MFM Pathophysiology Lectures

Question 1

What is the definition of peripartum cardiomyopathy (the non-Nichols version…)?

Answer 1

HF in last month of pregnancy or within 5 months post-delivery with absence of other causes

Question 2

What are some potential viral causes of peripartum cardiomyopathy?

Answer 2

Parovirus
HHV 6
EBV
CMV

Question 3

What are the risk factors for peripartum cardiomyopathy?

Answer 3

Chronic HTN
Preeclampsia
Obesity
Advanced maternal age, or the very young
African American race
Multiparous

Question 4

What is the most common cause of HF in pregnancy?

Answer 4

Chronic HTN with superimposed preeclampsia

Question 5

Dilated cardiomyopathy is classically associated with:

Answer 5

HIV

Question 6

What are the clinical findings of peripartum cardiomyopathy?

Answer 6

Cardiomegaly
Perihilar opacification
Ejection Fraction < 45%

Question 7

What is the treatment for peripartum cardiomyopathy?

Answer 7

Diuretics to reduce preload
Hydralazine to reduce afterload
Digoxin for inotropic effects

Question 8

What is the prognosis for those with peripartum cardiomyopathy?

Answer 8

Takes a year to regain function –> DO NOT GET PREGNANT until you are better!

Return to normal in 6 months has better prognosis

Long-term prognosis worse in nonpregnant ladies with idiopathic cardiomyopathy

Question 9

What is the control drug of choice for asthma in pregnancy? **potential test question

Answer 9

Budesonide (inhaled corticosteroid)

Question 10

What are the outcomes of pregnant asthmatics?

Answer 10

1/3 no change
1/3 improve
1/3 worsen (during weeks 24-36)

Question 11

Asthma worsens pregnancy outcomes in patients with these conditions

Answer 11

Preeclampsia
Pre-term birth
Low birth weight

Question 12

How does FRC change during pregnancy?

Answer 12

Decrease ~ 20%

Question 13

How does bronchial responsiveness change during pregnancy?

Answer 13

More responsive (to methacholine challenge)

Question 14

What are some reasons pregnancy worsens asthma?

Answer 14

GERD, mucosal edema, URI, stress, decreased FRC

Question 15

When are pregnant women most likely to have an asthma attack?

Answer 15

Wks 17-24

Question 16

What effects can asthma have on the fetus?

Answer 16

Increased:
IUGR
Hypoxia
LBW
Mortality

Question 17

How should you monitor pregnant asthmatics?

Answer 17

Monthly spirometry

Peak flow meter 2x/d

Question 18

Inhaled steroids are pregnancy category __ and oral steroids are category __

Answer 18

B, C

Question 19

How should you monitor the fetus in pregnant asthmatics?

Answer 19

US @ 32 wks, every 4 weeks, when suspecting IUGR, and after exacerbations

Question 20

Diagnostic definition of APAS?

Answer 20

Prior or current VTE or characteristic OB complications + a relevant lab value (anticardiolipin or lupus anticoagulant) on two or more occasions, 6 weeks apart

Note: moms without APAS may have + antibody titer

Question 21

What hemodynamic changes occur in thromboembolic disease of pregnancy?

Answer 21

High progeserone increases decidua
Fibrinogen levels double
Clotting factors increase
vWF increases
Protein S decreases

Question 22

What are the high risk thromboembolic disorders of pregnancy?

Answer 22

Factor V Leiden homozygous mutants
Antithrombin III deficiency
Prothrombin gene homozygous mutants

Question 23

What are the lower risk thromboembolic disorders of pregnancy?

Answer 23

Factor V Leiden heterozygous mutants
Prothrombin heterozygosity
Protein C deficiency
Protein S deficiency

Question 24

What are some pregnancy-specific risk factors for thromboembolic disease?

Answer 24

Increased parity
Postpartum endomyometritis
Operative delivery
C/S

Question 25

The inherited thrombophilias are all __ inherited except for __

Answer 25

AD | Hyperhomocysteinemia (AR)

Question 26

What is the most important modifier of risk for inherited thrombophilias?

Answer 26

Personal or family hx of venous thrombosis (duh)

Question 27

What are some diagnostic methods for DVT?

Answer 27

Venous US: MC method D-dimer: product of fibrin degradation Contrast venography: 20% are intolerant MRI: superior to US

Question 28

What is the characteristic EKG change in PE?

Answer 28

S1, Q3, inverted T3

Question 29

What is an adverse event associated with long-term therapy with unfractionated heparin? **potential test question

Answer 29

Osteoporosis

Question 30

At what time in pregnancy should you switch from LMWH back to unfractionated and why?

Answer 30

36 weeks; because LMWH is hard to reverseand don't want to deal with that during L&D

Question 31

When is warfarin most teratogenic and what anomalies does it cause?

Answer 31

6-12 weeks | MR, nasal hypoplasia, microphthalmia

Question 32

What drug is used to reverse the effects of unfractionated heparin? **potential test question

Answer 32

Protamine

Question 33

What are some signs of a trophoblastic mole?

Answer 33

Passing grape-like structures and very high hCG

Question 34

What disease does DES exposure increase your risk for?

Answer 34

Clear cell vaginal cancer

Question 35

Very heavy bleeding with first menses should prompt testing for:

Answer 35

Von WIllebrand disease

Question 36

What drugs are associated with abnormal uterine bleeding?

Answer 36

Anticoagulants, salicylates, prostaglandin inhibitors (mifepristone), contraceptives, psychotropic drugs

Question 37

What's the predominant cause of AUB in reproductive years?

Answer 37

Anovulation | others: PCOS, pituitary, and thyroid dysfunction

Question 38

What are the risk factors for endometrial cancer?

Answer 38

> 3, obesity, infertility, family hx of colon cancer, excess estrogen exposure

Question 39

What is the gold standard diagnostic method for HSV and what finding is expected?

Answer 39

Viral culture; intranuclear inclusion bodies

Question 40

Contrast HSV IgM and IgG seropositivity

Answer 40

IgM: not useful; positive during recurrent episodes | Use IgG for diagnosis

Question 41

DOC for HSV?

Answer 41

ACV

Question 42

When should you begin HSV suppression during pregnancy?

Answer 42

36 weeks to reduce need for C/S from outbreak

Question 43

The classic clinical scenario for CMV?

Answer 43

Day-care workers (also think of pregnant women with young children)

Question 44

When is risk of CMV transmission greatest during pregnancy, and when is fetal injury greatest?

Answer 44

3rd trimester infections - greatest transmission | 1st trimester infections - greatest harm

Question 45

What are the manifestations of CMV infection?

Answer 45

Most common: asymptomatic Mono-like syndrome Guillain-Barré: progressive polyneuropathy that begins peripherally associated with CMV infection

Question 46

What is the incubation period of CMV?

Answer 46

About 40 days | Viremia detected 2-3 weeks after infection

Question 47

What is CMV avidity?

Answer 47

Reflects modifications to IgG and tells you age of infection Avidity less than 25% indicates infection in previous 3 months

Question 48

How is maternal CMV during pregnancy diagnosed?

Answer 48

Serum samples 3-4 weeks apart tested for IgG >4x increase in titer

Question 49

What ultrasound findings would you expect for a fetal CMV infection?

Answer 49

Cerebral calcifications (pathognomonic!) Hepatosplenomegaly Ascites Hydrops

Question 50

How is fetal CMV diagnosed?

Answer 50

Amniocentesis and then PCR (more sensitive) or viral culture

Question 51

During preconception counseling it is important to say this about obesity

Answer 51

1. "It's a health condition" - use classifications 2. Explain risks 3. Encourage lifestyle changes (FRAMES motivational interviewing) 4. Refer as needed

Question 52

What risks are associated with obesity in pregnancy?

Answer 52

Low rates of fertility (rev. with WL) due to anovulation (PCOS), leptin, infrequent intercourse, and spontaneous abortion

Question 53

Bariatric surgery is indicated for whom?

Answer 53

BMI > 40, or BMI > 35 with complications of obesity

Question 54

Gastric bypass is associated with lower risk of these complications

Answer 54

Preeclampsia, gestational diabetes, congenital abnormalities, avg. weight gain

Question 55

Bypass is associated with higher risk of these complications

Answer 55

C/S | PPROM

Question 56

Which nutrients should you screen for during pregnancy counseling?

Answer 56

B12, iron, vit. D, Ca2+

Question 57

What is Dumping syndrome?

Answer 57

Rapid absorption of simple sugars --> don't use glucola to test for gestational diabetes! Use fasting and post-prandial sugar levels

Question 58

What disorder is classically associated with high birth weight?

Answer 58

Diabetes

Question 59

What disorder is associated with newborns with large organs and tongues?

Answer 59

Beckwith-Wiedemann

Question 60

What is the definition of IUGR?

Answer 60

A fetus that fails to reach growth potential / technically, birth weight < 10th percentile

Question 61

What are some extrinsic causes of IUGR?

Answer 61

*Maternal vascular disease (e.g., pre-eclampsia --> low perfusion) - 30% *Nutrition abnormalities: Vitamins: zinc, folate Oxygen delivery: Hgb-opathies, COPD, high alt. Infection TORCH, esp. Rubella Toxins: EtOH, tobacco, drugs, warfarin, anticonvulsants Placental

Question 62

What are some intrinsic causes of IUGR?

Answer 62

Genetics: chromosomal abnormalities, esp. trisomies and TUrner's Multiparity If IUGR is early-onset (< 26 wks), 25% have abnormal karyotype

Question 63

What does Doppler US for IUGR look for?

Answer 63

Umbilical artery: for placental vascular resistance Middle cerebral artery: for 'brain sparing effect' Should never show backward flow

Question 64

Examination of amniotic fluid would show this finding in IUGR

Answer 64

Oligohydramnios