Académique Documents
Professionnel Documents
Culture Documents
I.
INTRODUCTION
II. OBJECTIVES
III. PATIENTS PROFILE
A.
B.
C.
D.
E.
F.
Personal Data
Chief Complaint
History of Past Illness
History of Present Illness
Family Health History
Activities of Daily Living
INTRODUCTION
OBJECTIVES
PATIENTS PROFILE
A. Personal Data
My patient B.V. was 43 years old lives in Citrus City of San Jose del Monte Bulacan.
She was born December 24, 1972. She only finished first year high school. She was
single and a plain housewife having 8 children with her live-in partner. She has no
previous occupation since she started to be with her partner. She was a Filipino and her
religion was Born-Again Christian. The date of interview was on March 11, 2012. The
informant was her mother L.B.
B. Chief Compalint
Madaming tubig na lumabas nung pinanganak ko itong baby ko as verbalized by
the mother.-Polyhydramnios
defecated every morning sometimes 2x a day but she had difficulty in urinating
according to her because the amount of fluid she intake was not proportionate when
she urinated. She estimated half of her fluid intake and urinated 4-5 times a day
maybe the reason for her was uncomfortable to urinate.
PHYSICAL ASSESSMENT
.A.
GENERAL APPEARANCE
My clients general appearance was medium frame body built, had an upright posture and
had smooth rhythmic gait. Appropriately dressed. She had no body odor and obvious physical
deformities. Her clinical measurements were follows; approximately 52 ft. weighs
approximately 56kgs. Her vital signs were as follows; body temperature was 36.7C/ axilla,.
Respiratory was 21 cpm, pulse rate was 79 bpm and 110/90 mmhG.
B. MENTAL STATUS
My clients mental status was conscious and was oriented to time, place and person. She
was cooperative enough in our interactive interview and uses complex words for communication.
C. SKIN
My clients skin color was brown complexion. She had no any abrasions or lesion found.
Temperature was warm, dry, rough elastic turgor and mobile. Her hair was evenly distributed and
variable in amount.
D. NAILS
My clients nail plate shape was convex 160; nail condition was smooth and nail bed
color was pale, capillary refill within 3 seconds.
F. EYES
My clients eyes are straight normal, eyebrows are thin, eyelids and eyelashes have
effective closure. Blink response was bilateral, eyeballs were symmetrical, Bulbar Conjunctiva
was clear while Palpebral Conjunctiva was pink and scleras were white. Pupils were equally
reacting to light and accommodation. Visual acuity was good he can identify the object 12-14
inches away with a 20/20 vision on Snellen chart and can able to read news print. Lacrimal
Gland, Lacrimal Sac, and Nasolacrimal Duct are no edema and excess tearing.
G. EARS
My clients ear auricle color was the same with his skin color. Symmetrically align with
outer cantus and elastic and firm. Pinna recoils when folded. Responds to normal voice and no
difficulty in hearing. Sound was heard in both ears or was localized at the center of the head and
air-conducted hearing is greater than bone-conducted. External canal was present of some
cerumen.
H. NOSE
My clients nose her external color also the same with her skin there no lesions found.
Septum was on the midline. Mucosa is pink, both patent because air moves freely, nasal cavity
was moist and non-tender of sinuses.
I. MOUTH
My clients lip was dark gray, tongue was on the midline, texture was rough color was
pink and movable. She has 4 missing teeth such molars located one in upper right side also one
in lower left side and two on right side and presence of dental caries in the remaining molars and
teeth. Gums were dark gray in color.
J. PHARYNX
My clients uvula was on the midline. Mucosa was pink, tonsils were not inflamed, and as
well as the posterior pharynx was not congested, and gag reflex was present.
K. NECK
My clients neck muscles were equal in size symmetrical strength of muscles. Lymph
nodes were not palpable as well as thyroid gland and trachea was on the midline.
N. ABDOMEN
My clients abdomen was same on her skin color. There are no lesions found and
presence of striae gravidarum or stretch marks and no lesions. The movement was symmetrical.
She had hyperactive bowel sounds of 39 times/minutes that time. Absence of arterial bruits and
friction rub.
O. UPPER EXTRIMITIES
My clients upper extremities have 5/5 muscle tone and 5/5 muscle strength. There are no
deformities. As palpated all the pulse in her upper extremities it was regular in rhythm of
peripheral pulses and strong in quality. Lymph nodes were not palpable.
P. LOWER EXTRIMITIES
My clients upper extremities have 5/5 muscle tone and 5/5 muscle strength. There are no
deformities. As palpated all the pulse in her lower extremities it was regular in rhythm of
peripheral pulses and strong in quality. Lymph nodes were not palpable.
Q. GENITALIA
Genitalia of my client were shaved and skin of vulva is darker than the rest of the body.
Labia were hyprertrophy and relatively symmetric but it were loose. Inflammation and swelling,
and bloody discharge are still present due to 1st day postpartum. No enlargement or tenderness.
DIAGNOSIS
A. CLINICAL DIAGNOSIS
Polyhydramnios means you have too much amniotic fluid in your uterus (womb). It happens in
about one in 500 pregnancies in the UK, so it isn't common. Most cases of polyhydramnios are
mild or moderate.
The amniotic fluid surrounding your baby protects him from being hurt if you have a blow, or if
your tummy is squashed. The fluid also protects your baby against infection, as well as helping
his lungs to develop.
The amount of fluid around your baby gradually increases until there is about one litre (1.76
pints) surrounding him at 38 weeks. This amount decreases to about 800ml (1.4 pints) by 40
weeks. Your baby will regularly swallow amniotic fluid, which then passes out of his body as
urine. This is how he controls the volume of amniotic fluid around him.
When this delicate balance is disturbed, the volume of amniotic fluid can increase rapidly. In
severe cases of polyhydramnios, there may be as much as three litres (5.3 pints) of fluid, or three
times the normal amount, around your baby.
You may notice that your tummy is getting large and feeling taut, and that your skin is stretched
and shiny. You might feel uncomfortable and breathless and find it hard to climb a flight of
stairs.
Polyhydramnios usually starts from about 30 weeks of pregnancy and will develop gradually.
However, in rare cases, usually at about 20 weeks, it comes on very rapidly over the course of
just a few days.
Polyhydramnios tends to make the following pregnancy symptoms worse:
indigestion
heartburn
constipation
swollen legs
varicose veins
stretch marks
Diagnosed
If you have polyhydramnios, when your midwife or doctor carries out an examination, you'll
appear to be large for dates (macrosomia). She may find it difficult to feel your baby or hear his
heartbeat. That's because there's so much fluid around your baby that he can easily move around.
Ultrasound scans can confirm a diagnosis of polyhydramnios. The sonographer will measure the
amount of fluid in four areas around your baby to work out your amniotic fluid index (AFI). This
is normally in the range of 10cm (4in) to 25cm (10in) in yourthird trimester. So an AFI over
25cm means you have polyhydramnios. The higher the AFI, the more severe the problem is.
Sometimes the scan may also reveal a reason for the condition, such as a multiple pregnancy or
a pregnancy complication.
Causes
It's difficult to find the cause of polyhydramnios. In about two thirds of cases, no cause can be
found. The extra fluid could be due to a problem with your baby, the placenta, or with your own
health.
Possible causes are:
Diabetes, when your blood sugar levels aren't well controlled. Your baby produces more
urine, which increases the volume of amniotic fluid. Your doctor will give you a glucose
tolerance test to check your blood sugar levels.
Being pregnant with identical twins, where twin-to-twin transfusion syndrome has
developed.
A complication with your baby which is stopping the fluid going through his system. This
could be due to a blockage in his food pipe (oesophagus) or a problem with his muscle
control. This will mean he can't swallow amniotic fluid and regulate the amount that's
around him.
Management
This depends on the severity of your condition and whether a cause has been found. In mild
cases where a cause can't be found, your condition is likely to get better on its own as your
pregnancy progresses.
Your doctor and midwife will advise you to rest as much as possible, which may mean starting
your maternity leave early. You may need to be admitted to hospital.
If your blood sugar levels are high, and you're not already being treated for diabetes, you may be
referred to a diabetes specialist. That way your blood sugar levels will go down and this will
reduce the amount of fluid.
You will have regular checks on your progress, either in hospital if you've been admitted, or as
an outpatient at the antenatal clinic.
An ultrasound scan may spot other problems with your baby and will keep track of your fluid
levels. If a detailed scan shows that nothing is wrong, your baby is almost certainly fine and the
polyhydramnios will be caused by something else.
If a problem with your baby is identified, your treatment will be similar to the treatment for twinto-twin transfusion syndrome. Depending on the cause of the extra fluid, you may be prescribed
a drug which reduces the amount of urine your baby produces.
If your baby has an abnormality which can be operated on, your labour may need to be induced.
Your baby will then be transferred to a neonatal surgical unit. In the unit, a specialist surgeon will
perform an operation to help your baby. Rest assured that your doctor will talk to you about the
best course of action for you and your baby.
In severe cases, it may be possible to drain some of the amniotic fluid to reduce the volume. This
may reduce the risk of you going into premature labour or the placentastarting to come away
from the wall of your uterus.
But there is a risk with this technique. The procedure increases your chance of infection and may
also cause you to go into labour. Also, the fluid often builds up again, meaning the procedure will
need to be repeated.
Even if you do rest, because your uterus is swollen, you may still go into labour prematurely.
Your midwife will explain the signs of premature labour to you so you can contact the hospital
immediately if your waters break or if you start to have contractions.
Effects
Your labour is likely to be normal. However, the weight of your baby and the extra fluid may
cause you to give birth early. If your waters break before labour starts, call an ambulance.
If your contractions start before 37 weeks, call the delivery suite and tell them what's happening.
If there's nobody who can take you to hospital, call an ambulance.
If you're known to be having problems with your baby, you'll be booked into a regional referral
centre to give birth. That's where they'll have the best facilities for looking after your baby.
Even if your baby seems fine, and you don't have to go to a specialist hospital, you will be very
carefully monitored during labour. This is for a number of reasons:
The extra fluid in the uterus makes it difficult for your baby to settle his head down into
your pelvis. So if your waters break, the umbilical cord may be pulled down into your
vagina and in front of his head. If this happens, you may need an emergency caesarean
section.
The placenta may come away early if your uterus suddenly shrinks as the amniotic fluid
is released.
You have an increased risk of heavy bleeding (haemorrhage) after your baby is born, so
a managed third stage will be recommended.
If you have diabetes, or if you have a big baby, your midwife will make sure that your
baby moves steadily down through your pelvis. This means he won't get stuck, though his
shoulder may become caught. If this happens, an obstetrician will help you get into
a position that frees your baby.
If your symptoms are getting worse and you are in late pregnancy, your obstetrician may
recommend your labour is induced.
Your obstetrician may also suggest in advance that you have an elective caesarean. This may be
the case if:
your baby won't settle into any particular position (unstable lie)
Try to remember that most women with polyhydramnios go on to have healthy babies,
particularly if the condition is mild.
If you feel breathless:
It may be that you have heartburn because your uterus is pushing against your stomach. To ease
this:
Try not to lie down straight after a meal, and don't eat just before going to bed.
Don't eat or drink anything which makes your heartburn worse, such as spicy food.
Polyhydramnios will probably make you may feel anxious, as well as on the large side. But there
are ways to lessen your anxiety:
Gather as much information as you can, as early as you can, at your antenatal classes.
Find enjoyable distractions. If you're too self-conscious about your size to go out, invite
friends over, or catch up on DVDs.
Talk to other mums-to-be in the BabyCentre community who have experienced what
you're going through.
If you have polyhydramnios and notice new symptoms, or if your existing symptoms become
worse, call your midwife or go to your nearest hospital immediately.
White blood cell (WBC) count is a count of the actual number of white blood cells per
volume of blood. Both increases and decreases can be significant.
White blood cell differential looks at the types of white blood cells present. There are five
different types of white blood cells, each with its own function in protecting us from
infection. The differential classifies a person's white blood cells into each
type: neutrophils (also known as segs, PMNs, granulocytes,
grans), lymphocytes, monocytes, eosinophils, and basophils.
Red blood cell (RBC) count is a count of the actual number of red blood cells per volume
of blood. Both increases and decreases can point to abnormal conditions.
Hemoglobin measures the amount of oxygen-carrying protein in the blood.
Hematocrit measures the percentage of red blood cells in a given volume of whole blood.
The platelet count is the number of platelets in a given volume of blood. Both increases
and decreases can point to abnormal conditions of excess bleeding or clotting. Mean platelet
volume (MPV) is a machine-calculated measurement of the average size of your platelets.
New platelets are larger, and an increased MPV occurs when increased numbers of platelets
are being produced. MPV gives your doctor information about platelet production in your
bone marrow.
Mean corpuscular volume (MCV) is a measurement of the average size of your RBCs.
The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in
anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are
smaller than normal (microcytic) as is seen in iron deficiency anemia or thalassemias.
Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of oxygencarrying hemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a
higher MCH, while microcytic red cells would have a lower value.
Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average
concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia) are
seen in conditions where the hemoglobin is abnormally diluted inside the red cells, such as
in iron deficiency anemia and in thalassemia. Increased MCHC values (hyperchromia) are
seen in conditions where the hemoglobin is abnormally concentrated inside the red cells,
such as in burn patients and hereditary spherocytosis, a relatively rare congenital disorder.
Red cell distribution width (RDW) is a calculation of the variation in the size of your
RBCs. In some anemias, such aspernicious anemia, the amount of variation (anisocytosis) in
RBC size (along with variation in shape poikilocytosis) causes an increase in the RDW.
^ Back to top
Purpose:
The CBC is a very common test. Many patients will have baseline CBC tests to help determine
their general health status. If they are healthy and they have cell populations that are within
normal limits, then they may not require another CBC until their health status changes or until
their doctor feels that it is necessary.
If a patient is having symptoms such as fatigue or weakness or has an infection, inflammation,
bruising, or bleeding, then the doctor may order a CBC to help diagnose the cause. Significant
increases in WBCs may help confirm that an infection is present and suggest the need for further
testing to identify its cause. Decreases in the number of RBCs (anemia) can be further evaluated
by changes in size or shape of the RBCs to help determine if the cause might be decreased
production, increased loss, or increased destruction of RBCs. A platelet count that is low or
extremely high may confirm the cause of excessive bleeding or clotting and can also be
associated with diseases of the bone marrow such as leukemia.
Many conditions will result in increases or decreases in the cell populations. Some of these
conditions may require treatment, while others will resolve on their own. Some diseases, such as
cancer (and chemotherapy treatment), can affect bone marrow production of cells, increasing the
production of one cell at the expense of others or decreasing overall cell production. Some
medications can decrease WBC counts while some vitamin and mineral deficiencies can cause
anemia. The CBC test may be ordered by the doctor on a regular basis to monitor these
conditions and drug treatments.
Interpretaions:
The following table explains what increases or decreases in each of the components of the CBC
may mean.
NAME
White Blood Cell
INCREASED/DECREASED
May be increased with infections, inflammation,
cancer, leukemia; decreased with some medications
(such as methotrexate), some autoimmune conditions,
some severe infections, bone marrow failure,
and congenital marrow aplasia (marrow doesn't
develop normally)
%
Neutrophil/Band/Seg/Gran This is a dynamic population that varies somewhat
Neutrophi
from day to day depending on what is going on in the
l
body. Significant increases in particular types are
associated with different
temporary/acute and/or chronic conditions. An
Lymphs
Lymphocyte
example of this is the increased number of
lymphocytes seen with lymphocytic leukemia. For
% Mono
Monocyte
more information, see Blood Smear and WBC.
% Eos
Eosinophil
% Baso
Basophil
Neutrophi Neutrophil/Ban/Seg/Gran
l
Lymphs
Lymphocyte
Mono
Monocyte
Eos
Eosinophil
Baso
Basophil
TEST
NAME
INCREASED/DECREASED
RBC
Hgb
Hemoglobin
Hct
Hematocrit
MCV
Mean Corpuscular Volume Increased with B12 and Folate deficiency; decreased
with iron deficiency andthalassemia
MCH
Mean Corpuscular
Hemoglobin
MCHC
Mean Corpuscular
May be decreased when MCV is decreased; increases
Hemoglobin Concentration limited to amount of Hgb that will fit inside a RBC
RDW
Platelet
Platelet
MPV
Results:
Blood Type: O+
Date: 03-05-12
HEMATOLOGIC RESULTS
Hemoglobin
145
F 120-150 g/L
Normal
M 140-170 g/L
Hematocrit
0.46
F 0.37-0.47
Normal
M 0.40- 0.50
WBC Count
11.4
5-10x109
DIFFERENTIAL COUNT:
Segmenters
0.69
0.55-0.65
Lymphocytes
0.31
0.25-0.35
Date: 03-10-12
HEMATOLOGIC RESULTS
Hemoglobin
154
F 120-150 g/L
M 140-170 g/L
Hematocrit
0.49
F 0.37-0.47
Infections
M 0.40- 0.50
WBC Count
13.9
5-10x109
DIFFERENTIAL COUNT:
Segmenters
0.81
0.55-0.65
Lymphocytes
0.19
0.25-0.35
The Urinalysis is used as a screening and/or diagnostic tool because it can help detect substances
or cellular material in the urine associated with different metabolic and kidney disorders. It is
ordered widely and routinely to detect any abnormalities that require follow up. Often,
substances such as protein or glucose will begin to appear in the urine before patients are aware
that they may have a problem. It is used to detect urinary tract infections (UTI) and other
disorders of the urinary tract. In patients with acute or chronic conditions, such as kidney disease,
the urinalysis may be ordered at intervals as a rapid method to help monitor organ function,
status, and response to treatment.
Purpose:
A routine urinalysis may be done when you are admitted to the hospital. It may also be part of a
wellness exam, a new pregnancy evaluation, or a work-up for a planned surgery. A urinalysis will
most likely be performed when you see your health care provider complaining of symptoms of
a UTI or other urinary system problem such as kidney disease. Somesigns and symptoms may
include:
abdominal pain
back pain
This test can also be useful when monitoring certain conditions over time.
Interpretation:
Urinalysis results can have many interpretations. Abnormal findings are a warning that
something may be wrong and should be evaluated further. Generally, the greater the
concentration of the atypical substance, such as greatly increased amounts of glucose, protein, or
red blood cells, the more likely it is that there is a problem that needs to be addressed. But the
results do not tell the doctor exactly what the cause of the finding is or whether it is a temporary
or chronic condition.
A normal urinalysis does not guarantee that there is no illness. Some people will not release
elevated amounts of a substance early in a disease process, and some will release them
sporadically during the day, which means that they may be missed by a single urine sample. In
very dilute urine, small quantities of chemicals may be undetectable.
For additional details on what certain results may mean, click on the links below:
Visual examination
Chemical examination
Microscopic examination
The information obtained from different reflections are recomposed back into a picture on
the monitor screen (a sonogram, or ultrasonogram). Movements such as fetal heart beat
and malformations in the feus can be assessed and measurements can be made accurately
on the images displayed on the screen. Such measurements
form the cornerstone in the assessment of gestational age,
size and growth in the fetus.
A full bladder is often required for the procedure when
abdominal scanning is done in early pregnency. There may be
some discomfort from pressure on the full bladder. The
conducting gel is non-staining but may feel slightly cold and
wet. There is no sensation at all from the ultrasound waves.
A short history of the development of ultrasound in pregnancy can be found in the History
pages.
and blighted ovum will usually give typical pictures of a deformed gestational sac
and absence of fetal poles or heart beat.
Fetal heart rate tends to vary with gestational age in the very early parts of pregnancy.
Normal heart rate at 6 weeks is around 90-110 beats per minute (bpm) and at 9 weeks is
140-170 bpm. At 5-8 weeks a bradycardia (less than 90 bpm) is associated with a high risk
of miscarriage.
Many women do not ovulate at around day 14, so findings after a single scan should always
be interpreted with caution. The diagnosis of missed abortion is usually made by serial
ultrasound scans demonstrating lack of gestational development. For example, if ultrasound
scan demonstrates a 7mm embryo but cannot demonstrable a clearcut heartbeat, a missed
abortion may be diagnosed. In such cases, it is reasonable to repeat the ultrasound scan in
7-10 days to avoid any error.
The timing of a positive pregnancy test may also be helpful in
this regard to assess the possible dates of conception. A
positive pregnancy test 3 weeks previously for example, would
indicate a gestational age of at least 7 weeks. Such
information would be useful against the interpretation of the
scans. Please read the FAQs for more comments.
In the presence of first trimester bleeding, ultrasonography is
also indispensible in the early diagnosis of ectopic pregnancies and molar pregnancies.
Many structural abnormalities in the fetus can be reliably diagnosed by an ultrasound scan,
and these can usually be made before 20 weeks. Common examples
include hydrocephalus, anencephaly, myelomeningocoele, achondroplasia and other
dwarfism, spina bifida, exomphalos, Gastroschisis, duodenal atresia and fetal hydrops. With
more recent equipment, conditions such as cleft lips/ palate and congenital cardiac
abnormalities are more readily diagnosed and at an earlier
gestational age. (Also see the FAQ and Anomalies pages).
First trimester ultrasonic 'soft' markers for chromosomal
abnormalities such as the absence of fetal nasal bone, an
increased fetal nuchal translucency (the area at the back of the
neck) are now in common use to enable detection of Down
syndrome fetuses.
Read also: Soft Markers - A Guide for
Professionals and Ultrasonographic "soft markers" of fetal
chromosomal defects.
Ultrasound can also assist in other diagnostic procedures in prenatal diagnosis such
as amniocentesis, chorionic villus sampling, cordocentesis (percutaneous umbilical blood
sampling) and in fetal therapy.
5. Placental localization.
Ultrasonography has become indispensible in the localization of
the site of the placenta and determining its lower edges, thus making a diagnosis or an
exclusion of placenta previa. Other placental abnormalities in conditions such
as diabetes, fetal hydrops, Rh isoimmunization and severe intrauterine growth
retardation can also be assessed.
6. Multiple pregnancies.
In this situation, ultrasonography is invaluable in determining the
number of fetuses, the chorionicity, fetal presentations, evidence of
growth retardation and fetal anomaly, the presence of placenta previa,
and any suggestion of twin-to-twin transfusion.
retardation and congenital malformation in the fetus such as intestinal atresia, hydrops
fetalis or renal dysplasia. See also FAQ and comments.
8. Other areas.
Ultrasonography is of great value in other obstetric conditions such as:
a) confirmation of intrauterine death.
b) confirmation of fetal presentation in uncertain cases.
c) evaluating fetal movements, tone and breathing in the Biophysical Profile.
d) diagnosis of uterine and pelvic abnormalities during pregnancy e.g. fibromyomata
and ovarian cyst.
Transvaginal Scans
With specially designed probes, ultrasound scanning can be done with the probe placed in
the vagina of the patient. This method usually provides better images (and therefore more
information) in patients who are obese and/ or in the early stages of pregnancy. The better
images are the result of the scanhead's closer proximity to the uterus and the higher
frequency used in the transducer array resulting in higher resolving power. Fetal cardiac
pulsation can be clearly observed as early as 6 weeks of
gestation.
Vaginal scans are also becoming indispensible in the early
diagnosis of ectopic pregnancies. An increasing number of
fetal abnormalities are also being diagnosed in the first
trimester using the vaginal scan. Transvaginal scans are also
useful in the second trimester in the diagnosis of congenital anomalies. Read one of my
presentations at OBGYN.net-Ultrasound.
Doppler Ultrasound
The doppler shift principle has been used for a long time in fetal heart rate detectors.
Further developments in doppler ultrasound technology in recent years have enabled a great
expansion in its application in Obstetrics, particularly in the area of assessing and
monitoring the well-being of the fetus, its progression in the face of intrauterine growth
restriction, and the diagnosis of cardiac malformations.
A good 3-D image is often very impressive to the parents. Further 2-D scans may be
extracted from 3-D blocks of scanned information. Volumetric measurements are
more accurate and both doctors and parents can better appreciate a certain
abnormality or the absence of a certain abnormality in a 3-D scan than a 2-D one and there
is the possibility of increasing psychological bonding between the parents and the baby.
An increasing volume of literature is accumulating on the usefulness of 3-D scans and the
diagnosis of congenital anomalies could receive revived attention. Present evidence has
already suggested that smaller defects such as spina bifida, cleft lips/palate,
and polydactyl may be more lucidly demonstrated. Other more subtle features such as lowset ears, facial dysmorphia or clubbing of feet can be better assessed, leading to more
effective diagnosis of chromosomal abnormalities. The study of fetal cardiac malformations
is also receiving attention. The ability to obtain a good 3-D picture is nevertheless still very
much dependent on operator skill, the amount of liquor (amniotic fluid) around the fetus, its
position and the degree of maternal obesity, so that a good image is not always readily
obtainable.
More recently, 4-D or dynamic 3-D scanners are in the market and
the attraction of being able to look at the face and movements of your
baby before birth was also enthusiastically reported in parenting and
health magazines. This is thought to have an important catalytic effect
for mothers to bond to their babies before birth. What are known as
're-assurance scans' and the rather misnamed 'entertainment scans'
have quickly become popular.
Most experts do not consider that 3-D and 4-D ultrasound will be a
mandatory evolution of our conventional 2-D scans, rather it is an additional
piece of tool like doppler ultrasound. Most diagnosis will still be made with the
2-D scans. 3-D ultrasound appears to have great potential in research and in
the study of fetal embryology. Whether 3-D ultrasound will provide unique
information or merely supplemental information to the conventional 2-D
scans will remain to be seen.
Click here
for some good sample images courtesy of Dr. Bernard Benoit. Visit the GE
4D site for more pictures and information. Dr. Najeeb Layyous's 3-D and 4-D website also
has many more pictures and clips. Read also the FAQ page.
A short history of the development of 3-D ultrasound in pregnancy can be found in
the History pages.
The Schedule
There is no hard and fast rule as to the number of scans a woman should have during her
pregnancy. A scan is ordered when an abnormality is suspected on clinical grounds.
Otherwise a scan is generally booked at about 7 weeks to confirm pregnancy, exclude
ectopic or molar pregnancies, confirm cardiac pulsation and measure
the crown-rump length for dating.
A second scan is performed at 18 to 20 weeks mainly to look
for congenital malformations, when the fetus is large enough for
an accurate survey of the fetal anatomy. multiple pregnancies can be firmly
diagnosed and dates and growth can also be assessed. Placental position is
also determined. Further scans may be necessary if abnormalities are
suspected.
Many centers are now performing an earlier screening scan at around 11-14 weeks to
measure the fetal nuchal translucency and to evaluate the fetal nasal bone (and more
recently, to detect tricuspid regurgitation) to aid in the diagnosis of Down Syndrome. Some
centers will do blood test biochemical screening at the same visit.
Further scans may sometimes be done at around 32 weeks or later to evaluate fetal
size (to estimate the fetal weight) and assess fetal growth. Or to follow up on possible
abnormalities seen at an earlier scan. Placental position is further verified. The most
common reason for having more scans in the later part of pregnancy is fetal growth
retardation. Doppler scans may also be necessary in that situation.
The total number of scans will vary depending on whether a previous scan has detected
certain abnormalities that require follow-up assessment. What is often referred to as
a Level II scan merely indicates a "targeted" examination where it is done when an
indication is present or when an abnormality is suspected in a previous examination. In fact
professional bodies such as the American Institute of Ultrasound in Medicine does not
endorse or encourage the use of these terms. A more "thorough" examination is usually
done at an a perinatal center or specialised clinic where more expertise and better
equipments may be present.
One should not dwell too much on the definitions
or guidelines for a level II ultrasound scan. The prenatal
sonologist should always try very hard to look for and assess
any abnormality that may be present in the fetus. It is not very
meaningful to be talking about level III or even level IV scans.
That a pregnancy should be scanned at 18 to 20 weeks as a
rule is gradually becoming a matter of routine practice. Please
go to the FAQ page and News page for other discussions. A
rather thorough discussion paper on Ultrasound screening in pregnancy can be found here.
Read also the RCOG's paper on routine screening in pregnancy.
It should be bornt in mind that prenatal ultrasound cannot diagnose all malformations and
problems of an unborn baby (reported figures range from 40 to 98 percent), so one should
never interpret a normal scan report as a guarantee that the baby will be completely
normal. Some abnormalities are very difficult to find or to be absolutely certain
about.
Some conditions, like for example hydrocephalus, may not have been obvious at
the time of the earlier scan. The position of the baby in the uterus has a great deal to do
with how well one sees certain organs such as the heart, face and spine. Sometimes a
repeat examination has to be scheduled the following day, in the hopes the baby has
moved.
Images tend also to be strikingly clear in skinny patients with lots of amniotic fluid, and
frustratingly fuzzy in obese women, particularly if there is not much amniotic fluid as in
cases of growth restriction. As in almost every endeavor, there is also a wide difference in
the skill, training, talent, and interest of the sonographer or sonologists. The improvements
in equipment has also lead to the earlier detection of abnormal structures in the fetus
bringing along with it "false positives" and "difficult-to-be-sure-what-will-happen" diagnosis
that could generate huge amount of undue anxiety in patients.