wall (the decidua vera).

Here,
the two decidua areas fuse,
CU 4 CARE OF THE FETUS
which is why, at birth, the entire
inner surface of the uterus is
EMBRYONIC STRUCTURE stripped away, leaving the organ
highly susceptible to
A. THE DECIDUA
hemorrhage and infection
After fertilization, the corpus B. CHORIONIC VILLI
luteum in the ovary continues to function
rather than atrophying, because of the
influence of human chorionic
gonadotropin (hCG), a hormone
secreted by the trophoblast cells. This
causes the uterine endometrium to
continue to grow in thickness and
vascularity, instead of sloughing off as in
a usual menstrual cycle. The
endometrium is now termed the decidua
(the Latin word for “falling off”), because
it will be discarded after the birth of the
child. The decidua has three separate
areas:

1. Decidua basalis, the part of the

endometrium that lies directly
under the embryo (or the portion
where the trophoblast cells
establish communication with
maternal blood vessels)

2. Decidua capsularis, the portion

of the endometrium that Once implantation is complete, the
stretches or encapsulates the trophoblastic layer of cells of the
surface of the trophoblast blastocyst begins to mature rapidly. As
early as the 11th or 12th day, miniature
3. Decidua vera, the remaining villi that resemble probing fingers, termed
portion of the uterine lining. As chorionic villi, reach out from the single
the embryo continues to grow, it layer of cells into the uterine
pushes the decidua capsularis endometrium to begin formation of the
before it like a blanket. placenta. At term, almost 200 such villi
Eventually, the embryo enlarges will have formed (Knuppel, 2007)
so much that this action brings All chorionic villi have a central
the decidua capsularis into core of connective tissue and fetal
contact with the opposite uterine capillaries. A double layer of trophoblast

1
cells surrounds these. The outer of the diameter and 2 to 3 cm in depth,
two covering layers is the covering about half the surface area of
syncytiotrophoblast, or the syncytial the internal uterus at term.
layer. This layer of cells produces
CIRCULATION
various placental hormones, such as
As early as the 12th day of
hCG, somatomammotropin (human
pregnancy, maternal blood begins to
placental lactogen [hPL]), estrogen, and
collect in the intervillous spaces of the
progesterone.
uterine endometrium surrounding the
The middle layer, the
chorionic villi. By the third week, oxygen
cytotrophoblast or Langhans’ layer, is
and other nutrients, such as glucose,
present as early as 12 days’ gestation. It
amino acids, fatty acids, minerals,
appears to function early in pregnancy to
vitamins, and water, osmose from the
protect the growing embryo and fetus
maternal blood through the cell layers of
from certain infectious organisms such
the chorionic villi into the villi capillaries.
as the spirochete of syphilis. This layer of
From there, nutrients are transported to
cells disappears, however, between the
the developing embryo.
20th and 24th weeks. This is why syphilis
Placental osmosis is so
is not considered to have a high potential
effective that all except a few substances
for fetal damage early in pregnancy, only
are able to cross from the mother into the
after the point at which cytotrophoblast
fetus. Because almost all drugs are able
cells are no longer present (Ainbinder,
to cross into the fetal circulation, it is
Ramin, & DeCherney, 2007). The layer
important that a woman take no
appears to offer little protection against
nonessential drugs (including alcohol and
viral invasion at any point.
nicotine) during pregnancy
(Rogers-Adkinson & Stuart, 2007).
PLACENTA
For practical purposes, because
the process of osmosis is so effective,
there is no direct exchange of blood
between the embryo and the mother
during pregnancy. Because the outer
chorionic villi layer is only one cell thick
after the third trimester minute breaks do
occur and allow occasional fetal cells to
cross into the maternal bloodstream, as
well as fetal enzymes such as
alpha-fetoprotein (AFP) from the fetal
liver.
The placenta (Latin for “pancake,” which About 100 maternal uterine
is descriptive of its size and appearance arteries supply the mature placenta.
at term) arises out of the continuing To provide enough blood for exchange,
growth of trophoblast tissue. Its growth the rate of uteroplacental blood flow in
parallels that of the fetus, growing from a pregnancy increases from about 50
few identifiable cells at the beginning of mL/min at 10 weeks to 500 to 600
pregnancy to an organ 15 to 20 cm in

2
mL/min at term. The woman’s heart rate, first missed menstrual period (shortly
total cardiac output, and blood volume after implantation has occurred) through
increase to supply blood to the placenta about the 100th day of pregnancy.
Uterine perfusion, and thus Because this is the hormone analyzed by
placental circulation, is most efficient pregnancy tests, a false-negative result
when the woman lies on her left side. from a pregnancy test may be obtained
This position lifts the uterus away from before or after this period. The woman’s
the inferior vena cava, preventing blood blood serum will be completely negative
from being trapped in the woman’s lower forhCG within 1 to 2 weeks after birth.
extremities. If the woman lies on her Testing for hCG after birth can be used
back and the weight of the uterus as proof that placental tissue is no longer
compresses the vena cava, placental present.
circulation can be so sharply reduced The purpose of hCG is to act as
that supine hypotension (very low a fail-safe measure to ensure that the
maternal blood pressure and poor uterine corpus luteum of the ovary continues to
circulation) occurs (Knuppel, 2007). produce progesterone and estrogen. This
At term, the placental is important because, if the corpus
circulatory network has grown so luteum should fail and the level of
extensively that a placenta weighs 400 to progesterone fall, the endometrial lining
600 g (1 lb), one sixth the weight of the will slough and the pregnancy will be lost.
baby. If a placenta is smaller than this, it hCG also may play a role in suppressing
suggests that circulation to the fetus may the maternal immunologic response so
have been inadequate. A placenta larger that placental tissue is not detected and
than this may also indicate that rejected as a foreign substance.
circulation to the fetus was threatened,
because it suggests that the placenta 2. Estrogen.
was forced to spread out in an unusual Estrogen (primarily estriol) is
manner to maintain a sufficient blood produced as a second product of the
supply. The fetus of a woman with syncytial cells of the placenta. Estrogen
diabetes may also develop a contributes to the woman’s mammary
larger-than-usual placenta from excess gland development in preparation for
fluid collected between cells. lactation and stimulates uterine growth to
accommodate the developing fetus.
ENDOCRINE FUNCTION
Aside from serving as the 3. Progesterone.
conduit for oxygen and nutrients for the Estrogen is often referred to as
fetus, the syncytial (outer) layer of the the “hormone of women”;
chorionic villi develops into a separate, progesterone as the “hormone of
important hormone-producing system. mothers.” This is because, although
estrogen influences a female
1. Human Chorionic Gonadotropin.
appearance, progesterone is necessary
The first placental hormone
to maintain the endometrial lining of the
produced, hCG, can be found in
uterus during pregnancy. It is present in
maternal blood and urine as early as the
serum as early as the fourth week of

3
pregnancy, as a result of the continuation not touch the endometrium) gradually
of the corpus luteum. After placental thin, leaving the medial surface of the
synthesis begins (at about the 12th structure smooth (the chorion laeve, or
week), the level of progesterone rises smooth chorion). The smooth chorion
progressively during the remainder of the eventually becomes the chorionic
pregnancy. This hormone also appears to membrane, the outermost fetal
reduce the contractility of the uterus membrane. Its purpose is to form the sac
during pregnancy, preventing premature that contains the amniotic fluid.
labor.

4. Human Placental Lactogen (Human

Chorionic Somatomammotropin).
hPL is a hormone with both
growth-promoting and lactogenic
(milk-producing) properties. It is
produced by the placenta beginning as
early as the sixth week of pregnancy,
increasing to a peak level at term. It can
be assayed in both maternal serum and
urine. It promotes mammary gland A second membrane lining the
(breast) growth in preparation for chorionic membrane, the amniotic
lactation in the mother. It also serves the membrane or amnion, forms beneath the
important role of regulating maternal chorion. Early in pregnancy, these
glucose, protein, and fat levels so that membranes become so adherent that
adequate amounts of these nutrients are they seem as one at term. At birth they
always available to the fetus (Taylor & can be seen covering the fetal surface of
Lebovic, 2007). the placenta, giving that surface its
typically shiny appearance. There is no
PLACENTAL PROTEINS nerve supply, so when they
The placenta also produces spontaneously rupture at term or are
several plasma proteins. The function of artificially ruptured, neither woman nor
these has not been well documented, but child experiences any pain.
it is thought that they may contribute to In contrast to the chorionic
decreasing the immunologic impact of membrane, the amniotic membrane not
the growing placenta through being part only offers support to amniotic fluid but
of the complement cascade (Knuppel, also actually produces the fluid. In
2007). addition, it produces a phospholipid that
initiates the formation of prostaglandins,
C. THE AMNIOTIC which can cause uterine contractions and
MEMBRANES maybe the trigger that initiates labor

The chorionic villi on the medial surface

D. THE AMNIOTIC FLUID
of the trophoblast (those that are not
involved in implantation, because they do

4
Amniotic fluid is constantly being newly cause oligohydramnios, or a reduction
formed and reabsorbed by the amniotic in the amount of amniotic fluid (less than
membrane, so it never becomes 300 mL in total, or no pocket on
stagnant. Some of it is absorbed by ultrasound larger than 1 cm) (Knuppel,
direct contact with the fetal surface of the 2007).
placenta. The most important purpose of
amniotic fluid is to shield the fetus
against pressure or a blow to the
mother’s abdomen. Because liquid
changes temperature more slowly than
air, it also protects the fetus from
changes in temperature. As yet another
function, it aids in muscular development,
because it allows the fetus freedom to
move. Finally, it protects the umbilical
cord from pressure, protecting the fetal
oxygen supply. Even if the amniotic
membranes rupture before birth and the
bulk of amniotic fluid is lost, some will
The major method of absorption, always surround the fetus in utero,
however, occurs because the fetus because new fluid is constantly formed.
continually swallows the fluid. In the fetal Amniotic fluid is slightly alkaline, with a
intestine, it is absorbed into the fetal pH of about 7.2. Checking the pH of the
bloodstream. From there, it goes to the fluid at the time of rupture helps to
umbilical arteries and to the placenta, differentiate it from urine, which is acidic
and it is exchanged across the placenta. (pH 5.0–5.5).
At term, the amount of amniotic fluid has
increased so much it ranges from 800 to E. THE UMBILICAL CORD
1200 mL
If for any reason the fetus is The umbilical cord is formed
unable to swallow (esophageal atresia or from the fetal membranes (amnion and
anencephaly are the two most common chorion) and provides a circulatory
reasons), excessive amniotic fluid,or pathway that connects the embryo to the
hydramnios(more than 2000 mL in total, chorionic villi of the placenta. Its function
or pockets of fluid larger than 8 cm on is to transport oxygen and nutrients to
ultrasound), will result. Hydramnios also the fetus from the placenta and to return
tends to occur in women with diabetes, waste products from the fetus to the
because hyperglycemia causes placenta. It is about 53 cm (21 in) in
excessive fluid shifts into the amniotic length at term and about 2 cm (3 ⁄4 in)
space (Bush & Pernoll, 2007). thick. The bulk of the cord is a gelatinous
Early in fetal life, as soon as the mucopolysaccharide called Wharton’s
fetal kidneys become active, fetal urine jelly, which gives the cord body and
adds to the quantity of the amniotic fluid. prevents pressure on the vein and
A disturbance of kidney function may arteries that pass through it. The outer

5
surface is covered with amniotic until the embryo’s hematopoietic system
membrane. is mature enough to perform this function
(at about the 12th week of intrauterine
An umbilical cord contains only life).
one vein (carrying blood from the
placental villi to the fetus) but two arteries
(carrying blood from the fetus back to the
placental villi). The number of veins and
arteries in the cord is always assessed
and recorded at birth because about 1%
to 5% of infants are born with a cord that
contains only a single vein and artery.
From 15% to 20% of these infants are
found to have accompanying
chromosomal disorders or congenital
anomalies, particularly of the kidney and
heart (Lubusky et al., 2007).Blood can be
withdrawn from the umbilical vein or
transfused into the vein during
intrauterine life for fetal assessment or
treatment (termed percutaneous
umbilical blood sampling [PUBS]).

In about 20% of all births, a

loose loop of cord is found around the
fetal neck (nuchal cord) at birth. If this
loop of cord is removed before the
newborn’s shoulders are born, so that
there is no traction on it, the oxygen The yolk sac then atrophies and remains
supply to the fetus remains unimpaired
only as a thin white streak discernible in
(Jackson, Melvin, & Downe, 2007).
Because the umbilical cord contains no the cord at birth. Between the amniotic
nerve supply, it can be cut at birth without cavity and the yolk sac, a third layer of
discomfort to either the child or woman primary cells, the mesoderm, forms. The
embryo will begin to develop at the point
PRIMARY GERM LAYERS where the three cell layers (ectoderm,
At the time of implantation, a entoderm, and mesoderm) meet, called
blastocyst already has differentiated to a the embryonic shield. Each of these
point at which two separate cavities germ layers of primary tissue.
appear in the inner structure: (1) a large Knowing the origins of body
one, the amniotic cavity, which is lined structures helps to explain why certain
with a distinctive layer of cells, the screening procedures are ordered for
ectoderm, and (2) a smaller cavity, the newborns with congenital malformations.
yolk sac, which is lined with entoderm A radiographic examination of the kidney,
cells.In humans, the yolk sac appears to for example, may be ordered for a child
supply nourishment only until born with a heart defect. A child with a
implantation. After that, its main purpose malformation of the urinary tract is often
is to provide a source of red blood cells

6
investigated for reproductive Blood arriving at the fetus from
abnormalities as well. the placenta is highly oxygenated. This
All organ systems are complete, blood enters the fetus through the
at least in a rudimentary form, at 8 umbilical vein (called a vein even though
weeks’ gestation (the end of the it carries oxygenated blood, because the
embryonic period). During this early time direction of the blood is toward the fetal
of organogenesis (organ formation), the heart).Blood flows from the umbilical vein
growing structure is most vulnerable to to the ductus venosus, an accessory
invasion by teratogens (any factor that vessel that directs oxygenated blood
adversely affects the fertilized ovum, directly to the fetal liver.
embryo, or fetus, such as cigarette Blood then empties into the fetal
smoking). inferior vena cava so oxygenated blood
is directed to the right side of the heart.
FETAL CIRCULATION Because there is no need for the bulk of
blood to pass through the lungs, it is
shunted, as it enters the right atrium, into
the left atrium through an opening in the
atrial septum, called the foramen ovale.
From the left atrium, it follows the course
of adult circulation into the left ventricle
and into the aorta. A small amount of
blood that returns to the heart via the
vena cava does leave the right atrium via
the adult circulatory route—that is,
through the tricuspid valve into the right
ventricle, and then into the pulmonary
artery and lungs to service the lung
tissue. However, the larger portion of
even this blood is shunted away from the
lungs through an additional structure, the
ductus arteriosus, directly into the aorta,

MILESTONES OF FETAL GROWTH

AND DEVELOPMENT
As early as the third week of
intrauterine life, fetal blood begins to I. END OF 4TH
exchange nutrients with the maternal GESTATIONAL WEEK
circulation across the chorionic villi. Fetal
circulation differs from extrauterine At the end of the fourth week of
circulation because the fetus derives gestation, the human embryo is a group
oxygen and excretes carbon dioxide not of rapidly growing cells but does not yet
from gas exchange in the lung but from resemble a human being.
gas exchange in the placenta. ● Length: 0.75–1 cm

7
 ● Weight: 400 mg
● The spinal cord is formed and III. END OF 12TH
fused at the midpoint. GESTATIONAL WEEK
● Lateral wings that will form the (FIRST TRIMESTER)
body are folded forward to fuse
at the midline. ● Length: 7–8 cm
● The head folds forward and ● Weight: 45 g
becomes prominent, ● Nail beds are forming on fingers
representing about one-third of and toes.
the entire structure. ● Spontaneous movements are
● The back is bent so that the possible, although they are
head almost touches the tip of usually too faint to be felt by the
the tail. mother.
● The rudimentary heart appears ● Some reflexes, such as the
as a prominent bulge on the Babinski reflex, are present.
anterior surface. ● Bone ossification centers begin
● Arms and legs are budlike to form.
structures. ● Tooth buds are present.
● Rudimentary eyes, ears, and ● Sex is distinguishable by
nose are discernible. outward appearance.
● Urine secretion begins but may
II. END OF 8TH not yet be evident in amniotic
GESTATIONAL WEEK fluid.
● The heartbeat is audible through
● Length: 2.5 cm (1 in) Doppler technology.
● Weight: 20 g
● Organogenesis is complete. IV. END OF 16TH
● The heart, with a septum and GESTATIONAL WEEK
valves, is beating rhythmically. ● Length: 10–17 cm
● Facial features are definitely ● Weight: 55–120 g
discernible. ● Fetal heart sounds are audible
● Arms and legs have developed. by an ordinary stethoscope.
● External genitalia are forming, ● Lanugo is well formed
but sex is not yet distinguishable ● Liver and pancreas are
by simple observation. functioning.
● The primitive tail is regressing. ● Fetus actively swallows amniotic
● The abdomen bulges forward fluid, demonstrating an intact but
because the fetal intestine is uncoordinated swallowing reflex;
growing so rapidly. urine is present in amniotic fluid.
● An ultrasound shows a ● Sex can be determined by
gestational sac, diagnostic of ultrasound.
pregnancy (Fig. 9.8).
V. END OF 20TH
GESTATIONAL WEEK

8
 ● Length: 25 cm could survive if born at that time),
● Weight: 223 g if they are cared for after birth in
● Spontaneous fetal movements a modern intensive care facility.
can be sensed by the mother. ● Hearing can be demonstrated by
● Antibody production is possible. response to sudden sound.
● The hair forms on the head,
extending to include eyebrows. VII. END OF 28TH
● Meconium is present in the GESTATIONAL WEEK
upper intestine. ● Length: 28–36 cm
● Brown fat, a special fat that will ● Weight: 550 g
aid in temperature regulation at ● Meconium is present as far as
birth, begins to be formed behind the rectum
the kidneys, sternum, and ● Active production of lung
posterior neck. surfactant begins.
● Vernix caseosa begins to form ● Eyebrows and eyelashes
and cover the skin. become well defined.
● Passive antibody transfer from ● Eyelids, previously fused since
mother to fetus begins. the 12th week, now open.
● Definite sleeping and activity ● Pupils are capable of reacting to
patterns are distinguishable (the light.
fetus has developed biorhythms ● When fetuses reach 24 weeks,
that will guide sleep/wake or 601 g, they have achieved a
patterns throughout life). practical low-end age of viability
(earliest age at which fetuses
VI. END OF 24TH could survive if born at that time),
GESTATIONAL WEEK if they are cared for after birth in
(SECOND TRIMESTER) a modern intensive care facility.
● Hearing can be demonstrated by
● Length: 28–36 cm response to sudden sound.
● Weight: 550 g
● Meconium is present as far as VIII. END OF 32ND
the rectum GESTATIONAL WEEK
● Active production of lung ● Length: 38–43 cm
surfactant begins. ● Weight: 1600 g
● Eyebrows and eyelashes ● Subcutaneous fat begins to be
become well defined. deposited (the former stringy,
● Eyelids, previously fused since “little old man” appearance is
the 12th week, now open. lost)
● Pupils are capable of reacting to ● Fetus responds by movement to
light. sounds outside the mother’s
● When fetuses reach 24 weeks, body.
or 601 g, they have achieved a ● Active Moro reflex is present.
practical low-end age of viability ● Iron stores, which provide iron
(earliest age at which fetuses for the time during which the

9
 neonate will ingest only milk after ● Creases on the soles of the feet
birth, are beginning to be cover at least two thirds of the
developed. surface
● Fingernails grow to reach the
end of fingertips. PREVENTING FETAL EXPOSURE
TO TERATOGENS
IX. END OF 36TH
GESTATIONAL WEEK A teratogen is any factor, chemical or
● Length: 42–48 cm physical, that adversely affects the
● Weight: 1800–2700 g (5–6 lb) fertilized ovum, embryo, or fetus. At one
● Body stores of glycogen, iron, time, it was assumed that a fetus in utero
carbohydrate, and calcium are was protected from chemical or physical
deposited. injury by the presence of the amniotic
● Additional amounts of fluid and by the absence of any direct
subcutaneous fat are deposited. placental exchange between mother and
● Sole of the foot has only one or fetus. When infants were born with
two crisscross creases, disorders, it was attributed to the
compared with the full crisscross influence of fate, bad luck, or, in some
pattern that will be evident at cultures, evil spirits. Today, it is
term. acknowledged that a fetus is extremely
● Amount of lanugo begins to vulnerable to environmental injury.
diminish.
EFFECTS OF TERATOGENS TO
● Most babies turn into a vertex FETUS
(head down) presentation during
this month. Several factors influence the
amount of damage a teratogen can
X. END OF 40TH cause. The strength of the teratogen is
GESTATIONAL WEEK one of these. For example, radiation is a
(THIRD TRIMESTER) known teratogen. In small amounts
● Length: 48–52 cm (crown to
(everyone is exposed to some radiation
rump, 35–37 cm)
every day, such as from sun rays), it
● Weight: 3000 g (7–7.5 lb)
causes no damage. However, in large
● Fetus kicks actively, hard enough
doses (e.g., the amount of radiation
to cause the mother
necessary to treat cancer of the cervix),
considerable discomfort.
serious fetal defects or death can occur.
● Fetal hemoglobin begins its
conversion to adult hemoglobin. The timing of the teratogenic
The conversion is so rapid that, insult makes a significant impact on
at birth, about 20% of damage done to the fetus. If a teratogen
hemoglobin will be adult in is introduced before implantation, either
character. the zygote is destroyed or it appears
● Vernix caseosa is fully formed. unaffected. If the insult occurs when the
● Fingernails extend over the main body systems are being formed (in
fingertips. the second to eighth weeks of embryonic

10
life), a fetus is very vulnerable to injury. lymphadenopathy. Even in light
During the last trimester, the potential for of these mild symptoms,
harm again decreases because all the ● if the infection crosses the
organs of a fetus are formed and are placenta, the infant may be born
merely maturing. with central nervous system
damage, hydrocephalus,
Two exceptions to the rule that
microcephaly, intracerebral
deformities usually occur in early
calcification, and retinal
embryonic life are the effects caused by
deformities.
the organisms of syphilis and
● Pre Pregnancy serum analysis
toxoplasmosis. These two infections can
can be done to identify women
cause abnormalities in organs that were
who have never had the disease
originally formed normally.
and so are susceptible (about
A third factor determining the
50% of women).
effects of a teratogen is the teratogen’s
● Instruct pregnant women to
affinity for specific tissue. Lead and
avoid undercooked meat and
mercury, for example, attack and disable
also not to change a cat litter box
nervous tissue. Thalidomide, a drug once
or work in soil in an area where
used to relieve nausea in pregnancy,
cats may defecate to avoid
causes limb defects. Tetracycline, a
exposure to the disease.
common antibiotic, causes tooth enamel
● If the diagnosis is established by
deficiencies and, possibly, long-bone
serum analysis during
deformities. The rubella virus can affect
pregnancy, therapy with
many organs: the eyes, ears, heart, and
sulfonamides may be prescribed.
brain are the four most commonly
● Pyrimethamine, an antiprotozoal
attacked.
agent, may also be used. This
drug is an anti folic acid drug, so
TERATOGENIC MATERNAL
INFECTION it is administered with caution
early in pregnancy to prevent
1. Toxoplasmosis reducing folic acid levels.
● Toxoplasmosis, a protozoan
infection, is spread most 2. Rubella
commonly through contact with
● The rubella virus usually causes
uncooked meat, although it may,
only a mild rash and mild
also be contracted through
systemic illness in a woman, but
handling cat stool in soil or cat
the teratogenic effects on a fetus
litter (Friars, 2007).
can be devastating (Johnson &
● As many as 1 in 900
Ross, 2007).
pregnancies may be affected by
● Fetal damage from maternal
toxoplasmosis.
infection with rubella (German
● A woman experiences almost no
measles) includes hearing
symptoms of the disease except
impairment, cognitive and motor
for a few days of malaise and
challenges, cataracts, cardiac
posterior cervical

11
 defects (most commonly patent family, is another teratogen that
ductus arteriosus and pulmonary can cause extensive damage to
stenosis), intrauterine growth a fetus while causing few
restriction (IUGR), symptoms in a woman (Lilleri et
thrombocytopenic purpura, and al.,2007).
dental and facial clefts, such as ● It is transmitted from person to
cleft lip and palate. person by droplet infection such
● Typically, a rubella titer from a as occurs with sneezing.
pregnant woman is obtained on ● If a woman acquires a primary
the first prenatal visit. A titer CMV infection during pregnancy
greater than 1:8 suggests and the virus crosses the
immunity to rubella. A titer of less placenta, the infant may be born
than 1:8 suggests that a woman severely neurologically
is susceptible to viral invasion. A challenged (hydrocephalus,
titer that is greatly increased over microcephaly, spasticity) or with
a previous reading or is initially eye damage (optic atrophy,
extremely high suggests that a chorioretinitis), hearing
recent infection has occurred. impairment, or chronic liver
● A woman who is not immunized disease. The child’s skin may be
before pregnancy cannot be covered with large petechiae
immunized during pregnancy (“blueberry-muffin” lesions).
because the vaccine uses a live ● However, diagnosis in the
virus that would have effects mother or infant can be
similar to those occurring with a established by the isolation of
subclinical case of rubella. After CMV antibodies in blood serum.
a rubella immunization, a woman ● Unfortunately, there is no
is advised not to become treatment for the infection even if
pregnant for 3 months, until the it presents in the mother with
rubella virus is no longer active. enough symptoms to allow
● All pregnant women should avoid detection. Because there is no
contact with children with rashes. treatment or vaccine for the
Infants who are born to mothers disease, routine screening for
who had rubella during CMV during pregnancy is not
pregnancy may be capable of recommended.
transmitting the disease for a ● Women can help prevent
time after birth. Because of this, exposure by thorough hand
an infant may be isolated from washing before eating and
other newborns during the avoiding crowds of young
newborn period. children at daycare or nursery
settings.
3. Cytomegalovirus

● Cytomegalovirus (CMV), a
member of the herpes virus

12
4. Herpes Simplex Virus (Genital ● placental spread of herpes
Herpes Infection) simplex virus has increased the
importance of obtaining
● The first time a woman contracts
information about exposure to
a genital herpes infection,
genital herpes or any painful
systemic involvement occurs.
perineal or vaginal lesions that
The virus spreads into the
might indicate this infection at
bloodstream (viremia) and
prenatal visits.
crosses the placenta to a fetus
● Intravenous or oral acyclovir
posing substantial fetal risk
(Zovirax) can be administered to
(ACOG, 2007)
women during pregnancy (Karch,
● If the infection takes place in the
2009). The primary mechanism
first trimester, severe congenital
for protecting a fetus, however,
anomalies or spontaneous
focuses on disease prevention.
miscarriage may occur.
Urging women to practice safe
● If the infection occurs during the
sex is important to lessen their
second or third trimester, there is
exposure to this and other
a high incidence of premature
sexually
birth, intrauterine growth
● transmitted infections. Advising
restriction, and continuing
adolescents to obtain a vaccine
infection of the newborn at birth.
against HPV (Gardasil) should
Unless recognized and treated,
lessen the incidence of genital
the fetal mortality and morbidity
herpes infection in the future
rates are as high as 80%
(ACOG, 2007).
● If a woman has had herpes
5. Other Viral Diseases
simplex virus type 1 infections
before the genital herpes It is difficult to demonstrate other viral
invasion or if the genital herpes teratogens, but rubeola (measles),
(type 2) infection is a recurrence, coxsackievirus, infectious parotitis
antibodies to the virus in her (mumps), varicella (chickenpox),
system prevent spread of the poliomyelitis, influenza, and viral hepatitis
virus to a fetus across the all may be teratogenic. Parvovirus B19,
placenta. the causative agent of erythema
● If genital lesions are present at infectiosum (also called fifth disease), a
the time of birth, however, a fetus common viral disease in school age
may contract the virus from children, if contracted during pregnancy,
direct exposure during birth. For can cross the placenta and attack the red
women with a history of genital blood cells of a fetus. Infection with the
herpes and existing genital virus during early pregnancy is
lesions, cesarean birth is often associated with fetal death. If the
advised to reduce the risk of this infection occurs late in pregnancy, the
route of infection. This infant may be born with severe anemia
awareness of the

13
and congenital heart disease (Barankin, days; an increasing titer,
2008). however, suggests that
reinfection has occurred. In an
A. Syphilis.
infant born to a woman with
● Syphilis, a sexually transmitted syphilis, the serologic test for
infection, is of great concern for syphilis may remain positive for
the maternal–fetal population up to 3 months even though the
despite the availability of disease was treated during
accurate screening tests and pregnancy.
proven medical treatment, as it is ● The newborn with congenital
growing in incidence and places syphilis may have congenital
a fetus at risk for intrauterine or anomalies, extreme rhinitis
congenital syphilis (Walker, (sniffles), and a characteristic
2009). Early in pregnancy, when syphilitic rash, all of which
the cytotrophoblast layer of the identify the baby as high risk at
chorionic villi is still intact, the birth (Chakraborty & Luck, 2007).
causative spirochete of syphilis, When the baby’s primary teeth
Treponema pallidum, cannot come in, they are oddly shaped
cross the placenta and damage (Hutchinson teeth).
● the fetus. When this layer
B. Lyme Disease.
atrophies at about the 16th to
18th week of pregnancy, however, ● Lyme disease, a multisystem
the spirochete then can cross disease caused by the
and cause extensive damage. If spirochete Borrelia burgdorferi, is
syphilis is detected and treated spread by the bite of a deer tick.
with an antibiotic such as The highest incidence occurs in
benzathine penicillin in the first the summer and early fall. The
trimester, a fetus is rarely largest outbreaks of the disease
affected. If left untreated beyond are found on the east coast of
the 18th week of gestation, the United States (Mullen, 2007).
hearing impairment, cognitive After a tick bite, a typical skin
challenge, osteochondritis, and rash, erythema chronicum
fetal death are possible. migrans (large, macular lesions
● For this reason, serologic with a clear center), develops.
screening (by either a VDRL or a Pain in large joints such as the
rapid plasma reagin test) should knee may develop. Infection in
be done at a first prenatal visit; pregnancy can result in
the test may then be repeated spontaneous miscarriage or
again close to term (the 8th severe congenital anomalies.
month) if exposure is a concern. ● To spread the spirochete, the tick
Even when a woman has been must be present on the body
treated with appropriate possibly as long as 24 hours.
antibiotics, the serum titer After returning home from an
remains high for more than 200 outing, therefore, a woman

14
 should inspect her body carefully well advised not to work with live virus
and immediately remove any products during pregnancy.
ticks found. If she has any
symptoms that suggest Lyme 7. Teratogenic Drugs
disease or knows she has been ● Many women, assuming that the
bitten, she should contact her rule of being cautious with drugs
primary health care provider during pregnancy applies only to
immediately. prescription drugs, take
● Treatment of Lyme disease for over-the-counter drugs or herbal
pregnant women differs from that supplements freely. Although not
for nonpregnant women. The all drugs cross the placenta
drugs used for nonpregnant (heparin, for example, does not
adults, tetracycline and because of its large molecular
doxycycline, cannot be used size), most do. Also, even
during pregnancy because they though most herbs are safe,
cause tooth discoloration and, ginseng, for example, used to
possibly, long-bone malformation improve general well-being, or
in a fetus. A course of penicillin senna, used to relieve
will be prescribed to reduce constipation, may not be safe
symptoms in the pregnant (Der Marderosian & Beutler,
woman. 2007).
● Because the symptoms of Lyme ● Any drug or herbal supplement,
disease are chronic but not under certain circumstances,
dramatic (a migratory rash and may be detrimental to fetal
joint pain), women may not welfare. Therefore, during
report them at a prenatal visit pregnancy, women should not
unless they are educated about take any drug or supplement not
their importance and are asked specifically prescribed or
at prenatal visits if such approved by their physician or
symptoms are present. nurse-midwife.
● A woman of childbearing age
6. Potentially Teratogenic Vaccines
and ability should not take any
Live virus vaccines, such as measles, drug other than one prescribed
HPV, mumps, rubella, and poliomyelitis by a physician or nurse-midwife
(Sabin type), are contraindicated during to avoid exposure to a drug
pregnancy because they may transmit should she become pregnant.
the viral infection to a fetus (Rojas, ● The use of recreational drugs
Wood, & Blakemore, 2007). Care must during pregnancy puts a fetus at
be taken in routine immunization risk in two ways: the drug may
programs to make sure that adolescents have a direct teratogenic effect,
about to be vaccinated are not pregnant. and intravenous drug use risks
Women who work in biologic laboratories exposure to diseases such as
where vaccines are manufactured are

15
 HIV and hepatitis B (Donnelly et eating food), not necessarily the
al., 2008). direct result of the alcohol.
● Narcotics such as meperidine ● However, alcohol has now been
(Demerol) and heroin have long firmly isolated as a direct
been implicated as causing teratogen. Fetuses cannot
intrauterine growth restriction remove the breakdown products
(IUGR). The use of marijuana of alcohol from their body. The
alone apparently does not, large buildup of this leads to
although the long-term effects of vitamin B deficiency and
marijuana during pregnancy are accompanying neurologic
still unstudied. Cocaine, damage.
particularly its crack form, is ● Women during pregnancy should
potentially harmful to a fetus be screened for alcohol use
because it causes severe because an infant born with fetal
vasoconstriction in the mother, alcohol syndrome (FAS) not only
compromising placental blood is small for gestational age but
flow and perhaps dislodging the can be cognitively challenged
placenta. Its use is associated (Shankar, Ronis, & Badger,
with spontaneous miscarriage, 2007).
preterm labor, meconium ● Women are best advised,
staining, and IUGR (Rojas, therefore, to abstain from alcohol
Wood, & Blakemore, 2007). completely. Be certain to ask
● An area of recreational drug use about binge drinking (consuming
that needs to be examined is that more than five alcohol drinks in
of inhalant abuse (“huffing”). an evening) as women may refer
Substances frequently used as to this as only “occasional
inhalants include gasoline, drinking.” Refer women with
butane lighter fluid, Freon, glue, alcohol addiction to an alcohol
and nitrous oxide (NIOSH, treatment program as early in
2007). pregnancy as possible to help
them reduce their alcohol intake.
8. Teratogenicity of Alcohol
9. Teratogenicity of Cigarettes
● Evidence over the years has
shown that when women ● Cigarette smoking is associated
consume a large quantity of with infertility in women.
alcohol during pregnancy, their Cigarette smoking by a pregnant
babies show a high incidence of woman has been shown to
congenital deformities and cause fetal growth restriction
cognitive impairment. It was (Lawrence & Haslam, 2007). In
assumed in the past that these addition, a fetus may be at
defects were the result of the greater risk for being stillborn
mother’s poor nutritional status (Hogberg & Cnattingius, 2007)
(drinking alcohol rather than and, after birth, may be at

16
 greater risk than others for apparently is killed. If the zygote
sudden infant death syndrome. is not killed, it survives
Low birth weight in infants of apparently unharmed. The most
smoking mothers results from damaging time for exposure and
vasoconstriction of the uterine subsequent damage is from
vessels, an effect of nicotine. implantation to 6 weeks after
This limits the blood supply to a conception (when many women
fetus. are not yet aware that they are
● Another contributory effect may pregnant). The nervous system,
be related to inhaled carbon brain, and retinal innervation are
monoxide. Secondary smoke, or most affected.
inhaling the smoke of another ● As a rule, therefore, all women of
person’s cigarettes, may be as childbearing age should be
harmful as actually smoking the scheduled for pelvic x-ray
cigarettes. All prenatal examinations only in the first 10
healthcare settings should be days of a menstrual cycle (when
smoke-free environments for this pregnancy is unlikely because
reason. ovulation has not yet occurred),
● The best way to urge women to except in emergency situations.
discontinue smoking is to A serum pregnancy test can be
educate them about the risks to done on all women who have
themselves and their fetus at a reason to believe they might be
first prenatal visit. It may be pregnant before diagnostic tests
effective to encourage women to involving x-rays are scheduled.
sign a contract with a health care
provider to try to stop or to join a
smoking-cessation program.

10. Radiation

● Rapidly growing cells are

extremely vulnerable to
destruction by radiation. That
makes radiation a potent
teratogen to unborn children
because of their high proportion
of rapidly growing cells.
Radiation produces a range of
malformations depending on the
stage of development of the
embryo or fetus and the strength
and length of exposure. If the
exposure occurs before
implantation, the growing zygote

17