MFM

Question 1

When is AFP checked

Answer 1

Between 15 and 22 weeks gestation

Question 2

High AFP causes

Answer 2

Open NTD
GI abn (liver necrosis, esophageal or intestinal obstruction, omphalocele, gastroschisis)
Renal abn
Masses
Multiple gestation
If unexplained elevation - ^risk of IUGR or fetal death

Question 3

Low AFP causes

Answer 3

Trisomies
Fetal death
Inaccurate GA
Gestational trophoblastic disease

Question 4

First trimester maternal screen

Answer 4

At 10-13 weeks
PAPP-A
B hCG
Combined with maternal age - detects 60-65% T21

+ nuchal translucency 10-14 weeks
Mat age + PAPP A + BhCG + NT detects 78-89% of T21 and 91% of T18

Question 5

Abn nuchal translucency risk of aneuploidy

Answer 5

1 in 6
Normal is 0.5mm-2mm; >3mm is abn
Explanations for nuchal translucency:
Cardiac failure
Extracellular matrix abn
Abn lymphatic system

Question 6

Hygroma testing

Answer 6

50% chance aneuploidy
If euploid 50% with major fetal malformation
If found -> get details US, fetal echo, offer CVS

Question 7

Quadruple screen

Answer 7

14-20 weeks
AFP
Mat unconjugated estriol
BhCG
Inhibin A

Question 8

Low AFP, high BhCG, low uE3, high inhibin A

Answer 8

T21 on quad
Detects 75-81%

Question 9

Low AFP, low BhCG, low uE3, normal inhibin A

Answer 9

T18 quad
Detects 60%

Question 10

T13 quad

Answer 10

Not helpful

Question 11

Cell free DNA - obtained when & indications

Answer 11

9 weeks GA
Screening test
^ aneuploidy risk
RhD genotype
Sex identification in X-linked genetic disorders
Risk of CAH

Question 12

Smith-Lemli-Opitz
Prenatal screen

Answer 12

Low uE3, low AFP, low bhCG

Question 13

Turner syndrome quad screen

Answer 13

Low AFP, high BhCG, low uE3, high inhibin A if hydrops, low inhibin A if no hydrops

Question 14

Timing of amnio, CVS, and PUBS

Answer 14

Amnio 15-20 wk
CVS 10-13 wk
PUBS >19 wk

Question 15

Teratogenic effects:
ACEI

Answer 15

Greatest risk in 2nd & 3rd tri
Oligo, skull hypoplasia, renal tubular dysgenesis
Postnatal hypotension and oliguria

Question 16

Teratogenic effects:
Alcohol

Answer 16

Worse earlier in gestation
Worse with greater amounts less frequently than chronic small amounts
Abn in 3 areas: physical, growth, neurodevelopment

Question 17

Teratogenic effects:
Carbamazepine

Answer 17

Craniofacial defects, fingernail hypoplasia, growth restriction
NTD, developmental delay
Decreased placental transfer of vit K

Question 18

Teratogenic effects:
Cocaine

Answer 18

Placental abruption
Cutis aplasia, porenchephaly, ileal atresia, cardiac abn, fetal growth restriction, GU abn

Question 19

Teratogenic effects:
Cyclophosphamide

Answer 19

Exposure early in pregnancy
Missing or hypoplastic digits, cleft palate, single coronary artery, imperforate anus, growth restriction, microcephaly

Question 20

Teratogenic effects:
Phenytoin (hydantoin)

Answer 20

Digit and nail hypoplasia, cleft lip/palate, IUGR, FTT, wide anterior fontanelle, hernias, dec placental vit K transfer, maybe cardiac abn (PS, AS, VSD)

Question 21

Teratogenic effects:
Retinoic acid

Answer 21

1st tri exposure
Cardiac: TGA, TA, TOF, VSD, DORV, IAA, retroesophageal subclavian artery
Microtia, hypertelorism, triangular facies, facial nerve palsies, limb reduction, hydrocephalus, thymic and parathyroid abn

Question 22

Teratogenic effects:
Lithium

Answer 22

Ebsteins anomaly

Question 23

Teratogenic effects:
Methotrexate

Answer 23

6-8 weeks after conception exposure
Cranial dysplasia, broad nasal bridge, low set ears, micrognathia, microcephaly, IUGR

Question 24

Teratogenic effects:
Phenobarbital

Answer 24

Cleft lip/palate, cardiac abn, decreased placental transfer of vit K

Question 25

Teratogenic effects: Salicylates

Answer 25

Risk thrombocytopenia Intrauterine closure of PDA, PH

Question 26

Teratogenic effects: Valproic acid

Answer 26

NTD, long thin fingers, hyperconvex nails, narrow bifrontal diameter, anteverted nostrils, midface hypoplasia, cardiac (CoA, hypoplastic left heart, AS, IAA, ASD, PA w/IVS)

Question 27

Teratogenic effects: Warfarin

Answer 27

Exposure 6-12 weeks GA Nasal hypoplasia, mental deficiency, seizures, stippled bone epiphyses Heparin does NOT cross the placenta

Question 28

Symmetric IUGR/SGA

Answer 28

HC proportional to rest of body Early onset (prior to 3rd trimester) Risk of perinatal depression is low Blood flow to ICA is normal Normal glycogen fat and glucose stores Etiology: Usually intrinsic, results from chromosomal abnormalities, congenital infections, and some IEM

Question 29

Asymmetric IUGR/SGA

Answer 29

HC % greater than weight % Onset 3rd trimester (but can develop between 16-32 weeks as well) Risk of perinatal depression is increased Blood flow to the ICA is increased (thus the brain growth is spared) Low glycogen and fat stores so an increased risk of hypoglycemia Etiology: usually environmental, results from uteroplacental insufficiency from preE, cHTN, or severe maternal DM

Question 30

Neonatal effects of IUGR

Answer 30

Depressed immune system (decreased lymphocyte number and function and decreased Ig levels) Hyperglycemia (bc of low insulin and increased catecholamines) Hypoglycemia (bc of low stores) Hypothermia Hypocalcemia (bc of decreased vascular supply in utero) Perinatal depression (bc of acute on chronic stress) Polycythemia (bc of chronic hypoxemia) Mortality risk 5-20x greater than AGA counterpart

Question 31

Mechanism of hydrops

Answer 31

Congestive heart failure (most common) Anemia Lymphatic obstruction Decreased plasma on osmotic pressure with increased capillary permeability

Question 32

Postnatal management of NI hydrops

Answer 32

See what’s been performed. Chromosomal analysis, metabolic studies, CBC, blood type, Hb electrophoresis, skeletal X-rays, echocardiogram, US of abdomen and chest, genetics evaluation

Question 33

Range for uterine artery gas

Answer 33

7.4/32/95 sat 98%

Question 34

Range for Uterine vein gas

Answer 34

7.34/40/40 sat 76%

Question 35

Range for umbilical vein gas

Answer 35

7.35 (7.25-7.45) / 38 (26-49) / 29 (17-40) sat 68%

Question 36

Range for umbilical artery gas

Answer 36

7.28 (7.18-7.38) / 49 (32-65) / 18 (5-30) sat 30%

Question 37

Non immune fetal hydrops

Answer 37

1. Disorders a/c CHF (most common) 2. Anemia 3. Obstructed lymphatic flow 4. Decreased plasma osmotic pressure with increased capillary permeability (Heme: TTTS, homozygous alpha thal, rbc enzyme deficiencies, severe fetomaternal hemorrhage; Cardiac: arrhythmia, CHD, cardiac mass, cardiomyopathy; Vascular malformation: AVM, vascular accident, lymphatic obstruction; Infection: coxsackie, parvo, CMV, syphilis, toxo, rubella, herpes, adenovirus; Genetic: aneuploidy, syndrome; Metabolic: LSD, GSD type IV; Endocrine: thyrotoxicosis; Pulmonary: chylothorax, CPAM, pulmonary sequestration; Other: congenital nephrotic syndrome, CDH, skeletal dysplasia, placental/coed abnormalities)

Question 38

Causes of neonatal withdrawal

Answer 38

Narcotics Barbiturates Stimulants Depressants and sedatives (like alcohol) SSRI

Question 39

Timing of symptoms narcotic withdrawal

Answer 39

Heroin within 48 hours Methadone within 48-72 hours and symptoms can last for 4-6 months CNS, ANS, GI, Resp symptoms

Question 40

Timing of symptoms barbiturates

Answer 40

DOL 4-7 Acute (irritable, crying, no sleep, tremors, hiccups) and subacute stage (voracious appetites, reflux, gagging, irritable, sweating, sensitive to sound, poor sleep)

Question 41

Timing of symptoms for stimulants

Answer 41

Within 72 hours Symptoms due to drug toxicity rather and withdrawal so symptoms are stimulant symptoms

Question 42

Timing of symptoms for depressant and sedatives

Answer 42

Ethanol 3-12 hours (initial ~72 hours hyperactive and irritable and then lethargic phase for ~48 hours) Sedative or hypnotic meds usually not until after few days

Question 43

Timing of symptoms for SSRI

Answer 43

Within 48 hours and resolve within 48 hours Symptoms in 1/3 of neonates exposed Tremors, hypertonic, sleep disturbance, GI disturbance, high pitched cry Can have PH (poor neonatal adaptation)