General mix Flashcards
(152 cards)
1
Q
- Most likely diagnosis with unilateral pleural effusion?
A
o Hydrothorax
2
Q
- Source of metabolic fuel for fetal myocardium
A
o Lactate
3
Q
- Most direct cause of myometrial contraction
A
o MLCK (myosin light chain kinase)
4
Q
- Which steroid influences sodium reabsorption
A
o Fludrocortisones
5
Q
- Injury with brachial plexus injury resulting in Erb’s palsy:
A
o C5-C6
6
Q
- How does Iodide treatment work?
A
o Inhibits release of thyroid hormone
7
Q
- Preeclampsia is associated with which of the following? 1) urinary calcify, thromboxane, angiotensin
A
o Decreased urinary calcium
o PEC IS ASSOCIATED WITH: no change in thromboxane, increased sensitivity to angiotensin
8
Q
- Which rate of dopamine infusion improves renal blood flow?
A
o 4microg/min
9
Q
- Most important for PGE2 production?
A
o Arachidonic acid
10
Q
- Most likely diagnosis with cystic hydroma
A
o Normal Turner T21 T13/T18
11
Q
- Aspartoacylase deficiency is associated with which disease?
A
o Canavans (acetylasportalase deficiency)
12
Q
Expanasion of vulvar hematoma limited by which of the following?
A
Colles fascia
13
Q
Large c-section incision injures iliohypogastric nerve, what is the most likely result?
A
o Decreased sensation at the mons
o Can also be asked opposite; give mons, ask for nerve
14
Q
Both parents have normal stature, but both kids have achondroplasia – most likely reason
A
Gonadal mosaicism
15
Q
What is pulmonary capillary wedge pressure (PCWP?)
A
o LV pre-load
16
Q
- Stillbirth in setting of cholestasis, most likely finding?
A
Mecoium stained fetus/placenta
16
Q
- Stillbirth in setting of cholestasis, most likely finding?
A
Mecoium stained fetus/placenta
17
Q
Preload and afterload optimized, which med can improve cardiac contractility?
A
o Hydralazine
18
Q
Which is associated with inappropriate failure to reject the null?
A
o Type II error
19
Q
Formula for odds ratio is:
A
o AD/BC
o In actual words: ratio of exposed vs unexposed cases DIVIDED BY exposed vs unexposed controls
20
Q
Which enzyme deficiency is a concern with chloroprocaine?
A
o Pseudocholinesterase- enzyme to break down ester type of anesthesia
21
Q
Patient can’t dorsiflex after forceps
A
Peroneal
22
Q
Medication lingers for 2 years and to avoid pregnancy with it
A
o Etretinate
To treat psoriasis
23
Q
What can directly be measured by PA catheter?
A
o Cardiac output
24
- #1 fetal anomaly in obese patients?
o NTD
25
- Which Ashkenazi disease is treatable with enzyme replacement?
o Gaucher?
26
What changes with dialysis in pregnancy?
o More frequent sessions (smaller fluid shifts)?
27
GA at which fetal alveolarization occurs?
36 weeks
28
What is due to pituitary deficiency?
o Diabetes insipidus
29
- #1 cause of vulvar hematoma (artery)
IInternal pudendal artery
30
In TRAP, what is found in the acardiac twin’s Doppler?
Pulsatile UA / continuous UV flow
31
- What contracetion do you NOT give someone who has pp depression?
Depo, also not good for insulin sensitivity?
32
Which coagulation factor decreases in pregnancy?
o 11 and 13
33
Worst malaria to get
o Plasmodia falciparum
o Common to get anemia
33
Worst malaria to get
o Plasmodia falciparum
o Common to get anemia
34
Worst karyotype for mother to have?
o 45XX: t (21,21)
35
- Best medicine for intermittent angina in patient with hypertrophic cardiomyopathy
o Propanolol ( and verapemil)
36
- Least helpful in treatment of vWF?
Platelets
37
What antibiotics cause obligatory salt load?
Ticarcillin plus clavulanic acid
38
What antibiotics cause obligatory salt load?
Ticarcillin plus clavulanic acid
39
Borders of pelvic inlet?
Sacral promontoary, arcuate line, superior aspect of pubis
40
Ductal dependent lesions (5-6)
Coarct
Interrupted Ao
HRHS
Pulmonary atresia
Pulmonary stenosis
TOF with severe pulm stenosis
41
Highest risk of hemorrhage with neonatal circumcision with deficiency of
Hemophilia Factor 9
42
Low E3
Icthyosis
T21 and T18
Smith Lemli Opitz
Pregnancy loss
43
Major problem with cohort study
Selection bias
44
Mechanism of iodine and steroids in thyroid storm
Prevention conversion of T4 to T3
45
Mechanism of iodine and steroids in thyroid storm
Prevention conversion of T4 to T3
46
Case control versus cohort study
Case control: OR
Cohort: RR
47
Which has clinically significant levels of factor 10? in terms of blood products
FFP
FFP: 2,5,7,9,10, 11
- 1 unit of FFP raises the fibrinogen level 10mg/dl/unit; ONLY source of 5, 11, and 12
Cryo: 8, 13, fibrinogen, vWF
48
Aldosterone levels in pregnancy
Increase
49
ANP atrial natriuretic peptide in pregnancy
Increase
50
Angiotensin levels in pregnancy
Increase
51
Mechanism of Glyburide
Increased insulin releast from alpha cells of pancreas
- primary mechanism of action of glyburide is to stimulate releast of insulin from beta cells; it also increases glucose transport, increases insulin receptors
52
What nerve is most often injured during prolonged pushing with hyperflexed legs?
Femoral
- Obturator – L2, L3, L4
- Femoral – L2, L3, L4; depressed knee jerk reflex
- Comm peroneal: branch of sciatic
- Pudendal: S2-S4
53
Inability to flex right foot back; numbness in lower portion of right leg after forceps delivery
Common peroneal
54
Which is NOT true about the differences between prostaglandin F2 alpha and prostaglandin E2, levels of CAMP, contractions
Both initially cause myometrial contraction
- E2 (cervidil; dinoprostone) – cervical ripening; causes increased cAMP which initially causes uterine relaxation; later will cause contractions
- F2alpha (Hemabate) – stimulates contraction; bronchoconstriction
55
Embolization of hypogastric artery will NOT affect which vessel?
Superior gluteal
- Common iliac divides into internal and external iliac; the internal then divides into anterior and posterior divisions
- Posterior division:
- Iliolumbar
- Lateral sactral
- Superior gluteal
- Anterior Division:
- Inferior gluteal
- Middle rectal
- Uterine
- Obturator
- Vaginal
- Inferior vesical
- Superior vesical
- Umbilical (obliterated)
- Internal pudendal
56
Which organ gets greatest proportion of fetal blood flow at term?
Lungs
- Gram for gram, adrenals and spleen have the largest blood flow
- Lungs get 8-10%
- Brain gets 5%
57
Which value from vesicocentesis in fetus is associated with fetal renal failure?
Urine Osmolality of 300mOsm/L
- Values should be less than or equal to:
- Sodium 100mg/dL
- Osmolality 200 mOsm/dL
- Chloride 90mg/dL
- Total protein 20mg/dL
- Calcium 8 mg/dL
- Beta 2 microglobulin 4mg/L
58
Hemolytic disease of the newborn
Duffy
Anti- K
anti-Fya
Kidd (Jka)
Anti-c
Anti MNSs
59
Hemolytic disease of the newborn
Duffy
Anti- K
anti-Fya
Kidd (Jka)
Anti-c
Anti MNSs
60
Treatment of pseudotumor
- Pseudotumor diagnosed by increased ICP on LP
- LP, lasix, steroids, aspirin have been used to treat/symptomatic relief
61
Treatment of pseudotumor
- Pseudotumor diagnosed by increased ICP on LP
- LP, lasix, steroids, aspirin have been used to treat/symptomatic relief
62
Baby DOL1 developed jaundice; term, breastfed; SVD. Infant is A+, mother is O+. Direct Coombs test on cord blood is positive. What is likely cause of jaundice?
ABO incompatibility; usually presents in first 24-48 hours; can occur in 1st pregnancy. Breast feeding jaundice usually occurs later (1 week)
63
Which is not a consequence of hypoparathyroidism?
a. renal calculi
b. chvotsek's sign
c. trousseau's sign
d. muscle cramps
Maternal renal calculi
- Chvostek’s sign(flexion of face muscle on tapping facial nerve) and Trousseau’s sign (flexion of hand on tapping wrist), muscle cramps, stridor, AMS can be seen with hypoparathyroidism.
- Renal calculi are seen with HYPERparathyroidism
64
Which Swan-Ganz reading is associated with pulmonary edema?
Increased pulmonary capillary wedge pressure
- PCWP is usually 6-12mmHg in pregnancy
- Colloid oncotic pressure 22-23mmHg
- Gradient of about 12; if gradient drops to about 4mmHg, pulmonary edema occurs
- Can occur from increase in PCWP or drop in colloid osmotic pressure
65
Which of the following has the lowest mortality rate in pregnancy?
Corrected TOF
- Group 1: ASD, VSD, PDA, mitral stenosis NYHA I or II, pulmonic/tricuspid disease, bioprothetic valves
- Group 2: marfans with normal root, coarctation without valve involvement, previous MI, uncorrected TOF, MS NYHA III or IV
- Group 3: Eisgenmengers, PHTN, Marfans with dilated aortic root, Coarctation with valvular involvement, cardiomyopathy with impaired LV function
66
Which coagulation factors decrease in pregnancy?
Factor 11 and 13
- Increase: 1, 7, 8, 9, 10
67
What is side effect of alpha-methyldopa? (anti HTN drug)
Hemolytic anemia
68
Mother with ptylism, what is diagnosis? (excess salivation)
Electrolyte imbalance
69
Mother with ptylism, what is diagnosis? (excess salivation)
Electrolyte imbalance
70
Where is GnRH synthesized? (other than hypothalamus)
placenta
71
What hormones does the plant make?
GnRh, hpL, hCG, ACTH, TRH, CRH, somatostatin
72
Which cytokines are anti-inflammatory?
IL 10 (and 4,6,11,13)
73
Which cytokines are anti-inflammatory?
IL 10 (and 4,6,11,13)
74
Subgaleal hematoma is collection between?
Periosteium and epicranial aponeurosis
75
Adrenal gland and location of steroid synthesis
- Glucocorticoids are made in zona fasciculate
- Mineralocorticoids are made in zona glomerulosa
76
Most indicative of worsening asthma?
Nocturnal symptoms
77
Largest component of fatty acids
Palmitic acid
78
Largest component of fatty acids
Palmitic acid
79
What percentage of results are > 2 SD from the mean in a 2-tailed test?
.5%
80
Which malarial species is worst for the fetus?
P falciparum
81
pentalogy of cantrell
o Pentalogy of Cantrell:
Ectopia cordis
Omphalocele
Sterna defect
CDH
Pericardial defect
82
Ossification issues
Skull: osteogenesis imperfecta Type III
spine: anchordogeneis
83
Bowed lower legs, normal upper
Campomelic dysplasia
84
Hitchhiker thumb
Diastrophic dysplasia
85
Telephone receiver femur
Thanatophoric dysplasia
severe shortening fo the limbs- micromelia
narrow thoras
telephone receiver femurs
cloverleaf shaped cranium
86
Telephone receiver femur
Thanatophoric dysplasia
severe shortening fo the limbs- micromelia
narrow thoras
telephone receiver femurs
cloverleaf shaped cranium
87
Examples of mitochondrial inheritance
- Passed in cytoplasm of the ovum
o Exclusive maternal transmission
o If mother is affected, disease is passed to all her offspring
o Expressivity is variable
- Displays heteroplasmy
o Different mitochondria may or may not have the mutation
o Severity of disease is proportional to the relative proportions of normal and abnormal mitochondrial DNA
o Affected males cannot transmit the disease; affected females transmit to all their children
- Example:
o Kearns-Sayre syn: opthalmoplegia, retinal degeneration, heart block
o Leber hereditary optic neuropathy: optic atrophy, blindness, tremor, dystonia
o Leigh’s disease: encephalopathy, lactic acidemia, hypotonia
o Myoclonic epilepsy with ragged red fibers
88
o 4p deletion: - May occur de novo or as result of parent with balanced chromosomal rearrangement which cannot separate properly at meiosis
Wolf-Hirshhorn syndrome: shielded forehead
89
5p deletion
Cri du chat; larynx affected
90
5p deletion
Cri du chat; larynx affected
91
7q deletion:
Williams syndrome: need to to microarray; down turned mouth; CHD, supravalvular aortic stenosis
92
15q11 (mat) deletion
Angelman syndrome
93
15q11 (pat) deletion
Prader Willi Syndrome – hypotonia; eating disorder; obesity; thin upper lip
94
Del 22q11
velocardiofacial syndrome (DiGeorge) – long nose
95
Del 17p11.2
Smith magenis syndrome: square jaw; behavior issues
96
enzyme associated with X-linked ichthyosis
X-linked ichthyosis is due to a placental sulfatase deficiency. Placental sulfatase is necessary for conversion of fetal estrogen to estradiol, and its deficiency results in abnormally low estriol levels in pregnancy. It usually presents as ichthyosis alone in 90% of cases and can be treated with topical agents. Another condition with low estriol levels is Smith-Lemli-Opitz syndrome (C p.239). Low estriol levels are also associated with higher risk of Trisomy 21 and Trisomy 18, but these will usually show abnormalities of other analytes as well.
97
Duffy antibodies
In addition, so are anti-Duffy antibodies (mainly anti-Fya and anti-By3). One antibody in the Duffy group is NOT associated with hemolytic disease of the newborn, and that is anti-Fyb.
98
Which parental karyotype will most likely result in a fetus with Trisomy 21?***
A: mother is 45 XX, -21,+t(14q21q)
B: father is 45 XY, -21,+t(14q21q)
C: mother is 45 XX, -21,+t(15q21q)
D: mother is 44 XX, -21,+t(21q21q)
The answer is D.
The mother in answer D carries a balanced reciprocal translocation of the long arms of chromosome 21. Although she is phenotypically normal, her gametes will either carry only the double chromosome 21 or will have no chromosome 21 at all, which is incompatible with life. She is unable to have normal children.
The other answers have an equal chance of producing normal gametes, gametes with a balanced 14,21 translocation, or an unbalanced translocation involving the extra 21 chromosome. Theoretically this would result in a 1/3 risk of a child with Down’s syndrome (C p.19).
99
202. Which of the following antibodies is associated with hemolytic disease of the newborn by suppression of fetal erythropoesis?
A: anti-Jka
B: anti-K
C: anti-c
D: anti-MNS
The answer is B.
Anti-K antibodies are in the Kell group. Anti-Jka is in the Kidd group, anti-MNS is a group unto itself, and anti-c is in the Rh group. All of these except the Kell group cause fetal anemia by hemolysis. The Kell group causes hemolysis and suppresses fetal erythropoesis, which is why delta OD450 measurements are not reliable in these pregnancies (C p.554-556).
100
202. Which of the following antibodies is associated with hemolytic disease of the newborn by suppression of fetal erythropoesis?
A: anti-Jka
B: anti-K
C: anti-c
D: anti-MNS
The answer is B.
Anti-K antibodies are in the Kell group. Anti-Jka is in the Kidd group, anti-MNS is a group unto itself, and anti-c is in the Rh group. All of these except the Kell group cause fetal anemia by hemolysis. The Kell group causes hemolysis and suppresses fetal erythropoesis, which is why delta OD450 measurements are not reliable in these pregnancies (C p.554-556).
101
210. Which heart condition is worsened by preloading the patient with IV fluids before epidural anesthesia?
A: Mitral regurgitation
B: Aortic insufficiency
C: Aortic stenosis
D: Pulmonary hypertension
? The answer is C.
Aortic stenosis is a condition that is particularly sensitive to changes in fluid status. This is particularly apparent in patients experiencing postpartum hemorrhage or decreased systemic resistance from epidural anesthesia. Increasing the preload by blousing with IV fluids can lead to increased workload on the heart due to the increased pressure gradient across the aortic valve (G p.1003). In general however, hypovolemia poses a greater risk than fluid overload.
Mitral stenosis is even more sensitive to fluid overload. If this answer is present it would probably be better than aortic stenosis.
102
214. Folate supplementation would be most useful in the setting of which medication?
A: Carbamazepine
B: Sulfamethoxazole and trimethoprim
C: Lithium
D: More than one of the above
The answer is D.
A number of medications that are used in pregnancy are classified as folic acid antagonists. The antiepileptic medications as a class have been associated with increased risk of neural tube defects, and folic acid supplementation is probably a good idea in patients on any of these medications. Specifically, however, the increased risk of NTDs associated with carbamazepine has been shown to be reduced with folic acid supplementation (C p.285). Other than antiepileptics, methotrexate, aminopterin, and trimethoprim are folic acid antagonists.
103
A mom with myasthenia gravis delivers an infant. What is the best step in management for hypotonia in a 4 day-old neonate?
a. IVIG
b. Intubation
c. Anticholinesterase drug
d. Expectant management
C
104
How does carbamazepine decrease the efficacy of OCPs?
b. Decrease in SHBG
c. Induce hepatic enzymes
d. Increased degradation of hormones (estrogen/progesterone)
C
105
How does carbamazepine decrease the efficacy of OCPs?
b. Decrease in SHBG
c. Induce hepatic enzymes
d. Increased degradation of hormones (estrogen/progesterone)
C
106
What is the mechanism by which increased cAMP leads to myometrial relaxation?
b. Deactivate myosin light chain kinase
107
What is the mechanism by which indomethacin prevents contractions?
a. COX-2 inhibition in the amnion
b. COX-1 in the choriodecidua
c. PGE3 in the choriodecidua
A
108
What is the concern with giving an epidural to a patient with aortic stenosis?
a. Increased SVR
b. Decreased SVR
c. Tachycardia
d. Bradycardia
B
109
How do amino acids and calcium cross the placenta?
a. Active transport
b. Facilitated diffusion
c. Endocytosis
d. Simple diffusion
A
110
How does glucose cross the placenta
facilitated diffusion
111
Woman who is 26ish weeks and has Hodgkins Type 2 lymphoma. What do you do?
Chemo
Chemo/radiation
Wait until delivery
Creasy page 946: Therapy typically delayed until 2nd or 3rd trimester. Therapy for HL in pregnancy during 2nd and 3rd trimesters consists primarily of chemotherapy. ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) appears to be safe in pregnancy and because HL is potentially curable, the regimen should be offered to all patients unless delivery is expected within 2-3 weeks. Radiotherapy should typically be delayed until after delivery and is rarely used alone.
112
What is the fetal SaO2 values in LV, ascending aorta, ductus arteriosus, descending aorta?
LV 60
Ascending aorta 60
Ductus arteriosis 53
Descending aorta 55
113
Effects on Aveolar canalization
Nicotine
Hypoxia
Thyroxine
Factors that delay/interfere with alveolarization:
Mechanical ventilation in preterm infants, glucocorticoids, proinflammatory cytokines (TNF alpha, IL-6), chorio, hypoxia, poor nutrition, nicotine
Factors that stimulate alveolarization:
Vitamin A, thyroxine
114
Effects of beta mimetic and CCB on muscles
Bmimetics act through specific receptors on myometrial cells to active cAMP dependent protein kinase A, which inhibits myosin light chain phosphorylation and decreases intracellular calcium myometrial relaxation
Have also seen this question phrased as beta mimetics increase what (cAMP)
Smooth muscle contraction requires calcium, ATP binding to myosin light chain kinase and phosphorylation of MLCK, and actin/myosin cross bridges.
Other tocolytics:
Magnesium (although not a tocolytic): inhibits calcium entry into cells through voltage dependent channels (due to increased intracellular mg levels) causes hyperpolarization of cell and cell membrane. Also competes with calcium for calmodulin binding decreased affinity of calmodulin for myosin light chain kinase.
Nifedipine: CCB. Inhibits the entry of calcium ions via voltage dependent calcium channels
115
MOST associated with toxo (fetal)
chorioretinitis
UptoDate:
In symptomatic neonates
Chorioretinitis 85-92%
Intracranial calcifications 50-85%
Hydrocephalus 30-68%
Thrombocytopenia 40%
Anemia 20-50%
Hepatosplenomegaly 30-40%
Toxo is like CMV: less transmission in early pregnancy, but worse sequelae if transmitted
Risk of transmission: 15% at 13w, 44% at 26w, and 71% at 36w
Risk of sequelae: 61% at 13w. 25% at 26w, 9% at 36w
116
MOM trial – what was improved
Bladder function
Bowel function
Lower motor function
Lower sensory
ACOG summary of MOMS from PB 187: Management of Myelomeningocele Study (MOMS), a prospective randomized clinical trial that compared standard postnatal repair of myelomeningocele to intrauterine repair of the defect in the second trimester. All fetuses were between 19 0/7 weeks and 25 6/7 weeks of gestation at randomization with a normal karyotype and an upper border of the spina bifida between T1 and S1, and all had evidence of an Arnold–Chiari malformation on ultrasonography and fetal MRI. All fetal repairs were done at one of three sites in the United States. A total of 158 patients were randomized and evaluated at 12 months after delivery. In utero spina bifida closure resulted in a lower incidence of the composite outcome of fetal or neonatal death or need for shunt placement by 12 months (68% versus 98%, RR, 0.70; 97.7% CI, 0.58–0.84) and a lower incidence of hindbrain herniation at 12 months (64% versus 96%, RR, 0.67; 95% CI, 0.56–0.81). Children who had prenatal surgery were more likely to have a level of function that was two or more levels better than expected and were more likely to be able to walk without devices or orthotics. There were no differences between the groups with regard to cognitive test scores
117
Features of fetal thyrotoxicosis
Creasy page 1031: Features of fetal thyrotoxicosis include HR >160, FGR, fetal goiter, advanced bone age, and craniosynotosis. Hydrops/death may occur in extreme cases.
It is usually caused by transplacental passage of TSIs, and occurs in 1% of women with Graves. Predicated by maternal TSI levels in excess of 300% of normal, although routine screening of TSI levels is not recommended. Tx with antithyroid drugs (ie PTU). Consider PUBs if there is doubt about fetal thyroid disease.
Creasy page 1029: Risks of hyperthyroidism in pregnancy:
Low birth weight: OR 2.4 for controlled, 9.2 for uncontrolled
Preterm birth: 2.8 controlled, 16.5 uncontrolled
PRETERM BIRTH MOST COMMON OUTCOME IN UNCONTROLLED HYPERTHYROIDISM
118
Most common cause of triploidy
Dispermic diandric is most common form of triploidy (90%), is consistent with partial hyditaform mole
119
Placenta biochem
enzymes, fetal enzymes
Remember that placenta lacks 17 alpha hydroxylase
Fetus lacks HSD3B1
HSD11B2 degrades steroids going through placenta (protects fetus from maternal cortisol)
Aromatase = CYP19 = final step in estrogen synthesis
Precursor for everything is LDL cholesterol
Note dexamethasone and betamethasone cross placenta, other steroids degraded by HSD11B2.
120
How does placental estrogen get derived from fetal androgen steroids
CYP19 = aromatase
121
168. Patient has a prolactinoma, what do you counsel regarding lactation
No problems to lactation (other options were tx with bromocriptine, suppresses lactation – not right; and some others I cannot remember)
122
Outcomes of uncontrolled maternal PKU
a. ACOG committee opinion #636: Children born to women with PKU on unrestricted diets have a 92% risk of developmental delays, a 73% risk of microcephaly, and a 12% risk of congenital heart defects as well as growth delay and seizures
123
B agonists and muscle
B agonists and muscle binds g protein coupled receptors, stimulates adenylate cyclase, leads to increased cAMP and decreased Ca2+, activates protein kinase A, inactivates MLCK
124
Rh neg does not receive rhogam
15% chance sensitization
125
Neonatal HLHS
HLHS: Need immediate PG, important to note that OXYGEN MAKES NEONATE
WORSE AS WORSENS PULMONARY OVER CIRCULATION. Is DA dependent lesion.
This baby WOULD be cyanotic
126
where is hPL made, where is gNRH made
hPL: syncitio
grNH: cytotrophoblasts
127
what is elevated for lactogenesis
Prolactin, insulin cortisol
128
Which of the following is decreased in pregnancy?
A- T-helper (Th) 2 cells
B- T-helper (Th) 1 cells
C- IL4
D- IL6
E- CD8 lymphocytes
ANSWER: B.
DECREASE is seen in the following:
Th1 (aka: T-helper cells)
Tc (T-cytotoxic cells)
The decrease in the above 2 suppresses secretion of IL2, INF-gamma, TNF-alpha
INF-alpha
CD4 T lymphocytes
Monocytes
INCREASE in the following:
Granulocytes and CD8 lymphocytes (especially in 3rd trimester)
Th2 cells (that then increase secretion of IL4, IL6, IL13)
C3 and C4 (2nd and 3rd trimester)
CRP, ESR, Leukocyte alkaline phosphatase
IL1beta in cervical mucous 10x higher in pregnancy
129
Inflammatory cytokies
Inflammatory: IL2,3,6,8, TNF alpha, INF alpha
130
Cystic hygroma and associated chromosomal issues by trimester
1TM: t21
2TM: Turner's
131
PCWP normal parameters and what is measuring
Next look at PCWP: think of preload, like the left heart. Normal is 6-12mmHg. If it is low you are
thinking an intravasculary dry patient versus if high you are thinking centrally wet. If you see a
PCWP >20mmHg generally think pulmonary edema. If you have a super high PCWP like
40mmHg you may have mitral stenosis. Think about treating a patient like this with an anti-HTN.
Of note, PCWP is not always accurate with MS. (PCWP represents Left Preload, and normal is
6-12mmHg)
132
Lidocaine with and without epinephrine
4 mg/kg (0.4 mL/kg of lidocaine 1 percent, maximum total dose: 300 mg [30 mL
of lidocaine 1 percent])
-Lidocaine WITH epinephrine – 7 mg/kg (0.7 mL/kg of lidocaine 1 percent,
maximum total dose: 500 mg [50 mL of lidocaine 1 percent with epinephrine]).
-Onset of action: 2-5min
-Duration of action: 30min-2hr for plain lidocaine (versus longer with EPI, up to
3hr, due to the added local vasoconstriction)
133
Which CCB has been linked with fetal cardiac depression or fetal cardiac arrest
when used with digoxin for treating fetal SVT?
A- Nicardipine
B- Nifedipine
C- Labetalol
D- Verapamil
E- Diltiazem
D
134
Which of the following is not associated with fetal side effects after the use of a
thiazide diuretic close to time of delivery?
A- Thrombocytopenia
B- Ototoxicity
C- Bleeding issues
D- Electrolyte disturbances
B. Thiazide is HCTZ and has those 3 effects. Ototoxicity can be seen with
the loop diuretic, Ethacrynic acid. The other loop diuretic, Lasix (furosemide)
stimulates renal synthesis of PGE2 and can increase risk of PDA in preterm
newborn.
135
What is the precursor for deoxycortisol?
A- Aldosterone
B- DHEA
C- Progesterone
D- Testosterone
ANSWER: C. Progesterone 🡪 (via 17alpha hydroxylase)🡪17OHP
Then 17OHP 🡪 (via 21hydroxylase) 🡪 deoxycortisol
Then Deoxycortisol - (via 11 beta hydroxylase) - cortisol
Note that Progesterone also converts to Deoxycorticosterone (via 21 hydroxylase).
Deoxycorticosterone - (via 11-beta hydroxylase) - corticosterone - (via
aldosterone synthase) - aldosterone.
Note that DHEA is the precursor directly to - (via 3 beta hydroxysteroid
dehydrogenase) - androstenedione
Androstenedione can take one of two routes:
(via aromatase) - estrone
(via 17 ketosteroid reductase) 🡪 testosterone
136
Luteoma effects on the mom
Luteoma (often bilateral solid masses) of pregnancy is solid and 35%
of the moms will have hirsuitism/virilization and 80% of the females born are
virilized (IF the mother is showing signs of virilization). Note that Hyperreactio
luteinalis does not virilize the female fetus. These are numerous bilateral theca
lutein cysts that will regress after pregnancy.
NOTE: another syndrome that could cause IRREVERSIBLE virilization of an infant is
Placental aromatase deficiency (see maternal masculinization as well that will
regress in postpartum period).
137
Which of the following lab would be elevated in a fasting blood panel in a pregnant woman?
A- glucose
B- cholesterol
C- creatinine
D- sodium
ANSWER: B. Cholesterol
Fasting: Non-pregnant Pregnant
Glucose 79 68 (down)
Insulin 9 16 (up)
Glucagon 126 130
Cholesterol 163 250 (up)
138
What is a normal amount of the amniotic fluid at 12 weeks gestation?
A- 10cc
B- 25cc
C- 50cc
D- 200cc
ANSWER: C.
In general: 8wk (10cc), 12 wk (50cc), 20wk (400cc), 22wk (630cc), 28wk (770cc),
max at 30-34cc then plateaus around 36-38wk then decreases (around 515cc at
41wk then decrease by 33% or about 70cc/wk)
Production rate: 7-17, so can say 10cc/d by 18wk and by term is 800cc/d
Amount fetus swallowing should always be less than amount they are peeing
From 22-33 weeks the 50% for AFI is about 14.5cm
In volume, oligo is <300-500cc after mid trimester and poly is >1500-2000cc
AFV max change rate is at around 22wk and max volume is at 30-34wk
Term fetal UOP is 700cc/d
The amnion/chorion doesn't really turn into a thick layer until 24 weeks when it
undergoes keratinization. Fetal urine turns HYPOTONIC starting around 12 weeks
and as the gestation increases the amniotic fluid becomes with lower and lower Na
and Cl and see an increase in Urea and Creatinine in the amniotic fluid (2-3 x higher
than the fetal plasma).
139
What is the approximate volume of the intermembranous space?
A- 100cc
B- 300cc
C- 800cc
D- 1000cc
ANSWER: B. states 200-500cc, or about 400cc/d at term. Note that the intervillous
space volume at term is 140cc.
140
What is the most reliable initial sign of malignant hyperthermia, clinically?
A- Tachycardia
B- Decreasing O2 saturation
C- Hypocarbia
D- Hypercarbia
E- Muscle rigidity
ANSWER: D. The hypercarbia is the MOST reliable and is RESISTANT to increasing
the patient’s minute ventilation. If the patient is spontaneously ventilated and gets
MH, they will have tachypnea as a response to the end tidal CO2 >60mmHg versus
those on controlled ventilation have a rising CO2 level at fixed/increasing vent
settings.
141
In the presence of thick meconium, which test for fetal lung maturity is still
valid?
A- Lechitin : spingomyelin ratio
B- Phosphatidylglycerol
C- Surfactant : albumin ratio
D- Lamellar body count
E- Optical density 650 (OD 650)
ANSWER: B. PG is NOT affected by blood or meconium or vag secretions. It is one of
the LAST pulmonary phospholipids found in amniotic fluid. Down side is that it has
a high false negative <36wk.
Tests affected by blood, but if result is mature is valid: L/S, S/A, LBC
Tests that meconium makes NOT valid: L/S, S/A, LBC (reduces count)
S/A: not affected by AFI whereas if there is oligo the LBC can be falsely increased
142
What is the best test for FLM to use for a diabetic mother?
A- Lechitin : spingomyelin ratio
B- Phosphatidylglycerol
C- Surfactant : albumin ratio
D- Optical density 650 (OD 650)
ANSWER: LBC or S/A, so either answer would work. DO NOT use PG as it shows up
later if a woman has bad BS control.
143
high risk alloimmunization ab
High risk antibodies: anti-c, anti-D, anti-E, and anti-K(Kell)
Low risk antibodies, still clinically significant alloantibodies (eg, anti-C, anti-e, anti-Jk(a),
anti-Jk(b), anti-Fy(a), anti-Fy(b), anti-S, and anti-s) generally cause only mild to moderate HDN if
the fetus inherits the corresponding antigen.
Williams: to cause hydrops – K, Fya (type of duffy), D.
144
Which of the following IgG is considered to be the most hemolytic in hemolytic disease of the
newborn?
A- IgG 2
B- IgG 1
C- IgG 3
D- IgG 4
E- IgG 5
ANSWER: C. only 1 and 3 play a role in hemolysis, 1 in the first tri and 3 being most hemolytic. 2 and 4 do
not play a role in hemolysis of the newborn.
145
When does a neonate need to be intubated?
A- HR 90 with peripheral cyanosis
B- never
C- HR 55 and with gasping, apnea, central cyanosis, low O2
D- HR 130 and on CPAP
E- HR 85 and on CPAP
ANSWER: C. Need to intubate when the HR is <60 and baby gasping, apneic, central cyanosis, low o2.
Need for CPAP when HR is >100 with labored breathing
146
Which is most commonly used to differentiate fetal from maternal blood?
A- MCV
B- I antigen
C- hCG
D- Apt test
E- Kleihauer-Betke
ANSWER: A, but all are correct, see below.
The purity of the fetal blood sample is commonly assessed using the mean
corpuscular volume (MCV) of red blood cells (RBC) since fetal RBCs are
larger than maternal RBCs. On occasion, this parameter can be misinterpreted
(eg, in the presence of some maternal hematologic disorders, such as macrocytic
anemia, or after repeated fetal transfusions of blood from an adult donor). Of
note, an elevated (ie, greater than 95th percentile for gestational age) MCV has
been proposed as a marker for trisomy or triploidy (table 2). In a population of
267 fetuses in which the prevalence of aneuploidies was 4 percent, the sensitivity
of this finding was 100 percent and the specificity ranged from 43 percent among
growth restricted fetuses to 58 percent among appropriate for gestational age
fetuses
147
Fetal breathing is increased the most by:
A- maternal hypercarbia
B- betamethasone
C- magnesium
D- maternal hypoglycemia
E- preterm labor
ANSWER: A. can be affected by time of day, GA, BS (as increases see increase in fetal
breathing), mom’s CO2. Increase in mom’s CO2 or O2 can see increase in fetal
breathing.
FB is decreased by: steroids, magnesium, preterm labor (note that PTL can decrease
breathing but NOT fetal movement), labor, low maternal oxygen status
FB is increased by: hypercarbia, hyperoxemia, high BS, terbutaline, Indocin (increase
fetal breathing by feeding the mom)
Note: terb and Indocin do not change movement, just increase breathing.
-Magnesium: decrease FHR reactivity in Preterm and maybe term fetus, decrease
breathing. No change in movement, tone, AFI
-ACS: decrease in FHR reactivity, breathing, movement, BPP for 1-3 days, no change
in tone.
148
What are the Acro-centric chromosomes
They are 13, 14, 15, 21, 22
149
A neonate presents 5 days after vaginal delivery with conjunctivitis. The most
likely infectious agent from mom is?
A- Neisseria gonorrhea
B- Chlamydia trichomoniasis
C- HIV
D- HSV
E- HPV
ANSWER: B. CT is the most common cause of neonatal conjunctivitis in the first 2
weeks postpartum, and then after it is NG. All bablies get prophylaxis against NG
with 3 items: erythromycin, tetracycline, and silver nitrate, to prevent NG (which
they would typically get in the first 4 days postpartum). If it was NG it is usually
bilateral and has a 21d incubation time.
Williams states: this triple therapy has NOT been good at preventing CT. And if an
infant presents with conjunctivitis in <1 month of age, consider CT as the reason!
Important: if mom is +CT at time of delivery, 60-70% risk baby gets it via passage
and 25-50% chance baby will get conjunctivitis in the fist 2 weeks.
150
The direct precursor of progesterone is what?
A- Estrone
B- Pregnenolone
C- Estradiol
D- Cholesterol
E- 17 hydroxyprogesterone
ANSWER: B. Pregnenolone 🡪 Progesterone via 3 beta hydroxysteroid
dehydrogenase (which is in the placenta, and very important, is NOT found in
the fetal adrenal gland: ie fetus lacks this enzyme)! This same enzyme takes
DHEA 🡪 androstenedione.
So, the PLACENTA makes PROGESTERONE for the fetus from PREGNENOLONE via
the enzyme 3BETA HYDROXYSTEROID DHASE.
Fetus CANNOT convert pregnenolone to progesterone. Placenta is primary source of
progesterone in pregnancy!
