MFM Flashcards
MCC of infant death in 🇺🇸
Congenital anomalies/ chromosomal (21%)
Disorders related to Prematurity (17%)
SIDS (6.5%)
MC presentation of acute chorio
Absent clinical manifestation
*Placental pathology is required to confirm
Associated with preterm birth
Primary marker for detection of fetal aneuploidy
Nuchal translucency
> 3mm - has 1 out of 6 risk for aneuploidy
Obtained between 10-15 weeks
Term IUGR - what is MC neurodevelopmental deficit?
ADHD is higher in term IUGR infants
MC perinatal complications in late preemies compared to term
Jaundice is the MC complication (50%)
Wedge shaped mass in lung with systemic arterial supply on fetal MRI. Dx?
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
Which plasma protein is associated with thrombotic features of antiphospholid syndrome?
Beta 2 glycoprotein 1
In TTTS which twin has chorionic magistral blood vessel pattern?
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
What is the goal Hct during PUBS?
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)
How does the following change in pregnant women? HR Blood volume CO/SV SVR
HR increases 10-20%
Blood volume increases 30% (ie relative anemia)
CO increases 30-50%
SVR decreases by 20%
Which enzyme correlates best with serum bile acid levels in a pregnant woman w Intrahepatic cholestasis of pregnancy?
Gluthathione S transferase alpha
Clinical finding most commonly seen in neonate born to mother with intrahepatic cholestasis of pregnancy?
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
Women with intrahepatic cholestasis of pregnancy are deficient in which trace element?
Selenium
Characteristics of placentas of obese women
- Hyper mature with increased # of terminal villi or accelerated villose maturation
- Acute inflammation -with > oxidative stress
- Larger than avg
- Decreased perfusion - infarction risk
Role of progesterone
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)
The greatest risk of congenital malformations in a diabetic mother occur with poor glucose control ____ of pregnancy
Prior to conception and 1st trimester
Fetal malformations are 2-4x higher in 🤰🏽 with diabetes compared to population
Risk of congenital anomalies with diabetes
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%
How do you diagnose antiphospholipid syndrome?
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
Most common congenital anomaly with gestational diabetes
Caudal regression syndrome
impaired development of lower half of body
Maternal risk factor with Highest likelihood ratio for the development of preeclampsia
Chronic hypertension
Then APS
What are lacunae on ultrasound used to diagnose
The presence of Lacunae lakes is used to diagnose abnormalities in placental implantation (ie - placental accreta)
What is the greatest risk factor for demise of recipient twin in TTTS?
Evidence of cardiomyopathy
Cardiac function of recipient twin
Which factors are associated with worse maternal fetal outcomes in preeclampsia ?
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
What are the risk factors for late preterm birth ?
AMA Multiple gestations Obesity Prior preterm delivery (OR 7.5) Short (<12 months) interpregnancy 🤰🏽 interval (OR 4)
Describe changes in immunity during pregnancy relating to helper T cells
Downregulation of maternal immunity
Switch from TH1 cellular immunity to TH2 antibody mediated immunity
How is glucose and cephalexin transplacentally transferred?
Facilitated diffusion
How are lipids and fat soluble vitamins transplacentally transferred?
Simple diffusion
Similar to O2 CO2 Na Cl and most meds
How are amino acids and H2O-soluble vitamins transferred?
Active transport
Similar to Ca Ph Mg Iron and Iodide
How is water and dissolved electrolytes transplacentally transferred?
Bulk flow
How are immunoglobulin G antibodies transferred?
Pinocytosis
Similar to other proteins
Marfan syndrome characteristics
AD
Gêne: fibrillin 15q21.1
Dilated aortic root, MVP
Lens subluxation (upward)
Highest risk to the fetus with IVF
Multiple gestation
What are non thrombotic complications of anti phospholipid syndrome (APS)
♥️ valvular disease
Hemolytic anemia
Livedo reticularis
Thrombocytopenia
Risk factors for abnormal placentation (accreta, increta, percreta)
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
What are Hofbauer cells?
Stromae histiocytes found in placental villi of a normal placenta
Describe Quintero stages of TTTS
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
Which growth pattern puts babies at risk for CAD in adulthood?
Remember metabolic syndrome….
Low BW
Slow growth in infancy
Excessive growth in childhood
Risks with gestational diabetes
Poor control preconception and in 1st trimester = increase risk for congenital anomalies
Poor control in pregnancy= increase risk for Neonatal morbidities
Common Neonatal findings in baby’s born to preeclamptic mothers
Thrombocytopenia
Neutropenia
*Usually seen with growth restricted
MC valvular problem in pregnancy
Mitral stenosis
Most of acquired valvular disease is 2/2 rheumatic fever
What imaging modality is best for early detection of gastrointestinal obstruction?
Fetal MRI
Describe findings of placentas of GDM mother
Large Chorangiosis (vascular change from low grade hypoxia-seen in DM, IUGR and gestational HTN)
What is the MCC of chronic infectious villositis (hint: intranuclear/cytoplasmic inclusion)?
CMV
Treponema pallidum
What is the MCC of fetal overgrowth in pregnancies with diabetes
Fetal hyperinsulinemia
Neonates born to mothers with APS are at high risk of?
Preterm birth
SGA
Autism/NDI with persistent APS-associated antibodies
Anticardiolipin and antibB 2 glycoprotein abs may persist for 6 mo
Difference between pre gestational DM placenta (Type 1) and gestational diabetes placenta?
Pre gestational dm placentas have:
immature chorionic villi
Increased proliferation index
Villose necrosis
MC complication associated with PUBS
Precutaneous villous sampling
Risk of fetal bradycardia (7-52%)
Spontaneously resolves
Severe in 3-4% of cases
Magnesium sulfate in preeclampsia reduces which maternal morbidities?
Progression to eclampsia 60%
May decrease risk placental abruption
Relative risk of morbidities in late preterm V’s term
Cerebral palsy (RR 2.7)
Cognitive deficits (RR 1.6)
Disorders of psychological development, behavior + emotional issues
Impaired work capacity
MC reason for preterm delivery with preeclampsia
Stillbirth (15-20%) HELLP (6-10%) Abruption Pulmonary edema (2-4%) Eclampsia (1-2%)
MC pregnancy specific complication of APS?
Preeclampsia (50%)
preterm birth (30%)
IUGR (30%)
What is a long term neonatal adverse outcome for Fetal thrombotic vasculopathy ?
- Neurologic stroke
Encephalopathy
CP
Teratogen exposure during which period is most likely to lead to deleterious effects?
0-12 weeks during organogenesis
Mother with Maculopapular rash starting in face, posterior auricular lymphadenopathy and prodromal symptoms. What is the neonate affected with and clinical features?
Rubella
Neonate clinical features:
Cataracts
PDA, Peropheral pulmonary artery stenosis
Microcephaly
Highest risk in first 12 weeks (most develop cardiac defects)
Sensorineural hearing loss
Common neonatal presentation of Cosackieviruses
Maculopapular rash (viral exanthem) Myocarditis
Type B associated with cardiac issues
Which torch infection can lead to hypertrophic cardiomyopathy?
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
Highest sensitivity of maternal serum AFP occurs at what gestational age?
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
Complications of nifedipine as a tocolytic?
Fetal hypotension
What are the characteristics of amniotic fluid (AF)?
Osmolality decreases with increasing gestational age (2nd trimester - due to increased fetal urine production)
AF volume + AFI (index) with bell shaped curve
What are the sources of AFV Production and Clearance During the 3rd Trimester?
- 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).
Types of Decelerations of FHR
Early —-> head compression
Variable —-> umbilical cord compression (u, v, w pattern)
Late —-> utero placental insufficiency
Sinusoïdal pattern —-> ominous
assocd with severe anemia
What is associated with fetal tachycardia ?
Fetal anemia
Maternal anemia
Maternal fever
Terbutaline treatment
(Magnesium is NOT associated)
What are predictors of preterm labor
Fibronectin > 50 (produced by amniocytes + cytotrophoblast)
IL- > 400
Cervical length <30 mm
Role of hPL
Promotes fetal growth
How does CO, SVR and BP change in pregnant woman?
Increased CO (30% CO goes to uterus) Decreased SVR and 3rd trimester BP decrease to maximize blood flow to uterus and placenta
How does red cell mass, pro and anticoagulants change in pregnancy?
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)
How does minute ventilation, RR and FRC?
Increase in minute ventilation
Deeper breaths not change in RR
Fall in FRC
Maternal TSH can change in early pregnancy, why does this happen?
Cross reaction with hcg making it low TSH but no actual change in hormone levels
What treatment should u avoid in mothers with hypothyroidism
Radioactive iodide (can concentrate and damage fetal thyroid)
TTTS
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)
Which twins get affected by TRAP?
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
At what GA do you screen for gestational diabetes?
24-28 weeks
Gestational diabetes in mother is associated w increased congenital anomalies (T/F)
False
Neonates born to mothers with GDM are at risk for what?
Metabolic syndrome in the future
Serial and ♥️ hypertrophy
- resolves in a few months
- treat poor cardiac output with b blockers (NOT pressors)
What is the most significant factor that affects risk of fetal malformations in mothers w gestational diabetes?
Preconceptual HgbA1c
If elevated cardiac dx, caudal regression syndrome, small left colon
Name some Neonatal metabolic derangements seen with maternal diabetes
• 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
Fetal and Neonatal Risk factors of maternal diabetes
Polyhydramnions 2/2 osmotic diuresis w fetal hyperglycemia
Polycythemia hypoCa Hyperbili Thrombotic events for hyperviscosity Neonatal RDS
Diagnosis of Gestational Hypertension?
Elevated BP >140 systolic or 90 diastolic in a previously normotensive mother
How does preeclampsia lead to placental insufficiency
Inadequate remodeling of maternal spiral arteries
Maternal systemic vascular dysfunction->multi organ involvement
Fetal and Neonatal effects of preeclampsia are
• 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!
Fetal impact of maternal hypertension
Preterm birth SGA / IUGR Hypoglycemia Thrombocytopenia Neutropenia Polycythemia HypoCa from mag sulfate
What is the MCC hypothyroidism in pregnancy
Chronic autoimmune (Hashimoto)
Fetal manifestations of Graves’ disease
- Fetal tachycardia
- Growth restriction
- Fetal hydrops
- Fetal goiter
MCC of neonatal Graves’ disease?
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
Mothers with lupus are at higher risk of which prenatal complication?
Preeclampsia
How does neonatal lupus cause heart block?
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
What is condition is responsible for 80-95% of all cases of congenital complete heart block (<5% present after birth)?
•Neonatal Lupus
What are the effects of SSRI on pregnancy
Paroxetine (Paxil), sertraline (Zoloft), fluoxetin
(Prozac), citalopram (Celexa)
• Early onset of symptoms
- In baby:
- Seizures, irritability, abnormal crying, tremor
- Pulmonary Hypertension
- NEC?
What is the triad of clinical features of Fetal Alcohol Syndrome?
1. Impaired pre- and postnatal growth (lUGR) 2. Abnormal facies 3. Abnormalities of CNS or subsequent neurodevelopment
How to differentiate type of twins
T= monochorionicity Lambda= dichorionicity
TTTS vs TAP vs TRAP
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)
Which is the most common conjoined twin type?
Thoracopagus
When does fetal breathing begin?
10 weeks
What is considered oligohydramnios?
AFI<5cm or MVP<2cm
Polyhydramnios
AFI>24cm (severe>34)
MVP>8cm
Low estriol levels
Smith Lemli Opitz
Placental sulfatase deficiency
What makes up the BPP?
NST Fetal body movement Breathing Fetal Tone Amniotic Fluid Volume
What to look at closely with fetal monitoring?
Baseline (110-160 HR)
Variability present (moderate 6-25 bpm - normal)
Accelerations (normal - indicates a normally oxygenated fetus)
Decelerations ?
What are NORMAL umbilical (fetal) arterial and venous blood gases?
- 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
B methasone for pts <32 weeks decreases risk of CP from 4% to 2%
True or False
True
When is delivery by C/S indicated in a fetus w abdominal wall defect?
Omphalocele with liver exposed
Effect of maternal marijuana use on neonate
Impairment in neurodevelopment, working memory and school performance
Warfarin effects on baby
Stippled epiphysis
Nasal bone abnormalities
