Chapter 49-51 OB First 1/2 Powerpoint

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1

Cardiac activity

Fetal demise

Examination Overview:

  • View _____ ____ at beginning of each study to ensure that fetus is alive
  • If _____ _____ or obvious anomaly initially recognized, sonographer better prepared to perform study and involve physician immediately
2

Heart rate

Presentation; lie

ADD

2nd & 3rd Trimester Protocol:

  • Check Fetal ____ ____
  • _____ and ____
  • Measurements: BPD/HC, AC, FL, HL, Cereb./CM, Lateral Ventricles, AFI
  • Embrace your ___
3

Maternal

Oblique

Fetal Presentation:

  • In relation to ____ long axis
  • When fetal lie is ____, generally described by stating which quadrant of uterus contains fetal head and direction and position of fetal spine
4

Occiput

Frank; complete

Mass; placenta previa

Fetal Presentation:

  • Vertex/ Cephalic - Also relationship of fetal _____ to maternal pelvis; OA or OP: may have difficulty imaging
  • Breech - ____ breech may be turned; _____ breech need c-section; May be described in relation of fetal sacrum to maternal pelvis
  • Transverse - If this lie in late pregnancy, look for ___ or ____ ____- some reason preventing movement into vertex.
5

Right; left

Gallbladder; apex

Left; anterior

Situs:

  • ____ and ____ sides of fetus need to be conceptualized to ensure normal situs (positioning) of fetal organs
  • ____ on right side and ____ of heart pointing toward fetal left side
  • Fetal aorta lies slightly to ___ of midline, anterior to spine, and IVC is to right of midline and slightly more ____ to aorta
6

12th

Circle; oval

Hypoechoic

Echogenic

THE CRANIUM

  • ossify by ____ week
  • check contour of skull bones
  • ____ at highest levels; ____ at ventricular, peduncular, basal levels
  • pathology or fetal death may distort normal shape of skull
  • ____ due to high water content
  • Sulcus and gyrus- more _____
  • Becomes more complex with GA
7

Plexus

Falx

Cranium:

  • Cerebellum
  • Choroid ___
  • Cisterna magna
  • Lat vents
  • Midline ___
  • CSP
8

Midline falx

Cranium:

_____ ___ is important landmark to visualize because its presence implies that separation of cerebrum has occurred

9

Two

Choroid plexus; frontal

Cranium:

  • Fetal ventricular system consists of ____ paired lateral ventricles, midline third ventricle, fourth ventricle adjacent to cerebellum
  • contains cerebrospinal fluid (CSF)
  • ____ ____ tissue within lateral ventricles produces CSF - located within roofs of each ventricle except at ____ ventricular horns
10

6.5

10

Cranium Lateral Ventricles:

  • Measure posterior horn of lat. Ventricle (atrium)
  • When measuring ventricle, locate atrium and measure directly across posterior portion, measuring perpendicular to long axis of ventricle rather than the falx, while placing calipers at junction of ventricular wall and lumen or cavity of ventricle
  • Normal atrium measures ___ mm
  • If atrium measures >___ mm, warrants serial imaging and further evaluation.
11

Back; posterior

Vermis

Cranium:

  • Cerebellum located in ____ of cerebral peduncles within _____ fossa
  • Cerebellar hemispheres joined together by cerebellar ____
12

5; normal

Nuchal Fold:

  • In second trimester, thickness of nuchal skin fold measured in plane containing cavum septi pellucidi, cerebellum, and cisterna magna
  • Values of skin thickness of __ mm or less up to 20 weeks’ gestational age ____
  • Fetuses with thickened nuchal skin at increased risk for aneuploidy
13

Shape; size

Vermis

Cerebellum:

  • Cerebellum ___ and ____
  • Connected by ____
  • Transverse cerebellar width (diameter)
  • Arnold Chiari
14

2-11; 5-6

Cisterna Magna

  • Normal excludes almost all spinal defects
  • Siz: normal ____ mm, average ____ mm
15

COR; Trv

Eye Orbits:

  • Measured in ___ or ___
  • Must see Two orbits to be normal
16

1/3

cephaloceles; bossing

micrognathia

Facial Profile:

  • In normally proportioned face, segments containing forehead, eyes and nose, and mouth and chin each form approximately ___ of profile
  • Note contour of frontal bone, nose, upper and lower lips, and chin
  • useful in assessing nasal bone
  • excluding forehead malformations such as anterior _____, abnormal slopes, or frontal ____
  • assessing chin to exclude abnormally small chin, ____
17

Parallel

13; X

Nasal Bone:

The nasal bone appears as a bright echo _____ to the echogenic skin interface in the superior aspect of the nose. Absent in Trisomy ___ and monosomy ___.

18

Swallowing

Macroglossia

Beckwith-Wiedeman

Fetal Tongue:

  • Oral cavity and tongue frequently outlined during fetal _____
  • Large tongue that persistently protrudes outside of mouth called _____
  • Macroglossia associated with ______ syndrome and aneuploidies
19

Tapers; widens

Laminae; spinal cord

Vertebral Column:

  • Normal fetal spine ____ near sacrum and ____ near base of skull
  • Double line appearance of spine referred to as “railway sign” and generated by echoes from posterior and anterior ____ and ____ ____
20

Three

Spinal column

Three

Vertebral Column:

  • In transverse plane, ____ ossification points visible
  • The three are spaced equidistant and ____ _____ appears as closed circle, indicating closure of neural tube
  • ____ echoes form circle or equilateral triangle that represents center of vertebral body and posterior elements (laminae or pedicles)
21

Spinal defect

Vertebral Column:

  • These elements should be identified in normal fetus.
  • The pedicles appear splayed in V-, C-, or U-shaped configuration in fetus with ____ ___
22

Fluid-filled; solid; homogeneous

Solid; homogeneous

The Thorax:

______ fetal lungs observed as ____, _____ masses of tissue bordered medially by heart, inferiorly by diaphragm, and laterally by rib cage

  • Fetal breathing
  • Size, texture, and location matter
  • ____, _____ masses of tissue
23

Heart

Rib cage

Diaphragm

The Thorax:

  • Bordered medially by ___
  • Laterally by ____
  • Inferiorly by _____
  • Ribs warrant further study if osteogenesis imperfecta
24

Transversely

Left; right; left

Perpendicular

Cephalad

Heart:

  • Lies more _____ in fetus than in adult because lungs are not inflated
  • Apex of heart directed toward ___ anterior chest, with ____ ventricle closest to anterior chest wall and ____ atrium closest to spine
  • Four chambers may be seen in view taken with beam _____ to septum or in view with beam _____ to valves
  • Four-chamber view may be obtained by angling ____ after obtaining transverse view of fetal abdomen that displays stomach
25

Left

Right; left

Heart:

  • Cardiac position, situs, axis
  • Apex of heart should point to fetal ___ side
  • Presence of equal sized ____ and ____ ventricle
26

Atria

Tricuspid; mitral

Heart:

  • Equal sized ___
  • Interventricular septum
  • Normal placement of _____ and ____ valves
  • Normal rhythm and rate
27

Echogenic; echogenic intracardiac focus (EIF)

Heart:

  • ____ structure, as bright as bone, that appears within cardiac chamber and persists despite changes in transducer position called ______
  • Normal variation appears in many normal pregnancies
  • May be, however, associated with increased risk of aneuploidy and cardiac defects
28

Four

Position

33-63

83-85

AIUM / ACR standards in the 2nd and 3rd trimesters include:

  • ___ chamber view
  • _____ of fetal heart in the thorax
  • LVOT and RVOT not yet part of standards

4 chamber view alone: _____% sensitive

With outflow tracts: ____% sensitive

29

LV, RV, IV

Left Ventricular Outflow Tract:

  • Identify: ___, ____, ____ septum, aorta (normal caliber), +/- LA, +/- RA
  • Medial wall of the ascending aorta merges with the top of the IV septum (most frequent location for VSD)
  • Pathology: VSD, tetralogy of Fallot, transposition, truncus arteriosus
30

Pulmonary artery; ductus arteriosus

Right Ventricular Outflow Tract:

Identify: branching of the main ___ into right ____ and _____ (to desc Aorta), asc aorta in cross section, desc aorta to left of spine; verify PA crosses anterior to asc aorta

Pathology: transposition, truncus arteriosus

31

Placenta

Metabolic rate; temperature; low

Oxygen; nutrients

Fetal Circulation:

  • Fetal oxygenation occurs in _____ where small fetal vessels on surface of villi bathed by maternal blood within intervillous spaces
  • Fetal basal ____ ____ and _____ are higher, causing fetal blood levels of essential nutrients to be relatively ____ compared with maternal blood
  • _____ and ______ from maternal blood cross by simple diffusion to fetal vessels
32

Liver

Left; right

Liver

Hepatobiliary System and Upper Abdomen:

  • ____ is large organ filling most of upper abdomen
  • ____ lobe of liver larger than ____ lobe because of large quantity of oxygenated blood flowing through left lobe
  • ____ appears pebble-gray; is discerned by its corresponding portal and hepatic vessels
33

Bowel; liver

Hyperechoic

Gastorintestinal System:

  • Echogenicity of fetal ___ typically greater than echogenicity of fetal ___
  • If fetal bowel as echogenic as fetal bone, known as ____ bowel
  • Associated with increased risk for aneuploidy and neonatal/childhood pathology
34

Abdominal; liver

Uncommon

Hepatobiliary System and Upper Abdomen:

  • Site at which _____ measurements reflect ___ size
  • Important to check for any collection of fluid around liver margins because this indicates ascites, fluid retention resulting from anemia, heart failure, or congenital anomalies
  • Liver masses _____, but may be detected
35

Gallbladder

GB

Left

Hepatobiliary System and Upper Abdomen:

  • Fetal ______ appears as cone-shaped or teardrop-shaped cystic structure located in right upper abdomen just below left portal vein
  • ___ should not be misinterpreted as left portal vein
  • ____ portal vein is midline vessel that appears more tubular and can be traced back to umbilical insertion
36

11

16

Gastrointestinal System:

  • Stomach becomes apparent as early as ___ th week of gestation because swallowed amniotic fluid fills stomach cavity
  • Full stomach should be seen in all fetuses beyond ___th week of gestation
37

Kidneys; bladder

Adrenal glands

13th

Ovoid; lack

Urinary System:

  • sonographers required to image and document ____ and ____
  • _____ _____ more prominent in fetus and seen adjacent to kidneys
  • Are apparent as early as ___ week of pregnancy
  • In 2nd trimester of pregnancy, kidneys appear as ____ retroperitoneal structures that ____ distinctive borders
38

Sagittal

5; 20

8; 20; 30

10; 30

Urinary System:

  • Measurement of renal pelvis typically made in ____ view of fetal kidney when fluid present
  • Deepest diameter of the fluid measured
  • Renal pelvis that measures
  1. >__ mm before ___ weeks GA
  2. >__ mm between __ and __ weeks GA
  3. >__ mm beyond __ weeks GA considered abnormal
39

Transverse

20th; 23

Urinary System:

  • Fetal adrenal glands most frequently observed in ____ plane just above kidneys
  • Adrenals seen as early as __ week of pregnancy and by ___ weeks assume rice-grain appearance
40

Oligohydramnios

Urinary System:

  • If cannot identify urinary bladder in presence of _____ , suspect renal abnormality or premature rupture of membranes
  • In some normal situations bladder may not be full because of decreased ingestion of fluid
  • When bladder empties in utero, it will typically refill within time frame of examination
41

Aqueductal stenosis; hemophilia

Chorionicity

Genitalia:

  • Providing information regarding gender identification clinically important when fetus at risk for gender-linked disorder like _____ _____ or _____
  • In multiple pregnancies there is medical indication for determining gender as it relates to _____
42

Short; short

Upper & Lower Extremities:

  • Guidelines for standard obstetric examination require sonographer to verify presence or absence of legs and arms
  • ___ femur and ___ humerus associated with increased risk for aneuploidy
  • Sonographer may not only measure fetal limb bones but also survey anatomic configurations of individual bones whenever possible for evidence of bowing, fractures, demineralization, as seen in several common forms of skeletal dysplasias
43

Hands; fingers

Phalanges; interphalangeal; metacarpals

Upper & Lower Extremities:

  • ____ and _____ may be viewed
  • Note if hands clenched throughout exam or if they open and close normally
  • When fingers viewed in sagittal plane, individual _____, _____ joints, _____, and digits may be observed
44

First

18

Upper & Lower Extremities:

  • Hand movement counts as positive demonstration of fetal tone—one component of biophysical profile
  • Individual fingers can often be counted in ___ trimester
  • Important to observe hands if anomaly suspected, as in chromosome disorders, such as trisomy __, in which clenching of hands common
45

Femur

Upper & Lower Extremities:

____ is most widely measured long bone; can be found by moving transducer along fetal body to fetal bladder

At this junction, iliac wings noted

By moving transducer inferior to iliac crests, femoral echo comes into view

46

...

Extra Fetal Obstetric Evaluation:

After fetus studied, evaluate

  • Placenta
  • Amniotic fluid
  • Pelvis
47

Absent

0.9; 30

Umbilical Cord:

  • ____ cord twists may be associated with poor pregnancy outcome
  • Cord easily imaged in both sagittal and transverse sections
  • Umbilical vein diameter increases throughout gestation, reaching maximum diameter of ___ cm by ___ weeks of gestation
48

Amniocentesis

Umbilical Cord:

  • Identification of placental insertion of cord important in choosing site for _______ and in selection of appropriate site for other invasive procedures
  • Rarely, umbilical insertion atypically located (velamentous insertion)
49

Oxygenated; deoxygenated

Posterior

Umbilical cord

Placenta:

  • Major role of placenta to permit exchange of _____ maternal blood (rich in oxygen and nutrients) with _____ fetal blood
  • Maternal vessels coursing _____ to placenta circulate blood into placenta
  • Blood from fetus reaches this point through the ____ ____
50

Amniotic cavity

Intrauterine pressure

Production

Amniotic Fluid:

  • Allows fetus to move freely within ____ ____
  • Maintains _____ _____ and protects developing fetus from injury
  • Umbilical cord and membranes, lungs, skin, and kidneys all contribute to _____ of amniotic fluid
51

2nd; 3rd

Umbilical cord

Membranes:

  • Inner membrane, amnion, and outer membrane, chorion, typically not seen during ___ and ___ trimesters
  • Amnion contiguous with membrane lining ____ ____
  • At site of umbilical cord insertion into placenta, amnion spreads out over surface of chorionic surface of placenta
52

3

Cervix:

Normal cervix in pregnancy is __ centimeters or longer

If cervix shortened or if internal os appears to have “V” or “U” shape, it may be important to monitor and/or intervene

53

Aneuploidy

Genetic Sonogram:

  • Includes all elements of standard obstetric examination with additional attention to “anatomy markers” for _____
  • Markers typically evaluated include nuchal fold, echogenic bowel, humerus length, femur length, echogenic intracardiac foci (EIF), renal pyelectasis
54

Age; biochemistry

Two

Genetic Sonogram:

  • Patients enter genetic sonogram with risk for aneuploidy determined by ___ or ____
  • If single marker found, risk may be increased by factor consistent with likelihood ratio associated with that finding
  • If 35-year-old women enters genetic sonogram with risk of 1 in 200 and echogenic bowel is found, risk can be adjusted and increased to 1 in 33
  • If ___ or more “anatomy markers” documented, risk increased even more
55

1/2

Genetic Sonogram:

  • Somewhat more controversial lowering risk if no anatomy markers found by factor of ___ or more
  • For example patient at age 35 with aneuploidy risk of approximately 1:200 may have that risk lowered by factor of one half or more with normal sonogram
  • Patient would be counseled regarding risk level of approximately 1 in 400
56

Hyperechoic

Genetic Sonogram:

Anatomy “markers” must be interpreted carefully and experience can eliminate errors associated with assignment of “markers” such as _____ bowel or EIF that include subjective assessment of echogenicity

57

Number

Estimation

Position

Basic Guidelines:

  • Cardiac activity
  • ____ of fetuses
  • ____ of Fetal Age
  • Biometry Measurements to include: BPD, HC, AC, FL,HL
  • Fetal ____
58

Position

Number

2nd & 3rd Trimester Ultrasound:

  • Placental _____
  • Placental Cord insertion
  • ____ of vessels in cord
  • Kidneys
  • AB cord insertion
  • Bladder & Stomach
  • 4-chamber heart/outflow tracts
59

12

2nd & 3rd Trimester Ultrasound:

  • Cerebral ventricles – measure width
  • Cerebellum - measure
  • Cisterna magna - measure
  • Spine
  • Diaphragm and heart situs
  • __ long bones, hands, feet
60

High

No

Midrange

Fetal Parts of Interest:

1. Structures that generate ____ amplitude echoes- (example-bones)

2. Structures that generate ___ internal echoes – stomach, bladder

3. Structures that generate ___ gray echoes -lungs, brain, spleen, liver, kidneys, and muscles.

61

Cephalic

Vertex

Breech

Head

Fetal Position:

  • ____ head down
  • ___ back of head 1st - face presentation when front of head is first
  • ____ is rump first, frank, footling or complete
  • Transverse or oblique - specify which side or quadrant ____ is located
62

Round; ovoid

Two

Gestational Sac Measurements:

  • Distended urinary bladder has effect on gestational sac measurement - Changes shape from ___ to ____ or teardrop
  • If sac round, measure one diameter inner to inner
  • If sac ovoid, make ___ measurements inner to inner - One transverse and other perpendicular to length