What is the connection between the pulmonary artery and aorta in a fetus
Ductus arteriosum
Where does the fetus get oxygen from
Placenta
Maternal circulation
From placenta to fetal hearth, what is involved
Umbilical vein –> Ductus venosus –>
Inferior vena cava –> Right atrium
What is the blood distribution from Right atrium in fetus
Some into Left atrium, some into Right ventricle
How does the blood get from Right to Left Atrium in fetus
Oval foramen
What is the distribution from Right ventricle in fetus
Pulmonary trunk –> Pulmonary arteries AND Ductus arteriosus to the descending aorta
When does the foramen ovale functionally close
By 3 months of age
When does Ductus arteriosus functionally close
10-15h post birth
What closes ductus arteriosus
Oxygen and pressure
What opens the ductus arteriosus
Prostaglandins
What is presenting symptoms of failed adaptation of fetus
Feeding difficulties
Fast breathing rate
Cyanotic episodes
What is atrial septal defect
The Oval foramen has not closed, leaking blood from Left to Right Atrium
What can happen with Ventricular Septal defect
Pulmonary hypertension, fluid leakage in lungs
What is aortic stenosis
Narrowing of the aortic valve
What is pulmonary atresia
Non-functional pulmonary valve
What is tetralogy of Fallot
Large ventricular septal defect
Pulmonary stenosis
Right ventricular hypertrophy
Overriding aorta
What is it called when the aorta and pulmonary trunk are swapped
Transposition of the great arteries
Definition of Extremely preterm
Week 27 or before
Definition of Very Preterm
Week 31 or before
Definition of Preterm
Week 36 or before
Definition of Term baby
Week 37-41
Definition of Post term
Week 42 or later
Normal birth weight
2.5kg - 4kg
Definition of Large for gestational age at birth
> 4kg
Defintion of small for gestational age at birth
What enhances baby adaption after birth
Cortisol and Adrenaline
What is hemolytic disease of the newborn
Alloimmune disease that breaks down RBC in the fetus
Why is Vitamin K given to newborns
To stop Hemorrhagic disease of the newborn casued by Vitamin K deficiency
What infections are screened for in infants
Hep B and C, HIV, TB, Group B Strep, Syphilis, Gonococcus
What vaccination is given at birth
Hep B
What vaccination is given first month of life if riskfactors are there
BCG vaccine
TB vaccine
When is routine vaccinations given
8 weeks
What Screening tests are done on infants
Universal hearing screen
Hip screen
Metabolic (Blood test)
Newborn examination: Head
OFC Moulding Overlapping sutures Fontanelles Cephalohematoma Caput succedaneum Ventouse/forceps marks
What is hemorrhage between skull and periosteum in a newborn called
Cephalhematoma
What is swelling of infants scalp called
Caput succedaneum
Newborn examination: Eyes
Size
Red reflex
Conjunctival hemorrhage
Squints
Newborn examination: Ears
Position
External auditory canal
FH of hearing loss
Tags/pits
Newborn examination: Mouth
Shape – Philtrum – Tongue tie – Palate – Neonatal teeth – Ebsteins pearls – Sucking/rooting reflex
What are Epstein pearls
Whitish-yellow cysts that form on the gums and roof of mouth.
Harmless
Newborn examination: Face
Facial palsy
Dysmorphism
Newborn examination: Respiratory
Chest shape Nasal flaring Grunting Tachypnea In-drawing Breath sounds
Newborn examination: Cardiovascular
Color – Saturation – Femoral pulse – Apex/thrills – Heart sounds
Newborn examination: Abdominal
Moves with respiration Distention Bile stained vomiting Passage of meconium Anus
Newborn examination: Genitourinary
Normal passage of urine
Normal genitalia
Undescended testes
Hypospadius
Newborn examination: MSK
Limbs and digits Movement Contractures Spine Sacral dimples Hip examination
What are the two Hip examinations called in newborns
Ortolani/Barlow
Newborn examination: Neurological
Posture
Tone
Movement
Reflexes
What is the reflex that newborns have when they fall backwards called
Moro
Newborn examination: Skin
Dryness/cracking
Milia
Birth marks
Erythema toxicum
Causes of preterm birth
Spontaneous Multiple pregnancy Preterm prelabor rupture of membranes Cervical incompetence And more
Risk factors of preterm labor
Multiple pregnancy (x9)
Smoking, alcohol and drugs
In vitro fertilisation
What is a good tool to assess preterm babies
Pulse oximetry
Lungs are immature
When should umbilical cord be clamped
If the baby is ok and can be kept warm, pause for a minute before clamping
How is a preterm baby kept warm
Keep baby in plastic bag under a radiant heater
Consideration with preterm lungs
Lungs are fragile and susceptible to over-inflation
When should growth charts be used with Gestational correction
Preterm babies
How long should Gestational correction be used
1 year for infants born week 32-36
2years for infants born before 32 weeks
Most commong Organism of neonatal sepsis
Group B strep
What is Respiratory distress syndrome
Syndrome that happens when newborn lungs can’t sufficiently provide enough oxygen
Signs and symptoms of Respiratory distress syndrome
Tachypnoea Grunting Intercostal recessions Nasal flaring Cyanosis
How is Respiratory distress syndrome managed
Maternal steroids
Surfactants
Ventilation (invasive or non invasive)
What are cardiovascular concerns in preterm infants
Patent ductus arteriosus
Systemic hypotension
What is intraventricular hemorrhage
A form of intracranial hemorrhage that occurs in preterm infants, which begins with bleeding into the germinal matrix
What are the risk factors for Intraventricular hemorrhage
Prematurity
Respiratory distress syndrome
What are the grades of Intraventricular hemorrhage
Grade 1-4
1 being best outcome
What is Necrotizing enterocolitis
Widespread necrosis in the small and large intestine
Most common Bacterial infections in neonates
Group B strep E. Coli Listeria myogenes Staphylococcus aureus Staphylococcus epidermidis
Common Viral infections in neonates
Cytomegalovirus
Parovirus
Herpes virus
Enteroviruses
What is Transient tachypnoea of the newborn (TTN)
Self-limited disease caused by problems of fluid clearance of the lungs. Presents at first few hours of life.
Tetralogy of Fallot is
- Pulmonary valve stenosis
- Overriding aorta
- Ventricular Septal Defect
- Right ventricular hypertrophy
What is Total Anomalous Pulmonary Venous Drainage (TAPVD)
Congenital cyanotic malformation where all pulmonary vessels are malformed and return blood to venous system rather than the left atrium.
What is hypoplastic heart
Congenital disease where part of the heart does not form properly causing cyanotic condition
What is Potter’s syndrome
Congenital disease where the kidneys are not developed properly causing lack of amniotic fluid and kidney failure.
What is Spina bifida
Congenital neural tube defect. The spine is not formed properly and the spinal canal is exposed. Severity depends if the skin close over or not.
What are the sections of the Apgar Score
Heart Rate – Resp.effort – Tone – Color – Response
What is the highest APGAR score
10
What is normal Resp rate of newborn
40-60/minute
What is normal heart rate of newborn
120-140/minute
What was the anti-emetic drug that caused severe birth defects and is now banned
Thalidomide
Green puke in infants mean
Malrotation with volvus until proven otherwise. Medical emergency
Does Heparin cross the placenta
No, it is a large molecular weight drug
Pharmokinetics during pregnancy, what happens to Absorption
May be affected by morning sickness
Pharmokinetics during pregnancy, what happens to Distribution
Increased plasma volume, decreased protein binding and fat stores alters the distribution.
Pharmokinetics during pregnancy, what happens to Metabolism
Increased liver metabolism of some drugs
Pharmokinetics during pregnancy, what happens to Elimination
Renally excreted drug elimination increases due to increased GFR
What teratogenic effect does ACE inhibitors/ARB have
Renal hypoplasia
What teratogenic effect does Lithium have
Cardiovascular defects
What teratogenic effect does Warfarin have
Limb and fascial defects
What teratogenic effect does Methotrexate have
Skeletal defects
Which Epileptic drugs should be avoided in pregnancy
Valproate and Phenytoin
Which diabetes drugs should be avoided in pregnancy
Sulfonylureas
Which anti-hypertensive drugs should be used in pregnancy
Labetalol
Methyldopa
Nifedipine
Which anti-hypertensive drugs should be avoided in pregnancy
ACE inhibitors
ARB
Most betablockers in late prgnancy
Which anti emetic is safe in pregnancy
Cyclizine
Which drugs are used in UTI in pregnancy
Amoxicillin or Cefalexin
Which pain reliever is used in pregnancy
Paracetamol
Avoid NSAIDs
Which drugs especially enters breast milk
Small molecules
Fat soluble
26y women, 28week pregnany, presents with swollen right leg. Differential diagnosis.
DVT
26y women, 28 week pregnancy, presents with swollen right leg. DVT confirmed on USS. Treatment?
LMWH- Low molecular weight Heparin
Which antibiotic during pregnancy or in early childhood may cause darkening of teeth
Tetracycline - Casue staining of bones and teeth
Which antiepileptic drug is associated with Cleft palate
Phenytoin
Discriminating facial features of Fetal alcohol syndrome
Flat midline – Short nose – Indistinct philtrum – Thin upper lip
Which antiepileptic drug is associated with neural tube defects
Valporate
What is population attributable risk
What proportion of this disease is attributable to this risk factor?
What is the BMI requirements for IVF
> 18.5
What is the smoking requirement for IVF
Non smoker for >3 months
Both partners
What is the methadone requirement for IVF
Methadone free for at least one year prior to treatment
What is the alcohol requirement for IVF
Neither partner should drink alcohol
Can a couple receive IVF if they have undergone voluntary sterilization
No
Even if they reversed it, (self funded)
What causes breast engorgement
Delay in first feed Ineffective positioning and attachment Restricted feeding Ineffective emptying Supplmentation
Appareance of breast in breast engorgement
Stretched shiny skin, edma.
May be red
Management of Engorgement
Warm baths or warm compress prior to feed –
Cold compress after feed to reduce edema –
Mild analgesia (paracetamol or Ibruprofen) –
Express milk if feed is not sufficient to reduce pressure
Poor management of engorgement may lead to
Mastitis
What causes Mastitis
Plugged milk duct – breast infection – poor position and attachment – infrequent feeds – consistent breast pressure – Dummies – Supplementation – Trauma
Signs and Symptoms of Mastitis (blocked duct)
Tender spot, redness, sore lump without fever
Signs and Symptoms of Mastitis (breast infection)
A tender spot or lump and a low grade fever
Signs and symptoms of Infective mastitis
Cracked nipple
Pus and blood in milk
Red streaks from site back into breast
Treatment of mastitis
Continue breastfeeding
Express milk if needed
Anti-inflammatory medication
Antibiotics if no improvement
What is the order of events in mastitis
Blocked duct –> Localized inflammation –> systemic response
Mastitis can lead to what if untreated
Abscess
Antibiotic treatment for Mastitis
Flucloxacillin
Clindamycin if Penicillin allergy
When is the prevalence of breast thrush low and other causes of breast pain should be considered
First 6 weeks after birth
Sign and symptoms of Breast thrush
Agonsing pain in BOTH breasts Pain is equal in BOTH breasts Pain AFTER feed Position and attachement is normal. No change in nipple color or shape after feed. \+ve oral swab for Candida albicans
What is Frenotomy
When the linguinal frenulum is cut. Done when baby has tounge-tie
What causes Breast Thrush
Candida Albicans
Signs of Thrush in infant
Nappy rash
Oral thrush
Baby pulling of breast while feeding
Baby windy, fretful or difficult to settle
Management of Breast Thrush
Observe breast and breastfeed –
Boil dummies and teats 20min/day
Wash towels and bras in hot water
CONTINUE FEEDING
Treatment of Superficial breast thrush
Miconazole cream
Treatment of Deep breast thrush
Fluconazole
300mg loading dose + 150mg daily for at least 10days
Treatment of Thrush in infant
Nyastin oral suspension
Treatment of Thrush in infant >4months
Miconazole oral gel
Bound anteriorally by the symphysis pubis, laterally by the iliopectineal lines, and posteriorly by the sacral promiotry
Pelvic inlet
Bound anteriorally by the pubic arch, laterally by the ischial tuberosities and posteriorly by the coccyx
Pelvic outlet
Woman presenting with multiple small painful ulcers on her genitalia and a flu-like illness. She is unable to urinate due to discomfort. Diagnosis
Herpes Simplex
Non-sexually active woman presents with a frothy brownish vaginal discharge, which has an offensive smell
Bacterial vaginosis
Woman presents with vulval irritation and a white discharge
Candida albicans
At what stage of development is embryo transfer most successful
Blastocyst
LH surge occurs at what duration prior to ovulation
24-36h
Changes in the Endometrium in the luteal phase are direct effect of which hormone
Progesterone
What is Clomifene
Non-steroidal infertility medication
Used to induce ovulation in polycystic ovarian syndrome.
Oligoasthenospermia menas
Low count and low motility
Teratoasthenospermia means
Abnormal form and low motility
Where does spermatogenesis occur in the testicle
Seminiferous tubules
Where is testosterone secreted from in a male
Leydig cells
7 week gestation, heavy vaginal bleed and abdominal pain. Cervix is slightly open with tissue visible. USS shows fetal heart beat. Diagnosis
Inevitable miscarriage
Most lymph (>75%) from the breast initially drains to the
Axillary lymph nodes
32y old lady has been seen in the unplanned pregnancy assessment clinic. Report shows an intrauterine sac measuring 40x32x25mm. Most likely diagnosis is
Delayed miscarriage
Antibiotic treatment for Chlamydia
Arithromycin
Preferred test for Chlamydia in an asymptomatic female is
First void urine NAAT
Main artery to the anterior abdominal wall
Inferior epigastric
In Down’s syndrome screening, nuchal thickness is measured by ultrasound at what time
11-14weeks
When can the fundus first be palpable in singelton pregnancy
12week
Week 5 lecture done
yes