Pregnancy

Gestational Diabetes - Neonate Presentation

• Neonates can present with hypoglycemia, polycythemia (high RBCs), and macrosomia (big baby).

Gestational Diabetes - Neonate Sequelae

• Exposure to high glucose in utero leads to increased insulin production, causing beta cell hyperplasia in neonates.
• Neonates can experience hypoglycemia postpartum since they have high levels of insulin.

Pregnancy Physiology - Relaxin

• Relaxin increases during pregnancy to increase laxity of ligaments and joints.
• Relaxin's main role is to facilitate vaginal delivery without breaking or rupturing the musculoskeletal system.
• Widened pubic symphysis in a mother likely indicates increased relaxin levels.

Pregnancy Physiology - Gestational Thrombocytopenia

• Gestational thrombocytopenia is commonly found in the 3rd trimester.
• Hemodilution, an increase in serum plasma decreases platelet concentration due to increased volume.
• Platelet consumption occurs when platelets get used and stuck in the placenta vessels.

Pregnancy Physiology - Thyroid Hormone Changes

• Increased estrogen concentrations raise the plasma concentration of thyroid hormone binding globulin.
• Total thyroid hormone concentration increases, but free thyroxine and TSH concentration remain unchanged.

Cardiac Physiology During Pregnancy

• Decreased systemic vascular resistance (SVR) from vasodilators creates a low-resistance system for blood flow to the placenta and baby.
• Blood volume is increased during pregnancy.
• Cardiac output and Preload increase during pregnancy with more volume.
• Increased blood volume and decreased SVR results in more blood returning to the heart.
• Afterload is decreased because the SVR is decreased so blood can easily get to the baby

Turner Syndrome

• Turner Syndrome: A female is born missing an X chromosome (45, XO).
• This condition is caused by a meiotic or mitotic nondisjunction.
• Infants with Turner syndrome commonly present with a short, webbed neck, dysplastic nails, horseshoe kidney, non-pitting edema, and streak ovaries.
• Non-pitting edema can be attributed to lymphatic blockage due to lymphatic network dysgenesis.
• Another characteristic of Turner syndrome is a posterior mass of cystic spaces separated by connective tissue, forming a cystic hygroma.
• Pregnancy is possible for women with Turner syndrome with the use of IVF.
• Streak ovaries (or atrophic ovaries) are a key feature of Turner Syndrome.

Fetal Development Timeline

• Week 1: Implantation occurs.
• Week 3: Gastrulation takes place.
• Week 4: Neurulation occurs.

Congenital Infections (TORCH)

• TORCH infections are transmitted to the fetus in utero, not during delivery.

Congenital Infections - Rubella

• Rubella presentation includes eye and heart symptoms, and loss of hearing.
• Maternal administration of a live attenuated vaccine before pregnancy prevents Rubella.

Congenital Infections - Syphilis

• Syphilis presentation includes umbilical cord inflammation with abscess-like foci of necrosis surrounding the umbilical vessels, a runny nose, and peeling skin rash.

Congenital Anomalies

• Congenital anomalies relate to deformations, disruptions, dysplasia or malformation.

Gestational Trophoblastic Disease - Choriocarcinoma

• Choriocarcinoma is a malignant tumor arising from trophoblasts.
• Patients will present with high Beta-hCG levels and develop lung problems due to metastasis.
• Methotrexate is a common Choriocarcinoma treatment.

Postpartum Hemorrhage Treatment - Tranexamic Acid (TXA)

• TXA inhibits plasminogen cleavage to prevent fibrin degradation.

Postpartum Hemorrhage Treatment - Oxytocin

• Oxytocin activates Gq-coupled receptors, promoting phospholipase C activity.
• PIP2 is cleaved into IP3 and DAG, which increases intracellular calcium release and causes uterine myocardial contraction.

Pierre Robin Sequence

• Respiratory distress, micrognathia, glossoptosis, and mandibular cleft are common.
• It involves altered development of the first pharyngeal arch.

Pharyngeal Cleft Cysts (Branchial Cleft Cyst)

• Characterized by a persistent cervical sinus.
• A painless, slowly enlarging mass on the side of the neck is observed.
• The mass does not move with swallowing and is located anterior to the sternocleidomastoid muscle.

Polyhydramnios

• Can be caused by Anencephaly or Duodenal Atresia

Oligohydramnios

• Oligohydramnios is typically associated with kidney dysfunction in the fetus.

Potter Sequence

• Compression of the fetus due to low amniotic fluid during pregnancy.
• Signs include flat facies, pulmonary hypoplasia, and limb deformities.

Prenatal Care

• Abnormal alpha-fetoprotein (AFP) levels during screening indicate errors in dating, which influences gestational age.
• AFP is decreased in Down syndrome and Edwards syndrome.

Hormonal Release - Beta-hCG

• Beta-hCG releases from syncytiotrophoblasts following implantation around 6-7 days after fertilization.
• It is detectable in serum by day 8 and in urine by day 14 post-fertilization.

Septic Abortion

• Presents as recent pregnancy termination with fever, tender abdomen, and malodorous fluids in the vaginal canal.
• Pathogens include Enterobacteriaceae, GAS, and Staph Aureus.

Thyroid Drugs During Pregnancy

• Methimazole and Propylthiouracil (PTU) are drugs used to treat hyperthyroidism in pregnancy
• MOA: PTU inhibits 5'-deiodinase and thyroid peroxidase, Methimazole inhibits only thyroid peroxidase
• Methimazole can result in teratogenic effects/hepatotoxicity
• PTU is used during the first trimester to minimize teratogenic effects by methimazole.
• After the first trimester, Methimazole is used because it prevents maternal hepatotoxicity

Preeclampsia

• New-onset high blood pressure (≥ 20 weeks gestation) with proteinuria and/or signs of end-organ damage during pregnancy.
• Abnormal placenta with poorly formed spiral arteries causes placental ischemia.
• Antiangiogenic factors are released by the ischemic placenta, leading to endothelial cell damage and widespread vasospasm.

Teratogens - Lithium

• Lithium is a mood stabilizer primarily used for bipolar disorder.
• Lithium can lead to Ebstein's anomaly.

Teratogens - Valproate

• Neural tube defects are caused by folate deficiency

Postpartum Depression

• Characterized by onset of symptoms for more than two weeks with little energy.
• Includes constant checking on the baby, not sleeping/eating, and feelings of being a bad mother, despite the baby's good health.

Androgen Insensitivity Syndrome

• Presentation includes normal external genitalia, breast development, and amenorrhea.
• No axillary or pubic hair can be observed.
• Congenital Presentation: Gonads found as two masses, typically in the labia majora.
• 46, XY Karyotype.
• Defective androgen receptor causes androgens (testosterone and DHT) to exert its effects during fetal development.
• A key characteristic is the absence of hair.

Germ Layers

• Endoderm develops into the epithelial lining, creating type II pneumocytes for surfactant secretion.
• Mesoderm develops into connective tissue structures/dura mater, muscles, dermis, bone, cartilage, cardiovascular system, lymphatic system, blood components, kidneys, adrenal cortex, and reproductive organs.

Constitutional Growth Delay

• Patients have parents of normal stature but show slow, steady growth, delayed pubertal development, and bone age below true age.
• Constitutional growth delay is separate from the results of the use of inhaled steroids.

Breastfeeding Hormones

• High prolactin levels facilitate breastfeeding after birth, which decreases GnRH, FSH, LH, and estrogen.
• Vaginal dryness and atrophy indicates estrogen deficiency, and not FSH nor LH deficiencies.

Ectopic Pregnancy

• Associated with vaginal spotting, missed period, lower than expected beta-hCG with abnormally rising levels, and no gestational sac in the uterus.

Placenta Accreta

• Abnormal attachment of the placenta to the myometrium.
• Presents with huge post-delivery hemorrhage.

Round Ligament Pain

• Described as dull pelvic pain radiating to the labia majora.
• Common during pregnancy.
• The round ligament extends from the superolateral part of the uterus where the fallopian tube inserts, passes through the inguinal canal, and ends in the labia majora.