Teratogens

• A teratogen is any factor,

chemical or physical,
that adversely affects the
fertilized ovum, embryo,
or fetus

• A fetus is extremely
vulnerable to environmental
injury, specifically at the
beginning or early weeks of
pregnancy
 Effects of Teratogens in the Fetus

• The strength of the teratogen

– In small amounts (everyone is exposed to some radiation every
day, such as from the rays of the sun), it causes no damage.
However, in large doses (e.g., a woman received radiation to treat
cancer of the cervix during pregnancy), serious fetal defects or
death could occur

• The timing of the teratogenic

– If a teratogen is introduced before implantation, for example,
either the zygote is destroyed or it appears unaffected. If the
insult occurs when the main body systems are being formed (in
the second to eighth weeks of embryonic life), a fetus is very
vulnerable to injury.
– During the last trimester, the potential for harm again
decreases because all the organs of a fetus are formed and are
merely maturing.
• Two exceptions to the rule that deformities usually
occur in early embryonic life are the effects caused
by the organisms of syphilis and toxoplasmosis.

• These two infections can cause abnormalities in

organs that were originally formed normally.

• Intimate partner violence is another teratogen

that can be responsible for injury to a fetus at any
stage of pregnancy
 Effects of Teratogens in the Fetus
• A third factor determining the effects of a teratogen
is the teratogen’s affinity for specific body tissues.
– Lead and mercury, for example, attack and disable
nervous tissue
– Thalidomide (Immunoprin), originally used to treat
nausea in pregnancy, is now prescribed for cancer
therapy, and it may cause limb defects
– Tetracycline (Apo-Tetra), a common antibiotic, causes
tooth enamel deficiencies, and possibly, long bone
deformities.
– The rubella virus affects many organs, with the eyes,
ears, heart, and brain the four most commonly attacked
Teratogenic Maternal Infection
• Teratogenic maternal infections involve viral,
bacterial, or protozoan organisms, which cross
the placenta from mother to fetus

• When newborns are tested to see if antibodies

against the common infectious teratogenic
diseases are present, the test is described
collectively under the umbrella term TORCH,
an acronym for toxoplasmosis, rubella,
cytomegalovirus, and herpes simplex virus
 Teratogenic Maternal Infections
• Malaria - caused by intraerythrocytic protozoa of the genus
Plasmodium transmitted to humans by the bite of an infected female
Anopheles mosquito. A number of drugs, such as chloroquine (Aralen) in the first
trimester and mefloquine (Lariam) in the second or third trimesters, are helpful.

• Toxoplasmosis - a protozoan infection, is spread most commonly

through contact with uncooked meat, although it may also be contracted
through handling cat stool in soil or cat litter

• Rubella (German Measles) - rubella virus usually causes

only a mild rash and mild systemic illness in a woman, but the teratogenic
effects on a fetus can be devastating, such as hearing impairment, cognitive
and motor challenges, cataracts, cardiac defects (most commonly patent
ductus arteriosus and pulmonary stenosis), restricted intrauterine growth
(i.e., small for gestational age), thrombocytopenic purpura, and dental and
facial clefts, such as cleft lip and palate
 Teratogenic Maternal Infections
• Herpes Simplex Virus (Genital herpes
infection)
– a sexually transmitted infection spread by intimate contact. The first time a
woman contracts an HSV infection, systemic involvement occurs. The virus
spreads into the bloodstream (viremia) and, if a woman is pregnant, can
cross the placenta to a fetus, thus posing substantial fetal risk
– Acyclovir (Zovirax) or valacyclovir (Valtrex) can both be safely
administered to women who develop lesions during pregnancy as well as
to their newborns at birth
– Either drug is recommended daily as prophylaxis at 36 weeks of pregnancy
to prevent a lesion at the time of birth
 Teratogenic Maternal Infections
• Cytomegalovirus (CMV)
– a member of the HSV family, is another teratogen that can cause extensive damage
to a fetus while causing few symptoms in a woman
– not sexually transmitted but spreads from person to person by droplet infection
such as occurs with sneezing.
– If a woman acquires a primary CMV infection during pregnancy and the virus
crosses the placenta, the infant may be born with severe neurologic challenges
(e.g., hydrocephalus, microcephaly, or spasticity) or with eye damage (e.g., optic
atrophy or chorioretinitis), hearing impairment, or chronic liver disease.
– The newborn’s skin may be covered with large petechiae (i.e., “blueberry muffin”
lesions).
– Because there is no treatment or vaccine for the disease, routine screening for
CMV during pregnancy is not recommended.
– Advise women to wash hands thoroughly before eating and to avoid crowds of
young children at daycare or nursery school settings to help prevent exposure
 Teratogenic Maternal Infections
• Syphilis
- Early in pregnancy, when the cytotrophoblast layer of the chorionic
villi is still intact, the causative spirochete of syphilis, Treponema
pallidum, apparently cannot cross the placenta and damage the fetus.
- When this layer atrophies at about the 16th to 18th week of pregnancy,
however, the spirochete can cross and cause extensive fetal damage
- If left untreated beyond the 18th week of gestation, hearing
impairment, cognitive challenge, osteochondritis, and fetal death are
possible.
- The newborn with congenital syphilis may have congenital anomalies,
extreme rhinitis (sniffles), and a characteristic syphilitic rash, all of
which identify the baby as high risk at birth
- When the baby’s primary teeth come in, they are often oddly shaped
(i.e., Hutchinson teeth).
 Teratogenicity of Tobacco
• Cigarette smoking is associated with infertility in women. If used by a
pregnant woman, it has been shown to cause fetal growth restriction. In
addition, a fetus may be at greater risk for being stillborn and, after birth,
may be at a greater risk than others for sudden infant death syndrome

• Low birth weights in infants of smoking mothers result from

vasoconstriction of the uterine vessels, an effect of nicotine.

• This limits the blood supply to a fetus. Another contributory effect may be
related to inhaled carbon monoxide. Secondary smoke, or inhaling the
smoke of another person’s cigarettes, may be as harmful as actually
smoking because of inhaled carbon monoxide
 Fetal Monitoring at
Prenatal Period

Francia C. Toledano RN MD
Lecturer
 Assessing Fetal Well - Being
• Fetal Heart Rate
- Fetal heart sounds can be
heard and counted as
early as the 10th to 11th
week of pregnancy by the
use of an ultrasound
Doppler technique. This
is done routinely at every
prenatal visit past 10
weeks.
 Assessing Fetal Well - Being
• Daily Fetal Movement Count (Kick
Counts)
– Fetal movement that can be felt by the mother (quickening)
occurs at approximately 18 to 20 weeks of pregnancy and
peaks in intensity at 28 to 38 weeks. After that time, a
healthy fetus moves with a degree of consistency at about
10 times per hour.

– Kick counts are particularly useful in growth-restricted or

post term pregnancies to reveal if a fetus is still receiving
adequate nutrition
 Assessing Fetal Well - Being
• Rhythm Strip Testing
– refers to an assessment of fetal well-being and
assesses the fetal heart rate for a normal
baseline rate
– Assist into a semi - Fowler’s position
– Attach an external fetal heart rate monitor
abdominally.
– Record the fetal heart rate for 20 minutes.
– Rhythm strip testing requires a woman to
remain in a fairly fixed position for 20 minutes.
 Rhythm strip testing
Variability denotes small changes in rate that occur
from second to second if the fetal parasympathetic
nervous system is receiving adequate oxygen and
nutrients
•Absent: No peak-to-trough range is detectable.
• Minimal: An amplitude range is detectable but the
rate is 5 beats/min or fewer.
• Moderate or normal: An amplitude range is
detectable; rate is 6 to 25 beats/min.
• Marked: An amplitude range is detectable; rate is
greater than 25 beats/min
 Nonstress Testing
• Measures the response of the fetal heart
rate to fetal movement
– Position the woman and attach both a fetal
heart rate and a uterine contraction
monitor.
– Instruct the woman to push the button
attached to the monitor (similar to a call
bell) whenever she feels the fetus move.
This will create a dark mark on the paper
tracing at these times.
 Interpretation of Non stress testing
• When the fetus moves, the fetal heart rate should increase approximately
15 beats/min and remain elevated for 15 seconds.
• If no increase in beats per minute is noticeable on fetal movement, further
testing may be necessary to rule out poor oxygen perfusion of the fetus.

• The test is said to be reactive (healthy) if two accelerations of fetal heart

rate (by 15 beats or more) lasting for 15 seconds occur after movement
within the time period.
• The test is nonreactive (fetal health may be affected) if no accelerations
occur with the fetal movements.
• The results also can be interpreted as nonreactive if no fetal movement
occurs or if there is low short-term fetal heart rate variability (less than 6
beats/min) throughout the testing period
 Nursing Intervention for non reactive
test
• If a 20-minute period passes without any fetal
movement, it may only mean that the fetus is
sleeping, although other reasons for lessened
variability are maternal smoking, drug use, or
hypoglycemia.
– oral carbohydrate snack, such as orange juice, it can
cause her blood glucose level to increase enough to
cause fetal movement.
– The fetus also may be stimulated by a loud sound to
cause movement.
 Amniotic Fluid Volume
• If a fetus is becoming so stressed in utero that circulatory and kidney function
is failing, urine output and, consequently, the volume of amniotic fluid will
decrease.

• A decrease in amniotic fluid volume puts the fetus at risk for compression of
the umbilical cord with interference of nutrition as well as lack of room to
exercise and maintain muscle tone.

• Between 28 and 40 weeks, the total pockets of amniotic fluid revealed by

sonogram average 12 to 15 cm.

• An amount greater than 20 to 24 cm indicates hydramnios (i.e., excessive

fluid, perhaps caused by inability of the fetus to swallow).

• An amount less than 5 to 6 cm indicates oligohydramnios (i.e., decreased

amniotic fluid, perhaps caused by poor perfusion and kidney failure).
 Nuchal Translucency
• Children with a number of chromosome
anomalies have unusual pockets of fat
or fluid present in their posterior neck,
which show on sonograms as nuchal
translucency.
• A biophysical profile is more accurate in predicting fetal well-being than any single assessment
• Because the scoring system is similar to an Apgar score determined at birth on infants, it is
often referred to as a fetal Apgar score.
 Interpretation
• Biophysical profiles may be done as often as daily during a high-risk
pregnancy.
• The fetal scores are as follows:
• A score of 8 to 10 means the fetus is considered to be doing well.
• A score of 6 is considered suspicious.
• A score of 4 denotes a fetus potentially in jeopardy.
Some centers use only two assessments (amniotic fluid index [AFI] and a
nonstress test) for the analysis.
Referred to as a modified biophysical profile, this predicts short-term
viability by the nonstress test and long-term viability by the AFI.

A healthy fetus should show a reactive nonstress test and an AFI range
between 5 and 25 cm
 Maternal serum Alpha - Fetoprotein
• AFP is a substance produced by the fetal liver that can be found in both
amniotic fluid and maternal serum (maternal serum α-fetoprotein [MSAFP]).

• The level is abnormally high if the fetus has an open spinal or abdominal
wall defect because the open defect allows more AFP to enter the mother’s
circulation than usual.

• MSAFP levels begin to rise at 11 weeks gestation and then steadily increase
until term.

• Traditionally assessed at the 15th week of pregnancy, between 85% and 90%
of neural tube anomalies and 80% of babies with Down syndrome can be
detected by this method
 Maternal Serum for Pregnancy-
Associated Plasma Protein A
• Pregnancy-associated plasma protein A
(PAPP-A) is a protein secreted by the
placenta; low levels in maternal blood are
associated with fetal chromosomal anomalies,
including trisomies 13, 18, and 21 or small-for-
gestational-age (SGA) babies.

• A high PAPP-A level may predict an LGA baby.

Invasive Fetal Monitoring
 Percutaneous Umbilical Blood
Sampling
• Percutaneous umbilical blood sampling (PUBS; also called
cordocentesis or funicentesis) is the aspiration of blood
from the umbilical vein for analysis.

• After the umbilical cord is located by sonography, a thin

needle is inserted by amniocentesis technique into the
uterus and is then guided by ultrasound until it pierces
the umbilical vein.

• To ensure the blood obtained is fetal blood, it is

submitted to a Kleihauer–Betke test, which measures the
difference between adult and fetal hemoglobin
 Fetoscopy
• Fetus is visualized by inspection through a fetoscope (an extremely narrow,
hollow tube inserted by amniocentesis technique), can be yet another way
to assess fetal well-being.

• This method allows direct visualization of both the amniotic fluid and the
fetus

• The earliest time in pregnancy a fetoscopy can be performed is

approximately the 16th or 17th week.

• For the procedure, the mother is draped as for amniocentesis.

– A local anesthetic is injected into the abdominal skin.
– The fetoscope is then inserted through a minor abdominal incision.
– If the fetus is very active, meperidine (Demerol) may be administered to the woman
to help sedate the fetus to avoid fetal injury by the scope and allow for better
observation.
 Advantages of Fetoscopy
• The main reasons the procedure is used are to:
• Confirm the intactness of the spinal column.
• Obtain biopsy samples of fetal tissue and fetal blood
samples.
• Determine meconium staining is not present.
• Perform elemental surgery, such as inserting a polyethylene
shunt into the fetal ventricles to relieve hydrocephalus or
anteriorly into the fetal bladder to relieve a stenosed urethra.

It may be possible to repair a neural tube defect such

as meningocele or improve the outcome of
myelomeningocele by fetoscopy