Ob exam #1 study slides

OB Exam 1Terms

Pregnancy

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.

Prenatal

Before birth

Postnatal

After birth

Perinatal

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

Neonatal

The time period including the first 4 weeks of life

Premature

A fetus born at less than 36 weeks gestational age

Postmature

A fetus born at greater than 42 weeks gestational age

Gravida

The number of pregnancies including the current one

The number of pregnancies carried to term

Nullipara (Nullip)

Characterizes a woman during her first pregnancy

Multipara (Multip)

Characterizes a woman after several pregnancies

Grand Multip

Characterizes a woman who has 5 or more successful previous

pregnancies

Trimester

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

Pregnancy dating

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

Nabothian cyst

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

mucus glands

Ovarian hyperstimulation

A syndrome usually seen in women who take certain fertility medicines

that stimulate egg production

Occurs after ovulation and ovaries become very swollen

Demise

The loss of a fetus at any stage

Chorionic villus sampling

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

Methotrexate

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 anti-rheumatic drug because it not only

decreases the pain and swelling of arthritis, but it also can decrease damage to joints

and long-term disability

Propaganda

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

Thoracoamniotic shunting

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

Macrosomia

Exceptionally large infant with excessive fat deposition in the

subcutaneous tisse

Most frequently seen in the fetuses of diabetic mothers

Maternal serum alpha-fetoprotein (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

Polycystic Ovarian Syndrome

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

Decidua

Endometrium of pregnancy“falling away”

Decidua basilis

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

into the placenta

Chorion frondosum

Villous chorion

Decidua capsularis

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

Chorion laeve

Smooth chorion

Decidua parietalis(decidua vera)

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

placenta

Chorion

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

Chorionic frondosum

(villous chorion) Interweaving of chorion villi and decidua basalis.

Establishes early utero-placenta circulation

Amnion

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

Syncytiotrophoblast

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

Placenta

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

Threatened abortion

Bleeding in early pregnancy

Inevitable abortion

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

Elective abortion

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

Missed abortion

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

continued bleeding

Therapeutic abortion

An induced abortion for the health of the mother

Pre-eclampsia

Having high blood pressure during pregnancy and too much protein in

urine at 20 weeks

Choriocarcinoma

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

Theca Lutein Cyst

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

of gonadotropins

Cervical cerclage

Surgical procedure to correct cervical incompetence

Cervix is stitched closed so that premature birth or miscarriage is

avoided

Decidual cast

Occurs when the decidua of the uterus discards

Appearance of the uterus when it comes out

Well known with ectopic pregnancies

Adnexa

Parts next to each other or attached to each other

Mullerian duct

Ducts in the embryo that develop into female parts

Idiopathic

Spontaneous or unknown cause or origin

Braxton hicks

False labor pains that often occur early on in pregnancy

Not a true contraction

Hyperemesis gravidarum

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

reduction in body weight

Blighted ovum

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

gestational sac remains

PAPP-A

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

Fundal height

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

Large for gestation age

A baby whose weight is greater than 4000 grams at term

Small for gestational age

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

Hi-risk pregnancy

A pregnancy with maternal or fetal factors which predispose to increase

maternal or fetal morbidity and mortality

• Bleeding• Polyhydramnios• Development of hypertension

Normal fetal heart rate

120 – 160 bpm with marked variability

Reactive fetal heart rate

Heart rate increases with movement

Aka: fetal heart acceleration

Estriol

Estrogen product produced by the placenta from fetal precursors

estradiol

Estrogen product produced by the placenta from maternal precursors

Triple screen

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

Fetal monitoring

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

Cervical effacement

Shortening of the cervix

Cervical dilation

Dilation (opening) of the cervix

Quickening

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

Oligohydramnios

Insufficient amounts of amniotic fluid

Polyhydramnios

Excessive amounts of amniotic fluid

Apgar score

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

newborns

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

Biophysical fetal profile

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

Dubowitz score

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

Primordia

The first recognizable, histologically differentiated stage in the development

of an organ

Allantois

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

Trisomy-13

A syndrome associated with the presence of an extra chomosome 13

Characterized by mental retardation, cardiac problems, and multiple

deformities

Verix or vernix caseosa

A white substance covering the skin of a baby directly after birth

Composed of sebum and cells that have sloughed off fetus’ skin

Pyelectasis or hydronephrosis

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

Transudation

A fluid or solute moving through a membrane

It moves by osmotic or hydrostatic pressure gradient

Wharton’s jelly

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

Congenital anomaly

Something that is unusual or different at birth

Minor anomaly

Defined as an unusual anatomic feature that is of no serious medical or cosmetic

consequence to the patient

Major anomaly

By contrast to minor anomaly might be a cleft lip and palate, a birth defect of

serious medical and cosmetic consequence to the child

Hydrocele

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

Cerebellar vermis

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

Cotyledon

Discrete elevations of chorioallantoic tissue of the ruminant fetal membranes that adhere intimately with the materal

caruncles to form placentomes

Aneuploidy

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

Haploid - 23

How many chromosomes after fertilization?

Diploid - 46

What do the follicles on an ovary produce?

estrogen

What does estrogen stimulate?

The endometrium to grow and thicken

What releases gonadotropin?

Hypothalamus

What stimulates the pituitary to release luteinizing hormone and FSH?

Gonadotropin

What does the luteinizing hormone stimulate?

For one follicle to mature

Where does the oocyte go after it is released?

Fallopian tube

What happens to the follicle after rupture?

Becomes corpus luteum & produces progesterone

What causes menstruation?

If fertilization doesn’t occur, estrogen & progesterone drop

Where does fertilization typically occur?

Fallopian tube

What happens to the corpus luteum after fertilization?

Continues to produce progesterone and some estrogen

What stage are weeks 1 – 4?

Zygote

Embryo

What stage are weeks 11 – 40 ?

Fetal stage

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?

Blastocyst

What feeds the blastocyst?

The thickened endometrial layer (decidua)

What are the outer cells of the blastocyst?

Trophoblast

What part of the blastocyst becomes the embryo?

The cell disc

What are the 2 layers of the trophoblast?

1. Inner – cytotrophoblast2. 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?

What is the purpose of hCG?

Extends the life of the corpus luteum/progesterone

When does the blastocyst implant?

7 days after fertilization

What happens to the primary yolk sac?

It disappears

What connects the secondary yolk sac to the fetal body?

Vitelline duct (yolk stalk)

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?

Nutrients and hematopoiesis

What days in the zygote stage does conception happen?

14 days

When does the morula become a blastocyst?

18 – 21 days

When does implantation begin?

19 – 21 days

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

Decidua basalis

Which decidua is not involved in implantation?

Decidua parietalis (decidua vera)

Which decidua develops into the placenta?

Decidua basalis

Which decidua covers the remaining endometrial cavity?

Decidua parietalis (decidua vera)

Which decidua closes over the blastocyst?

Decidua capsularis

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

Week 4

Formation stage

What structures are present in weeks 4 – 5?

• Yolk sac• Neural plate and folds

What are the sonographic features of week 4 – 5?

• 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?

Day 34 (4 weeks)

By what day should the yolk sac be seen?

Day 42 (5 weeks)

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

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

1800 mlU/ml

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

> 3 mm

What structures are present in 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

What are the sonographic 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?

5 mm CRL7mm CRL (2014 Notes)

What structures are seen in week 6 – 7?

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

What are the sonographic features of week 6 -7?

The amnion is close to the embryo

What is the CRL in week 6 -7?

9 – 10 mm

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?

21 – 23 mm

What happens in week 8 – 9?

• More straightening of axis• Touch pads swollen on fingers• Midgut herniates into the umbilical

cord (between weeks 8 – 12)• Brain hemispheres and falx formed

What are the sonographic features in week 8 – 9?

The choroid plexus is seen in the lateral ventricles

28 – 30 mm

What happens in week 9 – 10?

• Eyelids cover eyes• Brain structures complete• Rapid growth

30 – 40 mm

What would the CRL be week 11 & up?

40 – 85 mm

By when should the kidneys be seen in adult position?

15 weeksBy 14 weeks (2014)

By when should the stomach be seen?

12 weeks

When does the midgut herniation return to the abdominal cavity?

11- 12 weeks

When is the cerebellum formed?

11 Weeks

When does ossification of long bones begin?

12 weeks

When should cranial anatomy be seen?

After 12 weeks

When should the bladder be seen?

By 14 weeks

When should the 4 chamber heart be seen?

At 12 weeks

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?

By the crown rump length

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?

By 6 weeks(via TV)

What is the normal fetal heart rate?

90 – 175 bpm

When is the nuchal Translucency seen?

In the first trimester

When do you measure NT?

• 10 to 14 weeks

What is the nuchal lucency?

Anechoic area in the posterior nuchal region of the fetus

What does nuchal translucency screening detect?

What is a normal NT?

< 3.4 mm

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

What factors are include in nuchal transluceny screening?

• 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?

During the 7 – 8th week

What forms the umbilical vessels?

The allantois 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?

Chorion membrane

When does the amnion and chorion fuse?

By 16 weeks

When is quantitative hCG assessed?

1st and 2nd trimester

Where is beta hCG produced?

By trophoblasts

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?

by trophoblasts

What does a decrease in PAPP-A indicate?

Aneuploidy (Downs)

OB EXAM #1

1st Trimester Pathology

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

20 – 25 %

What is the continuation rate for light bleeding?

What is the continuation rate for moderate bleeding?

What is the continuation rate for heavy bleeding?

What are the non-pregnancy causes of bleeding?

• Cervical polyps• Cervical infection

What is a complication of hyperemesis gravidarum?

Dehydration

Hyperemesis gravidarum may be related to__________.

Elevated B-hCG

B-hCG are highest when?

• 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?

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

What is TAB?

Therapeutic abortion

What is SAB?

Spontaneous abortion

What percentage of pregnancies end in SAB?

75 % end in SAB before what week?

Week 16

What are the categories of SAB?

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

What is complete abortion?

Evacuation of all products of conception

What are the signs/symptoms of a complete abortion?

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

event• Disappearance of signs of pregnancy

What are the sonographic 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

What are the signs/symptoms of 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

What is a missed abortion?

An intact nonliving embryo

What are the signs/symptoms of a missed abortion?

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

What are the sonographic 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?

Pending abortion

What are the signs/symptoms of an inevitable abortion?

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

What are the sonographic features 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

What are the sonographic 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?

Early demise

What is 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?

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

What are the sonographic 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

What are the signs/symptoms of a threatened abortion?

• Closed cervix• Slight bleeding or cramping

Some bleeding in pregnancy is common from ___________

Implantation bleeding

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?

What are the sonographic features of a threatened abortion?

• Sonolucent crescent around GS

What could the sonolucent crescent around the GS be?

Subchorionic hemmhorage or unknown bleeding

What is habitual abortion?

3 or more miscarriages

What are the causes of habitual abortions?

• 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?

• 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

What are the signs/symptoms of an ectopic pregnancy?

• 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?

• 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?

Interstitial/cornual ectopic

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?

Interstitial/corual ectopic

Why does cornual ectopic have the highest maternal mortality rate?

Massive hemmorhage

What would a sac in the cervix be?

Cervical ectopic

What is the potential with a cervical ectopic?

Massive hemorrhage & Future Infertility

Which ectopic is difficult to diagnose?

Peritoneal ectopic

To diagnose a peritoneal ectopic, what must be seen?

The uterus separate from pregnancy

What may mimic an ovarian mass?

Ovarian ectopic

What type of ectopic is the history important?

Ovarian ectopic

What is a coexisting IUP and ectopic?

Heterotropic ectopic/pregnancy

Why are heterotopic ectopic/pregnancy increasing?

Infertility procedure

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?

Subchorionic hemorrhage

What causes subchorionic hemorrhage?

Implantation of blastocyst

What is subchorionic hemorrhage?

Low pressure bleeding between the gestational sac and placenta

What are the signs/symptoms of subchorionic hemorrhage?

• Bleeding & spotting• Uterine contractions

What are the sonographic features of subchorionic hemorrhage?

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

What is a Hydatidiform Mole?

Produce of conception in which trophoblast cells fail to differentiate so produces abnormal

placental tissueMore common in Asians

What are hydatidiform moles associated with?

Theca Lutein CystsOver$ due to high hCGLargest functional cyst

Bilateral 6-12 cmMultiple & septations common

Signs and Symptoms of Hydatidform Mole

• 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?

Placental hematoma

What is the cause of placental hematoma?

Placental separation

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

How large it is

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?

2nd trimester

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?

Less than 3.0 cm length

What are the sonographic features of an incompetent cervix?

• Funneling of Y, V, U shape

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

Cervical cerclage

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

• 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

_____________

1st trimester2nd trimester

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

Surgical removal

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

Leiomyomas

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

Estrogen

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?

1st and 2nd trimesters

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

What is a hydatidiform Mole?

• 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?

Asian descent

What are hydatidiform moles associated with?

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

What is a partial mole?

Hyperplasia of trophoblast will be localized within placenta rather than

general

What is the ploidy of a complete mole?

Normal diploid

What is the ploidy of an incomplete mole?

Triploid

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

Incomplete mole

What is an invasive 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

What is choriocarcinoma?

Malignant metastatic trophoblastic disease

What is the incidence of molar pregnancies progressing to choriocarcinoma?

2 – 5 %

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?

Curettage

What is the residual rate of choriocarcinoma after evacuation?

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

Cystic hygroma

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?

Excessive bleeding

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

Why is fetal reduction used?

To improve the survival rate of remaining fetus

Used with quadruplets or more to increase birth rate

When is fetal reduction used?

In late 1st trimester

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 foreheadFetal nose

Upper and lower lipsChin

What proportion is expected in the facial profile?

1/3 forehead1/3 eyes and nose

1/3 mouth and chin

What structures are present in the coronal face?

OrbitsEthmoid bonesZygomatic bone

Nasal septumMaxillae

Mandible

What structures are imaged in tangential views?

NostrilsMaxillaeMandible

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?

Medial to medial border

How is the outer orbital distance measured?

Lateral to lateral border

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

Better or as good as BPD

When does the appearance of the brain remain constant?

16 – 18 weeks

What is the appearance of the 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?

By 12 weeks

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

What is the appearance of the brain at the falx cerebri?

Thin midline hyperechoic line

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?

Choroid plexus

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

What structures are present in mid diameter?

• Midline falx• Cavum septum pellucidum• Thalmus• 3rd ventricle

What is the shape of the head at mid diameter?

Oval and symmetric

What level is the BPD taken?

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?

Mid diameter

Same as the BPD

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?

Occipital frontal diameter

What is being assessed at the corpus callosum?

It’s presence

Not documented unless pathology is seen

Where is the cerebellum?

Within the posterior fossa

What are the hemispheres joined by?

Cerebellar vermis

Where is the cerebellar width measurement taken?

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

When is the cerebellum width measurement valid?

To 20 weeks GA

How does the cerebellar width measurement coincide with the GA?

Width in mm = GA in weeks

What is the normal measurement of the cisterna magna?

3 – 11 mm

Where is the cisterna magna measurement taken?

From vermis to inner skull bone

What is the appearance of the cisterna magna?

Anechoic with linear echoes of dura

What is the normal measurement of the nuchal fold?

5 mm or less

When do you measure the nuchal fold?

Between 15 – 21 weeks

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

How will the lungs appear?

Solid and homogeneousSlightly hyperechoic to liver

How should the heart be imaged?

Using zoom

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?

Heart rate can slow

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?

< 4 mm

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

What is levocardia?

Heart is mostly in the left chest(normal)

What is dextrocardia?

Heart is mostly in the right chest

What is mesocardia?

Heart is mostly midline

What is levoversion?

Apex pointed to the left(normal)

What is dextroversion?

Apex pointed to the right

What is mesoversion?

Apex pointed to the midline

How do you get the LVOT from 4 chamber?

Sweep anterior for 5 chamberTurn 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?

3 – 8 mm

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?

What is the appearance of the 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?

Ductus arteriosis

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?

M-mode

What is used to assist in documenting blood flow?

Color Doppler

What plane is the diaphragm best seen in?

Longitudinal

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?

At 20 weeks

What is the appearance of the 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?

After 14 weeks

When can the stomach be seen?

After 12 weeks

What typically fills the stomach of the fetus?

Amniotic fluid

When can the kidneys be seen?

By 15 weeks

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

15 – 18 weeks

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

What is pyelectasis?

When the kidney pelvis contains small amounts of fluid

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

< 5 mm

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

< 8 mm

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

< 10 mm

What is being assessed with the bowel?

Echogenicity

Should be isoechoic to hyperechoic to liver

When can the bladder be seen?

By 14 weeks

How should the bladder appear?

Anechoic, if filled

If bladder fills and empties, what does this indicate?

Function of 1 kidney

How often does the bladder fill and empty?

Every 30 – 60 minutes

When should genitalia be documented?

When screening for congenitally linked disorders and multiple gestations

When can genitalia be seen?

15 – 16 weeks

Prior to 15 – 16 weeks how will labia appear?

Swollen

What is common to see in fetal testicles?

Hydrocele

When do the testicles descend?

28 weeks

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?

3rd trimester

When should the femur length be used?

After 14 weeks

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?

+ / - 5 days

What accuracy are dating measurements in the 2nd trimester?

+ / - 10 days

What accuracy are dating measurements in 3rd trimester?

+ / - 20 days

How often should interval growth assessments be taken?

At least 2 weeks apart

How is fetal blood oxygenated?

The placenta

How does the fetus receive oxygenated blood?

Umbilical vein

How does the umbilical vein bypass the liver?

Through the ductus venosus

How does blood bypass the RV (lungs)?

Through the foramen ovale

Where does the LV pump blood to?

Aorta and brain

Where does blood entering the RV come from?

SVC and coronary sinus

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?

1 cm wide

What is the length of the umbilical cord?

40 – 60 cm

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?

• Diabetes• LBW

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?

Cotyledons

What is the functioning unit of the placenta?

Chorionic villi

Where are the villi?

Within intervillous spaces

What bathes the villi with blood?

Spiral areries

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?

By 16 weeks

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?

< 5 cm

What are some variants seen?

• 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

Scattered calcifications; subtle idention of chorionic plate, irregular brightness

Basal echogenic calcification densities; comma like surface

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?

The placenta

Where is amniotic fluid produced after 18 weeks?

Kidneys

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?

5 – 10 cm

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

10 – 20 cm

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

20 – 25 cm

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

2.5 – 7.5 cm

What is fundal height in cm equal to?

Gestational age

When does quickening occur?

15 – 16 weeks

When does the fetus have daily movements?

16 – 20 weeks

What are the sonographic 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

Annular Placenta

• 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

Placenta Extrachorialis

• 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

Signs of Placenta Previa

• 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

Placenta Accreta

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

Placenta Increta

• Villi implant into myometrium

Placenta Precreta

• 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.

Placental Cysts

• 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

Fibrin Deposits

• 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

Intervillous Thrombus

• 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

Placental Infarcts

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

Teratomas(Placental Tumors)

• 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

Worst Placental Hemorrhage?

• Retroplacental

• Least severe?– Paraplacental/Marginal

Ob exam #1 study slides

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