Week 3 – Fetal environment (Lecture notes)

Impact on pregnancy + management, maintenance of pregnancy, protection, nutrition, respiratory +

excretory factors. Reduce risk out adverse outcome, placental config, placental grading criterea,
methods of AF volume,umbilical cord (function + insertion)

Amniotic fluid – DVP 2-10cm.

 Fetus move and grow
 Regulate temp
 Protect from injury
 Fetal lung development
Abnormal AF – interfere with growth, structural abnormalities, underlying abnormality.

AF Balance
1. Fetal urine production and swallowing
2. Intramembranous pathways – mvt water and solute between amniotic fluid and fetal blood
and placenta
3. Fluid gradient between fetus and mother

Measure
 AFI (amniotic fluid index). 4 quadrants, + SDP in each. <1cm, don’t measure.
 SDP /MVP (single deepest pocket/max vertical pocket) – mainly used in multiples
 Subjectively – 1st + 2nd trimester.
Tips
 Transducer perpendicular to centre of pocket of fluid.
 Uterine wall, cord, fetal parts not inc in measurement

Abnormalities
Oligohydramnios – reduction in fluid. DVP <2cm, AFI <5cm
 Structural abnormalities (renal agenesis, bladder outlet obstruction)
 Maternal/fetal disease (preeclampsia, FGR, postdates)
 Maternal meds (ACE inhibitors, ARBs, fetal demise)
 Prolonged exposure – fetal deformations (potters’ sequence, pulmonary hypoplasia)
 No visualistion of stomach/bladder.
 Limited mvmt, difficulty defining anatomy
Next – Look for fetal anomalies/assess fetal growth, maternal Hx, ?BPP.

Polyhydramnios – increase in AF – Mild AFI 25-30, DP >8cm. Mod AFI 30.1 -35, DP <12cm,
AFI >35.1, DP >16.
 Fetal anomalies, hydrops. Suggest fetal karyotype
 Pt Hx (screening for diabetes
 Refer to MFM for regular growth AFI, doppler assessment, +/- amnio reduction
 Excessive movement, great images.

Placenta – mother + fetus = nutrition, resp + excretory exchange hormone production. Poor placenta
– compromised fetal growth and development

Plancentation (draw image)

1. 1: decidua parietalis (outer ring)
2. 2: decidua capsularis – inner ring
 3. 3: decidua basalis + chorionic frondosum form placenta
4. Uterine cavity
5. Maternofetal Xchange present after 5 wks.

Placenta (1st trimester)

5-7wk – diffusely echogenic ring, chorionic tissue
6-13wk – placental site determined umbilical cord insert into centre chorionic frondosum

2nd – uniformly echogenic, well define hypo retro-placental space, sonolucencies, placental lakes,
intervillous thrombus
Relationship to internal os. Dist inf edge of placenta – int os.

Placental grading
0. No calcifications (1st, 2nd trim)
1. Scattered calc (2nd, 3rd trim)
2. Basal calcification + indentations along chorionic place (3 rd)
3. Dense basal and interlobular calc. late 3 rd (38-40 wks)

Placental config
Succenturiate lobe – connects main placenta by vessels
Bilobed – connected by thin bridge of tissue
Placenta membranacea – thin placenta.

Low lying placenta – inf margin within 2cm of int os

Marginal – inf margin extends to edge of int os but not covering
Partial praevia – placenta partially covers int os.
Complete praevia – placenta entirely covers int os.

Praevia – 3/1000
 Adv maternal age, multiparity, Mx preg, smoking, prev c section.
 Delivery planned LSCS at 36 weeks.
 Conclusive Dx 3rd trim, migration from int os unlikely.

Umbilical cord
 1x vein (o2 rich blood to baby)
 2X arteries – waste from baby
 Placental insertion location, fetal insertion appearance
 Cord appearance – knots, cysts, solid masses, thrombosis
Insertion
- Marginal - <2cm from edge, association w placental abruption, PP, SGA. Common in MCDA
twins
- Velamentous – inserts into membranes short distance from placental edge
- Vasa PRAEVIA – vessel in membrane that overlie cervix

Vasa Praevia
 Consider when have a low lying placenta or resolved PP, as well as setting of velamentous
cord insertion, succenturiate lobe or bi-lobed placenta.
 Include colour and PW – identify vessels overlying cervix
Cord Haematoma – extravasation of blood in surrounding Wharton jelly. Rupture in vein more
common. (1:10)
Common after invasive procedure. Assoc, with short cords, entanglement + trauma
50% perinatal mortality.
Fetus compromise due to exsanguination and compression of remaining vessels.

Gravid cervix length assessment

- PTB
- Induction of labour
- Prolonged preg
- Timing of LSCS
- Polyhydramnios management

TA –
- Fastest, least accurate, poorly visualised w empy bladder, overfilled bladder artificially
increase cervix length and can obscure vision of cervix
- Probe pressure and increased distance from probe to cervix can alter image
- Lower uterine segment contracts can disguise internal os.
- Bladder filling: over distended – false + of placenta praaevia, false -ve of competent cervix.

TV scan cervix length

 Empty bladder
 Sterile TV cover
 Insert probe into vagina
 Direct probe anterior to fornix
 Don’t measure during contraction

Cervical length must be interpreted with other factors: GA at measurement, clinical Sx, PHx/uterine
malformations, multiple vs singleton

Factors linked to PTB

Fetal/mother medical conditions, genetic influences, environment exposure, infertility treatments,
behavioural and socioeconomic factors, iatrogenic prematurity. <25mm cervis @ 18-24wks GA. 2 or
more terminations, Mullerian anomaly.

Asymptomatic short CL
 Cervical insufficiency
 Secondary to inflammatory/infection process
 More freq contractions

MEASUREMENTS
Normal – 25-50mm (14-30wks GA)
25mm as lower limit: 10% low risk have PTB, 25% high risk have PTB
High risk: Hx PTB, mid trimester pregnancy loss, deep/repeated cervical excisional procedures
(LLETS/cone biopsy), congentical anomalies, Mx pregnancy

Preterm labour (PTL) – regular contractions resulting in changes before 37wks.

~10% will delivery in next 7 days
Preterm Birth/Delivery (PTB/PTD) – 20-37wks – significant neonatal morbidity, mortality and adverse
long term health – cerebral palsy, vision, hearing, development delays. Financial burden on health
care.

PPROM – premature rupture of membranes

Signs for PTD
 Funnelling/wedging
 Residual cervical length <2cms.
 Funnel length >1.5cm, width >1.4cms. Funnelling over 40% of CL

Feta environment protocol

1. Cervix long (measurement)
2. Placenta Long (show fetal lie and uterine wall)
3. Placenta Transverse ( fetal lie and uterine wall)
4. Placenta to internal os (measurement)
5. Placental cord insertion (mt if necessary)
6. AFI if singleton >24wks OR multiple over 18Wks

Fetal Situs – L and R orientation of fetal organs

1. Situs solitus (normal)
2. Situs inversus
3. Situs ambiguous (heterotaxy)

Steps
1. Presentation (where is head)
2. What was is baby lying?
3. Are stomach and heart on same and correct side?

Method 1 – angle of 2 lines.

Intraventricular septum line (IVS) and line from sternum to septum(SS).
Cephalic – IVS line counter clockwise from SS line. (TV probe)
Breech – IVS line counter clockwise from SS line.
TV presentation – fetal heart on the left, IVS line clockwise to SS line if fetal head on
mothers left. Counter clockwise if fetal head to maternal right.

TV lie, sagittal probe – stomach/heart clockwise from spine – fetal head to maternal right

Method 2 – o’clock way (spine 12 o'clock always0

Cephalic – stomach 3 o'clock, heart pec 5 o'clock
Breech – stomach 9 o'clock, heart apex 7 o'clock

Situs
Right Left
Solitus (normal) RA LA
Major hepatic lobe Stomach
IVC Descending aorta
Inversus LA RA
 Stomach Major hepatic lobe
Descending Ao IVC
Ambiguous (heterotaxy) Variable Variable