Obstetrics and Neonatology Quiz

Ectopic Pregnancy

• Pregnancy occurring outside the uterus
• 98% occur in the fallopian tube, specifically the ampulla (mid-portion)
• Symptoms appear in the first trimester and include vaginal bleeding and abdominal pain (potentially mimicking appendicitis)
• Diagnosis is made via ultrasound
• Treatment options include methotrexate or surgery
• Risk factors for ectopic pregnancy include damage to the fallopian tube, prior ectopic pregnancies, tubal disorders (including ligation or surgery), and pelvic inflammatory disease (PID). Infertility, and Kartagener syndrome (ciliary dysfunction) are also risk factors.

Spontaneous Abortion (Miscarriage)

• Pregnancy loss before 20 weeks
• Can occur after 20 weeks as stillbirth or fetal demise
• Commonly presents as vaginal bleeding
• Often requires a D&C (dilation and curettage) to remove all tissue
• Chromosomal abnormalities in the fetus account for approximately 50% of cases
• Risk factors include maternal smoking, alcohol, cocaine use, maternal infection (TORCH infections), and hypercoagulable states, Lupus/antiphospholipid syndrome.

Amniotic Fluid

• Primarily composed of fetal urine and lung secretions
• Removed from the uterus primarily via fetal swallowing
• Oligohydramnios: low amniotic fluid; often a sign of fetal kidney problem
• Polyhydramnios: excessive amniotic fluid; potentially due to fetal swallowing complications or GI problems

Oligohydramnios

• Low amniotic fluid
• Often due to fetal kidney abnormalities (e.g., bilateral renal agenesis, posterior urethral valves)
• Can lead to Potter's sequence (a constellation of abnormalities due to lack of amniotic fluid cushioning)
• Potentially linked to Preeclampsia and maternal vascular disease
• Premature rupture of membranes (PROM) can contribute

Polyhydramnios

• Excessive amniotic fluid
• Commonly due to fetal swallowing malformations (e.g., esophageal/duodenal atresia), anencephaly, maternal diabetes, fetal hyperglycemia leading to polyuria, and fetal anemia
• Can cause high fetal cardiac output

Low Birth Weight

• Defined as less than 2500 grams (5.5 lbs)
• Causes include premature delivery and intrauterine growth restriction (IUGR)
• Increased risk of neonatal mortality and numerous newborn complications
• Risk factors include congenital abnormalities, multiple gestation, Preeclampsia, Abruptio placentae, maternal alcohol use, smoking, cocaine use.

Newborn Problems Associated with Low Birth Weight

• Hypothermia (low white/brown adipose tissue)
• Hypoglycemia (insufficient fetal glucose production)
• Hyperbilirubinemia (unconjugated bilirubin)
• Respiratory distress syndrome (RDS) (surfactant deficiency)
• Transient tachypnea of the newborn (inadequate lung fluid clearance)
• Pneumonia
• Respiratory failure
• Polycythemia (elevated red blood cell count due to hypoxia in utero)
• Necrotizing enterocolitis (intestinal necrosis/obstruction)
• Intraventricular hemorrhage (bleeding into the brain ventricles)

Persistent Fetal Circulation

• In utero, blood is shunted away from the lungs via the foramen ovale and ductus arteriosus
• At birth, pulmonary vascular resistance (PVR) falls as the lungs begin functioning, leading to changes in blood flow.
• Persistence of high PVR after birth can lead to shunting, hypoxemia (low blood oxygenation) and abnormalities of pulmonary vasculature (including smaller blood vessels and thickened vessel walls).

Immune Function

• Cellular immunity is impaired
• T-cells and B-cells are reduced at birth
• Some newborns have neutropenia

Hypertension in Pregnancy

• Pre-existing hypertension (elevated blood pressure prior to pregnancy)
• Gestational hypertension (blood pressure elevation during pregnancy with no proteinuria)
• Preeclampsia (blood pressure elevation with proteinuria)
• Eclampsia (preeclampsia with seizures)

Preeclampsia

• Multi-system disorder of pregnancy characterized by hypertension and proteinuria.
• Often occurs during the third trimester.
• Pathogenesis involves placental abnormalities: impaired trophoblast invasion, placental underperfusion, endothelial dysfunction
• Possible risk indicators include prior preeclampsia, first pregnancy, family history, multiple pregnancies, and pre-existing maternal conditions such as diabetes, hypertension, obesity, and chronic kidney disease.
• Complications include placental insufficiency, placental abruption, pulmonary edema, heart failure, liver hematoma, liver failure, disseminated intravascular coagulation (DIC), stroke, and renal failure.

Eclampsia

• Preeclampsia with seizures
• Often complicated by DIC and respiratory failure.
• Exact cause remains unclear, but linked to blood flow and endothelial dysfunction.
• Treatment is immediate delivery to prevent further complications.

HELLP Syndrome

• Hemolysis, Elevated Liver enzymes, Low Platelet count
• A variant/severe complication of preeclampsia
• Characterized by hemolysis, elevated liver enzymes, low platelet count
• Leads to coagulation activation and liver infarction
• Treatment involves delivery of the baby

Placental Abruption

• Premature separation of the placenta from the uterine wall
• Occurs during the third trimester of pregnancy, commonly with painful vaginal bleeding, abdominal or back pain, and uterine contractions.
• Risk factors include previous abruption, maternal hypertension/preeclampsia, smoking, cocaine use, abnormal uterus, and prior C-section.
• Possible complications are maternal shock, fetal distress/death, and DIC (Disseminated Intravascular Coagulation).

Cortical Necrosis

• Ischemic necrosis of the renal cortex
• Rare cause of acute renal failure often linked to DIC, often linked to placental abruption.
• Can lead to permanent renal failure
• Clinical signs include acute renal failure, anuria, hematuria, and flank pain

Placenta Previa

• Placenta implants over or near the cervix, rather than the upper part of the uterus, obstructing the birth canal.
• Common symptom is painless vaginal bleeding during pregnancy.
• May lead to preterm birth and usually involves C-section delivery.

Velamentous Umbilical Cord

• Umbilical cord inserts into the fetal membranes rather than the center of the placenta.
• Fetal vessels are exposed and lack protection from Wharton's jelly, which increases the risk of rupture and bleeding.

Vasa Previa

• Fetal blood vessels run within the membranes covering the cervix.
• Rupture of membranes leads to potential bleeding, requiring C-section delivery.

Abnormal Placental Attachment

• Placenta attaches to the myometrium (uterine muscle) instead of the decidua (lining of the uterus)
• Forms include:
  • Placenta accreta: placenta attaches to the myometrium, but not extending to the serosa.
  • Placenta increta: placenta penetrates the myometrium.
  • Placenta percreta: placenta penetrates the myometrium and extends through the serosa.
• Diagnosis often involves routine ultrasound
• Delivery usually requires C-section and sometimes hysterectomy.

Postpartum Hemorrhage

• Excessive bleeding after childbirth
• Uterine atony: the most common reason due to uterine failure to contract fully.
• Coagulopathy: blood loss consumes clotting factors, DIC(disseminated intravascular coagulation) is possible result
• Trauma: lacerations or surgical incisions

Amniotic Fluid Embolism

• Rare and often fatal complication of pregnancy involving entry of amniotic fluid and its contents into the maternal circulation during labor or shortly after.
• Key features are respiratory distress, hypotension, and massive hemorrhage, leading to DIC (disseminated intravascular coagulation), and potential seizures.

Gestational Tumors

• Rare tumors developing during pregnancy involving the placenta(trophoblast)
• Gestational Trophoblastic Disease (GTD): general term for these tumors
• Complete mole: no fetal cells, but the maternal cells will have doubled their genetic material.
• Partial mole: some fetal tissue exists, but the cells are not genetically normal.
• Involves trophoblast cells (placenta).
• Often benign, but sometimes malignant

Chorionic Carcinoma

• Malignant neoplasm arising from the placental trophoblast cells
• Can develop after a complete mole pregnancy
• Often follows complete mole pregnancy
• 15% develops locally invasive and 5% develop metastatic disease.
• Treatment includes chemotherapy (e.g., methotrexate or actinomycin D).
• Monitoring hCG levels is essential to detect persistent disease.
• Non-gestational variant is less common