Chapter 52 Powerpoint 1

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1

Abnormal

Vaginal

MATERNAL AND FETAL HIGH RISK FACTORS

  • Advanced maternal age
  • _____ maternal lab values
  • ____ bleeding
2

Insulin-dependent diabetes mellitus

Preeclampsia

MATERNAL AND FETAL HIGH RISK FACTORS

  • ____ ____ ____ ____ (IDDM)
  • Hypertension (HTN)
  • _____
  • Maternal systemic disease
3

35

Down syndrome

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
4

First; second

First

Screening Tests

  • 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
5

Second

Quad

Screening Tests

  • ____ 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)
    • Inhibin-A
    • Targeted ultrasound is detailed evaluation of all fetal anatomy seen at time of exam
6

Hydrops fetalis

Immune; non-immune

Abnormal Maternal Lab Values

  • ____ ____: condition in which excessive fluid accumulates within fetal body cavities
  • Two classifications of fetal hydrops: _____ hydrops and _____ hydrops
7

Maternal serum immunoglobulin

Antigen

Immune Hydrops

  • 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
8

RBCs

Hemorrhage

Fetal anemia

Rare

Immune Hydrops

  • 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
9

Destroys

Hemolysis

Immune Hydrops

  • 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)
10

Destroyed

Cannot

Immune Hydrops

  • Fetal bone marrow then replaces _____ RBCs
  • If bone marrow ____ keep up with destruction, new sites recruited to produce additional RBCs (extramedullary poiesis)
11

25% to 35%

Decreased

Immune Hydrops

  • Perinatal death rate for Rh-sensitized pregnancies___ - ___% before intrauterine transfusions performed
  • With aggressive treatment and modern intensive neonatal care, perinatal death rate _____ significantly
12

Fetal anemia

Immune Hydrops

  • Potential of ___ ___ can be determined by
    • Ultrasound surveillance
    • Amniocentesis
    • Cordocentesis
13

Pleural

Pericardial

Thickened

Sonographic findings of hydrops

  • Scalp edema
  • ____ effusion
  • ____ effusion
  • Ascites
  • Polyhydramnios
  • ____ placenta
14

fetal anemia

middle cerebral artery

fewer

Ultrasound Surveillance

  • 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
15

Rh

delta optical density

Amniocentesis

  • 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
16

breakdown

Bilirubin

bilirubin

Amniocentesis

  • 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
17

spectrophotometric

three; Liley

Amniocentesis

  • 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
18

negative

Delivered

Amniocentesis

Low zone: Rh-____ and mildly affected fetuses found in low zone

  • Should be followed expectantly
  • ____ at term
19

Downward; 38

Horizontal

Amniocentesis

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
20

death

death

Amniocentesis

High zone: Fetal ___ zone

  • Requires immediate treatment or ____ will result
21

umbilical vein

transfusion

Two

Cordocentesis

  • 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
22

Rare

low

Alloimmune Thrombocytopenia

  • ___ 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)
23

intracerebral hemorrhage

Cordocentesis

Alloimmune 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
24

not; fetomaternal

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
25

3

Rh

Nonimmune Hydrops

  • 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
26

Cardiovascular

Congestive heart failure

Nonimmune Hydrops

  • _____ lesions often most frequent causes of NIH
  • ___ ____ ____ may result from functional cardiac problems, as well as from structural anomalies
27

vascular

arteriovenous shunts

Nonimmune Hydrops

  • Obstructive ____ problems occurring outside of the heart can cause NIH.
  • Large vascular tumors functioning as _____ _____ can also result in NIH.
28

anemia

not

Severe

antibody screen

Nonimmune Hydrops

  • 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 ____ ____
29

sensitized

Nonimmune Hydrops

Sonographic findings

  • Fetus may appear similar to _____ baby.
  • Scalp edema, pleural and pericardial effusions, ascites
30

200 to 240

bowel

Nonimmune Hydrops

  • 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
31

not

Nonimmune Hydrops

  • 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
32

severity

Nonimmune Hydrops

  • 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
33

previa

abruption

main; third

prohibits

Vaginal Bleeding

  • 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
34

dilates

TV

Vaginal Bleeding

  • 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
35

umbilical cord

velamentous; succenturiate

Vaginal Bleeding

  • 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
36

...

Vaginal Bleeding

  • Placental abruption may cause vaginal bleeding during pregnancy
  • Premature separation of placenta from uterine wall
  • Look at area between placenta and uterine wall
37

1 to 2

20 to 30

Vaginal Bleeding

  • 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
38

same

thin echolucent

Vaginal Bleeding

  • 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.
39

color

not

Retroplacental

Vaginal Bleeding

  • 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
40

loss; congenital anomalies.

Diabetes

  • Insulin-dependent diabetic mellitus (IDDM) mothers at increased risk for pregnancy-related complications, including early and late trimester pregnancy ___and ___ ____
41

pyelonephritis

hyperemesis

Diabetes

  • Pregnancies may be complicated by frequent hospitalizations for
    • Glucose control
    • Serious infections such as ____
  • Need to be monitored frequently for adequate nutritional and fluid intake, especially if experiencing _____ in first trimester
42

Glucose

high; uncontrolled

Macrosomia; 90th

Diabetes

  • _____ 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
43

cesarean section

shoulder dystocia

Brachial plexus

Diabetes

  • 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.
44

small

restricted; growth restriction

distress; death

Hypertension

  • 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
45

toxemia

prostaglandin

Hypertension

  • 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
46

hypertension

Chronic

Hypertension

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

  • Pregnancy-induced _____ (includes preeclampsia, severe preeclampsia, and eclampsia)
  • ____ hypertension (present before woman pregnant)
47

Preeclampsia

neglected

Hypertension

  • _____ 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
48

hypertension; proteinuria

Hypertension

  • Severe preeclampsia may develop in some cases; refers to severity of ____ and ____
  • Generally indicates patient must be delivered immediately
49

Eclampsia

20

primary; secondary

Hypertension

  • _____ 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.
50

oligohydramnios

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.
51

Systemic lupus erythematosus

peripartum

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 __-__%
52

Placenta

increased

pericardial

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.
53

dehydration; electrolyte

Hyperemesis

  • 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.
54

4% to 6%; asymptomatic

25%; pyelonephritis

Urinary Tract Disease

  • Approximately __-__% of pregnant women have ____ bacteriuria
  • If bacteriuria not treated, __% develop _____
55

Pyelonephritis

Hydronephrosis

mild

Progesterone

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
56

hydronephrosis

Urinary Tract Disease

  • Enlarging uterus also compresses ureters at pelvic brim, causing _____ or obstruction.
  • Ultrasound examination may provide etiologic information
57

Physiologic

8 to 10 cm

diminish

Adnexal Cysts

  • _____ 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.
58

not

endometiomas

Adnexal Cysts

  • 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
59

neural tube defects

chronic

pregnancy-induced hypertension

Obesity

  • 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 ____-____ ____
60

eclampsia

Multiple

Obesity

  • Obese women also at increased risk for
    • Severe ____
    • ____ births
    • Urinary tract infections
61

benign

estrogen

Uterine Fibroids

  • Are ____ tumors of uterine smooth muscle
  • May be stimulated to excessive growth by hormones of pregnancy, specifically ____
62

necrosis

pain

Uterine Fibroids

  • 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.