some common pathologies in pregnancy 2

Question 1

40 year old woman
10 weeks pregnant
Scan: nuchal thickening

what investigations should be done

Answer 1

Amniocentesis: Trisomy 21 (Down syndrome)

Termination Of Pregnancy For Abnormality (TOPFA) at 20 weeks

Question 2

down syndrome post mortem findings

Answer 2

External features of Down syndrome (several minor anomalies e.g., single palmar crease, epicanthic folds, protuberant tongue….and several others)
Duodenal atresia (a major anomaly)

Question 3

What’s the most common cardiac defect in trisomy 21?

Atrial Septal Defect (ASD)
Ventricular Septal Defect (VSD)
Atrioventricular Septal Defect (AVSD)
Persistent Ductus Arteriosus
Tetralogy of Fallot

Answer 3

Atrioventricular Septal Defect (AVSD)

Question 4

Regarding livebirth children with genetic abnormalities, which statement is most correct?

Kleinefelter Syndrome (47XXY) is the most common.
Trisomies: Edwards (T18) most common, followed by Patau (T13) then Down (T21).
Trisomes: Edwards (T18) most common, followed by Patau (T13) then Trisomy 8.
Trisomies: Patau (T13) most common, followed by Edwards (T18), then Down (T21).
Trisomy 21 is the least common trisomy in all livebirths.

Answer 4

Trisomes: Edwards (T18) most common, followed by Patau (T13) then Trisomy 8.

Question 5

28 year old mother poorly controlled diabetes mellitus
Pregnancy doing well until 36 weeks – baby stops kicking

Scan: No fetal heart movement = Intrauterine Death or IUD. When born this baby will be called a stillbirth.

Trial of labour attempted but baby too big 🡪 caesarean section

most likely Postmortem:
findings

Answer 5

Postmortem: huge baby (‘diabetic cherub’)
with broad shoulders (shoulder dystocia)

Glucose crosses the placenta and raises babies blood glucose. Insulin goes up in baby
Baby cannot reduce babies glucose as mum keeps sending more across the placenta

Longterm high insulin and high glucose 🡪 massive growth
Susceptibility to intrauterine death

Question 6

what different problems are encountered by diabetic women in pregnancy

Answer 6

1st trimester: Malformations
3rd trimester: Intrauterine death (probable sudden metabolic and hypoxic problems)
Labour: Huge babies that obstruct labour
Neonatal period: hypoglycaemia

Question 7

how should diabetes be managed antenatally

Answer 7

Need good glucose control before conception (to prevent malformations) and then all the way through (to prevent metabolic complications)

Question 8

35 year old woman
Well throughout pregnancy
36 weeks – spontaneous labour
Labour progresses well but mum has fever
Fetal heart beat lost minutes before birth

Resucitation unsuccessful
‘Fresh’ stillbirth

what will be done

Answer 8

Examine placenta in all cases of stillborn babies (and babies who go to neonatal unit…….)

showing cut off membranes

Diagnosis = acute chorioamnionitis

Question 9

what do placental membranes contain

Answer 9

neutrophils

Trilobed nucleus is easily deformable and allows them to move easily into tissues.
Phagocytose (ingest) and destroy micro-organisms

Question 10

what is chorioamnionitis

Answer 10

Acute inflammation = neutrophils present in membranes (chorioamnionitis), cord, and fetal plate of placenta

Question 11

Which organism causes acute chorioamnionitis?

Streptococcus bovis
Escherichia coli O157
Escherichia coli
Staphlycoccus aureus
Klebsiella spp.

Answer 11

Escherichia coli

Question 13

Acute chorioamnionitis = Ascending infection

Answer 13

Bacteria are typically perineal or perianal flora (e.g., E.coli) which ascend vagina and get into the amniotic sac

Mother ill: has fever and raised neutrophils in blood
But: Mother can be well

Question 14

how is presentation of infection in baby displayed

Answer 14

Intrauterine death
Ill in 1st days of life 🡪 neonatal unit
Cerebral palsy later on in lifeC

Question 15

How does ascending infection affect baby’s brain?

Answer 15

Neutrophils produce cytokine ‘storm’. This activates some brain cells, which then get damaged by normal hypoxia of labour.

Question 16

24 year old woman
Intravenous heroin addict
Also on methadone, cocaine, temazapam, + other drugs
Do opiates cross the placenta?

Answer 16

yes

Question 17

why would a pregnant iv drug users baby need to be prebooked to deliver in large maternity unit

Answer 17

So that baby can be admitted to neonatal unit and treated for opiate withdrawal
Discharge home after 5 days in unit
At 3 weeks baby ‘overfeeds’ with constant mouthing movements (? Methadone withdrawal) then gets better

{Pregnancy often proceeds well if mother eating properly
Immediate withdrawal from heroin when baby is born
Later withdrawal from methadone}

Question 18

32 year old woman
Normal pregnancy to term
Decreased movements of baby at 40 weeks
Scan – No fetal heart beat

what is the diagnosis

Answer 18

intrauterine death

Question 19

what is an overtwisted chord

Answer 19

Common cause of intrauterine death and neonatal illness
Cause – unknown – but probably a result of the muscular arrangement in the artery walls of human (and horse!) umbilical cords (the muscle layers are oblique – slight twisting probably helps arterial pulsation to push blood along the vein in the long cords of horse and humans and may help resist external compression)

Question 20

A 33 year old woman who is 35 weeks pregnant, presents with abdominal and back pain. Which statement is least correct?

Routine observations are required for initial assessment.
USS will be of clinical benefit.
In the absence of PV bleeding, placental abruption can be ruled out clinically.
Referral to the on call Obstetric team is advisable.
Admission to hospital is possible.

Answer 20

In the absence of PV bleeding, placental abruption can be ruled out clinically.

Question 21

33 year old woman
Hypertension during pregnancy
Vaginal bleed at 35 weeks

US
Separation of part of the placenta from uterus with collection of blood (a haematoma) behind placenta
Haematoma enlarging during ultrasound

Answer 21

Emergency caesarian section
Baby has low APGARS
Unwell in neonatal unit for 5 days then much better.

Question 22

placental abruption

Answer 22

Means separation of placenta from uterine wall
Results in hypoxia in baby
Often causes antepartum haemorrhage in mother

causes
Hypertension
Trauma
Other: for example cocaine