DIP Episode 350 - The Clutch Teratogen Podcast (+ Step 2CK/3 Course Reminder)

Okay, welcome everyone. My name is Divine. This is episode 350 of the Divine Intervention Podcasts. And into this podcast we'll be going over a topic that is very short but also very high yield for the US Emily step. Really step one all the way through step three. So very important to know these topics and again just as a shout out if you are taking the US Emily step two CK or step three exams any time in the month of December and very likely I would say probably in the month of January. You should strongly consider taking the two courses I have next month. It starts on the 6th of December with the MBME Testicking Strategy scores from 2 to 4 30 pm Mountain Standard Time. We'll go over a bunch a ton of different high yield high fidelity testicking strategies and I'll also spend some time answering your questions on studying for and preparing for the exams. Again I get emails from people all the time that wow Divine I took your course my scores on Cubans have jumped my scores on my practice tests have increased. Well I've done really well on my exam. I get those emails probably almost every day. Usually many sometimes I'll get him multiple like multiple times a day. And then I have the 24th review course is going to be from the 7th to the 10th of December. It's going to be from 10 pm to 4 pm Mountain Standard Time each day. That's going to be from noon to 6 pm Eastern Standard Time each day.

Again we're going to review tons of material tons of high yield things from pediatric surgery, internal medicine, OB-guine, psych, neuro, bio statistics, effects, multi-system processes and disorders, communications, professionalism, review all those things. So again if you want to have a great experience and it's something you can take at the beginning of your dedicated period at the middle or at the end of your dedicated period. You show up you learn a ton. Again most people have like 120 to 130 pages worth of notes from the course. You're going to learn a lot. So I'll encourage you if you want to sign up just shoot me an email through the website and I'll give you some more details. So today let's just go ahead and jump into the topic. It's going to be teradogins. Again these are things that unfortunately you don't know you don't know. If you don't know them then you're going to be in big trouble on your exam. If you know them many times these things are easy points on the test. So we're going to be talking about the high-altoradogins our friends at the end of the end of the end of the end is love to test. So I mean obviously what if they give you a question about a lady they tell you that she has been an acne medication for a few years and that you know she has been lost to follow up and she gets pregnant right and then they say what's the most likely defect that they be found in the new in her in her fetus.

Well I remember isotret knowing right can cause a lot of problems. I search for it knowing can mess up your hocks chains right and that affects where your appendages are placed in the body right. That's why many times when you are placed on isotret knowing you have to be on two forms of birth control and you have to be registered actually to be on isotret knowing. Remember it's one of those powerful acne medications. Now what if they give you a question about a patient they tell you the dispassions are diabetic and then this person gets pregnant and then they tell you that oh which of these and that you know the person is taking hypoglycemia sticking statins and all these things and they see which ones are contraindicated in pregnancy. I would really hope you're thinking of statins remember you should never give statins to a pregnant woman right. Remember cholesterol synthesis is necessary for the development of the fetus so if you give something that inhibits H&G query reducties which helps those synthesize cholesterol that can cause problems with fetal development right. Now what if they give you a question about a person and they tell you that this person is you know he's on medication for migraines right. Again what kind of drugs would be contraindicated in that person. Well I would really really hope that you're thinking of ergotamine. Ergotamine those ergot agents and those drugs are generally for the most part contraindicated in pregnancy.

The thing is they are very the viso construct really well right so the thing is if you construct the placental arteries that can cause like an intrauterine growth restriction right. It can also cause phyto demice and also the thing is ergotamine can cause uterine contractions it's a very your terrotonic agent right you don't want to mingle into premature premature labor you don't want stuff like that right. So ergotamine like in general the migraine medications you want to think twice about those before you give them to a pregnant woman. Here's one thing I would say though here's one thing I would say. Remember migraine meds fall into two categories. There's those they used to treat acute migraines right. Things like so much reptine and things like ergotamine. They used them acutely but for chronic prophylaxis they gains migraines you cannot use so much reptine you don't want to give your patient a stroke right and sometimes these drugs like so much reptine if you give tick them chronically they can actually worsen your migraines. So remember we say that you should be on chronic migraine therapy if you have eight or more migraines a month right. In those cases we put people on things like beta blockers like propryonol we can put you on topiramate we can put you on a tricyclic antidepressant right. Those are all things you should keep in mind.

Now what if they give you a question about a person they tell you that this person has prosthetic valve right and they say oh which of these therapies this would be contraindicated in the patient. I really hope you're saying okay divine we cannot give this person a warframe. Remember warframe can cause a lot of problems in the fetus. It can cause the because again it's an anticoagulant it can make the baby to bleed it can cause fetal hemorrhage it can cause brain hemorrhage for the fetus it can cause bone problems right. Many times it can cause stippling of your epiphysal pleats right. So many times if a person is pregnant the thing you're gonna use in those circumstances you're gonna use hampers you can use hampers or you can use low molecular weight hampers in pregnancy. And then one thing I guess I would say is in general benzodiazepines are contraindicated in pregnancy right. In general you want to think twice before you use benzoes in a pregnant woman. Remember most times say for example like the seizure the sort of pregnancy which is a clumsy. We use magnesium in those circumstances right. Again benzoes are more like a second line agent. So you want to think twice before you use benzoes in a pregnant female. And then what if they give you a question about a person that's on therapy for endometriosis right and then they say okay which of these following medications has to be discontinued. Well I'll really be thinking of danazo. Right.

Danazo is a drug it actually works really well for endometriosis it's like a pro and reginic drug. So it can have more milk hormonal effects in the child. So obviously if it's a child then that child can be born with like precocious fever if it's a male child. If it's a female child she may have virulization. So you want to think twice before giving danazo to a pregnant female right. And then what if they tell you that a person has been on therapy well controlled rheumatoid arthritis and they're saying again which of the following has to be stopped in pregnancy. I really hope you're saying oh divine we're gonna go ahead and stop methyl trexitis right. Remember methyl trexitis can cause problems right. Methyl trexitis can cause problems I mean it's literally used in some fetal abortions right. So you don't want to give it to a woman right because it can cause abortion of the fetus because remember methyl trexitis inhibits dihydrofolid reductis. When inhibiting dihydrofolid reductis it can essentially inhibit DNA synthesis so it can cause all these neuro tube defects it can cause problems for the baby it can actually kill the baby right. Now what if they give you a question about an IV drug user right or you know a person that they tell you that she delivers a newborn and this newborn is noted to have like a VSD and things like that and has like a hypoplastic field. Well if you see this what should you be thinking about.

I really hope you're saying oh divine this is likely fetal alcohol syndrome. Remember the MBME is the love love love love love to test fetal alcohol syndrome. Let me tell you this trick if you see any problem so any abnormalities with the philtrum you're dealing with fetal alcohol syndrome right. So if you have like a smooth field tromb, hypoplasty field tromb, barely perceptible field tromb, thin field tromb, it doesn't matter what it is as long as you have a problem with the philtrum then that can cause fetal alcohol that's fetal alcohol syndrome right. It can cause like a thin upper lip it can cause shock power p-brow features so remember you see that's something we see in a person with downs right. So but the way you separate downs from fetal alcohol syndrome is that in fetal alcohol syndrome you're gonna have problems with the lips you're gonna have lip problems right and many times kids will fetal alcohol syndrome they're gonna have microcephaly right. In fact fetal alcohol syndrome is the most common cause is very high yield is the most common cause of preventable intellectual disability in the US right and if they tell you oh this child has like a holosistolic murmur being heard at the left-low external border. You want to think about a VSD the most common congenital heart defect. Founding kids a half fetal alcohol syndrome is a VSD right. Remember VSD if you don't fix them on time that can ultimately lead to isemenger syndrome right.

Now what if they give you a question about a woman they tell you that she's an IV drug user and she comes in the third trimester and she's complaining of like sodium onset CV abdominal pain and she has like this bleeding just fresh bright bright blood coming off from Hovergina. If you see this what you want to think about I really hope you're thinking about abruptio placenti right placenta la broption. Remember placenta la broption can be caused by cocaine use right because again remember cocaine is a sympathomimetic so it causes very powerful viso constriction if you constrict those placenta vessels that can cause ischemia to the placenta and the placenta can literally fall off and it can also cause an intrauterine phytodemax right. And again the thing is if you cut off some blood flow at least to the placenta through the placenta that can also make the baby not grow you're gonna have like an asymmetric intrauterine growth restriction where the child's head is like a relatively normal size but the body is small. Remember contrast that with us with symmetric IUGR where the head is small and the body is small usually that's caused more by like torch infections or like chromosomal abnormalities right. So cocaine again it's a sympathomimetic it's a powerful viso constrictor it can cause abruptio placenti right. Painful third trimester vaginal bleeding right.

You can also cause an asymmetric IUGR and remember it causes an asymmetric IUGR because it will cause problems like the little more leader like you know leader in pregnancy right. And then what kinds of anti-hypertensives should you absolutely not give to a pregnant woman or remember your asymmetrivers and your arms you don't want to give them right. Your under-tensing convertitins I'm inhibitors your under-tensing two receptor blockers you don't want to give them in pregnancy well why is that well again remember these drugs they can cause renal damage they can cause renal egenesis if the kidneys do not develop then the baby is not gonna urinate and remember that fluid the amniotic fluid is basically the baby's urine right.

So the baby can know urinate that's gonna cause problems the baby is gonna be banging their faces and heads into the urine vaults right and that can cause like you know you can cause like abnormal face disease it can cause hypopolis like problems with limb development right can cause so many problems right and you have again oligohydraminus right so the way they will test that is they will tell you that oh this child has um this woman is at like 33 weeks gestition and the amniotic fluid index is like less than 5 centimeters which is very little that tells you that there is oligohydraminus because those asymmetrivers are the arms the woman was seeking cause renal egenesis and then cause problems for the fetus right and then what if they give you a question about a patient that you know has a history of Wagner's remember Wagner's is called Granolomatosis with polyangitis right and it tells you again which of these medications has to be discontinued in that in that child remember cyclophosphamide remember which weight nurse remember that Ciancastoschethe or Trillowitz steroids and cyclophosphamide that cyclophosphamide is an alkalinity agent alkalinity agents are not great for kids they can cause renal egenesis right they can cause you to have cleft palates right they can even cause you to have no digits right so again these alkalinity agents like cyclophosphamide I phosphamide right in general if a woman is pregnant right she should probably not be in any kind of chemotherapy related agent or anything that kind of getting in hebediene synthesis right and then what if they give you a question about a newborn right and they tell you that oh the mom you know took some old medication that she had before for like a urinary tract infection you know she just took it during pregnancy and then they tell you that this newborn when he's called the newborn does not respond doesn't

turn towards the mom right if you see this you want to think about a menoplycosides right this child is not hearing this child has been exposed to a menoplycosides in utero and menoplycosides they are auto toxic remember we use a menoplycosides to treat men ears disease right and we use them to treat men ears disease because they cannot blade cranium nerve eat so which is your vestibular cochlear nerve right so I mean like what size you want to give them to pregnant woman because they can be auto toxic to the fetus and remember whenever you suspect that a feed like a child has a hearing loss one bull or perform a geometry right one a perform a geometry although many times the classic clue in an MBME exam that ooh this child needs a geometry is going to be that the child has language deletes right so they can give you a child language deletes language deletes tell you that hmm this child very likely has some kind of hearing loss right so you're going to go ahead and perform a geometry on MBME exams and then anti-pilectic drugs remember you essentially should never give these in pregnancy right should never give these in pregnancy feintoene vapurica said you know because again they can cause many problems right vapurica said especially can cause neuro tube defects right because again these drugs inhibit fully reabsorption they can cause neuro tube defects they can cause cleftly cleft palate they can cause cardiac problems right now let me say something though if a woman has been on an anti-pilectic drug and it's controlled as symptoms amazingly well and then because she's pregnant you're like okay let's bring down the dose or let's stop it entirely I noticed that she starts having seizures then the thing you generally want to do in those pregnant women is to put them back on an anti-pilectic because if no one has profound seizures that can kill the baby right now there'

s one anti-pilectic drug to which that rule that I just mentioned does not apply that drug is vapurica said doesn't matter how how bad the seizures are you need to find something else in pregnancy you should never absolutely absolutely never give a pre-carset to a pregnant woman remember vapurica said is bad right can cause profound neuro tube defects it can cause it's hepato toxic it can cause problems in the liver right so again you want to be careful of those kinds of things in general the anti-pilectic drugs that are good or safe in pregnancy it's gonna be things like Lamotrygene Lamotrygene is pretty safe for the most part in in pregnancy and then what if they give you a question about a lady she's like 35 years old and it tell you that she has had like multiple first and second trimester abortions right and then they tell you that trans vaginal ultrasound shows like a T shaped uterus if you see this what are you thinking about well I'll really hope that you're saying oh divine this person was probably exposed to die ethos steel best trolling uterus remember DES can cause a lot of problems right it can cause a clear cell adenocarcinoma of the vagina remember most times vaginoma lignances are gonna be squamous cell cancers not adenocarcinomas so you see a person they have an adenocarcinoma of the vagina and you really want to think about especially a clear cell adenocarcinoma of the vagina you want to think about DES exposure remember die ethos steel bestro and also loves to cause these anatomical uterine anomalies right so these are gonna be things like T shaped uterus like just a uterus that has weird shapes that's why those woman keeps having these recurring pregnancy losses and then remember your tetracycline right again they can test these things right they can tell you oh a woman had like the xodistic infection right but really a book don't free you know Lym

e disease took a medication right and then they tell you that oh that you know at you know the child is having like bone problems on all these things right you want to think about tetracycline tetracycline is remember they are very good at binding to divelent ions I mean this is one of the reasons why antacids you want to think twice before you give a person a tetracycline with antacids right if because the antacids will kill the tetracycline and they won't work right now one of the parts of your body contain a ton of calcium well your teeth your teeth contain calcium so tetracycline is combined and they can cause tooth discoloration right they can also cause problems with bone growth right because again your bones contain a ton of calcium right this is one of the reasons why if you are less than eight years old we don't give you tetracyclines in general on mbm exams right like Lyme disease if you are under eight years old many times we're gonna give you a moxicillin on your test or you can give you a macroid we don't give you tetracyclines on mbm's if you are under the age of eight the only situation where that road does not apply is with rocky mountain spotted fever everybody that has rocky mountain spotted fever including pregnant women get tetracyclines because the mortality of that disease is extremely high right so it's very high you'll to know that for purposes of of exams again if you notice as we're talking about some of these teradogins I'm trying to mix some integrations as we go along right and again what if they give you a question about an immigrant you know she's an immigrant mom she comes you know she delivers her baby and it's only that this baby has like seculatory collapse right and this baby has like an ashing Greek color to the skin if you see something like this right I want you to think about gray baby syndrome right why would they make it in an

immigrant on exams well remember poor and fanny called believe it or not is one of these drugs that I use very commonly in the developing world right for the most part in the US it is essentially not used right but in the developing world it is certainly used I can absolutely remember chloramphenicol being used as a drug back home in Nigeria right so chloramphenicol it can cause gray baby syndrome right you'll have an ashing Greek hue to the skin of the newborn or to the child and you'll notice that again the child has seculatory collapse again that's very high yield to know right and then remember trimeth open softenethoxysol right again it's a drug you want to avoid in pregnancy because again it's literally a fully synthesis inhibitor it can cause problems in the child right in fact all fully synthesis inhibitors trimeth open softenethoxysol pyramid amino sulphurizing which we use for toxoplasmosis you don't want to give those to a pregnant woman right that's why many times if a pregnant woman has toxoplasmosis you're gonna treat it with a drug known as spyramisin right you're gonna use a drug called spyramisin because you're not trying to abort the fetus or cause neuro tube defects and then it's very high yield to know right the tell you that you know a child they tell you that oh well this child has hypoplastic limbs right they tell you that the arms are missing the thighs are missing in this child right you notice that the distal extremities are connected to like the shoulders so let's say like the the you know after your arm you know you have like your hand and stuff let's say the hand is connected to the shoulders or you see that the legs are connected to the to like the your hip joint and stuff right that's fochomilia right that's a problem with thalido mites it's the proximal portions of the limbs of the extremities that I miss it right is the more distal po

rtions that will be connected proximately right that's fochomilia that's something get with thalido mites exposure right and then what if they give you a question about a patient that has a histral gravestis yeast right and then you notice that the newborn is like bald or has like absence of hair like it a well circumscribed distribution if you see this you want to think about a pleasier cutus right you absolutely want to think about a pleasier cutus on embankments right that's something you find with the anti thyroid medications right these are going to be drugs like pt you right purple phyllo uracel and methemazol and then what anti-depressant is contraindicated in pregnancy because the thing is most of the SSR Is are finding pregnancy especially sexually but the big one that's contraindicated is peroxetine remember peroxetine can cause pulmonary hypertension in the fetus right so you try to avoid it in a woman that is that is pregnant right and then again if they give you a question about a person that has a histral mania right you know has like a more disorder has bipolar disorder you know many times bipolar disorder you can treat it with lithium right but lithium can affect the right side of the heart it can cause problems with the right side of the heart it can mess up the right ventricle it can mess up the tracospate valve right it can cause like that fancy word itralization right you can basically that's Epstein's anomaly right so you want to try to avoid that that's why many times if we went out pregnant and they have bipolar disorder you can again put them on an anti-psychotic anti-psychotic exactly one of the greatest drugs to use for bipolar disorder in in pregnancy right and then if a woman has gestitional diabetes is that a problem uh absolutely it's a problem and the thing is our friends at the NBM Es they love to test these things right like being an inf

ant of a diabetic mom or the fetus of a diabetic mom can cause lots and lots of problems right it can cause problems with VS Ds right it can cause transposition of the grid vessels that's how you to high you to know for exams and it can cause something we call quadrarygression syndrome basically everything from the quadrospine down maybe hypoplastic or we not develop properly right so that's very high you to know some things you may see referred to as sireinomilia s-i-r-e-n-o-m-e-l-i-e sireinomilia again that's very high you to know for purposes of of exams and then remember insulin can inhibit the synthesis of sirefactin right so again the fetus of a diabetic mom or the infant of a diabetic mom can certainly certainly certainly have new neuro respiratory distress syndrome because again hyperinsulinemia leads to inhibition of the synthesis of of sirefactin you may be like divide wise the insulin high in the infant of a diabetic mom well if you think about it this child is in a ton of glucose coming through the placenta right so the beta cells in the child's pancreas are going to be like whoa okay well there's a lot of sugar let's try to prop up our insulin production so those pancreatic beta-i-let cells will undergo hyperplasia so you're going to stop making a ton of so you have i-let cell hyperplasia going to make a ton of insulin right so that ton of insulin again can inhibit sub-fractinta synthesis right so that can if you see it like a term child being born with antecedents of new neuro respiratory distress syndrome you want to think about gestitional diabetes in the mom as the cause and again we know that insulin loves to drive things into cells it loves to drive positive ions into cells right so you can drive like calcium into cells it can cause hypocardial cemeterials in a newborn it loves to drive glucose into cells it can cause hypoglycemia seizures in a newbo

rn right and again the thing is again insulin can cause hypoplesia of things right like for example the left colon can be hypoplastic that can present as philiotopasmiconyl right in an infant of a diabetic mom right so if your left colon does in develop well you're not going to be able to pass both right they call it small left colon syndrome right so again these are all things you need to know would feel a lot of all syndrome and then again just a few quick tidbits I want to throw in at the end here again remember for a newborn you don't want to for a newborn or pregnant woman you don't want to give a live at 10 withed vaccine right so things like the varicela vaccine the MMR vaccine the intranasal influenza vaccine those are all contraindicated during pregnancy right and again those are contraindicated kids that are less than a year old right really the only live at 10 withed vaccine I know of that we give to little kids on their year old is the rotavirus vaccine but other than that we do not give live at 10 withed vaccines to kids right and if you notice that a child is being born to a mom the mom has he be active he be going you're going to give that child the he be surface antigen and you're going to give that child the he be vaccine right remember the he be vaccine some of the vaccines that you get as a kid before you leave the hospital the reason we're very aggressive with he be in newborns is if a child develops her he be the risk of developing like long-term disease I think is more than 90% like chronic he be I think is more than 90% versus an adult getting he be where the risk of getting chronic disease I think is like 5% or less right so kids are not able to fight of he be infection very well so if you see a mom and she has active he be as the mom in the newborn is born go ahead and give the he be immunoglobulin to provide positive immunity and then go ahea

d and give a he be the he be vaccine right to give active immunity and then the final thing I believe I want to mention is if you have a child that's born to a mom with HIV right you want to give that child's side of you being easy to right side of you being side of you being so I think I'm going to go ahead and stop here I again I really hope that you have found this podcast to be helpful again this is something that I can pretty much almost promise you you're going to see quite a number of questions for this on step one on step two ck on step three so thank you for listening to me and joining me today please don't forget again if you want to sign up for the step two ck step three course or the MBME test against religious or shoot me an email through the website I do offer one or one tutoring for many exams step one step two ck step three pre clinical medical exams 30-ish-off exams there are some people for which I offer longitudinal tutoring although these things have to be I really means after me it made way ahead of time where I tutor you like all through med school like all through your shelf exams and stuff I've had a bunch of people do that and they've recorded a lot of really good success with that and then I do have these podcasts on Apple podcasts on Google podcasts and on Spotify at least the most recent 150 podcasts if you want everything from a episode one all the way to 350 you got to go to the website divineinterventionpodcasts.com again divineinterventionpodcasts.com and then many people have said that divine I love the life lessons that you share at the end of your podcast so I actually started a new website a few weeks ago it's called divineinterventionlifelessense.com.

There's actually a podcast related to that on Apple podcast you can find it as the divine intervention life lessons podcast again most of those podcasts they are pretty short and sweet and they go over like topics that are pertinent to humanity right like just common problems that people face as well as well as you know practical strategies for combating those problems so if that's something you're interested in just go there divineinterventionlifelessense.com and you listen to that and then also our You Tube channel is called the divineintervention USMLE podcast and videos again I post videos regularly I've started I've actually posted like two videos in recent times so if you're interested again just go subscribe to that You Tube website and you'll get those those resources so thank you for listening to me I do hope you have a wonderful day and if you need help with like more interviews or anything related to the ERAS application process again I've worked with tons of people I am presently working with tons of people on that so thank you for joining me today have a wonderful rest of your God bless you thank you

DES (Diethylstilbestrol) exposure.

Methotrexate (MTX).

Smooth philtrum, thin upper lip, and short palpebral fissures.

Cocaine (sympathomimetic).

Gray Baby Syndrome (ashen/slate-gray skin color) and circulatory collapse.

ACE inhibitors and AR Bs.

Inhibition of HMG-CoA reductase, disrupting necessary cholesterol synthesis for fetal development.

ACE inhibitors or AR Bs (due to risk of renal agenesis).

FAS involves specific lip/philtrum abnormalities (smooth philtrum, thin upper lip), whereas Down syndrome has generalized dysmorphic features.

Valproic acid (VPA).

Ebstein's anomaly (affecting the right side of the heart/tricuspid valve).

They cause tooth and bone discoloration due to binding calcium ions. The exception is Rocky Mountain Spotted Fever.

Hyperinsulinemia/Insulin excess, which inhibits the synthesis of surfactant and can cause hypoplasia of abdominal organs.

Inhibition of HMG-CoA reductase, disrupting necessary cholesterol synthesis for fetal development.

ACE inhibitors or AR Bs (due to risk of renal agenesis).

FAS involves specific lip/philtrum abnormalities (smooth philtrum, thin upper lip), whereas Down syndrome has generalized dysmorphic features.

Valproic acid (VPA).

Ebstein's anomaly (affecting the right side of the heart/tricuspid valve).

They cause tooth and bone discoloration due to binding calcium ions. The exception is Rocky Mountain Spotted Fever.

Hyperinsulinemia/Insulin excess, which inhibits the synthesis of surfactant and can cause hypoplasia of abdominal organs.