MFM Flashcards
What is the risk associated with PTU use?
Hepatotoxicity (0.1-0.2)
Routine LFT not recommended
What is the risk associated with methimazole in pregnancy?
Methimazole embryopathy
- esophageal/ choanal atresia
- Aplasia cutis = congenital skin defect
What is are common side effects of PTU and methimazole (2)?
Transient leukopenia (10%)
– do not stop medication
Agranulocytosis
– discontinue drug
– Fever and sore throat → ER
What is the evolution of the thryroid gland in pregnancy?
Enlarges by 30 %
How should you treat hyperthyroidism in pregnancy?
T1 : PTU – Propylthiouracil
T2: Methimazole
Switch early 2nd trimester
What are the targets for hyperthyroidism treatment in pregnancy?
T4 – High normal range or slightly above
Ignore TSH
Measure Free T4 (NOT TSH) q 2-4 wks
What is the DDx of decreased FEV1 (6) ?
Asthma
COPD
CHF
PE
Laryngeal or vocal cord dysfunction
Mechanical airway obstruction
How is asthma classified in terms of intensity?
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
What is the associated of asthma and perinatal outcomes?
Well treated asthma NOT related to adverse pregnancy outcomes
What neonatal complications can suboptimal treatment of asthma lead to?
Low birth weight
PTB
When to asthma exacerbations usually occur?
Between 24 - 36 weeks
What is the proportion of people that improve/ worsen with asthma in pregnancy?
2/3 improve
1/3 worsens
Which anti-epileptic drug is associated with the highest chance of congenital malformation?
The lowest?
Highest: Valproic acid
Lowest: Lamotrigine (< 2%)
What is the risk of congenital malformation in women taking AED in pregnancy?
4 - 8 %
(vs 2-3 % background risk)
What are the most common congenital malformations related to AED in pregnancy?
NTD
Cardiac malformations
Cranio-fascial defects
How do you follow a pregnancy of a patient on AED?
Folic acid
7 - 8 wks - Dating US
11 - 13 wks - Anatomic US
15 - 18 wks (up to 21 wks) - AFP levels (NTD) (up to 21 wks)
+/- Amnio for amnio fluid AFP + acetylcholinesterase levels
16 - 20 wks - Anatomy scan
22 wks : Fetal echocardiogram
Vitamin K 1 mg IM at birth
How long should a patient be seizure free before conceptions?
9 months
When can pt resume their regular AED levels?
Usually after 10- 14 days
Measure levels x 8 wks
What is the inheritance pattern of sickle cell disease?
Autosomal recessive
What test is used to perform and anti-body screen related to blood type?
Indirect Coombs test
What parameters of respiration are increased / decreased in pregnancy?
Decrease
Functional residual capacity (FRC) = Residual volume + expiratory reserve volume
Increase
Inspiratory capacity (IC)
Tidal volume
Resting minute ventilation
Unchanged
Total lung capacity (FRC+ IC)
Resp rate
What syndrome is cystic hygroma associated to ?
Truner Syndrome
Down’s syndrome
Other causes
- Infection
- Inherited as autosomal recessive
What is the significance for the fetus of anti-Ro (SSA) antibodies in the mother?
Risk of neonatal Lupus wich presents with congenital heart block (Hydrops Fetalis)
Neonatal lupus is responsible for 90-95% of congenital heart blocks
In which maternal diseases are anti-Ro (SSA) antibodies present (7)?
Sjögren (52%)
LSE (32%)
Mixed connective tissue disorder (29%)
Systemic sclerosis (21%)
Idiopathic inflammatory myopathies (19%)
RA (15%)
Primary biliary cholangitis (PBC)
What antibody can be found in ANA-negative (Antinuclear antibody) SLE?
Anti-Ro/ SSA
Anti-La Antibodies are specific to which diseases?
Sjögren
SLE
What is the upper limit of MCA dopplers?
1.5 MoM (multiple of median)
100% sensitive to detect fetal anemmia
What is the most common pathway to fetal demise in hydrops fetalis?
What is a useful US marker predicting fetal demise in hydrops fetalis?
Cause of death: fetal congestive heart failure
US finding: Umbilical venous pulsations
What is the definition of hydrops (#363)?
Fluid in at least 2 different fetal compartments
- Pericardial effusion
- Pleural effusion
- Ascites
- Skin edema (>5 mm at the level of the skull of chest wall)
Often associated to:
- Polyhydramnios (40 - 75% of cases)
- Placental thickening (> 4 cm (T2)or > 6 cm (T3))
What are the mechanisms leading to hydrops (3 + 2)?
(#363)
Intra-uterine anemia
Intra-uterine heart failure
Hypoproteinemia
Skeletal dysplasia
Chromosomal anomalies
What is the name for the most severe form of alpha-thalassemia?
What is the inheritence pattern?
Bart’s disease
Autosomal recessive
Who should you screen for alpha thalassemia in Canada?
Anyone that is not:
Japanese
Korean
Caucasion with northen european ancestry
First Nation
Inuit
What type of blood is used for fetal transfusion?
O negative
CMV negative
Maternally crossed-matched
What are the indicators of poor prognosis of fetal hydrops?
Fetal chromosomal anomalies
GA < 24 wks
Fetal structural anomalies (other then chylothorax)
What is the definition of mirror syndrome ?
What is the other name of this disease?
Development of maternal edema secondary to fetal hydrops
Often associated to severe PET
Ballantyne’s syndrome
Is immune or non-immune hydrops more common?
Non immune (85% of cases)
What are the two most common NTD?
(#314)
Spina bifida - 50 %
Anencephaly - 40 %
What is the best time to conduct a fetal MRI for NTD?
(#314)
Between 23 and 32 weeks
What are potential complications of MRI in pregnancy?
(still under investigation)
(#314)
Teratogenesis
Acoustic damage
Second trimester ↑ AFP levels can be associated with wich abnormalities (5)?
(#314)
Fetal skin disorders
Abdo wall defects
Fetal demise
Fetal nephrosis
Pregnancies with increased risk of placenta-related adverse events
How do you manage a positive MSAFP in the second trimester?
(#314)
Anatomy scan at 18 - 22 weeks
Amniocentesis
When is the ideal time to conduct an amnio?
(#314)
15 - 20 weeks
What are the risks associated with an amnio?
(# 314)
SAB 0.5 - 1 %
PPROM
Infection
Post-procedure spotting
What test should be ordered on AF from an amnio conducted for suspected NTD?
(#314)
AFP levels
Acetylcholinesterase level
Karyotype
Chromosomal microarray if available
What population has a high risk of developing severe life threatening allergy to latex ?
(# 314)
Patients with myelomeningocele
Recurrence of NTD was decreaed by what % in patients taking folic acid 5 mg?
(# 314)
72 %
How do you calculate MAP?
Systolic BP + 2x (distolic BP) / 3
Risk factors for placenta previa in primip
Multiple gestation
Increase maternal age
Infertility treatment
Previous abortion
Previous uterine surgical procedure
Maternal smoking
Maternal cocaine use
Male fetus
Non-white race
In what percentage of patients with a cystic hygroma are aneuploidies detected?
(Berghella p 481)
60 %
What are the most common antigens related to alloimmunization?
(Berghella MFM p 467)
RhD
Kell
What is the cut-off for abnormal MCA PSV?
(Berghella p 468)
> or = to 1.5 MoM
When can you start monitoring MCA PSV ?
(Berghella p 471)
15 weeks
How do you measure maternal antibody titers in her blood?
(Berghella p 468)
Indirect Coombs test
What is the most common cause of intrauterine fetal infection?
(#240)
CMV
(0.2-2.2 % of live births)
What value of the CMV avidity index indicates :
- Recent infection
- Remote infection
(#240)
Recent infection (<3 months): Avidity index < 30%
Remote infection (or reactivation): Avidity index > 60%
In what % of affected CMV fetus are US findings found?
(# 240)
Less than 25 %
Before how many weeks is it best to determine chorionicity ?
When does the Lambda sign disapear?
(260)
Measure before 14 weeks
Lambda sign may disapear between 16 - 20 wks
What medications can be associated with cleft palate ?
AED (phenytoin, valproate, topiramate)
MTX
Zofran (possible small association)
When dating Twin pregnancy, which twin should be used?
(#260)
Largest twin not to miss IUGR
What is the rate of congenital anomalies in twins
- in general
- in monochorionic?
(#260)
General: 1.2 - 2 x higher than singleton
Monozygotic: 2 - 3 x higher
When does growth of twins slow down?
( # 260)
30 - 32 weeks
What is the threashold for abnormal twin growth discordance?
(260)
> 20 % is abnormal if using EFW
> 20 mm if using abdominal circumference
Pattern of US for monochorionic and dichonionic pregnancies ?
(#260)
Monochorionic twins
- Start at 16 - 18 weeks
- Growth q 2-3 weeks
Dichorionic twins
- Start at 18 - 22 weeks
- Growth q 3-4 weeks
At how many weeks should UA dopplers be measured ?
What are the indications ?
(#295)
Measured at 19 - 23 weeks
Indications =
Suspicion of IUGR
Maternal RF for IUGR
What are the most common cancers in pregnancy?
(W OB)
Breast (1/5000)
Thyroid (1/7000)
Cervical (1 /8500)
Melanoma
Lymphoma
Is MRI ok in pregnancy?
Gadolinium OK in prengnancy?
FDG and breastfeeding?
MRI: Preferably after T1
Gadolinium: DO NOT use in T1, otherwise it’s OK
FDG: Discontinue breastfeeding x 72h post procedure
What is the most common gyne cancer in pregnancy?
Cervical
What are the most common cancers leading to placenta mets ?
Melanoma (if fetal mets, in liver and sub Q tissue. 80% mortality)
Leukemia
Lymphoma
Breast cancer
** POOR prognosis
Describes the benefits/ disavantages of corticosteroids at:
22 - 24 wks
24 - 34+6
34 - 36+6
Term
(#364)
22 - 24 wks
- ↓ Mortality
24 - 34+6
- ↓ Mortality
- ↓ RDS, IVH, NEC
34 - 36+6
- ↓ RDS, Mechanical ventilation
- ↑ Neonatal hypoglycemia
Term
- ↓ RDS, Mechanical ventilation
- ↑ Low academic abilities
Describe advantages of beta over dexa (3) and
dexa over beta (2)
(#395)
Beta vs dexa
- ↓ Chorio
- ↓ RDS
- ↓ Chronic lung disease
Dexa vs Beta
- ↓ IVH
- ↓ Length of NICU admission
Should you give beta to IGUR and what are potential implications?
(#395)
YES give to IUGR although resposiveness unknown
IUGR with beta have
- lower frequency of brain lesions
- higher frequency of weight < 10 % at shcool age
What are the RF for Vasa previa (5+)?
(#231)
IVF (LR 7.75)
Placenta previa in T2 (OR 22)
Bilobed placenta or Succenturiate placenta (OR 22)
Fetal anomalies (Renal tract, 2 VC, spina bifida, Exomphalos)
Prematurity, FGR, Antepartum hemorrhage
Management of pregnancy complicated by vasa previa ?
(#231)
Repeat TVUS serially as 15 % regression rate
Beta at 28 - 32 wks
Hospitalization at 30 -32 wks
CS at 34- 36 wks
O neg, irradiated blood for ressussitation
What amout of fetal blood loss can cause fetal death ?
(#231)
100 mL (shock and death)
What 1st line agents can be used as uterotonics post delivery ?
(#235)
Oxytocin = first line in SVD
- Preferred: 10 U IM at shoulder delivery of anterior shoulder
- Other :
- 20 - 40 U in 1000 mL @ 150 mL/h
- 5 - 10 U IV bolus (ONLY AFTER VAGINAL DELIVERY)
Carbetocin = first line in ELECTIVE CS
- 100 ug IV bolus over 1 min x 1
Carbetocin = first line if ONE RISK FACTOR for PPH instead of Oxytocin
- 100 ug IM x 1
Alternatives if oxytocin is not available
Ergonovine 200 ug IM x 1
Cytotec 600 - 800 ug PO/ SL/ PR
What measures reduced PPH?
(#235)
Uterotonics
Cord traction (modest benefit)
Uterine massage post placental delivery (unclear evidence)
List 3 genetic conditions associated with infertility
Chromosomal (47 XXX, Turner 45X)
Single gene disorders (Fragile X, Galactosemia)
Myotonic dystrophy
Nanoon Syndrome
Fanconi anemia
What is the most common congenital malformation ?
(Gabbe p 825)
VSD (35%)
