Ob exam #1 study slides

The implantation of a zygote into a
woman’s body. Pregnancy occurs when
a woman’s body responds to the
hormonal signals that indicate
fertilization has occurred. The ovum is
fertilized.

A 48-hour time period including the
day before and the day after birth

The time period including the first 4
weeks of life

A fetus born at less than 36 weeks
gestational age

A fetus born at greater than 42 weeks
gestational age

The number of pregnancies including
the current one

The number of pregnancies carried
to term

Characterizes a woman during her
first pregnancy

Characterizes a woman after several
pregnancies

Characterizes a woman who has 5 or
more successful previous
pregnancies

The 40 weeks from LNMP of a normal
pregnancy is divided into 3 trimesters of 13
week duration.
Pregnancy is 266 days +/- 10

When patient conceives 14 days after the
first day of the LNMP the pregnancy is 280
days or 40 weeks from the first day of the
LNMP

Last normal menstrual period; First
day of cycle or LMP

In US, dated from the 1st day of the
LNMP

The earlier in pregnancy the sonogram
is performed the more accurate the
dating

(fluorescence in situ hybridization)
Useful for gene-mapping and
identifying chromosomal
abnormalities like Trisomy-21 or
DiGeorge syndrome

A mucus filled lump on the surface of
the cervix caused by plugged up
mucus glands

A syndrome usually seen in women
who take certain fertility medicines
that stimulate egg production
Occurs after ovulation and ovaries
become very swollen

The loss of a fetus at any stage

The removal of a small piece of
placenta tissue (chorionic villi) from
the uterus during early pregnancy to
screen the baby for genetic defects

Percutaneous umbilical blood
sampling (PUBS)

A highly specialized prenatal test in
which a blood sample is removed
from the umbilical cord and tested
for genetic problems or infections

PUBS can be done after the 18th
week of pregnancy

One of the most effective and commonly
used medicines in the treatment of several
forms of arthritis and other rheumatic
conditions
Known as a disease-modifying antirheumatic drug because it not only
decreases the pain and swelling of
arthritis, but it also can decrease damage
to joints and long-term disability

Ideas, facts, or allegations spread
deliberately to further one’s cause or
to damage an opposing cause; also; a
public action having such an effect

The treatment of choice for
management of the fetus with
symptomatic fetal hydrothorax (FHT)
before 32 weeks of gestation

Intrauterine growth restriction
(IUGR)

Reduced growth rate (symmetrical
IUGR) or abnormal growth pattern
(asymmetrical IUGR) of the fetus;
resulting in a small for gestational
age (SAG) infant

Human chorionic gonadotropin
(hCG)

Hormone secreted by
syncytiotrophoblasts of the developing
embryo
Laboratory test indicates pregnancy
when values are elevated
hCG levels will likely decrease after the
1st trimester when the placenta takes
over

Exceptionally large infant with
excessive fat deposition in the
subcutaneous tisse
Most frequently seen in the fetuses
of diabetic mothers

Maternal serum alphafetoprotein (MSAFP)

Biomedical test used to assess fetal risk for
aneuploidy or fetal defect (neural tube
defects)
Component of the “triple screen”
Normal value varies with gestational age
Maternal serum is tested between 15-22
weeks of gestation to detect abnormal levels

Ovary doesn’t make all the hormones it
needs for the egg to fully mature, so the
follicle grows and builds up fluid
Most common cause of female infertility

Endometrium of pregnancy
“falling away”

The decidua in contact with the chorion
frondosum, which eventually develops
into the placenta

The decidua in contact with the chorion
laeve
When the decidua capsularis is pressed
against decidua vera on the opposite side
of the endometrial cavity by the developing
pregnancy, the villi attach to the chorion
laeve regresses or may slough off

Decidua parietalis
(decidua vera)

Endometrial lining which is not initially
involved in the implantation and is
therefore not associated with the
placenta

Extraembryonic membrane that is formed
from trophoblastic cells and forms the
outer wall of the blastocyst at the time of
implantation
Outer membrane adjacent to the uterine
wall, then extending over the fetal side of
the placenta

(villous chorion) Interweaving of chorion
villi and decidua basalis.
Establishes early utero-placenta
circulation

The inner membrane which holds the embryo suspended in
the amniotic fluid
Amnion extends over the placenta except at the umbilical
cord where it is continuous with the outer membrane of the
cord
@6 weeks amnion is closely adjacent to the embryo
@8 weeks is more circular in shape
By 10 weeks occupies most of gestational sac
By 15th week it is fused with the chorion

Cells form isolated spaces called lacunae
which later develop into intervillous
spaces in the placenta where maternal
blood flows and makes contact with fine
fetal capillaries in the villi, finger like
projections of placental tissue

Organ that provides hormones to
support pregnancy and that is the site of
communication between the mother’s
blood and fetal capillaries contained
within the villi

Term assigned after it is determined that
the pregnancy is non-viable

Medical term for an induced abortion
performed at a woman’s request

Occurs when the products of gestation
remain in the uterus and cause
continued bleeding

An induced abortion for the health of
the mother

Having high blood pressure during
pregnancy and too much protein in
urine at 20 weeks

Type of gestational malignant tumor
that arises from the trophoblasts of the
forming placenta within the uterus

Nonfunctional cyst found on the ovary
and are associated with excess amounts
of gonadotropins

Surgical procedure to correct cervical
incompetence
Cervix is stitched closed so that
premature birth or miscarriage is
avoided

Occurs when the decidua of the uterus
discards

Appearance of the uterus when it comes
out
Well known with ectopic pregnancies

Parts next to each other or attached to
each other

Ducts in the embryo that develop into
female parts

Spontaneous or unknown cause or
origin

False labor pains that often occur early
on in pregnancy
Not a true contraction

Excessive vomiting during early
pregnancy that results in at least a 5%
reduction in body weight

A miscarriage in which the baby does
not develop or demises early but the
gestational sac remains

Pregnancy Associated Plasma Protein A
Can be a part of 1st trimester screening
measure with a blood test

Dilation and curettage
A procedure in which the cervix is
dilated in order to remove the
endometrium

Mean sac diameter
Figured from several different
measurements

Abdominal measurement of the uterine
length
Measured from the symphysis pubis to
the tip of the fundus in cm
The cm length approximates the weeks
of gestation

A baby whose weight is greater than
4000 grams at term

A full term baby whose weight is less
than 2500 grams at birth

A pregnancy with maternal or fetal
factors which predispose to increase
maternal or fetal morbidity and
mortality
• Bleeding
• Polyhydramnios
• Development of hypertension

120 – 160 bpm with marked variability

Heart rate increases with movement
Aka: fetal heart acceleration

Estrogen product produced by the
placenta from fetal precursors

Estrogen product produced by the
placenta from maternal precursors

A measurement of estriol, HCg, and AFP
in the maternal serum

Monitoring of fetal heart rate and
uterine contractions

Placental reserve
(placental suficiency)

Measurement of the ability to supply
sufficient oxygen to the fetus even during
contractions, which reduce maternal blood
supply to the placenta
*If placental reserve is not adequate, it is
said that the patient has placental
insufficiency

Dilation (opening) of the cervix

Initial perception of fetal movement by the
mother
Usually occurs between 17 and 21 weeks
*inexact method of determining EDC
Timing related to:
• Parity
• Position of the placenta
• Awareness of mother

Insufficient amounts of amniotic fluid

Excessive amounts of amniotic fluid

Standard for comparing the condition of the
baby at birth and a way of detecting depressed
newborns
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•
•
•
•

Measurements of 0,1,2 are given for:
Heart rate
Respiratory effort
Muscle tone
Reflex irritability
Color

**Apgars are noted at 1 & 5 mins after birth
**healthy baby will have an apgar of 8-10

An intrauterine score designed to detect
depressed fetuses
Scores of 0 or 2 are given for:
• Fetal breathing movements
• Gross body movement
• Fetal body tone
• Reactive fetal heart rate
• Amniotic fluid volume

Standard test of the baby’s physical
characteristics and neurological (reflex)
responses that is completed in the
nursery during the first 24 hours of life

The first recognizable, histologically
differentiated stage in the development
of an organ

A vascular fetal membrane of reptiles,
birds, or mammals that is formed as a
pouch from the hindgut and that in
placental mammals is intimately
associated with the chorion in formation
of the placenta

Produced by the cells of the implanting
egg and can be produced in the absence
of an embryo
Can be detected in maternal plasma or
urine by 8 – 9 days after ovulation

A syndrome associated with the
presence of an extra chomosome 13
Characterized by mental retardation,
cardiac problems, and multiple
deformities

A white substance covering the skin of a
baby directly after birth
Composed of sebum and cells that have
sloughed off fetus’ skin

Dilation of the renal pelvis in a fetus due
to urine or fluid collection
• Hydronephrosis – when it exceeds
10mm at 20-24 weeks
• Pyelectasis – when greater than 4mm
and less than 10mm in a fetus under
24 weeks

A fluid or solute moving through a
membrane
It moves by osmotic or hydrostatic
pressure gradient

A supportive tissue derived from
extraembryonic mesoblast that
surrounds the umbilical cord protecting
the vessels within

Without it may be easier to compress
the vessels and even cause fetal death

Something that is unusual or different at
birth

Defined as an unusual anatomic feature
that is of no serious medical or cosmetic
consequence to the patient

By contrast to minor anomaly might be a
cleft lip and palate, a birth defect of
serious medical and cosmetic
consequence to the child

A fluid-filled sac surrounding a testicle
that results in swelling of the scrotum
Up to 10% of male infants have a
hydrocele at birth, but most disappear
without treatment within the first year
of life

Portion of the cerebellum in the midline
is not as prominent as the lateral
hemispheres

Receives visual input from the superior
colliculus and is involved in coordinating
eye movements and speech

Discrete elevations of chorioallantoic
tissue of the ruminant fetal membranes
that adhere intimately with the materal
caruncles to form placentomes

Refers to the abnormal copy number of
genomic elements
One of the most common causes in
morbidity and mortality in human
populations

OB Exam 1
Normal First Trimester

How many chromosomes are in a
gamete

How many chromosomes after
fertilization?

What do the follicles on an ovary
produce?

The endometrium to grow and
thicken

What stimulates the pituitary to
release luteinizing hormone and
FSH?

What does the luteinizing
hormone stimulate?

Where does the oocyte go after
it is released?

What happens to the follicle
after rupture?

Becomes corpus luteum & produces
progesterone

If fertilization doesn’t occur, estrogen
& progesterone drop

Where does fertilization typically
occur?

What happens to the corpus
luteum after fertilization?

Continues to produce progesterone
and some estrogen

What stage are weeks 5 – 10?

What stage are weeks 11 – 40 ?

When and how is a morula
formed?

By day 3 – 4, from the fertilized ovum
(zygote) divides

What is the organized form of
the morula?

The thickened endometrial layer
(decidua)

What are the outer cells of the
blastocyst?

What part of the blastocyst
becomes the embryo?

What are the 2 layers of the
trophoblast?

1. Inner – cytotrophoblast
2. Outer layer - syncytiotrophoblast

What does the cytotrophoblast
form?

• Chorion
• Amnion
• Connecting stalk

What does the
syncytiotrophoblast do?

• Invade the decidua
• Form lacunae (which develop into
intervillous spaces)

What hormone does the
trophoblast secrete?

Extends the life of the corpus
luteum/progesterone

When does the blastocyst
implant?

What happens to the primary
yolk sac?

What connects the secondary
yolk sac to the fetal body?

Where is the secondary yolk sac?

In the extraembryonic coelum,
between the amnion and chorion

What is normal size for the
secondary yolk sac?

What is the function of the
secondary yolk sac?

What days in the zygote stage
does conception happen?

When does the morula become a
blastocyst?

What happens in days 25 – 26 of
the zygote stage?

• Implantation complete
• Lacunar network formed
• Focal thickening of the decidua at
the site of implantation

What happens in response to
estrogen and progesterone?

Transformation of endometrial cells
into glycogen and lipoid cells

What are the 3 distinct layers of
the decidua?

• Decidua basalis
• Decidua capsularis
• Decidua parietalis (decidua vera)

Which decidua attaches at the
chorion frondosum

Which decidua is not involved in
implantation?

Decidua parietalis (decidua vera)

Which decidua develops into the
placenta?

Which decidua covers the
remaining endometrial cavity?

Which decidua closes over the
blastocyst?

When can the Intradecidual Sac Sign
/ Double decidua sign be seen?

What structures are present in
weeks 4 – 5?

• Yolk sac
• Neural plate and folds

What are the sonographic
features of week 4 – 5?

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•
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•

Yolk sac in the gestational sac
Located in the fundus
Round or oval with smooth walls
Decidual thickening of >3mm

Where would the yolk sac been
seen in week 4 – 5?

Between the amnion and chorion

By what day should the
gestational sac be seen?

By what day should the yolk sac
be seen?

In week 4 – 5, what should the
diameter of the gestational sac be?

In weeks 4 -5 what should the
hCG count be?

In weeks 4 – 5, what should the
decidual wall thickening measure?

weeks 5 – 6?

• Limb buds
• Primordia of liver, pancreas, lungs,
thyroid gland, heart
• Neural groove closes and the
primary brain vesicles form
• Opitcal vesicles
• 2 heart tubes fuse and contraction
begins with unidirectional blood flow

features of week 5 – 6?

• Double blep sign (amnion with yolk sac
• Embryo may be seen adjacent to yolk
sac
• Embryo heart beat
• Double decidua sign

What week should the embryo be
seen?
Or size of the gestational sac?

By week 6, or gestational sac of 1.5 cm

What would the embryo measure to
be able to detect heart beat?

What structures are seen in
week 6 – 7?

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Brain has single vesicle
Heart bulges from the body
Embryo is C-shaped
Arm buds elongate, leg buds appear
Nostrils and eyes develop

features of week 6 -7?

The amnion is close to the embryo

What happens in week 7 – 8 ?

• Body axis straightens
• Arms & legs extend straight forward
• Digits, ears, eyelids, elbow, and wrists are
formed
• Pulmonary trunk separates from heart
• renal pelvis, calyces, and ureters form
• Brain has 3 vesicles

What would the CRL be in week
7 – 8?

• More straightening of axis
• Touch pads swollen on fingers
• Midgut herniates into the umbilical
cord (between weeks 8 – 12)
• Brain hemispheres and falx formed

features in week 8 – 9?

The choroid plexus is seen in the
lateral ventricles

8 – 9?

What happens in week 9 – 10?

• Eyelids cover eyes
• Brain structures complete
• Rapid growth

9 – 10?

What would the CRL be week 11
& up?

By when should the kidneys be
seen in adult position?

By when should the stomach be
seen?

When does the midgut herniation
return to the abdominal cavity?

When is the cerebellum formed?

When does ossification of long bones begin?

When should cranial anatomy be
seen?

When should the bladder be
seen?

When should the 4 chamber
heart be seen?

What does the mean sac
diameter correlate with?

Menstrual age
(1 cm = 1 week)
((Accurate through Wk 8)

What diameter should the yolk
sac never exceed?

What is the most accurate way to
date a pregnancy?

With what accuracy does the CRL
date the pregnancy?

+ / - 5 days
((To 13 Wks Gestation))

What is included in the mean sac
diameter?

Only anechoic fluid space, not walls

Where should the gestational sac
be located?

To one side of the endometrium near
fundus

When should the yolk sac be
seen?

When the mean sac diameter is
8 mm

When should the fetal heart rate
be visualized?

What is the normal fetal heart
rate?

When is the nuchal Translucency
seen?

Anechoic area in the posterior nuchal
region of the fetus

What does nuchal translucency
screening detect?

The risk for having a child with
trisomy 21, 13 and 18

What factors are include in
nuchal transluceny screening?

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PAPP-A values
BhCG lab values
Maternal age
Fetal nuchal translucency
measurement

What forms the umbilical cord?

The fusion of the yolk stalk and
allantoic duct

When does the umbilical cord
develop?

What forms the umbilical
vessels?

What is the cavity between the
amnion and chorion?

Extraembryonic coelum
(chorionic cavity)

What is the inner membrane that
suspends the embryo in amniotic
fluid?

Amniotic membrane –
Covers the cord as it expands

What is the outer membrane that
implants to form the placenta?

When does the amnion and
chorion fuse?

When is quantitative hCG
assessed?

When should the 2nd international
standard be positive?
(Pregnancy Test)

7 – 10 days after conception

What could be the cause for
increased serum levels?

• Incorrect dates
• Multiple gestations
• Trophoblast dissease (greater than
60,000 mIU/ml early

What could be the cause of
decreased serum levels?

• Incorrect dates
• Embryonic demise
• Ectopic pregnancy – will show
slow rise but overall value is
decreased

Where is PAPP-A glycoprotein
produced?

What does a decrease in PAPP-A
indicate?

OB EXAM #1
1st Trimester Pathology

What is the incidence of bleeding
in pregnancy after the LNMP?

What is the continuation rate for
light bleeding?

moderate bleeding?

heavy bleeding?

What are the non-pregnancy
causes of bleeding?

• Cervical polyps
• Cervical infection

What is a complication of
hyperemesis gravidarum?

Hyperemesis gravidarum may be
related to__________.

• Molar pregnancies
• Higher in twins than singletons

What are common causes of pain
in pregnancy?

• Movement of retroverted uterus to an
anteverted position
• Torsion of corpus luteum cyst or theca
lutein cyst (with molar pregnancy or
hyperstimulation
• Cramping with bleeding may signify
cervical dilation or venous congestion
• Should pain or leg pain associated with
ectopic pregnancies

What does the development of
hypertension in the first trimester
related to?

Poor function or the presence of a
molar pregnancy

What does development of
hypertension later in pregnancy
relate to?

One symptom in the triad signaling
development of pre-eclampsia

What are the etiologies of
pregnancy failure/disruption in 1st
trimester?

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Idiopathic
Endocrine factors
Corpus luteum failure
Mullerian duct anomalies
Embryonic failure
Chromosomal anomalies

What percentage of pregnancies
end in SAB?

75 % end in SAB before what
week?

What are the categories of SAB?

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Complete abortion
Incomplete abortion
Missed abortion
Inevitable abortion
Blighted ovum
Threatened abortion
Imminent abortion

Evacuation of all products of
conception

What are the signs/symptoms of
a complete abortion?

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•
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Rapid decline in hCG
Heavy vaginal bleeding with tissue/clots
Cramping
Cessation of pain and bleeding after
event
• Disappearance of signs of pregnancy

features of a complete abortion?

• An empty uterus with a clean
endometrial stripe
• No adnexal mass or free fluid
• Moderate to bright endometrial
echoes (may be thickened)

Incomplete abortion is also
known as _______

Retained products of conception

an incomplete abortion?

• Slow fall or plateau of hCG
• Moderate cramping
• Persistent moderate to heavy
bleeding

What are the sonographic features
of an incomplete abortion?

• Complex echo pattern within
endometrial cavity
• Bright echoes, may shadow to air
bubble or bone fragments
• Thickened endometrium

a missed abortion?

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•
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hCG levels less than expected
Loss of pregnancy symptoms
Brownish vaginal discharge
Some cramping/pain

features of a missed abortion?

• Absent cardiac and limb activity
• Fetal size is less than expected
• Uterine size is less than expected

What is an inevitable abortion
also called?

an inevitable abortion?

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Uterus is small for dates
Variable/low hCG levels
Vaginal spotting
Cervical dilation

of an inevitable abortion?

• Gestational sac is not in the
fundus and closer to the cervix
• Rupture of membrane with no
chance of survival

What are the sign/symptoms of
an imminent SAB?

• Moderate cervical effacement
• Rupture of membranes/leaking
fluid
• Prolonged bleeding
• Persistent cramping

features of an imminent SAB?

• Heart rate is less than 90
• Persistent misshapen yolk sac
• Gestation sac in the cervix or
lower uterine segment
• Cervical dilation
• Small gestational sac

What is thought to be the cause
of a blighted ovum?

Anembryonic pregnancy/empty sac.
The gestational sac in utero without
embryo or yolk sac, with irregular
borders

What are the sign/symptoms of a
blighted ovum?

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•

Uterus is small for dates
Variable hCG levels
Vaginal spotting
Closed cervix

features of a blighted ovum?

• No identifiable embryo in a
gestational sac that is bigger than
25 mm
• Absent double blep sign

What is a threatened abortion?

The future of pregnancy at risk but is
currently viable
Not able to diagnose sonographically

a threatened abortion?

• Closed cervix
• Slight bleeding or cramping

Some bleeding in pregnancy is
common from ___________

What is the chance of loss in
pregnancy under 7 weeks after the
heartbeat has been seen?

What is the chance of loss in
pregnancy over 7 weeks after the
heartbeat has been seen?

of a threatened abortion?

• Sonolucent crescent around GS

What could the sonolucent
crescent around the GS be?

Subchorionic hemmhorage or
unknown bleeding

What are the causes of habitual
abortions?

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Often genetic incompatibility
Fibroids
Uterine anomalies
Adenomyosis
Incompetent cervix

What is the incidence of all
pregnancies for an ectopic
pregnancy?

What percentage of ectopic
pregnancies are in the fallopian
tube?

Where do ectopic pregnancies
occur?

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•
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Peritoneum
Ovarian
Cervical
Interstitial/cornual
Intermural
Heterotopic

What is the occurrence of maternal
deaths with an ectopic pregnancy?

What are the risk factors for
ectopic pregnancies?

• Damage to Fallopian tubes
• Previous PID or ectopic
• Tubal surgeries
• Endometriosis

• Use of IUD
• Infertility treatment

an ectopic pregnancy?

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•
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Pain
Vaginal bleeding (35 %)
Palpable adnexal mass
Asymptomatic
Shock if ruptured
hCG doesn’t rise as it should

What is the occurrence of a live
extrauterine pregnancy in the
adnexa?

Where is an ectopic most
commonly found?

The same side with the corpus
luteum
(has the appearance of a cyst)

What are features of a
pseudogestational sac?

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•
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•

No embryo or yolk sac
Centrally located
Homogeneous echoes within
High resistant waveform

What is the trend in hCG with
ectopic pregnancies?

To increase at slower rates than
normal

If no IUP is seen and hCG is greater
than 1000 IU/ml, what does this
typically indicate?

Ectopic pregnancy or very recent
miscarriage

What is the pre-symptomatic
phase of ectopic pregnancy?

May be picked up by low hCG level,
lack of IUP on sonogram

What is the symptomatic phase
of ectopic pregnancy?

• Tubal rupture, intraperitoneal
bleeding
• Shock, hypotension, abdominal pain

What is the 2nd most common
type of ectopic pregnancy?

What are the features of an
interstitial/cornual ectopic
pregnancy?

• Eccentric sac location in uterus
• Less than 5 mm distance from sac
to uterine serosa
• May be live or may just be a mass

What kind of ectopic pregnancy has
the highest maternal mortality rate?

Why does cornual ectopic have the
highest maternal mortality rate?

What would a sac in the cervix
be?

What is the potential with a
cervical ectopic?

Massive hemorrhage & Future
Infertility

Which ectopic is difficult to
diagnose?

To diagnose a peritoneal ectopic,
what must be seen?

The uterus separate from pregnancy

What may mimic an ovarian
mass?

What type of ectopic is the
history important?

What is a coexisting IUP and
ectopic?

Heterotropic ectopic/pregnancy

Why are heterotopic
ectopic/pregnancy increasing?

What is the treatment for ectopic
pregnancies?

• Oral low does methotrexate,
which kills trophoblastic tissue
• Injection of methotrexate directly
into sac
• Laparoscopy to remove portion
affected

What is the cause of the most
common bleeding in the 1st
trimester?

What causes subchorionic
hemorrhage?

What is subchorionic
hemorrhage?

Low pressure bleeding between the
gestational sac and placenta

subchorionic hemorrhage?

• Bleeding & spotting
• Uterine contractions

of subchorionic hemorrhage?

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•
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•

Crescent shaped
Echogenic area (recent)
Anechoic (old)
No color Doppler

Produce of conception in which trophoblast cells
fail to differentiate so produces abnormal
placental tissue
More common in Asians

What are hydatidiform moles
associated with?

Theca Lutein Cysts
Over$ due to high hCG
Largest functional cyst
Bilateral 6-12 cm
Multiple & septations common

Signs and Symptoms of
Hydatidform Mole

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Increased hCG (Hyperemesis)
Bleeding
HTN/Preeclampsia
Decrease AFP
Uterus Enlarged
Theca Lutein Cysts (Bilateral)

What is seen more in the 2nd
trimester, and is a higher pressure
bleed?

What is the cause of placental
hematoma?

What relates to the outcome of the
pregnancy with placental
hematomas?

What is the appearance of a
placental hematoma?

Similar to subchorionic hemorrhage

What is the incidence of fetal
demise with placental hematoma?

When is an incompetent cervix
most common?

What are the characteristics of
an incompetent cervix?

• Shortening, and opening so that
membranes may protrude
• Painless dilation and delivery

What length is considered
shortened in a cervix?

of an incompetent cervix?

• Funneling of Y, V, U shape

What is the treatment(s) of an
incompetent cervix?

What are the masses that coexist
with pregnancy that are seen?

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•
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Corpus luteum cyst
Leiomyomas
Myometrial contractions (mimics a mass)
Hematosalpinx/hematoma
IUCDs with coexisting IUP
Uterine anomalies

A corpus luteum cyst is most
common in _____________, and
usually regresses by _____________

If a corpus luteum cyst continues
after then 1st trimester, what is then
considered?

What type of uterine mass may
increase in size in 1st trimester and
early 2nd trimester?

What causes leiomyomas to
increase in size in the 1st and 2nd
trimesters?

What is a concern with
leiomyomas and pregnancy?

Can compress the sac if it grows too
fast

What are the features of a
leiomyoma?

• Attenuates sound
• Hyper to hypoechoic
• Differentiate from Braxton-Hicks
contractions by:
• Decreased vascular in fibroid
• Doesn’t disappear over time

When are myometrial
contractions most common?

What are the features of a
myometrial contraction?

• Painless contraction
• Myometrium thickens for 20 – 30
mins
• Spontaneously disappears

What causes
hematosalpinx/hematoma?

Implantation bleeding or other GYN
infection

• Gestational trophoblastic disease
The product of conception in which the
trophoblast cells fail to differentiate so
they produce abnormal placental tissue

To whom are hydatidiform moles
most common?

Theca lutein cysts
•
•
•
•
•

Largest functional cyst
Seen 20 – 35 % of the time
Overstimulation due to high hCG levels
Bilateral
Multiple and septations common

What are the sign/symptoms of a
hydatidiform mole?

•
•
•
•
•
•
•

Bleeding
Increased hCG
Hyperemesis
Preeclampsia
Decreased AFP
Uterus is large for gestational age
Theca lutein cysts (bilateral)

Is a complete mole benign or
malignant?

Benign form, with malignant
potential

What is the cause of a complete
mole?

An abnormal ovum, or 2 sperm
fertilizing an ovum

What is the incidence of a partial
(incomplete) mole of all moles?

Is a partial mole considered
benign or malignant?

Benign, has very little malignant
potential

What is the appearance of the
placenta with a partial mole?

Enlarged and engorged with cystic
spaces

Hyperplasia of trophoblast will be
localized within placenta rather than
general

What is the ploidy of a complete
mole?

What is the ploidy of an
incomplete mole?

Can a fetus coexist with a complete
mole or incomplete mole?

Hydropic villi invades myometrium

What percentage of molar
pregnancies move to an invasive
mole?

What are the sign/symptoms of
an invasive mole?

• Persistent bleeding
• Elevated hCG

Malignant metastatic trophoblastic
disease

What is the incidence of molar
pregnancies progressing to
choriocarcinoma?

What are the
characteristics/appearance of
choriocarcinoma?

• Spreads quickly
• Complex in appearance
throughout myometrium

What is the sonographic appearance
of choriocarcinoma in the 1st
trimester?

•
•
•
•

May appear normal
Appear like a missed abortion
Incomplete abortion/blightled ovum
Echogenic mass in endometrium
•

Cyst may be too small

What is the sonographic appearance
of choriocarcinoma in the 2nd
trimester?

• Snowstorm / grape clusters
• mid level tissue with cysts
(chorionic villi)

What is the treatment for
choriocarcinoma?

What is the residual rate of
choriocarcinoma after evacuation?

What is the most common
abnormality of the first trimester in
the fetus?

What is cystic hygroma likely
associated with?

Chromosomal abnormalities
• Trisomy 21, 18, 13 and Turner’s
syndrome (most common)

What is the sonographic features
of cystic hygroma?

• Vary in size
• Soft tissue thickening on posterior
neck and thorax
•

**must differentiate from NT

What are the abnormalities
found in the 1st trimester fetus?

•
•
•
•
•

Cystic hygroma
Umbilical cord cyst
Obstructive uropathy
Abdominal wall defects
Cranial anomalies

What is methotrexate used for?

To terminate early pregnancy
(most common for ectopic
pregnancy)

How effective is methotrexate
injected if 6 weeks or less and the
intact embryo is seen?

What are complications of
methotrexate being injected?

What is dilation and curettage (D&C)
or dilation and evacuation (D&E)?

Method where the cervix is manually
dilated and the endometrium is
scraped away

When is in vitro fertilization
considered?

After 1 year with no conception

What is the sonographic usage
for in vitro fertilization?

•
•
•
•

Assess infertility cause
Ovary monitoring during stimulation
Egg retrieval assistance
Assess embryo after implantation

What are complications of in
vitro fertilization?

• Multiple gestations
• Fetal reduction
• Hyperstimulation syndrome

To improve the survival rate of
remaining fetus
Used with quadruplets or more to increase birth
rate

What techniques are used in
fetal reduction?

• Transcervical aspiration of GS
•
•

Infection possibility
Increases cervical incompetence

• Transvaginal puncture and embryo aspiration
•
•
•

Use of general anesthesia
Possible abortion
Infection possibility

• Tranabdominal injection of potassium chloride
•

Increased pregnancy loss when performed later in pregnancy

OB Exam 1
2nd Trimester Routine Sonogram

What percentage of fetuses are
in the cephalic position at term?

What percentage of fetuses are
in the breech position at term?

What is the occurrence of fetuses in
the shoulder/transverse position at
term?

What structures are included in
the facial profile?

Fetal forehead
Fetal nose
Upper and lower lips
Chin

What proportion is expected in
the facial profile?

1/3 forehead
1/3 eyes and nose
1/3 mouth and chin

the coronal face?

Orbits
Ethmoid bones
Zygomatic bone
Nasal septum
Maxillae
Mandible

What structures are imaged in
tangential views?

Nostrils
Maxillae
Mandible
Ears

Why do we document nose and
lips?

To look for continuity of the upper lip
(assessing for cleft)

What is assessed in the orbits?

That there are 2 present, and their
spacing

How is the inner orbital distance
measured?

How is the outer orbital distance
measured?

What does the OOD (outer orbital
distance) measurement compare to?

When does the appearance of
the brain remain constant?

fetal brain by sonogram?

Hypoechoi – anechoic
(small reflectors and water content high)

What kind of artifact is expected
while imaging the fetal brain?

• In the near field ½ of brain
• Reverberation or shadowing

When do the bones in the skull
ossify?

What is the shape of the skull
more superior (high)?

What is the shape of the skull
inferior (low)?

What is the ventricle pathway?

•
•
•
•
•
•
•
•

Lateral ventricles
Foramen of Monro/interventricular foramen
3rd ventricle
Aqueduct of Sylvius/cerebral aquaduct
4th ventricle
Foramen of Maendie/Median Aperature
Subarachnoid space
Venous system

brain at the falx cerebri?

What is the appearance of the brain
just inferior to the falx cerebri?

White matter tracts parallel to falx

At the level of the lateral ventricles
what other structure is seen?

What are the characteristics of
the choroid plexus?

• Echogenic tear shaped
• Near the posterior end of ventricles
• The atria measure < 10 mm

What is the largest width of the
cranium?

mid diameter?

•
•
•
•

Midline falx
Cavum septum pellucidum
Thalmus
3rd ventricle

What is the shape of the head at
mid diameter?

How is the BPD measurement
taken?

• Leading edge to leading edge of bone
• No skin or tissue included

When is the BPD most accurate
for growth and dates?

In the 2nd trimester

After 13 weeks

What level is the head
circumference taken?

How is the head circumference
taken?

Outer margin of the skill, not including
any tissue

What is another optional
measurement that can be taken at
the mid diameter?

What is being assessed at the
corpus callosum?

It’s presence

Not documented unless pathology is
seen

What are the hemispheres joined
by?

Where is the cerebellar width
measurement taken?

At the level of the cerebellum, vermis,
and 4th ventricle

When is the cerebellum width
measurement valid?

How does the cerebellar width
measurement coincide with the GA?

What is the normal measurement of
the cisterna magna?

Where is the cisterna magna
measurement taken?

From vermis to inner skull bone

cisterna magna?

Anechoic with linear echoes of dura

What is the normal
measurement of the nuchal fold?

When do you measure the
nuchal fold?

What is the apperance of the
sphenoid bone by sonogram?

How should the vertebral column
be imaged?

Coronally image the cervical, thoracic,
and lumbar/sacral spine – to the tip of
the sacrum

What is being looked for when
assessing the vertebral column?

•
•
•
•
•
•

2 -3 ossification points
Tapers at sacrum
Widens near skull base
3 spread equidistance
Spinal column is closed circle
Integrity of skin surface

How will an abnormal vertebral
column appear?

Splayed in a V or U configuration

What structures are assessed in
the thorax?

•
•
•
•

Ribs/bones
Lungs
Heart
Diaphragm

What is to be imaged for the
ribs/bones?

Only documented when confenital
anomalies suspected

Solid and homogeneous
Slightly hyperechoic to liver

How should the heart be
imaged?

What should be imaged in the
heart?

• 4 chamber view
•

With septum perpendicular to beam

• Outflow tract
•

RVOT, LVOT

What commonly happens if the
heart is compressed or imaged for
long periods?

What is being assessed in the 4
chamber view?

• Equal sized atria and ventricles
respectively
• Foramen ovale flaps into LA
• Moderator band in RV
• TV more apical than MV
• Ventricular septal defects
• Atrial septal defects

What are the normal
measurements of the IVS?

What is the position and axis in
the fetus?

•
•
•
•
•
•

Transverse
Apex points toward left
RV lies toward sternum
LA lies toward spine
IVS ~ 45 degree angle from midline
Heart is approximately 1/3 the size of
the chest

Heart is mostly in the left chest
(normal)

Heart is mostly in the right chest

Apex pointed to the left
(normal)

How do you get the LVOT from 4
chamber?

Sweep anterior for 5 chamber
Turn 45 – 90 degrees for PLAX

What is being assessed in the
LVOT view?

• IVS for VSD
• Continuity of IVS and Ao wall
• Continuity of posterior Ao wall and
anterior MV leaflet
• Ao root caliber

What is the normal Ao root
caliber?

In what view can the pulmonary
trunk be measured?

In the PSAX view what is being
assessed?

• Spatial relationship between Ao & PA
(should be equal)
• See the ductus between the PA and Ao
• Branching of the 2 main pulmonary
arteries

What is the best view for great
vessel transposition?

ductus arteriosis from a sagittal
view?

Like a hockey stick
(less curved than the AA)

What is the first thing to come
into the thoracic aorta?

What is the normal
measurement of the aortic arch?

3 – 8 mm (20 – 40 weeks)

Never > 1 cm

What are the other structures that
can be seen, but not routinely
documented?

• Pulmonary vein
• IVC
• SVC

What is used to assess
arrhythmias?

What is used to assist in
documenting blood flow?

What plane is the diaphragm
best seen in?

What is to be visualized when
looking at the diaphragm?

That the stomach is inferior and the
heart is superior to the diaphragm

What is the site for abdominal
measurement?

At the portal vein within the liver

When is the gallbladder in the
right quadrant?

liver?

Midlevel gray and vessels seen within it

How is the abdominal
circumference taken?

• Outer margin of skin
• At the level of the left portal vein as J
or L from umbilical vein

What structures are seen when
the AC is taken?

• Liver
• Stomach
• Possible adrenals
•

****NOT KIDNEYS

AC is most accurate in what
trimester for weight?

When should the abdominal
circumference be taken?

What typically fills the stomach
of the fetus?

When do the kidneys begin to
produce larger amounts of urine for
amniotic fluid?

How do the kidneys appear in
the 2nd trimester?

Ovoid with ill defined borders

How do the kidneys appear in
the 3rd trimester

Borders and pelvis are more defined

When the kidney pelvis contains small
amounts of fluid

With pyelectasis prior to 20 weeks,
how much is considered
insignificant?

With pyelectasis between 20 – 30
weeks, how much is considered
insignificant?

With pyelectasis after 30 weeks,
how much fluid is considered
insignificant?

What is being assessed with the
bowel?

Echogenicity

Should be isoechoic to hyperechoic to
liver

How should the bladder appear?

If bladder fills and empties, what
does this indicate?

How often does the bladder fill
and empty?

When should genitalia be
documented?

When screening for congenitally linked
disorders and multiple gestations

Prior to 15 – 16 weeks how will
labia appear?

What is common to see in fetal
testicles?

When do the testicles descend?

Which extremities should be
imaged?

What should be seen in the
extremities?

• That all hands/feet are present
• That hands extend
• Assess foot bottom

How should the femus length be
measured?

• Using the most anterior femur
• Only the diaphysis

Is the femur length more or less
affected by IUGR?

Femur length is most accurate
INDIVIDUAL measurement for
dates/growth in what trimester?

When should the femur length
be used?

When should the other long
bones be measured?

If there is 2 weeks difference between
femur length and other measurements

What accuracy are dating
measurements in the 1st trimester?

measurements in the 2nd trimester?

measurements in 3rd trimester?

How often should interval
growth assessments be taken?

How is fetal blood oxygenated?

How does the fetus receive
oxygenated blood?

How does the umbilical vein
bypass the liver?

How does blood bypass the RV
(lungs)?

Where does the LV pump blood
to?

Where does blood entering the
RV come from?

Where does deoxygenated blood
leave the fetus?

Via the umbilical arteries from fetal iliac
arteries

What close when the umbilical cord
is clamped at birth and the lungs fill
with oxygen?

• Ductus venosus
• Foramen ovale
• Ductus arteriosis

How wide is the umbilical cord?

What is the length of the
umbilical cord?

What is the layout of the
umbilical cord?

The arteries spiral the larger vein

What is the likeliness of having
only one umbilical artery?

• 1 % in singletons
• 7 % in twins

When is it common to have only
1 umbilical artery?

What surrounds the umbilical
cord?

Wharton’s jelly
(connective tissue)

What is the role of the placenta?

Permits exchange of oxygenated
maternal blood with deoxygenated fetal
blood

What are the lobules of the
placenta called?

What is the functioning unit of
the placenta?

What bathes the villi with blood?

What forms the maternal portion
of the placenta?

Decidua basalis – called the basal plate

What forms the fetal portion of
the placenta?

Chorion frondosum – called the
chorionic plate

When does the chorion fuse with
the amnion?

Where does the umbilical artery
branch?

Along chorionic plate of the placenta

What forms the umbilical vein?

The confluence of chorionic villi

What is the function of the
placenta?

•
•
•
•

Respiration
Nutrition
Excretion
Protection
•

Microorganisms/rejection

• Storage
•
•
•
•

Carbohydrates
Protein
Calcium
Iron

• Hormone production (by syncytiotrophoblast
cells)
•
•
•

hCG
Estrogen
progesterone

What is the sonographic
appearance of the placenta?

•
•
•
•

mid gray
Homogenous
Hyperechoic to uterus
Chorionic plate is more echogenic than
basal plate
• Endometrial veins seen behind basal
plate

What is the normal
width/thickness (AP) of the
placenta?

• Subplacental maternal venous
congestion
•

Tubular vascular areas under the placenta in
myometrium

• Placental lakes/lacunae
•
•

Sonolucent/hypoechoic areas under, in, or on
the edge of the placenta
Slow vascular flow

• Myometrical contraction
•

Thickened hypervascular area under the
placenta

• Fibrin in intervillous spaces near basal
plate of placenta
•

10 % develop calcifications

What should be assessed for the
placenta?

•
•
•
•
•

Location
Echogenicity
Entire length
Locate upper and lower margin
Placental grade

What describes placental grade
0?

Homogenous with smooth chorionic
plate

1?

Scattered calcifications; subtle idention
of chorionic plate, irregular brightness

2?

Basal echogenic calcification densities;
comma like surface

3?

Irregular calcification densities with
shadowing; subchorionic fibrin deposits,
indentions go to basal plate – cumulus
clouds

What are the normal contents of
amniotic fluid?

•
•
•
•
•
•

Bilirubin
Fetal cells
Vernix caseosa
Fetal enzymes – AFP
Nutrients
Urea

What is the function of amniotic
fluid?

• Fetal movement / prevents adherence
• Symmetrical growth of fetus
• Equalizes pressure
•

Aids in lung maturity

• Consistent temperature
• cushion

Where is amniotic fluid produced
in the 1st trimester?

Where is amniotic fluid produced
after 18 weeks?

How should amniotic fluid be
assessed?

• With the transducer perpendicular to
the table
• Don’t include myometrium, cord
loops or extremities

In 4 quadrant/amniotic fluid
index what is considered low?

In 4 quadrant/amniotic fluid index,
what is considered normal?

In 4 quadrant/amniotic fluid
index, what is considered high?

What is the normal range in a
single pocket of amniotic fluid?

What is fundal height in cm
equal to?

When does the fetus have daily
movements?

characteristics of placentomegaly?

• Placenta weighing >600 g
• Thickness > 5 cm

What is a Succenturiate Placenta?

• Placenta w/ 1 or more accessory lobes
• Vessels may infarct & necrose
• Associated w/
– Velamentous insertion
– Vasa Previa

Sonographic Assessment of
Succenturiate Placenta?

• Extra lobes w/ same echogencity
• Ant. & Post. Placenta seen
• Assess if connecting vessels overly cervix

• Forms like band or ring attached all the way
around uterus
• Placenta Membranacea
– No differentiation of trophoblastics into chorion
frondosum or laeve
– Placenta villi retained may cover all GS
– Amnion & chorion absent replaced by billy
– Previa Association

• Edge of placental membrane lifts away from
uterine wall and folded back on itself w/in
amniotic space
• Portion not covered by chorionic plate
• Sheet or shelf if severe

Circummarginate vs Circumvallate

• Circummarginate more likely
– Fetal membrane insertion is flat

• Circumvallagte
• Thickened rolled chorioamniotic membranes
peripherally

• Painless bright red bleeding
• Premature contraction
• Transverse fetal position

Sonographic Technique for Placenta
Previa

• TV or transperineal
• Contraction/Braxton Hicks
• Lateral placenta most common false positive

• Villi anchored/adherent to myometrium
instead of decidua so absence of decidua
basalis

• Villi implant into myometrium

• Infiltrate past myomerium and implant in/past
serosa of uterus

Appearance of Accreta, Increta, &
Precreta

•
•
•
•
•
•
•
•
•

Normal
Common location at Ant. lower uterine seg.
Large numerous placental lacunae
Turbulent flow at jxn b/w myometrium &
placenta w/ color
Hypoechoic interface b/w placenta &
myometrium obscure
Thinning of myometrium over placenta
Bulging or protrusion of placenta into bladder
Placenta heterogenous & thick
May present as ant. placenta previa in hist. c-sec.

• Anechoic structure appearing anywhere on
surface of placenta
• Placental lakes-lacunae
– Under chorionic plate
– Irregular anechoic structures
– Maternal pools of blood won’t demonstrate color
filling

• Hypoechoic regions w/in placenta containing
strand like material
• Linear echogenic streaks w/in anechoic lesion
• No vascular flow
• From thrombosis from pooling & stasis of
maternal blood in perivillous & subchorionic
spaces

• Intraplacental hemorrhage or clot due to
breaks in villi capillaries
– Clot into cystic space w/ fibrin strangds

– RH sensitivity & increased AFP

Appearance of Intervillus
Thrombus

• Hypoechoic to anechoic masses w/in placenta
increase in size w/ maturity
• Cystic spaces w/ fibrin strands

• Ischemic areas of necrosis when obstruction
of the spiral arteries occurs

• Benign, some malignant
• Contain structures derives from the three
germ cell layers
• Complex mass in placenta w/ calcification
possible

Chorioangioma
(Placental Tumors)

• Benign tumor from proliferation of chorionic
vessels
• Capillary hemangiomas
• Can become an AV malformation shunting
blood away from the fetus
• Associated w/ increased AFP and/or hCG

• Retroplacental

• Least severe?
– Paraplacental/Marginal

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