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Recent Advances in High Risk Pregnancy
Dilip Kumar Dutta
SECTION — I: OBSTETRICS COMPLICATIONS
CHAPTER 1:
Pre-eclampsia and Eclampsia
ETIOLOGY AND PATHOPHYSIOLOGY
PLACENTAL BED
Oxidative Stress
Investigation
Classification
Management
Delivery
For evaluation of fetal condition following are important
Severe Pre-eclampsia
Management
Magnesium Sulphate for Seizure Prophylaxis
ANTIHYPERTENSIVE AGENTS
Severe Pre-eclampsia at or after 34 weeks of Pregnancy
Patients before 24 weeks of Pregnancy
Patients Presenting between 24 and 34 weeks of Pregnancy
Maternal Outcome in Pre-eclampsia
Perinatal Outcome in Pre-eclampsia
ECLAMPSIA
Diagnosis
TYPE OF ECLAMPSIA
Management
Anticonvulsant
Dosage of Magnesium Sulphate
Magnesium Sulphate Toxicity
Management
Dosage
Control of Hypertension
Delivery
Care after Delivery
Maternal and Perinatal Outcome
HELLP SYNDROME
Criteria for Diagnosis of HELLP Syndrome2
Maternal and Perinatal Outcome
Management
REMOTE PROGNOSIS
Prevention
CHAPTER 2:
Preterm Premature Rupture of Membranes (PPROMs)
PATHOPHYSIOLOGY
EVALUATION OF PPROMs (Box 2.2)
NEONATAL COMPLICATIONS OF PPROMs
MATERNAL COMPLICATIONS OF PPROMs
Mid-trimester PPROMs
PPROMs Occurring after 26 weeks Gestation
WHEN TO DELIVER?
PPROMs Occurring after 34 weeks Gestation
PPROMs Prior to 32 weeks Gestation
PPROMs Occurring between 32-34 weeks Gestation
POINTS TO REMEMBER
CHAPTER 3:
Preterm Labor
INTRODUCTION
DEFINITION1
INCIDENCE
Relevant Terms and Definitions2
Etiology of Preterm Labor
Epidemiology3
PREDICTION OF PRETERM LABOR
PREVENTION OF PRETERM DELIVERY
CLINICAL FEATURES OF PRETERM LABOR
Symptoms of Premature Labor
Signs of Preterm Labor
Investigations
Management of Preterm Labor
Treatment
Between 20 to 24 weeks of Gestation23
Between 24 to 34 weeks of Gestation
Beyond 34 weeks of Gestation
Preterm Delivery
Neonatal Consequences of Preterm Birth
CONCLUSION
ACOG RECOMMENDATIONS51
Major Recommendations
Classification of Evidence Levels
Grades of Recommendations
CHAPTER 4:
Alloimmunization to Isoimmunization
HISTORICAL ASPECTS
MATERNAL Rh SENSITIZATION
THE DOSE OF ANTIGEN NEEDED TO PRODUCE Rh SENSITIZATION
INCIDENCE
PREVENTION OF Rh D ISOIMMUNIZATION
EVALUATION OF PATIENT WITH SUSCEPTIBILITY TO Rh ISOIMMUNIZATION
Zygosity of Father
Non-invasive Prenatal Determination of Fetal Rh D Status
Maternal Titer
Amniocentesis
Doppler Study
COMPARISON OF AMNIOCENTESIS AND DOPPLER MANAGEMENT
TREATMENT WITH INTRAUTERINE TRANSFUSION
NEONATAL MANAGEMENT
Management of Hyperbilirubinemia
Exchange Transfusion
Intravenous Immunoglobulin
Metalloporphyrins
Hydration
Phenobarbitone and Albumin
Management of Anemia
RBC Transfusion
Erythropoietin
Iron
Management of Other Associated Morbidities
Hydrops Fetalis
Thrombocytopenia
Cholestasis
Long-term Neurological Outcome
CONCLUSION
CHAPTER 5:
Intrauterine Growth Restriction (IUGR)
ASYMMETRIC vs SYMMETRIC GROWTH RETARDATION
CAUSAL FACTORS
Screening the Fetus for Growth Restriction
Biometry and Amniotic Fluid Volumes
Uterine Artery Doppler Measurement
Umbilical Artery Doppler Measurement
Middle Cerebral Artery Doppler
Venous Doppler Waveforms
Three-dimensional Ultrasonography
PREVENTIVE MEASURES
Management
Clinical Management
Labor and Delivery
Outcome
CONCLUSION
CHAPTER 6:
Cerclage and Cervical Insufficiency
DEFINITION
INCIDENCE
Cervical Structure and Function
The Cervical Plug Factor
Etiology
Congenital (Primary)
Traumatic (Secondary)
Dysfunctional
Cervicitis/Stromal Destruction/Hormonal
Multiple Gestation (Infertility)
Pathophysiology of Premature Cervical Ripening
Role of Cytokines
Diagnosis
Management
Cerclage
Patient Selection for Cerclage Procedure
Double Cerclage/Cervical Occlusion
Cerclage: Technical Aspects
CONCLUSION
CHAPTER 7:
Placenta Previa
CLINICAL PRESENTATION AND DIAGNOSIS
Pathophysiology
CLINICAL PRESENTATION
TRANSVAGINAL ULTRASONOGRAPHY FOR PLACENTA PREVIA
Low-lying Placenta in the Second Trimester: Significance
Role of Double Set-up Examination
CONSERVATIVE MANAGEMENT OF PLACENTA PREVIA
Introduction
MANAGEMENT BEFORE 28 WEEKS PREGNANCY
MANAGEMENT AFTER 28 WEEKS PREGNANCY
Asymptomatic Patients
Women Presenting with Bleeding
SURGICAL MANAGEMENT OF PLACENTA PREVIA
Introduction
SURGICAL INTERVENTION
Treatment During Pregnancy but before Viability
Treatment During Pregnancy after Viability
Amniotomy and Vaginal Delivery
Cesarean Section
CHAPTER 8:
Placental Abruption
INTRODUCTION
Pathophysiology
Etiology of Abruption
Diagnosis
CLASSIFICATION OF DEGREE OF PLACENTAL ABRUPTION
Management
Principles of Management
General Measures
Assessment of Fetal Well-being
Early Delivery—Timing and Method of Delivery
Expectant Management
Treatment of Complications
Pitfalls
PERINATAL MORTALITY AND MORBIDITY
Maternal Mortality
CONCLUSION
CHAPTER 9:
Twin Pregnancy
ZYGOSITY AND CHORIONICITY
SONOGRAPHIC DETERMINATION OF AMNIONICITY AND CHORIONICITY
Identification of a Membrane Separating the Fetuses
Fetal Sex Determination
Assess the Presence of Lambda (“Twin Peak”) Sign
Other Signs
RISK FACTORS FOR DIZYGOTIC TWINNING
Sex Ratios with Multiple Fetuses
DIAGNOSIS
MATERNAL COMPLICATIONS
FETAL COMPLICATIONS
TWIN - TWIN TRANSFUSION SYNDROME
ACARDIAC TWIN
CONJOINED TWINS
SINGLE FETAL DEMISE
Preterm Labor
Preterm Premature Rupture of Membranes
ANTENATAL MANAGEMENT
OPTIMAL TIME FOR DELIVERY IN MULTIPLE GESTATIONS
ROUTE OF DELIVERY
Monoamniotic Twins
INTRAPARTUM MANAGEMENT
MANAGEMENT OF SECOND TWIN
THIRD STAGE OF LABOR
TWIN ENTRAPMENT
CHAPTER 10:
Amniotic Fluid Abnormality in Pregnancy
INTRODUCTION
ABNORMALITY OF AMNIOTIC FLUID VOLUME
POLYHYDRAMNIOS (HYDRAMNIOS)
Etiology of Hydramnios
Causes of Polyhydramnios
Increased Fetal Urinary Flow
Increased Lung Fluid
Reduced Swallowing
Other Fetal Abnormalities
Placental
Medical Conditions in the Mother
Diagnosis
PRENATAL ULTRASONOGRAPHY AND POLYHYDRAMNIOS
Prognosis
Management
Amnioreduction
Indomethacin Therapy
OLIGOHYDRAMNIOS
Etiology
Causes of Oligohydramnios7
Diagnosis
PRENATAL ULTRASONOGRAPHY AND OLIGOHYDRAMNIOS
Fetal Prognosis
Management
Amnioinfusion
CONCLUSION
CHAPTER 11:
Venous Thromboembolism in Obstetrics
INTRODUCTION
PHYSIOLOGY OF HEMOSTASIS
The Coagulation Cascade
Endogenous Anticoagulants
Fibrinolysis
PATHOPHYSIOLOGY OF THROMBOSIS IN PREGNANCY
Hypercoagulability
Venous Stasis
Vessel Wall (Intimal) Injury
RISK FACTORS FOR VTE
Inheritable Thrombophilia and Venous Thromboembolism
DIAGNOSIS OF VENOUS THROMBOEMBOLISM
Deep Vein Thrombosis
Signs and Symptoms
INVESTIGATIONS
Doppler Ultrasonography
Venography
Limitations
Isotope Venography
Impedence Plethysmography
Iodine 125 Fibrinogen Counting
Computed Tomographic Venography
Magnetic Resonance Imaging
Duplex Doppler Imaging
D-Dimer Screening
PULMONARY EMBOLISM
Signs and Symptoms
Differential Diagnoses
Investigations
PULMONARY ARTERIOGRAPHY
D-dimer Assays
VENTILATION–PERFUSION SCANNING (V/Q Scan)
SPIRAL COMPUTED TOMOGRAPHIC PULMONARY ANGIOGRAPHY
MAGNETIC RESONANCE ANGIOGRAPHY
LOWER EXTREMITY VENOUS ULTRASONOGRAPHY EVALUATION
MANAGEMENT OF VENOUS THROMBOEMBOLISM
Prepregnancy Counseling
General Measures
THROMBOPROPHYLAXIS
TREATMENT IN ANTENATAL PERIOD
1. Treatment of VTE
Monitoring
2. Management of Life-threatening PTE
Dose
Maintenance
MANAGEMENT DURING LABOR and DELIVERY
POSTNATAL ANTICOAGULATION
CHAPTER 12:
Fetal Death
INTRODUCTION
Definition
Etiology
CLINICAL FEATURES OF FETAL DEATH
Symptoms
Signs
Complications
Management
Breaking Bad News
Expectant Management
Induction of Labor
Indications
Single Fetal Demise in Case of Twin Pregnancy
Postpartum Examination
Careful Examination of Fetus
Careful Examination of Placenta and Cord
Postdelivery Care
Maternal Screening
Prevention
CONCLUSION
SECTION — II: MEDICAL COMPLICATIONS
CHAPTER 13:
Thyroid Disease in Pregnancy
PHYSIOLOGY OF THYROID IN PREGNANCY
FETAL THYROID GLAND
CLASSIFICATION OF THYROID DISEASE IN PREGNANCY
HYPOTHYROIDISM
Overt Hypothyroidism
Investigations
Complications
Treatment
Post Delivery Follow-up
Subclinical Hypothyroidism
Isolated Hypothyroidism
HYPERTHYROIDISM
Overt Hyperthyroidism
Diagnostic Tool
Investigations
Complications
Gestational Transient Thyrotoxicosis
Therapeutic Approach
Subclinical Hyperthyroidism
THYROID STORM OR HEART FAILURE
POSTPARTUM THYROIDITIS
CHAPTER 14:
Renal Disease in Pregnancy
RENAL FUNCTION DURING PREGNANCY
EFFECT OF PREGNANCY ON KIDNEY DISEASE
How Kidney Disease Affects Pregnancy?
RENAL DISEASES OCCURRING IN PREGNANCY
Urinary Tract Infections
Acute Renal Failure
Dialysis-requiring ARF
PREGNANCY IN PRE-EXISTING RENAL DISEASES
Effect of Renal Insufficiency on Pregnancy
Principles of Management
Antenatal Strategy and Decision Making
Managing Pregnant Women Undergoing Dialysis
Pregnancy in Renal Transplant Recipients
CHAPTER 15:
Asthma During Pregnancy
PREVALENCE OF ASTHMA DURING PREGNANCY
ASTHMA SEVERITY CLASSIFICATION
EFFECTS OF UNCONTROLLED ASTHMA ON PREGNANCY
Management
Avoidance of Asthma Triggering Factors
Patient Education
Pharmacologic Therapy
Inhaled Corticosteroids
Cromolyn
Theophylline
Inhaled β2-Agonists
Leukotriene Moderators
Oral (Systemic) Corticosteroids
Management of Allergic Rhinitis
ANTENATAL MANAGEMENT
PHARMACOLOGIC STEP THERAPY DURING PREGNANCY
HOME MANAGEMENT OF ASTHMA EXACERBATION
HOSPITAL MANAGEMENT
Management of Asthma During Labor and Delivery
BREASTFEEDING
SUMMARY
CHAPTER 16:
Hypertension in Pregnancy
PRE-ECLAMPSIA
PATHOPHYSIOLOGY OF PRE-ECLAMPSIA
Morphological Changes
Investigations (Lab findings)
Prediction and Prevention
Prevention of Pre-eclampsia
Management
Criteria for Delivering Patients with Severe Pre-eclampsia
Method of Termination of Pregnancy
1. Induction of Labor
2. Cesarean Section
Management during Labor
Puerperium
ACUTE FULMITANT PRE-ECLAMPSIA (EMINENT ECLAMPSIA)
Management
Eclampsia
Differential Diagnosis
Features Favoring Eclampsia
Causes of Maternal Death
General Management
Specific Management
Regime of MgSO4 for Management of Severe Pre-eclampsia and Eclampsia
Regime
Treatment of Complications
If Fits Controlled
Indication of Cesarean Section
CHAPTER 17:
Diabetes Mellitus in Pregnancy
CLASSIFICATION OF PREGNANT PATIENTS WITH DIABETES
CARBOHYDRATE METABOLISM IN PREGNANCY
Diagnosis of Overt Diabetes During Pregnancy
Detection of Gestational Diabetes
Oral Glucose Challenge Test (OGCT)
Effects of Pregnancy on Diabetes
Effects of Diabetes on the Pregnancy
Maternal Effects
Effects of Diabetes on the Fetus
Neonatal Complication
Management of Diabetes
CHAPTER 18:
Heart Disease in Pregnancy
PRE-PREGNANT MANAGEMENT
ANTENATAL MANAGEMENT
MANAGEMENT OF LABOR
Roll of Cardiac Surgery in Pregnancy with Heart Disease
Open Heart Surgery during Pregnancy
CONGENITAL HEART LEISONS
Left-to-Right
Obtructive Leisons
Cyanotic Heart Disease
Other Cardiovascular Conditions
Pulomonary Hypertension
Peripartum Cardiomyopathy
Ischemic Heart Disease
Marfan's Syndrome and Pregnancy
CHAPTER 19:
Inherited Thrombophilias in Pregnancy
INTRODUCTION
TYPES OF THROMBOPHILIAS
Inherited Thrombophilias
Abnormalities of pro-coagulant Factors
Deficiencies of Endogenous proteins in the coagulation cascade
Factor V Leiden
Associated Risks
Prothrombin Gene Mutation
Associated Risks
Protein C (PC)
Protein S (PS)
Antithrombin
Incidence
Associated Risks
Protein C and Protein S
Antithrombin Deficiency
Acquired Thrombophilias
Mixed Inherited and Acquired
Hyperhomocysteinemia
Associated Risks
Diagnosis of Inherited Thrombophilia
Evaluation of the Placenta from Complicated Pregnancies
MANAGEMENT OF THROMBOPHILIC PREGNANT WOMEN
Antenatal Care
Obstetric Management
Intrapartum
Postpartum
Women Recommencing Warfarin
Breastfeeding
Advice
CONCLUSION
CHAPTER 20:
Antiphospholipid Antibody Syndrome in Pregnancy
INVESTIGATIONS FOR ANTIPHOSPHOLIPID ANTIBODIES
Management
Aims of Treatment during Pregnancy
Drugs
Management Options
Antenatal Management
LABOR AND DELIVERY
POSTPARTUM
CHAPTER 21:
Anemia in Pregnancy
CRITERIA OF PHYSIOLOGICAL ANEMIA
EFFECTS OF ANEMIA ON MOTHER
EFFECTS OF ANEMIA ON FETUS
TYPES OF ANEMIA
Iron Deficiency Anemia
Stages of Iron Deficiency
INVESTIGATING IDA
Laboratory Iron Studies
Serum Iron and Total Iron-Binding Capacity
Serum Ferritin
Evaluation of Bone Marrow Iron Stores
Red Cell Protoporphyrin Levels
Serum Levels of Transferrin Receptor Protein
Chest x-ray in Suspected Pulmonary Tuberculosis
Prophylaxis Supplementation
Prophylaxis
Fortification
Food Fortification in Developing Countries
Biofortification
Treatment of Iron Deficiency Anemia
Oral Route
Parenteral Route
Intravenous Route
Repeated Intravenous Injections
Intramuscular Injections
Role of Erythropoietin
Role of Blood Transfusion
Precaution during Blood Transfusion
Management during Labor
Puerperium
Anemia Associated with Chronic Disease
Megaloblastic Anemia
Folic Acid Deficiency
Vitamin B12 Deficiency
Clinical Features of Megaloblastic Anemia
Diagnosis of Megaloblastic Anemia
Complications of Megaloblastic Anemia
Treatment of Megaloblastic Anemia
Acquired Hemolytic Anemia
Autoimmune Hemolytic Anemia
Drug-induced Hemolytic Anemia
Pregnancy-induced Hemolytic Anemia
Paroxysmal Nocturnal Hemoglobinuria
Aplastic or Hypoplastic Anemia
HEMOGLOBINOPATHIES
Thalassemia
Alpha-thalassemia
Beta-thalassemia
Sickle Cell Hemoglobinopathies
Diagnosis of Hemoglobinopathies
Management of Sickle Cell Disease in Pregnancy
Management of Sickle Cell Crisis in Pregnancy
Prenatal Counseling
Management of Thalassemia in Pregnancy
Hereditary Hemolytic Anemia
CONCLUSION
CHAPTER 22:
Urinary Tract Infection in Pregnancy
INTRODUCTION
Classification
PHYSIOLOGICAL CHANGES IN THE URINARY TRACT DURING PREGNANCY
Anatomical Changes
Functional Changes
ETIOPATHOGENESIS
ASYMPTOMATIC BACTERIURIA (ABU)
Significance of Bacteriuria
Screening for ABU
Treatment of ABU
ACUTE CYSTITIS
ACUTE PYELONEPHRITIS
Management of Acute Pyelonephritis
COMPLICATIONS OF URINARY TRACT INFECTION
SUMMARY
Practice Points
CHAPTER 23:
HIV in Pregnancy
HIV INFECTION
Mode of Infection
ROUTES OF TRANSMISSION
Perinatal Transmission
RISK FACTORS FOR TRANSMISSION IN PREGNANCY
EFFECT OF PREGNANCY ON HIV VIRUS
EFFECT OF HIV INFECTION ON PREGNANCY
COUNSELING
HIV-TESTING
ELISA Test for HIV
Comb AIDS-RS Test (HIV-I and HIV-II) Immunodot Test
HIV Tridot Test
Other Tests
ANTENATAL MANAGEMENT
CHOICE OF ARV DRUGS THERAPY
Prophylactic Therapy
Definitive ARV Drug Therapy
HAART Therapy (Three drug regimen—Highly Active ART)
ADVERSE EFFECTS OF ARV DRUGS
Evidence to Support Use of ARV Therapy
Essentials for success of ARV therapy are:
DECISION FOR CHOICE OF ROUTE OF DELIVERY
MODIFIED OBSTETRICAL PRACTICES
BREASTFEEDING PRACTICES
NEONATAL MONITORING
NEONATAL ARV THERAPY
DECISION FOR CONTRACEPTION
REPRODUCTION IN DISCORDANT HIV COUPLES
ETHICAL ISSUES RELATED TO HIV
UNIVERSAL PRECAUTIONS
PPTCT PROGRAM
FOLLOW UP OF HIV INFECTED WOMEN AFTER DELIVERY
HIV VACCINE
ACKNOWLEDGMENT
CHAPTER 24:
Genital Herpes in Pregnancy
INTRODUCTION
CLINICAL PRESENTATION
Primary Genital Herpes
Nonprimary First Episode Infection
Recurrent Genital Herpes
Asymptomatic Viral Shedding
PERINATAL TRANSMISSION OF Herpes simplex Virus (HSV)
Diagnosis
TREATMENT OF GENITAL HERPES IN PREGNANCY
Antiviral Therapy
Primary or First Episode HSV infection
Recurrent Infection
Disseminated Herpes
NEONATAL HERPES
TREATMENT AND CARE OF THE NEWBORN
STRATEGIES FOR PREVENTING VERTICAL TRANSMISSION OF HERPES
Antenatal
Intrapartum
Postpartum
CHAPTER 25:
Obesity in Pregnancy
INTRODUCTION
EFFECT OF OBESITY ON PREGNANCY OUTCOME
METABOLIC SYNDROME
Intrapartum Complications
Postpartum Complications
Aftercare
Obesity Related Outcomes on the Fetus
Preterm Birth
Macrosomia
Management of Obese Women from Prepregnancy to Postpartum
Preconception Counseling
Optimal Weight Gain
CONCLUSION
SECTION — III: IMAGING TECHNIQUE
CHAPTER 26:
Role of Ultrasonography in High-risk Pregnancy
IMAGING IN HIGH-RISK PREGNANCY
HIGH-RISK PREGNANCY
Women who have Medical Problems before becoming Pregnant
Women who Develop Medical Problems during Pregnancy
Women with Problems related to Pregnancy
Ultrasonography in Obstetrics
CLINICAL APPLICATIONS OF ULTRASONOGRAPHY (USG)
US Evaluation
US Findings
Tubal Pregnancy
Cornual Pregnancy
Interstitial Pregnancy
Cervical Pregnancy
Ovarian Pregnancy
Scar Pregnancy
Intra-abdominal Pregnancy
Heterotopic Pregnancy
Role of USG in Expectant Treatment of Ectopic Pregnancies
Hydatidiform Mole
Routine Anomaly Scan
Detection of Fetal Structural Abnormalities with US during Early Pregnancy
Fetal Head, Spine, and Face
Spina Bifida
Holoprosencephaly
Dandy-Walker Complex
Fetal Nasal Bone
Fetal Neck and NT Screening
Fetal Heart
Fetal Abdominal Wall
Omphalocele
Gastroschisis
Fetal Urinary Tract
Fetal Skeleton
Multiple Gestations
Conjoined Twins
US Evaluation of Fetal Growth: Prediction of Neonatal Outcome
ROLE OF BIOPHYSICAL PROFILE IN ANTENATAL Fetal SURVEILLANCE AND Fetal OUTCOME IN PREGNANCIES WITH IUGR
Placental Morphologic and Functional Imaging in High-risk Pregnancies
Functional Imaging of Placenta
Morphologic Imaging of Placenta
Placenta Previa
Vasa Previa
Placenta Accreta/Percreta
Placental Abruption
Placental Tumors
Can MR Oxygenation Imaging be Used to Assess at Risk Pregnancies?
CHAPTER 27:
Fetal Monitoring during Pregnancy and Labor
INTRODUCTION
HISTORICAL ASPECT
During First and Second Trimester
Third Trimester
Who are the Candidates?
What are the Tests?
1. Fetal Movement Count
2. Nonstress Test
3. Vibroacoustic Stimulation Test
4. Contraction Stress Test
5. Biophysical Profile
6. Doppler Velocimetry
7. Visual Acoustic Stimulation Test
INTRAPARTUM MONITORING
Intermittent Auscultation versus Continuous Monitoring
Fetal Tachycardia
Fetal Bradycardia
Abnormal Baseline Variability
Sinusoidal Pattern
Early Deceleration
Late Deceleration
Variable Decelerations
Labor Admission Test (LAT)
Reactive
Equivocal/Suspicious
Abnormal/Ominous
Fetal Blood Sampling
Fetal Pulse Oximetry (FPO)
Fetal Electrocardiogram Analysis
Fetal Scalp Stimulation (FSS)
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