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MFM Written Boards > Practice Questions - Large Doc 3 (125-396) > Flashcards

Practice Questions - Large Doc 3 (125-396) Flashcards

1
Q

Fetal O2 dissociation curve:
- ____ shift
- What causes increased O2 affinity?

A

L shift - higher fetal hgb, increased O2 carrying capacity (higher O2 sat for lower PaO2)

Increased O2 affinity - decrease of 2,3 DPG binding to fetal hgb
- 2,3 DPG and acidosis shift curve to R (release O2 to tissues)

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2
Q

Most common cause of fetal bradycardia:

A

Complete heart block (50% have structural defect) or major structural anomaly (AV canal)

Other causes:
- BB
- Fetal panhypopituitarism
- Fetal brain stem injury
- Isoimmunization
- Postcervical block - occurs 7min later and lasts 8min

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3
Q

Fetal testosterone importance

A

Max at same time as max hCG

hCG from syncytiotrophoblasts acts as LH surrogate to stimulate replication of Leydig cells and T synthesis 🡪 male sex differentiation
- T acts on Wolffian ducts -> vas deferens, epidydimis, seminal vesicles
- In external genitalia, converted to 5-alpha DHT for virilization

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4
Q

Causes of severe thrombocytopenia in newborn

A

Prematurity - RDS, placental insufficiency, sepsis

Term - NAIT, ITP

Can also be caused by SLE

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5
Q

Gestational thrombocytopenia

A

Increased platelet destruction that occurs in normal pregnancy

Most common cause of TCP in pregnancy
- Need to rule out PEC and other causes (ANA, APAS< HIV)

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6
Q

PKU
- Inheritance?
- Enzyme affected?
- Clinical sequelae?
- How to reduce risk?

A

Autosomal recessive
Absence of phenylalanine hydroxylase
- Can’t metabolize to tyrosine
Excess phe -> neuro damage, MR, hypopigmentation, microcephaly, CHD
Maintain maternal levels 2-6
Phe crosses placenta by active transport

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7
Q

Factors considered w/ AFP

A

Maternal weight (decreases w/ increased weight)
Smoking (increases)
# fetuses
GA
Diabetes
Maternal age

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8
Q

Where is GnRH synthesized? What does it do in the placenta?

A

Hypothalamus
Placenta - cytotrophoblasts
- Stimulates hCG
- Peaks at 8wks

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9
Q

Where is hCG made?

A

Syncytiotrophoblasts

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10
Q

Which coags increase and decrease in pregnancy?

A

Increase - I, VII, VIII, IX, X
Decrease - XI, XIII
Same - II, V, XII

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11
Q

Monozygotic twins rate

A

0.4% of births

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12
Q

Local anesthesia toxicity

A

CNS and CV components

Excitation, tinnitus, disorientation -> seizure
Tachycardia and HTN -> hypotension, arrhythmia, cardiac arrest

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13
Q

Which local anesthetic is more cardiotoxic?

A

Bupivicaine - longer half life

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14
Q

Treatment of SVT

A

Vagal

Then - digoxin, adenosine, CCB
Fetal bradycardia can result from meds

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15
Q

ASA side effects

A

Decreased ctx (prostaglandin inh) -> delayed labor
Plt dysfunction in neonate w/in 5 days of taking
Closure of fetal DA

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16
Q

ACEi effects on fetus

A

Late-onset IUGR, oligo
Neonatal hypotension, anuria
Most severe - renal tubular dysgenesis - early oligo, pulm hypoplasia, contractures, hypocalvaria

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17
Q

Contraindication to prostaglandin F2 alpha

A

Asthma

Also known as carboprost (hemabate)

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18
Q

Turner syndrome - etiology

A

Postzygotic mitotic error
Age unrelated
Maternal X retained 80%

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19
Q

Most common intracranial finding of NTD

A

Decreased cisterna magna

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20
Q

Most common fetal sustained tachyarrhythmia

A

SVT
Then atrial flutter, then afib

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21
Q

Fluids in DKA

A

NS until glucose <250, then D5NS

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22
Q

Myometrial contractility

A

Actin/myosin -> myosin light chain kinase -> contraction

Increased intracellular calcium -> activated MLCK -> contraction

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23
Q

Fetal risk with chlamydia

A

Conjunctivitis (50%)
Pneumonia (3-18%)

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24
Q

Pregnancy prognosis in RA

A

1st tri - 74% remission
2nd tri - 20%
3rd tri - 5%

90% PP flare (most likely to improve)

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25
Q

Pregnancy prognosis in CHTN

A

Temporary fall in BP, rises in 3rd trimester somewhat higher than early pregnancy

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26
Q

Pregnancy prognosis in SLE

A

Rule of 1/3

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27
Q

Pregnancy prognosis in SS

A

Complications more common, more likely to worsen

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28
Q

Fetal hydantoin syndrome

A

IUGR, MR, craniofacial (cleft, wide mouth, thin upper lip), hypoplasia of distal phalange/nails, wide-spaced nipples

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29
Q

Risk of NTD w/ valproate

A

1%

Also 1% with carbamazepine

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30
Q

Warfarin embryopathy

A

5% risk, 6-12wks GA
Nasal hypoplasia, bone stippling, ophtho (optic atrophy), MR

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31
Q

Fetal alcohol syndrome

A

IUGR
Facial (small palpebral fissures, small/absent philtrum, epicanthal folds, flattened nasal bridge, low set ears, midface hypoplasia)
CNS (MR, ADD)

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32
Q

Isotretinoin sequelae

A

Microtia/anotia
Micrognathia
Cleft palate
CHD
Thymus
Retinal/optic nerve abnormalities
CNS malformations including hydrocephalus

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33
Q

Diseases caused by mitochondrial inheritance

A

MERRF
LHON
Leigh
Pigmentary retinopathy

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34
Q

Most common karyotype in partial mole

A

Triploid

69 XXY (70%)

2 paternal, 1 maternal

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35
Q

Findings in 45 XO

A

Lymph collections
CHD (L sided - coarc)
Renal (agenesis, horseshoe/pelvic kidney)

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36
Q

T21 findings

A

60% thickened NF/NT
10% cystic hygroma
50% CHD
2% duodenal atresia
2% omphalocele
5% pyelectasis

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37
Q

Most common causes of hydrocephalus

A

Aqueductal stenosis (43%)
Dandy-Walker (12%)
Communicating (38%, often idiopathic)

Most common genetic cause - X-linked hydrocephalus

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38
Q

Association w/:
CPC
Holoprosencephaly
Clenched hands

A

CPC - T18
Holoprosencephaly - T13
Clenched hands - T18

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39
Q

Anencephaly causes urinary estradiol to:

A

Decrease - absent fetal zone of adrenal cortex (no HPA means no ACTH stim of fetal adrenals)

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40
Q

Toxo diagnosis

A

Active infection - rise in IgG x 2
- Very high titers >1:512 indicate more recent infection

PCR - allows prenatal dx in a day

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41
Q

Histopathology - chorioamnionitis

A

Mononuclear and PMNs in chorion

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42
Q

Histopathology - Syphilis

A

Large, pale placenta. Villi lose arborization and are thicker, club shaped.

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43
Q

Histopathology - Erythroblastosis fetalis

A

Large placenta. Villous stromal edema. Increased fetal RBCs in vessels.
No trophoblast proliferation (unlike mole)

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44
Q

Histopathology - Mole

A

Villi mass of vesicles. Hydrops, villous stromal edema, absence of blood vessels in edematous villa, proliferation of trophoblastic epithelium, absence of fetus/amnion

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45
Q

Abruption causing IUFD w/ consumptive coagulopathy - next steps

A

If severe enough to kill fetus, stabilize mom and induce

Moderate bleeding, uterus tetanic and painful w/ grade 3 abruption
Low hgb/hct, fibrinogen, platelets
High fibrin degradation products

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46
Q

Who has the lowest glucose?
- Non-pregnant
- Pregnant
- Newborn

A

Term fetus or newborn (15 lower than mom in 3T)
Then pregnant (68)
Then non-pregnant (79)

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47
Q

Who has the lowest Hgb/Hct?
- Non-pregnant
- Pregnant
- Newborn

A

Pregnant - hgb 11
Non-pregnant - hgb 13
Fetal - hgb 17

Hct - fetus 43.5 at term, neonate 51-59

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48
Q

Who has the lowest calcium?
- Pregnant mom
- Fetus

A

Maternal - 9.2
Fetal - 10.4

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49
Q

Who has the lowest iron?
- Non-pregnant
- Pregnant mom
- Fetus

A

Non-pregnant - 90
Maternal - 56
Fetal - highest >100

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50
Q

Incidence of chromosomal abnormalities in 1st trimester SAB?

A

50-60%
Most commonly autosomal trisomy

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51
Q

Incidence of chromosomal abnormalities in IUFD?

A

5%

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52
Q

Incidence of chromosomal abnormalities in screened neonates?

A

Major congenital anomaly - 3%
0.18% by age 25

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53
Q

Reasons for elevated AFP other than NTD?

A

Underestimate GA
Multiples
IUFD
Isoimmunization
Cystic hygroma
Other causes of fetal edema/skin defects
- Omphalocele, gastroschisis

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54
Q

Basis of KB test

A

HgbF resistant to acid (remains intact) and uptake of stain - are pink, maternal cells “ghost-like”

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55
Q

KB calculation for Rhogam

A

Volume of fetal blood = % fetal cells x 50

Need 1 vial (300mcg) for every 30ml fetal blood

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56
Q

High spinal - location, management

A

T4
Numbness/weakness in fingers/hands means C6-8 involved (close to diaphragm)
If breathing and ok CV status, reassurance and O2
If diaphragm involved, need assisted ventilation
CV support as needed
Displace uterus lateral

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57
Q

Normal cord gases

A

Venous - pH 7.32-7.35; pCO2 38.2-43.8, HCO3 20.4-22.6, BE -2.4-2.9
Arterial - pH 7.24-7.28, pCO2 49.2-56.3, hCO3 22-24.1, BE -2.7-3.6

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58
Q

Cord gas in metabolic acidosis

A

Normal pCO2, decreased HCO3

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59
Q

Cord gas in respiratory acidosis

A

Increased pCO2, normal HCO3

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60
Q

Fetal effects of maternal hyperventilation

A

Maternal resp alkalosis, decreased pCO2
Severe anxiety, ASA toxicity, fever, sepsis, PNA/PE, high altitudes

Increased FHR?
Shift in O2 dissociation curve? Lower pO2 in umbilical cord and lower uterine blood flow, but alkalosis causes L shift and higher affinity of hgb for O2. This plus increased umbilical blood flow compensates to allow O2 delivery to fetus to remain constant

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61
Q

Fetal effects of maternal hypoventilation

A

Increased pCO2 -> respiratory acidosis in baby

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62
Q

Scalp pH interpretation

A

pH is same as capillary blood - lower than umbilical venous pH, similar to arterial
Cutoff <7.2 is abnormal

Metabolic acidosis occurs when fetus receives inadequate O2 to maintain normal metabolism and has to switch to anaerobic metabolism

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63
Q

What happens to maternal cholesterol in pregnancy?

A

Increases
Lipids increase - total, free, and triglycerides
Due to estrogen, progesterone, hPL
- HDL peaks at 25wks

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64
Q

Lipid profile in diabetics?

A

Increased TG, decreased HDL

TG and VLDL correlate w/ estriol and insulin

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65
Q

Breakdown of zygosity in twinning

A

Dizygotic = 80% (variable in diff populations)
Monozygotic = 20% (0.3% of all births)
- 13-14% mo/di (75% of monozygotic twins)
- 6-7% di/di (25% of monozygotic twins)
- 1% mo/mo

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66
Q

Listeria

A

Transplacental transmission - Microabscess, chorio (granulomatosis infantiseptica)
50% mortality
- Worse prognosis w/ prematurity
- 100% loss in 1T, 70% in 2T, <5% in 3T
Early onset sepsis (infxn in 1st week of life - acquired during or after birth)
Can also have late-onset - more variable
Can manifest as meningitis - usually after 3 days of age

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67
Q

Coxsackievirus

A

Hepatitis, myocarditis, encephalitis
Chorio

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68
Q

Varicella

A

Congenital varicella syndrome:
In 1st half of pregnancy - can cause malformations
- Chorioretinitis, cerebral cortical atrophy, hydronephrosis, skin/body leg defects
- Highest risk 13-20wks

Neonatal VZV infection:
Exposure before or during delivery means no maternal antibody protection
- Can lead to disseminated visceral and CNS disease -> death
VZIG should be given if maternal infection within 5 days of delivery

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69
Q

How long after MMR should you wait to conceive?

A

3 months

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70
Q

What CV issues are beta blockers used in?

A

Marfan’s - aortic root diameter >4cm
Mitral stenosis - BB to reduce HR, allow diastolic flow across valve, improve pulm congestion; most also need lasix
Septal defects - BB for HR control
- W/ significant pulm/systemic shunt, can normally expand CO but with high pulm flow, may get tachyarrythmias
IHSS - BB if pt has angina, dizziness, exertional dyspnea to reduce contractility and HR

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71
Q

Placental sulfatase deficiency

A

= X-linked ichthyosis (X-linked recessive)

Causes low estrogen, long pregnancies, difficult to get into labor

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72
Q

Recurrence risk of pyloric stenosis

A

Doesn’t follow classic Mendelian inheritance, but is likely hereditary
- Multifactorial threshold model - caused by polygenic inheritance of genes that are modified by sex and environmental factors
- Model assumes that the “liability” to pyloric stenosis is determined by the additive effect of numerous genetic and environmental factors and that the condition is expressed when an individual’s liability exceeds a critical threshold value = all or none

More common in males
If affected female, siblings/children have even higher chance of being affected - recurrence 2-3% higher than avg
- Male siblings/offspring at greatest risk

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73
Q

What conditions that cause mental retardation are correctable in infancy?

A

Maple syrup urine disease
- AR, due to deficiency of branched chain ketoacid dehydrogenase
- Increased levels of branched-chain amino acids leucine, isoleucine, and valine
- Dietary restriction to reduce toxic metabolites - BCAAs

PKU
- AR
- Early dx to prevent neurologic disease - treatable

Congenital hypothyroidism
- Most commonly due to thyroid agenesis
- Most sequelae preventable - early and aggressive thyroxine replacement

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74
Q

Most common cause of intellectual disability?

A

Genetic abnormalities
- Chromosomal abnormalities - Down syndrome single most common known genetic cause of ID
Prenatal causes - 73%

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75
Q

What percent of children w/ 5min Apgar <5 will have ID?

A

5%

Associated w/ 25% cases of CP

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76
Q

Definition of perinatal asphyxia

A

pH <7, BE >11, Apgar <3 at 5min
Evidence of neuro sequelae like seizure, hypotonia, etc; organ system dysfunction

Unlikely to have ID in absence of seizure or CP (isolated cognitive deficits unlikely)

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77
Q

Robertsonian translocation - risk of abnormal child

A

15% if carried by mom, 2% if by dad

5% of RPL

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78
Q

Estriol in pregnancy
- Precursor?
- When is it detected and when does it surge?
- What can abnormal estriol signify?

A

Precursor - DHEAS (fetal adrenals)
Detected at 9wks, surges at 35-40wks
Abnormal could signify - fetal compromise (drops quickly after fetal death), anomalies (T21, anencephaly, adrenal atrophy), mole (low levels due to absence of liver/adrenal - no precursors)

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79
Q

DU antigen

A

Weak D
Same as Rh positive - mom will need Rhogam if fetus DU positive and she is neg

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80
Q

What happens to the following in pregnancy?
- Estriol
- Bilirubin
- AST/ALT/GGT
- Alk phos

A

Estriol - increases
Bili, AST/ALT, GGT - slighly lower
Alk phos - doubles due to heat stable placental alk phos

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81
Q

Drug clearance in pregnancy
- Hydrocortisone
- Phenobarb and carbamazepine
- Dilantin

A

Hydrocortisone - no change in clearance, no increase dose, 20-30mg/day usually
Phenobarb and carbamazepine - increased hepatic clearance 2/2 protein binding (seizure threshold lowered)
Dilantin - serum conc falls in pregnancy, rises in labor and PP
- Total serum concentration declines due to falling albumin levels. Free levels unchanged

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82
Q

Hereditary risk of eclampsia

A

Sisters and daughters of eclamptics 25-37% risk of preE and 3-4% risk of eclampsia with G1

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83
Q

Neonatal Graves - sx, treatment

A

Goiter - can obstruct airway
Jaundice, thrombocytopenia

Treatment - thionamides, BB, iodine
- Methimazole in neonates - PTU has more frequent and severe side effects in childhood

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84
Q

Prenatal diagnosis of T21

A

80% in <35 yo
Triple screen - 60%

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85
Q

Prenatal dx of CF

A

75% are delta F508
- If neg mutation on standard, consider linkage analysis
Allele R117H more common w/ b/l absence of vas deferens
Dx w/ PCR, PAGE

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86
Q

How to treat mag toxicity?

A

Calcium gluconate 10ml of 10% solution over 3 min

Half life of mag = 4h

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87
Q

Most common neonatal infection?

A

CMV
- DNA herpesvirus
- If primary, 40% transmission rate
- Of these, 10-15% with disease, most asymptomatic
- Of disease, 90% have sequelae, 10% normal
- Of asx, 5-15% develop sequelae

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88
Q

Asthma in pregnancy
- What drug can cause bronchospasm?
- Rates of worsening?

A

Indomethacin can cause bronchospasm
30% worsen in pregnancy
60% - behaves similar in subsequent pregnancies
1-10% exacerbations during labor, 18x higher for CD
10% risk of PEC, 10% IUGR, 7% PTD, 2% GDM

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89
Q

US safety levels

A

ALARA
No malformations w/ diagnostic US
Set lower than safe elvel - <100mW/cm2 unfocused, <1W/cm2 focused

Watts per square cm = intensity

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90
Q

Delta OD450 - what is it and what does it predict?

A

Bilirubin in amniotic fluid due to fetal hemolysis - reaches AFI from pulmonary secretions and diffusion
- Bili shifts density w/ peak at 450nm
- Estimates degree of RBC hemolysis

Amniotic fluid delta OD (optical density) 450 values accurately predict severe fetal anemia in D-alloimmunization

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91
Q

Amnio for fetal lung maturity values:

A

Sphingomyelin - not related to FLM
Lecithin rises w/ GA and S falls
- L/S >2 is normal, significant for appropriate fetal lung development

RDS 73% of L/S <1.5
- 50% L/S 1.5-1.9
- 2% if >2

PG (phosphatidylglycerol) - appears at 35wks if mature
- Can be used w/ blood or mec
PI (phosphatidylinositol) - decreases as PG appears (share a precursor, CDP diacylglycerol)

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92
Q

Most common local anesthetics used in epidurals?

A

Bupivicaine (marcaine) and chloroprocaine
- Bupivicaine - longer half-life, delayed onset
- Combine w/ narcotic for less motor blockade
Continuous epidural infusion a/w late decels - more common w/ bupivicaine than chloro or lido

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93
Q

Cholinesterase deficiency

A

Can’t metabolize esters (local anesthetics=caines)
Autosomal recessive - fetus could be affected

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94
Q

Folate
- Dietary sources?
- Where is it stored?
- S/sx of deficiency?

A

Water soluble
Greens, peanuts, liver
Stored in liver x 6wks
- Levels fall after 3wks deficiency
Hypersegmented neutrophils -> RBC folate drops -> megaloblastic bone marrow
- Hypersegmented neutrophils, followed by macrocytosis, followed by anemia
Most common cause of megaloblastic anemia in pregnancy
- Increased need for folate in pregnancy due to fetal demand, decreased gastric absorption

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95
Q

Hemoglobin electrophoresis in beta thal minor

A

Increased A2 >3.5%
Increased F >2%

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96
Q

Hemoglobin electrophoresis in S-beta thal

A

S 70-95%
F < 20%
A2 >3.5%
Some hgbA (if beta thal plus)

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97
Q

Hemoglobin electrophoresis in SCT

A

S 30%
A > S
- A:S ratio usually 60:40

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98
Q

Hemoglobin electrophoresis in Hgb SC

A

50% S
50% C

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99
Q

Hemoglobin electrophoresis in Hgb SS

A

> 90% S
<10% F
No A

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100
Q

What are next steps in pregnancy w/ IUD in place?

A

Remove
- 54% SAB, 20% IUGR if left in place
- Risk of septic AB
- 25% SAB if removed

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101
Q

Uterine anomalies - risk to pregnancy

A

Survival
- 58% bicornuate
- 65% septum
PTL
- 37% unicornuate
- 20-80% bicornuate
- 4-17% septum
29% of all ended in loss

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102
Q

Drugs contraindicated in breastfeeding

A

Amantidine
Amiodarone
Chemo
Bromide
Cocaine
Chloramphenicol
Dipyrone
Gold salts
Iodide
Radioactive
Large dose ASA

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103
Q

What decreases fetal breathing?

A

PGE2 (labor
Narcotics

104
Q

What increases fetal breathing?

A

Indomethacin
Theophylline
Increased core temp

105
Q

Spermicide

A

Nonoxyl-9
Next to cervix, effective 1hr max
High failure rate

106
Q

Cause of bleeding from umbilical cord stump
Testing

A

Immediate = platelets
Delayed = soluble component disorder (factor VIII)
Oozing >2d after dental procedure = vWD

PTT intrinsic (VIII or IX)
PT extrinsic (V, VII, X)
Bleeding time (platelet # and function)
Clotting time (fibrinogen)
- No clot in 10min means <50mg/dL
Normal coag screen - either factor XIII deficiency or vascular abnormality

107
Q

Intracranial venous occlusive disease
- When does it occur?
- Symptoms?
- LP results?
- How to diagnose?
- Prognosis?
- Treatment?

A

3rd trimester or PP
Sx - HA, paresis, focal/generalized seizures, drowsiness, confusion, fever, speech/vision/sensory disturbance
- Intermittent HTN
- Suspect if isolated HA w/o other evidence of preeclampsia
LP - increased CSF pressure, protein
Dx w/ CT or MRA
1/3 die, can recur
Tx - dex?, mannitol, anticonvulsant, heparin to prevent extension

108
Q

Sensitivity

A

Disease correctly identified by positive test

TP/TP+FN

109
Q

Specificity

A

Healthy correctly identified w/ negative test

TN/TN+FP

110
Q

PPV

A

True positives of those who test positive

TP/TP+FP

111
Q

NPV

A

True negatives of those who test negative

TN/TN+FN

112
Q

Treatment of thyroid storm

A

ICU
Supportive care - fluids, correct lytes, O2 if needed, tylenol for fever
PTU (preferred - more rapid onset, inhibition of conversion of T4 to T3)
Beta blocker
Iodine 1hr after thionamides
Steroids to reduce peripheral conversion

ASA can increase thyroid hormones
Dig if CHF
Abx if infection

113
Q

Renal transplant in pregnancy

A

Should wait 18-24mo before pregnancy
- Ok if minimal proteinuria, no HTN, no rejection, no calyceal dilation, Cr <1.4

Sequelae:
- 40% SAB in 1st trimester
- 9% serious rejection
- 45-60% PTD
- 30% PEC
- 20% IUGR
Pregnancy has no effect on graft function
10% will die w/in 7 years of pregnancy, 50% w/in 15 years

114
Q

In utero exposure to hep B - cancer risk

A

40% risk in chronic carrier infected neonatally

115
Q

In utero exposure to DES - cancer risk

A

1/1000 - incomplete carcinogen

116
Q

In utero exposure to cyclosporin, cyclophosphamide - cancer risk

A

No cancer risk

117
Q

Seizure med teratogenisis

A

Most common anomaly = cleft
CHD - risk higher on meds, polytherapy

118
Q

Prostaglandins for IOL
- What are prostaglandins?
- Precursors?
- Half-life?
- What makes F2, E2, prostacyclin?
- What do E and F do?

A

Bioactive lipids; hormone-like function; E and F are paracrine/autocrine hormones
Precursors - arachidonic acid and fatty acids
Half-life 1-2min
F2 - maternal decidua
E2 - fetal membranes (amnion)
Prostacyclin - myometrium
F - promotes contractions
E2 - cervical maturation

119
Q

Progesterone synthesis

A

Syncytiotrophoblast uses maternal cholesterol to make pregnenolone (or uses fetal pregnenolone), which is converted to progesterone by 3-beta-steroid dehydrogenase (fetus doesn’t have 3-b-OH-d)
- Progesterone passes into fetal circulation, metabolized in fetal adrenal into corticosteroid sulfates
- Passes into maternal circulation - makes uterus quiescent
Placenta can’t convert pregnenolone or progesterone to DHEA - lacks 17-alpha-hydroxylase

120
Q

Estrogen synthesis in pregnancy

A

Fetus uses LDL to make DHEAS in adrenals
- Sends to placenta - converts to androstenedione -> estrone and testosterone -> estradiol
DHEAS sent to fetal liver - converted to 16-a-OH DHEAS
- Sends to placenta - 16-OH androstenedione -> estriol

Placenta lacks 17-a-hydroxylase, so it can’t produce estrogen de novo from cholesterol and can’t convert progesterone to DHEAS

121
Q

Hyperparathyroidism - maternal effects

A

Fatigue, N/V, constipation, dyspepsia, polyuria, nephrolithiasis, pancreatitis, HTN, bone disease

Treatment - hydration, loop diuretics, oral bisphosphonates, calcitonin (opposes PTH), mag, sometimes dialysis

122
Q

Hyperparathyroidism - fetal effects

A

Hypocalcemia/tetany (suppression of fetal PTH), prematurity, SAB
High rate of complications and death

123
Q

Mortality of maternal cardiac disease by groups

A

Group 1 - minimal disease
- 0-1% mortality
- NYHA I/II
- ASD, VSD, PDA, corrected tet, bio valve,

Group 2
- 5-15% mortality
- NYHA III/IV
- AS, coarc w/o valve involvement, uncorrected tet, prior MI, Marfan w/ normal aorta
- MS w/ afib, artificial valve = worse

Group 3
- 25-50% mortality
- PHTN, coarc w/ abnormal valve, Marfan w/ abnormal valve, Eisenmengers, PP cardiomyopathy w/ persistent decreased LV function

124
Q

Mechanism of contractions (cAMP)

A

Beta 2 adrenergic receptors (R) on uterine smooth muscle.

Stim of R 🡪 adenylate cyclase via stim of G protein 🡪 increased cAMP 🡪 protein kinase A 🡪 myosin light chain phosphorylation 🡪 also decreased Ca entry and increased Ca efflux. Net result is relaxation.

125
Q

Neonatal adaptation to extrauterine life

A

First few breaths make FRC
Clearance of fluid - chest compression when passing through birth canal
Expansion of lungs stimulates surfactant release, which stabilizes FRC
PVR decreases -> increased flow to lungs
Low placental resistance closes off circulation and establishes high resistance systemic circulation to reduce R->L shunt through DA/FO
Increase in PaO2 -> closure of DA

126
Q

UA Dopplers

A

Measurements taken near placental insertion have lower resistance
- Resistance higher at abdominal insertion
- Dopplers are worse at UCI than PCI
Don’t always have diastolic flow <15wks
Breathing can affect Dopplers (make them better?)

127
Q

Hepatitis B timeline (serology)

A

HBsAg 🡪 HBeAg 🡪 HBcIgM🡪 anti HBe 🡪 core IgG 🡪 HbsAb

HBsAg, then HBeAg
Anti-HBc (anti-core) IgM
Anti-HBe
Anti-HBc IgG
Anti-HBs (anti-surface) = immunity

128
Q

Mechanism of action - methyldopa

A

Central alpha2 receptor agonist
Reduces SVR
CO/renal flow unchanged
Side effects - dry mouth, drowsy, lethargy, LFT abn, hem anemia, +Coombs, postural hypotension

129
Q

Mechanism of action - Clonidine

A

Potent alpha2 adrenoreceptor agonist
- Decreases norepinephrine release from central and peripheral sympathetics
Rebound HTN
CO/renal flow unchanged
Urinary secretion

130
Q

Mechanism of action - Prazosin

A

Alpha 1 blockade
Vasodilates to reduce preload and afterload
Renal flow unchanged
Metabolized in liver, 2-3h half-life
Side effects - fluid retention, orthostasis, congestion

131
Q

Mechanism of action - CCB

A

Inhibit calcium influx to block smooth muslce contraction
Vasodilation, reduction in PVR
CO/renal blood flow unchanged
Side effects - flushing, peripheral edema, dizziness, HA

132
Q

Mechanism of action - ACEi

A

Blocks angiotensin II
Vasodilation
Inhibits bradykinin

133
Q

Mechanism of action - Hydralazine

A

Direct peripheral vasodilator acting on vascular smooth muscle
Increases CO
Renal blood flow unchanged
Side effects - fluid retention, tachycardia, palpitations, HA, SLE, neo thromb
Half-life 3h

134
Q

Mechanism of action - Labetalol

A

Beta blocker
CO and RBF unchanged
Side effects - tremulousness, flushing, HA

135
Q

Mechanism of action - Thiazide

A

Takes 3-5d for 3-5% reduction in plasma and extracellular volume
Decreased CO, return to baseline after 1mo
Long term decrease in PVR afterward - decreased sodium in smooth muscle

136
Q

What increases risk of aspiration from anesthesia?

A

> 25ml in stomach or pH <2.5
Uterus - increases intragastric pressure
GES less competent
Delayed gastric emptying (low motilin)
Increased gastrin (more acidic, volume higher)

137
Q

What is the risk of conversion to SVT with PACs?

A

1%

138
Q

Most common risk factor for brachial plexus injury

A

Prolonged labor/difficult delivery?

139
Q

Cocaine teratogenic effects

A

Skull defect, cutis aplasia, porencephaly (due to bleed), heart defects, atresias, UT abnormalities, bowel/limb infarct
SAB/IUFD

140
Q

When can a fetus respond to sound?

A

Hearing organs 24wks
Brain response 26-28wks

141
Q

Why is hypoxia during intubation faster in pregnancy?

A

Increased metabolic demand, reduced FRC - reduced O2 reserve
- Hypoxia happens more rapidly if ventilation or CO become inadequate

142
Q

Triploidy - sequelae

A

Holoprosencephaly, ventriculomegaly, ACC, NTD, facial abn, IUGR, SUA, syndactyly, CHD, GU abn

143
Q

Type 1 triploidy

A

Diandric - add’l chromosome set is paternal
Large cystic placenta, IUGR, elevated hCG/AFP/Inhibin

144
Q

Type 2 triploidy

A

Digynic - add’l chromosome set is maternal
Small non-cystic placenta, IUGR, low hCG/estriol

145
Q

Symptoms of renal transplant rejection

A

Fever, oliguria, abn labs, CVA tenderness, renal enlargement
Can only r/o w/ biopsy
Follow w/ serial labs

146
Q

Why don’t anti-lewis antibodies cause HDFN?

A

Not true erythrocyte antigens
Secreted by other tissues and absorbed on RBC surface. Fetal erythrocytes acquire very little antigen in utero and react very weakly to anti-Lewis.

147
Q

Physiology of aortic stenosis

A

Without valve replacement, 50% survive 5 years after angina, 3 after syncope, 2 after LV failure
Pregnancy - may have increasing exercise intolerance
Gradient of 60 or less do well

Excess LV overload. Ventricular hypertrophy increases cardiac O2 requirement. Increased diastolic pressure impairs coronary perfusion. LV requires adequate filling to generate sufficient systolic pressure to produce flow across valve. Small loss of LV filling results in large fall in CO - very sensitive to loss of preload (hemorrhage, epidural). Pulmonary edema d/t excess preload better tolerated than hypotension/hypovolemia.

148
Q

Major cause of ureteral dilation in mom?

A

Begins 2nd month, peaks 2nd trimester
2cm diameter
Compression by ovarian plexus and uterus
Progesterone/smooth muscle relaxation contribute
More prominent on R - dextrorotation of gravid uterus, engorged R ovarian vein

149
Q

Placental glucose

A

70% of glucose taken up by uterus consumed by placenta
1/3 converted to lactate (fetal energetic substrate)
Aerobic

150
Q

Prolactinoma in pregnancy

A

Stop bromocriptine unless levels >200 or abnormal MRI
No a/w congenital anomalies
Complications - 1-4% w/ microadenoma, 35% w/ macroadenoma
Worsening s/sx - visual field testing, MRI if abn

151
Q

HPV transmission to fetus

A

Causes laryngeal papillomatosis in kids
5-30% oropharyngeal transmission
3% infants seropositive at 1-2yrs

152
Q

Aromatase deficiency

A

Androstenedione not converted to estradiol
- Excess ASdione secreted to mom and baby causing virilization
- Males have delayed puberty and tall stature

153
Q

What can accelerate fetal lung maturation?

A

Steroids
TRH
T3
Beta agonists
Prolactin
EGF
TGF-alpha

154
Q

What can delay FLM?

A

Androgens
Insulin
TGF-beta

155
Q

Dose of thioamide during thyroid storm?

A

PTU 300mg q6h

156
Q

Absent stomach - DDx

A

1% of normal fetuses
Esophageal atresia
TEF
CDH
Clefts (impaired swallowing)
CNS disorder
Arthrogryposis
TTTS
T18
Triploidy
Renal agenesis
Oligohydramnios

157
Q

Polycystic kidney disease - types

A

Type 1
- AR, infantile
- Big kidneys, cysts not visible
- Oligo, hepatic fibrosis
Type 2
- MCDK
- Failed development of metanephros
- No normal tissue
- Contralateral abnormal in 40%
Type 3
- AD, adult
- Renal failure in 5th decade
- Berry aneurysm
Type 4
- Obstructive cystic dysplasia
- Small, cysts, hydro
Syndromes - Meckel Gruber, T13, Beckwith-Wiedemann, Tuberous sclerosus

158
Q

Most common antenatal finding in toxo?

A

Ventriculomegaly

Also - intracranial calcifications, liver calc, ascites, hydrops, placentomegaly

159
Q

Most important factor influencing Apgar?

A

Gestational age

160
Q

What does confidence interval mean?

A

95% probability that the interval contains the population mean
- Contains true RR w/ 95% confidence

161
Q

RR vs OR

A

RR - risk of exposed to risk of non-exposed
- (a/a+b)/(c/c+d)
OR - odds exposure in diseased group divided by odds exposure in non-diseased group
- ad/bc
- Used in case control - approximates RR when cases are representative of all w/ disease, controls represent population, and disease infrequent

162
Q

Management of vWD

A

Check factor VIII levels periodically
Pretreatment if <50% of normal

163
Q

Test for alloimmune thrombocytopenia?

A

HPA-1a

164
Q

High dose aspirin in pregnancy

A

No teratogenesis
Decreased uterine contractility
Newborn platelet dysfunction if taken within 5 days
Closure of fetal DA

165
Q

Fragile X

A

Most common cause of familial intellectual disability
FMR1 gene
CGG repeats
- Can only expand when transmitted by female
Premutation - 56-229
20% asymptomatic and non-transmitting
Not perfect transmission 2/2 mosaicism and ionization

166
Q

TTP symptoms

A

Pentad:
- MAHA
- Thrombocytopenia
- Neurologic abnormalities
- Fever
- Renal

167
Q

Preeclampsia is associated w/ what changes in:
- Renin
- Fibronectin
- Ang II

A

Renin/angII/ald - all decrease in PEC (normally increase in preg)
Fibronectin - increased 2/2 endothelial damage
Ang II - increased vascular sensitivity

168
Q

Exercise to the point of exhaustion is not recommended in pregnancy because…

A

If prolonged, increases fetal heart rate (5-15 bpm). Reduced birth weight 2/2 decreased fat. Changes in uterine blood flow compensated by hemoconcentration to increase O2 carrying capacity and increased placental oxygen extraction.

169
Q

Phospholipase A2 - mech of action
What bacteria is associated?

A

Cleaves arachidonic acid from fetal membranes to make it available for prostaglandin synthesis
Bacteroides, peptostrep, fusobacterium, strep viridans, strep fecalis, GAS and GBS, E. coli, Klebsiella, staph epi
- These bacteria produce phospholipase A2 and can cause PTL

170
Q

Abx for salmonella

A

Chloramphenicol - most effective
- Also bactrim, amp, cipro, cefotaxime

171
Q

Heroin effects

A

Increased withdrawal
IUGR, PTD, IUFD, meconium, low Apgars

172
Q

Chi square test

A

Nominal, proportions, or dichotomous data in contingency table

173
Q

Paired t test

A

Okay if individuals followed over time to see if there is a change in the value of some continuous variable
Considers variation from one group of people

174
Q

Simple t test

A

Compare means of continuous variable in two samples to see if there is a difference

175
Q

Mann Whitney U test

A

Non-parametric to compare two groups of ordinal data (more than 2 values and have implied direction from better to worse but aren’t continuous)

176
Q

Selection bias

A

When subjects are self-selected into study groups
Commonly seen in studies of treatment methods and terminal diseases

177
Q

Allocation bias

A

Investigator chooses non-random method of assigning subjects to study groups
May occur if a random method is chosen but not followed

178
Q

Trisomy 20 mosaicism

A

Most common mosaic trisomy dx with amnio
93% are normal phenotype

179
Q

Paracentric vs pericentric inversion

A

Paracentric - inversion does not involve centromere, occurs in only 1 arm
Pericentric - inversion includes centromere
Risk of affected child - 1-3%, 5-10% if already have affected child

180
Q

What increases risk of loss w/ CVS?

A

Fundal placenta
Increased # of passages
Prior bleeding

181
Q

Myotonic dystrophy

A

Autosomal dominant
Most common cause of adult myopathy
Wide age of onset
Unstable CTG repeats, chromosome 9
- 3-30 repeats normal
- Can increase via transmission from either parent
Fetal effects - poly, arthrogryposis
Affected moms - SAB, PTL, poor uterine contractions, hemorrhage
Regional anesthesia preferred
Dx made by DNA probe

182
Q

Beta thal

A

A2 >3.5%, F >2%
Chromosome 11

Major - Cooley’s anemia, hemolysis, need transfusions
- Neonate healthy until HgbF falls (6mo)
- Improved w/ deferoxamine
- Some need BM transplant
Minor - hypochromia, microcytosis, slight to mod anemia

183
Q

vWF

A

Platelet adhesion to subendothelial collagen and formation of hemostatic plug

184
Q

Symptoms of TTP

A

90% have neuro sx
- HA, backache, AMS, convulsions, stroke

185
Q

Lupus anticoagulant

A

Prolongs PT, aPTT and RVV times

186
Q

Beta2 glycoprotein

A

Anticoagulant inhibition of prothrombinase activity of platelets
High concentration in syncitiotrophoblast
Can prevent implantation or 🡪 intervillous space thrombosis

187
Q

Myasthenia - what local anesthetic to use?

A

No procaine if taking AChE blockers - convulsions since not metabolized
Lidocaine ok

188
Q

Erythema migrans

A

Lyme disease
PCN
- If allergy, cefuroxime or erythromycin

189
Q

Desquamating rash

A

Toxic shock syndrome
- Exotoxin TSS toxin-1
- Renal/liver failure, DIC
Rash when recovering

190
Q

Cold agglutinin

A

Mycoplasma or mono - can cause autoimmune hemolytic anemia

191
Q

PCN resistant bacteria?

A

Mycoplasma - use macrolide

192
Q

What is not a/w DES?

Ectopic
SAB
PTL
Cervical insufficiency
Corrected perinatal mortality

A

Corrected perinatal mortality

193
Q

Peripartum cardiomyopathy - mortality

A

25-50% - CHF, arrhythmia, VTE
50% resolve in 6mo
- Of those who don’t, 85% die in 4-5yrs

194
Q

Drugs that affect efficacy of OCPs

A

rifampin, phenobarb, phenytoin, primidone, carbamazepine, ethosux, Griseofulvin, troglitazone

195
Q

OCPs can potentiate action of:

A

diazepam, chlordiazepoxide (Librium), TCAs, theophylline, BBs, caffeine, steroids, ETOH

196
Q

OCPs an decrease efficacy of:

A

Tylenol, ASA, benzo, methyldopa, oral anticoag, oral hypoglycemic

197
Q

Platelet disorders in pregnancy:
- Highest maternal mortality
- Maternal plt count normal
- Corrected w/ plasmapheresis
- Low neonatal/fetal counts

A

Highest maternal mortality: TTP
Maternal platelet count normal: NAIT
Corrected with plasmapheresis: TTP
Low neonatal/fetal counts: ITP, alloimmune, thiazide

198
Q

Factor XIII deficiency

A

AR
Commonly fatal in affected infants
ICH from trivial trauma, poor wound healing
Coags normal
Dx by dissolution of clot in urea
Treat w/ FFP, whole blood, cryo

199
Q

What heart defect causes cyanosis in pregnancy?

A

Tetraology
- SVR decreases in pregnancy, shunting worsens

200
Q

Cardiac defect w/ highest maternal mortality?

A

PHTN
Coarc w/ valve abnormality
Marfans w/ aortic involvement

201
Q

Cardiac defect treated w/ propranolol?

A

IHSS (those w/ angina, SVT, or arrhythmia)

202
Q

Cardiac defect affected by shortened diastole?

A

MS - shortens filling time and increases mitral gradient -> pulm edema

203
Q

Blood gas alterations w/ variable decels

A

Transient cord compression - causes respiratory acidosis

204
Q

Arginine vasopressin causes what FHR pattern?

A

Sinusoidal

205
Q

Components of cryo

A

Factor VIII, XIII, vWF, fibrinogen

206
Q

Meperidine half-life

A

3.5h

207
Q

Tay Sachs - how to diagnose, enzyme affected

A

CVS or amnio for enzymatic assay or molecular analysis
Lack hexosaminidase (test is for enzyme level in blood)
Death in 1st decade
Carrier detection by serum leukocytes

208
Q

Which is d/t a gene deletion?

Sickle cell
Beta thal
Alpha thal

A

Alpha thal
Others - mutation

209
Q

How to diagnose PKU

A

Molecular methods - testing level of Phe in blood (don’t have to test DNA)

210
Q

Hurler syndrome (Mucopolysaccharidosis)

A

AR
Deficiency of alpha L iduronidase
Activity measured by amnio

211
Q

What neonatal infections are associated w/ deafness?

A

CMV
Rubella

212
Q

Homologous translocation

A

Only have abnormal gametes
- Cause trisomy or monosomy

213
Q

How much do ppx antibiotics at time of Cesarean decrease infection?

A

50%
mostly wound and uterine

214
Q

Causes of increased twinning

A

Race
Hereditary
Age
Parity
Fertility drugs (dizygotic)

215
Q

Incidence of chromosomal abn in SABs

A

45-60%

216
Q

Single most important aspect to genetic counseling:

A

Pedigree

217
Q

Proportion of infants w/ T21 born to women under 35

A

80%

218
Q

Linkage analysis

A

A gene-hunting technique that traces patterns of disease in high-risk families. It attempts to locate a disease-causing gene by identifying genetic markers of known chromosomal location that are co-inherited with the trait of interest
- Identifies a specific chromosome w/ closely linked polymorphism
At least 1 affected member, the family member at risk, and 1 or both parents must be tested

219
Q

Limb defects in trisomies

A

T13 > T18 > T 21

220
Q

Accuracy of fetal echo?

A

Sensitivity 85%
- False negs w/ minor anomalies like small VSDs
- False pos w/ coarcs and VSDs

221
Q

What is obstructive cystic renal dysplasia?

A

Also called Potter type IV
Complication from prolonged obstruction of bladder outlet or urethra
Small kidney, fibrous tissue, cortical cysts
Unilateral - UPJ or UVJ obstruction
Bilateral - severe urethral atresia, PUV

222
Q

Microcephaly diagnosis

A

HC 3 SD below mean
33% with ID if HC 2-3 SD below, 62% if <3 SD

223
Q

Heparin side effects

A

Hemorrhage w/ lacs
HIT - 3-6%, manifests in 2-3wks
Osteopenia - more common w/ higher doses, longer durations, smokers

224
Q

PE - prevalence
Most common sx

A

Equal prevalence ante and PP, but higher mortality PP
Most common sx - dyspnea, chest pain, then cough
Most common findings - tachypnea, dyspnea, pleuritic pain

225
Q

Equivocal HIV testing

A

Considered positive with both +ELISA and western blot
Repeat test later
PCR can be useful to detect virus

226
Q

HIV epidemiology

A

Most common - sexual transmission, then IVDU

227
Q

Which has a decreased maternal serum concentration?

Insulin
FFA
Estradiol
PTH
Amino acids

A

Amino acids - due to placental uptake

228
Q

Umbilical venous blood characterized by:

Higher pO2 than intervillous space
Higher pCO2 than UA
Lower pO2 than intervillous space
Lower pH than UA
Lower hgb than uterine artery

A

Lower pO2 than intervillous space
- Venous blood is going back towards fetus - needs to be lower than intervillous space or else oxygen wouldn’t simply diffuse into the venous blood

229
Q

Classification of human placenta?

A

Hemochorioendothelial – maternal blood directly bathes syncytiotrophoblast

230
Q

What GA is AFI at max?

A

34wks

231
Q

Forceps

A

Kiellands: no pelvic curve
Barton: platy pelvis. Traction of head in transverse position
Tucker McClanes: Non-fenestrated and overlapping shanks
Simpsons
Elliot: fenestrated, overlapping shanks, greater pelvic curve than Simpsons

232
Q

Most common perinatal complication of PPROM?

A

RDS
Most common cause of death = prematurity

233
Q

What is the evaluation of an Rh negative mother?

A

Indirect Coombs = maternal antibody detection
Direct Coombs = evaluates fetus
- Detects antibodies attached to RBCs

234
Q

Most common cause of neonatal death?

A

Major anomalies

235
Q

Amniotic fluid composition

A

Osmolality falls w/ increasing GA to 250-260 near term
UA, urea, and creatinine increased
Protein declines after 32wks

236
Q

Immune globulin should be given to pregnant women for:

A

Hep A
Rubeola (measles) - w/in 3 days
Hep B
Varicella - w/in 96h

237
Q

Contraindication to breast feeding?

CMV
HSV
HBV
HCV
HIV
Mastitis

A

Mastitis

238
Q

Contraindication to beta mimetics

A

Absolute - maternal cardiac dz, severe preE, antepartum hemorrhage, uncontrolled DM, hyperthyroid
Relative - controlled DM, HTN, h/o severe migraines, increased risk of pulm edema

Beta mimetics (terb) - stimulate B2 adrenergic receptors, increase maternal HR and CO, produce peripheral vasodilation

239
Q

Risk factors for vasa previa

A

Velamentous insertion
Low lying placenta
Accessory lobe
Multiples
IVF

240
Q

Asthma in pregnancy:

Severity likely to increase
Increased risk of PTD
Long term corticosteroids contraindicated
Theophylline for acute asthma management

A

Increased risk of PTD

241
Q

Prophylaxis against aspiration PNA

A

Fasting, antacid to reduce gastric acidity, cricoid pressure (Sellick).

242
Q

Best anesthetic for asthmatic

A

Epidural w/ local/opioids - pain relief and avoidance of resp depression
Narcotics and ET can cause bronchospasm
If general must be used, ketamine doesn’t release histamine and is better
Depolarizing agents can cause bronchospasm

243
Q

Gut migration in embryonic development

A

At 8 weeks (6 fetal weeks), herniation occurs d/t midgut loop
Returns by 12 weeks or 61 mm CRL

244
Q

Contraindication to regional anesthesia:

A

Cardiac conditions that won’t withstand reductions in SVR: AS, PHTN, cyanotic lesions

245
Q

Highest flow rate in fetus:

Umbilical artery
Descending aorta: 67% of total cardiac output
Ascending aorta
Pulmonary artery

A

Pulmonary artery

246
Q

Etiology of preE

A

Spiral arteries
- Usually invade endovascular trophoblast. In preE decidual vessels but not myometrial vessels are invaded by endovascular trophoblasts.
- Magnitude of defective trophoblast invasion of spiral arteries correlated with severity of preE

247
Q

Highest hemoglobin oxygen saturation in fetus?

IVC
LA
RA
LV
RV

A

LA (70)

248
Q

Contraindications to OCPs

A

Absolute - VTE, bad liver, breast cancer, undx vag bleeding, pregnant, smoker >35
Relative - fibroids, GDM, elective surgery, epilepsy on meds, obst jaundice in preg, SCD/trait, DM, gall bladder dx

249
Q

Meckel-Gruber

A

AR
Cystic dysplasia of kidney (100%)
Postaxial polydactyly (55-75%)
Occipital encephalocele (63-80%)

250
Q

Most common complication of subclavian line placement?

A

Pneumothorax

251
Q

Hunter syndrome

A

Mucopolysaccharidosis II
XR
Gargoylism - course facial features
ID, skeletal abn, short stature

252
Q

ROC curve

A

Y axis = sensitivity
X axis = 1-specificity (false positive rate)
If sensitivity = false pos rate, diagonal straight line results, which is of no benefit; upper left would be best

253
Q

Risk of NTD w/ valproate

A

1.5%

254
Q

SBE prophylaxis - indications

A

Cyanotic heart disease unrepaired or incompletely repaired
Previous endocarditis
Surgical shunts
Artificial valves
Transplant w/ bad valve

Don’t need for C/S unless chorio

255
Q

Most common anomaly w/ diabetes?

A

CHD
Next - CNS

256
Q

Most frequent complication to preeclamptic receiving epidural?

A

Hypotension

MFM Written Boards (5 decks)

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