208, 209, 210 Pregnancy

Question 1

What changes occur in the uterus during pregnancy?

Answer 1

massively increases in size and volume

hypertrophy from estrogen (and maybe progesterone)

increased blood flow

Question 2

What changes occur in the cervix during pregnancy?

Answer 2

softening, cyanosis (early pregnancy)

hypertrophy and hyperplasia with eversion of columnar endocervical glands

production of mucus rich in immunoglobulins (protects from vaginal bacteria)

Question 3

What changes occur in the vagina during pregnancy?

Answer 3

increased vascularity (Chadwick sign)

increased mucosal thickness

loosened connective tissue

hypertrophy of smooth muscles

Question 4

How long is the corpus luteum present and functional during pregnancy?

Answer 4

until 7 weeks gestation

Question 5

What are the symptoms of a luteoma?

Answer 5

maternal virilization

no effect on fetus

Question 6

What cardiac changes are normal in pregnancy?

Answer 6

heart displaces up and to the left (looks in larged on CXR)

increased blood volume (50%)

increased resting heart rate (15%)

both of which lead to increased cardiac output

Question 7

What vascular changes are normal in pregnancy?

Answer 7

blood pressure decreases in second trimester and returns to normal levels in third trimester

impaired venous return with an increase in SVR

Question 8

What respiratory changes are normal in pregnancy?

Answer 8

elevated diaphragm and increased subcostal angle

increased tidal volume, decreased residual volume

Question 9

What GI changes are normal in pregnancy?

Answer 9

displacement of stomach and intestines by uterus

increased hepatic blood flow (can have “abnormal” alk phos and albumin)

reduced gallbladder contractility

Question 10

What renal/urinary changes are normal in pregnancy?

Answer 10

increased kidney size and GFR (may need to serum creatinine decrease)

uterine displacment of ureters

increased bladder pressure

Question 11

What hematologic changes are normal in pregnancy?

Answer 11

hypervolemia

increased erythrocyte volume (slight increase in Hb and Hct)

increased iron requirement

can have slight leukocytosis (increased CD8, decreased CD4)

increased clotting factors

Question 12

What factors regulate placental transfer of nutrients?

Answer 12

maternal blood flow and surface area of exchange

concentration of nutrients and mode of transport

rate of fetal blood flow and surface area of exchange

Question 13

What changes to fetal circulation occur at birth?

Answer 13

foramen ovale closes

ductus venosus and umbilical vessels collapse

closure of ductus arteriosus (due to marked decrease in pulmonary vascular resistance because of loss of fluid)

Question 14

What makes most of the amniotic fluid volume?

Answer 14

fetal kidneys secreting urine (after 16 weeks of gestation)

Question 15

What is the difference in O2 saturation between fetal and adult hemoglobin?

Answer 15

fetal hemoglobin has increased oxygen affinity relative to adult hemoglobin

Question 16

What is the role of CRH in labor and delivery?

Answer 16

stimulates maternal adrenals to produce DHES –> increases placental estrogen synthesis –> stimulates myometrial contractility

also accelerates maturation of fetal lungs

Question 17

What factors mediate myometrial contractility for labor and delivery?

Answer 17

prostaglandin F2alpha and oxytocin bind to cells and promote calcium channel opening –> depolarizes cells and leads to contraction of myocytes

Question 18

Frequency of contractions is controlled by ____________; force of contractions is controlled by ____________.

Answer 18

Frequency of contractions is controlled by frequency of action potentials; force of contractions is controlled by numer of fibers activated.

Question 19

What are the milestones of stage 1 of labor?

Answer 19

interval between onset of labor and full cervical dilation

oncet of painful contractions with variable duration

rapid survical change

Question 20

What are the milestones of stage 2 of labor?

Answer 20

interval between full cervical dilation and delivery of fetus

can last up to 4 hours (nulliparas) or 3 hours in multiparas

epidural analgesia decreases duration

Question 21

What are the milestones of stage 3 of labor?

Answer 21

interval between delivery of neonate and delivery of placenta

usually occurs 10-30 mins after delivery

Question 22

A 33 yo G3P2 at 28 weeks presents to her internist for her flu shot. She appears well but her resting heart rate is 100 bpm and her BP is 90/60. Her internist orders a CXR, which demonstrates a mildly enlarged cardiac silhouette. A d-dimer is elevated. An ABG is done that demonstrates mild respiratory alkylosis. What is her most likely diagnosis?

a) pulmonary embolus
b) acute influenza
c) cardiomyopathy
d) normal pregnancy

Answer 22

d) normal pregnancy

all of these changes (increased HR, decreased BP, enlarged CXR cardiac silhouette, elevated coagulation factors, mild respiratory alkylosis) are normal in pregnancy

Question 23

A 38 yo G2P1 @ 7 weeks of pregnancy is taken to the operating room for suspected ovarian torsion. Laparoscopy confirms this diagnosis and the left ovary is removed. Pathology confirms the presence of a corpus luteum cyst on the removed ovary. What should be given to maintain her pregnancy?

a) nothing
b) estrogen
c) progesterone
d) hCG

Answer 23

c) progesterone

Question 24

Oxygenated blood is delivered to the fetus from the:

a) umbilical arteries
b) umbilical vein
c) fetal lungs

Answer 24

b) umbilical vein

Question 25

What treatments should be offered during preterm labor?

Answer 25

antenatal corticosteroids (fetal lung development) antibiotics for GBS infection diagnosis and treatment of underlying causes

Question 26

What strategies may be used to prevent preterm birth?

Answer 26

17-hydroxyprogesterone caproate vaginal progesterone cerclage in short cervix (a stitch) if prior preterm labor screen/treat bacteriuria treat symptomatic bacterial vaginosis smoking cessation longer intervals between pregnancies

Question 27

What is the definition of cervical insufficiency?

Answer 27

painless cervical dilation in absence of contractions, usually mid-trimester may result in membrane prolapse, preterm premature rupture of membranes (PPROM) and preterm labor

Question 28

What is the difference between PROM and PPROM?

Answer 28

PROM = rupture of membranes prior to onset of labor PPROM = rupture of membranes prior to onset of labor and before 37 weeks gestation

Question 29

How is premature membrane rupture diagnosed?

Answer 29

sterile speculum exam with vaginal pooling of basic fluid and microscopic "ferning" patterns

Question 30

How is PROM/PPROM managed?

Answer 30

hospitalize for duration of pregnancy with expectant management + steroids/antibiotics (if \< 34 weeks)

Question 31

What is placenta previa?

Answer 31

implantation of placenta in location where it covers cervical os characterized by painless bright red vaginal bleeding

Question 32

What are the risk factors for placenta previa?

Answer 32

prior cesarean delivery, multiparity, advanced maternal age, prior placenta previa, smoking

Question 33

What are the treatments for placenta previa?

Answer 33

monitor with pelvic rest planned C-section at 37 weeks expectant management if appropriate monitor for progression to placenta accreta

Question 34

What is vasa previa? How is it diagnosed?

Answer 34

vaginal bleeding from fetal vessels can theoretically diagnose with an Apt test (fetal blood cells won't lyse in alkaline solution), but usually does not happen becuase this is an indication for rapid delivery (only takes minutes for a fetus to bleed out)

Question 35

What is placental abruption?

Answer 35

premature separation of placenta from the uterine wall and most typically characterized by vaginal bleeding in the presence of uterine contractions vaginal bleeding may not always be evident (can be concealed bhind placenta)

Question 36

What are the risk factors for placental abruption?

Answer 36

hypertension, prior abruption, abdominal trauma, smoking, cocaine, uterine anomalies or submucosal fibroids, PPROM

Question 37

What is the definition of fetal growth restriction? What are common causes?

Answer 37

fetus less than 10th percentile for a given gestational age fetal: aneuploidy, fetal anomalies, infection, multiple gestation uteroplacental: chronic hypertension, preeclampsia, chronic abruption maternal: malnutrition, drug use, smoking, chronic medical conditions

Question 38

What is the definition of preeclampsia?

Answer 38

new-onset hypertension and proteinuria can have severe features (BP \>160/110, maternal symptoms like headache/RUQ pain, hepatic injury/failure, renal injury/failure, pulmonary edema, coagulopathy, HELLP syndrome)

Question 39

What is the definition of Rh alloimmunization?

Answer 39

exposure of Rh negative mother to Rh positive fetal blood leads to antibody production that can result in hemolytic disease of fetus/newborn in subsequent pregnancies ## Footnote *prevent by giving Rh Ig to all pregnant women who are Rh negative*

Question 40

What are the common etiologies of spontaneous abortion/miscarriage?

Answer 40

definition: pregnancy loss before week 20 of gestation chromosomal abnormalities (most common), congenital anomalies, infection, uterine anomaly, maternal medical condition

Question 41

What are the common etiologies of intrauterine fetal demise/stillbirth?

Answer 41

definition: pregnancy loss after 20th week gestation chromosomal abnormalities, congenital anomalies, maternal medical conditions, hypertensive disorders of pregnancy, infection, multiple gestations

Question 42

What is the mechanism of disease leading to Rh alloimmunization of the fetus? What is the earliest gestational age at which this can occur?

Answer 42

maternal IgG antibodies can cross placenta and directly hemolyze fetal RBCs that are Rh positive treat starting at 28 weeks gestation

Question 43

How do fetal growth restriction and preeclampsia result in preterm delivery?

Answer 43

both are iatrogenic indicators --\> balance of risk of harm to mother/fetus is higher with continued pregnancy than with delivery

Question 44

What is the difference between cervical insufficiency and preterm labor?

Answer 44

CI presents from weeks 16-24 with painless cervical dilation preterm labor occurs later with painful uterine contractions and cervical changes

Question 45

What are the contents of the umbilical cord?

Answer 45

2 umbilical arteries (deoxygenated) 1 umbilical vein (oxygenated) stroma (Wharton's jelly) *covered by amnion*

Question 47

What structures of the placental disc come from the mother vs. fetus?

Answer 47

maternal: intervillous blood, decidua of disc and membranes fetal: cord, chorionic plate, villous tree, chorion + amnion of membranes, trophoblasts in decidua

Question 48

What is uteroplacental insufficiency?

Answer 48

problems with getting maternal blood from circulation into the placenta, associated with hypertension and preeclampsia ## Footnote *caused by failure of fetal trophoblasts to remodel maternal vessels --\> hypertension secondary renal arterial stenosis*

Question 49

What are the placental manifestations of uteroplacental insufficiency?

Answer 49

abnormal maternal vessels (thick walled), global underperfusion problems (ex. growth restriction), focal/regional underperfusion (infarct, placental abruption)

Question 50

What is fetal vascular malperfusion?

Answer 50

problems getting fetal blood into the placenta and back associated with cord accident and problems with fetal circulation (ex. heart disease, abnormal umbilical cord, thrombosis)

Question 51

What are causes of acute placental inflammation?

Answer 51

neutrophil-predominant inflammation in the placenta caused by vaginal/GI microbes or hematogenous spread

Question 52

What are the maternal and fetal responses to acute placental inflammation?

Answer 52

maternal response: subchorionitis, chorionitis, amnion necrosis fetal response: phlebitis, umbilical arteritis, necrotizing funisitis

Question 53

What is chronic placental inflammation?

Answer 53

lymphocyte or macrophage inflammation of the placenta caused by infection or maternal anti-fetal rejection

Question 54

What are the complications of placenta previa?

Answer 54

requires c-section if delivery attempted, can lead to severe hemorrhage with maternal and/or fetal demise

Question 55

What are the types of abnormally adherent placenta?

Answer 55

accreta = placental tissue on myometrium increta = invasion of fetal placental tissues into myometrium percreta = invasion of fetal placental tissues through uterine serosa and onto adjacent structures

Question 56

What are the different placental manifestations of twins?

Answer 56

dichorionic, diamniotic (thick dividing membrane) monochorionic, diamniotic (thin dividing membrane) monochorionic, monoamniotic (no membrane)

Question 57

What gametes make up a partial mole? What is the hCG level? What are the findings?

Answer 57

gametes: 1 egg + 2 sperm (69 chromosomes) elevated hCG fetal parts present, some hydropic placental villi

Question 58

What gametes make up a complete mole? What is the hCG level? What are the findings?

Answer 58

gametes: empty ovum + 2 sperm (46 chromosomes) very elevated hCG no fetal tissue, many hydropic villi ("grapes" and snowstorm on ultrasound)

Question 59

Which type of molar pregnancy has a higher risk of choriocarcinoma?

Answer 59

complete moles

Question 60

What are the components of the fetoplacental interface? Is there normally mixing of maternal and fetal blood in the placenta?

Answer 60

fetoplacental interface = barrier between fetal and maternal vasculature chorionic villous is where it resides formed in midtrimester out of cytotrophoblasts and syncytiotrophoblasts barrier allows for exchange of gasses and nutrients WITHOUT mixing of the two circulations

Question 61

When there is amniotic fluid infection, acute inflammatory cells emanate from both fetal and maternal circulations in response to chemotactic stimuli and can be seen in placental tissues. In which anatomic components of the placenta are you most likely to see maternal inflammatory cells? fetal inflammatory cells?

Answer 61

maternal acute inflammatory cells (neutrophils) can be seen in the membranes of the placenta where they originate from the blood vessels in the parietal decidua; also in the subchorionic space fetal acute inflammatory cells can also be seen in the chorionic plate, emanating from the large fetal vessels; also seen exiting the umbilical vessels in the umbilical cord

Question 62

A woman undergoes a spontaneous 1st trimester abortion. Examination of the passed tissue shows a fetus and an abnormal appearing placenta. Genetic testing by karyotype shows the conceptus is triploid, 69 XXY. Is this a complete mole? Partial mole? Is more testing needed?

Answer 62

this is likely a partial mole (complete mole would be diploid) need additional testing to be sure