Study Guide Questions Flashcards
1
Q
Organisms associated w/ UTI/pyelo and alkaline urine
A
Proteus, Klebsiella, Ureaplasma
2
Q
Placental transport mechanism – Amino Acids
A
Active transport
3
Q
Placental transport mechanism – Glucose
A
Facilitated diffusion
4
Q
Placental transport mechanism – placental transfer of medications
A
Passive transport/simple diffusion
5
Q
Umbilical venous PO2 is always lower than….
A
Uterine venous PO2
6
Q
Prostaglandin that causes uterine relaxation
A
Prostacyclin
7
Q
Trinucleotide repeat # associated with pre-mutation fragile X
A
55-200
8
Q
Anti-inflammatory cytokine
A
IL-10
9
Q
Disease associated with repeats of DNA
A
Fragile X
Huntingtons
Myotonic dystrophy
10
Q
Maternal viral infections not compatible with breastfeeding
A
HIV
active/untreated TB
?Varicella
11
Q
Paternal exposures associated with early pregnancy loss
A
Mercury Lead Pesticides Hydrocarbons Anesthetic gases
12
Q
Paternal exposures NOT associated with early pregnancy loss
A
Atomic radiation
Agent orange
Recreational drugs
13
Q
Time in pregnancy that ciprofloxacin is recommended
A
anthrax exposure/treatment
14
Q
Antibiotic to avoid in Myasthenia Gravis
A
Gentamycin
15
Q
Gaucher disease is missing which enzyme
A
Glucocerebrosidase
16
Q
Canavan disease is missing what enzyme
A
Aspartoacylase
17
Q
Tay-Sachs is missing what enzyme
A
Hexosaminidase A
18
Q
Niemann-Pick is missing what enzyme
A
Sphingomyelinase
19
Q
Anesthesia med used for epidural hypotension that will decrease maternal HR
A
Phenylephrine
20
Q
Chemo toxicities: Adriamycin Bleomycin Methotrexate Cisplatin Cyclophosphamide
A
- Heart
- Pulm fibrosis
- Stomatitis
- Ototoxicity, renal toxicity
- Ovarian function
21
Q
Acrocentric chromosomes
A
13,14,15,21,22,Y
22
Q
Neonatal conjunctivitis caused by _____ in first 2 weeks postpartum
A
C. trichomoniasis
23
Q
Neonatal conjunctivitis caused by ______ at 21 days postpartum
A
N. gonorrhea
24
Q
Neonates get ppx for conjunctivitis against which bacteria?
A
N. gonorrhea
25
If you have to do GETA on asthmatic, which meds are preferred?
Ketamine-- bronchodilation
| Propofol -- airway reflexes
26
Acute treatment for Guillan-Barre
IVIG and plasmapheresis (steroids not effective)
27
MCDA risk of co-twin death following twin demise
10%
28
MCDA risk of co-twin neurologic abnormality following death of 1 twin
10-30%
29
% uterine blood flow going to endometrium
80-90%
30
Another name for prostacyclin
PGI2
31
Cervical ripening --> increased tissue vascularization....what drives this?
VEGF
32
With advancing GA there is an increased water content to the cervix to allow ripening/dilation....this is due to accumulation of what substance in cervix?
Hyaluronan content
33
True/False there is a genetic component to timing of parturition?
True
34
What hormone steeply rises before onset of labor?
Estrogen
35
How does the fetus contribute to starting labor?
Fetus is thought to influence placental steroid hormone production through activation of the fetal HPA axis
36
Steroids produced by fetal adrenal gland
DHEAS
| Cortisol
37
How can fetal DHEAS become an estrogen?
Directly aromatized to estrone in the placenta
OR
16-hydroxylated in the fetal liver, then converted to estriol in the placenta
38
In order for estrogen synthesis in the placenta to occur what must be present?
Fetal C19 androgens as a steroid precursor
39
What happens to maternal CRH in pregnancy?
Increase, mostly in 3rd trimester and then decrease sharply after delivery
40
What is the source of elevated CRH in pregnant women?
Placenta
41
Placenta CRH production is up-regulated by what?
Fetal corticosteroids
42
Placental enzyme that protects the fetus from high levels of maternal glucocorticoids?
11B-HSD2 (11 beta-hydroxysteroid dehydrogenase)
Converts cortisol to cortisone (inactive form)
43
Where is progesterone receptor located?
Nucleus
44
Perimortem TTTS occurs due to what anastomoses
AA and VV…the blood from living twin preferentially streams into the low pressure dead or dying twin
45
Peripartum TTTS is due to what anastomoses
AA and VV
46
Causes of acute peripartum TTTS
Delayed cord clamping
Pressure differences from contractions
Changes in fetal position
47
Hormone levels that are higher in recipient twin of TTTS
ANP
BNP
ENDOTHELIN 1
48
Protective anastomoses in TTTS
AA
49
Are VV anastomoses higher or lower in TTTS? AA?
Higher VV
| Lower AA
50
If one twin of TTTS has a velementous cord and or smaller placental share, is it the donor or recipient twin?
Donor
51
TAPS is defined as severe twin discordance in….
Hemoglobin
52
TAPS occurs due to
Small inter-twin anastomoses leading to chronic blood transfusion
53
Why doesn’t poly-oli happen in TAPS?
Chronic nature of the pathophysiology
54
Renin levels in donor/recipient of TTTS
Donor - high renin
| Recipient- low renin
55
Angioarchitecrture pattern of TAPS
Small, 3-4 AV
| Few small AA and VV
56
In TRAP what type of anastomosis cause the problem
The acardiac twin is fed by an AA anastomosis
57
2 events that must happen to get TRAP
1. One twin has circulator failure or nonfunctional heart in first trimester
2. Placenta has a direct AA that can support acardiac twin
58
% acardiac twins with chromosomal problem
30-50%
59
Part of acardiac twin usually more developed
Lower limbs
60
PCIs for TRAP
Usually close together or share a common insertion site
61
Placental findings in sFGR
Unequal placental sharing, peripheral PCI of one or both twins
62
Embryo splits 8-12d post fertilization
Mono-mono
63
Twinning with embryo splitting at 13-16d post fertilization
Conjoined
64
PCIs of mono-mono
Close to each other and connected by large AA anastomoses
65
Conjoined twins with fused UC. How many vessels present in cord?
Variable, 3-8
66
T/F - peripheral PCI and SUA common in mono-mono
True
67
In fetal growth discordance of twins one twin must be…
FGR
68
Equation for growth discordance
Big-little/big
69
Zygosity of mole-fetus twin
Dizygosity
70
Zygote splits 0-3 days post fertilization
Di-di
71
Zygote splits 3-8 days post fertilization
Mono-di
72
CD4 count threshold for opportunistic infections in HIV
<200
73
CAART medication that can be associated with glucose intolerance
Protease inhibitor
74
PCP prophylaxis
TMP-SMX at CD4 <200
75
MAC prophylaxis
Azitrhomycin at CD4 < 50
76
Infections associated with increasing perinatal transmission in HIV
Hep C
CMV
BV
Genital ulcer
77
HIV transmission risk with +VL and no medications
25%
78
HIV transmission risk with +VL and ZDV
8%
79
HIV transmission risk with VL <1000 and meds
1-2% (some lower reports)
80
VL cutoff for cesarean in HIV+
>1000 copies
81
Frequency of HIV RNA level checks
1st visit
2-4 weeks after initiating or changing meds
Monthly until undetectable, then at least q3 months
At 34-36 weeks to assess MOD
82
Timing of C-section for HIV+
38 weeks
83
ZDV regimen for c-section
3hours preop
1st hour - loading dose of 2mg/kg
2nd and 3rd hour - continuous infusion of 1mg/kg/hr
Continued as continuous until delivery
84
ZDV intrapartum for <1000 copies HIV
50-999 can give continuous infusion intrapartum , less than 50 the transmission seems less (expert opinion)
85
HIV+ scheduled for c-section for VL presents 1 week earlier with ROM...what is MOD?
Individualize -- unclear if csection after onset of labor or ROM prevents transmission
86
HIV med that interferes w/ methergine
Protease inhibitors
87
Purpose of intrapartum ZDV
Pre-exposure ppx to the fetus
88
Neonatal HIV ppx should be initiated how quickly
6-12hrs after birth
89
Neonatal HIV ppx when VL <50
4 weeks of zidovudine
90
Neonatal HIV ppx when VL >50
cART (zidovudine, lamivudine, nevirapine OR raltegravir) for 6 week course
91
High risk neonatal HIV ppx for VL>50 and what other circumstances?
New diagnosis of HIV this pregnancy
| Not taking any meds
92
cART general recommendations
Dual NRTI (nucleoside reverse transcriptase inhibitor) + Integrase inhibitor OR protease inhibitor
93
NRTI dual meds
Tenofovir + Lamivudine
Tenofovir + Emtricitabine
Abacavir + Lamivudine
94
Integrase inhibitor meds
Dolutegravir
| Raltegravir
95
Protease Inhibitor
Atazanavir plus ritonavir
| Darunivar plus ritonavir
96
Pre-conception or 1st visit lab tests in HIV+
```
VL
CD4 count
Drug resistance genotype panel
Toxoplasmosis immunity
Hep B, Hep A, Hep C
TB screening
G6PD screening
HLA b7501 screening
```
97
If HLA-B5701 HIV genotype, which medication to avoid
Abacavir
98
Where is progesterone mostly produced?
Corpus luteum until 7-9 weeks, then placenta
99
Progesterone function in mid-late pregnancy
Uterine quiescence -- limits PG production, inhibits expression of CAP genes (contraction associated protein)
100
T/F - estrogen exert effect by binding to nuclear receptors
True
101
Type of PG secreted by:
- Fetal membranes
- Decidua
- Myometrium
- Fetal membranes: PGE2
- Decidua: PGF2a
- Myometrium: PGI2
102
PGs that promote uterine contractions
PGF2a, PGE1, PGE3, Thromboxane
103
PGs that inhibit uterine contractions
Prostacyclin, PGE2, PGD2
104
PG regulation occurs within what cascade
Arachidonic acid cascade
105
In general how are PGs formed
from free arachidonic acid that is released from membrane phospholipids through phospholipase enzymes
106
How do PGs induce myometrial contractions
Increasing calcium influx into myometrial cells
| Enhancing gap junction formation
107
Oxytocin is released from what organ
posterior pituitary
108
T/F: during pregnancy oxytocin is degraded primarily by placenta
True - oxytocinase
109
What happens when myometrial Oxytocin receptor is activated (on cellular level)
Interaction w/ G-binding protein, simulates phospholipase C activity, increase production of ITP and influx of calcium
110
Myometrial contractions lead to increased intracellular concentrations of
Calcium
111
Substances that cross placenta via pinocytosis (4)
IgG
Insulin
LDL
Transferrin
112
Molecules that corss placenta via active transport
```
Amino acids
Ca
Iron
Phosphorus
Iodine
Vit C
```
113
Molecules that follow simple diffusion across placenta
CO2, O2, free fatty acids
114
Drugs that work on afferent arterioles of kidney
NSAIDs
115
Drugs that work on efferent arterioles of kidney
ACEi ARBs
116
Factors that promote surfactant associated protein A production
cAMP analogues
Epidermal growth factor
T3
117
C-19 steroids are the precursor to....
estrogens
118
Enzyme that is present in fetal adrenal gland but NOT in placenta
17-hydroxylase (needed to convert C-21 steroids to C-19 steroids)
119
enzymes needed for estrogen formation in placenta, located in what cells?
synctiotrophoblasts
120
low maternal estrogen levels
anencephaly
fetal demise
umbilical cord ligation
121
What day does blastocyst implant on endometrium?
Day 8-10 after ovulation
122
Majority of implantation sites are located where in uterus
upper 2/3 of uterus, more commonly on side of corpus luteum
123
_____ are thought to be essential for allowing the blastocyst (trophoblast specifically) and endometrium to "attach"
Integrins (alphav-beta3)
124
Controlled invasion of maternal vascular system by the ______ during implantation
Cytotrophoblast
125
3 factors that regulate trophoblastic invasion of maternal vascular system
Stimulate invasion:
1. Epidermal growth factor
2. Interleukin-1B
Inhibit invasion:
3. Trnasforming growth factor-B
126
Peak trophoblastic invasion of maternal vessels occurs at what GA
12 weeks
127
Functional unit of placenta
Chorionic villi
128
Structure of a chorionic villi
Core: connective tissue and abundant capillaries that connect with fetal circulation
Inner layer: cytotrophoblasts
Outer layer: synctiotrophoblasts
129
Type of hormones made by (1) cytotrophoblasts (2) syncytiotrophoblasts
(1) peptide
| (2) peptide, steroid
130
Elevated NK cells in endometrium associated with....
recurrent implantation failure
131
hCG is structurally similar to what hormones
alpha subunit: TSH, LH, FSH
| beta subunit: LH
132
Predominant producer of hCG
syncytiotrophoblasts
133
when can hCG be detected in urine/serum
7-8 days before expected menses
134
when is peak hCG production (100,000)
9-10 weeks gestation
135
What is the role of hCG in early pregnancy?
Rescue corpus luteum from premature demise
Can also stim CL to make estradiol, 17-hydroxyprogesterone, relaxin, inhibin through the LH receptor
136
Placenta takes over progesterone production at what GA
9-10 weeks GA
137
T/F: fetal ovary is active
False - it does not secrete estrogens until puberty
138
T/F - the fetal teste is active in utero
True - Leydig cells produce testosterone levels equivalent to adult male
139
Hormone that provides initial stimulus for teste development
hCG
140
What hormones/hormone conversions are needed to allow final maturation of male genital structures in the fetus?
Local conversion of testosterone to dihydrotestosterone by 5a-reductase
141
What placental hormone protects maternal system from being affected by fetal testosterone?
Placental aromatase
142
During first 6weeks of gestation, CL makes progesterone. What type of progesterone is elevated?
17alpha-OHP
143
Precursor to placental progesterone synthesis
Maternal LDL cholesterol
144
Placental enzyme converting Cholesterol --> Pregnenolone
CYP450
145
Placental enzyme converting Pregnenolone --> Progesterone
3beta-hydroxysteroid dehydrogenase
146
Location of placental conversion of cholesterol --> progesterone
Mitochondria
147
Major estrogen formed in pregnancy
Estriol
148
How is estriol different from estradiol and estrone?
Estriol is cleared more rapidly and has low affinity for sex hormone-binding globulin
149
Precursor substrate for estrogen synthesis in pregnancy
Androgen precursors (DHEAS)
150
Placental cells responsible for estrogen synthesis
Syncytiogrophoblasts
151
Placental enzymes needed to make estrogen
1. sulfatase to take 16alpha-OH-DHEAS to DHEAS
| 2. aromatase to take DHEAS to 17beta estradiol (-->estriol) + estrone
152
X-linked condition cause by placental sulfatase deficiency
Congenital X-linked ichthyosis
153
Effects of placental aromatase deficiency
Virilization of fetus and mother
154
Low levels of maternal serum estrogen caused by....
1. placental sulfatase deficiency
2. placental aromatase deficiency
3. fetal demise
4. anencephaly
5. complete mole
6. pseudocyesis
155
Which progesterone receptor is upregulated at the time of labor?
PR-A
156
How is progesterone thought to regulate uterine contractions
The ratio of PR receptors (PR-A to PR-B) in myometrial tissue predicts overall uterine contractile state.
When PR-B > PR-A progesterone promotes relaxation and anti-inflammatory genes
When PR-A > PR-B progesterone promotes uterine contractions and proinflammatory genes
157
Functions of elevated estrogen
1. increase gap junctions for myometrial contraction
2. increase uteroplacental blood flow
3. prepare breast for lactation
4. fetal development, organ maturation, surfactant production
158
Low 1st trimester PAPP-A levels associated with...
T21
T18
T13
159
2nd trimester low PAPP-A
FGR
| HTN
160
Function of PAPP-A
Cleaves IGF-binding proteins to make IGF available for trophoblast invasion and early fetal development
161
where is PAPP-A made?
Embryo
| Syncytiotrophoblast
162
What is PGF? Where is it produced?
VEGF analogous
| Made in extravillous cytotrophoblasts
163
How is PGF a biomarker for preeclampsia?
increased sFLt:PGF levels associated with preeclampsia
164
Human chorionic somatomammotropin (AKA hPL) is produced by? function?
Syncytiotrophoblasts
| Nutritional needs of fetus met
165
Function of pregnancy specific glycoproteins
modulate the maternal immune response
| low levels = SAB, FGR
166
Metabolic changes of pregnancy
```
Hyperinsulinemia
Insulin resistance
Fasting hypoglycemia
Increased circulating lipids
Hypoaminoacidemia
```
167
Etiology of insulin resistance in pregnancy
Human chorionic somatomammotropin and placental GH thought to be responsible
168
T/F -- maternal beta cell islet hyperplasia in pregnancy
True
169
When do HDL and LDL cholesterol increase in pregnancy?
HDL in early pregnancy
| LDL in late pregnancy
170
T/F - if prolonged maternal fast, gluconeogenesis will occur
False -- ketonemia, hypoinsulinemia and hyopglycemia
171
Where is Relaxin produced?
```
Corpus luteum
Decidua
Placenta
Prostate
Atria
```
172
Causes of elevated Relaxin levels
Multiples
| OHSS
173
T/F - Prolactin can be found in amniotic fluid
True - made by decidua, thought to function in regulation of solute and water transport
174
Period when breast most permeable to drugs?
During colostrum phase, 1st week PP
175
Factors that increase transfer of drugs into breastmilk
1. Non-ionized molecules
2. Non-protein bound molecules
3. Smaller molecules (<200)
4. Water soluble molecules (lipid barrier)
5. Long half-life
6. High pKa (breastmilk is more acidic 7.0)
176
Breastfeeding contraindications
1. HIV
2. Active/untreated TB
3. Active drug use
4. Infant with galactosemia
5. Ebola, Lassa, Marburg, Dengue viruses
6. Breast CA
7. Certain medications
177
Hormone causing myoepithelial contraction for milk expression
Oxytocin
178
Hormone that produces breastmilk
Prolactin
179
Soft markers, highest to lowest LR for aneuploidy
1. Nuchal thickening
2. Echogenic bowel
3. Short humerus
4. Short femur
5. EIF
6. UTD
180
Top 5 causes of pregnancy-related death
1. CV conditions
2. Infection or sepsis
3. Cardiomyopathy
4. Hemorrhage
5. Embolism
181
Physiology changes in:
1. Blood/plasma volume
2. HR
3. CO
4. SVR
1. Increase 40%/50%
2. Increase ~15bpm
3. Increase 40%
4. Decrease 20%
182
Aldosterone levels _____ in pregnancy
Increase (leading to Na and H20 retention)
183
T/F: the local anesthetic requirement is decreased in pregnancy
True
184
Treatment regimen to improve AFE outcomes
AOK - atropine, ondansetron, Ketorolac
185
NYHA Classes
1 - no symptoms
2 - symptoms with greater than normal activity
3 - symptoms with normal activity
4 - symptoms with rest
186
MOA of Terbutaline
Beta-agonist
187
Medications that can increase pulmonary resistance
```
Hemabate
Methergine
Misoprostol
Stadol
Systemic narcotics if hypoventilation and increased CO2 occurs
```
188
Oxytocin as a large bolus can lead to....
Decreased SVR and subsequent hypotension
189
Contraindications to Methergine
Severe HTN or preeclampsia
Ischemic heart disease
Vasoconstrictive disease
Pulmonary HTN
190
Hemabate contraindications
Severe asthma
| Pulmonary HTN
191
MOA of Magnesium as dilating vascular beds
- Increasing prostacyclin release
- Decreasing plasma renin activity
- Decreasing angiotensive-converting enzyme activity
192
Anti-HTN that increases arteriolar vasodilation
Hydralazine
193
Hydralazine increased blood flow notably to what organs
Uterus and kidneys
194
Side effects of Hydralazine
Reflex tachycardia
| Possible ventricular arrhythmia without b-blockade
195
T/F - Nitroprusside preserves uterine blood flow
True
196
Negative side effects of Nitroprusside
Reflex tachycardia
Cyanide toxicity with long term use
Cerebral vasodilation
197
Negative effect of Nitroglycerin
Uterine relaxant
198
Anti-HTN that increases renal perfusion and urine output
CCB's
199
Medications that can be used if eclamptic seizure is prolonged
Propofol
| Midazolam
200
IV fluid restriction in preeclampsia
80-100mL/hr
201
T/F - IV fluid preloading decreases hypotension following regional anesthesia
False
202
Muscle relaxants that should be avoided with Mg use
Vecuronium and Rocuronium -- nondepolarizing muscle relaxants
203
ABG values in pregnancy
```
pH - 7.44
pO2 - 104
pCO2 - 27-32
HCO3 - 18-22
Base excess - -3
```
204
How would ABG in pregnancy be different in morbidly obese pregnant woman
Decrease pO2 to 85, decrease pCO2 to 30 and increase in base excess to -4
205
If bronchoconstriction in asthmatic needing GETA, what induction agents can be used?
Ketamine and/or Propofol
206
What causes shortened interval from apnea to desaturation and hypoxia in GETA
Decreased FRC and increased oxygen consumption
207
GETA induction agents if hemodynamic instability is a concern
Ketamine and/or Etomidate
208
Muscle relaxant good for GETA
Succinylcholine
209
Historic definitions of sepsis
- Temp >38 or <36
- HR >90
- RR >20
- WBC >12k or <4k
210
Most common causes of sepsis
1. UTI/pyelo
2. Chorio/Endometritis
3. Septic AB
4. NEC fasciitis
4. Septic thrombophlebitis
211
In those using amphetamines or cocaine - hypotension tends to respond better to what pressor?
Phenylephrine
212
Induction agent to be avoided in active amphetamines or cocaine use?
Ketamine
213
Agents to prevent hypertension when needing GETA for amphetamines or cocaine use?
Nicardipine or short-acting opioids like remifentanyl
214
Why might hypotension after regional anesthesia occur in those with active amphetamines or cocaine use?
Endogenous catecholamine depletion
215
What is test dose for epidural?
3mL of Lidocaine + 5mcg Epinephrine -- to assess if accidental intravascular or subacrachanoid placement
Motor block = subarachnoid placement
HR increase 20bpm = intravascular placement
216
Drugs of choice for epidural
Bupivacaine or Ropivacaine (long acting)
| Fentanyl
217
Why not lidocaine or chloroprocaine in epidural?
Lidocaine - shorter duration, higher motor block (good for instrumental delivery or second-stage block)
Chloroprocaine - rapid onset but short duration
218
Common side effect of spinal opioids?
Pruritus
219
Vasopressors/Inotropes to use in AFE
Vasopressor - norepinephrine
| Inotropes - Dobutamine, Milrinone
220
Suspected trigger for AFE
entrance of material from the fetal compartment into the maternal circulation resulting in abnormal activation of proinflammatory mediator systems
221
What happens to uterus in AFE?
oxygenated blood is shunted away from uterus
| catecholamine induced uterine hypertonus
222
Risk factors for AFE
```
Operative delivery (cesarean or vaginal)
Placenta previa
Placenta accreta
Placenta abruption
Smaller: uterine rupture, cervical lacerations, eclampsia, poly, multiples
```
223
1st signs of AFE
Hypotension and hypoxia
224
Goal of serum glucose following AFE (critical illness)
140-180
225
Temperature recommendations following cardiac arrest
32-36 degrees
226
Risk of therapeutic hypothermia
Hemorrhage
227
Common echo finding following AFE
Dilated and hypokinetic right ventricle
228
How to improve RV function following AFE?
Inotropes - dobutamine and milrinone
| Decreasing pulmonary vascular restriction - the inotropes as well as sildenafil, prostacyclin, inhaled NO
229
What is the trend in heart function/failure following AFE?
RV failure followed by LV failure
230
Platelet goal in massive DIC
>50k
231
Factor VII only as last resort for DIC, why?
excessive diffuse thrombosis and multiorgan failure
232
Diff dx of AFE?
```
MI
PE
Air embolism
Anesthetic complications
Anaphylaxis
Eclampsia
Sepsis
```
233
Risk of congenital varicella if maternal infection occurs < ——- weeks
20
234
Findings in congenital varicella
```
Dermal scarring - 73%
CNS delay, microcephalic - 62%
Chorio retinitis/eye defects - 52%
Limb hypoplasia
Rudimentary digits
FGR
CNS abnormalities
```
235
% of fetuses with congenital varicella after primary maternal infection
Up to 2%
236
Neonatal varicella risk highest if maternal infection occurs
5 days before delivery through 2 days postpartum highest risk but 1-4 weeks before delivery is still possible
237
Neonatal varicella rx
Varicella IgG
238
Time between maternal varicella and US detection of fetal effects
Five weeks
239
If seronegative mother exposed to VZV what is tx
VZV IgG within 4 days of exposure (continue until 10 days post exposure)
240
Maternal chicken pox infection treatment
Oral acyclovir
241
If neonatal VZV occurs what is treatment
IV Acyclovir
242
Pulmonary VZV treatment
IV Acyclovir
243
VZV vaccine schedule
2 doses, one month apart
244
Part of TSH molecule that confers specificity
Beta subunit
245
Difference between Iodine and Iodide
```
Iodine = taken in by diet
Iodide = reduced form that is taken up by thyroid gland
```
246
Organs that can uptake/clear Iodide
Thyroid
| Kidney
247
Function of thyroglobulin versus TBG?
TBG binds T3/T4 in maternal serum
| Thyroglobulin binds T3/T4 in thyroid follicle colloid
248
Thyroid peroxidase is needed for what?
Converts Iodide --> Iodine in thyroid follicle
249
T3/T4 bind to what type of receptors
Nuclear receptors, T3>T4
250
Testing of which thyroid level is most accurate in critical illness and why?
Free T4
| Critical illness leads to elevated rT3 as physiologic response
251
Effects of pregnancy on:
1. TBG
2. TSH (thyrotropin)
3. Total T4
4. Free T4
1. TBG increased due to estrogen stimulation
2. TSH decreases due to elevated hCG levels (mostly 1st trimester)
3. Total T4 increases
4. Free T4 slight increase due to hCG stimulation
252
How does T4 convert to T3 in peripheral tissues
Via deiodinase enzyme
253
Deiodinases found in placenta
Converts T4 --> T3
Type II: in placenta to make T3
Type III: in placenta to make rT3
254
T/F: Dietary Iodine is taken up by placenta
True
255
When does fetal thyroid start to function
~12-14wks GA (12 wks starts concentrating iodine)
256
Most of the fetal T4 is converted to what and how in the fetus?
T4 converted to rT3 by placenta type III deiodinase
257
What type of thyroid hormone does fetal brain depend on
T3, made by T4 conversion to T3 by type II placental deiodinase
258
Does maternal T4 cross placenta? Maternal TSH?
T4 - yes
| TSH - no
259
Amniotic fluid levels of thyroid hormone are reflective of maternal or fetal serum levels?
Fetal
260
What happens to thyroid hormone levels in neonate?
Surge in TRH/TSH following birth leads to high levels of T3 (mostly) and T4 for 4-6 weeks after birth (thought to happen for thermoregulation function)
261
Effect of neonatal cooling on neonatal thyroid hormones
Exacerbate the normal increase in neonatal thyroid hormone production
262
T/F: Iodine renal clearance increases in pregnancy
True
263
How to assess if maternal iodine intake is sufficient?
If iodine excrection >100ug in 24hrs
264
Dietary Iodine recommendation for pregnancy/lactation
WHO: 250ug of Iodine daily
| ACOG/IOM: 220ug pregnant, 290ug lactation
265
Fetal brain development relies on thyroid hormone for development...is it maternal or fetal thyroid hormone that supplies this need?
1st and 2nd trimester - maternal T4 converted to T3
| 3rd trimester - fetal T4 converted to T3
266
T/F: GTN and hyperemesis can present with serum/clinical evidence of hyperthyroidism
True - GTN can present as thyroid storm and need treatment. Don't treat with HG as it doesn't improve symptoms and is transient
267
Why does goiter happen when Iodine deficiency?
Elevated TSH stimulates thyroid glandular hypertrophy
268
Nutritional deficiency that can exacerbate Iodine deficiency?
Selenium
269
Symptoms of cretinism
Mental retardation
Deaf-mutism
Pyramidal syndromes
270
Most common etiology of hypothyroidism?
autoimmune thyroiditis AKA Hashimoto’s thyroiditis
271
What are the anti-thyroid antibodies that can cause hypothyroidism?
Anti-TPO
| Anti-Thyroglobulin
272
T/F: Anti-TPO can cross placenta?
True -- but doesn't have any fetal effects
273
Positive anti-TPO but no evidence of clinical hypothyroidism --- what are they at risk for?
Becoming hypothyroid in pregnancy, developing postpartum thyroiditis
274
Most common antibody in Hashimoto's thyroidits
Anti-TPO
275
Medications associated with causing hypothyroidism
Lithium
| Amiodarone
276
If no pregnancy/trimester specific free T4 or TSH lab ranges, what can you use as estimate?
T4 - 1.5x higher than nonpregnant state (AKA about 50% increase after 16wks)
TSH - <3-4 (lower limit decrease by 0.4, and upper limit decrease by 0.5)
277
Levothyroxine dose change in pregnancy
Increase 30% in first trimester
278
Preconception TSH goal for hypothyroid patients
<2.5
279
Levothyroxine dosing
1.6mcg/kg/day
280
Can you use dessicated thyroid or T3 replacement for hypothyroidism in pregnancy?
No -- doesn't cross placenta for fetal brain development
281
What are the types of TSH receptor antibodies?
TSI - thyroid stimulatory antibodies (TRAb)
| TBII - thyroid inhibitory antibodies
282
Can thyroid stimulating (TSI) and thyroid inhibitory binding (TBII) antibodies cross placenta?
Yes --- can cause fetal thyroid dysfunction
283
T/F: anti-TPO or anti-thyroglobulin may be seen in hyperthyroidism
Yes
284
Most common cause of hyperthyroidism?
Graves disease (hyperthyroidism, goiter, thyroid eye disease, myxedema)
285
When should you test for TSI (TRAb) in hyperthyroidism?
After 20 weeks, as they may be falsely negative with high hCG levels
286
MOA of thioamide therapy
Prevent iodination of thyroglobulin and prevent thyroglobulin production
PTU also prevents peripheral conversion of T4-->T3
287
Which thioamides should be used in each trimester?
1st: PTU
| 2nd/3rd: MMI
288
Concerns with PTU use?
Liver toxxicity
289
Concerns with MMI use?
```
Cutis aplasia
Choanal atresia
TE fistula
Abdominal wall defects
VSD
Facial anomalies
```
290
PTU:MMI dosing equivalents
20:1 (100mg PTU:5mg MMI)
291
Thioamide side effects
rash, itching, lupus-like syndrome, bronchoconstriction, agranulocytosis, transient leukopenia
292
When to take thioamide when breastfeeding
3-4hours before feeding
293
Goal T4 of thioamide treatment
Upper limit of normal
294
Fetal signs of over-treatment of maternal hyperthyroidism?
Signs of fetal hypothyroidism -- bradycardia, FGR, goiter
295
Rate of fetal hyperthyroidism
1-5%
296
What predicts higher chance of fetal hyperthyroidism?
Maternal TSI level >300% measured at 18-22 weeks
297
T/F: women s/p radiodide ablation can have fetal hyperthyroidism
Yes -- check for presence of ab in serum
298
Fetal symptoms of hyperthyroidism
Tachycardia, goiter, FGR, craniosynostosis, advanced bone age, hydrops
299
Treatment of fetal hyperthyroidism?
Maternal thioamide treatment
300
After radioactive iodine therapy, how long to avoid pregnancy?
6 months
301
What to do if accidental radioactive iodine treatment in early pregnancy?
Potassium Iodide and thionamide treatment within 7-10 days of exposure
302
If thyroid surgery needed in pregnancy, what can you give preop to decrease thyroid vascularity?
potassium iodide
303
Effect of potassium iodide on thyroid function
decreases t3/t4 levels by inhibiting release from thyroid
304
Risks of thyroid surgery
hypoparathyroidism, recurrent laryngeal nerve paralysis
305
Protocol for thyroid storm treatment
1. PTU loading dose then continuous dosing
2. Potassium Iodide 1hr after PTU (can also use sodium iodide, lugol solution, lithium carbonate)
3. Dexamethasone to block peripheral conversion
4. B-blockers
306
Reason to do thyroidectomy in pregnancy for CA
lymph node metastasis or substantial growth before 24 weeks
307
Serum level checked to determine if biochemical evidence of thyroid CA following thyroidectomy
Thyroglobulin
308
Typical course of postpartum thyroid disease
Hyperthyroidism followed by hypothyroidism (treat the hypothyroidism)
309
T/F: thyroid gland enlargement in pregnancy
True - 30%
310
If thyroid storm patient has iodide anaphylaxis history, what can you give instead?
lithium carbonate
311
US characteristics of malignant thyroid nodule
hypoechoic pattern
irregular margins
microcalcifications
312
Deficiency of what enzyme predisposes to fetal hydantoin syndrome
Epoxide hydrolase
313
Fetal hydantoin syndrome associated with use of what medication
Phenytoin
314
Features of fetal hydantoin syndrome
```
Hypoplasia of nails/distal phalanges
Developmental delays
Flat, broad nose
Webbing of neck
Microcephaly
Growth restriction
```
315
CVR >1.6 is predictive of what
hydrops
need for early surgery
RDS at birth
316
Signs of fetal hyperthyroidism
- High FH
- Goiter
- Advanced bone age
- Poor growth
- Craniosynostosis
- Hydrops
317
Anti-inflammatory cytokine
| Pro-inflammatory cytokine associated w/ PTL
anti: IL10
pro: IL6
318
For smooth muscle relaxation -- what things must happen (2 major things)
- decreased intracellular Ca levels
| - increased myosin light chain phosphatase
319
Effect of NO2 on smooth muscle
relaxation
320
Difference between ephedrine and phenylephrine for post-anesthesia hypotentions
Ephedrine - alpha and beta agonists. Associated with fetal tachycardia
Phenylephrine - drug of choice
321
Weight gain recommendations for twins
18.5-224.9: 37-54lbs
25-29.9: 31-50lbs
>30: 25-42lbs
322
Weight gain recommendations singletons
<18.5: 28-40lbs
19-24.9: 25-35lbs
25-29.9: 15-25lbs
>30: 11-20lbs
323
Clinical manifestations of hyperparathyroidism
```
Nephrolithiasis
Fractions
Hypercalcemia
Hyperemesis
Pancreatitis
```
324
Fetal/neonatal effects of maternal hyperparathyroidism
```
Hypocalcemia
Tetany
PTB
FGR
IUFD
```
325
Cause of acromegaly
GH secreting adenoma in pituitary
326
Increased risk of what outcomes for acromegaly in pregnancy
GDM
| gHTN
327
Medical therapies for acromegaly
Somatostatin analogues (avoid in pregnancy)
Ocretotide
328
Elevated hormone levels in acromegaly
IGF-1
| Prolactin (compression or mixed type adenoma)
329
What drives increased fetal calcium needs in pregnancy?
PTHrp
330
Placental transport mechanism of Calcium
Active transport
331
Immediate treatment for K of 6.9
Ca gluconate (or calcium chloride) followed by insulin and glucose
332
Most common chorioangioma location
In the placenta on the fetal side near the cord insertion (appears to bulge into amniotic cavity)
333
Vascular flow through chorioangioma is maternal or fetal in origin?
Fetal
334
Fetal complications of chorioangioma
Hydrops
Poly
FGR
Anemia
335
Chorioangioma size more likely to have complications
>5cm
336
T/F: chorioangioma is not a true neoplasm
True -- is the result of reactive proliferation
337
T/F: vascularity of chorioangioma may change over gestation
True
338
Location of placental teratoma
Between amnion and chorion
339
Associated abnormalities in cases of chorioangioma
Fetal hemangiomas
SUA
Beckwith-Wiedmann
340
How do anti-epileptic medications decrease birth control efficicay?
Induce hepatic enzymes that accelerate metabolism of OCPs
341
Antiepileptics associated with NTD's
Valproate (highest at 1-2%)
| Carbamazepine (0.9%)
342
Coagulation factors that decrease in pregnancy
Protein S
Factor XI (likely unchanged or slight decrease)
Factor XIII
343
For vWD you want vWF Ag and Factor VIII levels to be > ____ for delivery
50
344
Difference between the types of vWD
Type 1: AD, quantitative problem, responds to DDAVP
Type 2: AD, qualitative problem, 1st line is vWF concentrates/Factor VIII
Type 3: AR, severe quantitative problem, doesn't respond to DDAVP
345
MOA of DDAVP
Stimulates relase of vWF and Factor VIII from endothelial cells
346
% chance of PPH with vWD
30% chance for immediate and/or delayed
347
Platelet count thresholds for non-bleeding women nearing delivery
Vaginal >30,000
| Cesarean >50,000
348
Therapy to raise platelet counts in ITP
Steroids
IVIG
^^require 1 week to work
Platelet transfusion - if needed immediately
349
General platelet count goals in pregnancy
>30k with >50k at term
350
For ITP if you give steroids when will effect take place
3-7 days after initiation
351
When is IVIG used for ITP?
- refractory to steroids
| - perioperative setting when platelet count <10k
352
If using IVIG for ITP when do you see response?
7-10 days and it lasts for about 30 days
353
Incidence of stillbirth per 1,000 within 1 week of (a) BPP (b) modified BPP (c) CST (d) NST
a - 0.8
b - 0.8
c - 0.3
d - 1.9
354
Change EDD if discrepancy is more than ____ days at
(a) less than 8w6d
(b) between 9w and 13w6d
(c) between 14w and 15w6d
(d) between 16w and 21w6d
(e) between 22w and 27w6d
(f) between 28w and beyond
```
a - 5 days
b - 7 days
c - 7 days
d - 10 days
e - 14 days
f - 21 days
```
355
Teratogenicity associated with efavirenz
ONTD
356
T/F: Warfarin crosses placenta
True
357
GA that warfarin has highest risk of teratogenicity
6-12 weeks
358
T/F: Warfarin can cause fetal bleeding at any GA
True
359
Clinical manifestations of warfarin embryopathy
Defects in cartilage/bone formation -- nasal hypoplasia, short limbs, short digits, stippled epiphyses
360
Hep B treatment
Tenofovir
361
Interpretation:
HbsAg - negative
Anti-HBc - negative
Anti-HBs - negative
Not immune or acutely infected. Susceptible to infection.
362
Interpretation:
HbsAg - Negative
Anti-HBc - Positive
Anti-HBs - Positive
Immune through natural infection
363
Interpretation:
HbsAg - Negative
Anti-HBc - Negative
Anti-HBs - Positive
Immune through vaccination
364
Interpretation:
HbsAg - Positive
Anti-HBc IgM - negative
Anti-HBs - negative
Acute infection
365
Hep B - what antigen stays positive once chronically infected
HBsAg
366
What factors (2) in chronic Hep B increases chance of perinatal transmission
1. Positive HBeAg (increase from 10-30% to 90-95%)
| 2. Maternal viral load >5 log copies/mL (>1 million)
367
Neonatal tx for maternal Hep B positive
HBIg and HBV within 12hrs of life
368
If diagnosed with chronic Hep B what other virus should be tested for
Hep A
369
T/F: lamivudine for hep B treatment
False -- higher rates of viral resistance
370
Chronic Hep B --- treat or don't treat in pregnancy?
Consider treatment after 28-32 weeks if viral load >6-8 log (1-100 million) copies/mL
371
T/F: Hep D has no effect on pregnancy or fetus
True
372
RF for PVL
1. pretermers with IVH
| 3. chorio
373
most likely outcome of neonatal PVL
spastic diplegia, seizures
374
Phenylalanine is converted to ____ by _____
Tyrosine by phenylalanine hydroxylase
375
HIV/HepB coinfection -- which meds to avoid
Telbivudine
Emtricitabine
Adefovir
Lamivudine
376
Idiopathic intracranial HTN treatment
```
Carbonic anhydrase inhibitors - acetazolamide (try to use after 20 weeks)
Topamax
Furosemide
Serial LP's
Short course of steroids (vision loss)
```
377
CHD lesions that will lead to neonatal cyanosis (Ductal dependent)
```
HLHS
Severe/critical AS
Critical coarctation (differential cyanosis)
Interrupted aortic arch (differential cyanosis)
TOF w/ pulm stenosis
Pulmonary atresia, intact septum
TOF - varies
Tricuspid atresia/ebstein
TGA
```
cyanosis but not ductal depd
TAPVC
Truncus
