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Where does the word pelvis come from?
Latin and Greek, meaning "dish" or "bowl"
Central section of the skeleton/ positioned etween the lower end of the spine, which it supports, and the lower extremeties, upon which it rests.
pelvic girdle
Four bones of the bony pelvis
sacrum (posterior), coccyx (posterior), two innominate bones (fusion of the ilium, ischium, and the pubis/ anterior and lateral)
What is the pelvis divided into?
False pelvis and true pelvis, divided by an imaginary plane running from the sacral prominence to the upper margin of the symphysis pubis
sits above the imaginary plane and is bounded by the iliac wings/ is a broad shallow cavity that supports the abdominal viscera (bowel)
False pelvis
sits below the imaginary plane and is further divided into pelvic inlet and pelvic outlet
True pelvis
part of the true pelvis bounded by the pubic bones anteriorly and the sacral promontory posteriorly
pelvic inlet
part of the true pelvis bounded by the ischial tuberosities laterally and the coccyx posteriorly
pelvic outlet
In the absence of masses in the nongravid pt, the uterus, ovaries, and adnexa are situated in the _____.
true pelvis
ligaments that bind the pelvic bones together
osseous
ligaments that support the uterus and ovaries
suspensory
arise superiorly and laterally from the uterus and inferiorly from the vagina to provide primary support for the uterus
cardinal ligament
(suspensory)
**(lateral) extend from the lateral aspects of the uterus, and attach to the lateral pelvic side walls
broad ligament
(suspensory)
extend posterolaterally from the supravaginal cervix, encircle the rectum, and insert onto the fascia over the sacrum
sacro-uterine ligament
(suspensory)
**situated anterior and inferior to the broad ligaments and fallopian tubes, they attach the uterine cornu to the anterior pelvic wall
round ligament
(suspensory)
attach the inferior ovary to the uterine corny, posterior to the fallopian tube on each side
ovarian ligament
(suspensory)
attach the ovary to the posterior layer of the broad ligament on each side
mesovarium ligament
(suspensory)
the superior margin of the broad ligament on each side, lteral to the fimbria of the fallopian tubes, through which course the ovarian vessels and nerves
infundibulopelvic ligament
(suspensory)
bind the sacrum and iliac bones
sacroiliac ligament
(osseous)
bind the sacrum, iliac, and coccyx
sacrosciatic ligament
(osseous)
bind the sacrum and coccyx
sacrococcygeal ligament
(osseous)
bind the two pubic rami
pubic ligament
(osseous)
False pelvic muscles
rectus abdominus, psoas major, iliacus
forms the anterior margin of the abdominal and pelvic spaces/ it extends from the symphysis pubis to the costal margin
rectus abdominis muscles
(false pelvis)
originates at the lower thoracic vertebrae and extends lateral and anterior as it courses through the lower abdomen, along the pelvic side wall to eventually insert on the lesser trochanter/ just inferior to the iliac crest, it merges with the iliacus muscle creating the iliopsoas muscle/ it forms part of the lateral margins of the pelvic basin
psoas major muscles
(false pelvis)
**arises at the iliac crest and extends inferiorly until it merges with the psoas major/ it forms the ilac fossa on both of the pelvic side walls.
iliacus muscle
(false pelvis)
**constitute the pelvic diaphragm muscles
levator ani and coccygeus muscles
**attach to the side of the true pelvis, extend madially to fuse with the opposite side, and thus form the floor of the pelvic cavity.
levator ani muscles
(true pelvis)
aruse from the ischial spine and the sacro-sciatic ligament on either side, insert onto the coccyx and close the posterior part of the pelvic diaphragm and outlet
coccygeus muscle
(true pelvis)
**triangular muscle arising from the anterolateral wall of the pelvis/ extends from the brim of the true pelvis and exits through the lesser sciatic foramen to insert on the greater trochanter of the femur.
obturator internus
(true pelvis)
arise from the sacrum, pass laterally through the greater sciatic notch, and insert on the greater trochanter of the femur/ they are identified posteriorly in the pelvis
piriformis muscle
(true pelvis)
musculomembranous, highly distensible sac located between the symphysis pubis and the vagina
urinary bladder
Where do the ureters insert in the bladder?
the inferior third of the posterior wall on either side
superior concavity of the bladder
dome
Three layers of tissue in the bladder
outer epithelial, middle muscularis, and inner mucosal
allows for the exretion of urine, arises along the inferior middle portion of the urinary bladder/ at it's point of exit, it is surrounded by a thickened region of bladder wall referred to as the internal urethral sphincter.
urethra
When is the bladder adequately full for transabd scanning?
when the dome of the bladder extends above the fudnus of the uterus
muscular tube, approximately 7-10 cm in length, extending from the cervix to the external vaginal introitus/ composed of smooth muscle, elastic connective tissue, and stratified squamous epithilium which line the inner surface/ the upper portion attaches circumferentially to the cervix approx half way up
vagina
ring-like blind pouch that surrounds the cx
vaginal fornix
surrounds the posterior aspect of the external cx/ is a frequent site of vaginal fluid collections due to gravity dependence
posterior fornix
surround the lateral aspect of the external cervix on either side.
lateral fornices
surrounds the anterior aspect of the external cervix/ is much smaller than the posterior fornix
anterior fornix
muscular structure suspended by ligaments and normally located in a mid-sag plane in the true pelvis/ bordered ant by the bladder and post by the rectosigmoid colon
uterus
the largest part of the uterus/ contains the uterine cavity/ the corpus is predominantly muscular and widens superiorly as the fundus, above the insertion of the fallopian tubes/ the cone-shaped cornua are lateral, where the tubes enter the uterus/ the lower uterine segment, sometimes called the isthmus, transitions into the cx at the location of the internal os
body of uterus
located posterior to the angle of the urinary bladder/ comprised predominantly of collagenous and elastic tissue/ narrower than the uterine body and measure 3-4 cm in length in the nulliparous female/ the mucosal-lined endocervical canal is contiguous with the uterin cavity at the internal os and opens into the upper vagina at the external os/ the lower portion projects into the vagina
cervix
Largest organ in the normal female pelvis when the bladder is empty
uterus
A mobile, hollow, muscular, pear-shaped structure partially covered in peritoneum
uterus
Normal menarchal uterus measurements
7.5cm long, 5cm wide, 2.5 cm AP
Three layers of the uterus
External or serous layer
Middle or muscular layer
Internal mucous layer
External uterus layer
peritoneum surrounds the uterus except where the baldder lays against it at the cervical-vaginal connection
Myometrium
middle uterus layer that composes majority of the uterus/ primarily smooth muscle that is longitudinal and circular
Endometrium
-inner uterus layer
-lined by a thin mucous membrane
-varies in appearance and thickness
Endo thickness of menstruating female
4mm - 12mm
Endo thickness of postmenopausal female
4mm - 10mm
Two layers of endometrium
Functional layer (zona functionalis) and deep basil layer (zona basalis)
Retroflexion
uterus tipped backward at cervix
Retroversion
uterus tilted posterior
Retroversion with retroflexion
uterus tilted posterior and tipped backward
The uterus is supported in its midline position by...
paired broad ligaments, round ligaments, and uterosacral ligaments
**double fold of peritoneum/ provide bilateral support for the uterus
broad ligaments
What do the broad ligaments surround?
the fallopian tubes, round ligaments, ovary, paraovarian, connective tissue, unstriped muscular fiber, blood vessels, and nerves
**Occupy space between the layers of broad ligament and occur in front of and below the fallopian tube/ these two cords commence on each side of the superior aspect of the uterus and course upward and lateral to the inguinal canal and labia majora
round ligaments
**attach ovaries to uterus
ovarian ligaments
**attach ovaries to pelvic wall
suspensory ligaments
located in the adnexa, are contained in a special fold of the broad ligament called the mesosalpinx
fallopian tubes
Normal measurements of fallopian tubes
12 cm long, 1 to 4 mm in diameter
funnel-shaped lateral tube that projects beyond the broad ligament to overlie the ovaries/ free edge of the funnel has fimbrae
infudibulum
fimbrae
fingerlike projectors draped over the ovary on the free edge of the infudibulum of the fallopian tubes
widest part of the fallopian tube
ampulla
**where does fertilization occur?
ampulla
hardest part of the fallopian tube, lies just lateral to the uterus
isthmus
part of the fallopian tube that pierces the uterine wall
interstitial
muscular tube composed of primarily smooth muscle with some skeletal muscle fibers/ is the passageway for the products of the menstrual cycle and is easily distendible/ has a mucous membrane lining in its muscular wall to recieve secretions
vagina
How long is the vagina?
10 cm
**Where does the vagina lie?
ant to the rectum and anal canal and post to the pubic symphysis, urinary bladder, and urethra
Where is the urethra located?
in the lower part of the anterior vaginal wall
opening of the urethra
external urethral meatus/ ant to the opening of the vagina
found in the upper end of the vagina, near the external cx/ has ant side and post side/ post side is covered with peritoneum and may perforate by instruments being misdirected causing peritonitis
fornix
almond shaped, attached to the back of the broad ligament by mesovarium, sometimes called suspensory ligament/ lie in ovarian fossa
ovary
ovary measurement
3cm
what is the ovarian fossa bounded by?
external iliac vessels, ureter, and obturator nerve
ovarian blood supply
receives blood from ovarian artery/ blood drained by ovarian vein into IVC on right and on LEFT into left renal vein
outer region of the ovary that surrounds the medulla consisting primarily of follicles in varying stages of development/ it is covered by dense connective tissue, the tunica albuginea, and a thin single layer of cells, the germinal epithelium
cortex
part of ovary composed of connective tissue containing blood, nerves, lymphatic vessels, and some smooth muscle
medulla
provides blood to the pelvis cavity through the external and internal iliacs
common iliac artery
course along the pelvic brim
external iliac artery and vein
runs down into the pelvis on the post wall to provide multiple branches to the pelvic structures
internal iliac artery
enters the pelvis as it courses ant to the internal iliac artery to empty into the post base of the bladder
ureter
**supplies blood to the uterus, arises from the internal iliac artery/ courses medially over the ureter in the base of the broad ligament to the uterus at the cervical level/ tortuous
uterine artery
**two sources of blood supply to the vagina
ant surface supplied with blood from a branch off the uterine artery/ post surface is supplied from a branch of the internal iliac vessel
where does the ovary receive its blood supply?
from the aorta
the ovarian arteries are...
tortuous
The pelvis is divided by...
an oblique line that separates the greater (false) and the lesser (true) pelvis.
passes through the sacrum to the superior margin of the pubis symphysis
pelvic brim
cephalic to the pelvic brim and is bordered by the abdomen cephalically and the lesser pelvis caudally
greater pelvis
part of the abdominal cavity found below the pelvic brim
pelvic cavity
formed by the sacrum and coccyx covered by the piriformis and coccygeus muscles
posterior wall of pelvic cavity
lateral margins of the pelvic cavity
hip bones covered by the obturator internus muscle
formed by the levator ani and coccygeus muscles
lower margin of the pelvic floor
region above the diaphragm
pelvic cavity
smaller area below the pelvic floor
perineum
lowest part of the peritoneal cavty
rectouterine pouch/ Pouch of Douglas/ posterior cul-de-sac
originates at the lower thoracic vertebrae and extends lateral and ant as it coursed through the lower abdomen/ separates from the vertebral column at the level of L5 and coursed through the pelvis to insert on the lesser trochanter
psoas major muscle
forms the lateral margins of the pelvic basin/ formed just inferior to the iliac crest when the psoas major merges with the iliacus muscle
iliopsoas muscle
arises at the iliac crest and extends inferiorly until it merges with the posas major to form the pelvic side wall
iliacus
pass out from the pelvis through the sciatic foramina to attach to the greater tuberosity of the femur
piriformis and obturator internus
muscular part of the sacrospinous ligament and forms the posterior part of the pelvic diaphragm
coccygeus muscle
**forms the anterior part of the pelvic diaphragm
levator ani muscles
form the floor of the pelvis
levator ani muscles
play an important role in rectal and urinary continence and maintain the position of the uterus and ovaries
levator ani muscles
reproductive cell produced by the ovaries
ovum
**ovaries produce two known hormones/ they are responsible for maintaining secondary gender characteristics, preparing the uterus for implantation, and for development of the mammary glands
estrogen and progesterone
What is estrogen secreted by?
follicles
**What is progesterone secreted by?
corpus luteum
Reproductive years
begin around age 11 to 13 at the onset of menstruation and end around 50 years of age
once a month when an ovum is released from one of the two ovaries/ speculated that this alternates between the two ovaries
ovulation
begin development in embryonic life and remain in the ovaries until menses begins/ some mature and discharge from the ovaries on a monthly basis while others die
ova
prepuberty stage, time before the onset of menses
premenarche
stage after reaching puberty, onset of menses
menarche
menses has stopped permanently
menopause
The cyclic changes of the uterus during the menstrual cycle are directly related to...
the interaction of the hormones produced by the ovaries and the hormones from the pituitary gland
**Approx days 1-4/ the ovaries contain many primary follicles/ uterus is shedding the superficial layer of the endo
menstrual phase
**days 5-14/ ovaries begin a period of rapid growth under the influence of fsh/ the ova grows, fills with fluid, and begins to secrete estrogen/ one follicle reaches maturity/ ovulation occurs
proliferative phase
**One follicle grows to reach maturity/ estrogen levels increase to trigger production of more fsh/ pituitary gland begins to secret luteinizing hormone/ shift in hormones causes the release of egg from ruptured follicle/ at the same time estrogen levels increase and the endo beings to regenerate
ovulation in the proliferative phase
**approx days 15-29 (to the onset of menses)/ collapsed follicle begins to grow and form corpus luteum, or yellow body which secretes progesterone and estrogen/ progesterone levels increase and the endo prepares to accept fertilized egg/ if fertilization does not occur, the corpus luteum will degenerate due to decreased progesterone and estrogen levels, menses occurs, and the cycle starts over/ if fertilization does occur the corpus luteum conts to secrete these hormones for about 3 months until placenta forms
secretory phase
Hormonal contraceptives
-oral: contains estrogen and progesterone/ inhibit ovulation and changes endo linig and cervical mucus
-depot-medroxyprogesterone acetate: injected every 3 months/ inhibits ovulation and thickens mucus
-Levonorgestrel implants: thin capsules inserted under the skin of the upper arm/ inhibits ovulation and thickens mucus
-Post-coidal hormonal contraceptive (pcc): morning after pill/ should be administered within 72 hours after unprotected sex
Barrier contraceptive methods
-diaphragm
-cervical cap
-condoms
Surgical Fertility control
hysterectomy/ elective abortion
Intrauterine Contraceptive Device (IUD)
foreign body placed in the endometrial cavity providing a hostile environment thus discouraging implantation/ ovulation and corpus luteum formation is not impaired/
Types: -Progestasert has core of progesterone that is released over a period of time/ T-shaped/ currently on the market
-Paraguard Copper T is wrapped in fine copper stranding/ currently on market
-Lippes loop
-Copper 7
-Saf-T-Coil
-Dalkon Shield
IUD Placement
Inserted in the uterus cavity during menses and provide reliable birth control/ pt should check for proper placement weekly by palpating string in cx/ If string is not felt the iud could have been expelled or the string could have retracted into the uterus/ sensitive preg test is performed, if neg the dr will explore the uterine cavity with sterile hooked probe. if the iud is not found or if preg test is pos then an u/s is performed
Risk associated with iud's
usage with preg increases risk of spontaneous abortion/ iud can become imbedded in myometrium/ abscess formation/ perforation/ lost iud/ PID
Sonographic appearance of IUD
highly reflective/ entrance-exit reflections/ post shadowing/ focal uterine calcifications or intrauterine gas bubbles may simulate an IUD
two conjoined uteri that share the same medial wall, both have a fallopian tube, endo, and mymetrial structures, share the same cervix
bicornuate uterus
rare, two complete, independent uteri form, the fallopian tube attaches to the lateral angle of each uterus, each uterus functions separately, each one can sustain a pregnancy
Uterus didelphys
entire uterine cavity is separated by a thin septum
complete septum
half of uterus with only one fallopian tube attachment
unicornuate uterus
not uterine body, fallopian tubes come to a blind end, only a small ribbon of fibromuscular tissue is present or minute particles of the mullerian duct are present
uterine aplasia
most common tumor of uterus/ benign
fibroid/myomas/leiomyomas
benign tumor of uterus/ most often found in premenopausal women over 30 and younger in African-American women/ made of smooth muscle of uterin wall (myometrial tissue)/ encapsulated with a pseudocapsule so they are easy to remove/ may degenerate with atrophy and vascular compromise/ liquefaction, necrosis, hemorrhage, and ultimate calcification may take place
fibroid
**this benign tumor of the uterus usually does not become malignant, however it is sensitive to estrogen and may increase in size during pregnancy/ after menopause, with the regression of estrogen stimulation, the tumor becomes smaller but does not entirely disappear/ clinically they cause uterine irregularity and enlargement with the sensation of pelvic pressure and sometimes pain/ patterns of irregular bleeding, menometrorrhagia or menorrhagia are symptoms/ can contribute to infertility by distorting the fallopian tube or endometrial cavity, if located in the lower segment may interfere with vaginal delivery
fibroid
location of leiomyoma/ deforming the endometrial cavity and causing irregular or heavy bleeding
submucosal
location of leiomyoma/ deforming the myometrium, the MOST COMMON type
intramural
**location of leiomyoma/ sometimes becoming pedunculated and appearing as extraunterin masses
subserosal
characterized by nests of endometrial tissue within the myometrium/ causes heavy painful bleeding/ diffuse uterine enlargement/ not reliably diagnosed by ultrasound
adenomyosis
less than 5% of uterine malignancies/ derived from smooth muscle in the wall of the uterus/ thought to arise from preexisting leiomyomas/ resembles fibroids or endometrial CA/ enlargement of a fibroid in a perimenopausal or postmenopausal women raises the suspicion
Uterine leiomyosarcoma
**caused by unopposed estrogent (usually Premarin) and appears as thickening of the endometrium/ premenopausal women > 14mm, postmenopausal women > 8mm/ women on sequential estrogen and progesterone replacement can have endometrial measurements up to 15mm during the estrogen phase, so it is best to evaluate endo at BEGINNING or END of hormone cycle
Endometrial hyperplasia
usually asymptomatic but can cause uterine bleeding/ typically cause diffuse or focal endometrial thickening/ appear as either cysts or dense masses in endo cavity on u/s, better visualized when there is fluid in the endo
Endometrial Polyps
**Often occurs with PID but can also occur postpartum/ on u/s the endo appears prominent, irregular, or both with a small amount of endo fluid/ rarely gas bubbles form/ in the postpartum period the presence of retained tissue is difficult to distinguish from inflammatory debris or blood clots
Endometritis
Scar tissue found in women with a prior hx of uterine curettage or spontaneous abortion/ sonography may demonstrate bright echoes within the endometrial cavity
Synechiae
**MOST COMMON is adenocarcinoma occuring in perimenopausal and postmenopausal women with irregular bleeding/ associated with estrogen stimulation/ earliest change is thickened endo/ studies show that endo thickness of less than 5mm reliably excludes significant endo abnormalities/ tv us is helpful in screening by accurately measuring the thickness of endo and can also demonstrate myometrial invasion by showing an irregular interface between the endo and myometrium
Endometrial Carcinoma
most common type of endometrial carcinoma
adenocarcinoma
Occur with ectopic pregnancy, endometritis, degenerating fibroids, and recent abortion/ when visualized it should be measured AP without endometrium included
Small Endometrial Fluid Collections
should be regarded as suspicious/ can be caused by radiation in women who have had gyn malignancies/ or caused by uterine, cervical, tubal, or ovarian carcinoma/ can be caused by benin conditions such as congenital anomaly or cervical stenosis due to instrumentation or childbirth/ pt typically compains of abd pain and has abd mass/ usually has little or no bleeding/ can develop pyrometra (puss in uterus)/ sonographically appears as large endo fluid collection in a moderately enlarged uterus
Large Endometrial Fluid Collections
cervical cysts from dilated or obstructed transcervical gland/ round fluid filled structures usually less than 2 cm
Nabothian Cysts
Hyperplastic protrusion of epithelium of cervix/ usually from chronic inflammation may be pedunculated
Cervical Polyps
**acquired from prior irritation of cervix/ post-menopausal is usually asymptomatic while menopausal women have fluid filled uterus with oligomenorrhea or amenorrhea with cramping
cervical stenosis
Affects women of menstrual age/ areas of increased echogenicity or hypoechoic areas with an irregular outline signify changes compatible with CA/ discharge or bleeding, possible obstruction of ureters/ should be found with pap/ seen with EVUS or transrectal us/ look for bladder involvement/ us may be used for staging and biopsy
Cervical Cancer
**Seen in hysterectomy pts after surgery/ upper limits 2.1cm/ evaluated for fibrosis or mass especialy if hysterectomy was due to malignancy
Vaginal Cuff
cysts in vagina, fairly common with cystic appearance/ vag carcinoma show solid
Gartner's duct cyst
Occurs when dominant follicle fails to ovulate and remains mature/ the follicle should involute and regress in size/ thin-walled, small cyst/ may be multiple in number/ ovary is neither distorted or enlarged/ may lead to menstrual irregularity/ surgical intervention may be necessary
Follicular cyst
**Forms after a normal 12mm to 17mm corpus luteum ruptures/ will usually regress and spontaneously resolve/ hemorrhage may result/ when hemorrhagic, it may be assoc with varying degrees of intra-abdominal bleeding, pelvic pain, vomiting, tender enlarged ovary, elevated temp/ hemorrhagic cyst will be complex with areas of cystic hemorrhage/ must be differentiated from ectopic
Corpus Luteum
Formed to support the pregnancy until the tenth week of pregnancy/ thin-walled, unilateral cyst, can enlarge up to 5cm/ pt is usually asymptomatic
Corpus luteum of pregnancy
**Often bilateral/ the growths usually disappear by themselves, but may rupture/ not common/ can be associated with two rare gyn disorders: hydatiform moles and choriocarcinoma
Theca lutein cyst
aggressive uterine cancer that develops after pregnancy or hydatiform mole
choriocarcinoma
**rare benign tumor or mass that develops in the uterus/ it is essentially an over development of tissue that would normally become placental tissue/ often no fetus actually develops/ the cause of the abnormality is not known
hydatiform mole (molar pregnancy)
arise from gartner's duct remnant/ make up 10% of all adnexal masses/ usually found within the broad ligament/ often asymptomatic/ thin-walled, vary in size
paraovarian cyst
**most common in early childhood, ages 10 and under/ occurs when ovary partially or completely rotates/ may present with severe pelvic pain, nausea, vomiting, palpable adnexal mass/ ovary may be enlarged and hyperechoic/ doppler should demonstrate absence of flow
ovarian torsion
**one of the most common epithelial tumors/ 30% of all ovarian tumors/ benign serous cystadenoma generally found in women ages 20-50/ rapid growing/ may enlarge up to 20cm/ approx 70% of the masses are unilateral/ mass is cystic/ can be pedunculated, contain septa and debris
serous cystadenoma
**less common/ benign, multi-septated tumor that may extend into abdomen
Mucinous cystadenoma
**Commonly referred to as "dermoid cyst"/ 25% of ovarian neoplasms/ usually in young women/ may be filled with sebaceous material and hair/ 75% are unilateral/ irregularly shaped and thick-walled/ mild to acute abd pain/ adnexal fullness/ pressure symptoms/ complex cyst may shadow and may distort the peripheral bladder wall/ may range from cystic to complex depending on the amount of hair, teeth, and bone present
Cystic teratoma
Arise from ovarian stroma/ 5% of all ovarian neoplasms/ 90% unilateral/ range in size/ mostly found in women near 50-60/ solid, well-encapsulated tumors/ most common tumor is Meig's Tumor
Fibroma
**Characteristics of Meig's Syndrome (fibroma)
pelvic mass, hydrothorax, ascites, pleural effusion, characteristic resolve after tumor removal
Benign, solid, unilateral/ range in size/ menopausal and postmenopausal women/ pelvic pain and pressure/ malignancy is rare/ shadowing, calcifications, necrosis, and cystic degeneration may occur
Theca cell tumor
uncommon solid mass in women after 40 yrs of age
Brenner tumor
rare malignant tumor mainly in chidren and young adults
solid teratoma
rare malignant in females 10-30 yrs/ solid, irregular
Dysgerminoma
Secondary ovarian carcinoma with primary neoplasms of the GI tract
Krukenberg's tumor
**Ectopic endometrial tissue/ found on structures within pelvic and abdominal cavities/ implants can form cysts called endometrioma or chocolate cyst/ reproductive age/ multiple sex partners/ difficult to see on u/s/ dyspareunia, metromenorrhagia, dismenorrhea
Endometriosis
**Multiple, small thin-walled cysts/ also known as Stein-Leventhal Syndrome/ women ages 20-30/ polycystic ovaries, hirsutism, amenorrhea, enlarged ovaries, obesity, impaired infertility/ high LH/FSH ratio/ hyperandrogenization/ can have POD WITHOUT Stein-Leventhal/ ovaries enlarged bilaterally/ numerous small cysts/ may be unilateral
Polycystic Ovarian Disease
**Inflammatory condition of the uterus, cervix, ovaries, fallopian tuves, peritoneal surfaces./ may cause endometritis, salpingitis, hydrosalpinx, pysalpinx, and TOA, infection is usually bilateral, most often affects sexually active women during their childbearing years, most cases are thought to stem from std's (two most common are gonorrhea and chlamydia), may also be caused from bacteria entering the body after gyn events or procedures such as IUD insertion, childbirth, spontaneous or elective abortion, endometrial biopsy
PID- Pelvic Inflammatory Disease
PID may cause severe symptoms, minor symptoms, or no symptoms at all. Symptoms include:
vaginal discharge with a bad odor, painful urination, pain in the lower abd (often a mild ache), abnormal uterine bleeding, fever, chills, nausea, vomiting
___ is used to monitor follicle development during spontaneous or induced ovulation.
Ovarian scanning
Reasons to monitor follicles with u/s
Timing insemination, timing medication, dx of ovulatory malfunction
What is the cause of 20-40% of female infertility cases?
Tubal obstruction
Causes of tubal obstruction
adhesions from surgery, infection, ruptured appendix
**Hyperstimulation of the ovaries with medication (clomiphene, human menopausal gonadotropin-releasing hormong) is done ____ and continued for _____ days with frequent u/s monitoring of follicular growth.
after menses, 7 to 10 days
During induced hyperstimulation, follicles enlarge from ___ at the end of menses to over ___ 10 days later.
3-5mm/ over 20 mm
group of closely associated granulose cells, which surrounds the oocyte
cumulous oophorus
(Infertility) Before ovulation, ___ is seen on the wall of the clear follicle. HCG is administered when serverl follicles reach to size of ___ and the final maturation occurs.
cumulous oophorus/ 16mm
(infertility)
The oocytes are incubated and inseminated and then the fertilized ova are inserted through the cervix into the uterus. After ___ an u/s is done to look for gest sac.
3 weeks
Complications of ovarian stimulation
multiple gestations, hyperstimulation syndrome, must severe case occurs when the ovaries continue to enlarge rapidly after ovulation
also known as gestational age and is calculated by adding 2 weeks to the embryologic age (date from which conception occurs)
menstrual age
embryologic age
date from which conception occurs
the length of time calculated from the first day of the last normal period (LMP) to the point at which the pregnancy is being assessed
menstrual age
**A mature ovum is released at day ___ of the menstrual cycle.
14
The ovum is swept into the distal fallopian tube vis the ___
fimbrae
**Fertilization occurs here ___ days after ovulation
ampulla/ 1 to 2 days
The fertilized ovum is referred to as ...
zygote
The zygote undergoes rapid cellular division to form ___
16 cell morula
Further cell profileratin brings the morula to the ___ stage.
blastocyst
contains trophoblastic cells and the "inner cell mass" which forms the embryo
blastocyst
The blastocyst enters the uterus ____ days after fertilization
4-5 days
Implantation occurs ___ days after ovulation.
7-9 days
When implantation is completed the trophoblast goes on to form ___, which forms into the early gest sac.
primary villi
Within the conceptus, the inner cell mass matures into...
the embryonic disc, the future embryo, and the primary yolk sac.
**At approx __ days, the primary yolk sac is pinched off by the extra embryonic coelom, forming the ____.
23 days/ secondary yolk sac
The ____ is the yolk sac seen on u/s throughout the first trimester.
secondary yolk sac
At the beginning of the ___ week, the bilaminar embryonic disc undergoes gastrulatin and is converted into the trilaminar (three germ layer) embryonic disc.
5th week
______ begins at the beginning of the 5th week.
Organogensis
On u/s, the embryo is first seen when there is heart motion at approx ___
5.5 weeks
When you can first see the embryo, the approx crl is ___
2mm
When you first see the embryo, it is seen between the ____ and the ____.
secondary yolk sac and the immediate gestational wall
With tv u/s, the amniotic cavity and chorionic cavities can be seen after ___ weeks.
5.5 weeks
The chorion and amnion fuse at approx ____ weeks.
16 and 17 weeks
Embryonic period
6 to 12 weeks
Fetal period
begins after 10 weeks
At the beginning of the ___ week the embryo begins to take on a c-shape.
6th
Narrowing between the embryo and yolk sac creates the ____
yolk stalk
As embryonic folding occurs, the ___ aspect of the yolk sac is incorporated into the embryo developing the foregut, midgut, and the hindgut, and the entire gastrointestinal tract, liver, biliary tract, and pancreas.
dorsal aspect
At the same time as embryonic folding, the ____, ____, and ____ are brought together to form the umbilical cord.
yolk stalk, connecting stalk, and allantois
The limb buds are recognizable during the ___ week, and as is the embryonic tail.
6th week
The spine develops in weeks ___.
5-7
Sonographically parallel echogenic lines representing the spine can be seen ____.
7 to 8 weeks
During the ___ week, upper limbs form first, followed by the lower extremeties.
6th week
Hands and feet develop later and are complete by the end of the ___ week.
10th week
Sonographically, the limb buds can be detected from the ____ week on.
7th
Fingers and toes are visible at ___ weeks using tv u/s.
11 weeks
The anterior abdominal wall is developed by ____, and simultaneously the primitive gut is formed.
6 weeks
The midgut, derived from the ___, develops and forms the majority of the small bowel, cecum, ascending colon, and proximal transverse colon.
primitive gut
The ___ enlongates faster than the embryo is growing, causing the ___ to herniate into the base of the umbilical cord
midgut
**Until approx ___ weeks, the midgut loop continues to grow and rotate before it descends into the fetal abdomen at about ___ weeks.
10 weeks/ 11 weeks
**Bowel appears as an ___ in the base of the umbilical cord before 11 weeks.
echogenic mass
After ___ weeks, the echogenic mass is no longer visualized and echogenic bowel is seen within the fetal abd.
12 weeks
Around the ___ week, three primary brain vesicles develop: ____, _____, and _____.
6th week/ procencephalon, mesencephalon, and rhombencephalon
____ divides into two segments: the cephalic portion (_____) and the caudal portion (____)
rhombencephalon/ metencephalon, myelencephalon
Once the rhombencephalon divides with its corresponding flexure, the ___ forms/ this can be seen on u/s from _____ weeks
cystic rhomboid/ 8-11 weeks
The cerebral hemispheres may be seen at around ____.
9 weeks
The echogenic ___ fill the cerebral ventricles in the first trimester, and the sonolucent ____ can be seen around the choroids/ the cerebral falx may also be seen.
choroids/ cerebral spinal fluid (CSF)
The ____ is the first organ to function.
heart
The heart starts beating at approx ____ weeks.
5.3 to 5.5 weeks
By the end of the ___ week the heart has obtained its adult configuration.
8th
Cardiac activity should always be seen by ___.
46 menstrual days
FHR at 6 weeks
90 bpm
fhr at 9 weeks
170 bpm
fhr throughout the remainder of the first and second trimester after 9 weeks
approx 140 bpm
The most accurate dating during pregnancy
ultrasound within the first trimester
Two parameters for u/s during the first trimester
CRL and gest sac size
**___ is the most accurate measurement with deviations of + or - ____.
CRL, 5-7 days
CRL can be obtained as early as ___ weeks using tv u/s, using the heart motion to identify the embryo
5.5 weeks
CRL should be used until ___ weeks, when the fetus begins to curl making measurement of length difficult.
12 weeks
Gest sac size correlates closely with ___ early n pregnancy/ as a rule it remains accurate until ___ weeks of gestation.
menstrual age/ 8 weeks
Sonographically the gest sac or mean sac diamter is deterined by the sum of the ___, ___, and ____.
length, width, and height of the sac
When measuring the gest sac, only include ___.
fluid space, not the echogenic decidua.
Yolk sac should be seen within a sac measuring ____.
10-15 mm
Yolk sac should always be seen by ___.
20 mm
The normal diamter of the yolk sac should never exceed ____.
5.6 mm
___ yolk sacs have threatening outcomes.
Enlarged
Approx 10% of maternal deaths are related to ____
ectopic pregnancy
Ectopic preg assoc with:
pid, iud's, fallopian tube surgeries, infertility treatments, hx of ectopic
**Ectopic preg clinical findings
pelvic pain, vag bleeding, palpable adnexal mass
Most common location of ectopic preg/ other sites include ovary, broad ligament, peritoneum, and cx
95% within fallopian tube
As many as 20% of pts with ectopics also have ____
pseudogestaional sac (sac-like structure)
Guidelines to differentiate between early gest sac and pseudogestational sac
-Pseudogestational sacs do not contain embryo or yolk sac
-Pseudo are centrally located in the endo
-homogenous low level echoes can be seen in pseudo
-evaluate adnexal areas closely
-look for extrauterin gest sac with echogenic ring/ may contain yolk sac and sometimes embryo
-color doppler: increased blood flow in and around an ectopic most of the time
-free fluid found in approx 80% of pts with ectopic
Adnexal masses seen with ectopic
hematoma or hematosalpinx/ corpus luteum cyst can mimic ectopic/ endometrioma
symptoms of gestational trophoblastic disease in first trimester
vag bleeding, elevated beta-hcg, hyperemesis, preeclampsia
**anembryonic pregnancy
aka blighted ovum/ gest sac in which the embryo fails to develop/ u/s: large empty gest sac, no yolk sac, embryo, or amnion will be seen
**Incomplete abortion
u/s: intact gest sac with a nonliving embryo, collapsed sac, thickened endo, embryonic parts the may or may not cause acoustic shadowing
**Complete abortion
empty uterus, no adnexal masses, no free fluid, + hCG levels
Cardiac rates during the first trimester range from ____
90-170 bpm
FHR less than ___ have been shown to have poor prognosis.
less than 90 bpm
If gest sac is ___ less than the CRL, oligohydramnios is suspected.
4mm
**one of the most common abnormalities seen in the first trimester/ highly assoc with chromosomal anomalies
cystic hygroma
**For fetuses detected with cystic hygromas in the first and second trimesters, ___ is the most common karyotype.
Turner's syndrome
If cystic hygromas resolve by ___ weeks, most fetuses are chromosomally normal.
18
If cystic hygromas persist, all are ___.
abnormal.
If cystic hygroma or nucal thickening is seen in first trimester, ___ and ___ are required.
genetic counseling and further sonographic monitering
**Cystic hygromas seen in the first trimester may vary in size, but all appear on the ___ aspect of the ____ or ____.
posterior aspect/ fetal neck or upper thorax
**Caution should be taken not to mistaken cystic hygroma for ____.
normal amniotic membrane in which the embryo is lying
Abdominal wall defects must be distinguished from ____, which appears as an echogenic mass between ____ weeks.
normal physiologic midgut herniation/ 8 to 10 weeks
**___ is never herniated into the base of the umbilical cord so any evidence of this outside the ant abd wall should be considered abnormal.
Liver
**The diagnosis of ___ can be more difficult to diagnose in the first trimester, but reports have shown bowel to be separate from the umbilical cord.
Gastroschisis (right side)
**___ have been reported to be highly assoc with chromosomal abnormalities/ cannot be differentiated from normal physiologic bowel migration and should be diagnosed after ___ weeks.
Omphaloceles/ 12 to 14 weeks
dominant structure seen within the embryonic cranium during the first trimester/ fills the cranial vault
choroid plexus
Traditional cranial anatomy can be seen after ___ weeks, repeat u/s at this time to confirm any suspected anomalies.
12-14 weeks
Fetal abdominal organs, liver, biliary system, spleen, stomach, kidneys, and colon are well formed by the ___ trimester.
second
The stomach should be identified in the ____.
upper left quadrant.
Most fetuses have fluid in their stomach by ____ weeks or older.
14 to 16 weeks
The presence of an echogenic mass within the fetal stomach in a fetus with placental abruption should raise the possibility of ___.
hematoma
The umbilical vein courses ____ in the free margin of the ____.
cephalically/ falciform ligament
**The umbilical vein joins the umbilical portion of the left portal vein at the ___ margin of the ____.
caudal/ left intersegmental fissure of the liver
After birth, the umbilical vein collapses and becomes the ____.
ligamentum teres
The fetal liver accounts for ___ of the total fetal weight at 11 weeks and ___ of the total weight at term.
10%/ 5%
The hepatic veins and fissures are formed by the ___.
end of the first trimester
The normal gallbladder may be seen on u/s after ____.
20 weeks
The gallbladder is distinguished by its locatin to the ___ of the portal-umbilical vein.
right
The fetal spleen is homogenous in texture, similar in echogenicity to the kidneys and slightly ___ than the liver.
less echogenic
The fetal kidneys are located on either side of the spine and are apparent as early as ___.
15 weeks
A renal pelvis measuring __ mm beyond __ weeks is abnormal.
10mm beyond 20 weeks
Fetal adrenal glands can be seen as early as ___.
20 weeks
**The center of the fetal adrenal glands is ____ with a _____ outer border.
echogenic/ hypoechoic
The fetus normally voids approx every ___. If not seen, check again in 30 min.
60 minutes/ hour
**As long as fluid witin the fetal ballder and the amniotic sac is seen, you can assume...
at least one kidney is functioning properly.
Gender may be determined as early as ____, but it is better to wait until around 20 weeks.
14
**The apex of the heart should point to the ___.
fetal left side.
Rt and lt ventricles and rt and lft atria should be ___.
equal in size
The foramen of ovale opens toward the __ as blood is shunted from the right atrium, bypassing the lungs.
left atrium
**The ___ inserts lower, or closer, to the apex, than the mitral valve. Both valves ___ during diastole and ___ during systole.
tricuspid valve/ open/ close
The fluid filled fetal lungs are solid homogenous masses of tissue bordered medially by the __, inferiorly by the ___, and laterally by the ___.
heart, diaphragm, ribs
In the sag view, the lungs can be seen ___ to the diaphragm.
superiorly
Spinal defects are suspected when the trv spine appears as...
a V, C, or U shape
make up the chorion/ form the fetal portion of the placenta called the chorion frondosum
trophoblastic cells
fetal portion of the placenta
chorion frondosum
forms the maternal portion of the placenta/ is one of the endometrial layers
decidua basalis
the reaction between the blastocyst and the myometrium
decidua basalis
portion of the decidua that "envelops" the blastocyst
decidua capsularis
reaction of the endo on the opposite side of implantation
decidua vera (parietalis)
The ___ on the implanted side rapidly increase in size and number to form the chorion frondosum or villous chorion.
chorionic villi
Two types of trophoblastic cells
syncytiotrophoblast and cytotrophoblast
the outer layer with multinuclear cells
syncytiotrophoblast
the inner layer with mononuclear cells
cytotrophoblast
trophoblastic cells that together with the decidua form the placenta
chorion frondosum
chorion opposite the implantation side
chorion laeve
fetal surface of the placenta
chorionic plate
maternal surface of the placenta
basal plate
The amnion and chorion fuse by the ___. If separation is seen after this, it may be assoc with poly or previous amnio.
16 weeks
**The yolk sac lies...
between the amnion and chorion
When the cord is attached to the margin of the placenta/ usually has no signficance unless it is affected during delivery
battledore placenta
attachment of the umbilical cord to the chorion beyond the margin of the placenta/ tends to be assoc with unsupported cord vessels (lack Wharton's jelly) and may tear loose during delivery and cause hemorrhage
velamentous placenta
when the cord is over the internal os
vasa previa
cord insertion into the margin of the placenta
battledore placenta
spontaneous painless uterine contractions described originally as a sign of pregnancy
braxton-hicks contractions
**chorionic plate of the placenta is smaller than the basal plate, with a flat interface between the fetal membrances and the placenta
circummarginate placenta
**chorionic plate of the placenta is smaller then the basal plate/ the margin is raised with a rolled edge
circumvallate placenta
**also known as gestational trophoblastic disease/ abnormal proliferation of the trophoblastic cells in the first trimester
molar pregnancy
growth of the chorionic villi superficially into the myometrium
placenta accreta
growth of the chorionic villi deep into the myometrium
placenta increta
**placenta completely penetrates the uterine serosa (outer covering)
placenta percreta
**placenta completely covers the lower uterine segment (internal os)
placenta previa
one or more accessory lobes connected to the body of the placenta by blood vessels
succenturiate placenta
occurs when the intermembranous vessels course across the cervical os
vasa previa
premature detachment of the placenta from the maternal wall/ occurs in 1 in 120 pregnancies/ bleeding occurs at the basalis/ clinically, preterm labor, vag bleeding, abd pain, fetal distress or demise, uterine irritability/ u/s: abnormal size and texture and hypoechoic to isoechoic area either retroplacental or subchorionic (echogencity depends on age of bleed)
Abruptio placenta
Retroplacental abruption
from spiral arteries and is a high pressure bleed/ found in assoc with hypertension and vascular disease/ may show no bleeding vaginally if blood remains retroplacental
Marginal abruption
from tears in the marginal veins and is a low-pressure bleed/ assoc with smoking
2nd most common tumor occuring in 1% of pregnancies/ usually small and benign proliferation of fetal vessels/ complications include poly, fetal hydrops, fetal cardiomegaly, iugr, fetal demise, and premature labor/ elevated afp/ u/s shows well circumscribed solid or complex mass protruding from fetal side of placenta/ may be near cord insertion
Chorioangioma
Maternal factors that may affect placenta grade
diabetes, hypertension, Rh isoimmunization, smoking
Grade 0 placenta
most early placentas/ smooth homogenous texture with a well defined chorionic and basal plate/ no echogenic densities
Grade 1 placenta
has indentations and small undulations of the chorionic plate with small echogenic densities (calcium)/ basal plate remains smooth
Grade 2 placenta
echogenic areas within placental tissue/ indentions (comma like) in the chorionic plate/ echogenic foci along basal plate/ most pregnancies have grade 2 placentas when delivered at term
Grade 3 placenta
deep indentations forming echogenic rings around placental tissue, creating cauliflower appearance or cotyledon appearance/ may be anechoic areas within the sections which represent placental lakes/ calcifications along the basal plate which may shadow/
Normal placenta at delivery
15-20 cm in diameter, 4 cm thick, and around 500-600 grams (1 to 1 1/2 lbs)
Type of abortion with no pain or bleeding
missed abortion
double bleb sign
amniotic and yolk sac attached to gest sac with embryonic disc in between
Type of cerclage that is sometimes permanent and makes a c-section neccessary
Shirodkar
most common type of cerclage
McDonald's procedure
central portion of vertebrae
centrum
**Valve between right atrium and right ventrile, 3 flapped valve
Tricuspid
**2 flapped valve between left atrium and left ventricle
Bicuspid
**Angle heart is positioned at
45 degrees to the left
Cephalic index equation
BPD/OFD * 100
**Cephalic index < 70%
Dolichocephaly
**Cephalic index >85%
Brachycephaly
Cephalic index between 70-85%
normal
puerperium
after delivery
cancer in the myometrium, formed after conception, aka hydatiform mole
chorioadenoma druens
Most common cause of post partum hemhorrhage
uterin atony
**unit of measurement for MSAFP
MoM, >2 is elevated
PG (phosphatidylglycerol)
lung maturity
**PUBS
percutaneous umbilical cord blood sampling/ cordocentesis/ >18 weeks
lithopedian
"stone baby"
Deuel's sign
fetal death/ halo
**prosencephalon fails to develop into two hemispheres/ cyclopia/ proboscis, alobar most serious
holoprosencephaly
**Where are encephaloceles usually found?
occipital and frontal region of cranium
**What is holoprosencephaly most often assoc with?
cyclopia/proboscis
At what age do you measure nuchal thickness?
10-14 weeks
abnormally large bladder
megacystis
****What is hcg produced by?
trophoblast cells of the placenta
what hormone stimulates cervical mucus production?
estrogen
dystocia
abnormal or difficult labor
Fundal placenta
implanted on the uterine fundus
Posterior placenta
implanted on the post wall
Ant placenta
implanted on the ant wall
fundal ant placenta
when the placenta is implanted in the fundus and projects onto the ant wall
fundal post plac
implanted in the fundus and projects on to the post wall
Accuracy of bpd between 17- 26 weeks
+/- 11 days
Accuracy of bpd after 26 weeks
+/- 3 weeks
The skull grows ___ per week in the 2nd trimester and ___ per week in the third.
3mm/ 1.8mm
GASA
growth adjusted sonor age/ obtain a measurement at 20-26 weeks, then compare it to a one taken between 31 and 33 weeks/ growth intervals are compared with averages to determine fetal size.
**The fetal abdomen should be measured in trv plane at the elvel of the umbilical vein and stomach. This is where the umbilical vein branches into the ___ forming a J shape.
portal vein
The ___ is almost as accurate as the BPD for dating.
femur length
Measure the femur from __ to __.
major trochanter to the external condyle
When the femur is more the __ weeks off from the other measurements, all long bones should be measured and the exam should be considered a target exam.
2 weeks
Accuracy of femur length
+/- 2 weeks
Normal range of afi
8-20 cm
polyhydramnios
fluid greater than 22 cm
oligohydramnios
fluid less than 5 cm
**If the fetus cannot urinate, fluid will be __. If the fetus cannot swallow, fluid will be ___.
low/ high
**5 parameters of BPP
cardiac non-stress test/ fetal breathing movements/ gross fetal body movement/ fetal tone/ amniotic fluid volume
NST
done using doppler to record fhr and its reactivity to uterine contractions/ usually 40 min/ normal or reactive if fhr increases by 15 bpm or more twice in the study, accelerations last at least 15 sec, and gross fetal movements are noted over 20 min without late decelerations
BPP- fetal breathing movements
at least one episode lasting 30 sec during a 30 min study
BPP- fetal body and trunk gross movements
at least 3 definite extremity or trunk movements are seen in 30 min
BPP- fetal tone
at least one episode of extension/flexion of an extremity or the spine
BPP- AFV
two pockets with at least 2 cm of fluid in each or afi within normal limits
vertex/cephalic
fetal head is located at the level of the symphysis pubis
breech
when the lower extremities or lower body are found in the lus and the head is visualized in the uterine fundus
Frank Breech
flexion of the hips and extension of both knees toward the fetuses head/ may be safely turned for vag delivery
Complete breech
both hips and lower extremeties are found in the lower pelvis/ c-section
Incomplete breech
single or double footling/ hips are extended and one or both feet are the presenting parts closest to the cx/ c-section
**Twin-to-twin transfusion
monochorionic pregnancy/ arteriovenous shunt within shared placenta through which the arterial blood of one twin is pumped into the venous blood of the other/ donor twin's arterial blood is shunted through the recipient twin's venous system/ donor twin has less blood, becomes anemic, oligo/ recipient twin gets too much blood, too large, poly, may have heart failure or hydropic/ "stuck twin"/ both may die
Conjoined twins
identical twins that develop with a single placenta from a single fertilized ovum/ same sex and race/ more often female/ more often in India and Africa/ separate 13 days after fertilization
**Immune hydrops signs seen on u/s
scalp edema, abdominal or other tissue edema, ascites or effusions in fetus, poly, large thick placenta, large liver and/or spleen
**What is nonimmune hydrops most often assoc with?
cardiovascular problems
If poly and macrosomia are seen, this may indicate ____.
poor maternal glucose control
**___ are assoc with maternal hypertension, causing fetal growth restriction.
small placentas
Pregnancy induced hypertension (PIH)
includes preeclampsia and eclampsia
Preeclampsia signs
high blood pressure, proteinuria, edema/ untreated may cause seizures or death to mother and fetus
Eclampsia
serious and must be delivered immediately before seizures and coma sets in/ more common in first pregnancies
**u/s findings with hypertension
oligo, fetal growth restriction, placental abruptions
At ___ weeks, the fetal heart should be heard with doppler
12
At __ weeks, the uterine fundus should be ___.
20 weeks, at the level of the umbilicus.
If see spaulding's sign, exaggerated curve of spine, or gas in fetus, you can assume...
the fetus has been dead over 48 hours
****Advantages of chorionic villi sampling (cvs)
-done earlier than amnio (10-12 weeks)
-results faster (in a week)
-earlier results allow more options
**Neural tube defects and other structural malformations cannot be detected with...
cvs
Amniocentesis
15-16 weeks/ approx 20mL collected with second trimester amnio/ approx 1 mL with earlier amnio
Cordocentesis
analyze chromosomes/ fetal blood obtained through needle aspiration of teh umblical cord/ can be useful when used to wamnio and also in anomalies found later in preg.
most common chromosomal anomaly
Trisomy 21 (Down's)
**Trisomy 21
Down's/ more frequent with ama but can occur with any maternal age/ have one extra chromosome at the 21 pair location/ have heart defects and alimentary disorders that cause early death/ mental retardation is always present (degree is different)/ respiratory problems, eye problems, and premature aging/ amnio to confirm
**Sign u/s may see with Down's/Trisomy 21 (do not assure diagnosis)
nuchal fold > or equal to 6mm/ hypoplasia of the middle phalanx or clindodactly of the 5th finger (overlapping, larger than normal space between first and second toes/ short femur/ duodenal atresia/ shortened ear lenght/ heart defects/ iugr/ mild pyelectasis >4mm AP/ echogenic bowel/ mild ventriculomegaly/ simean crease/ nonimmune hydrops/ brachycephaly/ flattened nose bridge
2nd most common trisomy
Trisomy 18/ Edward's syndrome
**Trisomy 18
3 chromosomes at the 18 location/ abnormal triple screen is good indicator/ 90% die withinn first year and large portion spontaneously abort/ survivors have short life span and are severely mr and physically limited.
**U/s signs for trisomy 18
vsd (90%), dolichocephaly, microcephaly, hydrocephalus, agenesis of corpus callosum, cerebellar hypoplasia, agensis of corpus callosum, cerebellar hypoplasia, strawberry shaped head, choroid plexus cyst, low set ears, micrognathia, cleft lip and palate, hypertelorism, persistently clenched hangs, talipes (clubfoot), rocker-bottom feet, overlapping fingers, limb reduction, dandy walker malformation, abnormal cisterna magna, 2 vessel cord, omphalocele, diaphragmatic hernia, neural tube defect, cystic hygroma, renal anomalies
**In 3rd trimester, seeing the combo of poly, iugr, and abnormal hand posturing is highly predictive of ...
Trisomy 18
Trisomy 13/ Pateu's syndrome
3 chromosomes at the 13 location/ severe with brain anomalies/ most die within first year
**u/s signs of trisomy 13
holoprosencephaly, agenesis of corpus callosum, microcephaly, hypotelorism, proboscis, cyclopia, single nostril, micrognathia, vsd, asd, hypoplastic left heart (90% have heart anomalies), omphalocele, renal anomalies, meningomyelocele, polydactyly, talipes, rocker bottom feet, overlapping fingers, cystic hygroma, echogenic chordae tendineae, may be confused with Meckel-Gruber syndrome
Triploidy
when 2 sperm fertilize one egg/ creates extra set of chromosomes (69 instead of 46)/ occurs in 1% of pregnancies/ most spontaneously abort in first trimester
**U/s signs of triploidy
heart defects, renal anomalies, omphalocele, meningomyelocele, agenesis of corpus callosum, hydrocephalus, dwm, low set ears, hypertelorism, cleft lip and palate, micrognathia, cryptorchidism, ambiguous genitalia, syndactyly (fused digits), talipes, iugr, oligo, placental degeneration/ live births die shortly after birth/ mosaic form is possible and may be compatible with life, but sever mental retardation is present
**Turner's syndrome
missing one of the sex chromosomes/ only one X present at the point of sex chromosomes/ may show elevated msafp if cystic hygroma is present/ will be girl
**U/s signs assoc with Turner's syndrome
cystic hygroma (most common sign), cardiac anomalies, lymphedema, hydrops, renal anomalies, short femur, most spontaneously abort/ poor prognosis with large cystic hygroma and edema or hydrops
**If a fetus with Turner's syndrome survives, it will be girl and have problems such as...
immature sexual development, amenorrhea, short stature, webbed neck, cubitus valgus (abnormal elbow angle), shield chest or barrel chest with widely spaced nipples, hearing problems, require hormonal replacements, normal intelligence
rupture of the amnion that leads to entrapment or entanglement of the fetal parts by the sticky chorion
Amniotic band syndrome
**group of disorders having in common the existence of an omphalocele, macroglossia, and visceromegaly
Beckwith-Wiedmann syndrome
defect in the lower abdominal wall and ant wall of the urinary bladder
cloacal extrophy
**opening in the layers of the abdominal wall with evisceration of the bowel and occasionally the stomach and genitourinary organs
gastroschisis
**anomaly with large cranial defects, facial cleft, large body wall defects and limb anomalies
Limb-body wall complex
**develops when there is a midline defect of the abdominal muscles, facia, and skin that results in the herniation of teh intraabdominal structures into the ase of the umbilical cord
omphalocele
Most common congenital heart defect
VSD
2nd most common heart defect
ASD
3rd most common heart defect
pulmonary stenosis
Hypoplastic right heart
pulmonary atresia causes right ventricle under development/ tricuspid atresia/ be sure it is not on the left
Epstein's anomaly
congenital heart anomaly in which the tricuspid valve has dysplastic leaflets with altered structure and/or position/ us: fetal echocardiography has proved to be reliable in differentiating the variants of tricuspid valvular disease, diagnosing associated cardiac lesions and predicting subsequent outcome
Tetralogy of Fallot
most common form of cyanotic heart disease (interruption in blood flow casing cyanosis or blue color to skin)
Hypoplastic Left Heart
group of congenital anomalies characterized by underdevelopment of the aortic valve, left ventricle, mitral valve, and left atrium/ is the congenital heart anomaly that imposes the most severe form of impedance to aortic blood flow in humans/ used to be known as aortic atresia/ aortic atresia is not always synonymous with an underdeveloped left ventricle and about 6% of all pts with aortic atresia will have a normal sized lf ventricle/ bad prognosis
Transposition of the great arteries
aorta connected to right vent/ pulmonary artery connected to left vent/ no problems in utero/ good prognosis post natally with surgical intervention
Single ventricle
single ventricle of indeterminate, left, or rt ventricular type 1 with two separate atrioventricular valves or a common valve/ a rudimentary chamber is present with ventricles of the lt ventricular type, and may be present when the dominant ventricle has a right ventricular morphology
**Absence of skull and of the cerebral hemispheres/ coronal section through the fetal face will show bulging eyes with absence of the frontal bones, given the appearance of a frog
anencephaly
___ is not considered a neural tube defect since if occurs when the mesenchyme does not migrate over brain.
Acrania
developmental abnormality characterized by a partial or complete absence of calvarium, with complete but abnormal development of brain tissue/ characterized by partial or complete absence of the neurocranium, with complete but abnormal development of brain tissue/ this rare lethal congenital anomaly has important implications for ob management and counseling/ us allows early diagnosis
Acrania
refers to the absence of the cranium with the exception of the occipital bone
Meroacrania
form of anencephaly with rudimentary brain and cranium
Meroanencephaly
**Midline frontonasal herniation of brain and/or meninges through a skull defect/outcome depends on contents of the sac/ if it is just the meninges (lining of the brain) prognosis is better than if actual brain tissue is present
Cephalocele
**aka myelomeningocele, meningocele, and raschisis/ can be defined as a midline vertebral defect, resulting in exposure of neural contents to the amniotic fluid/ in the immense majority of cases, the defect is located on the post vertebral arches/ in rare cases the defect is caused by division of the vertebral column
spina bifida
**cleft of opening in spine covered with skin
spina bifida occulta
**contains meninges only
meningocele
**contains meninges and spine material
meningomyelocele
**very large and severe form of spina bifida
raschisis
**Almost all cases of spina bifida are assoc with ___, characterized by herniation of the cerebellar vermis through the foramen Magnum. In these cases, the fourth ventricle is dislocated towards the neural canal, the post fossa is shallow, and the tentorium is also displaced downwards. This finding is amost invariabley assoc with ___.
Arnold-Chiari type II malformation/ obstructive hydrocephalus
**varies in degree/ agenesis or hypoplasia of cerebellum with dilated 4th ventricle/ us: post fossa cyst that can vary considerably in size, splaying of the cerebellar hemispheres as a result of complete or partial agenesis of the cerebellar vermis, enlarged cisterna magna cauesd by cerebellar vermis anomaly and post fossa, ventriculomegaly
Dandy Walker Malformation
**covers a range of anomalies with varying degrees of abnormal brain cleavage/ three forms: alobar (most severe), semilobar, lobar (mildest)
Holoprosencephaly
fibrous tract that connects the cerebral hemispheres and aids in learning and memory
corpus callosum
Agenesis of the corpus callosum
etiology is unclear, but is thought to involve a vascular disruption or inflammatory lesion before 12 weeks/ may be assoc with other cns malformations, autosomal dominant, autosomal recessive, or x-linked syndromes, also trisomy 13 and 18/ isolated may be asymptomatic or assoc with mr and/or seizures/ absence of corpus callosum, elevation and dilation of the third ventricle, widely separated lat ventricular frontal horns with medial indentation of the medial walls, dilated occipital horns (colpocephaly) giving the lat vents a teardrop shape/ other findings assoc with this include holoprosencephaly, dwm, cranial lipoma, arnold-chiari malformation, hydrocephaly, encephalocele, porencephaly, microcephaly, lissencephaly
Vein of Galen aneurysm
rare arteriovenous malformation/ vein will be enlarged and communicate with normal appearing arteries/ sporadic with male predominance/ usually isolated, but can be assoc with congenital heart defects, cystic hygroma, and hydrops/ prognosis is generally poor, especially when assoc with hydrops/ when symptoms appear later in childhood prognosis is good/ us: cystic space that may be irregular in shape and is located midline and postersuperior to the third vent, turbulent flow with doppler, always use color doppler to rule out cysts
**Choriod plexus cysts
cysts that are round or ovoid and found within the choroid plexus/ made up of csf/ usually isolated but can be assoc with trisomy 18 and 21/ will often resolve by 22-26 weeks/ us: cysts ranging from .3 to 2 cm, unilateral or bilateral, solitary or multiple, unilocular or multilocular, enlargement of the vent with large cyst
Hydranencephaly
destruction of the cerebral hemispheres by occluesion of the internal carotid arteries/ brain parenchyma is destroyed and replaced by csf/ the midbrain and cerebellum are present/ basal ganglia, choroid plexus and thalamus may be spared/ may be assoc with poly/ no existing structural or chromosomal anomalies are assoc/ prognosis is poor, with death occuring at birth or shortly after
What is hydranencephaly caused by?
congenital infection or ischemia
Hydranencephaly u/s
absence of normal brain tissue with almost complete replacement with csf/ absent of partially absent falx/ presence of midbrain, basal ganglia, and cerebellum/ choroid plexus may be seen/ macrocephaly may occur
What might hydranencephaly be confused with?
severe hydrocephalus, but the presence of an intact falx and surrounding brrim of brain tussue may help differentiate/ or holoprosencephaly with sever ventriculomegaly
Ventriculomegaly aka Hydrocephalus
dilation of the vents of the brain/ hydracephalus occurs when ventriculomegaly is coupled with enlargement of the fetal head/ cause by obstruction of cerebral spinal fluid flow/ mild may be assoc with trisomy 21, 13, and 18/ dilated when >10mm/ dangling choroid/ possible dilation of 3rd and 4th vents
eyes too close together
hypotelorism
hypertrophied tongue
microglossia
small chin
micrognathia
small eyes
microphthalmia
Cleft lip occurs due to...
primary and seconday palate not fusing
Cleft palate is when ...
lateral palatine processes fail to fuse
Esophageal atresia
usually assoc with a tracheoesophageal fistula/ when this occurs amniotic fluid cannot pass to the intestines for absorption and poly results
Esophageal stenosis
narrowing of the esophagus, usually the distal third portion/ occurs from incomplete recantilization of the esophagus during the 8th week of development
Duodenal stenosis
narrowing of the pyloric sphincter
Duodenal atresia
complete blockage at the pyloric sphincter/ assoc with trisomy 21/ require immediate surgery after birth to connect stomach to jejunum bypassing obstruction
Umbilical hernia
when the intestines return normally to the abdominal cavity and then herniate either prenatally or postnatally through an inadequately closed umbilicus/ differs from omphalocele in that the protruding mass is covered by subcutaneous tissue and skin
Hirschsprung's disease (megacolon)
congenital disorder in which there is abnormal innervation (the arrangement or distribution of nerves to an organ or body part) of the large intestines/ difficult to diagnose prenatally, but may be suspected when dilated bowel loops are seen
LETHAL autosomal recessive short limb dwarfism marked by long bone and trunk shortening, decreased echogenicity of the bones and spine, and flipper like appendages
Achondrogenesis
a defect in the development of cartilage at the epiphyseal centers of the long bones producing short, square bones
Achondroplasia
short-limb dysplasia that manifests in the second trimester/ conversion abnormality of cartilage to bone affecting the epiphyseal growth centers/ extremeties are markedly shortened at birth with a normal trunk and frequent enlargement of the head
Heterozygous achondroplasia
short limb dwarfism affecting fetuses of achondroplasia parents
Homozygous achondroplasia
congenital condition characterized by decreased mineralization of the bones resulting in ribbon like and bowed limbs, under ossified cranium, and compression of the chest/ early death often occurs
Hypophosphatasia
metabolic disorder affecting the fetal collagen system that leads to carying forms of bone disease/ intrauterine bone fractures, shortened long bones, poorly mineralized calvaria, and compression of teh chest found in type II
Osteogenesis Imperfecta
anomalies of the hands and feet in which there is an addition of a digit/ may be found in assoc with certain skeletal dysplasias
Polydactyly
LETHAL short limb dwarfism characterized by a marked reduction in the length of the long bones, pear shaped chest, soft tissue redundancy, and frequently clover leaf skull and ventriculomegaly
Thanatophoric dysplasia
rounded calyces with renal pelvis dilation measuring greater than 10mm AP
Calyectasis
occurs when the kidney is located on the opposite side of the uretal orifice
crossed renal ectopia
failure of the testes to descend into the scrotum
cryptorchidism
protrusion of the post wall of the urinary bladder, which contains the trigone of the bladder and the uretic orifices
extrophy of the bladder
**dilated renal pelvis
fetal hydronephrosis
condition in which both ovarian and testicular tissues are present
hermaphroditism
forms when the inferior poles of the kidney fuse while they are in the pelvis
horseshoe kidney
**collection of fluid in the vagina and uterus
hydrometrocolpos
dilated ureters
hydroureters
abnormal congenital opening of the male urethra on the underside of the penis
hypospadia
autosomal recessive disese that affects the fetal kidneys and liver/ the kidneys are enlarged and echogenic on u/s
infantile polycystic kidney disease
multiple cysts replace normal renal tissue throughout the kidney/ usually causes renal obstruction
Multicystic dysplastic kidney disease
occurs when the kidney does not migrate upward into the retroperitoneal space
pelvic kidney
**occurs only in males/ is manifested by the presence of a valve in the post urethra/ causes back up of urine in the bladder, ureter, and severe cases in the kidneys/ severe oligo with complete obstruction/ prognosis invariably fatal but placement of a bladder shunt improves survival
posterior urethral valve
**characterized by renal agenesis, oligo, pulmonary hypoplasia, abnormal face and malformed hands/feet
Potter's syndrome
dilatation of the fetal abd secondary to severe bilateral hydro and fetal ascites/ fetus also has oligo and pulmonary hypoplasia
Prune-belly syndrome
dilated renal pelvis measuring 5 to 9 mm AP
Pyelectasis
renal system fails to develop
Renal agenesis
Most common fetal anomaly
Hydronephrosis
**occurs as a response to a blockage of urine at some junction in the urinary system/ may be uni or bilateral/ unilateral commonly results from an obstruction at the juction of the renal pelvis and ureter (ureteropelvic junction obstruction)
Hydronephrosis
most common reason for hydro in neonates/ obstruction at the junction of the renal pelvis and ureter/ causes are abnormal bends or kinks in the ureter, adhesions, abnormal valves in ureter, abnormal outlet shape at UPJ or absence of the long muscle that is imperative to normal excretion of urine/ us: collection of urine located medially within the renal pelvis that communicates with the calyces. the ureter, bladder, and amniotic fluid are usually normal since this is most commonly unilateral
Ureteropelvic Junction Obstruction
commonly presents with dilation of the ureter (megaureter)/ results from a primary ureteral defect (stenotic ureteral valves or fibrosis) and occur secondray to obstruction at another level
Ureterovesicle Junction Obstruction
adrenal tumor that may be observed prenatally
Neuroblastoma
occurs in male fetuses and is an accumulation of seroud fluid surrounding the testicle/ may occur bilateral or unilateral/ usually benign
Hydrocele
46 XX, masculinization of the external genitalia- enlarged clitoris, abnormalities of urogenital sinus, and partial fusion of labia
Female Pseudohermaphrodites
46 XY/ variable external and internal genitalia depending on the development of the penis and genital ducts
Male Pseudohermaphrodites
When a long bone measures 4 SD or more below the mean for gest age. An FL-AC ratio <0.16 helps define the degree of shortness as severe.
Severe micromelia
Severely hypoplastic thorax
small chest, lungs cannot develop, thus survival is impossible/ a thoracic circumferance less than the 5th percentile for gest age is considered indicative of a lethal skeletal defect
This uniformaly lethal skeletal dysplasia is characterized by extreme rhizomelia, bowed long bones, a narrow thorax with normal trunk length, and relatively large head/ name derived from Greek "thanatophoros" meaning death-bearing/ us: cloverleaf skull, severely shortened limbs, hypoplastic thorax, platyspondyly, mild hypomineralization, poly
Thanatophoric dysplasia
autosomal recessive/ most severe form of achondrogenesis, with severe micromelia, short trunk, protruding abd, poor skull, and vertebral ossification, small pelvic bone
Type I
autosomal dominant/ less severe form of achondrogenesis, large head compared to body, relatively normal skull ossification but lack of vertebral ossification, small chest, thicker ribs without fractures/ us: lack of vertbral ossification, large head possibly with decreased ossification of the cranium, severely shortened limbs, small chest, poly, assoc with cleft lip/palate, micrognathia
Type II
A disorder of production, secretion, or function of collagen, the earliest diagnosis of type II has been reported at 15 weeks ga/ normal us after 17 weeks should exclude type II/ abnormally fragile bones, which are hypomineralized, fracture in utero, resulting in severe micromelia and irregularity of the bones/ us: presence of fractures or excessive callus formation of long bones, severe micromelia, severe hypomineralization of skull, small bell-shaped thorax, multiple rib fractures
Osteogenesis Imperfecta Type II
rare bony demineralization disorder resulting from low levels of serum and tissue alkaline phosphatase/ us: severe micromelia, with possible bowing of long bones, severely underossified bones, marked demineralization of cranium resulting in an apparent increased echogenicity of the falx cerebri, fractures may be present
Congenital hypophosphatasia
lethal skeletal dysplasia characterized by bent or bowed limbs/ most commonly the tibia and femurs are affected/ assoc with congenital heart disease, hydronephrosis, hydrocephalus/ us: bent long bones, especially lower ext bones, narrowed thorax and hypoplastic or absent scapulae, assoc CNS and renal anomalies
Camp(t)omelic dysplasia
rare lethal dysplasia characterized by polydactyly and an extremely small thorax/ death results from respiratory insufficiency/ us: severe micromelia, polydactyly, severely narrowed thorax with short ribs, gamut of other anomalies (cardiac, renal, cleft lip/palate)
Short-rib polydactyly syndrome
Osteogenesis Imperfecta Types I, III, and IV
NON-lethal, type I (most common) and iv generally have good prognosis/ occasional fractures, mild limb bowing, easy bruising, and blue sclera/ type I also manifests deafness
Osteogenesis Imperfecta types i and iv u/s
limb shortening or bowed bones, usually nt until after 24 weeks ga/ normal mineralization, but occasionally demineralization with type i/ isolated fractures
osteogenesis imperfecta type iii u/s
moderate to severe shortening of long bones/ thickened hypoechoic irregular lower extremity bones
permanent curvature or deflection of one or more fingers/ severe cases have overlapping digits and a clenched hand
clinodactyly
the fusion of digits, either soft tissue or bony fusion
syndactyly
lower extremity fusion and abnormal or absent foot structures/ oligo, single femur or two femora constantly seen side by side, abnormal or absent foot structures, assoc with bilateral renal agenesis (BRA) and skeletal abnormalities
Sirenomelia (mermaid syndrome)
most cases are sporadic, some are assoc with diabests/ includes spectrum of skeletal anomalies of the lower spine and lower limbs, such as sacral agenesis, lumbar spine or lower thoracic spine agenesis/ there are assoc anomalies of the gi and gu tracts, the cns, and heart/ us
caudal regression syndrome
abnormal curvature of the spine may involve any segment, but most frequently the thoracolumbar spine is affected/ assoc with other structural defects is common, most notably cns and vater, but severe curvatures are assoc with lethal anomalies such as anencephaly, limb-body wall complex, and amniotic band syndrome
scoliosis and kyphosis
Diaphragmatic hernias usually occur on the ___ side.
left
***Gastroschisis is not assoc with...
increased risk of chromosomal abnormalities.
Which lobe of the liver is larger in the fetus?
left
most common cause of prune belly syndrome
puv (posterior urethral valve)
**what is assoc with unilateral renal agenesis for females and males?
females: uterine anomalies
males: testicular hypoplasia, agenesis, or hypospadias
abnormal migration of neurons from the germinal matrix to the surface of the brain/ the surface of the brain lacks normal sulci and gyri and appears smooth/ diagnosis is not make until 3rd trimester/ assoc with mild ventriculomegaly and possibly an abnormal corpus callosum
Lissencephaly
abnormal clefts in the cereral hemispheres in the region of the primary fissures/ clefts are usually bilateral symmetrical, but not always/ brain appears split into ant and post parts
schizencephaly
**Dandy-Walker malformation
assoc of large cisterna magna, ventriculomegaly, cerebellar vermian agenesis/ thought to be due to failure of the vellum medullare to regress, combined with cerebellar cleft malformation and failure of the cerebellar commissure to develop into the vermis/ causes obstruction of 4th ventricle outflow and subsequent cystic enlargement of the post fossa
presence of cystic areas within the cerebral parenchyma/ cystic cavities may communicate with the ventricular system or subarachnoid space and are varied in size and location/ believed to be result of lysis of in utero intracranial hemorrhange or cstic encephalomalacia/ some consider hydranencephaly severest form of this
porencephaly
most severe/ large single cavity with minimal amount of cerebral tissue surrounding it, fused thalami, and a facial syndrome with hypotelorism and other craniofacial anomalies
alobar holoprosencephaly
more cerebral tissue present, occipital lobe present, assoc cleft palate and cleft lip
semilobar holoprosencephaly
interhemispheric fissure is developed, but there is variable degree of fusion and the csp is absent (some survive)
lobar holoprosencephaly
Hypothesis for the cause of hydranencephaly
intrauterine infarction secondary to bilateral ica occlusion or malformation/ primary agenesis of the neural wall
Are any other defects assoc with hydranencephaly?
no
Filly's Rule
If the atrium of the lateral vent and the cisterna magna both measure less than or equal to lomm, there is a 95% negative predictive value for ANY cns anomaly.
**most common cause of hydrocephaly
aqueductal stenosis (narrowing of the aqueduct of sylvius- 3rd vent outflow)/ may result from inflammatory process of developmental anomaly/ noncommunicating
dramatic neural tuve defect, characterized by an exaggerated sinal lordosis, cervical rachischisis, and an occipital encephalocele/ us: exaggerated, hyperextionson of the fetal head, demonstration of cervical spina bifida
iniencephaly
**Chiari type 2 malformation
variable displacement of the cerebellum, 4th vent, and medulla oblongata through the foramen magnum
lemon sign
frontal bossing of cranium
**banana sign
dislocated cerebellum and obliteration of the cisterna magna
completely open spine with herniation and/or destruction of the spinal cord
rachischisis
**failure of closure of the vertebral column without any associated external abnormalitites
spina bifida occulta
begins with the formation of the neural plate, then the neural folds, and the ultimate fusion and closure as the neural tube
neurulation
thickening of embryonic ectoderm and adjacent mesoderm
neural plate
an invagination of the neural plate along its central axis
neural groove
thickening of the neural plate lateral to the neural groove/ these folds cont to thicken and grow toward the midline until they meet and fuse leaving both ends open (neuropores)
neural folds
any substance causing abnormal structures in an embryo
teratogen
***Elevated msafp
> or equal to 2 MOM/ assoc with wrong dates, mult gests, open neural tube defects, ventral wall defects
**Decreased msafp
wrong dates, trisomies 13, 18, 21, fetal demise,
**hCG and uE3 levels in Downs
hCG tends to be elevated 2 times the median level and uE3 tends to be lower than normal
**hCG, AFP, and uE3 levels in Trisomy 18
all are decreased
Pt presents with cramping and heavy vag bleeding for 3 days. What is the most liekly explanataion?
incomplete spontaneous abortion
The highest oxygenated blood is found in what fetal heart chamber?
right atrium
**The cisterna magna appears on u/s as
anechoic space inferior to the cerebellum
The foramen of ovale helps direct blood from the rt atrium to the
lt atrium
**Some of the fetal blood that passes into the liver via the umbilical vein goes directly into the ductus venosum. The rest passes into the ...
portal venous system
****The third vent is a midline intracranial structure surrounded by a hypoechoic region call the
thalamus
The chorionic membrane is derived from what component of the conceptus?
trophoblast
The ductus arteriosus allows passage of blood from the pulmonary art to the
aortic arch
***The most common us finding assoc with Patau's syndrome is...
holoprosencephaly
The fetal position that has a higher incidence of cord prolapse
footling breech
No identificaiton of an embryonic pole by what criteria of sac size is considered abnormal?
MSD > 25mm
**Lat displacement of the ant horns of the lat vents, upward displacement of the third vent, absence of the csp, and assoc neurologic abnormalities describe...
agenisis of the corpus callosum
A yolk sac is considered abnormal when diameter exceeds...
6mm
In a ruptured ectopic pregnancy, which section of the fallopian tube is potentially the most life-threatening?
Interstitial
A small rounded echogenic structure within the left vent of a fetal heart most likely is...
chordae tendineae/ papillary muscle
(efi)
**Hypertension decreases blood flow and results in...
small placenta
Epiphyseal centers will not be identified before ...
30 weeks
With normal growth during first trimester, the gest sac should grow....
1mm per day
Which long bone is least likely to be affected by intrauterine growth restriction?
clavicle
Twin growth is similar to that of singletons up to..
30 weeks
A molar pregnancy that is considered invasive but does not metastasize is called...
chorioadenoma destruens
The postpartum period lasts...
6-8 weeks
The ureter and iliac vessels are ___ to the ovary.
posterior
gonadotropin releasing hormone is secreted by...
hypothalamus
uterine arteries flow in nongravid uterus
inceasing resistance with age
**two forms of endometriosis
diffuse and localized
localized overgrowths of endo tissue
endometrial polyps
flow in metabolically active tissue, like ovarian malignancy
low velocity and high resistance
in menstruating women, doppler evaluatin should be done in...
early follicular phase
mean sac diameter within 5mm of crl indicates...
increased risk for preg failure
CRL in cm + 6
ga in weeks
CRL in mm + 42
ga in days
Umb artery doppler
low resistance, progressively so with increasing gest age
overlapping skull bones in fetal demise are seen...
one week after the death
what does pubs sample?
umbilical vein
first day of period until day 14 (ovulation)
follicular phase
ovary phase after ovulation, correlates with secretory phase
luteal phase
increased LH, decreased FSH
PCOS