Chapter 52 Powerpoint 2

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1

37

15% to 20%

Intracranial

Premature Labor

  • Is onset of labor before __ weeks of gestation
  • Is obstetric complication occurring in ___-____% of all pregnancies
  • Premature infants at greater risk for having problems:
    • Respiratory distress syndrome
    • ______ hemorrhage
    • Bowel immaturity
    • Feeding problems
2

Intrauterine

anomalies

Premature Labor

  • Potential etiologies of preterm labor
  • Premature rupture of membranes
  • ____ infection
  • Bleeding
  • Fetal _____
3

restriction

cervix

Premature Labor

  • Polyhydramnios
  • Multiple pregnancy
  • Growth _____
  • Maternal illness (diabetes or hypertension)
  • Incompetent ____
  • Uterine abnormalities
4

Amniotic fluid

Cervical

Placental

Premature Labor

  • Ultrasound assessment of preterm labor patient should include:
    • ____ _____ assessment
    • _____ assessment
    • Fetal number
    • _____ assessment
    • Targeted ultrasound
5

half

50%

Fetal Death - Intrauterine fetal death accounts for roughly ____ of all perinatal mortality.

  • Cause of death cannot be determined in approximately ___% of cases. Known causes:
    • Infection
    • Congenital or chromosomal abnormalities
    • Preeclampsia, diabetes
    • Placental abruption
    • Growth restriction
    • Blood group isoimmunization
6

bleeding

tissue

blighted ovum

Fetal Death

  • Clinically, first trimester pregnancy loss may be diagnosed when patient presents to her physician with:
    • Vaginal _____
    • Cramping
    • Passage of ____
  • Ultrasound examination may reveal ____ ____ or fetus with no heart motion.
7

20

umbilicus

20

Fetal Death

  • Second trimester pregnancy landmarks important in determining whether pregnancy proceeding normally
  • ___ weeks of gestation
    • Uterine fundal height should have risen to _____
    • Uterus should measure approximately __ cm above symphysis pubis.
8

16 and 20

Fetal Death

  • Mother should also perceive fetal movements on daily basis beginning between ____ and ____ weeks of gestation.
  • Failure to achieve any one of these landmarks may prompt clinician to request an ultrasound examination.
9

Heart beat

Overlap

curvature; gas

Fetal Death

  • Ultrasound findings associated with fetal death:
    • Absent ____ ____
    • Absent fetal movement
    • _____ of skull bones (Spalding’s sign)
    • Exaggerated ______ of fetal spine; ___ in fetal abdomen
10

Chromosomal

infection

insufficiency

Small for Gestational Age

  • Can be due to:
    • _____ anomalies
    • Intrauterine ____
    • Genetics
    • Placental _____
11

symmetrically

smaller

Small for Gestational Age

  • If chromosomal anomalies are etiology for fetus measuring small, growth often _____ affected
  • All fetal measurements will be _____ than expected for gestational age.
12

asymmetrical

normal; small; smaller

Small for Gestational Age

  • When placental insufficiency is cause, fetuses often develop _____ intrauterine growth restriction pattern
  • This pattern results in a ____ head measurement with _____ abdominal circumference and _____-than-expected limb growth.
13

increased

premature

5

larger

Multiple Pregnancy

  • Mother with multiple gestation at _____ risk for obstetric complications
  • Fetuses at increased risk of _____ delivery and congenital anomalies
  • A twin has __ times greater chance of perinatal death than singleton fetus
  • Patient’s uterus may be _____ on examination than expected for dates
14

neural tube

elevations

neural tube

Multiple Pregnancy

  • Maternal serum alpha-fetoprotein (MSAFP) screening performed routinely to detect _____ _____ defects
  • Twin pregnancies, by virtue of having two fetuses rather than one, are associated with _____ of MSAFP
  • Patient with elevated MSAFP may present for a scan to rule out ____ ____ defects and be found to be carrying twins
15

placentation

chorions; amnions

zygotes; timing

Multiple Pregnancy

  • In each multiple gestation evaluated by ultrasound, sonographer needs to evaluate _____ type.
  • This refers to number of _____ (chorionicity) and _____ (amnionicity)
  • In twin pregnancy, this depends on number of ____; in monozygotic twinning, depends on _____ of zygotic division
16

Dizygotic

Monozygotic

Dizygotic

Dizygotic Twins

  • Two types of twins
    • ______ (fraternal)
    • _____ (identical)
  • _____ twins arise from two separately fertilized ova.
  • Each ovum implants separately in uterus and develops its own placenta, chorion, and amniotic sac (diamniotic, dichorionic).
17

Placentas

separate

Dizygotic Twins

  • ______ may implant in different parts of uterus and be distinctly separate or may implant adjacent to each other and fuse
  • Although placentas fused, their blood circulations remain distinct and _____ from each other
18

Monozygotic

early; late

Monozygotic Twins

  • ______ twins (identical) arise from a single fertilized egg that divides, resulting in two genetically identical fetuses.
  • Depending on whether fertilized egg divides ____ or ____, there may be one or two placentas, chorions, and amniotic sacs.
19

0 to 4

4 to 8

Monozygotic Twins

  • If division occurs early, __-___days postconception, there will be two amnions and two chorions (dichorionic, diamniotic).
  • If division occurs at __-__ days, there will be one chorion and two amniotic sacs (monochorionic, diamniotic).
20

8

One

One

Monozyogtic Twins

  • If division occurs after __ days
    • Two fetuses present
    • ___ chorion
    • ___ amnion (monochorionic, monoamniotic)
21

13; conjoined

Monozygotic Twins

  • If division occurs after __ days, division may be incomplete, resulting in _____ twins.
  • Twins may be joined at variety of sites:
    • Head
    • Thorax
    • Abdomen
    • Pelvis
22

two; amnion

twin-to-twin transfusion

Monozygotic Twin

In monochorionic diamniotic pregnancies, only ___ layers of _____ separate twins

Because circulations of monozygotic twins communicate through single placenta, they are at increased risk for syndrome known as ___to____ ____

23

resorption

vanishing

reabsorbed

Vanishing Twin

  • If demise occurs very early, complete _____ of both embryo and gestational sac or early placenta may occur
  • See textbook Figure 52-36
  • Sometimes referred to as “_____” twin
  • Once ______, products of conception of this twin will no longer be seen on ultrasound.
24

flattened

papyraceous

  • If fetus dies after reaching size too large for resorption, fetus markedly _____ from loss of fluid and most of soft tissue
  • Termed fetus _____
  • See textbook Figure 52-37
25

stuck

diamniotic; polyhydramnios

16 and 26

monochorionic

Poly-Oli Sequence

  • Also known as _____ twin syndrome
  • Characterized by _____ pregnancy with _____ in one sac
  • Severe oligohydramnios
  • Smaller twin in other sac
  • Usually manifests between ___ and ___ weeks’ gestation
  • Majority involve _____ gestations
26

polyhydramnios

oligohydramnios

insufficiency

Poly-Oli Sequence

  • Stuck twin syndrome may result due to:
    • Fetal anomaly in one sac resulting in _____
    • Compressing blood flow in normal twin’s placenta, resulting in _____
    • Placental ____ in one placenta
    • TTS
27

polyhydramnios

stuck

stuck twin

Poly-Oli Sequence

  • When oligohydramnios exists in one sac and _____ in other
  • Small twin may appear _____ in position within uterus
  • Termed “____ ____”
28

arteriovenous

venous system

Poly-Oli Sequence

  • TTS exists when there is ______ shunt within placenta
  • Arterial blood of one twin is pumped into ____ ____ of other twin
  • Donor twin becomes anemic and growth restricted
29

less

much

excess

hydropic

Poly-Oli Sequence

  • Twin has ____ blood flow through kidneys, urinates less, develops oligohydramnios
  • Recipient twin gets too ____ blood flow
  • Twin may be normal or large in size
  • Fetus has ____ blood flow through kidneys and urinates too much, leading to polyhydramnios
  • Twin may even go into heart failure and become ____
30

dying

restricted

heart failure

Poly-Oli Sequence

  • If twin-to-twin transfusion exists, both twins at risk of ____
    • Smaller one because its nutritional and oxygen rich blood supply is severely _____
    • Larger one because of ___ ____
  • Depending on gestational age, may be forced to deliver fetuses early if it appears one or both of twins at risk of dying in utero
31

amniocentesis

ligation

Laser

Poly-Oli Sequence -

  • Treatments for stuck twin syndrome include:
    • Serial _____
    • Selective feticide
    • Umbilical cord _____ of one twin
    • ____ occlusion of anastomosing placental vessels
32

Rare

heart; body

Acardiac Anomaly

  • Is another abnormality unique to twin gestations
  • ___ anomaly occurring in monochorionic twins
    • One twin develops without a ____ and often absence of upper half of ____
33

artery; artery

Reversed

Acardiac Anomaly

  • Proposed that this occurs due to ____ to _____ connection in placenta that leads to perfusion of abnormal twin via co-twin
  • _____ direction of blood flow in abnormal twin alters hemodynamic properties needed for normal cardiac formation.
34

13

Conjoined Twins

Occur from incomplete division of embryo after ____ days from conception

35

Thoracopagus

Omphalopagus

Craniopagus

Pygopagus

Ischiopagus

  • Five types of conjoined twins
    • _____ (joined at thorax)
    • _____ (joined at anterior wall)
    • _____ (joined at cranium; syncephalus is conjoined twins with one head)
    • ____ (joined at ischial region)
    • ____ (attached at buttocks)
36

A

Sonographic Approach

  • Fetal gestational sacs should be assigned label (typically alphabetical letter) to consistently identify them in follow-up exams:
    • Sac and fetus directly over internal os labeled __
    • Sacs above that additionally identified by placental location or additional identifying left or right side of uterus
37

number

6

6

Sonographic Approach

  • Important role of first trimester sonography to determine pregnancy _____ (singleton, twin, or higher-order multiple gestation)
  • After __ weeks of gestational age, determining pregnancy number easily accomplished by counting embryos in uterus
  • Before __ weeks, embryo not consistently visualized; sonographer must count gestational sacs and small yolk sacs
38

membrane

diamniotic; identical

two

Sonographic Approach

When scanning multiple gestations always attempt to determine whether there are one or two amniotic sacs by locating _____ that separates sacs

If two sacs seen, pregnancy known to be _____, but sonography will not be able to indicate whether twins are _____

Both monozygotic and dizygotic twins may have ____ amniotic sacs.

39

diamniotic

Sonographic Approach

  • Documentation of membrane separating fetuses confirms presence of _____ pregnancy
  • Membrane, composed of amnion with or without chorion, exhibits characteristic appearance that permits distinction from other membranes of pregnancy
40

placentas

away

Sonographic Approach

  • In twin pregnancy with two separate ______, membrane extends between fetuses obliquely across uterus from edge of placenta to contralateral edge of other placenta
  • If only one placental site exists, membrane extends between fetuses ____ from central portion of placental site
41

Does not

No

synechiae

septations

bands

  • Fetus may touch membrane but ____ ____ cross it, membrane does not adhere to entrap fetus
  • Membrane has ___ free edge within amniotic fluid
  • Features distinguish normal membrane separating twins from other membranes or membranelike structures within amniotic fluid
    • Uterine _____
    • Partial uterine _____
    • Amniotic ____
42

smaller

20

6

  • Twins are ____ in size at birth than singleton fetuses of comparable gestational age.
  • Reported predictors of discordance of growth between twins:
    • Difference in estimated fetal weight of >__%
    • Difference in BPD of __ mm
    • Difference in AC of 20 mm
    • Difference in femur length of 5 mm