Chp. 32: Fetal Environment and Maternal Complications

causes of nonimmune hydrops

1. Chorioangioma 2. Cystic adenomatoid malformation 3. Diaphragmatic hernia 4. Fetal (nonimmune) anemia 5. Fetal infections 6. Idiopathic 7. Structural anomalies of the cardiac and lymphatic systems 8. Trisomy 13 9. Trisomy 18 10. Trisomy 21 11. Turner syndrome

Thin placental causes

1. Diabetes mellitus (long-standing) 2. IUGR 3. Placental insufficiency 4. polyhydramnios 5. preeclampsia 6. small-for-dates fetus

Thick placenta causes

1. diabetes mellitus 2. maternal anemia 3. infection 4. fetal hydrops 5. Rh isoimmunization 6. multiple gestation

functions of the placenta

1. gas transfer 2. excretory function 3. water balance 4. pH maintenance 5. hormone production 6. defensive barrier

S/D ratio

Assesses the vascular resistance in the placenta by taking a sample of the umbilical artery. decreases with advancing age. Absence or reversal of diastolic flow in the umbilical artery is considered irregular and is associated with an increased incidence of IUGR and oligohydramnios. An elevated S/D ratio is associated with increased placental resistance and an increase in the risk of perinatal mortality and morbidity.

death

Because both the patient and the fetus have an increased risk of ___ with placenta previa, a C section is the preferred method of delivery.

maternal diabetes

Either pregestational or gestational. Pregestational diabetes, the mother already has a history of diabetes. Gestational diabetes, which is the most common type of diabetes during pregnancy, is pregnancy induced. screened for this around 26 weeks' gestation. major risk is macrosomia.

20

Fetuses with a 2VC have an approximate ___% chance of having additional abnormalities, and thus a thorough examination of the fetus for other findings is warranted.

placenta increta

Invasion of the placenta within the myometrium. sono: Loss of normal hypoechoic interface between the placenta and myometrium with invasion into the myometrium.

fetal alcohol syndrome (FAS)

Most common cause of intellectual disability in the US. Alcohol, which is a teratogen, crosses the placenta and can cause CNS damage. Children exposed to alcohol in utero have been shown to have an increase risk for growth restriction, mental impairment, physical abnormalities, and immune dysfunction. sono: 1. Microcephaly 2. Dysgenesis of the corpus callosum 3. Long round philtrum 4. Malformed ears 5. Microphthalmia 6. Cleft palate 7. Heart defects such as ventricular septal defects

pregestational diabetes

Mothers with ___ have a higher risk of miscarriage and toxemia, and the fetus has an increased risk of congenital anomalies, hypoglycemia, respiratory distress, perinatal mortality, and IUGR.

placenta percreta

Penetration of the placenta through the uterine serosa and possibly into adjacent pelvic organs. Loss of normal hypoechoic interface between the placenta and the myometrium with penetration beyond the serosa.

myometrium

Placenta accrete denotes the abnormal attachment of the placenta to the ___.

marginal placenta previa

Placenta lies at the edge of the internal os

Low-lying placenta previa

Placental edge extends into the lower uterine segment but ends more than 2 cm away from the internal os

Umbilical cord

The ___ has TWO ARTERIES and ONE VEIN.

retained products of conception (RPOC)

The normal postpartum uterus returns to its nongravid size 6 to 8 weeks after delivery. When additional placental tissue remains within the uterus after the bulk of the placenta has been delivered. clinical findings: 1. postpartum vaginal bleeding. sono: 1. Echogenic intracavitary mass that may contain some calcifications 2. Color Doppler signals within the retained placental tissue

90

The obese fetus is defined as a fetus that has an EFW of greater than the ___th percentile.

placental abruption

The premature separation of the placenta from the uterine wall before the birth of the fetus, thus causing hemorrhage. Maternal conditions that are linked to the development of ___ include HTN, preeclampsia, cocaine use, cigarette smoking, poor nutrition, and trauma.

placenta

Weighs btwn 450 and 550 grams. Has a diameter of 16-20 cm. Produces hCG in first tri, and progesterone and estrogen in 2nd and 3rd tri. Consists of 3 parts: 1. chorionic plate (closest to fetus) 2. placental substance 3. basal layer or basal plate. Thickness should not exceed 4 cm.

middle cerebral artery

When comparing the two Doppler signals, the ___ should generate a higher resistance flow pattern than the umbilical artery. has been shown effective at evaluating for hypoxia in a fetus that is measuring small for dates.

leiomyoma

Which of the following would be least likely associated with immune hydrops?

diethylstilbestrol

a drug administered to pregnant women from the 1940s to the 1970s to treat threatened abortions and premature labor that has been linked with uterine malformation in the exposed fetus

multicystic dysplastic kidney disease

a fetal renal disease thought to be caused by an early renal obstruction; leads to the development of multiple noncommunicating cysts of varying sizes in the renal fossa

intrauterine growth restriction

a fetus that is below the 10th percentile for gestational age (small for gestational age) and whose growth is impeded for some reason

cystic adenomatoid malformation

a mass consisting of abnormal bronchial and lung tissue that develops within the fetal chest

mirror syndrome

a rare disorder in which the mother suffers from edema and fluid buildup similar to her hydropic fetus

marginal cord insertion

abnormal cord insertion at the edge of the placenta. aka BATTLEDORE placenta.

fetal hydrops

accumulation of fluid within at least two fetal body cavities. sono: 1. Fluid accumulation within at least two fetal body cavities (pleural effusion, ascites, skin edema, pericardial effusion) 2. Fetal hepatosplenomegaly 3. Polyhydramnios

TORCH

acronym that stands for toxoplasmosis, other infections, rubella, cytomegalovirus, and herpes simplex virus. Can cross the placenta and influence the fetus. Cytomegalovirus is listed as the most common congenital infection. sono: 1. Intracranial calcifications 2. Microcephaly 3. Microphthalmia 4. Ventriculomegaly 5. Hepatosplenomegaly

uterine synechia(e)

aka amniotic sheets. Linear bands of scar tissue within the uterus. ___ are the result of intrauterine adhesions, as seen with Asherman syndrome. Associated with premature rupture of membranes, premature delivery, and placental abruption. Associated with fetal anomalies. sono: 1. Linear, echogenic band of tissue traversing the uterine cavity 2. The band does not involve fetal parts, and the normal fetus appears to move freely

marginal placental abruption

aka subchorionic hemorrhage. most common placental hemorrhage identified with sono.

uterine artery

an abnormal flow pattern will yield high resistance within the ___ when IUGR is present.

circumvallate placenta

an abnormally shaped placenta caused by the membranes inserting inward from the edge of the placenta, producing a curled-up placental shape

succenturiate lobe

an accessory lobe of the placenta

macrosomia

an estimated fetal weight of greater than the 90th percentile or the neonate that measures more than 4,500 in nondiabetic mothers and 4,000 g in diabetic mothers. Mothers who are prone to havethis type of fetus are those who suffer from diabetes, whether pregestational or gestational.

infantile polycystic kidney disease

an inherited renal disease that results in bilateral enlargement of the fetal kidneys and microscopic renal cysts; also referred to as autosomal recessive polycystic kidney disease

two-vessel cord

an umbilical cord with one artery and one vein; could possibly be associated with other fetal abnormalities and intrauterine growth restriction

eclampsia

clinical findings: 1. Long-standing, uncontrolled preeclampsia 2. Headaches 3. Seizures sono: 1. Oligohydramnios 2. IUGR 3. Gestational trophoblastic disease 4. Placental abruption 5. Elevated S/D ratio

placenta accreta, increta, and percreta

clinical findings: 1. Previous C section or uterine surgery 2. Painless vaginal bleeding if placenta previa is present 3. Possibly asymptomatic sono: 1. Placenta previa (frequent associated finding) 2. Loss of the normal hypoechoic interface between the placenta and the myometrium

bladder flap hematoma

clinical findings: 1. recent c section sono: 1. Anechoic or complex mass located between the lower uterine segment and the posterior bladder wall

erythroblastosis fetalis

condition in which there is an incompatibility between the fetal and maternal red blood cells

nuchal cord

condition of having the umbilical cord wrapped completely around the fetal neck

allantoic cyst

cyst found within the umbilical cord. most often found near fetal abd. May be associated with omphalocele and aneuploidy. sono: 1. Cystic mass within the umbilical cord 2. Most often noted close to the fetal abdomen

IUGR

defined as estimated fetal weight (EFW) that is below the 10th percentile at a given gestational age. The fetus is at risk if the mother suffers from chronic disease, drinks alcohol, smokes cigarettes, has poor nutrition, is younger than 17 or older than 35 years, or has a history of previous pregnancies that were considered growth restricted.

gestational diabetes

diabetes acquired as a result of pregnancy

anasarca

diffuse edema

immune hydrops

fetal hydrops caused by Rh incompatibility. is caused by the absence of a detectable circulating fetal antibody against the red blood cells in the mother. Is associated with erythroblastosis fetalis and Rh isoimmunization.

nonimmune hydrops

fetal hydrops caused by congenital fetal anomalies and infections

oligohydramnios

fetal malformations/ complications associated with ___: 1. Bilateral multicystic dysplastic kidney disease 2.Bilateral renal agenesis 3. Infantile polycystic kidney disease 4. IUGR 5. Posterior urethral valves 6. Premature rupture of membranes (PROM)

polyhydramnios

fetal malformations/ complications associated with ___: 1. Cardiac and/or chest abnormalities 2.Chromosomal abnormalities 3.Duodenal atresia 4.Esophageal atresia 5.Gastroschisis 6. Neural tube defects 7. Omphalocele 8. Rh incompatibility 9. Twin-twin transfusion syndrome

vasa previa

fetal vessels resting over the internal os of the cervix. these vessels are prone to rupture as the cervix dilates. sono: identification of vessels over the internal os of the cervix with the use of color doppler 2. valementous cord insertion

umbilical vein varix

focal dilatation of the intra-abdominal portion of the umbilical vein. May be associated with fetal aneuploidy, growth restriction, hydrops, and demise.

Wharton jelly

gelatinous material that is located within the umbilical cord around the umbilical vessels

cotyledons

groups or lobes of chorionic villi

posterior urethral valves

irregular thin membranes of tissue located within the male posterior urethra that does not allow urine to exit the urethra

biophysical profile

method of fetal monitoring with sonography to produce a numerical scoring system that predicts fetal well-being

chorioangioma

most common benign placental tumor. most common location fo the mass is adjacent to the umbilical cord insertion site at the placenta. When large, they can be associated with IUGR, polyhydramnios, and fetal hydrops. clinical findings: 1. possible elevation in MSAFP. sono: 1. solid, hypoechoic or hyperechoic mass within the placenta

Hemangioma of the umbilical cord

most common tumor of the umbilical cord, although rare. sono: 1. Solid hyperechoic mass within the umbilical cord2. Most often noted close to the cord insertion into the placenta

complete placental abruption

most severe abruption. results int he development of retroplacental hematoma, located btwn placenta and myometrium.

partial placental abruption

only a few cm of separation

complete (total) placenta previa

placenta covers the internal os completely

partial placenta previa

placenta partially covers the internal os

bilobed placenta

placenta that consists of two separate discs of equal size

abruptio placentae

placental abruption

venous lakes

pools of maternal blood within the placental substance. aka maternal lakes or placental lakes.

preeclampsia

pregnancy-induced maternal high blood pressure and proteinuria after 20 weeks' gestation clinical findings: 1. Maternal hypertension 2. Maternal edema 3. Maternal proteinuria sono: 1. Oligohydramnios 2. IUGR 3. Gestational trophoblastic disease 4. Placental abruption 5. Elevated S/D ratio

vernix

protective fetal skin covering

twin-twin transfusion syndrome

shunting of venous or arterial blood from one twin to another through placental circulation

Leiomyoma

sono: 1. Hypoechoic mass within the uterus 2. Posterior shadowing from mass 3. Degenerating fibroids may have calcifications or cystic components 4. Multiple fibroids appear as an enlarged, irregularly shaped, diffusely heterogeneous uterus

Grade 0 placenta

sono: Uninterrupted chorionic plate and homogeneous placental substance

Grade 2 placenta

sono: moderate indentations in the chorionic plate with "comma-like" calcification in the placental substance.

Grade 3 placenta

sono: prominent indentation in the chorionic plate that extends to the basal layer with diffuse echogenic and anechoic areas noted within the placental substance.

Grade 1 placenta

sono: subtle indentations on the chorionic plate, with some small calcifications within the placental substance.

placenta accreta

the abnormal Adherence of the placenta to the myometrium. sono: Loss of normal hypoechoic interface between the placenta and the myometrium

velamentous cord insertion

the abnormal insertion of the umbilical cord into the membranes beyond the placental edge. Often associated with vasa previa.

amniotic fluid index

the amount of amniotic fluid surrounding the fetus; the sum of four quadrant measurements of amniotic fluid. The AFI is measured using the anteroposterior dimensions obtained from the four quadrants of the amniotic sac and adding them together. The measurements should not include fetal parts or umbilical cord.

decidua basalis

the endometrial tissue at the implantation site, and the maternal contribution of the placenta. the endometrium beneath the developing placenta.

estimated fetal weight

the fetal weight based on sonographic measurements

neonatal period

the first 28 days of life

diaphragmatic hernia

the herniation of the abdominal contents into the chest cavity through a defect in the diaphragm

cervical length measurement

the length measurement taken from the internal os to the external os. Should measure at least 3 cm.

cervical incompetence

the painless dilation of the cervix in the second or early third trimester. clinical findings: 1. Painless dilation of the cervix 2. Premature rupture of membranes 3. Vaginal bleeding sono: 1. Cervical length of less than 3 cm 2. Funneling of the cervix (can produce a "U" or "V" shape)

chorion frondosum

the part of the chorion, covered by chorionic villi, that is the fetal contribution of the placenta. derived from the blastocyst and contains the chorionic villi.

cerclage

the placement of sutures within the cervix to keep it closed

funneling (cervical)

the result of the premature opening of the internal os and the subsequent bulging of the membranes into the dilated cervix. An early sign of an incompetent cervix. May take on a U shape or V shape.

premature rupture of membranes

the rupture of the amniotic sac prior to the onset of labor

blastocyst

the stage of the conceptus that implants within the decidualized endometrium

vitelline duct

the structure that connects the developing embryo to the secondary yolk sac

lower uterine segment

the term used for the isthmus during pregnancy

philtrum

the vertical groove seen between the upper lip and the nasal septum

umbilical vein

the vessel of the umbilical cord that carries oxygenated blood from the placenta to the fetus proceeds cephalad to connect to the left portal vein within the liver.

postpartum

time directly after giving birth and extending to about 6 weeks

exsanguination

total blood loss; to bleed out

umbilical arteries

two vessels of the umbilical cord that carry deoxygenated blood from the fetus to the placenta. once they enter the abdomen, they proceed caudal around the bladder to connect to the fetal internal iliac arteries.

symmetric IUGR

when the entire fetus is small. suspected causes: 1. Genetic disorders 2. Fetal infections 3. Congenital malformations 4. Syndromes

placenta previa

when the placenta covers or nearly covers the internal os of the cervix. Located in the lower uterine segment. A common cause of painless vaginal bleeding in the 2nd and 3rd trimesters. The placenta should be evaluated for ___ after 20 weeks with an empty bladder using a TA approach. clinical findings: 1. previous c section or uterine surgery 2. painless vaginal bleeding 3. possibly asymptomatic

shoulder dystocia

when the shoulder of the fetus cannot pass through the birth canal during pregnancy

asymmetric IUGR

wherein the femur length typically is normal while all other measurements are small for gestation. suspected causes: 1. Nutritional deficiency 2.Oxygen deficiency