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OBS/GYN - Pregnancy and Neonates (Pregnancy *Complications (Rh+…
OBS/GYN - Pregnancy and Neonates
Investigating a
possible pregnancy
Initial Investigations:
urine pregnancy Beta-hCG test
hCG = human chorionic gonadotropin
*Mother Complications or Sequelae from Pregnancy
gestational diabetes
pregnancy SHS = supine hypotension syndrome
Pregancy SHS = *supine hypotensive syndrome
when lying supine on back, uterus pushes on IVC
reduced venous return and hypotension
note this can also happen in right decubitis position
--> still pushing on the IVC
SHS case
Clinical Case
Notes
:
note that
Tx for Supine HypoTN
Tx = sleep in decubitis position = sideways
--> instead of lying on back
--> stops the uterus from pushing down on the IVC
Postpartum *OVT = ovarian vein thrombosis
similar to a DVT except it is in the Ovarian vein
--> inside the
*Embryo development, Placenta Chorion
Twins
Dizygotic Twins
from 2 different zygotes
can be different sexes
Amniotic Sac and Chorion
Dizygotic Twins Case example
dichorionic / diamniotic
Clinical Case
Notes
:
note that dizygotic twins always have separate chorions = monochorionic and separate placenta = monoamniotic
the placenta may fuse though, depending how far apart the embryo attach, etc.
Monozygotic Twins
from the same zygote = identical
Amniotic Sac and Chorion
*Teratogens
Cat Litter --> Toxoplasmosis
primary toxoplasmosis infection of mother passed to fetus through placenta
Toxoplasmosis -->
Clean up cat litter and you get a SICK CHIC
C = chorioretinitis
H = hydrocephalus
I = Intracranial
C = calcifications
note that hydrocephalus can be seen by 2 things:
enlarged ventricles --> excess blood in them
enlarged cranium
Tocoplasmosis cat litter example
Notes
:
note the triad for toxoplasmosis
hydrocephalus, intracranial calcifications chorionoretinitis
Clinical Case
Teratogenic = Folate
Synthesis Inhibitors
Vitamin toxicity
Vitamin A toxicity
Teratogenic Problems
1st trimester when organogenesis happens
can cause spontaneous abortion, fetal defects
Different forms of Vit A
provitamin A
--> carrots, sweet potatoes, green leafy vegetables
preformed Vit A
--> found in vitamin supplements
oral retinoic acid - acne treatment
teratogenic due to preformed Vitamin A that is readily converted to Vitamin A
--> get Vit A toxicity
think: "retin-A" = "red ACNE"
recall that fat-soluble vitamins can accumulate inthe body and cause toxicity whereas water-soluble vitamins cannot
remember:
"
A DEK" of cards has FAT kings and queens
--> Vit ADEK are FAT soluble
--> note that Vit C is water-soluble
*Fetal Alcohol Syndrome = FAS
caused by excessive drinking, especially in the first trimester of development?
Notes
:
FAS babies and kids look like MONKEYS
short palpebral fissures
--> compared with trisomy 21 with slanted upwards palpebral fissures
mouth comes out like a MONKEY snout
smooth longer philtrum (between nose and upper lip)
--> like a monkey
small and skinny upper lip
Pregnancy *Complications
Pregnancy Infections
Pregnancy Infections that cross the Placenta TORCH the fetus
note that many of the infections that can cross the placenta are in the herpes family
--> CYtomegalovirus = HHV type 5 is the most common
**
TORCH
toxoplasmosis
Others (parvovirus and others)
R = rubella (need vaccine)
C = cytomegalovirus
H = Herpes SV -2 and HHV 3 = VZV
Folate Deficiency and NTDs
Neural tube defects
NTDs = Neural Tube Defects
Detecting NTDs in Pregnancy
regular screening = high ACh Eseterase and AFP in amniocentesis
AFP can cross the placenta barrier
--> AFP in mother serum
second trimester ultrasound is recommended as the primary screening tool for NTDs, and MSAFP as a secondary screening tool
Example
:
Notes
:
NTDs have different severity
severity of a neural tube defect can range from moderate, such as spina bifida, to severe and non-life-compatible, such as anencephaly
the high AchE is because in NTDs it leaks out into the amniotic sac from the CSF of the open neural tube
Teratogenic = Folate
Synthesis Inhibitors
Folate = VB 9 and NTDs
Example
:
Notes
:
NTDs can come from VB 9 folate deficiency in pregnant women
any women of childbearing age needs to be on folate since
FOLATE AIN'T STORED
need to watch for medications that inhibit folate synthesis
classic example of meds that inhibit folate synthesis is the DHF inhibitor methotrexate used for people with RA
--> present in this case example
*NRDS = neonatal Respiratory Distress Syndrome
*NRDS = neonatal Respiratory Distress Syndrome 2
treatment for premature rupture and pregnancy earlier than 32 weeks
=
steroids
Clinical Presentation:
Notes
:
note that steroids start the process of neonates producing surfactant
note that immature surfactant if lethicin / sphingomyelin >= 2
*NRDS = neonatal Respiratory Distress Syndrome 1
Clinical Presentation:
Notes
:
note the main way to test for NRDS and whether a fetus is producing enough surfactant is to take a amniocentesis from the mother's amniotic sac and check the phospholipid content
surfactant is made from lethicin = which is a derivative from palmitoyl phospholipid content
premature labour and premature rupture of membranes are indications for amniocentesis because you need to know the maturation of the and level of surfactant in the fetus to see if they will get NRDS
lethicin / shingomyelin = L/S ratio > 2 is considered mature surfactant or mature fetal lungs
Rh+ Pregnancies
Clinical Presentation:
Notes
:
primigravid = pregnant for the first time
note that Rhesus = Rh antigens is not a single antigen, but an entire family of antigens where the anti-Rh-D antigen is the antigen in particular that mounts an immune response
*Ectopic Pregnancy
Endometrial Stroma Cells
are connective tissue cells of any organ, for example in the uterine mucosa (endometrium), prostate, bone marrow, lymph node and the ovary. They are cells that support the function of the parenchymal cells of that organ. The most common stromal cells include fibroblasts and pericytes.
Decidualization of the endometrium
functional changes to the endometrium occur in order for the fertilized egg to implant and get nutrients
dilated and coiled endometrial glands
vasculrized and edematous strom of the endometrium
*Ectopic Pregnancy
Notes
:
note that all the surrounding appendages of the uterus are called adnexa
--> fallopian tubes, ovaries, ligaments, etc.
dilation and curettage of the uterus refers to dilating the cervix and curettage refers to the scraping of the uterus
--> this is performed for miscarriages and also for 1st term abortions of a fetus
--> also for ectopic pregnancies
during the secretory phase of the menstrual cycle that follows directly after ovulation
--> this is when the fertilized egg implants in the endometrium
--> this phase is marked by decidualization of the endometrium
Clinical Presentation:
Ectopic Pregnancy P/C
note they can present with orthostatic hypotension in addition to other findings
*Intracellular STIs are major risk factors for PID and EP
PID = Pelvic Inflammatory disease
EP = Ectopic pregnancy
Intracellular STI = N Gonorrhea + Chlamydia Trachomatus
Postpartum Endometritis
NOTES
:
note that postpartem endometritis
think endometriosis --> endometritis
Polyhydramnios
abnormally high amniotic fluid production
Notes
:
Polyhydramnios is the excess amount of amniotic fluid in a pregnancy
note that it is not normally due to excess production of the fluid, but instead depending on the baby
makes logical sense then that the 2 ways you get polyhydramnios is either by
--> excessive urination of the fetus
--> less drinking of the amniotic fluid by the baby
Clinical Case
*Molar Pregnancy
molar pregnancies are either
--> complete or partial molar pregnancy
p57 tells you whether it is a COMPLETE vs PARTIAL mole pregancy
Molar pregnancies are like HEINZ p57 bottles of ketchup...
"Heinz 57 is FILLED by the WOMEN who bottle it"
--> women make the protein p57
"Heinz 57 has IMPRINTED LABELS by the MEN who own it"
--> men imprint on the gene for the protein p57
Negative screen for p57 protein
--> no nucleus in the female egg
--> sperm doubles up on its genes
--> 46 chromosome ALL male = Complete mole
*Partial Molar Pregnancy
abnormal fetus is present WITHOUT cysts
2 sperm fertilize the same egg at the same time
--> 69 XXY / XXX / XYY
--> note that YYY can;t survive, need an X
*Complete Molar Pregnancy
hypertrophoblastic growth
--> high hCG levels and large uterus
fetus is NOT present with many cysts
"swiss cheese" cycts on fetal ultrasound, "bunch of grapes"
1 / 2 sperm fertilizes empty Ovum
--> sperm chromosomes duplicate
--> 46 XX / 46 XY
Clinical Cases
Clinical Case
Clinical Case
Notes
:
note that
Molar Pregnancy Example
complete molar pregnancy
Case presentation:
Notes
:
note that both partial and complete moles have cysts within the uterus
complete have absolutely no fetus present and no placenta
--> main difference is complete moles present with abnormally larger uterus and beta-hCg levels
--> due to hypertrophoblastic growth
Imaging and findings for Complete molar pregnancies
cysts from hypertrophoblastic growth without the proper egg with a nucleus in complete molar pregnancies
--> gives 2 findings
--> honey comb/ grape tissue in uterus
--> snowstorm on uterine ultrasound
NEGATIVE P57 protein screen
Snowstorm ultrasound seen in molar pregnancies
cysts from hypertrophoblastic growth without the proper egg with a nucleus in complete molar pregnancies
Honeycomb or Grapes in molar pregnancies
cysts from hypertrophoblastic growth without the proper egg with a nucleus in complete molar pregnancies
p57 testing in Molar pregnancies
negative for complete moles
positive for partial moles
Molar pregnancies are like HEINZ p57 bottles of ketchup...
"Heinz 57 is FILLED by the WOMEN who bottle it"
--> women make the protein p57
"Heinz 57 has IMPRINTED LABELS by the MEN who own it"
--> men imprint on the gene for the protein p57
Negative screen for p57 protein
--> no nucleus in the female egg
--> sperm doubles up on its genes
--> 46 chromosome ALL male = Complete mole
Oligohydramnios Causing Disease
think of Potter's face = crushed face due to lowered amniotic fluid
--> Potter Sequence Complication
Potter Sequence in Infants Complication
renal oliguria / anuria --> oligohydramnios --> pulmonary agenesis
respiratory failure
oligohydramnios --> increased pressure on th efetus's face + feet
--> Potters face + clubbed feet
Potter Sequence Pregnancy Complication example
cause of oliguria from infant can be many causes
--> polycystic kidney disease, posterior urethra deformity, renal agenesis
--> anything that causes anomally of the renall system and lowers urine output
Case presentation:
Notes
:
key is that in Potters sequence there is a loss of urine output from the fetus
the amniotic fluid is largely dependent on the urine the fetus produces
--> thus less urine = less amniotic fluid
the developing respiratry system of the fetus also requires there to be enough amniotic fluid for it to inhale while in the womb
it is useful so the fetus' alveoli can expand and grow
otherwise it has pulmonary agenesis
ARPCKD = Autosomal Recessive Polycystic Kidney Disease
has oligohydramnios and complications similar to Potter's sequence
ARPCKD case example
Clinical Case
Notes
:
same for Potters sequence the biggest problem with olgihydramnios is that the fetus doesn't produce enough urine
this makes up most of the amniotic fluid
this fluid the fetus breathes in
if not enough they get hypoplasia of the lungs and they get neonatal acute respiratory distress syndrome
*Low birth weight
defined as weight < 2.5 kg
--> think of the smallest plates at the gym are 2.5 kg
*Home
Pregnancy *Hormones
Beta hCG = human chorionographic Gonadotropin
Estrogen
Progesterone
Prolactin Axis
*Prolactin
stimulated by TRH = thyrotropic Releasing hormone
inhibited by all three estrogen, progesterone and inhibin
prolactin increases STEADILY throught pregnancy
progesterone biggest factor that inhibits lactation until birth
*Estrogen and Progesterone
BOTH stimulated by FSH and LH
BOTH gives negative feedback to BOTH anterior pituitary and HYpothalamus
*Estrogen
ESTROGEN =
"ES"
-->
ES
= Endometrial STIMULATOR
stimulated by FSH and LH
gives negative feedback to BOTH anterior pituitary and HYpothalamus
*Progesterone
PROGESTERONE =
"PROG + GESTerone"
-->
PROG
= PROlactin / LACtation inhibitor
-->
GEST
= gestation / endometrial supporter
stimulated by FSH and LH
gives negative feedback to BOTH anterior pituitary and Hypothalamus
progesterone biggest factor that inhibits lactation until birth
"PROGENY DROPS all at the same time"
--> DROPS = baby is born
--> Progesterone drops
--> Boobs drop = progesterone drop --> stops inhibiting prolactin
--> Boobs drop and lactate
*Syncytiotrophoblast Hormones
HCG = human CG and HPL = human placental lactogen
BOTH from the
SYN CITY
= Syncytiotrophoblast of the placenta
Beta - *hCG
hCG Alpha = SAME as all other TRH hormones
--> LH, FSH, TSH
--> reason why hCG causes hyperthyroidism
hCG Beta = UNIQUE to only hCG
--> reason why only BETA hCG levels used to detect pregnancy
released starting at 7 days gestation
--> ONLY detectable in blood at 7 weeks
--> only detected in urine at 2 weeks later
--> increases during 1st trimester
hCG and SEX / pregnancy is
EVIDENT in SYN CITY
--> syncytiotrophoblasts secrete hCG when the embryo implants
*Timing in Prgnancy
Gestation age vs. Embryonic Age
timing of specific hormones
*Gestation Age and Embryonic Age
Gestation age = simplest = LMP = last menstrual period
--> normal GEstation = 40 weeks
Embryonic Age = Ovulation and Conseption
--> accounts for ovulation being 2 weeks after last menses
--> Gestation age - 2 weeks
normal Embryonic age = 38 weeks
*APGAR SCORE
appearance, Pulse, Grimae (to stim), Activity, Respiration (cry)
blue /pale --> pink APPEARANCE
weak to strong grimace from GRIMACE RESPONSE
arms --> whole body ACTIVITY
weak to strong CRY from RESPIRATION
*Breastfeeding
lowers risk for breast cancer
most ideal nutrition and immunity for infant < 6 months old
--> IgA, macrophages and lymphocytes
see prolactin and hormones
SUCKLING = nerve stimulation releases oxytocin and prolactin
--> note that oxytocin only works on the uterus for contractions in the 3rd trimester
--> endometrial oxytocin receptors ONLY present in the 3rd trimester
"FORMULA if FORTIFIED"
"FORTIFIED"
= formula had Vit D that breastmilke does not
--> need to supplement Vit D in breastfeeding
also
Vit K
for bleeding
--> think mom and baby are both at risk of bleeding after birth
baby is given Vit K IM injection at birth
Supplements needed when Breastfeeding
Vit D
and
Vit K
iron
--> iron ONLY if low birth weight or premature
"FORMULA if FORTIFIED"
"FORTIFIED"
= formula had Vit D that breastmilke does not
--> need to supplement Vit D in breastfeeding
also
Vit K
for bleeding
--> think mom and baby are both at risk of bleeding after birth
baby is given Vit K IM injection at birth
*Preterm Delivery
less than 37 weeks
*Complications - Preterm infants
ARDS = #1 complication
--> from low surfactant = low L/S = lethicin/s ratio
IVH = Intraventricular
Hemorrhage
--> from germinal centre hemorrhage in lateral ventricles
*ARDS = Acute Respiratory
Distress Syndrome
*IVH = Intraventricular
Hemorrhage
Clinical Cases
Clinical Case
Notes
:
note that
Clinical Case
Intraventricular
Hemorrhage
Notes
:
Preterm and underweight babies are susceptible to intraventricular hemorrhage because the germinal matrix is a matrix of dense cellular and vascular areas where neurons and glial cells are developing before birth
germinal matrix is at the draining sites of the medullary veins
--> between the caudate and the lateral ventricles
--> if there is germinal matrix hemorrhage, then this blood spills into the ventricles
--> intraventricular hemorrhage
germinal matrix is gone by weeks 28 so risk of germinal matrix and subsequent intraventricular hemorrhage is highest for < 28 weeks gestation premature babies
*Germinal Matrix hemorrhage
--> Intraventricular hemorrhage
common complication in preterm babies
--> after ARDS
*uterus anatomy
