STI/AP labs

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ieast
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STI/AP labs
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2013-05-06 01:41:41
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  1. Chlamydia tx
    • azithromycin 1 g once
    • abstain X 7 days
    • toc in pregnancy after 3-4 wk
  2. chlamydia s/s
    • usually none: sometimes cmt etc suggestive of PID
    • screen: annualy <25 or other high risk
  3. gonorrhea s/s
    • usually none, sometimes dyspareunia, swelling, discharge
    • can also get gonococcal pharyngitis or rectal infection
  4. gonorrhea tx
    ceftriaxone 250mg IM plus azithromycin 1 g PO
  5. DGI
    • disseminated gonoccocal infection
    • stage 1: bacteremia- fever, chills, painful necrotic pustules
    • stage 2: acute septic arthritis, effusion in wrists, knees, ankles
  6. trichomoniasis s/s
    • yellow green malodorous discharge, itching, pain
    • strawberry spots on cervix, friable cervix
    • pH>4.5
    • pregnancy: PROM, LBW, preterm
  7. trichomoniasis tx
    flagyl 2gm PO once
  8. HSV treatment
    • primary: acyclovir 400 mg TID X 5 days
    • suppression: acyclovir 400 mg BID
  9. syphillis tx
    • PCN 2.4 million units IM X 1
    • doxycycline 100 mg PO BID X 14 days
  10. syphillis s/s
    • treponema pallidum- a spirochete
    • primary: chancre- painless papule erodes --> shallow ulcer
    • secondary: widespread rash on palms/soles, lymphadenopathy, 
    • latent:asymptomatic
    • tertiary: if not treated --> CP, cough, nodules, ulcers, arthritis, myalgia, HA, irritability, balance/memory probs, tremor
  11. PID
    • any combo of: endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis
    • s/s= one or more: CMT, adnexal tenderness, uterine tenderness
    • often: mucopurulent discharge, WBCs, temp, elevated ESR/CRP
  12. PID tx
    • ceftriaxone 250 mg IM plus doxycicline 100mg PO BID X 14 days
    • w/ or w/out flagyl 500 mg PO BOD X 14 days
  13. pediculosis pubis tx
    permethrin 1% cream applied and washed off after 10 min
  14. scabies tx
    permethrin 5% cream washed off after 8-14 hrs
  15. chancroid s/s
    • H. ducreyi
    • painful macule on external genitalia --> pustule --> ulcerated lesion
    •  can develop bilateral inguinal nodes (buboes)
  16. chancroid tx
    azithro 1 gm PO once
  17. granuloma inguinale
    • klebsiella granulomatis
    • painless subq nodules erode --> granulomatous heaped ulcers- beefy red, friable
    • no lymphadenopathy
    • can extend to pelvis, abd organs, bones, mouth
  18. granuloma inguinale tx
    • doxy 100 mg PO BID at least 3 wks until lesions have healed completely
    • pregnancy: azithro 1g PO weekly at least 3 wks until lesions have healed completely
  19. lymphogranuloma venereum
    • primary: painless vesicle or nonindurated ulcer, often unnoticed
    • --> tender lymphadenopathy, unliateral. lesions usually gone by the time seek tx
    • can --> proctocolitis, chronic colorectal fistulas/strictures
  20. lymphogranuloma venereum tx
    • doxy 100 mg PO BID X21 days
    • pregnancy: erythromycin base 500 mg PO QID X 21 days
  21. urethritis tx
    azithromycin 1g Po X1
  22. urethritis
    • often asymptomatic, can be gonorrheal or NGU
    • diagnosis- >5wbc
  23. epididymitis tx
    ceftriaxone 250 mg IM once PLUS doxy 100 mg PO BID X10days
  24. proctitis/proctocolitis/enteritis tx
    ceftriaxone 250 mg IM once PLUS doxy 100 mg PO BID X 7days
  25. antibody screen
    • Rh sensitized: >1:4 anti D antibodies
    • 1:8 r/t rhogam
    • others: >1:16 is critical
  26. h/h
    • 1st and 3rd: 11/33
    • 2nd: 10.5/32
    • non pregnant: 12/35-15/45
  27. Platelets
    • 150,000
    • refer<100
    • treat<50 w/ steroids
  28. GCT
    • 50 g
    • 130-140
    • >200=GDM
  29. GTT
    • 100 g - fasting, 1 hr, 2hr, 3 hr
    • ACOG: 105/190/165/145
    • OR 95/180/155/140
    • 2+ abnl or >126 fasting
  30. qualitative hcg
    should double every other day, peak 8.5-10wk
  31. HA1c
    • usually lower in pregnancy
    • 6.5
  32. Hgb electrophoresis
    • AA: 95%
    • A2: thalassemia 1.5-3.5%
    • F: <2% (fetal hemoglobin) —
    • C,D,H,S,E:  0  
    • AS/AC: sickle trait
    • SS/SC: sickle disease
    • indications: h/o anemia, SAB, MCV<80 w.out dec Fe
  33. thalassemia
    • AlphaThalassemia: Hb H — 
    • Beta: Increased A2 (3.5-7%), may have elevated F, low MCV and MCH — May be silent carrier or severely affected
  34. amnio
    16-20 wk
  35. CVS
    10-12 wk, transcervical or transabd
  36. lead
    • <5 safe
    • >44 need chelation
    • Fe decreases absorption
    • Vit C increases excretion
    • Ca decreases bone breakdown (where lead is stored)
  37. PPD
    • >5mm
    • unless BCG in last 5 yrs then >15
    • >20 always +
    • CXR after 20 wks
  38. rubella
    • titer 1:10 is immune
    • avoid pregnancy 4 wks post vaccine
  39. nuchal translucency
    11-14 wk
  40. quad screen
    • 15-20 wks
    • AFP, estriol, HCg, Inhibin A (quad only)
  41. syphilis testing
    • NOB, 3rd tri
    • VDRL/RPR= screen (often false + in pregnancy)
    • FTS-ABS: confirmation
    • most harmful STI to fetus
  42. urine cx
    • >100,00 CFU, can treat lower if symptomatic
    • consider suppression if >2
  43. CIN1
    • low grade/mild abnormalities
    • abnormal cells in bottom 1/3 of epithelium- close to initial site of HPV infection
  44. CIN2
    abnormal cells through bottom 2/3 of epithelium
  45. CIN3
    • high grade lesions
    • abnormal cells throughout entire epithelium
    • only place to go now is through BM; so closer cells are to top, more likely to become CA
  46. what pathologist is looking for on PAP
    • nucleus-cytoplasm ratio: less c is abnl
    • nuclear hyperchromasia: abnl cel has bigger/darker nucleus
    • nuclear/chromatin abnormalities:
  47. reactive cellular changes
    benign changes r/t tissue inflammation and repair (infection or iud)
  48. ASC-US meaning
    • atypical squamous cells- undetermined significance
    • nucleus <3x
  49. ASC-H
    • suggestive of high grade lesion
    • very abnormal looking cells but;
    • very few present or nucleus doesn't meet criteria for high grade lesion
    • always send to colpo
  50. LSIL
    • low grade squamous intraepithelial lesions: cellular changes that are diagnostic of HPV
    • nucleus >3x normal, dark
    • no/few nuclear abnormalities
    • usually r/t CIN1, but can be 2-3
    • colpo unless <21
    • many clear on own, 50% benign
  51. HSIL
    • high grade squamous intraepithelial lesions: HPV has integrated into the nuclei of these cells
    • colpo for everyone, even teens
    • 2% have invasive cancer
  52. ectocervix
    squamous: keratinized epithelium
  53. endocervix
    columnar: fluffy, friable
  54. ASCUS <20
    repeat in 12 mos
  55. ASCUS>20
    HPV dna testing 
  56. ASCUS HPV+
    colpo, unless <20, then repeat in 1yr
  57. ASCUS HPV-
    repeat pap 1 yr
  58. LSIL f/u
    colpo, unless <20, then rpt 1 yr
  59. ASC-H or HSIL
    everyone to colpo
  60. 5 Ps
    • partner
    • pregnancy prevention
    • protection from STI
    • practices
    • past history (of STI)
  61. BV tx
    flagyl 500 mg PO BID X 7 days
  62. BV s/s
    • most prevalent vaginal infection 
    • normal lactobacillus replaced by facultative/anaerobes → increased
    • amines and altered pH
    • epithelial cells slough, bacteria attach to them → clue cells
    • not STI: associated with new/multiple partners, douching, lack of lactobacilli; rarely
    • affects women who have never been sexually active
    • can→ PID, post-procedure infections
    • s/s:foul odor, increased thin white/grey discharge, mild irritation,post coital/irregualr spotting, burning after intercourse, urinary
    • discomfort
    • 50% asymptomatic
    • 3/4 Amsel’s criteria: abnormal gray discharge, pH >4.5, positive whiff test, and more than 20% of epithelial cells being clue cells
    • adverse pregnancy outcomes: PROM, PTL, chorio, postpartum endometritis
  63. complicated VVC
    • recurrent >4/yr
    • severe s/s
    • suspected non c.albicans
    • pregnancy
    • DM, severe medical illness, immunosuppression, other vulvovaginal condition
  64. desquamative inflammatory vaginitis
    • r/t menopause --> dyspareunia, yellow/green discharge, burning
    • elevated pH, neg. amines, often mistaken for trich, but no trichomonads
    • tx: 2% clindamycin cream X 14 days
  65. ferrous fumarate
    • 106 mg elemental iron per 325 mg tablet
    • 200 mg tid-qid
  66. ferrous sulfate
    • 65/325
    • 3 tabs TID on an empty stomach
  67. ferrous gluconate
    • 34 mg elemental iron per 300 mg tablet
    • 300-600 mg/day in divided doses
  68. vitamin A
    • mcg
    • NP: 700
    • P: 770
    • PA: 750
    • L: 1300
    • food: liver, dairy, yolk
    • AE: liver toxicity, esp r/t EtOH; can compete w/ vit D --> inc risk of hip fracture
  69. vitamin D:
    • mcg
    • NP: 5
    • P: 5
    • PA: 5
    • L: 5
    • food: fortified dairy, fish oil
    • AE: GI, anorexia, HA/N/V, metallic taste
  70. vitamin E
    • mg
    • NP: 15
    • P: 15
    • PA: 15
    • L: 19
    • food: vegetable oils, unprocessed cereal grains, fruit/nuts
    • AE: monitor on anticoags
  71. vitamin K
    • mcg
    • NP: 90
    • P: 90
    • PA: 75
    • L: 90
    • food: leafy greens
    • AE: monitor on anticoags
  72. Vitamin C
    • mg
    • NP: 75
    • P: 85
    • PA: 80
    • L: 120
    • food: citrus, tomatoes, potatoes
    • AE: GI, kidney stones, excess iron. 
    • smokers need more
  73. Vitamin B6
    • mg
    • NP: 1.3
    • P: 1.9
    • PA: 1.9
    • L: 2
    • food: fortified grains
    • AE: none from natural sources
  74. vitamin B12
    • mcg
    • NP: 2.4
    • P: 2.6
    • PA: 2.6
    • L: 2.8
    • food: fortified meat, fish, poultry, dairy
    • AE: none
    • >50 need to supplement
  75. Folate
    • mcg
    • NP: 400
    • P: 600 4gm if prior NTD
    • PA: 600
    • L: 500
    • food: enriched grains, leafy greens
    • AE: masks B12 deficiency
  76. calcium
    • mg
    • NP: 1000
    • P: 1000
    • PA: 1300
    • L: 1000
    • food: dairy, kale, brocoli
    • AE: kidney stones
    • reduced absorption in amenorrhea
  77. Iron req.
    • mg
    • NP: 18
    • P: 27
    • PA: 27
    • L: 9?
    • food: fortified dairy, cereal, fish oil
    • AE: GI
    • need higher intake in vegetarian diet
  78. Iodine
    • mcg
    • NP: 150
    • P: 220
    • PA: 220
    • L:
    • food: processed food, iodized salt
    • AE: elevated TSH, more susceptible w/ thyroid probs
  79. zinc
    • mg
    • NP: 8
    • P: 11
    • PA: 12
    • L: 12
    • food: fortified cereal, red meat, seafood
    • AE: reduced copper status
    • lower absorption in vegetarians
  80. thiamin
    • mg
    • NP: 1.1
    • P: 1.4
    • PA: 1.4
    • L: 1.4
  81. Riboflavin
    • mg
    • NP: 1.1
    • P: 1.4
    • PA: 1.4
    • L: 1.6
  82. niacin
    • mg
    • NP: 14
    • P: 18
    • PA: 18
    • L: 17
  83. phosphorus
    • mg
    • NP: 700
    • P: 700
    • PA: 1250
    • L: 700
  84. calorie req
    • 11-18: 2200
    • 19-24: 2100
    • 25-50: 2300
    • pregnant: add 300 (2nd/3rd tri)
    • lactating: add 500
  85. protein
    • 10% of calories or 0.8g/kg
    • 1.1g/kg in pregnancy/71 g/day (regular is 46/day)
    • total proteins: lentils, beef, cottage cheese, milk
  86. presumptive signs
    • experienced by woman
    • amenorrhea, N/V, breast changes, polyuria, fatigue, temp, colostrum, salivation, chadwick (blue vulva), quickening, skin changes
  87. probable signs
    • noted on exam
    • englarged abdomen, palpated fetal outline, ballotement, palpated fetal movement, enlarged uterus, + hCG
    • piskaceck: uterine irregularity to side of implantation
    • hegar: soft isthmus
    • goodell: soft cervix
  88. positive signs
    • FHT
    • sonogram
  89. heart tones
    • doppler: 9-12 wks
    • fetoscope: 18-20
  90. quickening
    • primigrav: 18-20 wks
    • multip: 16-18
  91. changing EDD
    • 1st tri: > 7 day
    • 2nd tri: > 10 day
  92. antibody screen
    • anti D: rh sensitized
    • kell kills lewis lives
  93. CBC
    • NOB, 28 wk
    • PLT- 150,000 refer <100, treat < 50
  94. GBS
    • 35-37 wk
    • good for 5 wks
    • doesnt cause PTL (UTI does)
    • UTI = marker for heavy colonization
  95. GC/CT
    • NOB, 3rd tri for continued/new High risk
    • can --> PTL, but don't harm fetus (same w/ trich)
  96. escutcheon
    pubic hair over mons
  97. posterior cul de sac
    • divides upper 1/4 of vagina/uterus from rectum
    • aka recto-uterine puch
  98. vulva
    all visible external structures
  99. prepuce
    where upper pair of lamella meet, superior to clitoris
  100. frenulum
    where lower lemella meet, inferior to cervix
  101. lamella
    labia minora divide at top to form two pairs which fuse around clitoris to form frenulum (lower) and prepuce (top).
  102. isthmus
    b/w internal os and endometrial cavity --> lower uterine segment during pregnancy
  103. fourchette
    where labia minora meet at bottom in low ridges of tissue
  104. cornua
    where fallopian tubes attach to uterus
  105. vestibule
    b/w fourchette and frenulum, contains vagina, urtethra, skenes, and bartholins
  106. vestibular bulbs
    • almond shaped aggregations of veins beneath bulbocavernosus muscle on either side of vestubule- open in middle of vagina 
    • can be injured during delivery --> hematoma
  107. bones of pelvis
    • saccrum
    • coccyx
    • 2 inominate bones: ileum, ischium, pubis
  108. ischial tuberosities
    lowest part of ischium- sit bone
  109. ischial spine
    • separate greater from lesser sciatic notch
    • sharp or blunt?
  110. pubic rami
    • arms of pubis
    • superior: articultes with opposite, and ilium --> part of acetabulum
    • inferior: down from superior, joins w/ inferior ramus of ischium below obturator foramen
  111. pubic arch
    where inferior pubic rami meet needs to be 90-100 degress for fetal head to pass (2 fingers)
  112. iliopectinal line
    • ridge on inner surface of ilium marking border of true pelvis
    • same as linea terminalis?
  113. boundaries of pelvic inlet
    • anterior: posterior superior margin of SP
    • lateral: iliopectineal lines
    • posterior: sacral promontory
  114. midpelvis boundaries
    • plane of least dimension
    • anterior: midpoint of SP
    • lateral: upper thirds of obturator foramina
    • posterior: junction of S2 and S3
  115. outlet boundaries
    • two triangles sharing base of bituberous diameter
    • anterior sides: pubic rami and ischial tuberosities
    • anterior apex: subpubic angle

    • posterior sides: sacrotuberous ligaments
    • posterior apex: sacrococygeal join
  116. anthropoid pelvis
    • narrow
    • adequate, but relatively short transverse
  117. android pelvis
    • heart shaped
    • wide posterior, narrow anterior 
    • anterior sagital diameter (from transverse to SP) is longer
  118. platypelloid pelvis
    • wide transferse, short everything else
    • rare!
  119. mixed pelvis
    • type= posterior
    • tendency= anterior
  120. anatomic conjugate of inlet
    • sacral promontory to middle of pubic crest
    • no clinical significance 11.5 cm
  121. obstetric conjugate of inlet
    • sacral promontory to posterior superior margin of SP (protrudes into pelvis)
    • what baby must pass through!
    • 11 cm
    • estimate by subtracting 1.5 from diagonal
  122. diagonal conjugate of inlet
    • sacral promontory to subpubic angle
    • >12.5 
    • subtract 1.5 to estimate obstetric conjugate
  123. transverse diameter of inlet
    • widest distance b/w illiopectinal lines
    • 12.5 cm
  124. inlet oblique diameters
    • sacroiliac joint to iliopectinal eminence on oposite side
    • 12.5
  125. posterior sagital diameter of inlet
    • intersection of Ap and transverse diameter to sacral promontory
    • 4.5
  126. midpelvis anterior diameter
    • SP to junction of S4/S5
    • 12 cm
  127. midpelvis transverse diameter
    • b/w ischial spines
    • 10.5
  128. midpelvis posterior sagital diameter
    • bispinous diameter to S4/S5 junction
    • 4.5-5 cm
  129. outlet AP diameter
    • anatomic: SP to tip of coccyx 9 cm
    • obstetric SP to sacrococcygeal joint 11.5 cm (coccyx pushed out of way)
  130. outlet transverse diameter
    • bituberous
    • 11
  131. outlet posterior sagittal
    bituberous to sacrococcygeal 9 cm
  132. outlet anterior sagittal
    • bituberous to subpubic
    • 6 cm
  133. pelvic tilt/inclination
    tilted fwd --> more room to come around promontory into sacral hollow under SP
  134. pelvic floor muscles
    • coccygeus (ischiococcygeus) and
    • levator ani= 2 muscles
    • -iliococcygeus and
    • -pubococcygeus= 3 parts
    • --pubovaginalis
    • --puborectalis
    • --pubococcygeus proper
  135. bulbocavernosus
    • surrounds vagina
    • figue 8 w/ anal sphincter
  136. 3 pelvic arteries
    clitoral, pudendal, uterine
  137. FSH
    targets ovaries --> growth and development og primary follicle
  138. LH
    targets follicle --> ovulation, corpus luteum formation
  139. menstrual cycle
    • ~GnRHpulses stimulate the release of FSH/LH → ovarian follicles develop and produce estrogen → negative feedback onto pituitary
    • ~when estrogen level becomes high enough, effect on is reversed→ mid-cycle positive feedback → LH/FSH surge → ovulation
    • ~LH→ ruptured follicle becomes corpus luteum, which secretes progesterone → decreased GnRH from hypothalamus (LH is increased to sustain corpus)
    • ~In the absence of pregnancy, corpus degenerates and progesterone falls → menstruation, GnRH pulses begin again
  140. follicular phase
    • development of ovarian follicles
    • days 1 -14
    • ~decreased estrogen by corpus luteum → rise in FSH at end of menstruation → development of increased receptors on granulosa cells to produce estrogen 
    • LH → stimulate cells production of androgens that get converted to estrogen by granulosa cells
    • day 5-7: dominant follicle develops
    • FSH decreases r/t negative feedback from estrogen 
    • LH surge r/t rising estrogen from dominant follicle
  141. ovulatory phase
    • 10-12 hours after LH peak (dependent on LH and estrogen)
    • nuclear membrane around oocyte breaks down, complete 1st meiotic division,
    • then cease, only to continue if fertilized
    • LH surge → synthesis of progesterone → enhances positive feedback of estrogen on LH → prostoglandins/enzymes → ovulation
  142. Luteal Phase
    • LH → granulosa cells enlarge , undergo luteinization → corpus luteum
    • functions 8 days after ovulation → progesterone/estrogen → negative feedback on hypothal/pituitary → prevent further ovulation
    • no fertilization → luteal cells degenerate → rapid fall in estrogen/progesterone → loss of negative feedback → increased LH/FSH
  143. proliferative phase
    • regrowth of endometrium; influenced by estrogen
    • starts day 4-5, lasts 10 days (until ovulation)
    • endometrial glands also become long and tortuous
  144. secretory phase
    • only occurs if woman ovulated
    • from day after ovulation until day 28
    • progesterone → endometrial glands become more thick/tortuous, fill w/ secretions; endometrium continues to thicken/nutritive
    • no implantation → corpus luteum shrinks → fall in estrogen/progesterone → endometrium regresses
    • enzymatic autodigestion of functional layer of endometrium → disrupt vessels → menstruation
  145. menstrual phase
    • prostoglandins → contractions and sloughing of degraded tissue
    • b/c clotting factors are lysed by enzymes, menstrual blood doesn't clot!
    • 2 days after start, estrogen → regeneration of surface epithelium,concurrent to shedding
  146. decidua
    layer of placenta that attaches to uterus
  147. cytotrophoblast
    supporting tissue
  148. syncytiotrophoblast
    invades endometrium and secretes hormones
  149. cotyledon
    maternal parts of placenta (AKA lobes)
  150. lacunae
    • system of intercommunicating channels that permeate syncytiotrophoblast
    • After invasion of superficial decidual capillary walls, lacunae become filled with maternal blood
  151. intervillous space
    As the lacunae join, a complicated labyrinth is formed that is partitioned by these solid cytotrophoblastic columns. The trophoblast-lined labyrinthine channels form the intervillous space
  152. amnion
    membranes facing into sac
  153. chorion
    outer layer of membranes
  154. placental development
    • Day 10-12: blastocyst completely engulfed in myometrium
    • Day 12: trophoblasts touch maternal blood → vulnerability b/c 1st time being affected by maternal substances
    • Trophoblast “invasion” is dampened by maternal protective response- otherwise placenta will overgrow entire uterus- angiogenesis mediated by VEGF and placental GF
    • spiral arteries are remodeled to become straighter to allow increased blood flow into placenta
    • villi initially located over the entire blastocyst surface; later disappear except over the most deeply implanted portion --> placenta
    • maternal arterial blood does not enter the intervillous space until around day 15.
    • In the first trimester, placental growth is more rapid than that of the fetus. But by approximately 17 weeks, placental and fetal weights are approximately equal. By term, weights ~ 1/6 fetus
  155. placental O2
    • similar to level in our veins, but fetal Hgb has higher affinity
    • iron preferentially diverted to fetus--> rare anemia
  156. placental barrier
    • have to cross 5 layers: 
    • (1) the microvillous membrane of the syncytiotrophoblast
    • (2) the syncytiotrophoblast cells,
    • (3) the basal membrane of the syncytiotrophoblast,
    • (4) the connective tissue mesenchyme of the
    • villus
    • (5) the epithelium of the fetal blood vessel

    • freely cross: glucose, AA, lipids, vitamins, minerals, H2o, ions, IgG (passive immunity 4-6 mos)
    • dont cross: IgM (if present, r/t fetal/neonatal infection)
  157. placental hCG
    • supports corpus luteum in early pregnancy
    • → continued progesterone production, but eventually no longer needed and drops to
    • indiscernible level
  158. placental progesterone
    • produced by ovary until ~8wks
    • growth of maternal organs to accommodate pregnancy, prepare breasts. 
    • Maintains quiescant uterus (no contractions until time)
  159. placental estrogen
    • lots!
    • continually increasing as pregnancy progresses, terminating abruptly after delivery.
  160. human placental lactogen
    • fetal growth: prevents maternal cells from taking up glucose → more glucose circulating, transported across placenta to fetus
    • Maternal lipolysis: increased levels of circulating FFA --> energy for maternal metabolism and fetal nutrition. 
    • anti-insulin or "diabetogenic" action: increased maternal insulin levels -->  favors protein synthesis and provides a readily available source of amino acids to the fetus.
    • potent angiogenic hormone: may play an important role in the formation of fetal vasculature
  161. placental CRH
    • early in pregnancy works w/ progesterone to maintain quiet uterus
    • upregulates in late pregnancy → prostoglandin production → labor
    • increases adrenal activity of fetus → streroid hormones → labor
  162. placental growth hormone
    • increases nutrient availability for the fetal-placental unit, promoting lipolysis and also gluconeogenesis.
    • It is also one of the key regulators of maternal insulin-like growth factor 1 (IGF1)
    • concentrations; reduced in cases of
    • intrauterine growth restriction
  163. umbilical cord structure
    • arteries have a lot of muscles → responds to temperature change and clamp down/spasm with delivery to prevent blood loss
    • wharton's jelly:protects vessels from undue pressure
    • seen on ultrasound by 42 days and is well established by 8 to 9 weeks
    • usually inserted near the center of the placenta but may be attached at any point
  164. amniotic fluid
    • sterile!
    • Main sources: amniotic membranes pulling in water from maternal side, and fetal urine
    • composition: Water, Albumin, Nitrogen compounds: urea, uric acid, creatinine,
    • Carbohydrates, Lipids, Electrolytes
    • membranes Held together by collagen: can
    • be broken by collagenase associated w/ ascending infection
  165. previa
    • implantation of the placenta over or near the internal cervical os so that it encroaches on a portion of the dilated cervix. 
    • classified as total, partial, or marginal; sometimes include low lying placenta
  166. abruption
    • separation of a normally implanted placenta before the delivery of the fetus.
    • initiated by hemorrhage into the decidua basalis with formation of a hematoma
    • Possible causes: maternal hypertension, compression or occlusion of the inferior vena cava, circumvallate placenta, or trauma.
    • The incidence of abruptio placentae is markedly increased with maternal cocaine use b/c induce vasoconstriction of placental blood
    • vessels and a sudden elevation in maternal blood pressure.
  167. accreta
    • placental implantation w/ abnormally firm adherence of all or part of the placenta to the myometrium. 
    • Increta: villi invade the myometrium
    • Percreta: penetrate through the myometrial wall
    • Associated with placenta previa, particularly in the presence of a uterine scar, and with significant morbidity including severe hemorrhage, uterine perforation, infection, and hysterectomy.
  168. circumvallate/marginate placenta
    • circumvallate placenta: the area of the chorionic plate is reduced. As chorionic
    • villi invade the decidua, the fetal membranes fold back upon themselves, creating a dense, grayish-white raised ring encircling the central portion of the fetal surface. The fetal vessels forming the cord stop at this ring rather than covering the entire fetal surface of the placenta. 
    • --> increased risk for abruptio placenta 

    Marginate (or circumarginate) placenta: also arise from a chorionic plate that is smaller than the basal plate. In these placentas the white ring composed of the fetal membranes coincides with the margin of the placenta, without the folding back of the membranes seen in circumvallate placentas
  169. succenturiate placenta
    • development of one or more smaller accessory lobes in the membranes attached to the main placenta by fetal vessels. 
    • The accessory lobes may be retained, leading to postpartum hemorrhage or infection. These placentas are often associated with malrotation of the implanting blastocyst with velamentous insertion of the cord.
  170. single uterine artery
    • associated with an increased incidence of fetal
    • cardiovascular and urinary tract anomalies
  171. batteldore placenta
    • insertion of the cord at or within 1.5 cm of the margin of the placenta
    • may be clinically benign but has been linked to preterm labor, fetal distress, and bleeding in labor due to cord compression or vessel rupture.
  172. vellamentous insertion
    • cord inserts into the membranes so that the vessels run between the amnion and chorion before entering into the placenta.
    • More common in multiples
    • may lead to rupture and fetal hemorrhage
    • associated with a high fetal mortality, particularly with vasa praevia

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