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OBSTETRIC PATHOLOGY > SONOGRAPHY AND HIGH RISK PREGNANCY > Flashcards

SONOGRAPHY AND HIGH RISK PREGNANCY Flashcards

1
Q

Maternal high-risk factors include
Risk Factors

A

• Maternal high-risk factors include
• Advanced maternal age
• Abnormal maternal lab values
• Vaginal bleeding
• Insulin-dependent diabetes mellitus (IDDM)
• Hypertension (HT)
• Preeclampsia
• Maternal systemic disease

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2
Q

Advanced Maternal Age (AMA)

A

*AMA refers to patient who will be 35 or older at time of delivery.
•Incidence of Down syndrome increases with age.
•In United States, standard practice to offer AMA women genetic counseling and invasive prenatal testing for karyotypic analysis.

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3
Q

• Screening for fetal anomalies performed when

A

• Screening for fetal anomalies performed in either first or second trimester
• First trimester testing looks for the pattern of biochemical markers associated with plasma protein A (PAPP-A) and free beta-hCG3.

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4
Q

Second trimester screening performed with maternal serum quad screen lab value and targeted ultrasound exam
•Quad screen looks at following serum markers:

A

> Alpha-fetoprotein (AFP)
Human chorionic gonadotropin (HCG)
Unconjugated estriol (uE3)
Inhibin-A
•Targeted ultrasound is detailed evaluation of all fetal anatomy seen at time of exam.

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5
Q

Hydrops fetalis

A

•Hydrops fetalis: condition in which excessive fluid accumulates within fetal body cavities
•Two classifications of fetal hydrops:
immune hydrops and nonimmune hydrops

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6
Q

•Two classifications of fetal hydrops:

A

immune hydrops and nonimmune hydrops

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7
Q

sensitization

A

• Is initiated by the presence of maternal serum immunoglobulin G (IgG) antibody against one of the fetal RBC antigens (known as sensitization)
• Antigen: substance that elicits immunologic response such as production of antibody to that substance

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8
Q

Immune Hydrops

A

• Occurs anytime mother exposed to RBCs antigens different from her own, as under these conditions:
• Father and fetus Rh+
• Mother Rh-
• maternal-fetal hemorrhage (mixing of blood)
• Maternal antibodies are produced against Rh antigen.

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9
Q

anasarca).

A

*Hemolysis can result in fetal anemia, leading to CHF and edema of fetal tissues (anasarca).

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10
Q

(extramedullary poiesis).

A

• Fetal bone marrow then replaces destroyed RBCs.
• If bone marrow cannot keep up with destruction, new sites recruited to produce additional RBCs (extramedullary poiesis).

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11
Q

Potential of fetal anemia can be determined

A

• Potential of fetal anemia can be determined by
• Ultrasound surveillance
• Amniocentesis
• Cordocentesis

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12
Q

•Sonographic findings of hydrops

A

•Sonographic findings of hydrops
• Scalp edema
• Pleûral effusion
• Pericardial effusion
• Ascites
• Polyhydramnios
• Thickened placenta

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13
Q

Ultrasound Surveillance in hydrops

A

•Another ultrasound tool to predict fetal anemia is
Doppler evaluation of middle cerebral artery (MCA).
•Anemia is condition in which there are fewer red blood cells, so blood viscosity is decreased.
* Anemia is condition in which there are fewer red blood cells, so blood viscosity is decreased.
•Decrease in viscosity results in decrease in resistance to flow.

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14
Q

Ultrasound Surveillance

A

*Following changes in vascular resistance and a reduction in blood viscosity there is an increase in cardiac output.
§As a result, the fetus develops a hyperdynamic circulation and blood flow is redistributed to vital end organs, including brain, heart and adrenals.
•Detected by increase in velocity in MCA

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15
Q

Amniocentesis

A

• One way to use amniocentesis to monitor pregnancy is to obtain sample of amniotic fluid for direct Rh testing of fetus.
• Second way is to monitor the isoimmunized pregnancy with delta optical density 450 (AOD450)
analysis of AF.

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16
Q

Amniotic Fluid testing in HDN
Hemolytic Disease of the Newborn (HDN)

A

Amniotic Fluid testing in HDN
• Hemolytic Disease of the Newborn (HDN)
Also called Hemolytic Disease of the Fetus and Newborn
(HDFN) or erythroblastosis fetalis.
• “classical” case: Rh-negative mothers with Rh+ infants
Other red blood group discrepancies between Mom and Baby
can also produce HDN
Fetal cells with antigen foreign to the Mom enter her circulation and stimulate the production of antibodies.
• Danger increases with each exposure.

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17
Q

Spectrophotometric

A

• Because hemolysis results in breakdown of red blood cells, a by-product, bilirubin, stains the amniotic fluid.
• Bilirubin absorbs light at the 450-nm wavelength.
• Spectrophotometric analysis of fluid indirectly measures amount of bilirubin present in fluid and therefore gives measure of degree of hemolysis.

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18
Q

• AOD450 categorized into three zones on Liley curve.

A

Liley’s Graph
Liley’s bottom zone represent affected or very mildy affected fetus. The middle zone show minimally affected fetus and the upper zone indicate moderate to marked hemolysis in fetus. Higher concentration of bilirubin in amniotic fluid is found in abnormal fetus.

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19
Q

Liley Graph
• The amniotic fluid is subjected to a spectrophoto-metric scan at steadily increasing wavelengths so that the change in the optical density at 450 nm
(AOD450) can be calculated.

A

gestational age in weeks.
• Zone 1 - Observe fetus for stress-repeat 2-4 weeks
• Zone 2 - Moderate disease: May require treatment
• Zone 3 - Severe problems - Deliver/treat

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20
Q

Amniocentesis

  1. Low zone
A
  1. Low zone: Rh-negative and mildly affected fetuses found in low zone
    > Should be followed expectantly
    • Delivered at term
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21
Q

Amniocentesis

Mid-zone:

A

Amniocentesis
2. Mid-zone:
= Downward trend within mid-zone indicates fetus probably affected but will survive; delivery should occur at 38 weeks of gestation
*Horizontal or rising trend: fetus in danger of death
Preterm delivery or intrauterine transfusion and preterm delivery indicated.

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22
Q
  1. High zone: Fetal death zone
A
  1. High zone: Fetal death zone
    •Reques immediate treatment or death will
    result
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23
Q

Cordocentesis

A

• Needle placed into fetal umbilical vein and blood sample obtained
• Lab evaluates sample for fetal blood type, hematocrit and hemoglobin.
• Fetal transfusion may be performed.
• Two methods of transfusing fetus

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24
Q

Alloimmune Thrombocytopenia
اولین ایمیون هیدروپس آنتیک بادی بر علیه گلبول قرمز
اینجا بر علیه پلاکت

A

• Rare circumstance
• Mother may develop immune response to fetal platelets in manner like that of RBCs.
• She develops antibodies to fetal platelets.
• Result can be fetus with dangerously low platelet count (thrombocytopenia).

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25
Q

thrombocytopenia

A

She develops antibodies to fetal platelets.
• Result can be fetus with dangerously low platelet count (thrombocytopenia)

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26
Q

Alloimmune Thrombocytopenia

A

• Infants born with this condition at increased risk for intracerebral hemorrhage in utero and spontaneous
bleeding
• Cordocentesis is to document fetal platelet counts before vaginal delivery attempted.
• Ultrasound to look for in utero fetal intracerebral hemorrhage

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27
Q

Cordocentesis in Alloimmune Thrombocytopenia

A

Cordocentesis is to document fetal platelet counts before vaginal delivery attempted

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28
Q

Ultrasound in Alloimmune Thrombocytopenia

A

• Ultrasound to look for in utero fetal intracerebral hemorrhage

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29
Q

Nonimmune Hydrops (NIH)

A

• NIH describes group of conditions in which hydrops present in fetus but is not result of fetomaternal blood group incompatibility.
• Numerous fetal, maternal, and placental disorders are known to cause or be associated with NIH.

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30
Q

often most frequent causes of NIH

A

• Cardiovascular lesions often most frequent causes
• Congestive heart failure may result from functional cardiac problems, as well as from structural anomalies.

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31
Q

Nonimmune Hydrops

A

• Obstructive vascular problems occurring outside of the heart can cause NIH.
• Large vascular tumors functioning as arteriovenous shunts can also fesult in NIH.

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32
Q

another well-recognized etiology for NIH

A

• Severe anemia of fetus another well-recognized etiology for NIH
• Anemia not caused by isoimmunization, but result
is the same
• Severe anemia may occur in donor twin of twin-to-twin transfusion syndrome, thalassemia, or significant fetomaternal hemorrhage.
• To make diagnosis of NIH, isoimmunization ruled out with antibody screen

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33
Q

• To make diagnosis of NIH,

A

• To make diagnosis of NIH, isoimmunization ruled out with antibody screen

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34
Q

Sonographic findings
•

A

Sonographic findings
• Fetus may appear like a sensitized baby.
• Scalp edemo pleural and pericardial effusions, ascites

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35
Q

• Other abnormal findings may be present indicating cause of hydrops.

A

• If hydrops the result of cardiac tachyarrhythmia, HR of 200 to 240 bpm is common
• If diaphragmatic hernia present, bowel visible in chest cavity

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36
Q

after fetal heart converted to normal rhythm in NIH

A

• If fetus anemic because of twin-to-twin transfusion, intrauterine transfusion will pot solve anemia
• problem because most of fetal blood being shunted to recipient twin.

37
Q

Abnormal placental implantation

A

A defect in the decidua basalis can cause the placenta to adhere
directly to the uterine myometrium placenta accreta,
• invade the myometrium-placenta increta, or
• completely invade through the myometrium-placenta percreta.

38
Q

Abnormal placental implantation
is a risk factor for a poorly developed decidua basalis, as is placenta previa.

A

Intrauterine scarring from previous infections or uterine surgeries

39
Q

These abnormal placental attachments can result in serious maternal and fetal complications, including
.

A

massive hemorrhage,
damage to organ structures surrounding the uterus,
cesarean-hysterectomy,
and Maternal or fetal death.

40
Q

Transvaginal image of placenta and maternal urinary bladder.

A

Normal sonographic appearance of the placenta. حتما مرز هایپواکویک بین میومتریوم و پلاسنتا چک‌ شود

(A) Transabdominal US demonstrated homogeneously hyperechoic second trimester placenta (asterisk)in relationship to hypochoic myometrium(arrows).

Transvaginal image of placenta and maternal urinary bladder.
Arrows are showing hypochoic vascular lacunae.
Curved arrow is pointing at loss of the subplacental hypochoic zone.

41
Q

Vaginal Bleeding

A

• Bleeding in second and third trimesters can be associated with placental anomalies
• Placenta previa
• Placenta abruption
• Placenta previa main cause for third trimester bleeding
• In this condition, placenta covers internal cervical os and prohibits delivery of fetus

42
Q

•
•to evaluate any structures in front of cervical os to see if vascular

A

Color Doppler to evaluate any structures in front of cervical os to see if vascular

43
Q

Vasa previa

A

Vasa previa rare condition in which umbilical cord is presenting part
• Life threatening to fetus
• Associated with velamentous cord insertion or succenturiate lobe

44
Q

Vasa previa must be distinguished from funic presentation (prolapse with the umbilical cord between the presenting part and the internal cervical os).

A

Vasa previa must be distinguished from funic presentation (prolapse with the umbilical cord between the presenting part and the internal cervical os).
In funic presentation, unlike in vasa previa, the umbilical cord moves away from the cervix during ultrasound evaluatipn; in vasa previa, the cord is fixed in place.

45
Q

• Placental abruption
•

A

• Placental abruption may cause vaginal bleeding during pregnancy.
• Premature separation of placenta from uterine wall
• Look at area between placenta and uterine wall

46
Q

• Look at area between placenta and uterine wall

A

• Normally, area hypochoic and 1 to 2 cm thick
• If thicker than 1 to 2 cm, may be due to abruption or uterine contraction
• Uterine contractions should resolve within 20 to 30 minutes and typically have central blood flow.

47
Q

Abruptions difficult to diagnose because

A

• Abruptions difficult to diagnose because clotted blood has same sonographic appearance as placental tissue
• If bleeding from abruption is recent, may notice thin echolucent area between placenta and uterus
• However, while one may be suspicious of an abruption, there may be no ultrasound signs of an abruption at all.

48
Q

Use color flow Doppler to search for abruption.

A

• Use color flow Doppler to search for abruption.
• Blood clots from abruption will not exhibit color
flow.
• Retroplacental area hypochoic due to large number of blood vessels (mainly veins)
• Sweep with color Doppler retroplacentally looking for flow void; if flow void present, be suspicious of abruption.

49
Q

Maternal Diseases of Pregnancy
Diabetes

A

Diabetes
• Insulin-dependent diabetic mellitus (IDDM)
mothers at increased risk for pregnancy-related complications, including early and late trimester pregnancy loss and congenital anomalies

50
Q

Diabetes

A

• Pregnancies may be complicated by frequent hospitalizations for
• Glucose control
• Serious infections such as pyelonephritis
• Need to be monitored frequently for adequate nutritional and fluid intake, especially if experiencing hyperemesis in first trimester

51
Q

DIABETES Need to be monitored frequently for

A

Need to be monitored frequently for adequate nutritional and fluid intake, especially if experiencing hyperemesis in first trimester

52
Q

Glucose primary fuel for fetal growth
• If glucose levels very high and uncontrolled, fetus

A

• Glucose primary fuel for fetal growth
• If glucose levels very high and uncontrolled, fetus may also become macrosomic
• Macrosomia defined as fetus whose weight >90th percentile for gestational age

53
Q

SHOULDER DISTOCIA

A

•Diabetes
• Macrosomic infant may become too large to fit through mother’s pelvis, necessitating cesarean section.
• If delivery accomplished
vaginally, may have difficulty delivering shoulders (shoulder dystocia)
• Brachial plexus nerve injuries may result.

54
Q

Small placenta
Large placenta

A

IUGR
HYPERTENTION
! Large placenta
HYdrops
Hematoma

55
Q

Hypertension

A

• Places both mother and fetus at risk
• Hypertensive pregnancies may be associated with small placentas.
• If placenta develops poorly, blood supply to fetus may be restricted, and growth restriction may result.
•Growth-restricted fetuses at increased risk of fetal distress and death in utero

56
Q

Term toxemia

A

• Various forms of hypertensive disease during pregnancy
• Term toxemia was used to describe hypertensive disorders, because believed that “toxin” in mother’s bloodstream caused hypertension
• Currently, pregnancy-induced hypertension considered to be caused by prostaglandin abnormalities

57
Q

• Terminology used in clinical practice to describe hypertensive states during pregnancy

A

> Pregnancy-induced hypertension (includes preeclampsia, severe preeclampsia, and eclampsia)
Chronic hypertension “(present before woman pregnant)

58
Q

• Preeclampsia is pregnancy condition in which high blood pressure develops with proteinuria (protein in urine) or edema (swelling).

A

• Preeclampsia is pregnancy condition in which high blood pressure develops with proteinuria (protein in urine) or edema (swelling).
• If hypertension neglected, patient may develop seizures that can be life-threatening to both mother and fetus.
• Severe preeclampsia may develop in some cases; refers to severity of hypertension and proteinuria
Generally, indicates patient must be delivered immediately

59
Q

Severe preeclampsia may develop in some cases;

A

Severe preeclampsia may develop in some cases; refers to severity of hypertension and proteinuria
Generally, indicates patient must be delivered immediately

60
Q

Eclampsia represents

A

• Eclampsia represents occurrence of seizures or coma in preeclamptic patient.

61
Q

• Chronic hypertension diagnosed in patients in whom

A

• Chronic hypertension diagnosed in patients in whom high blood pressure found before 20 weeks of gestation.
• Chronic hypertension can result from primary essential hypertension or from secondary hypertension. (renal, endocrine, or neurologic causes).

62
Q

Hypertension

A

• Doppler ultrasound can give information regarding fetal and maternal circulatory status, which may help determine pregnancies at risk for developing IUGR.

63
Q

Systemic Lupus Erythematosus

A

• Systemic lupus erythematosus (SLE) is chronic autoimmune disorder that can affect almost all organ systems in body.
cause maint women of childbearing age;
may cause multiple peripartum complications
• Incidence of spontaneous abortion and fetal death is 22% to 49%.

64
Q

Systemic Lupus Erythematosus

A

• Placenta affected by immune complex deposits and inflammatory responses in placental vessels
• May account for increased number of spontaneous abortions, stillbirths, and IUGR fetuses

65
Q

Systemic Lupus Erythematosus

A

• Fetus must be monitored to rule out congenital heart block and pericardial
effusion.
M-mode through the atrial and ventricular wall demonstrating a ventricular heart rate of 51 beats per minute and an atrial heart rate of 168 beats per minute in a fetus with complete heart block.

66
Q

Hyperemesis gravidarum

A

• Hyperemesis gravidarum exists when pregnant woman vomits so much she develops dehydration and electrolyte imbalance.

67
Q

Hyperemesis

A

• Hospitalization with IV fluid administration usually necessary
• Must ensure vomiting results strictly from pregnancy and notother disease, such as gallstones, peptic ulcers, or trophoblastic disease

68
Q

Urinary Tract Disease

A

• Approximately 4% to 6% of pregnant women have asymptomatic bacteriuria.

69
Q

• Pyelonephritis usually presents with flank pain, fever, and white blood cells in urine.

A

• Pyelonephritis usually presents with flank pain, fever, and white blood cells in urine.
• Hydronephrosis also presents with flank pain.
• Pregnancy normally associated with mild hydronephrosis.

70
Q

• Pyelonephritis

A

• Pyelonephritis usually presents with flank pain, fever, and white blood cells in urine.

71
Q

• Pregnancy normally associated with mild hydronephrosis.

A

• Pregnancy normally associated with mild hydronephrosis.

72
Q

Adnexal Cysts

A

• Physiologic ovarian cysts may be associated with early pregnancy.
• Cysts may be large, from 8 to 10 cm, and may be associated with pelvic pain.
• Cyst should diminish as pregnancy progresses.

73
Q

Adnexal Cysts

A

• If cyst does not resolve, surgical exploration may be necessary to rule out other ovarian pathology.
• Such pathology would include endometrioma dermoid cysts and cancer.
• Periodic ultrasound examinations necessary for follow-up of cyst.

74
Q

Obesity

A

• Maternal obesity associated with increased incidence of neural tube defects
• More obese women start pregnancy with chronic hypertension than women who are of normal weight.
• Obese women also at increased risk for pregnancy-induced hypertension

75
Q

• Obese women also at increased risk for

A

*Obese women also at increased risk for
* Severe eclampsia o
• Multiple births
• Urinary tract infections

76
Q

Uterine Fibroids

A

• Are benign tumors of uterine smooth muscle
• May be stimulated to excessive hormones of
pregnancy,
specifically estrogeno

77
Q

Uterine Fibroids

A

• If growth very rapid, the fibroid may outgrow its blood supply and undergo necrosis
• May cause pain and premature labor
• Ultrasound examination of uterus in pregnant woman may detect uterine fibroids.

78
Q

Premature Labor

A

• Is onset of labor before 37 weeks of gestation
• Is obstetric complication oc@urring in 15% to 20% of all pregnancies
• Premature infants at greater risk for having problems:
• Respiratory distress syndrome
• Intracranial hemorrhage
• Bowel immaturity

79
Q

Premature infants at greater risk for having problems:

A

• Premature infants at greater risk for having problems:
• Respiratory distress syndrome
• Intracranial hemorrhage
• Bowel immaturity
• Feeding problems

80
Q

• Ultrasound assessment of preterm labor patient should include:

A

Amniotic fluid assessment
• Cervical assessment
• Fetal number
• Placental assessment
• Targeted ultrasound

81
Q

Premature Rupture of Membranes.

A

Premature Rupture of Membranes.
The intrauterine membranes containing the fetus and amniotic fluid are usually intact until the mother is in early labor or they are intentionally ruptured to begin labor.
The membranes may rupture and cause the loss of amniotic fluid before labor begins, bringing the mother to a triage center for evaluation of PROM.
The amniotic sac containing the fluid protects the fetus from infection, and a disruption of this membrane without ensuing labor is a concern for the potential of infection.
The ultrasound staff is often asked to evaluate the amount of amniotic fluid in a pregnancy with a suspicion of PROM.
Oligohydramnios, or a decreased amount of amniotic fluid, may be evident and reported to the medical staff to help confirm the diagnosis.

82
Q

Fetal Death

A

• Intrauterine fetal death accounts for roughly half of all perinatal mortality.
• Cause of death cannot be determined in approximately 50% of cases. Known causes:
• Infection
• Congenital or chromosomal abnormalities
• Preeclampsia
• Placental abruption
• Diabetes
• Growth restriction
• Blood group isoimmunization

83
Q

• Clinically, first trimester pregnancy loss may be diagnosed when patient presents to her physician with:
• Vaginal bleeding
• Cramping

A

chinically, trad armor
diagnosed when patient presents to her physician with:
• Vaginal bleeding
• Cramping
• Passage of tissue
• Ultrasound examination may reveal blighted ovum or fetus with no heart motion.

84
Q

• Second trimester pregnancy landmarks important in determining whether pregnancy proceeding normally.

A

• Second trimester pregnancy landmarks important in determining whether pregnancy proceeding normally.
• CO weeks of gestation
• Uterine fundal height should have risen to umbilicus.
• Uterus should measure approximately 20 cm above symphysis pubis.
• Mother should also perceive fetal movements on daily basis beginning between 16 and 20 weeks of gestation.

85
Q

FETAL DEATH IN US
Ultrasound findings associated with fetal death:

A

• Absence of fetal heart rate usually prompts clinician to obtain ultrasound examination.
• Cessation of fetal movements should prompt an immediate search for fetal heart tones.
• If none are present, ultrasound examination will confirm or rule out intrauterine fetal demise.
Ultrasound findings associated with fetal death:
• Absent heartbeat
• Absent fetal movement
• Overlap of skull bones (Spalding’s sign)
• Exaggerated curvature of fetal spine; gas in fetal abdomen

86
Q

(Spalding’s sign

A

Overlap of skull bones.

87
Q

Small for Gestational Age

A

• Can be due to:
• Chromosomal anomalies
• Intrautefine infection
• Genetics
• Placental insufficiency

88
Q

Small for Gestational Age

A

• If chromosomal anomalies are etiology for fetus measuring small, growth often symmetrically affected
• All fetal measurements will be smaller than expected for gestational age.

89
Q

Small for Gestational Age

A

• When placental insufficiency is cause, fetuses often develop asymmetrical intrauterine growth restriction pattern.
• This pattern results in a normal head measurement with small abdominal circumference and smaller-than-expected limb growth.

OBSTETRIC PATHOLOGY (7 decks)

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