Case 17

Question 0

Metabolic abnormalities secondary to alcohol consumption

Answer 0

Hypertriglyceridaemia
Ketoacidosis
Fasting hypoglycaemia
Hyperuricaemia

Question 1

Alcohol metabolism

Answer 1

Ethanol to acetaldehyde via ADH and MEOS

Acetaldehyde to acetic acid via ALD

Acetic acid to acetyl CoA

First two steps confined to the liver

Question 2

How is osmolarity calculated?

Answer 2

2Na + glucose + urea

Question 3

Biochemical markers of alcohol abuse

Answer 3

Gamma GT
Carbohydrate deficient transferrin
Increased MCV

Question 4

Intimate partner violence

Answer 4

A pattern of assaultive and coercive behaviour including physical, sexual, psychological and economic aspects.

Question 5

Blastocyst attachment and implantation

Answer 5

Zona pellucida hatches

Apposition of blastocyst and endometrium

Decidual cells become epithelial-like and form the primary decidual zone

Local vascular permeability

Reduction in the number of desmosomes and apoptosis of endometrial epithelial cells facilitates trophoectodermal invasion of the secondary decidual zone

Question 6

What makes up the chorionic sac?

Answer 6

Trophoblast and extra embryonic mesoderm

Question 7

Functions of the syncytiotrophoblast

Answer 7

Invasion of endometrium and 1/3 of myometrium to form secure attachment

Proteolytic breakdown of spiral arteries to form lacunae which will later form the intervillous spaces

Secretion of hCG

Syncytiotrophoblasts express Fas ligand and do not express MHC

Question 8

Development of chorionic villi

Answer 8

Under the influence of extraembryonic mesoderm, cytotrophoblastic cells invade the syncytioteophoblast cell mass and form primary villi.

Secondary villi are formed when extraembryonic mesoderm invades the cytotrophoblast layer to form an inner mesodermal core.

Tertiary villi are formed when the extraembryonic mesoderm becomes vascularised with capillaries.

Cytotrophoblastic cells extend beyond the syncytiotrophoblasts to form the cytotrophoblastic shell

Some villi become attach to the cytotrophoblastic shell and become anchoring villi

Branch or terminal grow into the intervillous space

Question 9

Regions of the decidua

Answer 9

Basalis
Parietalis
Capsularis

Question 10

Fetal components of the placenta

Answer 10

Chorion frondosum - chorionic plate and villi

Chorion laeve

Question 11

Macrophages present in the placenta

Answer 11

Hoffbauer cells

Question 12

Placental circulation

Answer 12

Closed fetal circulation
Open maternal circulation

Maternal blood enters the intervillous space, regulated by cytotrophoblastic cell plugs.

Exchange between maternal and fetal blood occurs

Maternal blood is drained to the uterine veins

2 umbilical arteries, 1 umbilical vein. Umbilical vein has an internal elastic lamina

Question 13

What makes up the placental barrier?

Answer 13

Endothelial cells and their basal lamina

Cytotrophoblast and syncytiotrophoblast cells and their basal lamina

Question 14

Fetoplacental estrogen synthesis

Answer 14

The placenta synthesises progesterone which the fetal adrenal cortex converts to DHEA, DHEAS and cortisol. The placenta uses DHEA/S to form estrogens

Question 15

Placental hormones

Answer 15

Progesterone
Estrogen
Placental lactogen
Relaxin
Placental PTH-RP

Question 16

Role of the decidua in immunotolerance

Answer 16

Infiltrating leukocytes secrete IL-2

Prostaglandin secretion inhibits activation of NK cells

Question 17

Effects of pregnancy on maternal physiology

Answer 17

Increased tidal volume
Increased maternal blood volume
Increased GFR
Increased mammary gland growth and development
Increased nutrient requirements
Increased uterine size

Question 18

Mammary gland development

Answer 18

In utero: the nipple forms first, followed by the mammary bud, an ectodermal downgrowth. The buds give rise to solid mammary cords which later develop into lactiferous ducts.

Birth to puberty: few lactiferous ducts, no glands, fibrocollagenous tissue

Puberty: epithelial downgrowth and increased complexity of ductal system. Adipose tissue is laid down.

Question 19

Protective factors in breast milk

Answer 19

IgA
Lactoferrin
Lysozyme
Oligosaccharides 
Mucins

Question 20

Inactive mammary gland

Answer 20

Sparse glandular component
Mainly duct elements lined by low columnar epithelium
Sparse myoepithelial cells

Question 21

Pregnant mammary gland

Answer 21

Epithelial hypertrophy, lobules enlarge
Protein, sugar and fat containing vacuoles within glandular epithelium
Lymphocytes and plasma cells in the stroma
Colostrum may be present in glandular lumen later in pregnancy

Question 22

Initiation of lactation after parturition

Answer 22

Rise in cortisol during birth induces enzymes needed for milk production

Rapid decline in estrogen levels overcomes dopamine inhibition to stimulate maternal prolactin secretion

Question 23

Control of prolactin secretion

Answer 23

Dopamine secreted by the hypothalamus inhibits prolactin secretion

Suckling inhibits dopamine release via a neural reflex allowing prolactin release

Cessation of suckling stimulates to be released again, blocking prolactin release

Question 24

Milk ejection

Answer 24

Suckling stimulates neurons in the hypothalamus to cause release of oxytocin from the neurohypophysis Oxytocin stimulates myoepithelial cell contraction

Question 25

Facial anomalies in FASD

Answer 25

``` Short palpebral fissures Ptosis, strabismus Epicanthal folds Short upturned nose Depressed nasal bridge Smooth philtrum Thin upper lip ```

Question 26

CNS anomalies in FASD

Answer 26

``` Microcephaly Mental retardation Hypotonia Poor coordinaton Hyperactivity Sleep disorders Seizures Hydrocephalus ```

Question 27

Palliative care definition

Answer 27

An approach that improves the quality of life of patients and their families facing life-threatening illness through the relief and prevention of suffering by means of early identification and treatment of pain and physical, psychosocial and spiritual problems

Question 28

Aspects of palliative care

Answer 28

Provides relief from pain and distressing symptoms Affirms life and regards dying as a normal process Integrates spiritual and psychological aspects of patient care Offers support to help patients to live as actively as possible Offers a support system to help the family cope Uses a team approach Enhances QOL Applicable early in the course of illness

Question 29

WHO analgesic ladder

Answer 29

1. Non-opioid +/- adjuvants 2. Weak opioids +/- non-opioids +/- adjuvants 3. Strong opioids +/– non-opioids +/- adjuvants

Question 30

Analgesics

Answer 30

Step 1: paracetamol, aspirin Step 2: tramadol Step 3: morphine

Question 31

FASD spectrum

Answer 31

FAS Partial Fetal Alcohol Syndrome Alcohol Related Neurodevelopmental Disorder Alcohol Related Birth Defect

Question 32

Fetal alcohol syndrome definition

Answer 32

Specific pattern of facial features with pre/post natal growth deficit and CNS dysfunction with a positive history of maternal drinking during pregnancy

Question 33

Risk factors for FASD

Answer 33

``` Higher age, gravidity, parity Lower SES and income. Rural residence Timing - daily drinking, binge drinking Partner consumes alcohol Tobacco use Poor nutrition Metabolism ```