All things PRIOR to birth

What is Antepartum hemorrhage (APH) and what are some of the effect on baby?

Any major vaginal bleeding >24 weeks gestation.
This can be due to Placental abruption, placental previa or vasa previa.

Effect on neonate
1. Severe anemia

When do we do critical labs and what do each lab significance?

We do critical labs when there is sudden drop in sugar with no explainable reason
Make sure
1. Baby is actually feeding well

2. Heel had adequate perfusion

3. Assess the baby for - apnea, hypotonia, sucking reflex, exaggerated moro reflex, tremors, seizures or temperature instability.

4. Calculate GIR (even with just PO feeds, Is it 4-12mg/kg/min)

5. Critical lab is done in timely manner (not too long from initial low blood sugar or before any other intervention is done)
   
   
   Critical labs include
   1. Insulin- high or low

2. Growth hormone - It helps glucose, carbohydrates and fat metabolism so in hypoglycemia, it is low.

3. C-peptide - helps detect if a baby is producing excess insulin on their own or if hyperglycemia is caused by insulin resistance

4. B-Hydroxybutyrate

5. TSH

6. Free T4

7. Cortisol

8. Glucose

What are the main causes of hypoglycemia?

1. Transient Hypoglycemia

2. Decreased glycogen stores

3. Recurrent hypoglycemia?

   1. Hormonal excess hyperinsulinism

   2. Hormone deficiencies

   3. Hereditary defects in carbohydrate metabolism

   4. Hereditary defects in amino acid metabolism

What are some causes of transient hypoglycemia?

1. Perinatal stress

2. Sepsis

3. Asphyxia (or HIE)

4. Hypothermia

5. Polycythemia

6. Shock

7. Diabetic mother

8. Insufficient glucose administration

9. Maternal drugs (Chlorothiazide, labetalol or propranolol)

10. Exchange transfusion

11. LGA babies

What are some causes of decreased glycogen stores?

1. IGUR or SGA

2. Prematurity

3. Insufficient caloric intake (so maybe increase TFI?)

What are some causes of recurrent or persistent hypoglycemia?

1. Hormone excess hyperinsulinism
   a. Beckwith-Wiedemann syndrome (three hallmark - visceromegaly, macroglossia, hypoglycemia)
   b. Islet cell adenoma
   c. Adenomatosis
   d. Beta cell hyperplasia or dysplasis
   e. Nesidioblatosis

What are the main four clinical presentations with twins?

1. Prematurity

2. Uteroplacental insufficiency

3. Intrauterine growth restriction

4. Congenital anomalies

What are the three incidences that makes congenital anomalies common in twins? (Other than genetically inherited discorders)

1. Intrauterian space constraints

2. Disruption of normal blood flow secondary to placental vascular anastomosis (such as Velamentous cord insertion)

3. Defects in morphogenesis

What are the congenital anomalies common to twins and why?

1. Anomalies unique to multiple pregnancies such as conjoined twins

2. Deformations due to intrauterine crowding, restriction of movements leading to synostosis, torticollis, facial palsy, positional foot defects

3. Vascular disruptions (especially ones related to monozygotic vascular shunts can lead to birth defects)

   1. Acardia can also occur (artery to artery placental shunt where reverse flow can lead to development of amorphous recipient twin.

   2. In utero death of a co-twin can result to thromboembolic phenomena such as DIC, cutis aplasia, porencephaly of hydranencephaly, limb reduction defects, intestinal atresia, gastroschisis

4. Malformations (teratomas, VACTERL, holoprosencephaly sequence, anencephaly)
   
   V- vertebral abnormalities
   A- imperforate anus
   C- cardiac abnormalities
   T-tracheoesophageal fistula
   E - esophageal fistula
   R-Renal dysplasia
   L- Limb deformities