Chapter 52 Powerpoint 1
MATERNAL AND FETAL HIGH RISK FACTORS
- Advanced maternal age
- _____ maternal lab values
- ____ bleeding
Insulin-dependent diabetes mellitus
MATERNAL AND FETAL HIGH RISK FACTORS
- ____ ____ ____ ____ (IDDM)
- Hypertension (HTN)
- Maternal systemic disease
Advanced Maternal Age (AMA)
- AMA refers to patient who will be ___ or older at time of delivery
- Incidence of ____ ____ increases with age
- In United States, standard practice to offer AMA women genetic counseling and invasive prenatal testing for karyotypic analysis
- Screening for fetal anomalies performed in either ___ or ____ trimester
- ____ trimester testing looks for the pattern of biochemical markers associated with plasma protein A (PAPP-A) and free beta-hCG3
- ____ trimester screening performed with maternal serum quad screen lab value and targeted ultrasound exam
screen looks at following serum markers:
- Alpha-fetoprotein (AFP)
- Human chorionic gonadotropin (HCG)
- Unconjugated estriol (uE3)
- Targeted ultrasound is detailed evaluation of all fetal anatomy seen at time of exam
Abnormal Maternal Lab Values
- ____ ____: condition in which excessive fluid accumulates within fetal body cavities
- Two classifications of fetal hydrops: _____ hydrops and _____ hydrops
Maternal serum immunoglobulin
- Is initiated by the presence of ____ ____ ____ G(IgG) antibody against one of the fetal RBC antigens (known as sensitization)
- ____: substance that elicits immunologic response such as production of antibody to that substance
- Occurs anytime mother exposed to ____ antigens different
from her own, as under these conditions:
- Father and fetus Rh+; Mother Rh–
- Is maternal-fetal _____ (mixing of blood)
- Maternal antibodies are produced against Rh antigen
- In subsequent pregnancies, antibodies pass through placenta and destroy fetal blood cells, resulting in ____ ____.
- ____ today and can be prevented, if RhoGAM given
- Mixing occurs, mother develops antibody, maternal IgG able to cross maternal fetal barrier and enter fetal circulation
- Attaches to fetal red blood cell and ____ it (hemolysis)
- ____ can result in fetal anemia, leading to CHF and edema of fetal tissues (anasarca)
- Fetal bone marrow then replaces _____ RBCs
- If bone marrow ____ keep up with destruction, new sites recruited to produce additional RBCs (extramedullary poiesis)
25% to 35%
- Perinatal death rate for Rh-sensitized pregnancies___ - ___% before intrauterine transfusions performed
- With aggressive treatment and modern intensive neonatal care, perinatal death rate _____ significantly
- Potential of ___ ___ can be determined by
- Ultrasound surveillance
Sonographic findings of hydrops
- Scalp edema
- ____ effusion
- ____ effusion
- ____ placenta
middle cerebral artery
- Hydrops can be due to ____ ____.
- Another ultrasound tool to predict fetal anemia is Doppler evaluation of ___ ___ ___(MCA)
- Anemia is condition in which there are ___ red blood cells, so blood viscosity is decreased. Decrease in viscosity results in decrease in resistance to flow. Detected by increase in velocity in MCA
delta optical density
- One way to use amniocentesis to monitor pregnancy is to obtain sample of amniotic fluid for direct ___ testing of fetus
- Second way is to monitor the isoimmunized pregnancy with ___ ___ ___ 450 (ΔOD450) analysis of AF
- Because hemolysis results in ____ of red blood cells, a by-product, bilirubin, stains the amniotic fluid.
- ____ absorbs light at the 450-nm wavelength
- Spectrophotometric analysis of fluid indirectly measures amount of ____ present in fluid and therefore gives measure of degree of hemolysis
- Gestational age at which first amniocentesis performed depends on past obstetric history and clinical presentation.
- After amniocentesis performed, AF sent for _____ analysis
- ΔOD450 categorized into _____ zones on ___ curve
Low zone: Rh-____ and mildly affected fetuses found in low zone
- Should be followed expectantly
- ____ at term
Mid-zone: ____ trend within mid-zone indicates fetus probably affected but will survive; delivery should occur at __ weeks of gestation
- ____ or rising trend: fetus in danger of death
- Preterm delivery or intrauterine transfusion and preterm delivery indicated
High zone: Fetal ___ zone
- Requires immediate treatment or ____ will result
- Needle placed into fetal ___ ____and blood sample obtained
- Lab evaluates sample for fetal blood type, hematocrit and hemoglobin
- Fetal ____ may be performed.
- ___ methods of transfusing fetus
- ___ circumstance
- Mother may develop immune response to fetal platelets in manner similar to that of RBCs
- She develops antibodies to fetal platelets.
- Result can be fetus with dangerously ___ platelet count (thrombocytopenia)
- Infants born with this condition at increased risk for ____ ____ in utero and spontaneous bleeding
- _____ is to document fetal platelet counts before vaginal delivery attempted
- Ultrasound to look for in utero fetal intracerebral hemorrhage
Nonimmune Hydrops (NIH)
- NIH describes group of conditions in which hydrops present in fetus but is ___ result of _____ blood group incompatibility
- Numerous fetal, maternal, and placental disorders are known to cause or be associated with NIH
- Incidence approximately 1 in 2500 to 1 in 3500 pregnancies
- Accounts for __% of fetal mortality
- Why NIH occurs unclear; same processes described for hydrops associated with ___ sensitization may apply to NIH
Congestive heart failure
- _____ lesions often most frequent causes of NIH
- ___ ____ ____ may result from functional cardiac problems, as well as from structural anomalies
- Obstructive ____ problems occurring outside of the heart can cause NIH.
- Large vascular tumors functioning as _____ _____ can also result in NIH.
- Severe ____ of fetus another well-recognized etiology for NIH
- Anemia ___ caused by isoimmunization, but result is the same
- ____ 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 ____ ____
- Fetus may appear similar to _____ baby.
- Scalp edema, pleural and pericardial effusions, ascites
200 to 240
- Other abnormal findings may be present indicating cause of hydrops
- If hydrops the result of cardiac tachyarrhythmia, HR of __ - ___ bpm is common
- If diaphragmatic hernia present, ____ visible in chest cavity
- Resolution of ascites and gross edema documented after fetal heart converted to normal rhythm
- If fetus anemic because of twin-to-twin transfusion, intrauterine transfusion will ___ solve anemia problem because most of fetal blood being shunted to recipient twin
- Sonography can help clinician assess how sick fetus is by indicating ____ of hydrops and by biophysical profile
- Can then make informed choice when to deliver fetus
- Bleeding in second and third trimesters can be associated
with placental anomalies
- Placenta ____
- Placenta ____
- Placenta previa ____ cause for ____ trimester bleeding
- In this condition, placenta covers internal cervical os and ____ delivery of fetus
- If cervical os ____ with labor, is significant risk of placenta detaching from uterus, resulting in maternal hemorrhage, loss of oxygen and blood supply to fetus
- ___ sonography best way to evaluate relationship of cervical os to placental edge
- Vasa previa rare condition in which ____ ____ is presenting part
- Life threatening to fetus
- Associated with _____ cord insertion or _____ lobe
- Color Doppler to evaluate any structures in front of cervical os to see if vascular
- Placental abruption may cause vaginal bleeding during pregnancy
- Premature separation of placenta from uterine wall
- Look at area between placenta and uterine wall
1 to 2
20 to 30
- Normally, area hypoechoic and __-__ cm thick
- If thicker than 1 to 2 cm, may be due to abruption or uterine contraction
- Uterine contractions should resolve within __-__ minutes and typically have central blood flow
- Abruptions difficult to diagnose because clotted blood has ____ sonographic appearance as placental tissue
- If bleeding from abruption is recent, may notice ___ ____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.
- Use ___ flow Doppler to search for abruption
- Blood clots from abruption will ____ exhibit color flow.
- _____ area hypoechoic 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
loss; congenital anomalies.
- Insulin-dependent diabetic mellitus (IDDM) mothers at increased risk for pregnancy-related complications, including early and late trimester pregnancy ___and ___ ____
- Pregnancies may be complicated by frequent
- Glucose control
- Serious infections such as ____
- Need to be monitored frequently for adequate nutritional and fluid intake, especially if experiencing _____ in first trimester
- _____ primary fuel for fetal growth
- If glucose levels very ___ and ____, fetus may also become macrosomic
- _____ defined as fetus whose weight >__th percentile for gestational age
- Macrosomic infant may become too large to fit through mother’s pelvis, necessitating ____ ____.
- If delivery accomplished vaginally, may have difficulty delivering shoulders (____ _____)
- ____ ____ nerve injuries may result.
restricted; growth restriction
- Places both mother and fetus at risk
- Hypertensive pregnancies may be associated with ____ placentas.
- If placenta develops poorly, blood supply to fetus may be _____, and ____ ____ may result.
- Growth-restricted fetuses at increased risk of fetal ____ and ____ in utero
- Various forms of hypertensive disease during pregnancy
- Term ____ 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 _____ abnormalities
Terminology used in clinical practice to describe hypertensive states during pregnancy:
- Pregnancy-induced _____ (includes preeclampsia, severe preeclampsia, and eclampsia)
- ____ hypertension (present before woman pregnant)
- _____ is pregnancy condition in which high blood pressure develops with proteinuria (protein in urine) or edema (swelling)
- If hypertension ____, 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 ____ and ____
- Generally indicates patient must be delivered immediately
- _____ represents occurrence of seizures or coma in preeclamptic patient
- Chronic hypertension diagnosed in patients in whom high blood pressure found before ___ weeks of gestation
- Chronic hypertension can result from ____ essential hypertension or from ____ hypertension.
- Sonography team may be called on to perform serial scans for fetal growth and to monitor for adequacy of AF.
- If fetal growth falling off normal growth curve or _____ occurs, obstetrician may intervene and deliver fetus.
Systemic lupus erythematosus
22% to 49%
- ____ ____ ____ (SLE) is chronic autoimmune disorder that can affect almost all organ systems in body.
- Is most common in women of childbearing age; may cause multiple ____ complications
- Incidence of spontaneous abortion and fetal death is __-__%
Systemic Lupus Erythematosus
- _____ affected by immune complex deposits and inflammatory responses in placental vessels
- May account for ____ number of spontaneous abortions, stillbirths, and IUGR fetuses
- Fetus must be monitored to rule out congenital heart block (see Figure 52-17) and ___ effusion.
- Ultrasound useful in workup of vomiting in pregnant woman
- Nausea and vomiting common symptoms associated pregnancy
- Hyperemesis gravidarum exists when pregnant woman vomits so much she develops _____ and ____ imbalance.
4% to 6%; asymptomatic
Urinary Tract Disease
- Approximately __-__% of pregnant women have ____ bacteriuria
- If bacteriuria not treated, __% develop _____
Urinary Tract Disease
- _____ usually presents with flank pain, fever, and white blood cells in urine.
- _____ also presents with flank pain.
- Pregnancy normally associated with ___ hydronephrosis
- Hydronephrosis may result from combination of effects
- _____ has dilatory effect on smooth muscle of ureter
Urinary Tract Disease
- Enlarging uterus also compresses ureters at pelvic brim, causing _____ or obstruction.
- Ultrasound examination may provide etiologic information
8 to 10 cm
- _____ ovarian cysts may be associated with early pregnancy.
- Cysts may be large, from __-__cm, and may be associated with pelvic pain.
- Cyst should ____ as pregnancy progresses.
- If cyst does ____ resolve, surgical exploration may be necessary to rule out other ovarian pathology.
- Such pathology would include ____, dermoid cysts and cancer.
- Periodic ultrasound examinations necessary for follow-up of cyst
neural tube defects
- Maternal obesity associated with increased incidence of ___ ____ ____
- More obese women start pregnancy with ____ hypertension than women who are of normal weight.
- Obese women also at increased risk for ____-____ ____
- Obese women also at increased risk for
- Severe ____
- ____ births
- Urinary tract infections
- Are ____ tumors of uterine smooth muscle
- May be stimulated to excessive growth by hormones of pregnancy, specifically ____
- If growth very rapid, the fibroid may outgrow its blood supply and undergo ____.
- May cause ___ and premature labor
- Ultrasound examination of uterus in pregnant woman may detect uterine fibroids.