OB/GYN Test 3

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OB/GYN Test 3
2012-03-03 16:46:49
First Trimester

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  1. What gonadotropin produced by the anterior pituitary gland initiates the development of follicle within the ovary?
  2. As the dominant follicle develops, what hormone does it secrete?
    Estrogen (by theca interna cells of Graafian follicle)
  3. What hormone influences final stages of follicles development, & peaks causing ovulation?
  4. When does menstrual age begin?
    first day of LMP
  5. When does fetal age begin?
    begins at conception (2 weeks less than menstrual)
  6. Alternative names for fetal age?
    Conceptual age or Embryologic Age
  7. Importance of Menstrual Age?
    • schedule procedures
    • Interpretation of expanded maternal serum alpha-fetoprotein screen
    • plan/guess delivery within 38-42 weeks
    • evaluate growth
  8. What is the triple-marker?
    another name for Maternal alpha-fetoprotein
  9. Where/When does fertilization occur?
    • 24 to 36 hours after ovulation
    • Ampullary portion of fallopian tube
  10. What is the outer layer of the ovum?
    zona pellucida
  11. What is a fertilized egg called?
  12. What are gametes?
  13. What is a morula
    mitosis to 16-cells
  14. What comprises a blastocyst?
    trophoblast cells + inner cell mass
  15. When do blastocysts occur?
    day 7 after fertilization
  16. When will a blastocyst implant in the UT?
    7-9 days after fertilization
  17. What determines a positive pregnancy?
    trophoblast produces hCG
  18. When would a trophoblast produce hCG?
    GA around 3 weeks (days 20-21)
  19. During embryonic development, what are the 3 germ cell layers called of the trilaminar disk?
    • Endoderm
    • Mesoderm
    • Ectoderm
  20. What do the endoderm, mesoderm, and ectoderm form?
    form into all the major organs
  21. What is the first organ to function during embryonic development?
    heart (day 36)
    • 1 endometrium
    • 2 uterine endometrium epithelium
    • 3 inner cell mass
    • 4 trophoblast
    • 5 blastocyst cavity
    • 6 lumen of uterus
    • 7 endometrial stroma with blood vessels and glands
    • 8 syncytiotrophoblast
    • 9 cytotrophoblast
    • 10 inner cell mass (future embryo)
    • 11 lumen of uterus
  22. How many days does it take the zygote to reach the uterus after fertilization?
    3-5 days
  23. When would you use the term embryo?
    up to 9 weeks
  24. When would you use the term fetus?
    after 9 weeks
  25. When does the primary yolk sac cease to function?
    around 23 days
  26. Which yolk sac is seen during ultrasound?
    the secondary yolk sac
  27. What does the secondary yolk sac do?
    provides blood/nutrients to developing embryo
  28. When does the secondary yolk sac form?
    27-28 days after MA
  29. What is the approximate measurement of the gestational sac when the secondary yolk sac forms?
    3 mm
  30. What hormone do trophoblasts produce? Why?
    produces hCG to extend the life of the corpus luteum
  31. What produces proteolytic enzymes?
  32. What is the function of the proteolytic enzymes?
    erode the endometrial mucosa and maternal capillaries
  33. Def. the cellular and vascular changes occurring in the endometrium at the time of implantation
    Decidual Reaction
  34. 3 layers of the decidual reaction
    • decidual basalis
    • decidual casularis
    • decidual parietalis (vera)
  35. Define decidual basalis
    where the embryo is implanted into the endometrium (maternal portion of the placenta)
  36. Define decidual casularis
    thin portion of endometrium that covers the gestational sac
  37. Define decidual parietalis (vera)
    remaining endometrium unoccupied by the implantation that surrounds the rest of the uterine cavity (besides the implantation site)
    • 1 chorion laeve
    • 2 decidual capsularis
    • 3 amniotic cavity
    • 4 chorionic cavity
    • 5 decidual parietalis
    • 6 decidual basalis
    • 7 yolk sac
    • 1 decidual parietalis (vera)
    • 2 decidual basalis
    • 3 decidual capsularis
  38. What will the embryo appear as on week 5 sonographically?
    grain of rice
  39. What 2 things develop during week 5?
    • neurulation
    • 2 cardiac tubes
  40. When is the embryonic period?
    week 6-10
  41. What is the most critical time of embryonic development when all the internal and external structures are present and congenital malformations can originate?
    Embryonic Period
  42. What has developed at the end of week 6?
    • brain has 3 segments
    • primitive gut has formed
  43. What is the sonographic appearance of an embryo that is 8 weeks old?
    "peanut" shaped
  44. What has developed at week 8?
    • heart has adult form
    • midgut herniates
    • metanephros (primitive kidneys) ascend from pelvis
  45. What has developed at 10 weeks?
    • major organ systems established
    • embryo (maybe fetus) demonstrates human features
  46. When will the amniotic cavity fuse with the chorion?
    12-17 weeks after last menstrual period
  47. What has developed by week 11?
    • primitive kidneys reach adult position
    • limbs have fingers and toes
    • head (large) is disportionate to body
  48. What happens at week 12?
    midgut retracts into abdomen
  49. small GS within an echogenic endometrium with focal thickening at implantation site characterizes what?
    Intradecidual sign
  50. When can hCG be detected?
    3 weeks after LMP
  51. What is a Qualitative hCG?
    pregnant (yes or no)
  52. What is a Quantitative hCG?
    how much Glycoprotein is in the blood (suggests age)
  53. What does hCG stand for?
    Human Chorionic Gonadotropin
  54. Def. refers to the level at which a gestational sac should be visible with regards to hCG
    discriminatory level
  55. What is the discriminatory level for a TV exam?
    1500 mIU/ml
  56. What is the discriminatory level for a TA exam?
    6500 mIU/ml
  57. The symptoms below are associated with what?
    incorrect dates
    gestational trophoblastic disease (molar pregnancy)
    multiple gestations
    high hCG levels
  58. The symptoms below are associated with what?
    incorrect dates
    ectopic pregnancy
    embryonic demise
    low hCG
  59. Describe the normal sonographic gestational sac appearance
    • located within the fundus or midportion of the UT
    • small, round/ovoid, anechoic, fluid-filled
    • enclosed by hyperechoic walls
  60. What is the first structure seen within the gestational sac?
    yolk sac
  61. Where does the yolk sac lie?
    lies between the amniotic and chorionic cavities
  62. For TA exams, what MSD measurement of the gestational sac will the yolk sac be visible? (both early and always)
    • early 10-15mm
    • always 20mm
  63. For TV exams, what MSD measurement of the gestational sac will the yolk sac be visible?
    8 mm
  64. What is the normal diameter of the yolk sac at 5-10 weeks?
  65. What are the functions of the yolk sac?
    • provides nutrients to embryo
    • hematopoesis
    • development of the embryonic endoderm (forms primitive gut)
  66. yolk sac
  67. When does the double-bleb sign occur?
    5th-7th week
  68. What is the double-bleb sign?
    it's when the amniotic and yolk sac approximately the same size
  69. Double-Bleb Sign
  70. What the 2 fetal membranes?
    • amnion
    • chorion
  71. What becomes the covering of the umbilical cord?
  72. When does the amnion fuse with the chorion?
    between 12-16 weeks
  73. The Amnion is not vascular and develops from what?
  74. This structure surrounds the gestational sac and merges with the edge of the placenta.
  75. Which gender provides the structures below?
    inner cell membrane
    yolk sac
  76. Which gender provides the structures below?
    trophoblastic tissue
    gestational sac (chorion)
  77. 5 functions of the amniotic cavity
    • symmetrical growth
    • Prevents adhesions in the fetal membrane
    • Cushions embryo
    • maintain temperature
    • Allow movement = muscle tone
  78. What areas produce amniotic fluid?
    • chorion frondosum
    • chorionic membrane
    • amniotic membrane
    • skin
    • urinary tract
  79. What is primarily responsible for amniotic fluid production?
    urinary tract
  80. In the 2nd/3rd trimester amniotic fluid is regulated by what?
    fetal urination, swallowing, and fluid exchanges in lungs, membranes, and cord
  81. What is the sonographic appearance of amniotic fluid?
    anechoic with or without free-floating particles
  82. Def. not enough amniotic fluid
  83. Def. too much amniotic fluid
  84. What is associated with oligohydramnios?
    renal abnormalities
  85. What is associated with polyhydromnios?
    maternal complications, trisomy, GI obstruction
  86. What is the sonographic appearance of chorionic fluid?
    more echogenic than amniotic fluid
  87. Def. Embryonic tissue lining the exterior of the gestational sac
    Chorionic cavity
  88. What is the purpose of the chorionic cavity?
    to invade the decidua and establish nutrition for the embryo
  89. Define Chorionic Villi
    finger-like projections that project outward from the walls of the blastocyst into the decidua
  90. Define chorionic frondosum
    portion of the chorion located at the implantation site which later contributes to the formation of the placenta
  91. Define chorionic laeve
    thinly stretched chorion frondosum that didn't proliferate
  92. A heart rate will be visible on a TV exam when the CRL measures what?
  93. What is the normal heart rate at 6 weeks?
    90 bpm
  94. What is the normal heart rate at 9 weeks?
    170 bpm
  95. What is the normal heart rate between 10 and 24 weeks?
    140 bpm
  96. When does the umbilical cord form?
    end of 6th week
  97. What is contained in the umbilical cord?
    • 2 arteries
    • 1 vein
    • Allantois
    • Yolk stalk
  98. What umbilical structure is associated with bladder development?
  99. What umbilical structure connects the primitive gut to the yolk sac?
    yolk stalk
  100. Umbilical Cord
  101. Umbilical Cord
  102. Def. gelatinous substance within the umbilical cord
    Wharton's Jelly
  103. How is the gestational sac measured?
  104. Where do you measure the gestational sac?
    at the fluid-tissue interface
  105. How accurate is the gestational sac measurement for determing embryonic age?
    accurate to within one week
  106. When would you stop measuring the gestational sac for embryonic age?
    when the embryo is visible
  107. Which transducer is most accurate for measuring structures during early OB?
    high frequency transvaginal probes
  108. A gestational sac measuring MSD = 2mm corresponds to what age?
    4-4.5 weeks
  109. A gestational sac measuring MSD = 5mm corresponds to what age?
    5 weeks
  110. At what age will the yolk sac appear?
    5.5 weeks
  111. At what age will the embryo and yolk sac be visible?
    6 weeks
  112. What is the most accurate of all fetal measurements?
    crown rump length
  113. How many CRL should be taken?
    3 for accuracy and averaging
  114. When the fetal pole is visible how quickly does it grow?
    1-2 mm per day
  115. How is gestational age calculated from CRL?
    CRL (mm) + 42 = GA (days)
  116. When are CRL no longer necessary?
    after the 12th week
  117. Why are CRL measurements less accurate after the 12th week?
    due to curling
  118. Prosencephalon AKA
  119. Mesencephalon AKA
  120. Rhombencephalon AKA
  121. x3
  122. When do the lateral ventricles appear?
    9-11 weeks
  123. When does the choriod plexus appear?
    13 weeks
  124. Sonographic appearance of lateral ventricles?
  125. Sonographic appearance of choroid plexus?
    homogeneous, echogenic
  126. Choroid Plexus / Lateral Ventricles
  127. Def. failure of the fetal gut to return after it herniates
  128. Def. Absence of cranial vault/cerebral hemispheres
  129. Def. Lucency at the back of
    Nuchal Translucency
  130. Def. termination of the pregnancy prior to 20 weeks
  131. Spontaneous Abortion will occur approximately _____ weeks after embryonic demise.
  132. What percentage of pregnancies end in spontaneous abortion?
  133. 75% of spontaneous abortions occur before _____ weeks.
  134. What are some causes of Spontaneous Abortion?
    unknown, endocrine factors, failure or corpus luteum, interruption of embryonic development, chromosomal anomalies
  135. Spontaneous Abortion begins with ________ into the decidual basalis, followed by _______ and ________ around the implantation site causing the embryo to die.
    • hemorrhage
    • inflammation
    • necrosis
  136. What will the uterus and cervix do after a spontaneous abortion?
    uterus contracts, cervix dilates, and pregnancy is expelled
  137. What happens during a complete abortion?
    • Evacuation of ALL products of conception
    • Rapid decline in hCG levels
    • Vaginal bleeding with clots and tissue
    • Very painful cramping
    • Pregnancy symptoms disappear
    • Cessation of pain and bleeding after conceptus is passed
    • Sonographic appearance- thin endometrium, empty uterus
  138. What happens during an incomplete abortion?
    • Partial evacuation of products of conception
    • Slow fall or plateau of hCG levels
    • Moderate cramping
    • Persistent bleeding
    • Sonographic appearance- presence of complex echoes in endometrial cavity, retained products of conception
  139. incomplete abortion
  140. What happens during a missed abortion?
    • Presence of embryo/GS in uterus but no cardiac activity
    • hCG levels less than expected for dates
    • Loss of pregnancy symptoms
    • Brownish bleeding ordischarge without heavy bleeding or cramping
    • Sonographic appearance- no cardiac motion, no fetal motion, size < dates, hypoechoic embryo
  141. missed abortion
  142. Def. Condition in which the pregnancy appears normal but clinical signs such a bleeding or cramping suggest pregnancy is in jeopardy
    Threatened abortion
  143. What happens during an inevitable abortion?
    • SAB is imminent when any of 2 or more of the following clinical signs are noted:
    • –Moderate effacement of the cervix (shortening)
    • –Cervical dilatation > 3cm
    • –Rupture of membranes (little or no AFV)
    • –Bleeding for more than 7 days
    • –Persistent cramping
    • –Sonographic appearance- GS seen in the cervix or LUS, cervical dilatation
  144. Def. gestational sac seen in uterus but embryo failed to develop or died at a stage before it was visible
    anembryonic pregnancy
  145. What was an anembryonic pregnancy formerly called?
    blighted ovum
  146. What is the sonographic appearance of an anembryonic pregnancy?
    large gestational sac with no amnion, yolk sac, embryo
  147. What risks are associated with a large yolk sac?
    increase risk for spontaneous abortion and embryonic demise
  148. What is the max diameter of the yolk sac at 10 weeks gestation age?
    5-6 mm
  149. What risks are associated with abnormally shaped or calcified yolk sacs?
    embryonic demise
  150. A CRL of 5-9 mm with a heart rate of < 100 BPM or a CRL of 10-15 mm with a HR of < 115 BPM indicates
    Embryonic Bradycardia
  151. What is the most common reason for bleeding during the first trimester?
    Subchorionic Hemorrhage
  152. Def. an accumulation of blood beneath the chorion
    Subchorionic hemorrhage
  153. What is the sonographic appearance of an acute chorionic hemorrhage?
    • hyperechoic to isoechoic relative to placenta
    • 1-2 weeks sonolucent
  154. What is the most important criteria for subchorionic hemorrhage?
    • size of the bleed
    • should decrease with follow-up scans
  155. subchorionic hemorrhage
  156. subchorionic hemorrhage
  157. Describe an early pregnancy failure.
    • —Pregnancy shows sonographic evidence of cessation of growth & development & clinical findings are supportive
    • —Examples
    • Large empty GS
    • GS & Yolk sac only
    • No CA & smaller than normal or appropriately sized embryo
    • Remnants of a sac
  158. What is the name for a surgical abortion?
    suction dilation and curettage (D&C)
  159. What pills cause a medical bortionl?
    • mifepristone (600mg)
    • 2 days later misoprostol (400 µg)
  160. 91% of expectant miscarriages occur after ____ days.
  161. What is the leading cause of pregnancy related deaths during the first trimester?
    ectopic pregnancy
  162. Ectopic pregnancy is the cause of ____% of all pregnancy related deaths.
  163. What has caused ectopic pregnancies to increase of the past 10 years?
    • PID
    • Tubal surgeries
    • ART
  164. What are the symptoms of ectopic pregnancy?
    • + pregnancy test and empty uterus
    • adnexal mass
    • vaginal bleeding
    • lower abdominal pain
    • cramping on one side of the pelvis
    • sharp, stabbing pain in the pelvis, abdomen, or even shoulder or neck
    • dizziness
    • lightheadedness
  165. What are the risk factors for ectopic pregnancy?
    • Pelvic inflammatory disease (PID) -- 6 to 10 times higher than in women with no previous history of PID.
    • Previous ectopic pregnancy
    • Progesterone-bearing
    • IUD's -- 16% of pregnancies in women using progesterone containing IUD's were ectopics.
    • Tubal ligation
    • (sterilization) -- After non-laparoscopic tubal ligation, about 12% of
    • pregnancies are ectopic; after laparoscopic tubal coagulation, about 51% of pregnancies are ectopic.
    • Previous tubal surgery
    • Fertility treatment with ovulation induction or ovarian stimulation
    • In vitro fertilization (IVF) -- About 2 to 5% of clinical pregnancies resulting from IVF are ectopic. The figure is higher for women with a history of previous ectopic pregnancy or tubal infertility.
    • Some studies have suggested that tubal pregnancies are more likely in African American women.
    • Douching
    • Smoking
  166. What poplulation is at most risk for an ectopic pregnancy?
    • Varies patient population & inherent risk factors
    • All patients of reproductive age
  167. —Heterotopic
    Ectopic pregnancies
    • Coexistent intrauterine & ectopic
    • IVF & ovulation induction
    • 1 in 2000 pregnancies
  168. ring of fire
  169. What is the ring of fire sign?
    a tubal pregnancy with peripheral hypervascularity surrounding the extrauterine gestational sac
  170. What should you demonstrate if there is a live embryo in the adnexa
    show cardiac acitivity in M-mode, color, and power dopplar
  171. —Empty uterus and adnexal mass
    hCG >1500 mIU/ml
    Free fluid in pelvis
    Look for decidual reaction and “ring of fire” around ectopic
  172. —Sonographic pitfalls “pseudogestational sac”-fluid in the endometrial canal
    Mimics normal GS
    Look for decidual reaction
  173. —Surgical
    Resection of diseased tube
    Early diagnosis w/ TV = more conservative
    –Definitive diagnosis
    Goal is to find early before rupture
    61-93% success
  174. Methotrexate
    Cell growth inhibitor
  175. —Spectrum of pathologies resulting from the excessive proliferation of trophoblastic tissue
    —Paternal genomes control the proliferation of trophoblastic tissue, maternal genomes control growth of the embryo
    —GTD is caused from excessive paternal genomes
    Complete mole
    Partial mole
    Invasive mole
    Mole with coexisting normal fetus
    Gestational Trophoblastic Disease
  176. GTD clinical signs
    • Grossly elevated hCG levels >100,000 mIU/ml
    • Hyperemesis gravidarum (severe morning sickness)
    • Rapid enlargement of the uterus
    • Vaginal bleeding
    • Theca lutein cysts
    • Early onset of preeclampsia (htn, edema, proteinuria)
    • Hyperthyroidism
  177. —Most common form of GTD
    —1:1500 USA; 1:82
    —Risk factors include:
    < 20 yrs and >40 yrs
    Low economic status
    Diets deficient in protein and folic acid
    1: Duplicated male chromosomes and normal ovum
    2: Normal male chromosomes and empty ovum
    Complete Molar Pregnancy
  178. Haploid
    Single set of unpaired chromosomes
  179. —Hydropic chorionic villi enveloped by hyperplastic atypical trophoblasts
    —No embryo or fetal tissue is present
    —Sonographic findings:
    Multiple scattered cystic spaces filling a thickened endometrial cavity- “cluster of grapes”
    Uterus larger than dates
    Enlarged ovaries from theca lutein cysts
    Complete molar pregnancy
  180. hydatidiform mole
  181. —2 normal sperm fertilize the same normal ovum
    —2 types of chorionic villi
    Hydropic swelling (trophoblastic hyperplasia)
    Partial mole
  182. —Pathology
    Deformed GS
    Growth-restricted fetus with anomalies
    Large placental size with cystic spaces
    Trophoblastic proliferation not as severe
    Less severe than complete
    —Sonographic appearance is similar to a missed or incomplete abortion
    Partial Molar Pregnancy
  183. partial mole first trimester
  184. Therapy for molar pregnancy
    • —Uterine evacuation
    • —Monitor serum hCG-should fall over 10-12 weeks
    • —Avoid pregnancy for 1 yr.
  185. —2 conceptions occur as in twinning, but one develops into a mole and the other a normal fetus—
    Cases have been reported of normal going to term, but itis very risky. Mom has to be monitored closely for hemorrhage, severe HTN, or toxicity—
    Maternal risks are significant and termination is given as an option; Risk for future molar pregnancy or PTN increases
    Mole with coexisting normal fetus
  186. 2 types of Persistent trophoblastic disease
    • —Invasive mole
    • choriocarcinoma
  187. Persistent trophoblastic disease
    • —PTN can follow normal pregnancy, SAB, ectopic pregnancy, or GTD
    • —Severe cases of GTD are at the highest risk for PTN
  188. AKA Chorioadenoma destruens —Most common form of PTN (80-95%)—Trophoblastic tissue that penetrates the myometrium and/or adjacent structures. May penetrate the uterine wall and cause uterine rupture and hemoperitoneum —Considered a malignant, non-metastatic form of GTD—Diffuse echogenic material with cystic spaces filling the endometrial cavity and extending into myometrium (“more mole than uterus”)
    —Invasive Mole
  189. invasive mole
  190. —very rare—1:30,000 pregnancy; 1:40 molar pregnancies—Vascular invasion, hemorrhage, and necrosis of the myometrium are common—Tumor composed of syncytiotrophoblastic and cytotrophoblastic cells—Considered the malignant, metastatic form of GTD—Can metastasize to the lung, brain, liver, bone, GI tract, or skin
  191. Name Disease:
    —Elevated hCG
    —No embryo or fetal tissue present
    —Enlarged uterus
    —Mass with complex, marked vascularity
  192. choriocarcinoma
  193. Treatment for PTN
    • —Chemotherapy
    • —Radiation
    • —Hysterectomy
    • —Treatments performed as needed based on severity of disease
  194. If abnormality is suspected in 1st trimester follow-up is recommended or genetic testing:– by testing what?
    • Serum alpha-fetoprotein
    • –CVS
    • Amniocentesis
  195. What is the major advantage of screening anomalies in the 1st trimester?
    —maternal reassurance and/or counseling for parents of structurally abnormal fetuses
  196. Def. performed from 15 wksAmniotic fluid is drawn ransabdominally under U/S guidance to avoid fetus, placenta, and umbilical cord
  197. List the Genetic Testing options
    • —MSAFP- can detect
    • ONTD’s-open neural tube defects
    • Trisomy 13, 18, 21
    • Abdominal wall defects
    • —Chorionic Villus Sampling – performed 9-12 weeks gestation
    • U/S guidance transcervically or transabdominally
    • Trophoblastic cells are obtained and can reveal karyotype, chromosomal abnormalities,
    • Termination can be performed earlier if elected
    • —Amniocentesis – performed from 15 wks
    • Amniotic fluid is drawn transabdominally under U/S guidance to avoid fetus, placenta, and umbilical cord
  198. What type of US scans are the most accurate for assessment of fetal anatomy
    TV and TA sonograms are used for the most accurate assessment of fetal anatomy
  199. When do most congenital anomalies occur?
    Most originate in embryonic period
  200. When are most congenital anomalies diagnosed?
    —Most anomalies are diagnosed in the 2nd trimester due to fetal immaturity affecting visualization
  201. List some congenital anomalies
    • CNS
    • —Fetal face
    • —Fetal neck
    • —CV system
    • —GI tract
    • —Genitourinary System
    • —MS system
  202. Def. exaggerated, hyperextension of the neck, open spinal defects, occipital encephalocele
  203. Def. protrusion of the brain through a bony defect in the skull
  204. Def. absence of the brain and cranial vault, base of skull and face are present along with some brain tissue
  205. Def. partial or complete absence of the cranium, bony structures absent
  206. Def. lack of closure of the spinal column, bulging of spine or meninges into a sac; prognosis depends on severity
    Spina Bifida
  207. Def. cystic dilatation of the 4th ventricle and abnormal configuration of the cerebellum
    Dandy-Walker malformation
  208. Def. 3 levels of severity, absence of brain tissue in varying degrees; no cerebral hemispheres or ventricles
  209. Def. hydrocephaly, dilatation of the ventricles without enlargement of the cranium; increased amount of CSF
  210. Def. herniation of the abdominal contents into the umbilical cord; often associated with other congenital anomalies
  211. Def. open defect in the anterior abdominal wall; organs are not covered by a membrane, they are seen “floating” in the amniotic fluid; not associated with other congenital anomalies
  212. —Def. One of the most common abnormalities seen in the 1st trimester—Single or multiple cystic areas, of lymphatic origin, within the soft tissue surrounding the neck—Associated with chromosomal abnormalities such as Turner’s and Down syndromes
    Cystic Hygroma