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111 Cards in this Set
- Front
- Back
What is UPJ obs usually associated with?
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Nothing, isolated
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What about when it is?
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10%
Esophageal and anal atresia Hirschprungs Neural tube defects Cardiovascular defects |
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Association of choroid plexus cysts?
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No definite association with any given entity, and they are usually normal. But when you see one, you must look extra carefully for other anomalies.
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Like which?
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Trisomy 18 and 21
Decision to amniocentese is based solely on finding other anomalies that warrant it. The cysts themselves are just a marker to tell you to look more carefully. |
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Nuchal thickening and evidence of coarctation
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TURNERS
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What is Turners assd with?
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Nuchal abnormalities -- nuchal thickening to full cystic hygromas
Coarctation Renal anomalies (horseshoe) |
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Oligohydramnios, what does it cause?
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MSK anomalies like club foot and hip dysplasia, all the way to arthrogryposis
Pulmonary hypoplasia in severe cases |
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Oligohydramnios
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ARE MEMBRANES INTACT???
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Yes
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DO UMBILICAL ARTERY DOPPLER TO LOOK FOR PLACENTAL INSUFFIC. A HIGH SYSTOLIC TO DIASTOLIC FLOW RATIO IS INDICATIVE, MORE SO AS THE PREGNANCY PROGRESSES
REMEMBER, THIS IS A VERY IMPORTANT CAUSE OF OLIGO, ALONG WITH RENAL ANOMALIES, PROM, ETC |
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Complex ovarian mass
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Thick septations
Irregular walls Septal nodules Actual assoc mass |
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Complex ovarian mass, what now?
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Echogenicity of soft tissue component
Doppler flow |
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Complex ovarian mass
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3 types:
Epithelial Stromal Germ cell If complex looking, low resistance flow, think epithelial neoplasm like mucinous or serous cystadenoCA, TOA, endometrioma, corpus luteum cyst |
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Suggestive of malignancy in ovarian mass
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Associated ascites
Thick septations over 3 cm irreg wall, etc |
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Benign ovaraian masses with low resistance flow
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TOA
Endometrioma Dermoid Hormone secreting masses |
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Calculate resistivity index
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Peak sys flow minus end diastolic flow; divided by peak systolic flow
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What is considered low res flow
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0.4 or lower
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Most common congenital tumor of the newborn
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Sacrococcygeal teratoma
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Sacrococcygeal teratoma noticed in 4 month old baby
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Increased risk of malignancy when diagnosed more than 2 months postnatally
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Dandy walker -- what decreases risk of associated chromosomal abnormalities?
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VENTRICULOMEGALY
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15 wk with communication between 4th vent and cisterna magna
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NOT DANDY WALKER
Fusion of the 2 halves of the vermis does not occur until 18 weeks. |
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Dandy walker association
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1/3 have chromosomal abnormalities (any trisomy)
agenesis CC aqueductal stenosis encephalocele cardiac, GU, facial abnormalities |
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Vein of galen malfo associations
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Coarc
Transpo |
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Suspected previa 1st trimester US
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f/u in 3rd trimester
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False pos previa
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Anything that compresses the LUS
--full bladder --uterine contraction |
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Most common cause of obstruction at duodenal level
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Intrinsic duodenal atresia
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Other causes of duodenal obs
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External compression by LADD'S BANDS
Annular pancreas Preduodenal portal vein Malrotation |
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Duodenal atresia
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associated with COMPLEX CARDIAC ANOMALIES, which are the cause of death in most of these patients
Also, esophageal atresia, imperforate anus, renal malformations, biliary atresia |
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Nuchal stuff
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Nuchal translucency: 1st trimester. sagittal plane. <3mm. Becoming the new moneymaker.
Nuchal thickening: Axial plane, level of thalami, 2nd trimester. |
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Translucency thickness
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3mm
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Translucency timing
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10-14 weeks (its a moneymaker, because it can confirm or deny need for amnio early on, and help generate risk profile for older women)
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Fetal neck mass
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2 most important: Neural tube defect and cystic hygroma
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Most common neck mass on boards
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CYSTIC HYGROMA
People miss it all the time |
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importance of it
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Chromosomal anomalies
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Which ones
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Trisomy 21 and Turners
Makes cystic hygroma confusing, though, because they look different between the two of them |
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Thickned nuchal translucency, then thickened nuchal fold in 2nd trimester, not much in the way of cyst
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Trisomy 21
What the nuchal thickening is is just resorbed hygroma |
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Huge ugly cystic neck mass
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Turners cystic hygroma
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what is so damn important about cystic hygroma
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The lymphatic circulation terminates in the neck, in both the right lymphatic duct and the thoracic duct. It joins the venous circulation in the neck. When this joining occurs improperly, a cystic hygroma develops. You can imagine that anytime two systems have to come together, that can happen in many different ways and for many different reasons. Thus the incidence of cystic hygroma as different looking entities in different situations. It also explains why hygroma should immediately make you concered for the impending development of hydrops. If these 2 systems are not properly joined in the neck, you get a hygroma first, but then over time, there is further back-up of lymphatic circulation, and soon you start getting fluid accumulating in other spaces, like the pleura and peritoneal cavity and extremities.
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normal looking view of head or neck on fetal US
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LOOK FOR THE HUGE HYGROMA. IT IS SO BIG YOU DONT EVEN NOTICE IT. BUT AMNIOTIC FLUID WILL NOT HAVE SEPTATIONS IN IT, SO LOOK FOR THAT. FIND THE HYGROMA WHETHER HUGE OR JUST A LITTLE BIT OF NUCHAL THICKENING WITH A LITTLE CYST.
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Sagittal US image, kid with neck hyperextended.
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= Stargazer position -- kid with eyes looking upward
THINK INIENCEPHALY There will probably be a big posterior upper neck mass that is protruding. |
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Iniencephaly
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HUGE neural tube defect that extends from base of skull down to neck, where you will see an ENCEPHALOCELE, sometimes all the way down to sacrum, where you will see another mass of the myelomeningocele
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BIG UGLY FETAL MASS
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Teratoma
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most common fetal tumor
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Teratoma
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Mass growing out of mouth
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Gnathic teratoma
treat with EXIT procedure -- Deliver the head, intubate the baby while cord still attached, then fully deliver baby |
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Other mass in fetal neck
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GOITER
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FETAL NECK MASS
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Can I see the mass with color doppler to rule out a nuchal cord?
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Neck "have to knows"
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Iniencephaly
CYSTIC HYGROMA -- 70% will see it on boards. DONT GET TUNNEL VISION. LOOK FOR THE HYGROMA |
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Things you have to know
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hypoplastic left heart
Endocardial |
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4 chamber view, see RA, see RV, but not sure you see the LV.
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HYPOPLASTIC LEFT HEART SYNDROME
The ventricles are the easiest thing to see in the heart. When one is missing, its hypoplastic left heart |
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Hypoplastic left heart
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MUST BE DELIVERED AT TERTIARY CARE FACILITY
ASSOCIATED WITH TURNERS |
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start looking at sizes, look same.
Start looking at interventricular septum. See it, but then its gone towards the base |
Endocardial cushion -- shown on boards last year
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Figure out what way fetus is lying on all scans
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Cham
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Big heart. RV small compared with LV and RA.
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EBSTEIN'S MALFO
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LVOT -- you follow the aorta up and then all the sudden you come to a break, and then you see the RV and LV are going into this outflow path
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TRUNCUS -- won't be on boards
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Chest masses you must know
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CDH -- very high morbidity and mortality associated with it
CCAM Extralobar sequestration |
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22:30
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22:30
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CDH: Why?
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Two layers of muscle have to come together, and one of the places there is less coverage is in the back where the Bochdalek hernia occurs.
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Where?
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Bochdalek by far the most common
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CDH seen in fetus
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There are 2 predictors of prognosis:
1) Evaluate the amount of bowel up in chest, and for the presence of LIVER in the chest, which makes prognosis VERY bad. 2) If considering taking the baby to birth, MOTHER MUST HAVE AMNIOCENTESIS because 50% of these kids have associated chromosomal anomalies, which makes attempting to give birth to them silly. |
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Cystic mass in left hemithorax. DDx
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1) CDH with stomach up
2) Type I CCAM, LARGE cysts Tell these apart by looking in the abdomen. If there is no stomach there, its a CDH. |
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Still cant tell them apart
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Request FETAL MRI
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CDH designation in fetal imaging
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Don't do the type 1-3 thing
just call them MICROCYSTIC or MACROCYSTIC |
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Microcystic CCAM
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Can be hard to diagnose, because can have same echogenicity as the lung.
So you have to look for MASS EFFECT ON THE HEART and eversion of the diaphragm |
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Questionable chest mass
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IS THERE MASS EFFECT ON THE HEART
If not, very unlikely to have a chest mass |
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Solid chest mass
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DDx is microcystic CCAM and extralobar sequestration
to differentiate them, PUT ON DOPPLER. If you see flow from the aorta, it is a sequestration. If from PA, its a CCAM |
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Where is intralobar seq in the differential?
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NOWHERE. They are acquired lesions. Not seen in feti.
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Most common fetal tumor
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TERATOMA
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Fast growing fetal mass
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Immature TERATOMA
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Fetal abdomen required shots
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Stomach
Kidneys Cord insertion 3VC Bladder |
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First thing to comment on on every fetal case
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AMNIOTIC FLUID VOLUME
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Baby with low amniotic fluid volume, 1st trimester
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UTEROPLACENTAL INSUFFICIENCY
Fluid gets produced by baby-sweat early on Kidneys do not kick in until early 2ND TRIMESTER |
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Once you hit 2nd trimester, what happens to amniotic fluid balance
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BECOMES VERY COMPLEX
Everything still depends on uteroplacental circulation Kidneys main producer Baby breathing and swallowing fluid main ways of getting rid All has to be in homeostasis |
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Calculate AFI
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Take deepest pocket without fetal part (incl cord) in each quadrant, then add em up
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Normal AFI
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10 - 20 cm
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Which is better, poly or oligo?
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POLY because 2/3 are idiopathic, and no consequence or cause to worry about
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Poly
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Of the 1/3 that have known cause, mostly just that you have a big fetus whos got extra fluid. Macrosomic feti are typically related to maternal diabetes.
HOWEVER, there are anatomic causes TOO. |
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Baby with poly
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Look for
1) GI tract obstruction (esoph and duod) -- baby cant swallow 2) CNS malformation -- too stupid to swallow 3) Hydrops -- After the baby is done collecting fluid in all of its body compartments, it starts collecting it in its SURROUNDING FLUID. |
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Fetal US case, can't tell what is going on
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COMMON CASE ON BOARDS
THINK: WHY CAN'T I SEE ANYTHING?? OH, there is NO FLUID = oligohydramnios |
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How do you prevent this problem
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MAKE FLUID ASSESSMENT THE FIRST THING YOU DO ON A FETAL CASE
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Baby with oligohydramnios
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There is only a DRIP of fluid in there
The mnemonic is out of order, because the first thing you should think of is the last thing P = Premature rupture of membranes. That is the first question you MUST ASK before proceeding. D -- Demise R -- Renal (actually GU) anomalies 1) Renal agenesis 2) Bilateral MCDK 3) Posterior urethral valves I -- IUGR (usually due to uteroplacental insuff) P -- PROM |
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Fetal abdomen problems
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Only 2 types
ATRESIAS ABDOMINAL WALL DEFECTS |
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Atresias -- where?
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Most common = Duodenal
Next = esophageal Others = small bowel (jejunal or ileal) and anal |
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Esophageal atresia -- which is the type we care about
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By far the most common:
Proximal esophageal atresia with distal tracheoesophageal fistula |
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Diagnosis of esophageal atresia in 1st trimester
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USUALLY MISSED, because the diagnosis is suggested by the presence of POLYHYDRAMNIOS which is not evident in 1st trimester
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OB US -- Polyhydramnios
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OK, well 2/3 of these are normal. The majority of the rest are in macrosomic infants with diabetic mothers. A small remainder has one of the following abnormalities:
--Atresia (esophageal, duodenal are the ones that cause poly) --CNS malformation --Hydrops As you go through your checklist, you start by looking for duodenal atresia, the most common atresia. You do not see a double bubble sign. So then you notice that not only do you not see a DOUBLE bubble, you dont even see a single bubble; you don't see the stomach. The answer -- esophageal atresia |
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Peds case -- show you AP view of chest with NG tube, but its curled in the neck
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TEF with proximal atresia, distal fistula
How do you know? Because they show you there is air in the stomach. |
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Axial view of abdomen with double bubble
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Duodenal atresia
1/3 HAVE TRISOMY 21!!! Thus, if you see a double bubble, the next thing you do is RECOMMEND AMNIOCENTESIS!!! THEN, 1/2 of these kids have a major anomaly, usually cardiac. SO, THIS IS A HIGH RISK PREGNANCY ONCE YOU SEE A DOUBLE BUBBLE THIS IS THE MOST COMMON ONE ON BOARDS |
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Double bubble DDx
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The other causes of duodenal obstruction, i.e. Ladds bands, annular pancreas, are NOT severe enough to give you a true double bubble.
HOWEVER, we can have cysts which can be adjacent to the stomach, and cause the APPEARANCE of a double bubble. Choledochal cysts Mesenteric cyst Enteric duplication cyst Ovarian cysts -- easily go up there because of lax ovarian ligaments in these kids. |
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How do you make FIRM diagnosis of duod atresia?
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SHOW that you can see the 2 bubbles connected, and you have made the definitive diagnosis.
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Now you have diagnosis of duod atresia. Mom is going to need amniocentesis. BUT, they want to see pictures NOW.
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Look at the heart for an endocardial cushion defect
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Cystic lesion in abd or pelvis
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bladder, ovarian cyst, duplication cyst, mesenteric cyst, choledochal cyst
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cystic lesion in pelvis
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think first of distended bladder secondary to posterior urethral valves in a male, regardless of how large the cyst is. Key to making the diagnosis is to see funnel shaped posterior urethra. Also typically see shrunken echogenic kidneys when severe.
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Cystic lesion in pelvis, female
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the most common cystic lesion in females is ovarian cyst. They can become very large. They can extend up into the abdomen because of lax ligaments. And for the precise reason, they are prone to torsion.
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Mass in Sacrococcygeal region
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only two things to consider -- Sacrococcygeal teratoma , and myelomeningocele. Sacrococcygeal teratoma can be either cystic or solid. They can also become extremely large resulting in heart failure. If you see a fetus and then an extremely large mass, so large you don't even know where it's coming from, it's a teratoma, probably Sacrococcygeal teratoma.
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Important to see in every neuro sonogram
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cavum septum pellucidum
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too much water in brain
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three "Hs" in the differential: hydrocephalus, hydranencephaly, and holoprosencephaly
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normal falx, no brain seen
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hydranencephaly.
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hydranencephaly
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everything forms normally, then there is a huge stroke resulting in loss of the entire anterior circulation of brain. That's why the cranium, face, and falx are normal.
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Brain looks normal except for absent cavum septum pellucidum
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lobar holoprosencephaly
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Monoventricle with fused thalamus
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alobar
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Some formation of occipital lobe with monoventricle, dorsal sac
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semilobar
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Holoprosencephaly association
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TRISOMY 13. THEY GET AMNIO EVEN IF LOBAR
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Midline facial malformation
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associated with severe brain deformities such as holoprosencephaly
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Off midline cleft lip
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ISOLATED anomaly. BUT, if midline, they get amniocentesis.
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Hydrocephalus versus ventriculomegaly
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ventriculomegaly is just enlargement of the ventricles. Hydrocephalus also has enlargement of the head.
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Ventriculomegaly criteria
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greater than 10 mm at the level of the atria or dangling choroid.
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Ventriculomegaly identified
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not good enough to just say it's ventriculomegaly. There are three things in the differential. Aqueductal stenosis, Dandy-Walker malformation, and Chiari II malformation. Communicating hydrocephalus is much less common in a fetus than in in a neonate.
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chiari 2; the posterior fossa is abnormally small
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the cerebellar hemispheres are splayed
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Other neural tube defects; Encephalocele
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anencephaly
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Choroid plexus cysts; one in 500 chance of trisomy 18. Do not do amnio just based on these. Must look for other abnormalities. Hands
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cardiac
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Prenatal hemorrhages;If you say subchorionic hemorrhage you will never be wrong. You have decidua from the mom
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the chorion from the fetus. The hemorrhage occurs between the endometrium and the chorion. They can further be categorized as retroplacental
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MS AFP;Get elevated maternal serum alpha-fetoprotein with neural tube defects
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but also with abdominal wall defects. Alpha-fetoprotein is released by the fetus into the amniotic fluid. A small amount of that gets into the maternal's circulation. MS AFP goes down with aneuploidy (goes down with Down's).
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