Complete Breech

Frank Breech

Footling Breech

When is the embryonic period?

6-12 weeks

When is the 1st trimester?

0 - 13 weeks

When is the Fetal Phase?

12 + weeks

When is the 2nd trimester?

14 - 26 weeks

Dissecting vrs concealed?

in a marginal abruption the hemorrhage dissects beneath the placental
membrane & is associated with little detachment
in a retro-placental abruption if the blood remains
retro-placental the patient has no visible bleeding

How many days is a normal pregnancy?

280 days

What makes an OB scan difficult?

patient habitus

What is the purpose of a full bladder during an OB scan?

to measure the cervix
The bladder needs to be full to measure the
cervix, after that a full bladder is not required

What is the normal measurement of the cervix?

3 cm

What are the measurements for an OB scan?

BPD
HC
AC
Femur Length
HC/AC
CI
CIterna Magna
Ventricular Atria
Amniotic fluid (AFI)
Cerebellum

What images need to be included?

Face
Neck & Spine
4 chamber heart
diaphragm
stomach
kidneys
bladder
cord - 3 vessels
cord insertion
extremities
placenta
fetal lie
genitalia

What is a cephalic position?

generic term for head down

What are the different fetal positions?

longitudinal lie
transverse lie
oblique lie

Left Occiput Posterior
LOP

Left Occiput Transverse
LOT

Left Occiput Anterior
LOA

Right Occiput Posterior
ROP

Right Occiput Anterior
ROA

Right Occiput Transverse
ROT

What are the two footling breech positions?

single footling
double footling

What is an ECV?

external cephalic version

What must be done before an ECV can be performed?

OR must be booked in case of an emergency birth.

What can a shoulder presentation lead to?

Shoulder Dystocia

What is shoulder dystocia?

obstructed labour whereby after the delivery of the head, the
anterior shoulder of the infant cannot pass below, or requires
significant manipulation to pass below, the pubic symphysis. It is
diagnosed when the shoulders fail to deliver shortly after the fetal head.

What is the vertex presentation?

anterior and posterior fontanel presenting

How many babies are cephalic after 34 weeks?

90%

How many babies are breech at term?

3% to 4%

What is the incidence of abnormalities in breech babies?

6.3%

What is the incidence of abnormalities in vertex babies?

2.4%

What plane are brain anatomy and measurements taken in?

transverse

What should you do if the head is round rather than oval?

slide inferior

What can free a low head from the pelvis?

drinking water (filling bladder)
trendelenburg

What images are taken of the fetal head?

Faux cerebri (IHF)
Choroid Plexus
cavum septum pellucidum
Thalami
Cerebral peduncles
cerbellum & cisterna magna
Nuchal fold
orbits
profile
coronal facial views

What does the presence of the faux cerebri imply?

separation of the cerebrum has occured

Faux cerebri

What is the function of the choroid plexus?

produce cerebrospinal fluid

Choroid Plexus

What is the size of the choroid plexus at 20 week scan?

10 mm or less

Why is the choroid plexus image taken?

to exclude ventricular megaly

What is a dangling choroid plexus caused by?

ventricular megaly

dangling choroid plexus

What is the significance of choroid plexus cysts?

none baby can become brain surgeon or
increase the risk of T18

WHAT IS TRISOMY 18?

Trisomy 18, also known as Edwards syndrome, is a condition which is
caused by an error in cell division, known as meiotic disjunction. When
this happens, instead of the normal pair, an extra chromosome 18
results (a triple) in the developing baby and disrupts the normal
pattern of development in significant ways that can be
life-threatening, even before birth. A Trisomy 18 error occurs in
about 1 out of every 2500 pregnancies in the United States, about in
about 1 in 6000 live births. The numbers of total births is much
higher because it includes significant numbers of stillbirths that
occur in the 2nd and 3rd trimesters of pregnancy.

Cavum Septum Pellucidum

What is the cavum septum pellucidum?

arched band of nervous tissue that connects left & right cerebrum

What does the visualization of the cavum septum pellucidum imply?

excludes agenesis of corpus callosum

At what level is the BPD and HC taken?

the level of the thalami

What is the function of the thalami?

receive sensory impulses and transmits them to the cerebrum

thalami view

What is the function of the cerebral peduncles?

receive impulses from brain stem and transmit them to cerebrum
2-way path

How do you find the cerebral peduncles?

first find the thalami and the peduncles with pop out

cerebral peduncles

What is the function of the cerebellum?

equilibrium

What is the measurement of the cisterna magna at 20 weeks?

10 mm or less

What is the nuchal fold?

skin behind the neck

What is the normal measurement of the nuchal fold?

5 mm of less

What does the nuchal fold measurement determine?

rules out trisomy 21
production of abnormal amounts of collagen
Down-syndrome

What is anophthalmia?

No eyes

What is hypotelorism?

close eyes

What is hypertelorism?

far eyes

What is the purpose of taking an image of the orbits?

to rule out
hypotelorism
hypertelorism
anophthalmia

orbits

What is the purpose of the profile image?

exclude
anterior cephalocele - unicorn bony defect
frontal bossing

What is anterior cephalocele?

unicorn bony defect

What is frontal bossing?

protuding forehead

What is the significance of fetal tongue out?

Bad news -
aniplody
downs syndrome
tripody 21
Beckwith-Wiedemann syndrome

What is Beckwith-Wiedemann syndrome?

an overgrowth syndrome, which means that affected infants are
considerably larger than normal (macrosomia) and tend to be taller
than their peers during childhood.

What is micrognathia?

no chin

What is the purpose of coronal facial views?

exclude cleft lip
evaluate the integrity of nasal

How many cervical vertebra are there?

7

What happens to the cervical vertebra at the base of the skull?

widens

How many thoracic vertebra?

12

How many lumbar vertebra?

5

How many sacral vertebra?

5

How many coccyx vertebra?

4

What happens to the spine at the sacrum?

tapers

What is the most important when evaluating the spine?

follow skin covering
2 orientations

How do the lungs appear in the 1st & 2nd trimester?

isoechoic to the liver

How do the lungs appear in the 3rd trimester?

hyperechoic to the liver

What is situ?

positioning

What should happen if call made of omphalocele in 1st trimester?

Rescan at 14 to 15 weeks to rule out rotation of mid gut

How is situ evaluated?

apex of heart points to left
stomach - left
liver right
GB on right

How many heart anomalies can be excluded with the 4 chamber view?

65%

How many heart anomalies can be excluded with the 5 chamber view?

85%

What age can a pediatric echo be done to examine the heart?

18 weeks gestation

Symetry in the heart

What is the function of the foramen ovale?

shunting of blood from right to left

How much blood is shunted through the foramen ovale?

60%

What skirts blood through the foramen ovale?

eustation valve

Why must the heart septum be evaluated?

exclude wall defects

How is the 5 chamber best viewed?

baby lieing on back

How do you get the 5 chamber / aorta image?

angle up from 4 chamber view

How do you get the 5 chamber / pulmonary artery image?

angle up from aorta

What is evaluated to rule out diaphragmatic hernia?

heart superior to diaphragm
stomach inferior to diaphragm

Where do diaphragm abnormalities usually occur?

left side

Why is a diaphragmatic hernia dangerous?

stomach can move to the thoracic

What is esophagus atresia?

no stomach
esophagus ends in bind end tube

When is the stomach apparent?

11 wks

When must the stomach be seen?

16 wks

Why are the small intestines evaluated?

rule out meconium spillage
cystic fibrosis

Why are the large intestines evaluated?

to rule out anal atresia

What is the sonographic appearance of anal atresia?

dilated loops of bowel

When are the kidneys seen?

15 weeks

Where are the kidneys located?

retroperitoneal

how much of the abdominal circumference do the kidneys take up?

1/3

What is the normal measurement of the renal pelvis in the 2nd trimester?

5 mm or less

What is the normal measurement of the renal pelvis in the 3rd trimester?

7 mm or less

If the measurement of the renal pelvis is greater than 10 mm?

BAD

Where are the adrenals located?

superior to the kidneys

When can the adrenals be seen?

20 weeks

What is one of the problems scanning the adrenals?

can mimic kidneys
especially when kidneys are missing

What is the size of the adrenals?

50% the size of the kidneys

When can swallowing be seen?

8 - 11 weeks

What is the significance of the bladder being seen?

at least one kidney exists

At what age are the kidneys fully functioning?

16 weeks

What is the function of the kidneys before birth?

produce amniotic fluid

How often does a fetus void?

30 to 45 minutes

When does AFL peak?

34 weeks

When is XY genitalia best determined?

20 weeks
possible at 14 weeks

What is gender linked disorder?

hemophilia

When is XX genitalia best determined?

20 weeks
possible at 14 weeks

Why is it important to evaluate long bones?

determine fetal age
detection of skeletal dysplasia
detection of limb malformation

What is skeletal dysplasia?

dwarfism

When is the proximal humerus epiphyssis apparent?

39 weeks

What does the distal femoral epiphyssis indicate?

gestational age between 33 - 35 weeks

What do you evaluate with the extremities?

3 bones visible

What do you evaluate with the hands?

open good
closed fist - BAD BAD BAD

When the feet have a sandal gap what is indicated?

downs syndrome

what is a sandal gap?

gap between big toe and 2nd toe

What is the function of amniotic fluid?

movement
temperature control
shock absorber
normal lung development

What is AFI?

amniotic fluid index?

What contributes to amniotic fluid?

kidneys, lungs, cord & skin

When does fetal urine account for almost all amniotic fluid?

20 weeks

What is the sonographic appearance of amniotic fluid?

anechoic
floating vernix caseosa

When is AFI measured routinely?

after 24 weeks

What is oligohydraminos?

too little fluid

What is oligohydraminos?

What is pulmonary hyperplasia?

bad lung formation

What can oligohydraminos cause?

pulmonary hyperplasia
joint defect from restriction

What is a BPP?

evaluation of fetal well being

What is evaluated during a BPP?

NST
fetal tone
fetal breathing
fetal movement

What is NST?

Neonatal stress test
presence of 2 or more fetal heart rate
accelerations of at least 15 bpm in amplitude & of at least 15
seconds in duration associated with fetal movement in a 20 minute period

How is fetal tone evaluated?

extension & flexion

How is fetal breathing evaluated?

30 seconds worth

How is fetal movement evaluated?

trunk movement

How is AFI evaluated?

2 cm puddle

What is conceptual age?

fetal age
restricted to pregnancies in which the actual
date of conception is known
- in vitro fertilization
- artificial insemination

conceptual age + 14 days =

menstrual age

What is nagele's rule?

used my
LMP - 3 months + 7 days

What is menstrual age?

gestational age

What is gestational age based on?

first day of LMP

What is gestational age used for?

scedule invasive procedures
alpha-feto-protein screening
plan date of delivery
evaluate fetal growth

What is the most accurate sonographic technique for establishing
gestational age?

3 CRL
Crown rump length

What is the accuracy of the CRL?

+/- 5 days
95%

Why is s the CRL and excellent correlation of length and age?

pathological conditions minimally affect growth in the first trimester

What is the formula for gestational age in weeks?

(CRL)cm +6

When does the CRL become inaccurate?

after 12 weeks

Why is the CRL inaccurate after 12 weeks?

due to movement including extension and flexion

What is BPD?

Biparietal diameter

What is the accuracy of a BPD between 17 - 26 weeks?

+/- 11 days

What is the accuracy of a BPD after 26 weeks?

+/- 3 weeks

How is the BPD measurement taken?

outer to inner

What landmarks should bee visualized at the area of a BPD measurement?

Falx cerebri
cavum septum pellucidum
thalami

What is the ambiguous stage of the fetus?

13 - 14 weeks

Why is 13 - 14 weeks considered the ambiguous stage?

fetus is too big for CRL yet the landmarks for a BPD are not seen yet.
Use choroid plexus and head shape as the landmark

What is the formula for HC?

(BPD + OFD)(Pie)/2

How is the HC measurement taken?

outer to outer

Why is the HC a valuable measurement?

less affected by head compression

What should the shape of the head be in a fetus?

ovid

What does brachycephaly refer to?

a round head

How are the BPD measurements inaccurate with brachycephaly?

overestimate

What does Dolichocephaly refer to?

elongated head

How are the BPD measurements inaccurate with dolichocephaly?

underestimate

What is the cephalic index?

devised to determine the normality of the fetal head shape

What is the formula for C.I,?

BPD / OFD x 100

If the C.I. is <75% what is indicated?

dolichocephaly

If the C.I. is >85% what is indicated?

brachycephaly

If the C.I. is between 75% - 85% what is indicated?

Normal

What is AC?

abdominal circumference

Where is the AC taken?

level of the liver where the umbilical vein branches in the left
portal vein

The the AC should be taken in what plane?

transverse

What is the AC formula?

(D1 +D2)(pie) /2

What are the landmarks of the AC measurement?

stomach
3 ossification centers of the spine
portal vein

What is the importance of the AC?

Useful in predicting fetal weight
useful in monitoring normal fetal growth
AC size is a direct indicator of the size of the liver
useful in detecting fetal growth disturbances
such as IUGR

How accurate is femur length when determining GA?

about as accurate as BPD

When would you use femur length fo determine GA?

fetal head can not be measured due to position or anomaly
fetal death

Where is the femur measured?

from greater trochanter to the distal femoral condyle

What should happen if there is a > 2 week difference with other
biometric parameters?

measure all fetal bone
targeted exam should be done to rule out pathology
trisomy
dwarfism

What is a short femur a marker for?

trisomy
dwarfism

What are the normal gram measurement of the orbits?

ocular distance (OD)
binocular distance (BD)
interocular distance (IOD)

What is inter-ocular distance (IOD)?

between eyes

What is the binocular distance (BD)?

distance from outer orbit to contra-lateral outer orbit

What is the ocular distance (OD)?

distance of the orbit

What is the best measure of GA with the orbital measurements?

BD binocular distance

How are the orbital measurements taken?

outer to outer

When is a orbital measurement used to determine GA?

when ventriculomegaly or skeletal dysplasia exists making BPD
measurements inaccurate.

What are the orbital measurements useful in excluding?

Hypotelorism
hypertelorism
anophthalmus
microphthalmos

What is Hypotelorism?

close eyes

What is hypertelorism?

wide eyes

What is anophthalmus?

no eyes

What is microphthalmos?

small eyes

What are the parts of the cerebellum?

vermis and 2 lobes

Why is the cerebellum measured?

good correlation with GA
excluding Arnold Chiari seen in spina bifida
Dandy Walker syndrome

What is Arnold Chiari?

downward displacement of the cerebellum through the foramen magnum
banana shaped cerebellum

What is Dandy Walker?

hypoplasia of the vermis and cephalad rotation of the vermian
remnant cystic dilatation of the fourth ventricle extending
posteriorly

The placenta is composed of two components, what are they?

tissue from both mother and fetus

What is the fetal part of the placenta called?

Chorionic plate
chorion frondosum

What is the maternal part of the placenta called?

Decidua basalis
endometrial surface

What is the Decidua?

uterine lining (endometrium) during a pregnancy, which forms the
maternal part of the placenta.

What causes decidualize?

influence of hormones

Where is the Desidua Capsularis?

1

Where is the Desidua basalis?

6

Where is the Desidua parietalis?

5

Where is the chorion frondosum?

11

Where is the amnion?

12

Where is the chorionic cavity?

13

What is the chorionic villi?

functioning unit of the placenta
finger-like structures containing one fetal blood
capillary per villi

Where are the chorionic villi located?

intervillious space

What is the chorionic villi responsible for?

exchange of:
nutrients
waste
oxygen
carbon dioxide

Blood flow in the placenta is ______impedance.

low

Explain the blood flow from the uterus to the placenta and back.

uterine arteries
intervillous spaces
villous capillaries
umbilical vein
umbilical artery
villous capillaries
intervillous space
basilar vein

What is the function of the placenta?

Nutrition
respiration
excretion
protection
storage
hormone production (chorionic villi)

Explain the placenta evaluation.

position
echotexture / grade
size

What is changes in the maturing placenta referred to?

grading

Placenta maturation does not occur at the same rate in women

What can affect the maturation process?

Rh disease
diabetes

What is placenta grade 0?

smooth edges
homogeneous
1st - early 2nd

What is placenta grade 1?

small intraplacental calcifications
as early as 14 weeks
common until 34 weeks

What is placenta grade 2?

calcifications at basilar plate
greater than 30 weeks

What is placenta grade 3?

calcified indentions of placenta
35 weeks +
1/3 of term placenta

What are some causes of delayed placental maturation?

maternal diabetes
Rh sensitivity

What are some causes of advanced placental maturation?

maternal HTN
IUGR
smoking

What are some causes of a small placenta?

placental infarct
primary placental growth retardation
interuterine infection
chromosomal anomalies

What are some causes of a large placenta?

maternal diabetes
maternal anemia
non-immune Hydrops
interuterine infection
chromosomal anomalies

What is the normal size of the placenta?

less than 4 cm
1 mm thick for every week gestation

What is Placental Accreta?

attaches to myometrium

What is Placental Increta?

invades myometrium

What is Placental Percreta?

penetrates through uterus
(myometrium and serosa)

What are the risk factors of Placental Accreta?

placental previa
Hx of C-section
uterine surgeries
advanced maternal age

How is Placental Accreta detected?

elevated maternal serum AFT
MRI
Sonography

What is the sonographic appearance of Placental Accreta?

absent or thin myometrium under placenta
multiple lakes
increased vascularity
(Percreta) extrauterine mass
swiss cheese

Uterine wall should be thick!

What is a pregnancy loss of 19 week and under called?

miscarriage

What is a pregnancy loss after 20 week called?

Fetal Death

What is a placental abruption?

premature separation of the implanted placenta between 20 weeks and birth

What is a placental abruption associated with?

preterm labor / delivery
fetal death

How is placental abruption diagnosed?

history
physical findings:
-back pain
-bleeding

What are the signs and symptoms of placental abruption?

vaginal bleeding
pelvic pain
shock
asymptomatic

What are the risk factors of placental abruption?

hx of abruption
trauma
fibroids
placental previa

What is a Retroplacental abruption?

rupture of the spiral artery
separation of basal plate from the uterine wall
high pressure bleeds

What is Retroplacental abruption associated with?

HTN
vascular disease

What is the sonographic appearance of Retroplacental abruption?

anechoic subchorionic area between placenta and uterus
thickened uterus
collection greater than 2 cm

What is a subchorionic (marginal) abruption?

tears in the marginal vein
separates the chorion from decidua
low pressure bleed

What is associated with subchorionic (marginal) abruption?

maternal cig smoking

What is the sonographic appearance of subchorionic (marginal) abruption?

anechoic subchorionic area between placenta and uterus

Dissecting vrs concealed?

in a marginal abruption the hemorrhage dissects beneath the placental
membrane & is associated with little detachment
in a retro-placental abruption if the blood remains
retro-placental the patient has not visible bleeding

How far from the cervix is a low-lying placenta on a trans-abdominal exam?

less than 5 cm

How far from the cervix is a low-lying placenta on a trans-abdominal exam?

less than 2.5

What is the #1 cause of painless 2nd & 3rd tri bleeding?

placental previa

What are the risk factors for placenta previa?

multigravida
hx of c-sec
hx of therapeutic abortion
advanced maternal age
abnormal presentation
maternal anemia
closely spaced pregnancies

how many women have placenta previa after 24 weeks?

1: (150 =- 305)

What are the different types of placenta previa?

partial
complete
marginal
low

What is the difference between marginal and partial placental previa?

marginal just touches the cervix and partial covers some of the cervix

How many pregnancy are normal?

96%

What is wrong with the term placental migration?

Do not use around radiologists

What are the placental masses and lesions?

chorioangioma
teratoma
hemangioma
hematoma
thrombosis
placenta extrachorialis
placental cysts
membranous cord insertion
battledore placenta

What is a placental lake?

subchorionic fibrin depositions
NO CLINICAL SIGNIFICANCE

What is a placental chorioangioma?

vascular malformation, Similiar to a hemangioma
most common placental tumor can lead to fetal hydrops

What is the sonographic appearance of chorioangioma?

well-circumscribed mass; usually lobulated
hypoechoic
located within placental tissue
may contain calcifications

What is the cause of chorioangioma?

failure in development of the chorion villi persists

What is placenta membranacea?

rare
placenta develpos as a thin membrane along the
periphery of the chorion along the entire gestational sac

What is placenta membranacea associated with?

increase risk of
placenta accreta
placenta increta
placenta percreta

How many pregnancy have placenta extrachorialis?

1% to 2%

What are the two types of placenta extrachorialis?

circummarginate
circumvallate

What is circumvallate placenta extrachorialis?

chorionic plate is surrounded by a thick ring

What is associated with circumvallate placenta extrachorialis?

PROM
premature labor
placental abruption
hemorrhage

What is circummarginate placenta extrachorialis?

chorionic plate is surrounded by a thin ring
no clinical significance

How many pregnancies show placental cysts?

less than 20%

Where are placental cysts usually located?

subchorionic

placental cysts are difficult to separate from ______ ______.

intervillous thrombosis

What is velamentous (membranous) cord insertion?

cord inserts at placental margin into corion laeve
not protected my wharton's jelly

How often does a velamentous (membranous) cord insertion occur?

1% of pregnancies

What is velamentous (membranous) cord insertion associated with?

IUGR

What is IUGR?

Interuterine growth regressor

What is battledore placenta?

Cord inserts at placental margin.
Not clinically significant
looks like baddmitten

How often does battledore placenta occur?

7% of pregnancies

What is succenturiate placenta?

presence of one or more accessory lobes connected to the body of the
placenta by blood vessels

What is another name for succenturiate placenta?

bilobate placenta

What is the main problem with succenturiate placenta?

can rupture during labor
it can be left behind

What is the umbilical cord?

connection between the placenta and the fetus

What is the function of the umbilical cord?

essential link for oxygen and nutrients

What does the umbilical cord consist of?

2 umbilical arteries
1 umbilical vein

When is the umbilical cord usually seen?

week 9

What is wharton's Jelly?

surrounds the vessels within the umbilical cord to protect them

What is a short umbilical cord associated with?

abdominal wall defect

What is a long umbilical cord associated with?

prolapse
nuchal cord
true knots

What is another name of the umbilical arteries?

hypogastric arteries

What is umbilical cord prolapse?

cord gets caught in the endocervical canal

What is an umbilical nuchal cord?

cord wraps around neck

What is an umbilical true knots

knots

How many pregnancies is is an SUA found?

1%

What is an SUA?

single umbilical artery

What is the most common umbilical cord anomaly?

single umbilical artery

What is an SUA associated with?

congenital anomalies (25 - 50 %)
perinatal death
premature delivery
IUGR
chromosomal anomalies

What should happen when a 2 vessel cord is found?

very aggressive at 20 week exam lookig for anomalies

How to confirm two umbilical arteries.

follow cord from insertion to IIV

What does the umbilical arteries become after birth?

hypogastric ligaments

What is the normal A/B ratio in 3rd trimester?

less than 4:1

What is the RI after 26 weeks?

.45 - .58

End diastolic flow ______ with gestational age.

increases

What is absent or reverse EDF associated with?

fetal morbidity and mortality

What is the sonographic appearance of umbilical artery Doppler?

normal pulsatile pattern
forward flow

What happens if there is not end-diastolic flow in the umbilical artery?

be ready to go to OR but not emergency at this time...IN RED

What happens if there is reverse flow in the umbilical artery?

Emergency ....OR

What are the umbilical cord masses?

allatoic duct cysts
omphalomesenteric duct cysts
hemagioma
hematoma
mucoid degeneration of wharton's jelly
omphalocele
umbilical hernia

What is an Allantoic Duct cysts?

Allantoic cysts of the umbilical cord are extremely rare anomalies.

What are possible causes of a patient measuring Large for date?

gestational diabetes
palpating fibroids

What are possible causes of a patient with Increased Serum HCG?

gestational trophoblastic disease

What are some possible causes of a patient with Increased AFP?

twins
open neural tube defect

What are the increased risks of twins?

fetal death
premature delivery
fetal anomalies
maternal bleeding
vas previa

What is vasa previa

placenta over cervix
A condition in which blood vessels within the placenta or
theumbilical cord are trapped between the fetus and the opening to the
birth canal, a situation that carries a high risk the fetus may die
from hemorrhagedue to a blood vessel tearing at the time the fetal
membranes rupture or during labor and delivery

What is a fertilized egg called?

zygote

What is a fertilized egg that splits causing twins called?

monozygotic

What are two fertilized eggs causing twins called?

Dizygotic

How are multiple pregnancies classified?

# of chorion
# of amniotic sacs

What does the amount of separation depend on?

time of cell division

If a monozygotic divides 1-3 days post conception what is the result?

Dichorionic Diamniotic

If a monozygotic divides 4-8 days post conception what is the result?

Monochorionic Diamniotic

If a monozygotic divides 8-13 days post conception what is the result?

Monochorionic Monoamniotic

If a monozygotic divides 13+ days post conception what is the result?

conjoined twins

What is the most common form of conjoined twins?

thoracopagus

What is thoracopagus

joined at the thorax

What percent of conjoined twins are born alive?

60%

How many conjoined twins are fused on the ventral wall?

56%

polydramnios is commonly present in what type of twin?

conjoined

How many monozygotic twins are classified DCDA?

Dichorionic Diamniotic
25%

How many fetal deaths occur due to DCDA?

10%

How many monozygotic twins are classified MCDA?

Monochorionic Diamniotic
73%

How many fetal deaths occur due to MCDA?

10%

ow many monozygotic twins are classified MCMA?

Monochorionic Monoamniotic
2%

How many fetal deaths occur due to MCMA?

25%

How many twin pregnancy ends in a singleton birth?

70%

What is vanishing twin?

a small cystic collection appearing adjacent to gestational sac, that
appears to be a second gestational sac gets smaller and smaller.
Usually disappearing by the second trimester

What is papyraceous?

fetus passes around 14 weeks
fluid is reabsorbed
lost twin is wrapped in amniotic membrane
pushed to the side by developing fetus
persists as a soft tissue mass

When one twin dies the other may live depending on?

chorionicity
amnionicity
uterine response

What are problems of MCMA twins?

twin to twin transfusion
entangles umbilical cord

What are problems of MCDA twins?

twin to twin transfusion
stuck twin

What form of twins are in danger of twin to twin transfusion?

Monozygotic twins
MCMA
MCDA

What is twin to twin transfusion?

A/V shunt within the placenta
arterial blood of one twin is pumped into venous system of
the other twin

What happens to the donor with twin to twin transfusion?

anemic
IUGR
oligohydramnios

What happens to the recipient with twin to twin transfusion?

LGA = large for gestational age
polyhydramnios
Too much glucose and urinates to try to rid of it
eventually leads to CHF and possible death

What is the term used for abnormal growth when one twin is much
larger than the other?

Discordant growth

What is the term used for normal growth of twins?

concordant

When is evaluation of the number of chorions and amnions done?

best done in 1st trimeter

What are the signs of DCDA twins?

lambda sign
thick separating membrane

What are the signs of MCDA twins?

T sign
thin separating membrane

What is for sure when twins are of different genders?

dizygotic
DCDA

If cords insert into placenta at different locations?

DCDA

What is discordant growth?

differences of estimated weight between monochorionic twins is
greater than 20%

What is concordant growth?

differences of estimated weight between monochorionic twins is less
than 20%

During singleton pregnancy when is growth a cause for concern?

10th & 90th percentile
Real world
5th & 95th

What is dolichocephaly?

skiny head
common in twins

Why is dolichocephaly a pitfall?

underestimates BPD

What is Fetal Hydrops?

AKA Hydrops fatalis. Two sites of fluid accumulation or one site of
fluid collection and fetal ascites.

What is another name for fetal hydrops?

Hydrops fatalis

What are the types of fetal hydrops?

Immune Hydrops: results of Rh sensitivity

Nonimmune Hydrops: any hydrops in the absence of Rh sensitivity

What is Immune hydrops?

results of Rh sensitivity

What is Nonimmune Hydrops?

any hydrops in the absence of Rh sensitivity

What is the sonographic appearance of Fetal Hydrops?

Fluid collection
Fetal Ascites
Scalp Edema
Skin edema
Pleural Effusion
Pericardial effusion
Polyhydramnios
Large thick placenta
Enlarged fetal liver and spleen
Congestive heart failure

What is Rh sensitivity?

Rh- mother & Rh+ father = Rh+ baby
On second baby mothers antebodies cross the placenta and
cause hemolysis of eurthrocytes
baby tries to increase erythrocytes production
causing:
FCHF
Anemia
Edema

How is Rh sensitivity treated?

Rhogam shots at
28 weeks
3 days before delivery
anytime a procedure is done

What is Rh+ immunoglobin?

Rogram
anti-D

How is Immune Hydrops diagnosed?

ABO -Rh blood typing
antibody screening
Spectrophotometric evaluation of amniocentesis fro bilirubin
at 26 - 28 weeks

What is unlikely if antibody titer of < 1:16

interuterine fetal death

What is what i if antibody titer of < 1:16

interuterine fetal death

What is the sonographic appearance of Immune Hydrops?

Fluid collection
Fetal Ascites
Scalp Edema
Skin edema
Pleural Effusion
Pericardial effusion
Polyhydramnios
Large thick placenta
Enlarged fetal liver and spleen
Congestive heart failure

How is Immune Hydrops diagnosed?

Amniocentesis - Old method
Cordocentesis -

What can be checked with Cordocentesis?

fetal hemoglobin
test for bilirubin
if elevated excessive destruction of red blood cells

What does low hemoglobin mean during a Cordocentesis?

baby is anemic
transfusion can be done during Cordocentesis.

What is Low Zone immune Hydrops?

mildly affected
deliverable at term

What is Mid Zone immune Hydrops?

Fetus is affected but not an emergency
early delivery of intrauterine transfusion may be indicated

What is High Zone immune Hydrops?

Emergency
immediate treatment

What is Alloimmune Thrombocytopenia?

mother develops an immune response to fetal platelets
antibodes are produced
Baby has deficiency of cells for blood clotting
baby suffers from hemolysis

What is the treatment for Alloimmune Thrombocytopenia?

via cordocentisis

What is NIH?

Nonimmune Hydrops
Not a result of Rh- sensistivity

What are the causes of NIH?

Cardiovascular
Chromosomal
Twin to twin transfer
Urinary respiratory
G.I problems
Liver problems
Infectious problems
Placenta and umbilical cord problems
Parvo

What is Parvo?

dangerous to pregnant women before 20 weeks

What does parvo cause?

Hydrops

What is 5th disease?

Parvo

What is slap cheek syndrome?

parvo

What is done to determine the cause of non immune hydrops?

ultrasound

What is the sonographic appearance of NIH?

edema
* especially scalp edema
fetal ascites
pleural effusion
pericardial effusion
polyhydramnios
large thick placenta
fetal hepatomegaly
fetal spleenomegaly

What is Insulin Diabetes Mellitis?

Type I
pancreas does not produce enough insulin

Why is Type 1 Diabetes dangerous during pregnancy?

Elevated glucose fires up fetal growth (FAT babies)
fetuses are frequently macrosomic
shoulder dystokia
Increased difficult labor
increased fetal death
incidence of neural tube defect increases 10 fold

What is macrosomic?

Big ass baby
8 lbs 13 oz
4000 grams

What is done for diabetic pregnancy?

frequent U/S

What are the sonographic findings more common to diabetic mothers?

fetal macrosomia
polydramnios
increased fetal adipose tissue
caudal regression syndrome
congenital heart defects
Neural tube defects

What should be considered if polyhydramnios with a baby that is macrosomia?

Gestational Diabetes

Insulin diabetic who have diabetes under control reduce the risk of
structural anomalies

What are the sonographic appearance of Hypertension?

small placenta
Growth retardation
oligohydraminos
placenta abruption

What is Eclampsia?

Pregnancy induced hypertension prior to 20 weeks

What are possible problems of patients with pre-eclampsia?

maternal proteinuria
edema
possible seizures

What are possible problems of patients with sever pre-eclampsia?

baby must be delivered immediately

What are possible problems of patients with Eclampsia?

seizures and/or coma

What are some causes of Maternal Vomiting?

Hyperenemis graviarum
gallstones
peptic ulcers
trophoblastic disease
Twins = Higher hcg

What can excessive vomiting cause?

dehydration
admitted for IV therapy

How many preg patients will have bacteria?

4-6%
25% of 4-6 will have UTI

Why is mild hydronephrosis normal in pregnancy?

progesterone dilates the ureteric smooth muscle
uterine compression of the ureters
*Sever hydronephrosis is ABNORMAL

What is a Dysgerminoma?

germ cell tumor female counterpart of seminoma. Corpus Luteum of
pregnancy does not resolve

What is the Sonographic Appearance of Dysgerminoma?

Cyst on ovary
8 – 10 cm

Why are fibroids problematic with pregnancy?

grow in response to estrogen. Can rapidly grow and undergo necrosis.
They can become large and interfere with pregnancy.
compression effects on baby
Causing pain and preterm labor

How to tell the difference between fibroids and uternine contractions?

contractions resolve within 30 minutes
different blood flow patterns

What is fetal demise?

absence of fetal tone after 20 weeks

1/2 of fetal deaths can have determining factors

infection
congenital anomalies
pre-eclampsia
placenta abruption
diabetes growth retardation
Rh sensitivity

How many miscarriages happen in the 1st trimester?

15/20 : 100

What are signs of viability?

TV heartbeat at 5.5 weeks

Lack of fetal Doppler after 12 weeks or fetal movement after 16 weeks prompts?

Ultrasound

What are the signs of long term fetal death?

overlapping cranium (spaulding sign)
liquefaction of brain material
skin thickening / scalp edema
dependency
gas shadowing - Roberts sign

What is spaulding sign?

overlapping cranium

What is robert's sign in abdomen?

gas shadowing within fetus

What is Premature labor?

Onset of labor prior to 37 weeks gestation

What are possible causes of premature labor?

PROM
Intrauterine infection
Bleeding
Fetal abnormalities
Polyhydramnios
Multiples
IUGR
Maternal diabetes/hypertension

What are increased risks to the fetus With premature labor?

RDS
Intracranial hemorrhage
GI Immaturity
Eating problems but

At what a week he is a fetus viable In Born early?

22 weeks

What is EFW?

Estimated fetal weight

What is the EFW of a viable fetus?

Greater than 500 g
*22 weeks

What is PROM management?

Watching for signs of fetal distress
Infection
Monitor and olighydramnios
meconium and in fluid

What is external cephalic version?

Looking the baby

How many babies are breach at term?

4%

Why would an external cephalic version be performed?

Tried to reduce the number of Breech Babies
Breech babies are more likely to have a C-section
The section increases risk, Length of stay and length of recovery
Breech babies have low APGAR scores

What are breach babies increased risk for?

Cord prolapse
Prolonged labor - Increased risk of death
Complications - higher risk of chromosomal abnormalities

Wind is an external cephalic version most successful?

between 37 - 38 weeks

What should happen if call made of omphalocele in 1st trimester?

Re scan at 14 to 15 weeks to rule out rotation of mid gut

What is gastroschisis?

A wall defects tends to occur in boys on the right side

What is the sonographic appearance of gastroschisis?

Free floating loops of bowel in the amniotic fluid

What is Omphalocele?

the intestines, liver, and occasionally other organs remain outside
of the abdomen in a sac
35 – 60% caused by chromosomal abnormaities (bowel)

What is the sonographic appearance of Omphalocele?

intestines appear outside abdomen in pouch

At what week is head identified?
What is the dominant feature?

7 weeks
choroid plexus is the dominant feature

When is cranial anatomy best viewed?

12 - 14 weeks

What is the difference between omphalocele and gastroschisis?

omphalocele has a surrounding membrane
gastroschisis is in direct contact with amniotic fluid

What is Anacephaly?

Failure of closure of neurotube at cephalic end, brain is in direct
contact with amniotic fluid and dissolves.

What is the sonographic appearance of Anecephaly?

Frog apearance
no parenchymal tissue is seen above the orbits

What is Hydrancephaly?

brain necrosis results from obstruction of ICA – lack of nutrients

What is the sonographic appearance of Hydrancephaly?

Cystic mass in place of brain parenchyma

What is Turner syndrome?

congenital endocrine disorder
ovaries do not respond to FSH & LH

What is Cystic Hygroma?

Sign of Turner syndrome. Bad insertion of lymphatics into IJV.
Associated with Trisomy 12, 18, 21

What is the sonographic appearance of Cystic Hygroma?

Cystic mass in cervical region
septated

What is a umbilical cord cyst?

benign
Wharton's Jelly cysts
ophalomesentery duct cyst
Monitor for changes (can be caused by other abnormalities)

What is a placental hematoma?

collection of blood from detached placenta
Prognosis – size dependent

What is a Corpus Luteum Cyst?

secretes progesterone to support pregnancy until placenta takes over.
Less than 5 cm – normal
Greater than 5cm – intervention needed

Sonographic Appearance:
Septations

What is the most common location of an ectopic pregnancy?

ampulla - 80%
fimbrae - 0.5%
isthmus - 15%
Cervix - 0.1%

How many maternal deaths are ectopic pregnancy?

10%

What is the most dangerous area for ectopic?

interstitial AKA Cornial
rarest and most dangerous
very vascular

What are the associated risks factors of an ectopic?

PID
IUCD
fallopian tube surgery
inferitlity treatment
previous

What is the presentation of an ectopic?

Pain 97%
Vag bleeding 75%
palpable adnexal mass 50%

What do the beta hCG levels need to be to see an IUP?

500 IU/L trans vag
1800 IU/L trans abdominal

What will the Beta hCG levels be with ectopic?

lower than IUP

BhCG levels double every ____________?

2 days 1st 6 weeks
3 days 6+ weeks

What is a ring of fire?

Doppler
ectopic - trophoblastic tissue lights up
corpus luteum cyst - lights up also

What is a heterotopic pregnancy?

simutaneous intrauterine and ectrauterine pregnancy
Very rare
1:6000 / 8000 pregnancy

What is the cornual pregnancy ?

Ectopic pregnancy at cornual
Life threatening condition due to increased area vascularity and
possible rupture of tissue
SURGERY
RARE

How are ovarian ectopic pregnancies identify?

But complex mass on the ovary
Differential diagnosis hemorrhagic corpus luteum cyst
RARE 0.5%

What percent of pregnancies are abnormal?

4%

What day should a live embryo be seen?

46
6 weeks

What is a blighted ovum?

a fertilized ovum that does not result in a embryo.
something goes wrong after implantation.
normal signs of pregnancy will occur

What are the signs of a blighted ovum?

Large gestation all sac without inter gestation all anatomy
irregular shaped or abnormally shaped gestation all sac

What should the fetal heart rate be in first trimester?

90 to 170 bpm
Less than 90 bpm is very pour prognosis

Oligiohydramnios in 1st trimester

Poor prognosis
Associated with babies that are starving baby that are starving do
not urinate

What is the sonographic appearance of a complete miscarriage?

Empty uterus
No free fluid
No adnexal mass
hCG should be declining

What is the sonographic appearance of a incomplete miscarriage?

gestational sac may be normal with embryo w/ no fetal heart rate
misshappen gestational sac

RPOC?

retained products of conseption

What is a threatened abortion?

vaginal bleeding with a closed cervical OS in a preganancy of less
than 20 weeks.

What are the three forms of tropoblastic disease?

hydatiform mole - growth that forms inside the womb (uterus) at the
beginning of a pregnancy. Partial (2-1) complete (1-0)
invasive mole - chorioadenoma destruens grows
into the muscular wall of the uterus
choriocarcinoma -

What is the sonographic appearance of Gestational tropoblastic disease?

snowstorm late 1st
sac of grapes in 2nd

What are the two types of IUGR?

symmetrical
asymmetrical
10th (5th) percentile

What are the risk factors for IUGR?

previous
maternal hypertension
tobacco
uterine anomolies
placental hemorrhage

What are the problems associated with IUGR?

increased risk of antepartum death
perinatal asphyxia
Neonatal morbidity
later development problems

What usually causes symmetric IUGR?

1st trimester insult
hypertension
diabetes

What type of IUGR is most common?

asymmetric
usually caused by placental insufficiency

What is suggestive of Head sparring IUGR?

BPD & HC normal
AC small

What is suggestive of femur sparring IUGR?

FL 90th percentile
AC below 5th

What is the best indicator of IUGR?

AC
liver is severely affected by IUGR

What is the best indicator for predicting a symmetrical IUGR?

HC/AC ratio
EFW decreasing
ratio increases with increasing gestational age with IUGR

What is indicative of oligohydramnios?
polyhydramnios?

oligo< 5cm
poly >22 cm

What are the placental markers that indicate IUGR?

decreased placental thickness < 1.5 cm
grade 3 before 36 weeks
NOT good method!

What is the chance of fetal loss with CVS?

1% - 3%
missing limbs risk too

What are the advantages of CVS?

early (10-12 weeks)
results in 1 week
more options if early

What are the benefits of amniocentesis?
when is it done?

disgnose spina bifida
chromosomal abnormalities
15 - 20 weeks

Why would amnio be performed?

advanced maternal age
children with chromosomal abnormalities
AFT
U/S detected problems

What are physical features suggesting chromosomal abnormalities?

clenched hands
5th middle phalanx hypoplasia
choroid plexus cysts
ventriularmegaly
thickened nuchal fold
cardiac anomalies
omphalocele
spina bifida
foot anomalies

What is PUBS?

Percutaneous umbilical cord sampling
difficult
done on patients when CVS and amnio inconclusive

What is FISH?

experimental
florescent chromosomal markers into amniotic fluid
early detection of Trisomy 13 18 21
amniocentesis must be done after

Where is AFP found?

fetal spine
GI tract
liver
kidneys
transported to mother placenta

What are the causes of elevated AFP?

ectopia corditis
anterior abdominal wall defect
bowel obstruction
amniotic band syndrome
twins
renal disorders
placental lesions
fetal heart disease - hydrops / ascites
Cystic hygroma
maternal & fetal liver disease
oligohydramnios
heredity
blood contaminated anmiocentesis
virus / infection
high blood pressure

What are the causes of decreased AFP?

Trisomy 13, 18, 21
fetus younger than expected
fetal death
hydatidiform mole
spontaneous abortion

When do fetal AFP levels peak?

15 - 18 weeks.

Trisomy 18

Edwards not good usually fatal

Trisomy 21

downs

Trisomy 13

Patau's syndrom