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Chapters 22,23, 24, 25

When does Intrauterine Growth Restriction (IUGR) occur?

When developing fetus doesn't receive enough nutrition to provide for normal metabolic needs.

The major physiologic factor with IUGR is:

A decrease in uterine plasma volume.

IUGR causes are most related to what?

Uterus, placenta, AFV, and placental transfer rate

How much does the infant have to weigh to be considered IUGR?

Below the 10th percentile for gestational age.

IUGR infants are likely to be what? Why?

Hypoglycemic
(b/c of diminished stores of fat & glycogen)

What are the clinical signs of IUGR?

UT small for dates
History of maternal condition associated with IUGR

Symmetric IUGR (25%)

Growth restriction affecting the entire fetus.

What is the cause of Symmetric IUGR?

Genetic or due to maternal infection.

Symmetric IUGR measurement:

All measurements are >2 wks BELOW expected GA (based on LMP)

Symmetric IUGR - What diameter is consistent with dates when others are less than expected?

Transcerebellar diameter

Symmetric IUGR - sono

Oligohydramnios
Mature PL earlier than expected
Low BPP score

When does Asymmetric IUGR occur?

Last 8-10 weeks of pregnancy

What causes Asymmetric IUGR?

Hemodynamic patterns attempt to protect the brain, which receives the most nutrient rich blood first.

Asymmetric IUGR

Asymmetry between the head and abd

Asymmetric IUGR - what is the HC/AC ratio?

>2 SD

Asymmetric IUGR - The AC measures how many weeks behind the HC?

2 weeks

Asymmetric IUGR - sono

Oligohyramnios
Mature PL earlier than expected

Erythroblastosis Fetalis

Destruction of fetal RBC's by antibodies with subsequent fetal or neonatal complications.

What are the causes of Erythroblastosis Fetalis?

Rh incompatibility
ABO incompatibility
Isoimmune Disease
Other minor blood group incompatibility

What are the clinical findings of Erythroblastosis Fetalis?

CHF
Fetal Death
Hydrops Fetalis

Hydrops Fetalis

An excessive accumulation of fluid in fetal tissues and body cavities.

What are the two types of Hydrops Fetalis?

1. Immune
2. Non-Immune

What is usually present with Hydrops Fetalis?

Interstitial Edema
Pleural effusion
Pericardial effusion
Ascites

Immune Hydrops

Maternal antibodies recognize Rh antigens on fetus's RBC's as foreign & attack and destroy them.

What is the cause of Immune Hydrops?

Due to Rh (Rhesus) incompatibility
(AKA Rh isoimmunization)

Immune Hydrops occurs with what kinds of parents?

Rh-mother, Rh+father (Rh +fetus)

What results from the destruction of RBC's?

Erythroblast fetalis and fetal anemia
(which results in hydrops)

What determines fetal anemia?

Mid Cerebral Artery (MCA)

When does Immune Hydrops occur? Why?

Delivery, abortion, PL abruption, hemorrhage, or amniocentesis.

(b/c RBC's dont cross the PL)

What is given after each pregnancy or amniocentesis to prevent antibodies from forming?

RhoGam

Non-Immune Hydrops

Hydrops due to any cause other than Rh sensitization.

Non-Immune Hydrops causes: CIC CAT

C - cardiac anomalies (arrhythmias)
I - infection (TORCH) (Fifth Disease)
C - Chromosome abnormalities

C - Congenital hematologic disorders
A - Abdominal or pulmonary masses leading to venous
obstruction.
T - TTTS

What is the earliest sign of Hydrops Fetalis?

Pericardial Effusion

Hydrops Fetalis - sono - HAPPP F

H - hepatosplenomegaly
A - ascites
P - PL thickening
P - pleural effusion
P - polyhydramnios

F - fetal skin thickening (anasarca) (>5cm)

Fetal demise sono findings:

Absent cardiac activity
Exaggerated fetal position

Fetal Demise - Robert's Sign

Echogenic foci (gas) in pulmonary vessels or abdomen.

Fetal Demise - When do you usually see Robert's Sign?

About 1 week after demise

Fetal Demise - Spaulding's Sign

Overlapping skull bones.
Fetal maceration (softening of tissue after death)

Fetal Demise - When do you usually see Spaulding's Sign?

About 1 week after demise

Fetal Demise - Duel's Sign/Halo Sign

Halo effect seen secondary to subcutaneous scalp edema in fetal demise.

Diabetes Mellitus (DM)

Produces disorders of carbohydrate metabolism related to insulin deficiency.

Diabetes Mellitus is characterized by what?

Hyperglycemia

What can Diabetes Mellitus be related to?

Spontaneou (90%)
Pancreatic Disease
Hormonal Imbalence
Drug reactions

Diabetes Mellitus Type 1

Juvenile onset
Insulin Dependent

Diabetes Mellitus Type 2

Adult onset
Non-insulin dependent (occasionally insulin dep)

What is a serum marker for control of DM in insulin dependent patients?

Hemoglobin A1C

Gestational Diabetes

Glucose intolerance of pregnancy which results from hormonal and metabolic changes associated with pregnancy.

Gestational Diabetes frequently occurs in what trimester?

3rd trimester

What is Gestational Diabetes associated with?

Macrosomia

DM - congenital anomalies : NGGCCSS

N - neural tube defects
G - GI anomalies
G - GU anomalies
C - Cardiovascular anomalies
C - caudal regression syndrome
S - Single umbilical artery
S - skeletal anomalies

DM - fetal complications: RHHIM

R - respiratory distress syndrome
H - hypoglycemia
H - hypocalcemia
I - IUGR
M - macrosomia

Macrosomia fetal weight:

>4,000 grams
Birth weight >90th percentile for GA

Macrosomia is associated with what?

Hydrops
Polyhydramnios
Stillbirth
Birth trauma
dystocia

DM - sono - Fetal anatomy

Single umbilical artery
Oligo or Poly

DM - sono - PL changes

Thickened PL (gestational diabetes)

DM - sono - Growth related changes

IUGR (Diabetes predating pregnancy)
Macrosomia (gest diabetes)

Essential HTN

Pre-existing HTN that is not related to the pregnancy
(AKA: Chronic HTN)

PIH

Pregnancy induced HTN

Gestational HTN

HTN during pregnancy without signs of pre-eclampsia

GEPHS stands for what?

Gestational Edema Proteinuria Hypertensive Syndrome

GEPHS is also known as:

Toxemia of pregnancy

GEPHS occurs in what type of patients?

Primigravidas (1st time preg)
Multiple gestation
Patients with family history

What are the 2 classifications of GEPHS?

Pre-eclampsia
Eclampsia

Pre-eclampsia is characterized by what 4 things?

1. HTN
2. Generalized Edema
3. Proteinuria
4. Rapid weight gain (secondary to edema)

Eclampsia is characterized by what 3 things?

1. Convulsions
2. Coma
3. Death
(In addition to edema, proteinuria, HTN)

What are the maternal signs of Eclampsia? HAS HAG

H - HTN
A - ankle swelling
S - sudden excessive weight gain

H - headaches
A - abdominal pain and vomiting
G - generalized edema

Eclampsia - sono - FO PIIS

F - fetal demise
O - oligo

P - premature PL
I - IUGR
I - increased risk of abruption
S - sono used to track fetal growth

HELLP Syndrome (complications of pre-eclamspia)

H - hemolysis (breakdown of RBC's)
E - elevated
L - liver enzymes
L - low
P - platelets

TORCH Infections

T - toxoplasmosis
O - other (syphilis)
R - rubella
C - cytomegalovirus
H - herpes

Toxoplasmosis is caused by what?

Protozoan, T gondii
Commonly found in cat feces and uncooked meat

Toxoplasmosis may result in what? JIMMI CHTT

J - jaundice
I - IUGR
M - micropthalami
M - microcephaly
I - intracranial calcifications

C - CNS calcifications
H - hydrocephalus
T - thickened PL
T - thrombocytopenia

Rubella is also called:

German Measles

Rubella is especially teratogenic for the fetus during how many weeks?

1st 5 weeks of pregnancy

What are defects associated with Rubella?

Cataracts
Congenital Heart Disease
Deafness
Mental Retardation

Cytomegalovirus (CMV) causes what if it occurs in the 1st trimester?

Fetal Demise

What is the most common infection in pregnancy?

Cytomegalovirus

Cytomegalovirus may cause:

Spontaneous Abruption
IUGR
Fetal ascites
Fetal Death
Cranial anomalies
Chest anomalies

Herpes - when is it transmitted to the fetus?

During vaginal delivery
(C-section usually performed)

Parvovirus

Common respiratory viral infection

PUBS stands for:

Percutaneous Umbilical Blood Sampling

Maternal infections - sono - HII CCV

H - hydrops
I - IUGR
I - increased or decrease PL thickness

C - cranial/cerebral anomalies
C - cardiac anomalies
V - visceral calcifications (brain, liver)

Incompetent CX / Insufficient Cx

Premature dilation and enfacement of the UT CX.

Inability of the CX to prevent premature expulsion of the UT contents.

Is Incompetent CX congenital or aquired?

Either

Incompetent CX is most commonly related to what?

CX trauma

Cerclage

Stitch the CX closed
Placed via McDonald or Shirodkar Procedure

Incompetent CX - What would be seen prior to 34 weeks?

Shortened CX (<2.5 to 3 cm)

Incompetent CX - What is the most reliable thing when diagnosing?

Dilation of CX (>2 cm in the 3rd trimester)

What are the clinical signs of maternal anemia?

Hgb < 10g/100mm
Hct < 30%

What are the types of maternal anemias? IF DAT

I - iron deficiency (95%)
F - folic acid deficiency

D - drug induced hemolytic anemia
A - aplastic anemia
T - thalassemia

Uterine rupture is a major cause of what?

Maternal Death

What are the clinical signs associated with uterine rupture?

UT pain
Small amount of Vaginal Bleeding
Sudden increase in fetal station (position)

What are the sonographic signs associated with Uterine rupture?

Oligohydramnios
Large amount of maternal free intraperitoneal fluid

Preterm Labor

The onset of labor prior to 37 weeks

What are the etiologies of Preterm Labor? HUMMPP SAM

H - heavy smoking
U - UT anomalies
M - multiple gestation
M - maternal stress
P - poly
P - previous UT surgery

S - systemic infections (appendicitis with sepsis)
A - antepartum bleeding (previa, abruption)
M - maybe idiopathic

Premature Rupture of the Membranes (PROM)

Spontaneous rupture prior to labor

PROM clinical signs:

Large passage of watery fluid from VG

What are the PROM sono signs?

Oligohydramnios with NORMAL fetal bladder

What happens to UT fibroids during pregnancy?

Enlarge due to estrogen stimulation

Ovarian cysts are ------- seen during pregnancy.

Frequently

What 2 types of Ovarian Cysts are associated with pregnancy?

Corpus Luteum Cysts
Theca Lutein Cysts

Corpus Luteum Cysts are normal in which trimester?

1st trimester

Corpus Luteum Cysts usually regress by how many weeks?

12-15 weeks

Corpus Luteum Cysts secrete ------.

Progesterone

What do Theca Lutein Cysts occur with?

Gestational Trophoblastic Disease

Amniotic Band Syndrome is caused by what?

Disruption of the amnion early in pregnancy

Amniotic Band Syndrome

Bands of tissue that trap and constrict portions of the fetal body

What is the most severe associations with Amniotic Band Syndrome?

Limb-Body Wall Complex (LBWC)

Amniotic Band Syndrome - what are the craniofacial defects?

Asymmetric Encephalocele
Asymmetric Facial Clefts
Severe facial dysmorphia

Amniotic Band Syndrome - what are the limb defects?

Extremity amputation
Clubfoot

Amniotic Band Syndrome - What are the visceral defects?

Abdominal wall defects
Ectopia Cordis

Trisomy 13 is also called:

Patau's Syndrome

Trisomy 13 is associated with what?

Facies
Psychomotor Retardation
Multiple anatomic abnormalities

Trisomy 13 - What is the prognosis?

Poor
(85% die within the 1st year)

Trisomy 13 - What is associated with it? HIPS C

H - holoprosencephaly
I - IUGR
P - polydactyly
S - single umbilical artery

C - cleft lip/palate (esp median cleft)

What else is associated with Trisomy 13? TACO V

T - truncus arteriosus
A - agenesis of corpus callosum
C - cystic renal dysplasia
O - omphalocele

V - VSD

What is common with Trisomy 18 (Edwards Syndrome)?

IUFD
Stillbirth

What is the average lifespan with Trisomy 18 ?

5 days

What is Trisomy 18 associated with?

Psychomotor Retardation
Growth Deficiency

What pathologic abnormalities are associated with Trisomy 18 ? VAMPIR SOCS

V - VSD
A - ASD
M - micrognathia
P - polyhydramnios
I - IUGR
R - rocker bottom foot

S - "strawberry" shaped cranium
O - overlapping fingers
C - CP cysts
S - single umbilical artery

What else is associated with Trisomy 18? HODE

H - hydronephrosis
O - omphalocele
D - diaphragmatic hernia
E - enlarged CM

Trisomy 21 (Down's Syndrome) is associated with what?

Mental retardation
Characteristic physical appearance

Trisomy 21 - sono - DAVE TRENCH SPC

D - duodenal atresia
A - ASD
V - VSD
E - endocardial cushion defect

T - thickened nuchal fold
R - renal pyeliectasis
E - echogenic intracardiac focus
N - non-immune hydrops
C - cystic hygroma
H - hyperechoic bowel

S - small/absent nasal bone
P - pleural effusion
C - cinodactyly

Incidence rate for Trisomy 13,18,21:

Trisomy 13 - 1:6,000
Trisomy 18 - 1:3,000
Trisomy 21 - 1:710

Turner's Syndrome is also referred to as:

Monosomy X (45 XO)

Turner's Syndrome

Complete or partial absence of an X chromosome

Turner's Syndrome - sono

Cystic Hygroma
Lymphedema
Non-immune hydrops
Cardiovascular abnormalities
Horseshoe Kidneys
Renal Agenesis

Turner's Syndrome - postnatally sono

Hypoplastic/Aplastic UT
OV dysgenesis
Streak like ovary

Beckwith-Weidmann Syndrome

The presence of EMG anomalies:
E - exomphalos (omphalocele)
M - Macroglossia
G - Gigantism

Beckwith-Weidmann Syndrome is associated with what?

Cardiac malformations
PL enlargement
PL chorioangiomas
Postnatal renal tumor (Wilm's Tumor)

Pentalogy of Cantrell is associated with which 2 major defects?

Omphalocele
Ectopia Cordis

What are the other defects associated with Pentalogy of Cantrell?

Vertebral anomalies
ASD
VSD
Teralogy of Fallot
Trisomy 13 & 18
Turner's syndrome
Craniofacial abnormalities
Single umbilical artery
Fetal ascites

Meckel-Gruber Syndrome is autosomal:

Autosomal Recessive

Meckel-Gruber Syndrome

Includes:
Encephalocele
Polycystic kidneys
Polydactyly
Cleft Lip

VATER / VACTERL

V - vertebral anomalies
A - anal atresia
C - cardiac anomalies
T - tracheo-
E - esophageal fistula
R - renal & radial ray anomalies
L - limb deformities

Fetal Alcohol Syndrome

Results from excessive maternal alcohol consumption
(binge drinkers)

What is associated with Fetal Alcohol Syndrome?

IUGR
Mental Deficiency
Microcephaly
Micropthalmas
Cardiac Septal Defects
Hypospadias and other genital abnormalities

Holt-Oram Syndrome

Hereditary syndrome of malformations of the heart and upper extremities.

What is Holt-Oram Syndrome associated with?

Varied hand anomalies
Cardiac septal defects

Noonan Syndrome

Includes:
Facial anomalies (hypertelorism, low set ears)
Cystic hygroma
Cardiac abnormalities
Lymphedema

Treacher-Collins Syndrome is also called:

Mandibulofacial Dysostosis

Treacher-Collins Syndrome is autosomal:

Autosomal Dominant

Treacher-Collins Syndrome affects which 3 structures?

Ears, Mandible, Palate

What is associated with Treacher-Collins Syndrome?

Congenital heart defects
Small mandible
Micrognathia
Autosomal Trisomy
Holoprosencephaly

Ellis-Van Creveld Syndrome has a high prevalence rate in which culture?

The amish

What is associated with Ellis-Van Creveld Syndrome?

Polydactyly
Thoracic Dysplasia
Mild to moderate limb shortening
50% have CHD (most commonly ASD's)

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