Bi

rt
hDef
ect

Whati
sabi
rt
hdef
ect
?

Bir
thdefects(al
soknownascongeni
talanomali
es,congeni
talmal
for
mat i
ons,congeni
talabnormal
iti
es
orcongenitaldi
sor
ders)ar
eamajorcauseofdeathanddisabi
li
tyi
nchil
dren.Theyaret
hel eadi
ngcause
ofdeat
har oundtheti
meofbir
th(
peri
natalmor
tal
it
y).

Abirt
hdefectisanyabnormal
it
yoccurr
ingduri
ngpr
egnancy.Bir
thdef
ectsmaybedet ectedatanyt
ime
thr
oughoutaperson’
sli
feornotatal
l
.Theyarecommonlydetect
edduri
ngpregnancy
,attheti
meofbirt
h
orinear
lychi
l
dhood.

Bir
thdefect
smaybest r
uct
ural(
how thebodyisbuil
t)
,functi
onal(
how t
hebodywor ks)
,geneti
c,
chromosomalorbi
ochemi
calandmaybeminorormaj
orinnat
ure.I
nsomecases,
theymaybefat
al.

Themostcommonl yr epor
tedbirt
hdefect
sar echromosomal.Thi
smeanst herearemissi
ng,extr
aor
otherchangestochromosomes, whi
chcontai
nourgeneti
cinf
ormati
on.
Struct
uralbi
rthdef
ectsarelesscommonandi ncludeanomal
iesoftheur
inar
ytractandt
heheart.Some
st
r uct
uralbi
rt
hdefectscanbetreat
edsurgi
cal
ly.

Mi
nororMaj
or?
?

Cl
assi
fi
cat
ionofcongeni
talanomal
ies

Bi
rt
hdef
ect
scanbebr
oadl
ycl
assi
fi
edas:

 St
ruct
ural
:Str
uctur
albi
rt
hdefect
sareabnor
malit
iesinthestr
uct
ureofbodypar
ts.Forexampl
e,
abodypar
tisabsentori
mproper
lyf
ormed.Examplesincl
ude:

o spinabifi
da–i ncompleteclosingoft hebackboneandmembr anesaroundthespinal
cord
o hypospadias–wher ethet ubef rom thebladder(ur
ethr
a)i
sinanabnor malposi
ti
onin
mal ebabi
es
o cl
ef tl
i
p–anabnor malgapint heupperl i
p
o hear tdefect se. gventr
icularseptaldefect–anabnormalconnect
ionbet
weentheleft
andr i
ghtventri
clesofthehear t.
o cl
ubf oot,
mi ssi
ngorabnor mal li
mbs, etc.

Mostst r
uct
uraldef
ectsdev
elopintheear
li
estweeksofpr
egnancywhenallofthe
organsandtheskelet
onarefor
ming.Themostcommonstruct
uralbi
rt
hdef
ectsare
heartdef
ect
s

 Funct
ional
:anomal i
esaf fect
ingthewayt hebodywor ksordev el
ops.Exampl
esi ncl
udethose
aff
ect
ingthener voussy st
em orbrainsuchas:
o Downsy ndrome- -Chromosomeabnor mal
iti
es
o pheny lketonuria–amet aboli
cdi sorderwherethebodycan’ tbr
eakdownt heaminoacid
phenylalani
ne
o haemophi li
a–wher ethebodyl acksaspeci f
icf
act orneededforbl
oodclot
ting
o Tay -Sachsdi sease–adegener ativedisor
deraffecti
ngner v
ecell
sinthebrainandspinal
cord.

1
Ty
pesofMor
phol
ogi
ccongeni
talanomal
ies
-Somecondi
ti
onsar
eduet
oabnor
mal
tissuedev
elopment
:

 Amal formati
onisassoci
atedwit
hadi
sorderofti
ssuedev
elopment
.Malformat
ionsof
ten
occurinthefi
rstt
rimest
er.
 Ady splasi
aisadisor
derattheor
ganl
evelt
hatisduetoprobl
emswitht
issuedevel
opment.

-Condi
ti
onsal
socanar
iseaf
tert
issuei
sfor
med:

 Def ormationi sacondi ti

onar isi
ngf r
om mechani cal str
ess/ f
orcest hatmol dapar tofthe
fetusov erapr ol ongper i
od.Cl ubf oot,f
orexampl e,arecausedbycompr essioni nthe
amni oticcav ity.Def ormat ionsof tenoccuri nthesecondort hirdtrimest er,andcanbedue
tool i
gohydr amni osandi tof teni nv ol
vet hemuscul oskelet alsy st
em andmayber eversi
ble
post natal
ly.Anot herexampl ei st hef lattenedf aceseeni nPot t ersequence.
 Disruptioni nv olvesbr eakdownofnor mal tissuesi.emor phol ogical alt
rati
onofal r
eady
formedst ruct ur esandar ecausedbydest ructivepr ocesses.Di sruptionsar edef ects
occur ri
ngwhennor mal tissuei sdamagedori nterrupted, asi namni oti
cbandsequence.
Exampl esi ncl udesomecasesoff acialcleftsandmi ssingdi gitsorl imbsbyamni oti
cbands,
i
ntest i
nalat resi abyv ascul aracci dents.
 Whenmul t
ipl eef f ectsoccuri naspeci fi
edor deri.e,onemi shapl eadst oot herdisorderand
sooni nacascadeofev ent ,theyar eknownasaSequence.
o ASy ndr ome-i sagr oupofanomal i
esoccur ri
ngt oget herthataspeci ficcommon
cause.Thet ermi ndicat est hatadi agnosi shasbeenmadeandt hatt her i
skof
occur r encei sknown.
o Whi l
ei nAssoci at i
on, li
kei ssyndr omewher egroupofanomal i
esoccur stogether
mor ef requent lythanbychanceal one,butt hecausehasnotbeendet ermined.An
exampl ei sVECTERLassoci ati
on( vertebral,anal,car dial
, t
racheo- esophageal ,r
enal,
andl imbanomal i
es)

Causesofbi
rt
hdef
ect
s

Bi
rt
hdefect
scanoccurduri
nganyst ageofpr
egnancy
,howev
ermostoccuri
nthef
ir
stt
hreemont
hs
whent
heorgansoft
hebabyaredev
eloping.

Fact
orst
hatmaycont
ri
but
etoori
ncr
easet
hechancesofabi
rt
hdef
ecti
ncl
ude:

 Genet i
cs– anal t
eredor‘ f
aulty
’geneorsetofgenesusual l
ymeanst hatthei nfor
mation
containedintheparti
cul
argenei seitherchangedormi ssing.Whenacondi ti
oni si nher
it
ed,
Somet imesthebabyneedstor ecei
veacopyofanaf f
ectedgenef r
om onepar ent( e.
gMar fan
syndrome)orf r
om bothparents(e.
gCy st
icFi
brosi
sorSi ckl
eCel ldi
sease).Somet imesent i
re
chromosomesar einvol
ved.Therecanbet oomanyort oof ewchr omosomesort herecanbea
problem wi
ththestr
uctur
eoft hechromosome,forexample,babieswithDown’sSy ndromehav e

2
 ext racopyoft heent i
rechr omosome21.Genet ict est i
ngandscr eeni ngf ort hemostcommon
disor der scanhel pi dent i
fyanyi ssuespr iort oconcept ionandbi rth.
 Soci o-demogr aphi cf act or s–mat er nalageandsomeet hni cgr oupshav ebeenassoci atedwi th
ani ncr easedr iskofbi rt hdef ect s.Consangui ni t
y( wher epar ent sdescendf rom t hesameki nshi p
andhav esi mi largenet icmake- up)i sal soassoci atedwi thani ncr easedr i
skofbi rthdef ect s.
Coupl est hathav easi mi largenet icmake- upar emor el ikel yt ohav eacommongenev ariation
thatmayr esul ti nabi rthdef ect .Genet icscr eeni ngoft hesecoupl esbef oret ryi
ngf orababymay
i
dent ifypot ent ial i
nher iteddi sor der s.
 Dr ugsandal cohol– Pr obabl y,t hemostwel l-knownt er atogeni cdr ugi st halidomi de.I twas
dev el oped neart he end oft he 1950s byChemi e Gr ünent halas a sl eep-induci ng ai d and
ant iemet i
c.Becauseofi tsabi li
t yt opr ev entnausea,i twaspr escr ibedf orpr egnantwomeni n
[
42]
almost50count r
ieswor ldwi debet ween1956and1962. Unt ilWi lliam McBr i
depubl ishedt he
studyl eadi ng t oi ts wi thdr awalf rom t he mar keti n 1961,about8, 000 t o 10, 000 sev er ely
mal for med chi l
dr en wer e bor n.The mostt y picaldi sor der si nduced by t halidomi de wer e
reduct ionaldef or mi tiesoft hel ongbonesoft heext remi ties.Phocomel ia( congeni talcondi tion
thati nv olv esmal for mat ionsofhumanar msandl egswhi chr esul tsi naf li
pper -li
keappendage) ,
ot her wi sear ar edef ormi ty,t her ef or ehel pedt or ecogni set het er at ogeni cef fectoft henewdr ug.
Amongot hermal for mat ionscausedbyt halidomi dewer et hoseofear s, ey es, brain, kidney ,hear t
,
anddi gest iveandr espi rat oryt ract s.Ast hal idomi dei susedt odayasat reatmentf ormul ti
pl e
my elomaandl epr osy ,sev er albi rthsofaf f
ect edchi ldr enwer edescr ibedi nspi teoft hest rictly
requi r eduseofcont racept ionamongf emal epat i
ent st reat edbyi t.Dr ugssuchasal cohol ,
tobacco,i ll
egaldr ugsandcer t
ai npr escr iptionandov er -the- count ermedi cat i
onsar eal soknown
tocausecongeni talanomal iesi ft akendur ingpr egnancy .Thi si ncl udessomecompl ement ar y
andAy urv edi c( tradi ti
onalI ndian)medi cines.Al coholandt obaccoshoul dbeav oideddur ing
pr egnancy .
 Env i
ronment alf act ors–exposur et opest i
cidesandot herchemi cal s,suchasl eadandmer cur y
(includi ngsomecl eani ngpr oduct s)andr adi at ion( from x- r
aymachi nesorot hersour ces)may
i
ncr easet her iskofbi rthdef ect sandshoul dbeav oidedwher epossi bl e
 Vacci nepr event abl ei nf ect i
ons–dur ingpr egnancyi nf ect ionssuchasr ubel l
aandchi ckenpox
cancausebr ai n,hear t,limbandey eanomal ies.Somei nf ect iousdi seasescanbepr ev entedby
i
mmuni sat ion.Womenpl anni ngapr egnancyshoul densur et heyhav ebeeni mmuni sed.
 Ot heri nf ect i
ons–somei nf ect i
ousdi seasescancauseser ioushar mt ounbor nbabi es:
o Cy tomegal ov ir
us ( CMV) ,a v i
rus spr ead t hr ough bodi l
yf luids,can be passed f rom
mot her st ot hei runbor nbabyandmaycausedi sabi li
t y.Pr egnantwomenshoul dwash
thei rhandsaf terhandl ing bodi lyf lui dsf r
om babi esorchi ldren,f orexampl e,af ter
changi ngnappi esorwi pi ngnoses
o Toxopl asmosi si scausedbyapar asi te.I tcanbet ransmi ttedbyi ngest ionofr aw or
under cookedcont ami nat edmeat ;bydr i
nkingcont ami nat edunpast eur i
sedmi lkorby
exposur et oi nfect edani malf aeces, mai nl ycat s.Toav oidt oxopl asmosi s, ensur emeati s
proper lyst oredandpr epar edanddon’ tconsumer aw oruncookedmeat– ev eni n
rest aur ant s.Av oidchangi ngcatl itterwhi lepr egnant .I fnooneel secanper for mt het ask,
weardi sposabl egl ov esandwashy ourhandst hor oughl ywi thsoapandwar m wat er
after war ds
 Inadequat enut rit
ion–adequat ef olate( orsy nt het i
csuppl ement‘ folicaci d’)bef or eanddur ing
pr egnancymaypr ev entsomeneur alt ube( spi nalcor d)def ect s.Foodsr ichi nf olatei nclude
aspar agus,br occol i
,or anges,bananasandchi ckpeas.Mostwomendonotgetenoughf olat e
from t hei rdi et ,soaf ol i
caci dsuppl ementi sr ecommended.Adef iciencyi ni odinecanal sol ead
toi nt ellect ual di sabi l
ityi nchi ldren.
 Pr e-gest at ionaldi abet es–womenwhohav epr e-gest at i
onaldi abet esar eati ncr easedr iskof
poorheal th out comes.Managementand cont rolofbl ood sugarl ev els bef ore and dur ing
pr egnancymaydecr easet hef requencyandr iskofbi rt hdef ect s.
 Obesi ty–obesi tyi npr egnancyhasbeenassoci at edwi thi ncr easedr iskofcongeni t
alanomal y,
still
bi rthandi nf antdeat h.
 Di et–somef ishmaycont ainhi ghl ev elsofmer cur y.Exposur et omer cur ycanbehar mf ult ot he

3
 nervoussy stem oft hedev elopi
ngfetus.I fy ouar epr egnant ,avoidconsumpti
onoff i
shthat
containhighlevelsofmercur ysuchasshar k,or anger oughy ,swor df
ishandli
ng
 Indi
vidualpregnancyf actors–f orexampl e,t hemot her’
sbl oodandt hebaby’
sbloodmaybe
i
ncompat i
ble(knownasRhesusorRhdi sease) .
 Ferti
li
tytreatment–t hecont ri
buti
onofassi stedr eproduct iv
et echnology(
ART)tobir
thdefect
sis
uncertai
n.Somest udi
eshav eshownaposi tiveassoci ati
onbet weenART andcer tai
nbi r
th
defects,suchascl ef
tli
p/cleftpal
ate,
howev erot herstudiesf oundnoassoci at
ion

Alt
houghsigni
fi
cantpr
ogresshasbeenmadei nident
if
y i
ngetiol
ogi
ccausesofsomebi
rt
hdef
ect
s,
approxi
mat
ely65%havenoknownori
dent
if
iabl
ecause-I
diopat
hicCause

Pr
inci
plesoft
erat
ogenesi
s/t
erat
ology

Ter
atogenesi
sstudi
estheoccurr
enceofbir
thdefect
scausedbyext
ri
nsi
cfact
orst
hatar
ecapabl
eto
cr
osstheplacent
aanddi
sruptt
heembryo/
fet
aldev
elopment
.

Teratol
ogyi sthest udyofenv ir
onment -
inducedcongenit
alabnor
mal i
ties,t
heircauses,andthetreat
ment
opti
onsav ail
abl eforthoseaf f
ected.Theseabnormalit
iesarepri
ncipallyt
her esul
tofinfecti
ons,physi
cal
agents,met aboliccondi t
ionsorchemi calsandcancausedeat haswel lasphy si
cal,behavi
oral
,and
i
ntell
ectualdeficit
s.Themostwi delyacceptedinf
ecti
ousterat
ogensar eknownasTORCHi nfecti
ons.I
fa
womani sinfectedpr enat
ally
,perinat
all
y,peri
part
um,orev enpostnatall
y,thesepathogensar eknownto
causecongeni talbir
thdefects.

TORCHi
nfect
ionscl
assi
cal
l
yincl
ude:

 Toxoplasmosi s
 OtherI
nf ecti
ons(Vari
cel
la,
syphi
l
isandPar
vov
irusB19)
 Rubell
a
 Cytomegal ovi
rus(CMV)
 Herpessi mplexvi
rus(HSV)

TORCHi
nfectionshavealsobeenknownt
oi udeTr
ncl eponemapal
l
idum,Hepat
it
isv
iruses,andhuman
i
mmunodefi
ciencyvi
rus(HIV)
.

Ateratogeni
sanyplant,food,nut
ri
ti
onalst
ate,orphysi
calagentthatcancompr
omi
senor
malf
etal
dev
elopmentandr
esul
tintheproduct
ionofacongeni
tal
malfor
mat i
on.

Anagenti sconsi deredateratogenifit

sadmi ni
str
ationt othepregnantmot
hercauses,di
rect
lyor
i
ndirect
ly,st
ructuralorfunct
ionalabnor
malit
iesi
nthef etus,ori
nthechil
daft
erbi
rt
h,whichmaynotbe
apparentunti
llaterli
fe.

Ateratogencaninducechromosomalabnormalit
ies,preventimplantat
ionoft heconcept
us,andcause
abort
ionoftheearlyembry
o,l
atef
etaldeat
h,congenit
almal for
mations,orint
rauter
inegr
owthretar
dat
ion.
Intheneonatetheremaybefuncti
onalimpai
rment,e.g.deafness.Behaviour
alabnormali
ti
esandment al
ret
ardati
onmayal sooccur
.

Litt
leisknownaboutspeci f
ict
eratogeni
cmechanismsbutsomegeneralpr
inci
pleshav
ebeenf ormulated.
Suscept i
bil
it
ytoterat
ogensisgenet i
cal
lydet
ermi
ned.Ter
atogeni
cagentsmaybebenef ici
alorharmless
tothemot herbutharmfulorl
ethaltotheembryoorthefet
us.Mostdrugsandchemi calswil
lcrossthe
placenta.

4
Thetimi
ngoft heexposureiscrit
ical
lyi
mportantanddet er
minest hetypeoffetalt
oxici
tythatmi
ght
occur
,e.
g.malfor
mationorfunct
ionalimpai
rment.Ter
atogenici
tyisusual
lydose-
dependent
,andther
eis
evi
dencethatt
heter
atogeni
cit
yofadr ugmaybeenhancedbyco- admini
str
ati
onofaseconddrug.

Itwasprev
iouslybeli
evedthatthemammal ianembr y
odev el
opedint
hei mperv
iousuterusofthemot her,
prot
ectedfrom allextr
insi
cf act
ors.Howev er,af
terthethali
domidedisast
eroft he1960's,itbecame
apparentand mor e accepted thatt he devel
oping embryo coul
d be highlyv ul
nerabl
et o certai
n
envi
ronmentalagentsthathavenegli
gibleornon-t
oxiceff
ectstoadul
tindi
vi
duals.

Wi
lson'
s6pr
inci
plesofTer
atol
ogy
/Ter
atogenesi

Whatar
ethe6pr
inci
plesoft
erat
ogenesi
s?

I
nconsider
ingt
heeffect
sofdrugsonpregnancy
,iti
simport
antt
orememberthe6pr i
nci
plesof
t
erat
ology:
geneti
csuscept
ibi
li
ty,
devel
opmentstage,mechani
sms,endpoi
nts,access,
anddose
r
esponse.

Alongwi tht hi
snewawar enessoftheinuter
ov ulner
abi
li
tyofthedev el
opingmammal i
anembr y
ocame
thedev elopmentandr efnementofTheSi
i xPrincipl
esofTerat
ologywhi charesti
llappl
iedtoday.These
pri
nci plesoft er
atologywer eputfor
thbyJi
m Wi l
sonin1959andinhi smonographEnv i
ronmentandBi r
th
[
4]
Def ects. Itisthesepr i
nciplest
hatgui
dethest udyandunderstandingofterat
ogenicagentsandt hei
r
effectsondev elopi
ngor ganisms

 Genet icSuscept ibi li

ty :Suscept i
bil
ityt ot er atogenesisdependsont hegenot ypeoft heconcept us
andt hemanneri nwhi cht hisinteract swi t
hadv erseenv i
ronment alfactors.
 Dev el
opment sSt age:Suscept i
bil
ityt ot eratogenesi svarieswi ththedev elopment alstageatt he
ti
meofexposur et oanadv erseinfluence.Ther ear ecriti
calper i
odsofsuscept ibil
i
tyt oagent sand
organsy stemsaf f ect edbyt heseagent s.
 Mechani sms:Ter at ogeni cagent sacti nspeci ficway sondev elopi
ngcel lsandt i
ssuest oiniti
ate
sequencesofabnor mal development alev ents.
 Access:Theaccessofadv ersei nfluencest odev el
opingt i
ssuesdependsont henat ureoft he
i
nfluence.Sev eralf act or saffectt heabi li
tyofat er
atogent ocont actadev el
opingconcept us,
suchast henat ur eoft heagenti tself,r out eanddegr eeofmat ernalexposur e,rateofpl acent al
tr
ansf erand sy st emi c absor pti
on,and composi t
ion oft he mat ernaland embr y onic/fetal
genot ypes.
 EndPoi nt s:Therear ef ourmani fest ati
onsofdev i
antdev el
opment( Death,Mal f
ormat i
on,Gr owth
Retardat i
onandFunct ional Defect).
 DoseResponse:Mani festati
onsofdev iantdev el
opmenti ncreasei nf r
equencyanddegr eeas
dosagei ncr easesf rom t heNoObser v abl eAdv erseEf fectLev el(NOAEL)t oadosepr oduci ng
100%Let halit
y(LD100) .

Pr
event
ion/
Diagnosi
sofBi
rt
hDef
ect
s

 Befor
ebirth,ultr
asonographyandsometimesmagnet
icr
esonanceimaging,bl
oodtests,
amniocentesis,orchori
onicvi
ll
ussampli
ng
 Aft
erbirt
h,phy sical
examinati
on,ul
tr
asonogr
aphy
,computedtomography,magnet
icresonance
i
maging,andbl oodt est
s

5
Bef
orebi
rt
h

Befor
ebirt
h,doct
orsassesswhet
herawomanisati
ncr
easedr
iskofhavi
ngababywit
habirthdefect
(Pr
enatal
Diagnost
icTesti
ng)
.Thechancei
shi
gherf
orwomenwhohav ethef
oll
owi
ngriskf
actor
s:

 Ol
derage
 Havehadfr
equentmiscar
ri
agesorst
il
lbi
rt
hs
 Havehadotherchi
l
drenwithchr
omosomeabnor
mal
i
tiesorbi
rt
hdef
ect
sorwhodi
edi
n
i
nfancyf
orunknownreasons

Thesewomenmayneedmoni
tor
ingandspeci
alt
est
stof
indoutwhet
hert
hei
rbabyi
sdev
elopi
ng
normal
ly
.

I
ncr
easi
ngl
y,bi
rt
hdef
ect
sar
ebei
ngdi
agnosedbef
oret
hebabyi
sbor
n.

Ult
rasonogr
aphyoft
hefet
usiscommonlydoneduri
ngpregnancy.Magnet
icr
esonanceimagi
ng(MRI)of
thefet
usmayalsobedonewhenindi
cat
ed.Thesei
magingtestscanoft
endetectspeci
fi
cbi
rt
hdefect
s.

Somet i
mesbl oodt est scanalsohelp.Forexampl e,ahighlevelofal pha-fet
oprot ein(AFP)i nthemother
's
bloodmayi ndicat eadef ectofthebr ai
norspi nalcordorcertainotheror gans( seeSecond- Tr
imester
Screeni
ng).Mor erecent l
y,doctorsareusingat estcall
edcel l
-f
reefet alDNAanal y sis.I
nt hi
stest,a
sampleofapr egnantwoman' sbl oodisanalyzedt odeterminewhet herherf etushascer taingenet
ic
disor
ders.Thist estisbasedont hefactthatthemot her'sbloodcont ainsav erysmal lamountofDNA
(geneti
cmat erial)from thefetus.Thistesti
scal l
ednoni nvasi
vepr enatalscreening( NIPS).NIPScanbe
usedtodet ectani ncr easedri
skoft ri
somy21( Downsy ndrome) ,t
risomy13, ortrisomy18andcer tai
n
otherchromosomeabnor malit
ies.Doctorsusuallydofurthertest
ingwhenani ncr easedr i
skofagene
abnormalit
yisdet ected.

Amniocent esi
s( remov i
ngfl
uidfr
om ar oundt hef et
us)orchorionicvi
ll
ussampling(CVS)(removingti
ssue
fr
om thesacar oundt hedev
elopi
ngf etus)mayhel pconfi
rm asuspecteddiagnosis.Theflui
dgot t
enfrom
amniocent esi
scanal sobeanalyzedf orbiochemi calf
actor
s,suchasAFPandacet yl
chol
inestr
ase.In
addit
ion,fetalcel
ls,sl
oughedintotheamni oti
cfluidcanberecov eredandusedf ormetaphase
kary
ot y
pingandot hergenet
icanalysesdur ingtheseprocedures.

Af
terbi
rt
h

Afterbi
rt
h, thedoctordoesaphysical
exami nat
ionoft
henewbor n.Dur
ingthi
sexaminat
ion,
thedoctor
examinesthenewbor n'
sskin,
headandneck, hear
tandlungs,andabdomenandgenital
sandassesses
thenewbor n'snerv
oussy st
em andrefl
exes.Somenewbor nshaveaphy si
cal
appear
ancethatsuggest
sa
certai
ndisor der
.

I
ntheUnitedStates,
mostnewbornsundergor
out
inescr
eeni
ngbl
oodt
est
stodet
ectanumberof
metabol
i
cdi sor
dersandgenet
icdisor
der
s.

I
magi
ngtest
s,suchasul
tr
asonogr
aphy,computedtomography(CT),
andmagneti
cresonancei
magi
ng
(
MRI)
,maybedonebasedontheresul
tsofthephysical
examinat
ionandscr
eeni
ngtests.