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383 Cards in this Set
- Front
- Back
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Humans have a villous hemochorial placenta. What does this mean?
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maternal blood directly contacts the fetal trophoblast in the villi, but not the fetal blood.
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When does the pre-lacunar stage of placental development happen, and what is going on at that point?
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days 6-7 after ovulation, the syncytiotrophoblast starts to invade maternal tissue, and cytotrophoblasts start proliferating.
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When does the lacunar/trabecular stage of placental development happen, and what is going on at that point?
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days 9-12 after ovulation, the syncytiotrophoblast forms vacuoles, which merge into lacunae that open into maternal capillaries
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When does the villous stage of placental development happen, and what is going on at that point?
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days 13-18 after ovulation, the chorionic villi form and the placenta matures
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The villi of the placenta go through 3 stages of development. A primary villi consits of......?
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a cytotrophoblast core surrounded by syncytiotrophoblast
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The villi of the placenta go through 3 stages of development. A secondary villi consits of......?
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extraembryonic mesodermal mesenchyme grows into the cytotrophoblast, still surrounded by syncytiotrophoblast
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The villi of the placenta go through 3 stages of development. A tertiary villi consits of......?
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blood vessels form in the mesodermal core, surrounded by mesenchyme, cytotrophoblast, and then lined by syncytiotrophoblast
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What do the cytotrophoblast cells do once the anchoring villi reaches the tertiary stage?
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Form the column that anchors the villus to the maternal side, and also invades the myometrium and remodels mom's spiral arteries
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How many vessels are in the umbilical cord? What kind of blood do they contain?
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two arteries carrying deoxygenated blood, and one vein carrying oxygenated blood
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What makes up amniotic fluid?
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filtered maternal plasma, then an increasing amount of it is fetal urine and lung secretions. Mostly baby pee, though.
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What is the volume of the amniotic fluid at 18 weeks gestation?
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250 mL
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What is the volume of amniotic fluid at 32 weeks gestation?
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1000 mL
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What are some effects of oligohydramnios on the fetus?
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problems with lung development, and musculoskeletal development
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What are some causes of oligohydramnios?
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ruptured membranes, poor placental blood supply by the mom, genitourinary anomalies of the fetus, twin-twin-transfusion, ACE inhibitors and prostaglandin drugs
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what are some causes of polyhydramnios?
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esophageal atresia or neural tube defects in the fetus, fetal infection, fetal heart defects, maternal gestational diabetes
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What substance crosses the placenta in a diffusion-limited manner?
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oxygen is the most important one
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What does it mean to say that some nutrients cross the placenta in a flow-limited way?
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diffusion happens fast, and maternal blood flow is the rate-limiting step in nutrient transport
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Compare fetal Hb with adult Hb:
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fetal Hb has a higher affinity for oxygen, lower concentrations of 2,3DPG, and is adequately oxygenated at an O2 partial pressure of 20-25 torr.
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The placenta secretes two imporant, unique hormones. What are they, and what part of the placenta produces them?
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the syncytiotrophoblast secretes human chorionic gonadotropin (hCG) and human placental lactogen (hPL)
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As far as steroid synthesis is concerned, what enzyme do fetuses lack?
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aromatase
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As far as steroid synthesis is concerned, what enzyme does the placenta lack?
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16-alpha-OHase (can't make androgens from progesterone)
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How do the fetus and the placenta work together to make steroid hormones?
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placenta turns cholesterol into progesterone, fetal adrenals turn progesterone into DHEA, fetal liver turns DHEA into 16-OH DHEA, the placenta turns 16-OH DHEA into testosterone and estriol
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What antibodies are fetuses able to make?
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IgM
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What is the most common immunoglobin in the fetus?
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maternally-derived IgG (passive immunity)
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What is the danger of an Rh- mother having an Rh+ fetus?
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If the mom has IgG against Rh factor, then her immune system could attack the baby's RBCs
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What is the etiology of dizygotic twins?
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two eggs, independantly fertilized. fetuses have separate placentas and amniotic sacs.
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What is the etiology of monozygotic twins?
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one egg, one sperm, which divides into two zygotes for no good reason in the first few days.
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The egg divides within 3 days of fertilization; what is the mortality, placenta, and amniotic sac situation for these monozygotic twins?
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two placentas, two amniotic sacks, mortality of 8%
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The egg divides between 3 and 8 days after fertilization; what is the mortality, placenta, and amniotic sac situation for these monozygotic twins?
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one placenta, two amniotic sacks, mortality of 25%
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The egg divides between 8 and 13 days after fertilization; what is the mortality, placenta, and amniotic sac situation for these monozygotic twins?
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one placenta, one amniotic sack, mortality rate of 50%
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The egg divides more that 13 days after fertilization; what is the mortality, placenta, and amniotic sac situation for these monozygotic twins?
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one placenta, one amniotic sack, and the twins will be conjoined. Mortality is high
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What is the clinical significance of a bilobed placenta in a single-birth pregnancy?
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There is no problem if the single umbilical cord bridges the two placental lobes
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What is a circumvallate placenta?
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when the free membrane is rolled up around the edges of the placenta. slightly increased morbidity for the fetus.
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What is a velamentous insertion of the umbilical cord into the placenta?
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One where the umbilical vessels branch and the cord sheath ends before they reach the placenta
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What is a succenturiate lobe of the placenta?
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small segment of placenta separate from the main lobe, bridged by vessels. May not detach along with the rest of the placenta
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What is placenta previa? What are some of its complications?
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placenta grows over the cervix. Cause painless bleeding, fetus must be C-sectioned
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What is placenta Accreta? What are some complications?
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when the placenta grows through the myometrium. Causes 3rd trimester bleeding, can lead to deeper invasion
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What is going on during a retroplacental hemorrhage, and what can it lead to?
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bleeding between the uterus and maternal side of the placenta. The expanding hematoma can lead to early bleeding and abruption
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Fibrin deposits can naturally occur in the placenta, but they cause problems if they appear where?
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within the intervillous space or along the maternal surface of the placenta; it can block nutrients and oxygen from reaching the fetus
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What are the effects on the fetus of placental fibrosis, hemorrhage, or infarction?
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growth retardation, injury to organ systems, and fetal death
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Tiny nodules on the fetal surface of the placenta suggest what?
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oligohydramnios, or ahydramnios
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What characterizes chorioamnionitis?
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bacterial infection ascending up the birth canal, you see neutrophils and thickened, gray membranes
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What is funitis?
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infection of the umbilical cord
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What characterizes villitis?
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viral infection that comes across the uterus from the mom. Villi are swollen, necrotic, or calcified, filled with lymphocytes
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What percent of pregnant women have preeclampsia?
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6%
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What characterizes eclampsia?
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seizures, papilledema, very high blood pressure
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What characterizes preeclampsia?
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hypertension, headaches, proteinuria
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When during the pregnancy does preeclampsia usually rear its ugly head?
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last half, usually in the 3rd trimester
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What other disease processes can preeclampsia lead to?
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DIC, HELLP
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What is HELLP?
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Hemolysis, Elevated Liver function tests, Low Platelet count
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What is the etiology of preeclampsia?
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abnormal placental formation and cytotrophoblast invasion
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How do you cure preeclampsia?
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deliver the baby, and get rid of the placenta
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What causes a complete hyditaform mole?
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two sperm fertilize an egg with no nucleus. Usually 46,XX
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What does a complete hyditaform mole look like?
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no fetal tissue, lumpy grape-like nubbly-things all over
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How will the presense of a hyditaform mole manifest in serum tests?
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beta hCG will be sky-high
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How common are hyditaform moles?
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occur in 1 out of 1000 pregnancies
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What characterizes a partial hyditaform mole?
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some fetal tissue among the abnormal placental tissue. karyotype is usually 47,XXY
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What is the most dangerous sequela of a hyditaform mole?
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choriocarcinoma?
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How do you detect if a choriocarcinoma results from a hyditaform mole?
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serum beta hCG will remain very high even after the mole is removed
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what is the danger of a baby having a two-vessel cord?
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not much. It is associated with an increased risk for fetal malformations.
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What is the only type of twin situation where you can have twin-twin-transfusion?
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monochorionic, diamniotic, monozygotic
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What is going on in cases of twin-twin-transfusion?
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venous-arterial anastamoses shunt blood away from one twin and into the other one
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What are some consequences of twin-twin-transfusion?
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donor twin dies of malnutrition, recipient twin is fluid overloaded and dies of congestive heart failure.
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What is a fetus papyraceous?
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the mummified donor twin in cases of twin-twin-transfusion where the recipient twin survives
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What must the EGA be at the time of birth for a baby to be considered pre-term?
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less than 37 weeks
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What must the EGA be at the time of birth for a baby to be considered post-term?
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more than 42 weeks
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For a baby to fit into the category of IUGR, how small must it be?
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less than the 10th percentile
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What are some causes of babies being IUGR?
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fetal hypoxemia or malnutrition, maternal hypertension, preeclampsia, renal disease, drug use
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How heavy must the baby be at birth to be considered Large for Gestational Age (LGA)?
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in the top 10th percentile, or 4000 to 4500 grams
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What causes babies to be born LGA?
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maternal diabetes mellitus
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At what point does the embryo become the fetus?
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after the first 8 weeks of gestation
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What's the difference between a miscarriage and a stillbirth?
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miscarriage= fetal death before 20 weeks EGA
stillbirth= fetal death after 20 weeks EGA |
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At what EGA does a fetus become viable? What's so special about this point that makes it so?
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24 weeks. Up until then, lungs are immature and brain centers haven't developed completely.
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What is a nuchal cord? How serious is it?
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umbilical cord wrapped around the neck of the fetus. Happens all the time, only causes problems if it's tight
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What characterizes anasarca?
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generalized edema of the head, limbs, and organs, with transudate in the body cavities
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Hydrops Fetalis leads to what, now?
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anasarca and fetal death
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What immune-based thing can lead to hydrops fetalis?
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If an Rh- mom's antibodies attack the RBCs of her Rh+ fetus. Happens to a lesser extent with ABO blood types.
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What things, not immune-based, can lead to hydrops fetalis?
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parvovirus infection in the mother, fetal congenital heart defects, masses in the fetal lungs
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What characterizes a sacrococcygeal teratoma?
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large, skin-covered mass at the base of the fetal spine. Almost always benign.
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What is the lifetime prevalence for IPV in the united states for women? for men?
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women= 20-30%
men= 7% |
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What is the leading cause of death among pregnant women in the US?
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Intimate Partner Violence (IPV)
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What percentage of rapes are committed by a person known to the victim?
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60-70%
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What factors have no bearing at all on a person's risk for IPV?
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socio-economic status, race, level of education, employment status
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How does pregnancy affect the mom's plasma volume?
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It's increased by 50%
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How does pregnancy affect the mom's total RBC mass?
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it's increased by 20-30%
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How does pregnancy affect the mom's hematocrit?
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dilutional anemia, because the plasma volume increases more than the RBC volume does. 'crit goes down to 32-36
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Hoes does pregnancy affect mom's blood pressure?
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decreases until about 23 weeks, then slowly returns to normal
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What accounts for the changes in mom's blood pressure during pregnancy?
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progesterone causes increased NO production in the systemic vasculature, relaxing the smooth muscle of the vessels
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How does being pregnant affect mom's cardiac output?
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Increases by 40%, mostly due to an increase in stroke volume
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Hypertension in pregnancy is defined as a BP of.....?
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over 140/90 is the cutoff for hypertension in a pregnant woman
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What are the changes in preload and afterload in the heart of a pregnant woman?
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preload increases due to increased venous return
afterload decreases due to decreased vascular resistance |
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What are some changes seen in the heart itself during a woman's pregnancy?
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ventricular hypertrophy, increased contractility, increased compliance, increased end-diastolic volume
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What organs see more blood perfusion during pregnancy? Which ones do NOT?
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breasts, skin, uterus all see more blood.
No change in the liver or brain |
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What heart sounds might you hear in a pregnant woman?
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split S1
S3 systolic ejection murmur |
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Almost all pregnant women will notice palpitations and arrythmias. True or false? Why or why not?
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True! The heart is smashed up against the chest wall, so any arrhythmias are more noticable and usually nothing to worry about
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Wht cardiovascular changes are seen in a pregnant woman during labor?
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even more increased cardiac output due to the blood being shunted out of the uterus, and fluctuations in blood pressure
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How much blood does a pregnant women lose during a typical delivery?
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500-1000 mL
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What type of defective valve is better tolerated during pregnancy?
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regurgitant. Stenoic valves are more problematic, because in that case, the only way to increase CO is by heart rate, which wears the heart out
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What changes are seen to breathing patterns in pregnant women?
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respiratory rate is unchanged, vital capacity is unchanged but tidal volume increases, and residual volume decreases
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How does pregnancy affect blood gases in the mom?
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CO2 decreases, O2 increases
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How does pregnancy affect the chest wall in the mom?
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ribcage elevates and expands (by 5-7 cm circumference) in early pregnancy,
diaphragm pushed up 4 cm in late pregnancy |
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How does pregnancy effect pulmonary function tests?
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Doesn't affect them at all. FEV1/FVC and FEV1 stays the same.
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Pregnancy is a state of what, in terms of metabolic/respiratory, acidosis/alkalosos, primary secondary, conpensated/decompensated? Bad question I know, but I don't know of any other way to ask it
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pregnancy is a state of primary respiratory alkalosis with compensatory metabolic acidosis
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Which asthma medications are safe for pregnant women to take?
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All of them, pretty much. Inhaled steroids, albuterol, cromolyn, most antibiotics are all safe
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What is the PO2 in a pregnant woman? In a normal woman? How about the same thing for PCO2?
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pregnant O2: 100-108
normal O2: 95-100 pregnant CO2: 27-32 normal: CO2: 37-40 |
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What is the serum bicarb in a pregnant woman? In a normal woman? How about the same thing for blood pH?
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pregnant bicarb: 18-21
normal bicarb: 24-29 pregnant pH: 7.45 normal pH: 7.4 |
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What does progesterone do to the physical characteristic of the kidneys during pregnancy?
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Enlarges all parts of them
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Which kidney is more likely to develop pyelonephrits during pregnancy?
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The right one
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How does pregnancy change the GFR, renal plasma flow, and filtration fraction in the kidneys of the mom?
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GFR increases by 50%
renal plasma flow up by 60-70% filtration fraction (GFR/RPF) goes down |
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What happens to the serum creatinine and BUN in a pregnant woman?
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creatinine and BUN both go down
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In pregnant women with pre-existing kidney disease, what percent will have permanent worsening of that kidney disease?
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33%
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What happens to the number of peripheral WBCs in pregnant women?
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rises by a TON, but returns to normal in the first week post-partum
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What happens to TH1, TH2, and NKCs during pregnancy?
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TH1 and NKCs decrease
TH2 cells increase |
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Which clotting factors are elevated during pregnancy?
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fibrinogen, thrombin, 5, 7, 8, 9, 10, 12
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Which clotting factors decrease during pregnancy?
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11, 13, protein S, plasminogen
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Which clotting factors stay the same during pregnancy?
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protein C
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Which leg is more likely to develop a DVT in a pregnant woman?
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the left one
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How do you prophylax against DVTs in pregnant women?
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LMW heparin at first, with unfractionated heparin as due date gets closer
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What is the increased caloric need for a pregnant woman?
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200 kcal per day at first, 300 kcal per day in the 2nd/3rd trimester
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How much weight should a woman gain during a healthy, normal pregnancy?
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25-35 pounds
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Why do pregnant women suffer from enlarged hemorrhoids and varicosities?
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Increased portal pressure causing a backup of blood
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How does pregnancy affect the gallbladder of the mom?
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slower emptying, increased cholesterol in the bile, increased risk for gallstones
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What defines Hyperemesis Gravidarum?
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refractory nausea/vomiting, resulting in weight loss, dehydration, electrolyte imbalance, and ketonemia
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What is the cause of hyperemesis gravidarum?
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increased hCG and thyroid hormones
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Why do some pregnant women experience hyperpigmentation of the skin?
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hCG ramps up levels of melanocyte stimulating hormone
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What does the placenta do to maternal thyroid hormone?
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turns it into reverse T4, inactivating it
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What does the placenta do to maternal cortisol?
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Turns it into cortisone, which does not affect the baby in any way
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Talk about the structure of human chorionic gonadotropin
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1 alpha and 1 beta subunit. Alpha subunit is the same as the one in LH, FSH, and TSH
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What are the 5 important hormones secreted by the placenta?
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hCG, hPL, hPGH, progesterone, estrogen
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When do hCG levels peak in a pregnant woman?
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10-12 weeks post conception
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What does hCG do to the corpus luteum?
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causes it to stick around producing progesterone, until the placenta can take over progesterone production
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What does hCG do to the trophoblast?
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directs the differentiation into cytotrophoblast and syncytiotrophoblast, and controls the invasion into the decidua
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How does hCG affect maternal immune cells?
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kills off T-cells in the endometrium, so that the placenta and fetus don't cause immune reactions
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How does hCG affect the uterus?
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decreases the contractility by down-regulating gap junctions and decreasing intracellular calcium
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What hormone causes hyperemesis gravidarum?
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hCG
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Why do women in early pregnancy have a low TSH? IS this normal?
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Yes it's normal, because hCG suppresses TSH. Thyroid function is normal.
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What does it mean if the hCG doubles every week for the first 5-6 weeks of pregnancy?
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That you are healthy! It's supposed to do this. If is doesn't, that means the fetus aborted itself
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What placental hormone can be tested to see if the fetus has a trisomy or a placental insufficiency?
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hCG
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What is the molecular structure of hPL?
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191 amino acid protein
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What is another name for human placental lactogen (hPL)?
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human chorionic somatomammotropin (hCS)
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When do levels of hPL peak in the pregnant woman?
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30-34 weeks post conception
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What hormone does hPL share 90% of its amino acid sequence with?
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growth hormone
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What hormone causes an increase of insulin secretion in pregnant women?
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hPL
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What hormone causes an increase in liplysis and serum free fatty acids in pregnant women?
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hPL
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What is the molecular structure of hPGH?
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191 amino acid protein
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How are the actions of hPGH different from normal GH?
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hPGF is released steadily instead of in pulses, but they both stimulate IGF-1 in the mother
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What hormone stimulates gluconeogenesis in a pregnant woman?
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hPGH
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What will the hPGH level be in women whose fetuses have IUGR?
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low
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What hormones contribute to insulin resistance in pregnant women
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mostly hPGH, with a little help from hPL
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What does relaxin do?
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increases GFR and renal plasma flow, decrease systemic vascular resistance through NO production
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What prevents maternal lymphocyte and killer cell activation?
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progesterone
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Why does gastroparesis, urinary stasis, and constipation seem to go up in pregnant women?
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the progesterone they secrete causes smooth muscle relaxation to keep the uterus from expelling the baby, but it affects smooth muscle all over the body
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What hormone induces hypercoagulable state in pregnant women?
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estrogen
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What hormone causes the liver to ramp up production of hormone-binding globulins in pregnant women?
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estrogen
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What hormone is responsible for increased triglyceride synthesis in pregnant women?
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estrogen
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Why does the pituitary gland enlarge during pregnancy?
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high estrogen causes increased prolactin levels by stimulating lactotrophs; these hypertrophy and cause pituitary enlargement
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What receptor transports glucose from the mom's blood to the fetus' blood in the placenta?
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GLUT1
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Where does a pregnant woman's body get most of its calories from?
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free fatty acids from lipolysis
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what aspects of maternal metabolism can give rise to gestational diabetes?
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insulin resistance, impaired insulin secretion, increased hepatic glucose production
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Where is the error in normal-weight women who develop GDM?
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insulin secretion defect, similar to MODY or type 1 DM
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How many pregnancies involve GDM?
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3-14%
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What effects does GDM have on the fetus?
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macrosomia, shoulder distocia, cardiac defects, neonatal hypoglycemia, obesity later in life
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What effects does GDM have on the mother?
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increased risk of preeclampsia, infections, preterm labor, type 2 DM
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What is the risk for a mother with GDM to develop type 2 diabetes?
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40-50% risk within the next 5-10 years, 70% risk overall
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What is the risk for shoulder distocia in a 4500 gram fetus?
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50% if delivered vaginally
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How does respiratory distress syndrome in the infant result from GDM in the mom?
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excess glucose makes the baby big and fat, so he is born earlier, before his lungs have made enough surfactant
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Babies born to mothers with poor glycemic control have what risk for septal heart defects?
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35%
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Babies born to mothers with poor glycemic control have what risk for respiratory distress syndrome?
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30%
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How do you screen for GDM?
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50 gram oral glucose load; >130-140 is abnormal
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If a mother fails the GDM screening test, then what do you do to diagnose GDM?
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100 grams glucose OGTT, check levels at 1, 2, and 3 hours. 2 abnormal values is diagnostic of GDM
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What is the treatment for GDM?
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diet and excercise, glucose monitoring, insulin, glyburide
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How do you treat GDM mothers after they give birth?
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75 gram 2-hour glucose load test, 6-12 weeks postpartum
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How do total T4 and free T4 levels change in a pregnant woman?
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total T4 is elevated, free T4 is the same
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By how much does the mom ramp up thyroid hormone production during pregnancy?
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50%
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by how much does the mom ramp up thyroid binding protein during pregnancy?
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2-3 times
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What is a pregnant woman's iodine requirement? Why?
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significant increase over baseline, due to increased T4 production and renal iodine clearance, and fetal iodine requirements
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What happens to TSH levels during pregnancy?
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They can be normal to low, due to hCG's thyroid-stimulating effect
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What is the timeline for the development of the fetal thyroid?
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beings to function at 12 weeks, fully functional by 18 weeks
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What is the leading cause of maternal hypothyroidism worldwide?
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iodine deficiency
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How much iodine should a pregnant women ingest each day?
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200-300 micrograms/day
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What does the placenta do to maternal T3 before passing it on to the fetus?
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turns it into rT3, which is inactive. Oh well.
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What does T4 do in the fetus?
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neurogenesis, neuronal migration, myelination. All at 8-16 weeks, when they are dependant on maternal T4.
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Mild hypothyroidism in the mom can cause what in her kids?
|
mild cognitive defects
|
|
|
Maternal iodine deficiency can cause what in the fetus?
|
deafness, stunted growth, neurodevelopmental delay, death
|
|
|
How can hypothyroidism affect the mom when she's pregnant?
|
increased risk for preeclampsia, abruption, preterm birth, miscarriage
|
|
|
How do you treat hypothyroidism in pregnant women?
|
hormone replacement, with close monitoring of TSH and T4 levels
|
|
|
How can maternal hyperthyroidism affect the fetus?
|
fetal grave's disease leading to tachycardia, cardiac failure, growth retardation, brain problems
|
|
|
How can hyperthyroidism affect the pregnant mother?
|
increased risk of abruption, preeclampsia,
|
|
|
How should you manage Grave's disease in pregnant woman?
|
lower their meds so their free T4 is on the high end of normal
|
|
|
What happens to the fetus in a Grave's Disease mom if the doctor doesn't watch the anti-thyroid medication dose?
|
it crosses the placenta and destroys the fetal thyroid, making the baby hypothyroid even as the mom is hyperthyroid
|
|
|
What is the timeline of postpartum thyroiditis?
|
1-2 months of hyperthyroid, 4-8 months of hypothyroid, then return to normal
|
|
|
What is the risk for permanent hypothyroidism in women with postpartum thyroiditis?
|
20-50%
|
|
|
What is the definition of "labor"?
|
clinically defined as effective uterine contractions leading to dilation and effacement of the cervix and delivery of the fetus
|
|
|
What are the 4 stages of labor?
|
1)onset of effective contractions to complete dilation of cervix
2)...to delivery of the fetus 3)...to delivery of the placenta 4)first 6 hours after delivery |
|
|
What is the narrowest region of the pelvis? What are the dimensions?
|
midpelvis is the skinniest point: pubic symphysis to sacrum=11.5cm, between ischial spines=10.5cm
|
|
|
In terms of labor and delivery, what is meant by the "lie" of the fetus?
|
the orientation of the fetus's spine to the mom's spine
|
|
|
In terms of labor and delivery, what is meant by the "presentation" of the fetus?
|
what is coming out first? Head? Butt? Foot?
|
|
|
In terms of labor and delivery, what is meant by the "position" of the fetus?
|
orientation of the presenting part to the maternal pelvis. When headfirst, it is the direction the occiput is pointed
|
|
|
In terms of labor and delivery, what is meant by the "station" of the fetus?
|
location of the fetal presenting part relative to mom's pelvis; ie, how far down in the birth canal it is
|
|
|
What is the most common position of the fetus for a normal labor and delivery?
|
LOA or ROA
|
|
|
What landmark is the station of the baby measured against, during labor and delivery?
|
the ischial spines
|
|
|
What are the 4 stages of myometrial activation?
|
0) quiescense
1) activation 2) stimulation 3) involution |
|
|
How do the clinical stages of labor correlate to the myometrial phases of activation?
|
stages of labor 1,2, and 3 happen during myometrial phase 2.
stage 4 labor happens during myometrial phase 3 |
|
|
Where are oxytocin receptors concentrated in the uterus?
|
at the fundus
|
|
|
How does the uterus grow during pregnancy? and by how much?
|
cellular hypertrophy increaes uterus from 50 grams to 1000 grams
|
|
|
What hormone keeps the uterus in the quiescent phase up until labor starts? Through what mechanism?
|
progesterone, by blocking myosin light chain kinase in the uterus and inactivating prostaglandins
|
|
|
How does corticotropin releasing hormone (CRH) affect the pregnant uterus?
|
early pregnancy = quiescence by blocking myosin light chain kinase
late pregnancy = contraction by activating protein kinase C pathway |
|
|
How does CRH affect the fetus during late pregnancy?
|
stimulates fetal cortisol production, which stimulates pulmonary development and maturation
|
|
|
Oxytocin stimulates contractions in the pregnant uterus. Through what 3 mechanisms?
|
increases intracellular Ca++
activates myosin light chain kinase activates prostaglandin production |
|
|
What role to prostaglandins play in the later stages of pregnancy?
|
stimulate contractions by increasing intracellular Ca++ levels, and weakens the amnion and chorion for delivery
|
|
|
What are CAPS?
|
contraction activated proteins; proteins upregulated in the uterus in late labor that facilitate contractions
|
|
|
What are the 4 CAPS?
|
Ca++ channels
Gap junctions Oxytocin receptors Prostaglandin receptors |
|
|
Why are NSAIDs contraindicated during pregnancy?
|
They inhibit COX2, which means prostaglandin synthesis is inhibited, which means the uterus won't contract when it should
|
|
|
What is dinoprostone used for?
|
its a prostaglandin analogue applied directly to the cervix, promotes cervical effacement and induces labor
|
|
|
What is misoprostol used for?
|
prostaglandin analogue taken orally, stimulates uterine contractions and induces labor
|
|
|
What are some side effects of misoprostol?
|
GI cramps, diarrhea, nausea
|
|
|
What is oxytocin used for as an exogenously adminstered drug?
|
given IV, induces uterine contractions, but does not affect cervical dilation; only give if mom is fully dilated
|
|
|
What is methylergonovine used for?
|
controls post-delivery bleeding, causing body-wide smooth muscle contraction. Acts through adrenergic and serotonin receptors
|
|
|
If a drug is tocolytic, what does that mean?
|
The drug inhibits labor
|
|
|
In terms of OB/GYN, what is nifedipine used for?
|
inhibits labor by blocking calcium channels in the uterus, making it relax
|
|
|
In terms of OB/GYN, what is terbutaline used for?
|
inhibits labor by activating beta2 receptors on the uterus, causing it to relax
|
|
|
In terms of OB/GYN, what is magnesium sulfate used for?
|
not used much anymore, but it can inhibit labor if given IV
|
|
|
In terms of OB/GYN, what is indomethacin used for?
|
inhibits labor by inhibiting prostaglandin synthesis. Dangerous, can cause fetal ductus arteriosis to close, so its not used often
|
|
|
In terms of OB/GYN, what is ethanol used for?
|
Nothing anymore. Used in the '60s to delay labor by inhibiting oxytocin release from the pituitary
|
|
|
What is mifepristone used for? How does it work?
|
aborts fetuses younger than 9 weeks old. It's a progesterone receptor antagonist
|
|
|
Why would you give misoprostol to a women getting an abortion?
|
causes the uterus to expel the aborted fetus
|
|
|
Compare fetal blood pH to maternal blood pH. How can this affect pharmacokinetics?
|
Fetal pH is 7.25, maternal pH is 7.35. Thus, weakly basic drugs can become trapped in fetal blood
|
|
|
Maternal drugs passing to the baby through breastmilk? Expound on this, please.
|
Most drugs do get into breastmilk, but at subtherapeutic levels, except for lithium, etOH, tetracycline
|
|
|
What percent of erectile dysfunction is organic (biologic)? What percent is psychogenic (all in your head)?
|
organic = 80%
psychogenic = 20% |
|
|
What does sildenafil do? When do you use it?
|
inhibits phosphodiesterase, which leads to increased cGMP and NO, which leads to longer lasting erections
|
|
|
What are some side-effects of sildenafil?
|
light sensitivity, blurry vision, low blood pressure, headache, colorblindness
|
|
|
What are the 3 broad demographic approaches to prenatal screening?
|
population based
specific populatin subgroups highly targeted |
|
|
What sorts of prenatal disorders are screened for using the population based approach?
|
neural tube defects, Down's Syndrome, or anything that equally affects all populations
|
|
|
What sorts of prenatal disorders are screened for using the specific population subgroup approach?
|
thalassemia, sickle cell, Tay Sachs, or anything that affects a certain subpopulation
|
|
|
What sorts of prenatal disorders are screened for using a highly targeted approach?
|
hemophilia, or other things that the parents know runs in their family
|
|
|
At what point can you look for anatomical abnormalities with ultrasound?
|
18-20 weeks
|
|
|
At what point can you perfrom chorionic villus sampling (CVS) to check for birth defects?
|
between 9.5 and 11.5 weeks
|
|
|
At what point can you perfrom amniocentesis to test for birth defects?
|
after 14 weeks
|
|
|
What is the risk for fetal death during an amniocentesis procedure?
|
1 in 200
|
|
|
What is the risk for fetal death during a CVS procedure?
|
1 in 100
|
|
|
How are fetuses tested for Tay Sachs disease?
|
DNA testing or a hexosaminidase A / hexosaminidase ratio of amniocentesis or CVS samples
|
|
|
How are fetuses tested for sickle cell disease?
|
MCV less than 80%, iron sufficient, hemoglobin electrophoresis
|
|
|
How is a fetus tested for cystic fibrosis?
|
mom is tested for 23 known mutations; if +, dad is tested; if both +, then CVS/amniocentesis and test fetal DNA for the mutation
|
|
|
What is the carrier rate for a Cystic fibrosis gene among white people in the US?
|
1/25
|
|
|
What is the biggest risk factor for having a baby with Down's Syndrome?
|
advanced maternal age; 35 is the cutoff
|
|
|
What is the population risk in the US for Down's Syndrome?
|
1/800
|
|
|
What is the most common mechanism for acquiring Down's Syndrome?
|
trisomy 21, due to non-disjunction in the egg during meiosis 1
|
|
|
What portion of chromosome 21 actually causes Down's Syndrome?
|
band q22
|
|
|
What is the first test to see if a fetus has Down's Syndrome?
|
maternal blood levels of alpha-fetoprotein, hCG, estriol, inhibin, and PAPP-A
|
|
|
What is the population risk in the US for trisomy 13?
|
1 in 20,000
|
|
|
What is the population risk in the US for trisomy 18?
|
1 in 8000
|
|
|
In the first trimester, what is used to calculate gestational age?
|
crown-rump length on ultrasound
|
|
|
In the 2nd trimester, what is used to calculate gestatinal age?
|
biparietal diameter at the level of the septum pellucidum, and abdominal circumference at the level of theumbilical vein in the liver
|
|
|
In a normal pregnancy, how much alpha-fetoprotein is in the mom's serum?
|
None
|
|
|
elevated alpha-fetoprotein in the mom's serum is evidence of what?
|
fetal trisomy, neural tube defects,gastroschistis
|
|
|
What two compounds in the pregnant mom's serum suggest neural tube defects in the fetus?
|
alpha-fetoprotein and acetyl cholinesterase
|
|
|
What is the incidence of neural tube defects in fetuses?
|
1 to 2 per 1000
|
|
|
When can the embryo first be visualized on ultrasound?
|
6 weeks
|
|
|
increased nuchal thickness in the fetus on ultrasound between 10 and 14 weeks suggests what?
|
That the baby has Down's Syndrome
|
|
|
At what point can the fetal internal organs be visualized on ultrasound?
|
16-20 weeks
|
|
|
There are 10 criteria the WHO has determined for a valid screening program. The first 5 are, that the disease should be:
|
1) an important health problem
2) well understood 3) detectable at an early stage 4) early treatment is effective 5) a test is available for it |
|
|
There are 10 criteria the WHO has determined for a valid screening program. The last 5 are, that the disease should be:
|
6) test is inexpensive
7) test repeatable at intervals 8) health system can treat those who fail the screening 9) risks are less than the benefits 10) cost is balanced against benefit |
|
|
What is the difference between a screening test and a diagnostic test?
|
screening test is given to all, is cheap, and must be sensitive. Diagnostic tests are more expensive and specific
|
|
|
A good screening test has a high or low positive predictive value? Why?
|
low positive predictive value, in order to have no false negatives
|
|
|
Our public health system has divided the detection of disease in newborns into five parts, which are:
|
screening
follow up diagnostic test infant management evaluation of the system |
|
|
What are the 4 main categories of disorders screened for on a newborn screen?
|
metabolic conditions, endocrine disorders, hemoglobinopathies, hearing loss
|
|
|
What are 3 advantages that breastfeeding has over formula feeding for the infant?
|
1)immune protection through antibodies
2)nutrition balanced 3)skin-to-skin bonding enhances neural development |
|
|
What are 6 advantages that breastfeeding has over formula feeding for the mom?
|
1)prevents post-partum hemorrhage
2)weight loss 3)lactation amenorrhea 4)reduced risk of OBGYN problems 5)bonding with baby 6)economic benefit |
|
|
how is milk production changed in a malnurished woman?
|
doesn't alter macronutrient content that much, affects vitamins, minerals not affected except selenium & iodine
|
|
|
By how much should a breastfeeding woman increase her caloric intake in order to make adequate milk?
|
500 kcal
|
|
|
The protein in breastmilk is primarily of what form? Why is this important?
|
mostly whey, not casein. Easier for the baby to digest
|
|
|
How is breastmilk good for the baby's kidneys?
|
contains only low levels of renal solutes, which is good for the immature kidneys
|
|
|
Lactoferrin is found in breastmilk; what does it do?
|
bacteriocidal, binds iron so other bugs can't use it
|
|
|
What are the 4 categories of immune compounds found in breastmilk?
|
1)lactoferrin
2)IgA 3)bioactive macronutrients 4)cellular elements |
|
|
What immunoglobins are found in breastmilk? what is the timeline for their appearance?
|
IgA most common, is secreted into the milk 2-4 days after the mom is exposed to the antigen. All other Ig's are found in smaller amounts
|
|
|
What is the purpose of the bioactive macronutrients found in breastmilk?
|
oligosaccharides etc. bind to pathogens on the epithelium, supports growth of non-pathogenic normal flora
|
|
|
What cellular elements are found in breastmilk?
|
macrophages, neutrophils, some lymphocytes and epithelial cells, hormones, nucleotides.
|
|
|
What is the WHO's and AAP's recommendation for breastfeeding?
|
exclusively for the first 6 months, continue through the 1st (AAP) or 2nd (WHO) year of life
|
|
|
In US, what percentage of moms breastfeed exclusively up until their baby is 6 months old?
|
40%
(50% in colorado) |
|
|
What percent of women are still breastfeeding their baby at 12 months old?
|
20%
|
|
|
What demographics of women are more likely to breastfeed?
|
those >24, highly educated, live in New England or the West, not on WIC, not employed or only part time
|
|
|
What provides for the newborn's nutrition in the 3-4 days before mom's milk comes in?
|
colostrum, glycogen, fatty acid breakdown
|
|
|
How often should a baby nurse , from birth until 5 days old?
|
once every 1.5 to 3 hours
|
|
|
What is the pattern of weight loss and re-gain in a newborn?
|
loses weight for the first 2-4 days. Birth weight should be re-acheived by day 10
|
|
|
What defines Insufficient Milk Syndrome?
|
infant weight loss >7% of birth weight
or hasn't re-attained birth weight by 2 weeks old |
|
|
What is the most common cause of Insufficient Milk Syndrome?
|
inadequate milk removal leading to inadequate milk production. Primary milk insufficiency is rare.
|
|
|
How does the growth of breastfed infants compare to the growth of formula-fed infants?
|
breastfed babies gain weight faster during the 4 months, then slower after that, compared with formula fed babies
|
|
|
How many lobules does a normal breast have?
|
15-20
|
|
|
What is the functional unit of the breast?
|
Terminal Duct Lobular Unit (TDLU), which is all the acini and their terminal duct
|
|
|
What characterizes the intralobular stroma of the breast?
|
hormonally-responsive loos connective tissue that holds the TDLU's
|
|
|
What characterizes the interlobular stroma of the breast?
|
dense, fibrous tissue between the breast lobules
|
|
|
What is the order of structures of the breast, from acini to nipple?
|
acini -> terminal duct -> interlobular duct -> large duct -> lactiferous sinus -> nipple
|
|
|
What does the male breast have in common with the female breast? what's the big difference?
|
both have ducts, adipose, and fibrous tissue. Males have no acini and all the structures are smaller
|
|
|
Which nodes drain lymph from the breast?
|
axillary, supraclavicular, mediastinal
|
|
|
What is the cellular makeup of the ducts in the breast?
|
2 cell layer: inside is columnar epithelium, outside is an interrupted sheath of myoepithelial cells
|
|
|
What is the purpose of the myoepithelial cells of the breast ducts?
|
contractile, to push milk out
|
|
|
Where in the breast duct system does the columnar epithelium change to squamous epithelium?
|
just distal to the lactiferous sinus
|
|
|
At puberty, what causes the changes in the female breast?
|
estrogen and progesterone cause gland proliferation and duct formation
|
|
|
What parts of the breast are affected by hormones during the follicular phase of the menstrual cycle?
|
it's all unresponsive; the intralobular stroma looks just like the interlobular stroma
|
|
|
What parts of the breast are affected by hormones during the luteal phase of the menstrual cycle?
|
terminal ducts proliferate, intralobular stroma becomes edematous and loose
|
|
|
What parts of the breast are affected by hormones during the menses of the menstrual cycle?
|
TDLU's apoptose, lymphocytes invade the intralobular stroma, which becomes dense. The breast resets itself
|
|
|
What happens to the tissue of the breast during pregnancy?
|
rising sex hormone levels cause increased numbers of terminal ducts and enlarged TDLU's
|
|
|
What happens to the tissue of the breast during lactation?
|
terminal ducts form lots and lots of acini
|
|
|
What happens to the tissue of the breast post-menopause?
|
TDLU's atrophy, replaced by fatty tissue, lactiferous sinus and interlobular ducts don't change
|
|
|
What characterizes Juvenile Hypertrophy?
|
bilateral (almost never unilateral) breast development in pre-adolescent girls with no detected endocrine anomaly. Treat with reduction mammoplasty
|
|
|
Congenital inverted nipples are of no concern, except that......?
|
......underlying cancer can look exactly the same
|
|
|
What are some causes of gynecomastia in men?
|
hormonal imbalance, drugs, Klinefelter's syndrome, testicular tumors, liver disease, exogenous hormones
|
|
|
What are the histological changes seen in the male breast during gynecomastia?
|
ductal epithelial hyperplasia, stomal edema, fibrosis
|
|
|
What are the 3 types of inflammatory breast lesions?
|
Acute mastitis with breast abscess, chronic mastitis, fat necrosis of the breast
|
|
|
What is the most common cause and onset of acute mastitis?
|
Staph aureus infection through cracked nipples usually at the onset of lactation.
|
|
|
How do you treat acute mastitis?
|
drain the milk. If there is an abscess, drain that too.
|
|
|
Who is at risk for chronic mastitis?
|
postmenopausal women
|
|
|
What is the etiology of chronic mastitis?
|
obstructed, dilated ducts, leading to inflammatory infiltrate and swelling
|
|
|
What is the most common infiltrate seen in chronic mastitis?
|
B lymphocytes (plasma cell mastitis). Less commonly, it will be foam cells and fibrosis (granulomatous mastitis)
|
|
|
What characterizes fat necrosis of the breast?
|
Ischemia in pendulous breasts due to the arteries being stretched. Neutrophilic infiltrate around the necrotic fat cells leads to fibrosis and calcification
|
|
|
What are the 4 benign neoplasms of the breast?
|
1) fibroadenoma
2) lactating adenoma 3) intraductal papilloma 4) phyllodes tumor |
|
|
What characterizes a fibroadenoma of the breast?
|
solitary mass of proliferating ducts in a fibrous stroma. Does not progress to carcinoma. Usually in young women
|
|
|
What characterizes a lactating adenoma of the breast?
|
Same as a fibroadenoma, except it secretes milk and grows faster
|
|
|
What characterizes an Intraductal Papilloma of the breast?
|
papillary mass extending into the lumen of a large duct near the nipple. May bleed. Usually 1 cm or less
|
|
|
What characterizes a Phyllodes tumor?
|
proliferation of intralobular stroma and ductal epithelium. Can be benign or aggressive, up to 16 cm. Rare.
|
|
|
What characterizes FCC?
|
Fibrocystic Change is analagous to BPH in men; cysts and fibrosis proliferate in breast tissue as women get older. Normal process, but some changes predispose to cancer
|
|
|
What characterizes the cysts found in FCC?
|
from from TDLU's, may contain brown fluid or be bluish colored. May be un-palpable
|
|
|
What characterizes apocrine metaplasia found in FCC?
|
When TDLU epithelium turns into sweat-gland like epithelium. No symptoms. Histologically, cells have basal nuclei, blebs into the lumen, fine granular cytoplasm.
|
|
|
What characterizes Sclerosing Adenosis found in FCC?
|
proliferative acini/stroma with calcifications and fibrosis that distort normal ductal architecture. Looks like cancer but isn't.
|
|
|
Lobular Hyperplasia of the breast affects what structure?
|
the acini
|
|
|
What are the two types of lobular hyperplasia?
|
atypical lobular hyperplasia (ALH)
lobular carcinoma in situ (LCIS) |
|
|
What defines ALH?
|
less than 50% of lobules are filled with proliferating epithelium
|
|
|
What defines LCIS?
|
more than 50% of lobules are filled and distended by proliferating epithelium
|
|
|
What are the 3 types of ductal hyperplasia?
|
Unusual hyperplasia ->
atypical ductal hyperplasia (ADH) -> Ductal carcinoma in situ (DCIS) |
|
|
What do epithelial cells look like in Unusual Ductal Hyperplasia?
|
syncytial, nuclear overlap, no necleoli. Can see both epithelial and myoepithelial cells
|
|
|
What FCC's carry a 10 times increased risk for developing invasive cancer?
|
DCIS
LCIS |
|
|
What FCC's carry a 4 times increased risk for developing invasive cancer?
|
atypical ductal hyperplasia (ADH)
atypical lobular hyperplasia (ALH) |
|
|
What FCC's carry no increased risk for developing invasive cancer?
|
cysts, apocrine metaplasia, sclerosing adenosis, fibrosis, mild hyperplasia (less than 4 cells thick)
|
|
|
What percent of a lactating breast is made of milk glands?
|
63%
|
|
|
What percent of a non-lactating breast is made of milk glands?
|
20%
|
|
|
What percent of a lactating breast is intralobular fat?
|
7%
|
|
|
What percent of a non-lactating breast is intralobular fat?
|
49%
|
|
|
What is the first step in the embryological development of the mammary glands?
|
epithelium secretes PTHrP, which changes underlying mesenchyme to mammary mesenchyme
|
|
|
What is the second step in the embryological development of the mammary glands?
|
mammary mesenchyme supports differentiation of epithelium into milk glands and ducts
|
|
|
What happens if, as an embryo, your epithelial cells cannot make PTHrP?
|
No differentiation into mammary glands, and you won't develop them
|
|
|
What hormones stimulate the elongation and proliferation of the breast ducts?
|
estrogen and GH
|
|
|
What hormone stimulates the proliferation of lobules and acini in the breast?
|
progesterone
|
|
|
What hormone stimulates the maturation and activity of the acini in the breast?
|
prolactin
|
|
|
What hormone stimulates the myoepithelial cells in the milk ducts to contract?
|
oxytocin
|
|
|
How common are metastatic lesions to the breast?
|
Not very, usually only appear in advanced disease or patients under 20
|
|
|
What are the five histological patterns seen in ductal carcinoma in situ?
|
comedo (contains necrosis)
solid cribriform papillary micropapillary |
|
|
What hormone receptors are associated with what grades of DCIS?
|
low grade = estrogen/progesterone
high grade = Her2/neu |
|
|
Describe Paget's Disease of the nipple
|
DCIS that grows out from the duct and onto the skin of the nipple. Looks like a scaly rash
|
|
|
DCIS affects (one, both) breasts, and neoplastic cells stick (tightly, loosely) to the walls of the duct
|
DCIS affects one breast, cells stick tightly to the walls
|
|
|
LCIS affects (one, both) breasts, and neoplastic cells stick (tightly, loosely) to the walls of the ducts
|
LCIS affects both breasts, and cells are only loosely attached
|
|
|
What are the 5 types of invasive carcinoma of the breast to worry about for this test?
|
invasive ductal, no special type
invasive lobular tubular mucinous medullary |
|
|
The most common type of invasive breast cancer is:
|
invasive ductal carcinoma, no special type
|
|
|
Describe a well-differentiated invasive ductal carcinoma of no special type
|
well-formed ducts, cells look normal, express estrogen/progesterone receptors
|
|
|
Describe a poorly-differentiated invasive ductal carcinoma of no special type
|
irregular looking cells, no ducts or bad ducts, express Her2/neu receptors
|
|
|
What is the second most common type of invasive breast cancer?
|
invasive lobular carcinoma
|
|
|
Describe the appearance of invasive lobular carcinoma
|
single cells or rows of cells invading the stroma on their own
|
|
|
What molecule do tumor cells of invasive lobular carcinoma lack?
|
e-cadherin, which is why they metastasize so well. They don't stick to each other.
|
|
|
Where does invasive lobular carcinoma like to metastasize to?
|
CSF, GI tract, ovaries, uterus, peritoneum
|
|
|
Where does invasice ductal carcinoma of no special type like to metastasize to?
|
lungs, pleura
|
|
|
What are some characteristics of tubular carcinoma of the breast?
|
presents in women 40+, well differentiated, good prognosis, cribriform histology, estrogen/progesterone receptors
|
|
|
What are some characteristics of mucinous carcinoma of the breast?
|
well-circumscribed, small tumor cells floating in mucin, associated with BRCA1
|
|
|
What are some characteristics of medullary carcinoma of the breast?
|
well-circumscribed, solid cells with cancerous-looking nuclei, NO HORMONE RECEPTORS, associated with BRCA1
|
|
|
What are the three settings in which you might see sarcoma of the breast?
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1) spontaneous
2) following radiation therapy 3) chronic edema (Stewart-Treves Syndrome) |
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What differentiates fibroadenomas from phyllodes tumors?
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phyllodes tumors grow faster, overgrow the stroma, and have infiltrative borders
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Which component of a phyllodes tumor is prone to metastasize?
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the stromal component. The epithelial component does not metastasize
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Stage 0 breast cancer:
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DCIS or LCIS
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Stage I breast cancer:
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invasive carcinoma less than 2 cm, no lymph nodes
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Stage 2 breast cancer:
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invasive carcinoma less than 5 cm, with less than 3 lymph nodes
OR invasive carcinoma more than 5 cm with no lymph nodes |
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Stage 3 breast cancer:
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tumor <5 cm, >3 nodes
OR tumor >5cm, any nodes OR tumor any, >10 nodes OR skin involvement, chest wall fixation, inflammatory |
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Stage 4 breast cancer:
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any size tumor, distant lymph node metastasis
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What is the 5 year survival rate for people with Stage 0 breast cancer?
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92%
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What is the 5 year survival rate for people with Stage 4 breast cancer?
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13%
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What 5 factors make the prognosis bleak for people with breast cancer?
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1)lymph node metastasis
2)tumor size 3)local invasion 4)distant metastasis 5)inflammatory carcinoma |
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Well-differentiated breast cancer has a better or worse prognosis?
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well-differentiated tumors have better prognosis
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Overexpression of Her2/neu receptors on breast cancer tumors has a better or worse prognosis?
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Her2/neu means you have a worse prognosis
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What fraction of cases of breast cancer are due to the BRCA1 or BRCA2 gene?
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1/4
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What 3 other genetic syndromes are associated with breast cancer? What gene is mutated?
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1) Li Fraumeni, p53
2) Cowden, PTEN 3) Peutz-Jehger's, STK11 |
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A score of 1 on a mammogram test means, what?
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normal breast, no worries
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A score of 2 on a mammogram test means, what?
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benign lesion
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A score of 0 on a mammogram test means, what?
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you need to come back in for another mammogram right away
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A score of 3 on a mammogram test means, what?
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suspicious finding, take a biopsy
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A score of 4 on a mammogram test means, what?
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likely malignant, start cancer therapy at once
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At what age should women start getting mammograms?
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40 years old
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