Week 3 Repro

Inner cell mass: becomes fetus
Outer trophoblast: develops important endocrine fxns as well as contributing to formation of placenta

Circulatory, respiratory, digestive, renal, some endocrine

Increases its size by 1/3 to 1/2 during pregnancy. Mostly due to hyperplasia of the lactotrope's increased production of PRL

Estrogen and Progesterone

GH: stays about same or decreases
ACTH/TSH: increase some
FSH and LH: fall to low levels

Hyperthyroidism (hCT has some TSH-like activity), Cushing's, DM

Estrogen constricts the isthmus
Progesterone relaxes the isthmus

During follicular phase

Thins and alkalinizes it (facilitates conception).

3 days

Stimulates backward contractions in uterus.

OT, stimulates contractions to propel sperm up

Progesterone

The fact that it is ~10% sialic acid

Syncytiotrophoblast

Maintains corpus luteum; Stimulates Leydig cells in male fetus.

Doubles in ~1d (it doubles every 48 hours during 1st 6 wks). Peaks about 10-12 weeks and then drops rapidly before declining slowly throughout rest of pregnancy.

200x more what teh LH level was during the LH-ovulatory surge.

8d after fertilization (~1-2 days after blastocyst has undergone implantation). Detected in urine after 14 days.

Ectopic pregnancy, threatening abortion

hCS

By facilitated transport

Less than mom's

Maternal

Placental insufficiency

Increases

Corpus luteum (essential for 1st 7-8 weeks of gestation

Progesterone.

Synthesizes pregnenolone and progesterone from cholesterol

Decreases its androgenic potency which is especially important when the fetus is female

Estriol

Placenta + fetal adrenal

Three different estrogens: estriol, estradiol, estrone

Estriol is about 1/80 the potency of estradiol and about 1/7 that of estrone

Estrogen

Progesterone

Relaxin

Parathyroid Hormone-Related Peptide (PTH-rP)

Once labor is initiated. Estrogen has stimulated an increase in oxytocin receptors and distention of uterus may also serve to increase # of oxytocin receptors

Once contractions begin, they reflexively stimulate stronger contractions

They block lactation

25-30 weeks

Colostrum

Antibodies and other factors resulting in healthier babies. Some pediatric specialists recommend that babies are almost exclusively breastfed for the first 6 mos.

Simple diffusion

Facilitated Diffusion

Secondary Active Transport

Active transport (CaATPase)

W/ pregnancy, mom needs an additional 1 gm of iron to produce RBCs (Hb/RBC production increases). Need 600mg for maternal RBC production. 400mg for fetus and placenta RBC production. Need 60mg/day of elemental iron which can be supplied by 300mg of ferrous sulfate.

Increases ~30-40%. Stroke volume increaes initially, HR increases next.

Late systolic and ejection (due to decrease in viscoscity of the mom's blood and increase in stroke volume).

One during diastole

Systolic P dec is small.
Diastolic P dec is modest, then returns towards pre-preg levels

Abnormal

Iron depleted mother may experience iron deficient anemia, preterm labor, late-spontaneous abortion

Both total and ionized calcium levels usually higher in fetal than maternal blood.

1.5L/day of milk or more if nursing twins

Ca in mom's milk will come from either mom's dietary Ca intake or from mom's bones

Increases 30-40%

Decreases: because ventilation increases more than metabolic rate.

PO2 in placental venous blood is ~30 mmHg while the maternal arterial blood is ~100mmHg. This PO2 is adequate for the fetus because high fetal blood flow and high affinity that fetal Hb has for oxygen (ie 70% SO2 at PO2=30mmHg)

Domestic violence

Intimate partner violence

Triangle b/w tension building phase, explosive phase and calm phase

50%

9%

70% for both

Risk of abuse increases w/ each trimester and postpartum

3x greater

When she decides to leave

Murder

Safety: do you feel safe in relationship?
Afraid/Abused-Have you ever been in a relationship where you were threatened, hurt or afraid?
Friends/Family: are your friends or family aware that you have been hurt? Could you tell them and would they be able to give you support?
Emergency plan: do you have a safe place to go and the resources you need in an emergency?

Abuse

No. But if there is a gun or knife that has been used, you have to call police.

Yes, 30% (due to lack of space)

SELF BLAME, not emotionally ready to admit the reality of the situation, fear of failure, shame, fear of rejection, fear reprisal, believe no alternative exists, believe abuse will not occur again, lack of resources

Sexual assault

Rape

Up to 72 hours; can take 2 hours to collect

Safe refuge--not home

Saliva, blood, fingernail scrapings, bed sheets, underclothes, hard surfaces, condoms, dry swabs

TETANUS*, Gonorrhea, chlamydia, wet smear for trich or sperm, bacterial vaginosis, HIV, syphyllis, Hep B, Pregnancy (while waiting for police)

Azithromycin 1gm po (chlamydia) AND Cefiximine 400mg po (gonorrhea).
-If allergy to Azithromycin, then use Doxycycline 100mg BID for 7 days. Allergy to cephalosporins, then Cipro 500mg po

Metronidazole; 2 gm po today

Pen G, Benzathine 2/4 million units IM

3 dose vaccine

Within 72 hours of assault, Levonorgestrel (Plan B) 0.75 mg )(1now and 1 in 12 hours). OCP 0.05/0.03mg 4 tabs now and 4 in 12 hours.
-Also antiemetics (Zofran or Phenergan 1 hr prior to dose).
-Pt needs to sign if they do not want to take it

ALCOHOL*, Benzodiazepines, Gamma-hydroxybutyrate (GHB), Flunitrazepam (Rohypnol), Last 2 drugs cleared in 12 hours

PTSD*, Pregnancy, STDs, HIV, HPV, infertility

Post Traumatic Stress Disorder

Abuse

1) Acute and disorganization phase (lasts days to weeks; irritable, nightmares, etc)
2) Integration and resolution phase

12% (50% of the time it is sexual assault)

Physicians should routinely assess all pregnant women for domestic violence. Clinician should be aware of characteristics of abuse such as bruising, improbable injury, depression, late prenatal care and missed prenatal appts.

Routinely asking about domestic violence

Unintended pregnancy

Therapeutic abortion

Elective abortion

45 states banned abortion. Prohibited under Comstock (anti-obscenity) laws (contraception was also banned)

1/3 of states liberalized abortion laws

Colorado in 1967

1973 (Said right to privacy extends to reproductive health. States cannot limit access to abortion before viability, which is a gray area)

~6.4 annually with 1/4 ending in abortion.

51% intended; 49% unintended

Approximately 1.21 million

1/3

Slow, steady decline

Overall unintended pregnancy rates have stagnated. Unintended prego has inc by 29% among poor women while dec 20% among higher income women.

20's (esp 20-24)

in first 12 weeks (90%)

True

Reasons women have abortions

0.6/100,000 procedures (10x safer than carrying to term)

No

No

2/5: unintended
1/5: end in abortion

40%

46,000 (13% of maternal deaths)

Newer model leads to purely estrogenic activity in some tissues while partially estrogenic/anti-estrogenic activity in others

Beneficial estrogenic actions in select tissues w/ anti-estrogenic action in other tissues (bone, brain, liver breast, endometrium)

Tamoxifen, Toremifene

Prevents CA in high risk women (c/l breast)

Receptor antagonists in breast.
Agonist in bone

Block the binding of estrogen to ER positive cells

Cis has estrogenic activity.
Trans has anti-estrogenic activity (target tissue/gene/species variability)

Its trans-conformation (inhibits proliferation of BC cells and reduces tumor size); (Trans- has anti-estrogenic activity).

Increases disease free and overall survival--treatment lasts up to 5 years

50% response rate in ER+; 70% in ER-/PR-

Anti-resorptive effect on bone (clinical decrease in vertebral and hip fracture)

Decrease

No change in HDL/TH, raises Apo-A1

True

2-3x increased risk of DVT/PE/Stroke; 2x increased risk of endometrial carcinoma via partial agonist effects; "hot flashes." If post-menopausal and has breast CA, will re-introduce menopausal symptoms. Pregnancy category D

Analog of Tamoxifen and has similar pharmacological actiosn. Competitive inhibition of E binding to ER. Promote production of transforming growth factor-beta (TGF-Beta: inhibitory GF)

Toremifene has a slightly greater and more beneficial lipid profile effect (increases HDL)

Prevention and treatment of osteoporosis. Breast CA prophylaxis in high risk pt defined as: at least 1 breast biopsy showing lobular CIS or atypical hyperplasia. 1 or > 1st degree relatives w/ breast CA. 5 yr predicted risk of breast CA>1.66%

Has estrogenic actions on bone. Anti-resorptive effect (increased bone mineral density in lumbar spine, hip and femoral neck). Reduces vertebral fx by 30-50% and increases spinal BMD by 2%. No significant effects on non-vertebral fx.

Has + effects on lipids. Reduces LDL and +/- reduction in TG (no increase in HDL). Shown to reduce coronary events (nonfatal MI, death, hospitalization) in at-risk pt--not in those with existing CVD

Anti-proliferative effect. There is a decreased relative risk over yrs (RRR of up to 75% after 3 yrs vs. placebo; up to 72% after 4 yrs vs. placebo; up to 66% after 8 years vs. placebo).

NO; only invasive

No; no apparent risk of endometrial CA

Hot flashes, leg cramps, increased risk of DVT/PE (yet 30% < tamoxifen). Pregnancy category X.

No, Because it is an endometrial antagonist.

Infertility in anovulatory women. PCOS

Induction of ovulation in women w/ amenorrhea, PCOS, and dysfunctional bleeding w/ anovulatory cycles.

Primarily blocks inhibitory actions of estrogen on hypothalamus GnRH and pituitary gonadotropin release.

Increases it thereby stimulating the ovaries to develop oocyte follicles--customarily dosed b/w cycle--days 5&9.

Estrogen receptors in hypothalamus; prevents normal feedback inhibition and increased release of LH and FSH from pituitary, which stimulates ovulation.

Most significant effect on induction of ovulation in W w/ amenorrhea, PCOS, dysfunctional bleeding w/ anovulatory cycles

Multiple births (3-5%, 99% twins)--multiple simultaneous pregnancies
-Ovarian cysts (ovarian CA w/ prolanged use)
-Ho flashes
-Blurred vision
-Luteal-phase dysfxn (inadequate progesterone production)
-Ovarian enlargement

Metastatic ER+ breast CA in W w/ dz progression after tamoxifen therapy (tamoxifen failure)

Anti-estrogenic on breast CA cells/tumors; Used b/c of bulky side chain, fulvestrant hinders ER dimerization and increased degradation thereby abolishing ER mediated gene transcription (not just a receptor blocker).

Tamoxifen can't hinder ER dimerization and increase degradation thereby abolishing ER mediated gene transcription

Administered as monthly IM depo-injection

Hot flashes; GI distress (N/V); HA/back pain/asthenia

Breast CA

Second leading cause of CA-related death among W--2nd to lung CA

BRCA1, BRCA2

Increasing age*-Greatest risk;
-Also family history, mutations in BRCA1/2, early menarche, nulliparity, late menopause, estrogen use, dietary factors

Sporadic (70-80%: idiopathic, or genes that have not been discovered)

15-20%; No evidence of Mendelian inheritance; May be weaker predisposition. Non-genetic influences: env't/toxins, socioeconomic factors, diet, etc

Ovarian CA (5th leading COD from CA among US W)

~46% (better survival rate in women <62 yo)
-Non-mets 5 yr survival rate ~93%, but early dx is difficult

BRCA1 (70%), BRCA2 (20%), HNPCC (2%), Other single genes (8%)

Theya re tumor suppressor genes; Different types do cell division, controlling genes, DNA repair genes, apoptotic genes

Chr17

-Ring-finger domain @ N-terminus
-BRCT domatin at the C-terminus

In most tissues during G1 through S, may be involved in DNA repair during homologous recombination. Can activate p21 CDK inhibitor (growth suppressor at G1/S checkpoint)

Chr 13

Twice as large as BRCA1; No recognizable motifs

BRCA1 or 2

BRCA2

Breast CA 50-85% (often early age onset), 2nd primary breast CA (40-60%), Ovarian CA (15-45%), Possible inc risk for other CA: prostate, colon.

Similar but different from BRCA1. Breast CA 50%-85%, Ovarian CA 10-20%, Male breast CA (6%). Inc risk of prostate, laryngeal, pancreatic CAs

Incomplete penetrance (Variable inheritance)

True (more genes, more risk)

The longer you live w/ mutations, more likely to get CA (BRCA1>BRCA2)

Ashkenazi Jewish population. Account for most of the BRCA1 and BRCA2 breast CA

BRCA2

ID high risk individuals. ID non-carriers in families w/ known mutations=dec risk. Allows early detection and prevention strategies. May relieve anxiety.

Does not detect all mutations, continued risk of sporadic CA, may result in psychosocial or economic harm.

BRCA1: 17q21
BRCA2: 13q12.3

Younger age of onset in BRCA1 than BRCA2

p53

Breast CA< soft tissue sarcoma, leukemia, osteosarcoma, melanoma, colon CA, pancreatic CA, adrenal cortex CA, brain CA--has a lot of different types of CA in same family at young ages

90% for W, 70% for M; Breast CA: most frequent CA in adults; Bone and soft tissue sarcomas are MC in kids. Other CA: sarcoma, brain, adrenocortical, leukemia and other early onset CA

A tumor suppressor: the last stop for a gene before the cell goes into uncontrolled cell cycle replication and growth.

p53 activated, p53 ptn binds to DNA, upregulates transcriptional target ptns-p21 (CDK inhib) and GADD45 (DNA repair), p21 causes cell to arrest in G1 until successful repair occurs. If repair doesn't occur, GADD45 recognizes that and induces apoptosis along w/ BAX

Li-Fraumeni Syndrome

May be later because lack of breast development (protective)

Cowden Syndrome

Macrocephaly, trichilemmomas (mimic basal cell CA or wart), papillomatous papules by late 20s. Present w/ warts or facial papilloid. Hyperkeratosis. Nasal polyps. Thyroid abnormalities, fibrocystic breast and uterine dz, GI hamartomas, early onset uterine leiomyomata, macrocephaly, mental retardation

in any organ

AD

PTEN on Chr10

Phospholipid phosphatase (tumor suppressor gene). Mutated in Cowden Syndrome

Loss of fxn--no dephosphorylation, PIP 3 does NOT get turned back to PIP2--constitutive upregulation of PKB/AKT oncogenes--> accelerate/uncontrolled cell growth (tumors)

Breast, thyroid, uterine

Stimulus binds receptor, activates P13 kinase, P13 kinase phosphorylates PIP2 to PIP3 (phosphatidylinositol 3,4,5 triphosphate, pathways actiates, PIP3 lipid signaling molecule--> PTEN dephosphorylates PIP3 to PIP2 to control growth pathway*

Breast (25-50% increase risk) and follicular thyroid CA (~10%)

Lynch Syndrome

Lynch I: Rt sided predominance, multiple primary tumors
Lynch II: 1+ extracolonic colorectal CA< particularly endometrial carcinoma, followed by carcinoma of the ovary, small bowel, stomach and pancreas and transitional cell carcinoma of the ureter and renal pelvis

CA of stomach, small intestine, liver, gallbladder ducts, upper urinary tract, brain, skin and prostate. Women w/ this also have high risk of endometrium and ovarian CA

MLH1, MSH2, MSH6, PMS2 genes (w/ any of these there is an inc risk of CA bc they are tumor suppressor gnes)

DNA repair genes (mismatch repair)--microsatellite instability

Dinucleotide repeats: stable repeats can be polymorphic (CA12, CA14, CA16 are used as markers for forensics)

Genes that say "cell you're going to die" when p21 and GADD45 fail.

A10 repeat--if there is a frameshift and inc #, inc risk fo HNPCC which are associated w/ breast cancer

Fragile X syndrome, Huntington's (can occur in promoter, intron and exon regions)

Accelerates involution of uterus postpartum

Maternal antibodies in breast milk. Immunoglobin A (IgA) provides protection to infant's gut. Passive immunity from maternal lymphocytes

E, P, hCT, cortisol, insulin, prolactin, placental lactogen

Drop in placental hormones (esp. estrogen). Prior to delivery these hormones alter lactogenic effect of prolactin.

The secretion of prolactin and oxytocin- results in contraction of myoepithelial cells in the alveoli and milk ducts

Principle hormone for the synthesis of milk and the maintenance of lactation. Released from the AP as well as mammary gland

Responsible for the release of stored milk (let down). Secreted from the post pituitary by sensory stimulation from the nipple-areola complex

Colostrum is secreted: made of proteins, fat and minerals. Contains secretory IgA

Colostrum is replaced by mature milk: content varies w/ mother's nutrition and gestational age at delivery

Proteins, lactose,w ater, fat

Casien, lactalbumin, beta-lactoglobulin (not found in formula)

~1-2 ml/g of breast tissue/day

Constant for the first 6mos of lactation. Not stimulated as much bc baby storing food and sleeping through night

Avg q 2-3 hours. Depends on age of infant, varies infant to infant.

Mastitis

Staph aureus. Yeast is also very common and hard to treat. Pts c/o "stinging sensation."

Diflucan (also will need to inspect for thrush). Rx: penicillinase-resistant antibiotic like dicloxacilin 7-10 days. May result in breast abscess that requries surgical drainage. Do not need to discontinue breastfeeding! Discontinuing would leave milk stagnant, which puts more pressure on breast.

Inc frequency or duration of feedings, inc fluid intake, herbal meds like fenugreek, other meds like reglan (metoclopramide), seek help from lactation consultant. Intranasal oxytocin (for let down probs like stress)

NO. Use tight fitting bra, analgesics such as Tylenol or Motrin. Ice for discomfort--painful for 24-48 hours. Avoid stimulation of breast

The process of cessation of breastfeeding. Timing varies based on experience, desire and infant. After weaning, breast involutes and returns to a pre-pregnancy state (meaning it won't lactate, not appearance of breast).

Casien, lactalbumin, beta-lactoglobulin (not found in formula)

~1-2 ml/g of breast tissue/day

Constant for the first 6mos of lactation. Not stimulated as much bc baby storing food and sleeping through night

Avg q 2-3 hours. Depends on age of infant, varies infant to infant.

Mastitis

Staph aureus. Yeast is also very common and hard to treat. Pts c/o "stinging sensation."

Diflucan (also will need to inspect for thrush). Rx: penicillinase-resistant antibiotic like dicloxacilin 7-10 days. May result in breast abscess that requries surgical drainage. Do not need to discontinue breastfeeding! Discontinuing would leave milk stagnant, which puts more pressure on breast.

Inc frequency or duration of feedings, inc fluid intake, herbal meds like fenugreek, other meds like reglan (metoclopramide), seek help from lactation consultant. Intranasal oxytocin (for let down probs like stress)

NO. Use tight fitting bra, analgesics such as Tylenol or Motrin. Ice for discomfort--painful for 24-48 hours. Avoid stimulation of breast

The process of cessation of breastfeeding. Timing varies based on experience, desire and infant. After weaning, breast involutes and returns to a pre-pregnancy state (meaning it won't lactate, not appearance of breast).

Maternal dose, rate of maternal clearance, physiochemical properties of drug, composition of breast milk (fat and protein content), gestational age of infant

Sedation

no effect

Platelet dysfunction

Sedation and dec suckling

May alter gut flora, cause allergy or interfere w/ infection workup (avoid doxycycline and fluoroquinolone)

nodular goiter

No effect

No, but it may lead to earlier detection.

Examine w/ arms up and down, palpate for nodes (supraclavicular and axillary)

Examine w/ arms up and down, palpate of nodes (supraclavicular and axillary)

Right after period bc less tender and else likely to find cycle induced cysts. Look for contour and size changes.

At least annually

Contour, shape and symmetry, skin and nipple retraction.

Done w/ flat of hand, examine axillary and supraclavicular regions of lymphadenopathy, nipple for discharge

Might not want to check nipples b/c could inc. PRL level

Can be from old biopsy of CA, ulcerations (carcinoma), lesions, nipple discharge (bloody--trauma, breast-feeding, CA)
-Bloody discharge is always abnormal until proven otherwise
-Describe findings based on quadrants

Asymptomatic and symptomatic women

Routine screening begin at 40 y/o (could screen earlier if family hx or high risks)

Calcifications (need to watch + repeat in 6 mo OR biopsy), densities/nodes

Particularly beneficial in women <30y.o.

No. Do if something palpated or if mammogram is inconclusive.

Solid mass shows shadowing where rays can't penetrate. Solid masses are more worrisome.

Ultrasound

It is a useful adjunct but is expensive. The benefits are that it improves staging and treatment planning, enhances evaluation of augmented breasts, better for detection of recurrences. improves screening for those considered high risk, expensive, so only for special circumstances.

Aspirate of palpable mass; can be done in outpt setting/now usually surgeons. Can use US guidance. Smears are made of aspirate to view cytology.

Should not be used if there is clinical or mammographic evidence of malignancy

If either too deep for others OR for removal: excisional for small masses, incisional for large masses. Can be outpt w/ local or inpt w/ general anesthesia. Indicated for woman with clinically benign appearing lesion but (+) personal/FH of equivocal finding on mammo or FNA

-Suspicious mass that persists through a menstrual cycle
-Cystic mass that doesn't completely resolve w/ aspiration or contains blood fluid
-Spontaneous serous or seroanguineous nipple discharge

Fibroadenoma

Fibrous and glandular tissue

Women 15-25 yo (MC breast tumor <35yo)

Solitary, well circumscribed, freely mobile, usually non-tender.

Can stimulate growth; estrogen increases cause growth (prego, period)

Dark, but shadowing bc its solid

Rubbery orange

Excised typically when reach 2-4 cm (for cosmetic purposes--destroys breast architecture)
-If >15cm then have malignant potential and should be excised
-Could do a FNA

Intraductal papillomas

Within the lactiferous ducts of the breasts

Discovered by bloody, serous or turbid nipple discharge. Rarely found on exam bc typically not big enough to be picked up

Use mamogram and cytology to obtain dx.

Floating in duct

Excision of lesion and involved duct

Galactocele

usually due to some form of ductal occlusion-inflammation hyperplasia or neoplasm

Mastitis or abscess

Needle aspiration

Hyperplasia (formerly known as fibrocystic disease)

No

May be present in ~50% of women. Can involve any/all breast tissues

Increased risk of malignancy, so may biopsy/inc mammogram protocols

Thought to be due to decreased progesterone and increase in estrogen. Estrogen promotes growth of ducts and periductal stroma. Improve during pregnancy due to predominance of progesterone.

Usually bilateral and multiple.

Characterized by pain and tenderness. Tends to be cyclic (pre-menstrually). Exquisite breast pain right before onset of period.

Depends on age, severity of sx and risk of developing breast CA. May need imaging w/ US or mammo if suspicious. Cysts may be aspirated to relieve pain

Avoid caffeine. Low fat diet. Good support bra. Evening of primrose oil (not sure why it works, but it does). OC's may improve cyclic pain (don't get the estrogen inc.), NSAIDs

Yes.

Acceleration of recovery. Oxytocin's action on uterine involution (helps w/ bleeding).
Reduction in maternal response to stress (neuroendocrine pepties, oxytocin and prolactin, produce positive impact on social behaviors and maternal-infant bonding. Weight loss (a significant effect if BF continued). Prolongation of postpartum anovulation. Not a reliable method of BC.

Cancer: breast and ovarian cancer. Osteoporosis: maybe-more studies needed. Cardiovascular disease: studies show that must be significant time (at least 3 mo/child...up to 2 years in total time breastfeeding).

Family: approx $1000more/yr
Societal: - decrease medical costs of $331/child in acute costs; up to 20% reduction in medical costs over childhood; decrease parental work absences--unable to calculate. If all mothers who could breastfeed did, $13 billion/yr could be saved. 911 deaths per year avoided

Development of NEC (Necrotizing enterocolitis) in animal studies

IgA and IgG

Increases rate of gastric emptying (inc function), incrase intestinal lactase activity in the preemie. Decrease intestinal permeability, especially in the preemie

Decreased incidence of otitis media. Other respiratory infections.

Decreases their incidence

Decreases the incidence

Decreases incidence

Through middle school

Supplemental Vitamin D and probabl ysupplemental Fe (Vit D-400 units/day) b/c stress on mom has depleted stores and don't expose ourselves to enough sun

NO

Alignment, Areolar Grasp, Areolar Compression, Audible Swallowing, Total Seal Around Breast

Infant flexed at neck and hips, head level w/ breast; ear, shoulder, hip aligned. Mom comfy.

A suction issue

Nutritive

Incorrect

Correct

Flat or inverted nipples, pre-term (sometimes)

Poor stimulation (like if using a shield), if baby nursing great and no risk factors, don't pump. Risk factors preterm, poor nurser, breast surgery (esp reduction), hormones (ex is thyroid meds- may not have enough milk supply)

Not nursing at all 6-8 hrs, low blood sugar, breast reductions, weight loss >10% or approaching. If PRE-TERM, weak suck, mom sick, etc

1st day=7mL (stomach marble size)
2nd day=10mL (shooter marble)
3rd day= 15 ml (maybe even 25-30mL)
4th = 20mL (hopefully milk in by this time)

That the mom chose to do this even though she knew it might it might interfere w/ successful breast feeding

Provides baby with the colostrum, prevents painful engorgement, stimulate uterine contractions and lessens chance of hemorrhage, prevents newborn jaundice, gives baby practice nursing before the mom's breasts became full, stimulates mom's milk to increase more quickly

Birth-2 hrs: alert and eager

2-20 hours: light and deep sleep
20-24 hours: increased wakefulness

In the delivery room. The mom and baby will thank you, as will the lactation team

Arms bent, hands fisted; hands at face and head; sucking on hand, arm, wrist; open mouth; tongue out, mouth motions; head bobbing; trying to assume nursing positions

Within 2 days post-discharge (re-gain birth weight by 10 days-2 weeks)

Talk to infant, unswaddle, undress infant, change diaper, stroke or massage extremities and back, sit-ups, apply cool cloth to face, rub feet, roll kid back and forth and lift up-takes 4-5x; takes 3-45 sec to wake up infants

Cradle, Cross Cradle, Football, Side-sitting, side lying

5-10%.

Void/stool records

Urine w/ uric acid crystals (brick dust).

Dehydration

Day 1: 1-2 wet diapers
Day 2: 2-3 wet diapers
Day 3: 3-4 wet diapers
Day 4: 3-4 wet diapers
Day 5: 6 or more, MOST CRITICAL

Dark meconium (want out as quick as possible) or scant vol of stools. Should have transitional stools by the third day. By 4-5th day of life, the BM should be yellow with small curds--"mustard poops"; sweet smelling

6+ voids/24 hours
4+ stools/24 hours
Content after feeds
Wakes to be fed (every 3 hours or so)

8x in 24 hours

Yes

Fever, listlessness, skin losing its resiliency, weak cry

No, because they never express MHC class II Ag's

No, so no activation of CD8+ cells

Maternal NK cells

No, they are not. This is because the villous torphoblasts express a soluble form of HLA-G (sHLA-G). sHLA-G induces activated T cells to undergo apoptosis and downregulate NK lytic activity

Immune privileged sites such as thymus and palcenta

Genes HLA-A, B, and C are called classic (HLA-Ia) because they are the main actors in the immunologic response

Genes HLA-E, F and G

Placental immunosupression

IDO (indoleamine 2,3-dioxygenase)

Degrades and depletes it, which inhibits the growth of viruses, bacteria and parasites, because tryptophan is the least available and most important essential aa for growth

Many things including decreased proliferation of T cells and prevention of fetal rejection

Express CTLA-4-> interact w/ T-cells -> activate IDO -> metabolize tryptophan, T-cells are suppressed, and immunoregulation is achieved via apoptosis

Th2 cytokines (IL-10 and TGF-beta) and PGE-2.

Express the progesterone receptor (rPg), which resting cells do not.

RTF (Regeneration and Tolerance Factor)
PIBF (Progesterone Induced Blocking Factor)

aka TJ6; a cell-surface protein ID'ed in trophoblasts of early pacentas (7-9 weeks). It is cleaved to ield a soluble fragment which up-regulates teh production of IL-10 and interferes w/ IL-2 signaling (which is normally required for Th1 response and proliferation of T-cells), shifting the balance towards a Th2 T-cell response

It exerts a substantial anti-abortive activity: inhibits cytotoxicity of NK cells by blocking their degranulation and perforin release; also favors Th2 response :stimulates IL-3, IL-4 and IL-10; inhibits interferon, TNF-alpha, and IL-2. In B cells, it induces production of non-cytotoxic Abs which do not fix complement

RU 486/Mifepristone (RU 486 induced abortion can be thought of as an immuno-endocrine event)

Complement fixing IgG-2 cytotoxic Abs

Kill it by mechanism of complement dependent cytotoxicity

Complement regulatory proteins

MCP: cofactor for the inactivation of C3b and C4b

Decay accelerating factor. It prevents the assembly of the C3bBb complex (the C3-convertase of the alternative pathway), or accelerates the disassembly of preformed convertase

Intrinsic resistance; also express Fas ligand (FasL), which normally induces T-cell apoptosis upon immune withdrawal.

Abortion (TNF-alpha, TNF-gamma)

Uterine Th2 cytokines (Il-3, Il-4, IL-10)

Th2

Before maternal allorecognition occurs

Abortion: Th1=IL-2, IL-12, IFN-gamma, TNF
Pregnancy: Th2= IL-3, 4, 5, 6, 10, 13

Immune suppression and promotes a Th2-like state at the time of implantation in the uterus.

Cytokines in the seminal fluid such as GM-CSF

Intense influx of activated macrophages in teh post-coital uterus, by inflammatory cytokines such as IL-1, IFN-gamma, and TNF-alpha. This low intensity inflammatory response is then down-regulated by day 3.5 post-coitum

The expression of adhesion molecules on both the pre-implantation blastocyst and in the uterus, which facilitates embryo adhesion, attachment, and invasion. They also induce embryonic production of enzymes such as matrix metalloproteases, which are required for penetration of the stroma.

Anti-sperm Abs (ASAs), which block binding of sperm to the zona pellucida and can be produced by both genders

9-36% (male/autoantigenic=8-21%, female/isoantigenic=6-23%)

Invading pathogens, but should not attack sperm cells or the developing embryo. Protects against infectious agents. Protects establishment and maintenance of pregnancy. Acts adversely on fertility by generating ASAs.

No, all immune mechanisms are there, but work in unique ways; has all components of mucosal immunity=secretory component, IgA, IgG

No, both are primarily of the IgA and IgG-4 isotypes

Complement activation and sperm damage may result

Can interfere via various mechanisms: inhibition of sperm migration into/through the cervical canal, complement-dependent damage (IgG-3) of sperm membrane damage, phagocytosis of Ab-bound sperm by phagocytic cell (IgA, IgG), pregnant women w/ ASAs may have higher rate of spontaneous abortion

Macrophages and DC's

They might become "innocent bystanders." Women w/ PID have high incidence of ASAs

Because of a deficiency of one or more of the immunosuppressive factors in the partner's semen.

After exposure to sperm in both fertile and infertile women.

ASAs elicit the production of anti-idiotypic Abs which neutralize the ASA response

Anti-idiotypic AB production is weak/absent

An Ab that binds to the Ag-combining site of another Ab to either suppress or enhance the immune response, in this case essentially neutralizing Abs

1) An inherent lack of anti-idiotypic AB response to the ASA production
2) A hyperimmunization w/ sperm Ags as a concurrent event w/ pre-existing infection

In the early stages of development and sperm cells are not formed until puberty. Thus, sperm-specific Ags are NOT recognized as "self" by the adult immune system-> an immune response can be generated against them.

Sertoli cell tight junctions (immune-privileged site)

ASA

Only after ejaculation

1) Immunosuppressive therapies
2) Assisted reproductive technologies
3) Lab techniques

MC= corticosteroids; Increase in pregnancy rates and decrease in Ab titers with steroid therapy, weigh benefit/SE's

IUI: modest increase; Ovarian stimulation: better results; IVF: substantial improvement in helping transport problems, but does NOT overcome Ab0induced fertilization defects; IVF w/ intracytoplasmic sperm injection (ICSI): reserved for severe male factor infertility or couples who have failed IVF

Methods to prevent binding or to separate Ab sperm: recombinant soluble FA-1 Ag (increases acrosome rxn rate), immuno-adsorption w/ FA-1 increases Ab-free swimming sperm, 78% improvement after FA-1 adsorption, may have clinical applications in treatment of immuno-infertile men

Seminal plasma (PGs, TGF-beta, large molecules, cytokines), sperm surface molecules (anti-complement, IgA), idiotypic Ab network, immune suppressor cells in tract

Infectious agents, inflammatory cells, cytokines in semen, infection, inflammation, trauma in tract, decreased immunosuppressive factors in semen, ASA sperm activation of macrophages and immune cells, immune system deficiencies (lack of idiotypic Abs, lack of suppressor T-cell response)

15-20 lobes, varying # of ducts/lobules surrounded by CT

~30 ductules; also there are acini

A lactiferous duct that goes to the nipple.

Fat and CT stroma

Because may be missing imaging of tissue

Yes, esp in younger patients. They can be followed and/or removed w/o going into surgery

Annually after the age of 40

MLO and CC (Med to lat oblique and cranial-caudal). Make sure to see m and margins of breast, contour. Also ensure that the edges are not burned out

Low dose radiation/ low cost/ readily available

Look at the breasts side by side for parenchymal layout--thickest at upper and lateral portions

If requested by mammogram findings (lesion seen). Not a screening tool.

Ultrasound

No

Implant rupture. Good for implants (do not have to inject dye). Help dx cancer, esp high risk pts

How the dye is taken up in a lesion. CA has high vasc and break down of membrane. Dye rushes in quickly and out quickly vs fibroma where the dye does not leak out.

Scar appears like a mass and should not enhance after 1 year. If it does, biopsy it.

In axillary region and along the normal developmental nipple line extending in animals from the axilla along the chest to the abd, rarely attach to an extra nipple

Fibrocystic breast disease

Cyst formation, fibrosis, adenosis

Adenosis, sclerosis adenosis, apocrine metaplasia, cyst formation with or without rupture, ductal ectasia

Tx w/ simple aspiration, but DO NOT aspirate w/o imaging first (if try to aspirate and nothing comes out--> solid).

Lobulated, well circumcised, smooth margins (>75%); Simple: anochoic (no shadows), thin walled, no lobulations. Non-simple: internal grey=debris or hemorrhage

Thin and smooth walled, have no filling defects/irregularities. Ductal ectasia is common.

Plasma cell mastitis=benign

Dense calcification oriented along the breast ducts and pointing at the nipple.

Coarse

Fat necrosis

Fibroadenoma

Terminal ductal lobular unit due to localized hypertrophy

Single or multiple and can be of any size, may resemble LN

Breast ductules adn stromal tissue, may undergo adnenosis or hyperplasia

Fibroadenoma occuring in adolescents, can grow rapidly (cause a lot of problems)

>8cm- can remove surgically or may tx with the vacuum and mammotome, may come back esp in younger pts--can have a phyllodes tumor hiding w/in it so best to remove

May not need to remove, but may remove through a needle; most are between 1-2.5cm

No

Different shape and sizes, may resemble LN's, Hypoechoic, smooth margins, through transmission, solid, may have a lot of debris w/ a lot of echos w/in them; solid, firm and mobile on palpation

Oval/lobular mass w/ well-defined margins. With age, may become sclerotic and contain peripheral popcorn-like calcifications, eventually may become replaced by calcification

Oval, well-marginated homogenous masses. Wider than tall=indicates benign; like elongated since its not growing to skin or wall. May have gentle lobulations. HYPOechoic.

Phyllodes Tumor

No.
Mammo: dense round/oval, lobulated, well-circumscribed mass
US: well-marginated heterogenous mass which may contain cystic spaces; can hide masses

<1% of all breast cancers

Gynecomastia

As subareolar glandular tissue: may be u/l or b/l, symmetric or asymmetric

Benign gynecomastia= abnormal proliferation of benign ducts and supporting tissue which can cause subareolar mass, enlargement, pain

Yes in early stage if the cause is corrected, however it may progress to stromal fibrosis

Mammo

Neonates (maternal estrogens crossing the placenta), Adolescent boys (1 yr after the onset of puberty due to high estradiol), older men (decreasing testosterone levels)

Lipoma

Intramammary LN

Forms a fibrous capsule around it; contains all the fluid so can rupture the implant and the fibrous capsule will contains the fluid.

Intracapsular rupture. Surgically remove.

Linear lines w/in implant; Snaky lines seen w/ rupture of implant= "Linguine Sign"

Extracapsular rupture

Implant fold: do not call these ruptures

Superficial ducts

yes, it is common. Can see a shadow on mamow, confirmed w/ ultrasound. Can see a duct leading all the way to a small mass that's inside the duct; can be benign (most) or malignant, may will cause a nipple discharge, tx is removal via needle biopsy

Mostly benign, do not biopsy every single one. Benign-round, ovoid, coarse appearance, dense, primarily benign features

Lobulation

Stellate finding in breast

Calcifications of breast on imaging

Invasive ductal carcinoma

Infiltrating ductal carcinoma

Mucinous (colloid) adenocarcinoma

Ductal carcinomas in situ

Post biopsy scar

Needle localization for open biopsy

Breast CA

True

Being female (1:8 women in 90 year life span)

Clinical breast exam x3 years from 20-30, yearly at 40yo

Biopsy

Infiltrating ductal carcinoma

Gets a mammogram and then US immediately

Irregular, ill-defined borders, projections

Bad

Drying, Warmth, Clearing airways

Is the infant full term? Is the infant crying or breathing comfortably? Does the infant have good muscle tone?

Oxygen, positive pressure ventilation, chest compressions, meds (ie epinephrine)

Heart rate, respiratory effort, muscle tone, reflex irritability, color

between 7-10

Generally 4-6 hrs, temp 97.7-99.5, RR 40-60bpm, HR 120-160, pink color and good tone

PE, feedings, Hep B vaccine, Cardiac screening, Vit K IM, Eye care (prevent GC), Erythromycine 0.5% ointment

Hearing loss, screen for metabolic and genetic disorders (PKU, congenital hypothyroidism, galactosemia, toxoplasmosis and hemoglobinopathies, critical congenital heart disease

Early and often; esp. important in IDM, small, LGA, 7% or greater weight loss demands close follow-up (up to 10% is acceptable in most situations). Birth weight regained by 10-14 days.

Hypothermia, jitteriness, tremors, hypotonia, irritability, lethargy, stupor, apnea, poor feedings, seizures

Values above 25mg%; Can result in BIND (Bilirubin-induced neurologic dysfunction and/or kernicterus)

62 hours after initial discharge. Jaundice is by far the most frequent diagnosis (92%) other reasons include feeding problems, dehydration, and/or associated electrolyte abnormalities. Most readmissions are first time moms, older moms (>30), Asian or Pacific Islander ancestry, maternal diabetes, PIH

Respirations due to chest wall being so compliant, but without other signs of distress is acceptable and subsides in 4-5 hours

Retractions; these are not a normal finding

Grunting; this is very significant.
Also might find "singing." These are to keep the airways open.

Meconium aspiration, air trapping or TTN/"wet lung", cardiomegaly, pneumothorax

Diaphragmatic lesions: Paralysis (dificult delivery-brachial plexus injury, congenital rare), hernia-true life threatening emergency

7 or >

Flat

Large or small kids, push cord blood into baby=increase Hct=slugging;
Also IDM, SGA, LGA

Early passage of meconium

Cold stress, acidosis, infection

Acrocyanosis. Normal for first 24 hours- due to vasoconstriction as they are trying to learn how to maintain body temp. Closely assoc w/ cool surroundings. Perioral changes seen w/ sucking/feedings

Central cyanosis; persisting after 1st few mins of life is always abnormal-think cardiac dz/pulmonary dz

Port Wine Stains (Sturge-Weber, Klippel-Trenaunay), Salmon patches (Angel Kisses (Nevus flammeus, stork bite), Cafe au late

Greenish

May be the result of the infant being cold stress or an indicator of significant systemic illness. If warm and stays, worrisome, think cardiac or acidosis due to infection.

No... Think of stuff below and that twins could have had ignificant differences in cord blood. Poor cardiac output, asphyxia, severe anemia/anemia-very pale, acidosis, subcutaneous edema

Most often indicates severe acidosis in the newborn and often a poor outcome; seen in severe infections and cardiac disease w/ poor perfusion of tissue

Ballard scale: development progresses in a caudocephalic manner (foot to head)

28: little tone
32: LE tone develops resulting in flexion of hips and knees
36: UE and LE tone is apparent, but strong flexor tone of legs exceeds early flexor tone of arms

Hold all four extremities off bed while in supine position/at rest. Hands of term newborn are open periodically, but generally are closed (fisted) w/ the thumb adducted and folded.

Less

Side that does not droop

CN VII

Mobius Sequence (congenital absence of CN VI and VII nuclei)

Illness, respiratory depression (maternal pain meds), or CNS disturbance; infants w/ CNS/head trauma often exhibit a "high pitched" cry (scary)

Over zealous suctioning at delivery, hypocalcemia (rare), airway anomalies

Vascular ring or web (from pressure on airway--rare), Vocal cord paralysis or laryngomalasia or tracheomalasia--most common)

10mm diameter;
Total eye diameter is 17mm in the newborn

Trisomy-13

Congenital glaucoma (milky eyes)

Medial to lateral. Downs is upward; Treacher Collins/FAS/Apert/DiGeorge all have slant downward (medial canthus to lateral_. Many syndromes including Trisomy 13 and Apert have hypertolerorism.

RANDOM and at times disconjugate gaze. Should be gone by 4mos

3 weeks

At about 30 wks gestation, but may not be consistently seen until 35 weeks gestation.

Evaluated ot insure lack of opacity of the lens and cornea and to look for intraocular mass (retinoblastoma). In whites the reflex is red. Darker skinned infants, teh redreflex may be more of a pearly gray color. Finding a "white" red reflex indicates pathology (tumor, trauma, retinopathy of prematurity) and needs and urgent referral

Most have "blue" iris coloration, but in some darker skinned infants, the iris color may just be "dark," generally brown-dark brown.

95%

100-160

Legs is slightly higher than arms. Pulse pressure 25-30mmHg in term & 15-25 mmHg in preterm

No, because most babies have murmurs in the newborn period, most are transient and innocent.

Typically single and accentuated shortly after delivery (increased flow across AV valve) and w/ lesions that increase this flow (ie ASD)

At the upper left sternal border and is normally split--listen for the split (absence can mean pathology): aortic atresia, pulmonary atresia, truncus arteriosus, transposition of the great vessels (due to position).
Widely split S2 (ASD, total anomalous venous return)

A narrow split, but accentuated S2

Deserve a further evaluation

A ductal dependent lesion (coarctation of the aorta is most common), tricuspid atresia or pulmonary atresia

Stridor (narrowing), crepitance (secretions), rales (atelectasis/pneumonia-generally end of inspiration)

Diaphragmatic hernia and in SGA infants

Proximal obstruction or atretic lesion

Ascites (hydrops), Meconium ileus, Intrauterine midgut volvulus

W/ legs flexas as teh infant is sucking (pacified or gloved finger). Begin in lower abdomen, press long enough to allow infant to realx.

Result of hydronephrosis or cystic kidney disease--MC abdominal mass found in newborns

Liver: 1-3 cm below the RCM, with the left lobe extending across the midline. Smooth edge (normally), Soft;
Spleen should not be palpable (should be considered enlarged if palpable--infection/hematopoeisis)

Normally 3 vessels (2 arteries, 1 vein). A single artery is most often a normal variant. A single artery accompanied by any other abnormal (minor or major) is of concern; some feel teh history of a "short" cord may be related to syndromes (Downs)

Cephalohematoma (sub-periosteal blood extending to bone/doesn't pass midline) occurs in 1-2% of deliveries

Caput Succadaneum

Subgaleal hemorrhage
(very significant amt of blood loss is possible, enlarges after birth, crosses suture lines, can cover entire scalp and extend into the neck)

Scalp, skull, CNS abnormalities

Ectodermal defects

Frontal--> occipital

Tends to be familial; most comonly seen in teh saggital suture (dolichocephaly-keel head*)-lethal in femals?

Closure

Flats head common bc back is the best for baby to lay

Saggital suture most common, now thought to be due to relative intrauterine Vitamin D deficiency

Anterior (large variations can be concerning--associated w/ thyroid fxn/Calcium levels)

Listen to the head--over hte temporal regions and the anterior fontanelle (bruit-*AV-malformation)

Posterior rotation. If normal, the top will be in line w/ the eye

Being misshapen secondary to birthing or intrauterine positioning; If you suspect or find evidence of septal deviation, call ENT for eval/tx. Most often, just soft tissue swelling, which resolves in a few days

Fetal alcohol syndrome

Trisomy 13

Achondroplasia

Seckel syndrome (extreme short stature, large nasal bridge, microcephaly)

Mucus, edema (from well intentioned suctioning), real anatomical (tumor, encephalocele, Choanal atresia)

CHARGE syndrome: Coloboma, Heart defect, Atresia choanne, Retarded growth/development, Genital abnormalities, Ear abnormalities)

Defect of iris, keyhole looking; defect of eyelid

Pierre-Robins sequence

Epstein Pearls (epithelial cysts); Yes, they are normal

Hard palate bc tend to have floppy palates

Turner's syndrome (XO) and Noonan Syndrome

Trisomy-21 (Down's)

Cystic hygroma (lymphangioma), which is composed of dilated lymphatics. Most commonly lateral/posterior to SCM muscle

Is the trachea in midline? Is the thyroid enlarged or is there a medial neck mass? Is there a lateral neck mass?

LN up to 12mm are found in about 25% of healthy newborns. MC site is in teh inguinal area. Cervical nodes are not unusual. Can be related to congenital infections. Supraclavicular nodes are never considered normal.

Asymmetrical startle or Moro reflex- one hand will not elevate as high as other when startled.

Pectus excavatum (funnel); Pectus carinatum (pigeon breast)

When kids produce milk (white dot on nipple), may occur especially w/ repeated palpation so don't try ot milk them down.

C4, C5, C6, C7 (Arm extended and internal rotation=waiter's tip position). Palmar grasp is present. Can be just from stretching of nerve roots and can disappear (if doesn't in 3 weeks, then it won't)

Ortalanti: feeling click where head of femur is sliding back into place; Barlow: actually dislocating hip;

More common in female, if there are CNS abnormalities, w/ breech presentation. Re-examination hips before discharge--shown to be only consistent portion of the PE to pick up an abnormality not seen prior

~2.5 cm

Should resolve by 3 mos. If not down by 9-12 mos, evaluation by surgeon: see if warm bath will drop the testes to scrotum or do US

VATER (Vertebral defects, VSDs, Anal atresia, TE fistula/esophageal atresia, radial dysplasia

Vernix (marker for maturity when gone)

Stratum corneum; this allows for very significant water loss and is extremely susceptible to mechanical injury; but by 7-14 days of age, the stratum corneum matures reducing the loss of water

Post-maturity

Erythema toxicum neonatorum

Miliaria (miliaria rubra/heat rash)

Milia (white head looking)

at ~36 weeks gestation. Resolve spontaneously by a few mos

Transient Neonatal Pustular Melanosis

Mongolian spots (dermal melanosis)

In countries that severely restrict abortion-> laws that legalize abortions= increased mortality of death associated w/ abortion

With the stats that when under dictatorship, abortion was illegal. When it was illegal, death was higher. When legal, lower death rates.

Bt 1994 and 2000, severity of abortion related complications dropped. Fewer postabortion infections, largest gains by young women. Deaths due to unsafe abortion declined by at least 50%!

Abortion rates declined (Important: any type of contraceptive--not including traditional types)

Europe (also has high contraceptive use)

Unsafe abortion

13% (67,000/year)

Prevent unintended pregnancy, make abortion care safer, improve postabortion care, improve postabortion services

13+ weeks up to 24+ viability

Up to 9 weeks EGA

Antiprogestin

Antimetabolite

Three: Consent, 24 hours later take med, third for follow up

4-5 weeks from LMP

Speculum, tenaculum, dilators, suction cannulae, MVA syringe or cannulae, MVA syringe or electric suction devide

Give prophylactic antibiotics (doxy) (get infection in <2% of procedures)

0.5-3% of procedures

Unsafe abortion