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Fetal medicine 1

Question: 1 of 10
The following conditions can be treated by giving medication to the mother:
Fetal supraventricular tachycardia.

Correct

Accelerating surfactant production using antenatal steroids.


Correct
Reducing the risk of kernicterous in Rhesus Disease by giving mother Phenobarbitone.
Incorrect answer selected
Atropine to treat fetal congenital heart block.
Incorrect answer selected
Furosemide to treat fetal hydrops.

Correct

Glucocorticoid therapy given before pre-term delivery accelerates lung maturation and surfactant production
reducing the incidence in severity of RDS and IVH. For optimal effect it needs to be given at least 48 hours
before delivery, but this is often not possible. Digoxin or flucanide can be given to the mother to treat fetal
supraventricular tachycardia. Complete heart block is unresponsive to therapy, and Rhesus immunisation is
best treated with fetal blood transfusions into the umbilical vein. This may be required regularly from about 20
weeks of gestation. More on fetal hydrops here: Fetal hydrops
Copyright 2011 Dr Colin Melville

Question: 2 of 10
The following diagnoses can be reliably made on antenatal ultrasound performed before 20 weeks:
Spina bifida occulta

Incorrect answer selected

Gastroschisis

Correct

Ventricular septal defect

Incorrect answer selected

Gestational age

Correct

Down syndrome

Incorrect answer selected

Gestational age can be reliably estimated if performed before 20 weeks, but after this the margin for error
increases. Multiple pregnancies can be identified.
Up to 70% of major structural abnormalities can be identified, and more detailed scans and specialist centres
arranged.
Fetal growth can now be reliable measured from serial abdominal circumference, bi-parietal diameter and
femur length.
Oligohydraminos and polyhydraminos can also be diagnosed.
Although specialist centres can reliably diagnose major cardiac malformations, VSD can be very difficult to
detect.

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Nuchal fold thickness is being investigated as a possible means of making a diagnosis of Down syndrome, and
results are promising.
Copyright 2011 Dr Colin Melville

Question: 3 of 10
Regarding ultrasound scans of the neonatal head:
Intraventricular haemorrhages occur in 25% of very low birth weight infants.

Correct

Bleeds into the germinal matrix are unlikely to be associated with long term sequelae.

Correct

Most haemorrhages occur in the first 72 hours of life.

Correct

Grade 4 haemorrhages are unlikely to be symptomatic.

Incorrect answer selected

Ischaemic lesions are easily detected in the periventricular area.

Incorrect answer selected

Bleeds occur in about 25% of very low birth weight infants and are relatively easy to see. Ischaemic lesions are
much more difficult to detect, but may be marked by a flare in the periventricular area. Lesions can be graded
I-IV. Grade I means a bleed into the germinal matrix, and grade II is unilateral blood in the lateral ventricle.
Grade III means the changes are bilateral and associated with dilatation of the lateral ventricles, and grade IV
means that there are intracerebral abnormalities associated. Grade IV lesions are the most serious, and are
associated with significant risk of neurodevelopmental problems.
The worst outcomes are associated with bilateral periventricular leucomalacia.
Dilatation of the ventricles is readily detected on ultrasound scan, and the commonest cause is intraventricular
bleed. This may spontaneously regress, arrest or progress causing significant hydrocephalus with tense
fontanelle, suture separation and enlarging head circumference. Fits or other neurological symptoms may occur
at this stage, which is usually treated with a VP shunt.
Copyright 2011 Dr Colin Melville

Question: 4 of 10
The following statements are true regarding smoking in pregnancy:
Smoking assists in maturation of the fetal lung.

Correct

The reduction in birth weight is related to the number of cigarettes smoked per day.

Correct

Maternal smoking may adversely affect testicular function in male children Incorrect answer selected
Dysmorphic facies is a recognised complication.

Incorrect answer selected

The newborn baby may require adjustments in drug dosages because of it.

Incorrect answer selected

Smoking reduces birth weight which may be of critical importance if the baby is born pre-term. On average,
the babies of smokers weigh 170g less than non-smokers, but the reduction in birth weight is related to the
number of cigarettes smoked per day. Smoking is also associated with an increased risk of miscarriage and still
birth. The infant has a greater risk of Sudden Infant Death Syndrome. There is some evidence that maternal

Fetal medicine 3

smoking may adversely affect ovarian function in female children. No dysmorphic syndrome has yet been
described. It may assist in maturing the fetal lung.
Copyright 2011 Dr Colin Melville

Question: 5 of 10
Regarding hyaline membrane disease:
It is caused by deficiency of surfactant production by type 2 respiratory cells.

Correct

The hyaline membrane seen histologically is caused by a protenacious exudate.

Correct

It may be exacerbated by hypoxia, acidosis or hypothermia.

Correct

It occurs in 45% of children born before 28 weeks of completed gestation.


Steroids given antenatally to the mother stimulate surfactant production.

Incorrect answer selected


Correct

Surfactant is a mixture of lipoproteins produced by type 2 respiratory cells. It is excreted by the alveolar
epithelium, and results in a lowering of surface tension so that alveoli can remain patent. The hyaline
membrane on histology is formed by a protenacious exudate. The more preterm the infant the higher the
incidence of RDS, with the majority of those below 28 weeks gestation being affected, though the condition
can still occur rarely in the term infant. Hypoxia, acidosis or hypothermia increase the likelihood of it, and it is
also commoner in the infant of a diabetic mother. Antenatal steroids and exogenous surfactant therapy have
been major advances in its management.
Copyright 2002 Dr Colin Melville

Question: 6 of 10
Concerning blood flow in the fetus:
Blood flows from right to left through the foramen ovale.

Correct

Blood in the ascending aorta has a higher oxygen content than in the descending aorta. Correct
The ductus arteriosus is closed.

Incorrect answer selected

Pulmonary pressure equals systemic pressure.

Incorrect answer selected

The haemoglobin may be 20g/dl.

Correct

Persistence of the fetal circulatory pattern of right-to-left shunting through the patent ductus arteriosus and
foramen ovale after birth is due to an excessively high pulmonary vascular resistance. Fetal pulmonary
vascular resistance is usually elevated relative to fetal systemic or postnatal pulmonary pressure. This fetal
state permits shunting of oxygenated umbilical venous blood to the left atrium (and brain) through the foramen
ovale and bypasses the lungs through the ductus arteriosus to the descending aorta. After birth, pulmonary
vascular resistance normally declines rapidly as a consequence of vasodilatation due to gas filling the lungs, a
rise in postnatal PaO2, a reduction in PCO2, increased pH, and release of vasoactive substances. Normal
haemoglobin range in the first 1-3 days of life is between 14.5-22.5 g/dl.
Copyright 2002 Dr Colin Melville

Fetal medicine 4

Question: 7 of 10
Indications for chorionic villus sampling include:
Suspected Rhesus Disease

Incorrect answer selected

Chromosomal analysis

Correct

Enzyme analysis for inborn error of metabolism

Correct

DNA analysis for Duchenne muscular dystrophy

Correct

Suspected congenital infection

Correct

Chorionic villus sampling has slightly greater rate of fetal wastage than amniocentesis, but does have the
advantage of being possible in the first trimester before fetal movements have started. Indications include
chromosomal analysis, enzyme analysis, DNA analysis, and to obtain samples for PCR diagnosis of congenital
infection.
Copyright 2002 Dr Colin Melville

Question: 8 of 10
Concerning fetal lung development:
Type II pneumocytes are present at 24 weeks gestation.

Correct

Cuboidal cells are capable of gas transfer in utero.


Incorrect answer selected
There is virtually no smooth muscle in the terminal and respiratory bronchioles at 6 months of age.
Correct
The large airways are formed at 16 weeks gestation.
Correct
The adult complement of alveoli are present at birth.

Incorrect answer selected

Lung development proceeds with the budding of bronchi, bronchioles, and successively smaller divisions. By
20-24 wk, primitive alveoli have formed and surfactant production has begun (type II pneumocytes); before
that time, the absence of alveoli renders the lung useless as an organ of gas exchange. Alveolarisation is also
influenced by physical stimuli. Both the stretch by the liquid contained in the fetal lung and the periodic
distension provided by the action of the respiratory muscles during fetal breathing, for instance, appear to be
necessary for the development of the acinus. Their absence when the lungs or chest are compressed (as in the
case of a diaphragmatic hernia or oligohydramnios) or when fetal breathing is abolished (by spinal cord
lesions, for example) results in pulmonary hypoplasia with reduced numbers of alveoli.
Prenatal glucocorticoid therapy decreases the severity of RDS and reduces the incidence of other complications
of prematurity, such as intraventricular haemorrhage, patent ductus arteriosus, pneumothorax, and necrotising
enterocolitis, without affecting neonatal growth, development, lung mechanics or growth, or the incidence of
infection. Prenatal glucocorticoids may act synergistically with postnatal exogenous surfactant therapy. Alveoli
continue to develop up to the age of 8 or so: this is why patients with chronic lung disease tend to survive if
they get through the first two winters.
Copyright 2002 Dr Colin Melville

Fetal medicine 5

Question: 9 of 10
Hydrops fetalis is caused by intrauterine infection with:
Syphilis

Correct

Listeria

Incorrect answer selected

Parvovirus

Correct

Group B streptococcus

Incorrect answer selected

Toxoplasma

Correct

Causes of hydrops include:

IMMUNE: Haematologic: Rh and ABO incompatibility


NON-IMMUNE:
o Infectious: parvovirus, CMV, toxo, syphilis
o CVS: SVT, AV malformation, heart block
o Pulmonary: diaphragmatic hernia, lymphangiectasia
o Tumour: neuroblastoma, haemangioma, teratoma
o Hepatic: hepatitis, cirrhosis, fibrosis
o Renal: nephrosis, prune belly
o GI: atresia, volvulus, CF
o Metabolic: IDM, storage diseases
o Malformations: Arthrogryphosis, Noonan
o Chromosomal: XO, trisomies
o Idiopathic.

Copyright 2002 Dr Colin Melville

Question: 10 of 10
The following maternal conditions can cause disease in the fetus/newborn:
Hyperparathyroidism

Correct

Immune thrombocytopaenic purpura Correct

Myasthenia gravis

Correct

Diabetes mellitus

Correct

Thyrotoxicosis

Correct

Organ failure: Cholestasis, cyanotic heart disease, renal transplant


Immune: Rh/ ABO, Diabetes, Graves, myesthenia gravis, ITP, isoimmune neutropaenia or
thrombocytopaenia
Hormonal: endemic goitre, hyperparathyroidism, obesity
Other: pre-eclampsia, genital herpes, sickle, Drug addiction, PKU, melanoma.

Copyright 2002 Dr Colin Melville

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