteries

Maternal systemic vascular dysfunction->multi organ involvement

80
Q

Fetal and Neonatal effects of preeclampsia are

A

• 12%-25% of fetal growth restriction and SGA infants, as well as 15%-20%
of all preterm births

• These preterm births are generally indicated,
because the only known cure for preeclampsia is
delivery of the fetus and placenta!

81
Q

Fetal impact of maternal hypertension

A 
Preterm birth 
SGA / IUGR
Hypoglycemia
Thrombocytopenia
Neutropenia
Polycythemia 
HypoCa from mag sulfate
82
Q

What is the MCC hypothyroidism in pregnancy

A

Chronic autoimmune (Hashimoto)

83
Q

Fetal manifestations of Graves’ disease

A
  • Fetal tachycardia
  • Growth restriction
  • Fetal hydrops
  • Fetal goiter
84
Q

MCC of neonatal Graves’ disease?

A

Transplacentally transfer of stimulating TSH receptor antibodies

P/w fetal tachycardia IUGR fetal hydrops fetal goiter. Neonatal: irritability, tremor, exophtalmos, goiter

If severe thyrotoxicosis-hyperthermia, arrhythmia,
High output cardiac failure, death

Self limited, antibodies get cleared 3-12 weeks

Tx anti thyroid drugs and propanolol

85
Q

Mothers with lupus are at higher risk of which prenatal complication?

A

Preeclampsia

86
Q

How does neonatal lupus cause heart block?

A

Proposed that heart block results from binding of anti-
Ro/SSA and/or anti-La/SSB antibodies to fetal cardiac cells that have undergone physiologic apoptosis during remodeling, leading to autoimmune injury and
secondary fibrosis of the atrioventricular (AV) node
and its surrounding tissue

• Autoantibodies may also act by inhibiting calcium currents mediated by cardiac L and T type calcium channels

87
Q

What is condition is responsible for 80-95% of all cases of congenital complete heart block (<5% present after birth)?

A

•Neonatal Lupus

88
Q

What are the effects of SSRI on pregnancy

A

Paroxetine (Paxil), sertraline (Zoloft), fluoxetin
(Prozac), citalopram (Celexa)

• Early onset of symptoms

  • In baby:
  • Seizures, irritability, abnormal crying, tremor
  • Pulmonary Hypertension
  • NEC?
89
Q

What is the triad of clinical features of Fetal Alcohol Syndrome?

A 
1. Impaired pre- and postnatal
growth (lUGR)
2. Abnormal facies
3. Abnormalities of CNS or
subsequent neurodevelopment
90
Q

How to differentiate type of twins

A 
T= monochorionicity
Lambda= dichorionicity
91
Q

TTTS vs TAP vs TRAP

A

Risk of TTS is not the same in all monochorionic twins. - highest in mono-di twins (as opposed to mono-mono).
-Mono chorionic mono amniotic - less likely TTTS (they have a-a, v-a, v-v anastomoses; not so much a-v)

Twin anemia polycythemia sequence (TAPS), no amniotic fluid difference, usually
superficial as opposed to deep AV anastomoses

Twin reverse arterial perfusion sequence (TRAP), the cardiac system of one twin does
the work of supplying blood for both twins leading to “pump twin” and ´acardic twin”

TTS- larger a-v vessel anastomoses (has fluid shifts)

TAPS - smaller a-v vessel anastomoses (doesn’t have the fluid disturbance)

92
Q

Which is the most common conjoined twin type?

A

Thoracopagus

93
Q

When does fetal breathing begin?

A

10 weeks

94
Q

What is considered oligohydramnios?

A

AFI<5cm or MVP<2cm

95
Q

Polyhydramnios

A

AFI>24cm (severe>34)

MVP>8cm

96
Q

Low estriol levels

A

Smith Lemli Opitz

Placental sulfatase deficiency

97
Q

What makes up the BPP?

A 
NST
Fetal body movement 
Breathing 
Fetal Tone
Amniotic Fluid Volume
98
Q

What to look at closely with fetal monitoring?

A

Baseline (110-160 HR)
Variability present (moderate 6-25 bpm - normal)
Accelerations (normal - indicates a normally oxygenated fetus)
Decelerations ?

99
Q

What are NORMAL umbilical (fetal) arterial and venous blood gases?

A
  • Arterial 7.27/55/-3
  • Venous 7.35/40/-3

Metabolic: accumulation of lactic acid
- Hypotension, poor tissue perfusion with dysfunction
Respiratory: accumulation of COz
- Respiratory not associated with poor outcomes

100
Q

B methasone for pts <32 weeks decreases risk of CP from 4% to 2%

True or False

A

True

101
Q

When is delivery by C/S indicated in a fetus w abdominal wall defect?

A

Omphalocele with liver exposed

102
Q

Effect of maternal marijuana use on neonate

A

Impairment in neurodevelopment, working memory and school performance

103
Q

Warfarin effects on baby

A

Stippled epiphysis

Nasal bone abnormalities

NICU Board Review (19 decks)

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