high risk pregnancy and fetal growth

decreased rate of fetal growth

intrauterine growth restriction

IUGR is defined as fetal weight

at or below 10%

is IUGR the same as SGA

no

SGA is

fetus weight below 10% without reference ot cause

risk factors for high risk

✓Advanced maternal age

✓Abnormal maternal lab values

✓Vaginal bleeding

✓Insulin-dependent diabetes mellitus (IDDM)

✓Hypertension (HTN)

✓Preeclampsia

✓Maternal systemic disease

maternal factors for IUGR

• Previous history of fetus with IUGR

• Significant maternal hypertension

• History of tobacco use

• Presence of uterine anomaly

• Significant placental hemorrhage

• Placental insufficiency

result of first trimester insult, such as

chromosomal abnormality or infection

symetric IUGR

begins late in second or third trimester and usually

results from placental insufficiency.

asymmetric IUGR

clinical signs of IUGR

Decreased fundal height and fetal motion.

Key IUGR sonographic markers:

Grade 3 placenta before 36 weeks or

decreased placental thickness.

single most sensitive indicator of IUGR

AC

EFW below 10th percentile considered by most to be

IUGR

BPP parameters

1. Cardiac nonstress test (NST)

2. Observation of fetal breathing movements (FBM)

3. Gross fetal body movements (FM)

4. Fetal tone (FT)

5. Amniotic fluid volume (AFV)

normal NST

Two fetal heart rate

accelerations of 15 bpm or

more.

Resistive Index (RI) =

maximum systolic velocity – diastolic

velocity/systolic velocity

Systolic/diastolic Ratio (S/D) =

maximum systolic

velocity/diastolic velocity

Pulsatility index (PI) =

maximum systolic velocity – diastolic

velocity/mean velocity

Acceleration time (ACC) =

time from beginning of systole to peak

systole

Deceleration time (DCC) =

time from peak systole to end diastole

normal SD ratio

below 2.6

macrosomia is

birth weight of 4000g or greater or above 90th perecntile

macrosomia more frequent in women who are

✓Are multiparous

✓Are 35 years or older

✓Have pre-pregnancy weight of >70 kg (154 lb)

✓Have PI in upper 10%

✓Have pregnancy weight gain of ≥20 kg (44 lb)

✓Have a postdate pregnancy

✓Have history of delivering LGA fetus

AMA refers to patient

35 or older at time of delivery

quad screen

✓Alpha-fetoprotein (AFP)

✓Human chorionic gonadotropin (HCG)

✓Unconjugated estriol (uE3)

✓Inhibin-A

condition in which excessive fluid accumulates

within fetal body cavities

hydrops fetalis

initiated by the presence of maternal serum immunoglobulin antibody against one of the featl RBC antigens

immune hydrops

substance that elicits immunologic response such as production of antibody to that substance

antigen

Potential of fetal anemia can be determined by:

✓Ultrasound surveillance

✓Amniocentesis

✓Cordocentesis

Sonographic findings of hydrops:

✓Scalp edema

✓Pleural effusion

✓Pericardial effusion

✓Ascites

✓Polyhydramnios

✓Thickened placenta

amnio low zone

Rh-negative and mildly affected fetuses found in low

zone

amnio mid zone

ownward trend within mid-zone indicates fetus

probably affected but will survive; delivery should occur at 38

weeks of gestation.

amnio high zone

Fetal death zone

Needle placed into fetal umbilical vein

and blood sample obtained.

cordiocentesis

Mother may develop immune response to fetal platelets in manner

similar to that of RBCs.

alloimmune thrombocytopenia

group of conditions in which hydrops present in

fetus but is not result of fetomaternal blood group incompatibility.

nonimmune hydrops

some etiology of nonimmune hydrops

congestive heart failure, obstructive vascular problems, large vascular tumors, severe anemia

with nonimmune hydrops what is tachycardia

200-240

Bleeding in second and third

trimesters can be associated with

placental anomalies:

✓Placenta previa

✓Placenta abruption

main cause for third

trimester bleeding

placenta previa

umbilical cord is

presenting part.

vasa previa

vasa previa associated with

velamentous

cord insertion or succenturiate

lobe

placenta abruption sonography

• Normally, area hypoechoic and 1 to 2

cm thick.

• If thicker than 1 to 2 cm, may be due to

abruption or uterine contraction.

• Uterine contractions should resolve

within 20 to 30 minutes and typically

have central blood flow.

IDDM

insulin dependent diabetic mellitus

Pregnancies may be complicated by frequent hospitalizations for: in setting of diabetes

✓ Glucose control

✓ Serious infections such as pyelonephritis

If glucose levels very high and uncontrolled, fetus may also

become

macrasomic

Hypertensive pregnancies may be associated with

small placentas

small placenta may lead to

IUGR

used to describe hypertensive disorders, because

believed that “toxin” in mother’s bloodstream caused hypertension.

toxemia

Terminology used in clinical practice to describe hypertensive states

during pregnancy:

1. Pregnancy-induced hypertension (includes preeclampsia, severe

preeclampsia, and eclampsia).

2. Chronic hypertension (present before woman pregnant).

pregnancy condition in which high blood pressure

develops with proteinuria (protein in urine) or edema (swelling)

preeclampsia

represents occurrence of seizures or coma in preeclamptic

patient.

eclampsia

chronic autoimmune disorder

that can affect almost all organ systems in body.

systemic lupus erythematosus

Systemic Lupus Erythematosus most comon in

women of childbearing age

Systemic Lupus Erythematosus what to look for

-placenta by complex depositis and inflammatory responses to placental vessels

-rule out congenital heart block and pericardial effusion

hen pregnant woman vomits so

much she develops dehydration and electrolyte imbalance

Hyperemesis gravidarum

what is ultrasound used to in setting of hyperemeis

gallstones, peptic ulcers, trophoblastic disease

• Pregnancy normally associated with

mild hydronephrosis

• Maternal obesity associated with increased incidence of

neural tfects ube de

Obese women also at increased risk for:

✓Severe eclampsia

✓Multiple births

✓Urinary tract infections

onset of labor before 37 weeks of gestation.

premature labor

Potential etiologies of preterm labor:

✓Premature rupture of membranes

✓Intrauterine infection

✓Bleeding

✓Fetal anomalies

✓Polyhydramnios

✓Multiple pregnancy

✓Growth restriction

✓Maternal illness (diabetes or hypertension)

✓Incompetent cervix

✓Uterine abnormalities

accounts for roughly half

of all perinatal mortality.

fetal death

Ultrasound findings associated

with fetal death:

• Absent heart beat

• Absent fetal movement

• Overlap of skull bones

(Spalding’s sign)

• Exaggerated curvature of fetal

spine; gas in fetal abdomen

small for gestational age can be due to

✓Chromosomal anomalies

✓Intrauterine infection

✓Genetics

✓Placental insufficiency

Overlap of skull bones

Spalding’s sign

MSAFP

Maternal serum alpha-fetoprotein

elevated MSAFP patients there to rule out

neural tube defects vs twin

dizygotic=

maternal

monozygotic

identical

arise from a single fertilized egg that divides, resulting in two genetically identical fetuses.

Monozygotic twins

If division occurs early, 0 to 4 days postconception, there will be

dichorionic, diamniotic

If division occurs at 4 to 8 days, there will be

monochorionic, diamniotic

If division occurs early, 0 to 4 days postconception,

✓ two amnions

✓ two chorions

If division occurs at 4 to 8 days,

✓ One chorion

✓ two amniotic sacs

If division occurs after 8 days:

✓One chorion

✓One amnion

If division occurs after 13 days,

division may be incomplete,

resulting in

conjoined twins

Twins may be joined at variety of

sites:

✓Head

✓Thorax

✓Abdomen

✓Pelvis

monozygotic twins are increased risk for what syndrome

twin to twin

If demise occurs very early, complete resorption of both embryo

and gestational sac or early placenta may occur.

vanishing twin

If fetus dies after reaching size too large for resorption, fetus

markedly flattened from loss of fluid and most of soft tissue

Fetus Papyraceous

poly oli sequence aka

stuck twin syndrome

Characterized by diamniotic pregnancy with

polyhydramnios in one sac

poly oli sequence

TTS exists when there is blank within placenta

arteriovenous shunt

tts arterial blood of one twin is pumped into blank system of other twin

venous

in tts donor twin becomes blank and blank

anemic

and growth restricted.

When oligohydramnios exists in one sac and polyhydramnios in

other

Poly-Oli Sequence

stuck twin us

less blood flow through kidneys, urinates less, develops

oligohydramnios.

recipient twin poly oli

Recipient twin gets too much blood flow.

• Fetus has excess blood flow through kidneys and urinates too much, leading

to polyhydramnios.

If twin-to-twin transfusion exists, both twins at risk of dying.

smaller one because its nutritional and o2 rich blood suppy is severly restricted

✓Larger one because of heart failure

Rare anomaly occurring in

monochorionic twins.

✓One twin develops without a heart and

often absence of upper half of body

acardiac anomaly

acardiac twin due to blank connection in placenta

artery to artery

Conjoined Twins joined at thorax

Thoracopagus

Conjoined Twins joined at anterior wall

omphalopagus

conjoined twin jaoined at cranium

craniopagus

conjoined twins with one head

synecphalus

conjoined twin joined at ischial region

pygopagus

conjoined twin attached at buttocks

ischiopagus