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111 Cards in this Set

  • Front
  • Back
What is UPJ obs usually associated with?
Nothing, isolated
What about when it is?
10%


Esophageal and anal atresia

Hirschprungs

Neural tube defects

Cardiovascular defects
Association of choroid plexus cysts?
No definite association with any given entity, and they are usually normal. But when you see one, you must look extra carefully for other anomalies.
Like which?
Trisomy 18 and 21


Decision to amniocentese is based solely on finding other anomalies that warrant it. The cysts themselves are just a marker to tell you to look more carefully.
Nuchal thickening and evidence of coarctation
TURNERS
What is Turners assd with?
Nuchal abnormalities -- nuchal thickening to full cystic hygromas


Coarctation


Renal anomalies (horseshoe)
Oligohydramnios, what does it cause?
MSK anomalies like club foot and hip dysplasia, all the way to arthrogryposis


Pulmonary hypoplasia in severe cases
Oligohydramnios
ARE MEMBRANES INTACT???
Yes
DO UMBILICAL ARTERY DOPPLER TO LOOK FOR PLACENTAL INSUFFIC. A HIGH SYSTOLIC TO DIASTOLIC FLOW RATIO IS INDICATIVE, MORE SO AS THE PREGNANCY PROGRESSES


REMEMBER, THIS IS A VERY IMPORTANT CAUSE OF OLIGO, ALONG WITH RENAL ANOMALIES, PROM, ETC
Complex ovarian mass
Thick septations


Irregular walls


Septal nodules


Actual assoc mass
Complex ovarian mass, what now?
Echogenicity of soft tissue component


Doppler flow
Complex ovarian mass
3 types:


Epithelial


Stromal


Germ cell



If complex looking, low resistance flow, think epithelial neoplasm like mucinous or serous cystadenoCA, TOA, endometrioma, corpus luteum cyst
Suggestive of malignancy in ovarian mass
Associated ascites


Thick septations over 3 cm


irreg wall, etc
Benign ovaraian masses with low resistance flow
TOA


Endometrioma


Dermoid


Hormone secreting masses
Calculate resistivity index
Peak sys flow minus end diastolic flow; divided by peak systolic flow
What is considered low res flow
0.4 or lower
Most common congenital tumor of the newborn
Sacrococcygeal teratoma
Sacrococcygeal teratoma noticed in 4 month old baby
Increased risk of malignancy when diagnosed more than 2 months postnatally
Dandy walker -- what decreases risk of associated chromosomal abnormalities?
VENTRICULOMEGALY
15 wk with communication between 4th vent and cisterna magna
NOT DANDY WALKER


Fusion of the 2 halves of the vermis does not occur until 18 weeks.
Dandy walker association
1/3 have chromosomal abnormalities (any trisomy)


agenesis CC

aqueductal stenosis

encephalocele

cardiac, GU, facial abnormalities
Vein of galen malfo associations
Coarc


Transpo
Suspected previa 1st trimester US
f/u in 3rd trimester
False pos previa
Anything that compresses the LUS

--full bladder

--uterine contraction
Most common cause of obstruction at duodenal level
Intrinsic duodenal atresia
Other causes of duodenal obs
External compression by LADD'S BANDS


Annular pancreas


Preduodenal portal vein


Malrotation
Duodenal atresia
associated with COMPLEX CARDIAC ANOMALIES, which are the cause of death in most of these patients


Also, esophageal atresia, imperforate anus, renal malformations, biliary atresia
Nuchal stuff
Nuchal translucency: 1st trimester. sagittal plane. <3mm. Becoming the new moneymaker.


Nuchal thickening: Axial plane, level of thalami, 2nd trimester.
Translucency thickness
3mm
Translucency timing
10-14 weeks (its a moneymaker, because it can confirm or deny need for amnio early on, and help generate risk profile for older women)
Fetal neck mass
2 most important: Neural tube defect and cystic hygroma
Most common neck mass on boards
CYSTIC HYGROMA


People miss it all the time
importance of it
Chromosomal anomalies
Which ones
Trisomy 21 and Turners


Makes cystic hygroma confusing, though, because they look different between the two of them
Thickned nuchal translucency, then thickened nuchal fold in 2nd trimester, not much in the way of cyst
Trisomy 21

What the nuchal thickening is is just resorbed hygroma
Huge ugly cystic neck mass
Turners cystic hygroma
what is so damn important about cystic hygroma
The lymphatic circulation terminates in the neck, in both the right lymphatic duct and the thoracic duct. It joins the venous circulation in the neck. When this joining occurs improperly, a cystic hygroma develops. You can imagine that anytime two systems have to come together, that can happen in many different ways and for many different reasons. Thus the incidence of cystic hygroma as different looking entities in different situations. It also explains why hygroma should immediately make you concered for the impending development of hydrops. If these 2 systems are not properly joined in the neck, you get a hygroma first, but then over time, there is further back-up of lymphatic circulation, and soon you start getting fluid accumulating in other spaces, like the pleura and peritoneal cavity and extremities.
normal looking view of head or neck on fetal US
LOOK FOR THE HUGE HYGROMA. IT IS SO BIG YOU DONT EVEN NOTICE IT. BUT AMNIOTIC FLUID WILL NOT HAVE SEPTATIONS IN IT, SO LOOK FOR THAT. FIND THE HYGROMA WHETHER HUGE OR JUST A LITTLE BIT OF NUCHAL THICKENING WITH A LITTLE CYST.
Sagittal US image, kid with neck hyperextended.
= Stargazer position -- kid with eyes looking upward


THINK INIENCEPHALY


There will probably be a big posterior upper neck mass that is protruding.
Iniencephaly
HUGE neural tube defect that extends from base of skull down to neck, where you will see an ENCEPHALOCELE, sometimes all the way down to sacrum, where you will see another mass of the myelomeningocele
BIG UGLY FETAL MASS
Teratoma
most common fetal tumor
Teratoma
Mass growing out of mouth
Gnathic teratoma


treat with EXIT procedure -- Deliver the head, intubate the baby while cord still attached, then fully deliver baby
Other mass in fetal neck
GOITER
FETAL NECK MASS
Can I see the mass with color doppler to rule out a nuchal cord?
Neck "have to knows"
Iniencephaly


CYSTIC HYGROMA -- 70% will see it on boards. DONT GET TUNNEL VISION. LOOK FOR THE HYGROMA
Things you have to know
hypoplastic left heart


Endocardial
4 chamber view, see RA, see RV, but not sure you see the LV.
HYPOPLASTIC LEFT HEART SYNDROME

The ventricles are the easiest thing to see in the heart. When one is missing, its hypoplastic left heart
Hypoplastic left heart
MUST BE DELIVERED AT TERTIARY CARE FACILITY


ASSOCIATED WITH TURNERS
start looking at sizes, look same.

Start looking at interventricular septum. See it, but then its gone towards the base
Endocardial cushion -- shown on boards last year
Figure out what way fetus is lying on all scans
Cham
Big heart. RV small compared with LV and RA.
EBSTEIN'S MALFO
LVOT -- you follow the aorta up and then all the sudden you come to a break, and then you see the RV and LV are going into this outflow path
TRUNCUS -- won't be on boards
Chest masses you must know
CDH -- very high morbidity and mortality associated with it


CCAM


Extralobar sequestration
22:30
22:30
CDH: Why?
Two layers of muscle have to come together, and one of the places there is less coverage is in the back where the Bochdalek hernia occurs.
Where?
Bochdalek by far the most common
CDH seen in fetus
There are 2 predictors of prognosis:


1) Evaluate the amount of bowel up in chest, and for the presence of LIVER in the chest, which makes prognosis VERY bad.


2) If considering taking the baby to birth, MOTHER MUST HAVE AMNIOCENTESIS because 50% of these kids have associated chromosomal anomalies, which makes attempting to give birth to them silly.
Cystic mass in left hemithorax. DDx
1) CDH with stomach up


2) Type I CCAM, LARGE cysts


Tell these apart by looking in the abdomen. If there is no stomach there, its a CDH.
Still cant tell them apart
Request FETAL MRI
CDH designation in fetal imaging
Don't do the type 1-3 thing


just call them MICROCYSTIC or MACROCYSTIC
Microcystic CCAM
Can be hard to diagnose, because can have same echogenicity as the lung.


So you have to look for MASS EFFECT ON THE HEART and eversion of the diaphragm
Questionable chest mass
IS THERE MASS EFFECT ON THE HEART


If not, very unlikely to have a chest mass
Solid chest mass
DDx is microcystic CCAM and extralobar sequestration


to differentiate them, PUT ON DOPPLER. If you see flow from the aorta, it is a sequestration. If from PA, its a CCAM
Where is intralobar seq in the differential?
NOWHERE. They are acquired lesions. Not seen in feti.
Most common fetal tumor
TERATOMA
Fast growing fetal mass
Immature TERATOMA
Fetal abdomen required shots
Stomach

Kidneys


Cord insertion


3VC


Bladder
First thing to comment on on every fetal case
AMNIOTIC FLUID VOLUME
Baby with low amniotic fluid volume, 1st trimester
UTEROPLACENTAL INSUFFICIENCY

Fluid gets produced by baby-sweat early on

Kidneys do not kick in until early 2ND TRIMESTER
Once you hit 2nd trimester, what happens to amniotic fluid balance
BECOMES VERY COMPLEX


Everything still depends on uteroplacental circulation


Kidneys main producer

Baby breathing and swallowing fluid main ways of getting rid

All has to be in homeostasis
Calculate AFI
Take deepest pocket without fetal part (incl cord) in each quadrant, then add em up
Normal AFI
10 - 20 cm
Which is better, poly or oligo?
POLY because 2/3 are idiopathic, and no consequence or cause to worry about
Poly
Of the 1/3 that have known cause, mostly just that you have a big fetus whos got extra fluid. Macrosomic feti are typically related to maternal diabetes.

HOWEVER, there are anatomic causes TOO.
Baby with poly
Look for


1) GI tract obstruction (esoph and duod) -- baby cant swallow


2) CNS malformation -- too stupid to swallow


3) Hydrops -- After the baby is done collecting fluid in all of its body compartments, it starts collecting it in its SURROUNDING FLUID.
Fetal US case, can't tell what is going on
COMMON CASE ON BOARDS


THINK: WHY CAN'T I SEE ANYTHING??


OH, there is NO FLUID = oligohydramnios
How do you prevent this problem
MAKE FLUID ASSESSMENT THE FIRST THING YOU DO ON A FETAL CASE
Baby with oligohydramnios
There is only a DRIP of fluid in there


The mnemonic is out of order, because the first thing you should think of is the last thing P = Premature rupture of membranes. That is the first question you MUST ASK before proceeding.


D -- Demise

R -- Renal (actually GU) anomalies

1) Renal agenesis

2) Bilateral MCDK

3) Posterior urethral valves

I -- IUGR (usually due to uteroplacental insuff)

P -- PROM
Fetal abdomen problems
Only 2 types

ATRESIAS


ABDOMINAL WALL DEFECTS
Atresias -- where?
Most common = Duodenal


Next = esophageal


Others = small bowel (jejunal or ileal) and anal
Esophageal atresia -- which is the type we care about
By far the most common:

Proximal esophageal atresia with distal tracheoesophageal fistula
Diagnosis of esophageal atresia in 1st trimester
USUALLY MISSED, because the diagnosis is suggested by the presence of POLYHYDRAMNIOS which is not evident in 1st trimester
OB US -- Polyhydramnios
OK, well 2/3 of these are normal. The majority of the rest are in macrosomic infants with diabetic mothers. A small remainder has one of the following abnormalities:

--Atresia (esophageal, duodenal are the ones that cause poly)

--CNS malformation

--Hydrops


As you go through your checklist, you start by looking for duodenal atresia, the most common atresia. You do not see a double bubble sign. So then you notice that not only do you not see a DOUBLE bubble, you dont even see a single bubble; you don't see the stomach. The answer -- esophageal atresia
Peds case -- show you AP view of chest with NG tube, but its curled in the neck
TEF with proximal atresia, distal fistula

How do you know? Because they show you there is air in the stomach.
Axial view of abdomen with double bubble
Duodenal atresia


1/3 HAVE TRISOMY 21!!!


Thus, if you see a double bubble, the next thing you do is RECOMMEND AMNIOCENTESIS!!!


THEN, 1/2 of these kids have a major anomaly, usually cardiac.

SO, THIS IS A HIGH RISK PREGNANCY ONCE YOU SEE A DOUBLE BUBBLE


THIS IS THE MOST COMMON ONE ON BOARDS
Double bubble DDx
The other causes of duodenal obstruction, i.e. Ladds bands, annular pancreas, are NOT severe enough to give you a true double bubble.

HOWEVER, we can have cysts which can be adjacent to the stomach, and cause the APPEARANCE of a double bubble.

Choledochal cysts

Mesenteric cyst

Enteric duplication cyst

Ovarian cysts -- easily go up there because of lax ovarian ligaments in these kids.
How do you make FIRM diagnosis of duod atresia?
SHOW that you can see the 2 bubbles connected, and you have made the definitive diagnosis.
Now you have diagnosis of duod atresia. Mom is going to need amniocentesis. BUT, they want to see pictures NOW.
Look at the heart for an endocardial cushion defect
Cystic lesion in abd or pelvis
bladder, ovarian cyst, duplication cyst, mesenteric cyst, choledochal cyst
cystic lesion in pelvis
think first of distended bladder secondary to posterior urethral valves in a male, regardless of how large the cyst is. Key to making the diagnosis is to see funnel shaped posterior urethra. Also typically see shrunken echogenic kidneys when severe.
Cystic lesion in pelvis, female
the most common cystic lesion in females is ovarian cyst. They can become very large. They can extend up into the abdomen because of lax ligaments. And for the precise reason, they are prone to torsion.
Mass in Sacrococcygeal region
only two things to consider -- Sacrococcygeal teratoma , and myelomeningocele. Sacrococcygeal teratoma can be either cystic or solid. They can also become extremely large resulting in heart failure. If you see a fetus and then an extremely large mass, so large you don't even know where it's coming from, it's a teratoma, probably Sacrococcygeal teratoma.
Important to see in every neuro sonogram
cavum septum pellucidum
too much water in brain
three "Hs" in the differential: hydrocephalus, hydranencephaly, and holoprosencephaly
normal falx, no brain seen
hydranencephaly.
hydranencephaly
everything forms normally, then there is a huge stroke resulting in loss of the entire anterior circulation of brain. That's why the cranium, face, and falx are normal.
Brain looks normal except for absent cavum septum pellucidum
lobar holoprosencephaly
Monoventricle with fused thalamus
alobar
Some formation of occipital lobe with monoventricle, dorsal sac
semilobar
Holoprosencephaly association
TRISOMY 13. THEY GET AMNIO EVEN IF LOBAR
Midline facial malformation
associated with severe brain deformities such as holoprosencephaly
Off midline cleft lip
ISOLATED anomaly. BUT, if midline, they get amniocentesis.
Hydrocephalus versus ventriculomegaly
ventriculomegaly is just enlargement of the ventricles. Hydrocephalus also has enlargement of the head.
Ventriculomegaly criteria
greater than 10 mm at the level of the atria or dangling choroid.
Ventriculomegaly identified
not good enough to just say it's ventriculomegaly. There are three things in the differential. Aqueductal stenosis, Dandy-Walker malformation, and Chiari II malformation. Communicating hydrocephalus is much less common in a fetus than in in a neonate.
chiari 2; the posterior fossa is abnormally small
the cerebellar hemispheres are splayed
Other neural tube defects; Encephalocele
anencephaly
Choroid plexus cysts; one in 500 chance of trisomy 18. Do not do amnio just based on these. Must look for other abnormalities. Hands
cardiac
Prenatal hemorrhages;If you say subchorionic hemorrhage you will never be wrong. You have decidua from the mom
the chorion from the fetus. The hemorrhage occurs between the endometrium and the chorion. They can further be categorized as retroplacental
MS AFP;Get elevated maternal serum alpha-fetoprotein with neural tube defects
but also with abdominal wall defects. Alpha-fetoprotein is released by the fetus into the amniotic fluid. A small amount of that gets into the maternal's circulation. MS AFP goes down with aneuploidy (goes down with Down's).