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Pregnancy at Risk: A Practical Approach to High Risk Pregnancy and Delivery
Usha Krishna, Duru Shah, Vinita Salvi, Nozer Sheriar
SECTION ONE: EARLY PREGNANCY AT RISK
1:
Physiology of the Luteal Phase
Introduction
Structure and Development of Corpus Luteum
Regulation of Corpus Luteum Steroidogenesis
Paracrine and Autocrine Regulation of Corpus Luteum Function
Inhibin, Activin and Relaxin
Luteolysis
Corpus Luteum Rescue in Case of Pregnancy
Luteal-Follicular Transition
Clinical Significance of Luteal Phase
2:
Cytogenetics of Early Pregnancy Wastage
3:
Early Pregnancy Wastage in Assisted Reproduction
Introduction
What is Viable Pregnancy?
Pregnancy Outcomes
Biochemical Pregnancy (Menstrual Abortion)
Preclinical Abortion
Clinical Abortion
Natural Reproduction Compared to IVF
Incidence of Early Pregnancy Loss in IVF/ICSI Cycles
Incidence of Ectopic Pregnancy in IVF/ICSI Cycles
Incidence of Heterotypic Pregnancy in IVF/ICSI Cycles
Causes of Early Pregnancy Loss in Assisted Reproduction
Advanced Maternal Age
Sperm DNA Fragmentation
Chromosomal Abnormalities
Polycystic Ovarian Syndrome
Ovarian Hyperstimulation
Decreased Endometrial Blood Flow
Immunologic Disorders
Autoimmune (Against Self)
Alloimmune Response
Infectious Causes
Obesity
Hormonal Disorders
Pathological Lesions of the Uterus, Endometrial Cavity and Fallopian Tubes
Miscellaneous Factors
Summary
4:
Pregnancies after Embryo Reduction
Introduction
Complications
Factors Influencing the Risk of the Procedure
Choice of Technique
Starting Number of Pregnancies
Number of Fetuses Retained
Timing of the Procedure
5:
Current Status of Surgical and Nonsurgical Management of Ectopic Pregnancy
Introduction
Surgical Treatment
Laparotomy Versus Laparoscopy
Persistent EP After Conservative Surgical Treatment
Reproductive Outcome
Nonsurgical Treatment
Methotrexate
Systemic Methotrexate
Local Methotrexate
Local Versus Systemic Methotrexate
Prognostic Factors
Pain, beta-hCG and US Findings after Methotrexate Treatment
Expectant Management
Unusual Clinical Presentations
Conclusions
6:
Ovarian Hyperstimulation Syndrome in Pregnancy
Introduction
Incidence
Pathophysiology
Classification
Risk Factors
Prevention of OHSS
Management of OHSS
Outpatient Management
Criteria for Hospitalization
Hospital Management
Correction of Fluid Imbalance
Prevention of Thrombosis
Management of Ascites and Pleural Effusion
Surgical Therapy
Drugs
Pregnancy Care
SECTION TWO: RECURRENT PREGNANCY LOSS
7:
Management of Congenital Uterine Abnormalities
Conclusion
Acknowledgment
8:
Acquired Uterine Abnormalities Leading to Pregnancy Risk
Introduction
Uterine Fibroids
Conception Rate and Pregnancy Loss Post-myomectomy
Laparoscopic Myomectomy
Complications Encountered During Pregnancy
Interval Between Myomectomy and Pregnancy
Hysteroscopic Myomectomy
Uterine Artery Embolization (UAE)
Mechanism of Action
Interval between Uterine Artery Embolization and Pregnancy
Myomectomy vs UAE
Antenatal Complications after UAE
Placenta Accreta and Postpartum Hemorrhage (Post UAE)
Müllerian Anomalies
Bicornuate and Didelphic Uterus
Septate Uterus
Surgical Intervention and Outcome
Incompetent Cervix and Müllerian Anomalies
Intrauterine Adhesions (IUA)
Surgical Intervention and Pregnancy Outcome
Endometrial Ablation
Uterine Rupture During Pregnancy after Operative Hysteroscopy
Conclusion
9:
The Incompetent Cervix
Introduction
History
Definition
Etiology
Pathogenesis
Diagnosis
Advantage of Diagnostic Ultrasound
Methods of Treatment
Technical Details
High Cerclage (Figs 9.2 and 9.3)
Low Cerclage (Fig. 9.4)
Abdominal Cerclage (Figs 9.5A to C)
Complications of Cerclage Operation
Emergency Cerclage (Wurm Procedure)
Prophylactic Cerclage
Lash Procedure (Figs 9.7A to C)
Occlusion Suture (Double Cerclage)
Evidence-based Medicine: RCOG Trial
Possible Developments
10:
Antiphospholipid Syndrome
Introduction
Classification
Primary APS (PAPS)
Secondary APS (SAPS)
Familial APS Syndrome
Catastrophic APS (CAPS)
Diagnosis
Antibody Testing
Antiphospholipid Antibodies (aPL)
Lupus Anticoagulant
Anticardiolipin Antibodies
Revised Classification Criteria for the Antiphospholipid Syndrome
Indications for Testing
Mechanism of Pregnancy Loss
Management
Preconception Counseling
Low-dose Aspirin
Heparin
Low Molecular Weight Heparin
Fetal Monitoring
Postpartum Prophylaxis
Other Drugs Used in APS Syndrome
Warfarin
Corticosteroids
Intravenous Immunoglobulins
Plasmapheresis or Plasma Exchange
Fluvastatin
Summary
11:
Immunotherapy for Recurrent Abortion
Introduction
Paternal Human Leukocyte Antigen (HLA) Typing
Mixed Lymphocyte Culture (MLC) Reactivity
Antipaternal Lymphocytotoxic (anti-HLA) Antibody
Natural Killer (NK) Cell
Role of T Lymphocytes
Treatment
Patient Selection
Selection Criteria for Immunotherapy
Dosage
Frequency of Dose
Side Effects
Results
Intravenous Immunoglobulin (IVIG)
Indications
Conclusion
SECTION THREE: INFECTION IN PREGNANCY
12:
Toxoplasmosis in Pregnancy
Background
Epidemiology
Life Cycle
Transmission
Incidence and Prevalence
Pathology
Congenital Toxoplasmosis
Clinical Manifestations
Screening
Diagnosis
Serologic Tests
Measurement of IgG Antibodies
Measurement of IgM Antibodies
Interpretation of Results
Tests in Pregnancy to Distinguish between Acute and Chronic Infection
Fetal Infection—Prenatal Diagnosis
Prevention of Toxoplasmosis in Pregnant Women
Treatment
Prepregnancy
Prenatal
Labor and Delivery
Postpartum
13:
Rubella in Pregnancy
Introduction
Rubella Virus
Pathogenesis
Congenital Rubella Syndrome (CRS)
Risk of Transmission to Fetus and Outcome
CRS Classification
CRS Case
Suspected Case
Probable Case
Confirmed Case
Infection Only
Diagnosis
Laboratory Diagnosis
Prenatal Diagnosis
Therapy
Maternal Reinfection
Control and Prevention
Conclusions
Practice Points
14:
Perinatal Viral Infections
Human Papilloma Virus
Epidemiology
Microbiology
HPV Genome
Infection
Maternal-Fetal Transmission
Diagnosis
Laboratory Diagnosis
Treatment
Prevention
Cytomegalovirus
Epidemiology
Microbiology
Infection
Diagnosis
Management
Herpes Simplex Viral Infections
Epidemiology
Microbiology
Pathogenesis
Infection
Primary Infection
Initial Nonprimary Infection
Recurrent Herpes
Diagnosis
Laboratory Diagnosis
Management
Current Management Recommendations
Treatment
Acyclovir Use in Pregnancy
Future Management Strategies
Vaccines
Topical Use of Monoclonal Antibodies/Monoxynol-9
Varicella-Zoster Virus (VZV)
Epidemiology
Microbiology
Infection
Maternal-Fetal Transmission
Diagnosis
Viral culture
Direct VZV Detection
Serological Tests
Management
Parvovirus B19
Epstein-Barr Virus (EBV)
Other RNA Viruses
Enteroviruses
Influenza
Mumps
Venezuelan Equine Encephalitis (VEE) Virus
15:
Syphilis
Introduction
Primary Syphilis
Secondary Syphilis
Tertiary Syphilis
Diagnosis
Screening
Fetal and Neonatal Implications
Treatment
Jarish-Herxheimer Reaction
Treatment in Patients Allergic to Penicillin
Follow-up
Treatment of Congenital Syphilis
Conclusion
16:
Mycoplasma and Chlamydia in Pregnancy
Introduction
Mycoplasma Hominis, Ureaplasma Urealyticum
Chlamydia Trachomatis
Impact of Mycoplasma and Chlamydia on Pregnancy Outcome
Pregnancy Wastage
Congenital Malformations
Preterm Labor (PTL), Premature Rupture of Membranes (PROM)
Perinatal Infection
Clinical Presentation
Management
Screening for Mycoplasma and Chlamydia
Laboratory Investigations
Culture of Mycoplasma and Ureaplasma
Recent Advances in Laboratory Diagnosis
Clinical Management
Conclusions
17:
AIDS: Its Effects on Pregnancy and the Newborn
WHO Staging Sytem for HIV Infection and Disease in Adults and Adolescents
Clinical Stage I
Clinical Stage II
Clinical Stage III
Clinical Stage IV
Modes of Transmission
Factors Affecting Vertical Transmission
Effect of HIV on Pregnancy
HIV/AIDS and its Effects on Pregnancy
HIV Infected Women
Interventions for Prevention of Maternal to Newborn Transmission of HIV/AIDS
Diagnosis
Major Sign
Minor Signs
Counseling of HIV Positive Pregnant Women
Pre-and-Post Test, its Limitations and Confidentiality
Issues in Counseling HIV Positive Pregnant Women
Considerations Regarding Mode of Childbirth
Mother and Newborn Care during Labor, Delivery, Postpartum
First Stage of Labor
Second Stage of Labor
Third Stage of Labor
Postpartum
Fixed Drug Combinations
Management of HIV Infection
Antenatal Management
Management during Labor
Diagnosis and Management in Newborn
Goals of ART Therapy
Antiretroviral Therapy
Nucleoside Reverse Transcriptase Inhibitors
United Nations Newborn Feeding Recommendations for Hiv Infected Mothers
Contraceptive Advice
18:
Maternal Infections: A Laboratory Review
Toxoplasma
Toxoplasma Avidity Test
Rubella
Rubella Avidity Test
Definite Diagnosis in Unborn Baby
Diagnosing Rubella Infection in Neonates
CMV
Herpes Simplex
HIV
Poliomyelitis
Gonorrhea
Syphilis
Chlamydia
Influenza
Interpretation of Test Results
19:
Malaria in Pregnancy
Introduction
Disease Burden
World
India
Malaria in Pregnancy
Causative Organisms
Pregnancy and Malaria
Changes in Placenta
Clinical Features
Fever
Anemia
Splenomegaly
Effects of Malaria on Pregnancy and Fetus
Effects of Pregnancy onMalaria
HIV and Malaria
Complications of Malaria in Pregnancy
Risk to the Mother
Risk to the Fetus
Diagnosis
Microscopic Tests
Peripheral Smear Study—The MP Test
Quantitative Buffy Coat (QBC) Test
Non-microscopic Tests
Rapid Diagnostic Tests
Differential Diagnosis
Management of Malaria in Pregnancy
Drug Treatment in Pregnancy
Chloroquine
Amodiaquine
Sulfadoxine/Pyrimethamine
Mefloquine
Quinine
Quinidine
Artemisinin and its Derivatives
Atovaquone
Treatment of Vivax Malaria in Pregnancy
Management of Complications
Acute Pulmonary Edema
Hypoglycemia
Anemia
Renal Failure
Septicemic Shock
Management of Labor
Chemoprophylaxis in Pregnancy
Chemoprophylaxis in Breastfeeding
Personal Protection Against Mosquitoes
Control Measures to Reduce the Burden of MiP in India
Malaria Vaccines
Vaccine SPf66
Vaccine Against Malaria in Pregnancy
20:
Amebiasis, Giardiasis and Intestinal Helminthic Infections
Giardiasis
Diagnosis
Treatment
Worm Infections
Intestinal Nematodes
Hookworm Disease
Diagnosis
Treatment
Ascariasis (Roundworm Infection)
Diagnosis
Treatment
Enterobiasis (Threadworm, Pinworm and Oxyuria Infection)
Diagnosis
Treatment
Strongyloidosis
Diagnosis
Treatment
Trichuriasis (Trichocephaliasis, Whipworm Infection)
Diagnosis
Treatment
Cestode (Tapeworm Infections)
Diagnosis
Treatment
Echinococcosis (Hydatid Disease)
Diagnosis
Treatment
Trematodes
Diagnosis
Treatment
Tissue Nematodes
Filariasis
Diagnosis
Treatment
21:
Hepatitis in Pregnancy
Introduction
Viral Hepatitis
Hepatitis A
Hepatittis B
Hepatitis C
Hepatitis D Virus
Hepatitis E Virus
Autoimmune Hepatitis
Herpes Simplex Hepatitis
22:
Pregnancy and Tuberculosis
Introduction
Clinical Features
Unusual Clinical Presentations of Tuberculosis in Pregnancy
Tuberculosis Meningitis
Intestinal Obstruction
Ectopic Pregnancy
Tuberculous Mastitis
Investigations
Natural History of Tuberculosis Infection (Glassroth)20
Management of a Case of Pregnancy with Tuberculosis
Prenatal Management
Intranatal Management
Postnatal Management
Computerized Axial Tomography
Chemotherapy During Pregnancy
Drug Resistant Tuberculosis
Management of the Neonate
Effect of Pregnancy on Tuberculosis
Effect of Tuberculosis on Pregnancy
Congenital Tuberculosis
Conclusion
SECTION FOUR: INVESTIGATIONS IN THE PREGNANCY AT RISK
23:
Early Pregnancy Assessment
Common Reasons for Assessment
Serum Human Chorionic Gonadotropin (β-hCG)
When are Serial β-hCG Determinations Appropriate?
Natural History of Early Pregnancies
Ultrasound for Assessment in Early Pregnancy
RCOG Guidelines for Ultrasonography in Early Pregnancy
Gestational Sac
Embryo
Cardiac Activity
Yolk Sac
Gestational Age Assessment6
Subchorionic Hemorrhage
Fetal Viability
Clinical Correlations
Threatened Abortion
Role of Chromosomal Abnormalities in Spontaneous Losses
Ectopic Pregnancy
Suspected Trophoblastic Disease (Hydatidiform Mole)
Provision of Anti-D in Non-sensitized Rhesus Negative
Prenatal Screening of Fetal Defects (Chromosomal and Structural)
Fetal Neck and NT Screening
Nasal Bone (NB)
Frontomaxillary facial (FMF) Angle
Fetal Head
Anencephaly
Ventriculomegaly
Holoprosencephaly
Diaphragmatic Hernia
Fetal Heart
Tricuspid Flow
Ductus Venosus (DV)
Fetal Urinary Tract
Megacystis (Longitudinal Bladder Diameter ≥7 mm)
Fetal Abdominal Wall
Omphalocele/Exomphalos
Gastroschisis
Spina Bifida
Body Stalk Anomaly
Fetal Skeleton
Skeletal Dysplasias
Multiple Gestations
Conjoined Twins
Screening for Other Conditions
Conclusions
24:
Role of Genetic Investigations and Counseling
Assessing Pregnancy Risk Factors (Preconception – Prenatal)
Genetic Screening for Gamete Donors
Types of Prenatal Genetic Investigations
Screening Tests
Maternal Serum Screening
Combined Screening Tests
Serum Alpha-fetoprotein
Population Screening
Screening for Thalassemia
Diagnostic Methods of Fetal Diagnosis (Table 24.3)
Fetal Ultrasound and Color Doppler Sonography
Color Doppler
Placental and Umbilical Vessels
Renal Vessels
Intracranial Vessels
Intrathoracic Vessels
Intra-abdominal Vessels
Fetal Tumors
Visualization of Fluid Movements
Oligohydramnios: Differential Diagnosis
Laboratory Methods of Fetal Tissue Analysis
Fetal Karyotyping
Fetal Enzyme Assay
Fetal DNA Diagnosis
Preimplantation Genetic Diagnosis (PGD)
Problems in Preimplantation Chromosomal Diagnosis
Biopsy Techniques
Polar Body Biopsy (Noninvasive to Embryo)
Cleavage Stage Biopsy (6–8 Cells)
Blastocyst Biopsy
Uterine Lavage
Fetal Cells in Maternal Blood
Impact on Prevention
25:
Transvaginal Obstetric Ultrasound
Introduction
Technique of Examination
Normal Sonographic Findings in the First Trimester
Gestational Sac
Yolk Sac
Amnion
Embryo
Abnormal Sonographic Findings
Blighted Ovum/Anembryonic Gestation
Abortions
Ectopic Pregnancy
Gestational Trophoblastic Disease
Multiple Gestation
Signs of Early Pregnancy Failure
Fetal Anomalies
First Trimester Masses
Ovarian Masses
Uterine Masses
Cervical Length
Placenta Previa
Use of Transvaginal Doppler
Conclusion
26:
Color Flow Imaging in Obstetrics: Understanding its Art, Science and Technology
Introduction
Imaging Principles
Clinical Uses
How the Color Image is Formed
Asynchronous Color Flow Imaging
Synchronous Color Flow Imaging
Color Coding: The Information
Color in Relation to Obstetrics
Normal Pelvic Blood Flow
Ovarian Flow
Uterine Flow
Iliac Flow
Pregnancy
Technical Considerations in First Trimester
Abnormal First Trimester
Second and Third Trimester
Problem in Acquiring and Interpreting the Waveforms (Cudleigh and Pearce)
Artifactual Loss of End-diastolic Frequencies
Failure to Obtain a Signal
Uteroplacental Waveforms
Assessment of Maternal-Placental Unit (Fig. 26.3)
Means of Acquiring the Signal
Procedure
Combined Uteroplacental and Umbilical Artery Waveforms
Low Resistance Uteroplacental Waveforms
Normal Umbilical Artery Waveforms
Absent End-diastolic Frequencies in the Umbilical Artery Waveforms
High Resistance Uteroplacental Waveforms
Normal Umbilical Artery Waveforms
Absent End-diastolic Frequencies in the Umbilical Artery Waveforms
Mixed Resistance Pattern in the Uteroplacental Waveforms
Normal Umbilical Artery Waveforms
Absent End-diastolic Frequencies in the Umbilical Artery Waveforms
High Resistance Uteroplacental Waveforms
Absent End-diastolic Frequencies in the Umbilical Artery Waveforms and/or Reversal of Flow
Low Resistance Uteroplacental Waveforms
Absent End-diastolic Frequencies in the Umbilical Artery Waveforms
High Resistance Uteroplacental Waveforms
Normal Umbilical Artery Waveforms
Low Resistance Uteroplacental Waveforms
Normal Umbilical Artery Waveforms
Pathophysiology of Fetal Distress and Death
Indicators for Fetal Wellness
Tests for Fetal Wellbeing
Duplex Evaluation in Normal and High Risk Pregnancy
Color Coded and Pulsed Doppler Studies
Uterine Artery
Fetoplacental Circulation
Doppler Sampling Sites in the Fetus
Umbilical Artery
Middle Cerebral Artery
Ductus Venosus
Descending Aorta
Hypoxemia
Hypoxia
Asyphyxia or Acidosis
Summary
Conclusion
27:
Clinical Applications of Color Doppler
Introduction
Clinical Uses of Color Doppler
Color Doppler in Growth Restriction
Color Doppler in Fetal Anemia
Color Doppler in Fetal Anomalies
Color Doppler in Predicting Pre-eclampsia
Color Doppler in Down Syndrome Screening
3D Power Doppler Ultrasound (3D PDU)
28:
Biophysical Methods for Assessing Fetal Well-being
Introduction
Tests for Assessment of Biophysical Activity
Fetal Movement Count
Nonstress Test
Biophysical Profile
Technique for the Biophysical Profile
Physiological Basis of Biophysical Profile
Normal Fetal Behavior
Absent Fetal Behavior: How Long is Too Long?
Gradual Hypoxia Concept
Modified Biophysical Profile
Technique for Modified Biophysical Profile
The Effects of Medications on the Biophysical Profile
Visual Acoustic Stimulation Test
Chronic Responses
Amniotic Fluid Index
Sympathetic Responses
Startle Response
Acceleration
Behavioral States
Timing for Starting Fetal Surveillance
29:
Intrapartum Monitoring
30:
Antenatal Ultrasound Screening for Fetal Malformations
Introduction
Utility of Routine Antenatal Ultrasound Screening
Factors Affecting the Results of Routine Ultrasound Screening
Systematic Fetal Examination: ‘The Rule of Thre’
First Trimester screening for Anomalies
Conclusion
31:
Fetal MRI
SECTION FIVE: ENDOCRINE DISORDERS IN PREGNANCY
32:
Pregnancy Complications Associated with PCOS
Introduction
Background
Diagnosis
Epidemiology of PCOS
Pathophysiology of PCOS
Hypothalamopituitary Ovarian Axis Compartment Abnormalities
Androgen Excess
Ovarian Source
Adrenal Source
Systemic Metabolic Alteration
Hyperprolactinemia
Anovulation
Obesity and Insulin Resistance
Genetic Basis of PCOS
Long-term Health Risks
Endometrial and Ovarian Cancer
Diabetes Mellitus
Hypertension
Coronary Artery Disease
Pregnancy Complications Associated with PCOS
Early Pregnancy Loss
Etiology of EPL
Gestational Diabetes Mellitus
Gestational Hypertension
Preterm Delivery
Macrosomia
Mode of Delivery
Cesarean Section
Instrumental Vaginal Delivery
Perinatal Outcome
Small for Gestational Age (SGA) Babies
NICU Admissions
Perinatal Mortality
Role of Metformin
Metformin and Early Pregnancy Loss
Metformin and Gestational Diabetes
Conclusion
33:
Gestational Diabetes Mellitus
Diagnostic Criteria
Pathogenesis
Complications
Screening
Treatment
Medical Nutrition Therapy
Exercise
Insulin
Oral Agents
Glucose Monitoring
Antepartum Fetal Assessment
Peripartum Considerations
Postpartum Considerations
Use of Hypoglycemic Drugs during Lactation
Conclusion
34:
Thyroid Disorders in Pregnancy
Introduction
Normal Thyroid Physiology during Pregnancy
Autoimmune Thyroid Disease (AITD)
Euthyroid Status
Hypothyroidism
Subclinical Hypothyroidism
Overt Hypothyroidism
T4 Therapy during Pregnancy
Screening for Maternal Hypothyroidism during Pregnancy
Recommendations
Hyperthyroidism
Graves' Disease
hCG-mediated Hyperthyroidism
Diagnosis
Treatment of Hyperthyroidism
Antithyroid Drug (ATD) Therapy
Postpartum Thyroid Dysfunction
Postpartum Thyroiditis
Graves' Disease
Goiter and Nodules
Thyroid Cancer
Thyroid Function in the Fetus
Fetal/Neonatal Graves' Disease
35:
Adrenal Diseases in Pregnancy
Introduction
Adrenal Physiology during Pregnancy
Cushing's Syndrome (CS)
Treatment of Cushing's Syndrome
Hypocortisolism or Adrenocortical Insufficiency (AI)
Treatment of AI
Congenital Adrenal Hyperplasia (CAH)
Pheochromocytoma during Pregnancy
SECTION SIX: MEDICAL DISORDERS IN PREGNANCY
36:
Anemia in Pregnancy
Introduction
Definition
Classification
Prevalence
Common Causes of Anemia during Pregnancy
Iron Deficiency Anemia
Pathophysiology
Undernutrition in Pregnancy in India
Clinical Manifestations
Diagnosis
Recent Investigations
Differential Diagnosis
Megaloblastic Anemia (Folic Acid Deficiency Anemia)
Pathophysiology
Clinical Manifestations
Diagnosis
Other Anemias
Management
Iron Deficiency Anemia
Prevention
Curative Treatment
Response to Iron Therapy
Blood Transfusion
Role of Erythropoietin (EPO)
Management during Labor
Puerperium
Contraception
37:
Maternal and Fetal Outcome in Heart Disease
Introduction
Prepregnancy Counseling
Rheumatic Heart Disease
Mitral Stenosis
Mitral Regurgitation
Aortic Stenosis
Aortic Regurgitation
Endocarditis Prophylaxis
Congenital Heart Disease
Bicuspid Aortic Valve Stenosis
Coarctation of the Aorta
Marfan Syndrome and Aortic Dissection
Ventricular Septal Defect
Atrial Septal Defect
Patent Ductus Arteriosus
Repaired Tetralogy of Fallot
Pulmonary Hypertension and the Eisenmenger Syndrome
Acquired Heart Disease
Ischemic Heart Disease
Cardiomyopathy
Dilated Cardiomyopathy
Hypertrophic Cardiomyopathy
Peripartum Cardiomyopathy
Prosthetic Valves
Tachyarrhythmia
Conclusion
38:
Management of Seizures during Pregnancy
Introduction
Cortical Venous Sinus Thrombosis (CVT)
Management of Cortical Venous Thrombosis
Posterior Reversible Leukoencephalopathy Syndrome (PRLE)
Epilepsy and Pregnancy
Effect of Pregnancy on Epilepsy
Effect of Epilepsy on Pregnancy
Infertility
Complications of Pregnancy
Effect of Epilepsy and AED on Fetus
Malformations
Neuro-cognitive Development and AED Exposure in Utero
Preconception Management
Management of Epilepsy during Pregnancy
Monitoring for Fetal Malformations
Postpartum Management
Breastfeeding
Spacing and Contraception
Conclusion
39:
Nutritional Deficiency in Pregnancy
Introduction
Physiological Considerations Related to Requirement of Different Nutrients and Their Deficiencies
Energy Requirement and Weight Gain
Calorie
Protein/Amino Acids
Fat/essential Fatty Acids
Dietary Fibers
Vitamins
Folic Acid
Vitamin B12
Vitamin B6
Vitamin C
Vitamin E
Vitamin A
Vitamin D
Minerals
Iron
Calcium
Iodine
Zinc
Magnesium, Selenium, Copper, Manganese, Fluoride
High Risk Group From Nutritional Aspect
Teenage Pregnancy
Multiparity with Poor Birth Spacing
Obesity
Chronic Diseases and Infections
Long-term Drug Users
Diabetes
Multiple Pregnancy
Obstetric Problems Possibly Related to Nutritional Deficiency
Abortion
Congenital Malformation
Pre-eclampsia
Placental Abruption
IUGR
Conclusion
40:
Liver Disease in Pregnancy
Introduction
Liver Function Tests
Tests Based on Detoxification and Excretory Functions
Bilirubin levels
Serum Enzymes
Tests that Measure Biosynthetic Function of Liver
Serum Albumin
Serum Globulins
Coagulation Factors
Acute Fatty Liver of Pregnancy (AFLP)
Risk Factors
Acute Fatty Liver can Recur in Subsequent Pregnancies
Symptoms
Diagnosis
Differential Diagnosis
Treatment
Delivery of Fetus
Intrahepatic Cholestasis of Pregnancy (ICP)
Prevalence
Etiology
Multifactorial
Symptoms
Diagnosis
Differential Diagnosis
Prognosis
Treatment
Ursodeoxycholic Acid
Hellp Syndrome
Etiopathogenesis
Mississippi Classification of HELLP Syndrome 11
Symptoms
Diagnosis
Treatment
Prognosis
Hyperemesis Gravidarum10
Acute Viral Hepatitis
Clinical Phases
Prodromal Phase
Icteric Phase
Recovery or Post-icteric Phase
Liver Function Tests in Acute Viral Hepatitis
Serum Bilirubin
Serum Transaminases
Alkaline Phosphatase
Hepatitis A
Hepatitis B
Chronic Hepatitis
Hepatitis C
Hepatitis D
Hepatitis E
Maternal and Perinatal Outcome
Prevention
Treatment of Viral Hepatitis
Autoimmune Hepatitis (AIH)
Effect of AIH on Pregnancy
Effect of Pregnancy on AIH
Treatment
Wilson's Disease
Diagnosis
Effect on Pregnancy
Treatment
Cirrhosis and Pregnancy20
Drug Induced Liver Disease
Hepatic Rupture in Pregnancy
Symptoms
Treatment
Prognosis
Budd-Chiari Syndrome
Symptoms
Diagnosis
Treatment
Prognosis
Amoebic Liver Abscess and Pregnancy
Clinical Features
Serology
Diagnosis
Treatment
Liver Tumors and Pregnancy
Liver Transplant and Pregnancy
Effect of Liver Transplant on Pregnancy
Effect of Pregnancy on Liver Transplantation
41:
Pregnancy in Underlying Renal Disease
Management of Pregnancy in Women with Chronic Kidney Disease
Preconception Counseling
Monitoring of patient: Antenatal Care
Fetal Monitoring and Delivery
Pregnancy in Women on Maintenance Dialysis
What Women should know about Pregnancy on Dialysis29–31
Management of Dialysis in Pregnancy
Obstetric Management of Pregnant Dialysis Patient
Pregnancy in Kidney Transplant Recipient
Conclusion
42:
Psychiatric Disorders in Pregnancy
Introduction
Changes in Personality
Substance Use in Pregnancy
Management of Mother with History of Current Substance Use
Depression and Anxiety
Management
Postpartum Psychosis/Depression with Psychotic Symptoms
Management of Preexisting Psychiatric Disorders in Pregnancy
43:
Collagen Vascular Disorders and Pregnancy
Introduction
Common Collagen Vascular Diseases1–3
Issues of Fertility/Sterility
Impact of Collagen Vascular Disorders on Pregnancy and Vice-Versa
Rheumatoid Arthritis
Pregnancy and SLE
Transfer from Mother to Fetus
Impact of Pregnancy on Collagen Vascular Disorders
Special: Anti-rheumatics and Pregnancy
Special: Miscarriages and Antiphospholipid Syndrome (APS)
Clinical Criteria
Laboratory Criteria
Executive Summary
44:
Pregnancy Complicated by Malignancy
General Considerations
Effect of Pregnancy on Malignancy
Effects of malignancy on Pregnancy
Pelvic Malignancies Complicating Pregnancy
Cancer of the Vulva
Management
Cancer of the Vagina
Carcinoma of the Cervix
Management
Ovarian Cancer1,3
Management
Cancer of the Rectum4,5
Management
Extra Pelvic Malignancies in Pregnancy
Breast Cancer1,6
Management
Melanoma
Management
Thyroid Cancers
Management
Hodgkin's Disease10,11
Non-Hodgkin's Lymphoma10,12
Leukemias11,12
Chronic Leukemia
Management
Gastrointestinal Tumors
Central Nervous System Tumors5,13
Meningiomas
Pheochromocytomas14
Sarcoma1
Fetal and Placental Transmission of Malignancy15
Antineoplastic Therapy and Radiotherapy17
Conclusion
45:
Thalassemia and Sickle Cell Disease in Pregnancy
Introduction
Genetic Mechanisms and Pathophysiology
Pathogenesis
Maternal Adaptation to Pregnancy
Thalassemia Syndromes
β Thalassemia Minor
β Thalassemia Major
β Thalassemia Intermedia
Management of Pregnancy with Thalassemia Syndromes
Infertility
Transfusion and Chelation
Delivery
α Thalassemia
Sickle Cell Disease and Pregnancy
Sickle Cell Trait
Sickle Cell Disease
Fetal Complications
Obstetric Management
Treatment of Painful Crisis
Transfusion Therapy in Pregnancy
Indications for Transfusion during Pregnancy
Other Sickle Cell Related Comorbidities
Genetic Issues in Hemoglobinopathies
Summary
SECTION SEVEN: PLACENTAL INSUFFICIENCY
46:
Management of Hypertension in Pregnancy
Introduction
Aims of Management
Control of Hypertension
Diagnosis and Monitoring for Severe Pre-eclampsia
Obstetric Decision Making In Pre-eclampsia
Prevention and Treatment of Eclampsia
Principles of Management
Care after Delivery
HELLP Syndrome
Pre-eclampsia Superimposed on Chronic Hypertension
Conclusion
47:
Fetal Growth Restriction
Introduction
Definition
Antenatal Definition
Definitions Based on Size
USG Fetal Biometry: Abdominal Circumference < 5th centile
USG Estimated Fetal Weight < 5th Centile
Ponderal Index
Customized Fetal Weight Charts
Definitions Based on Growth
Neonatal Definitions
Low Birth Weight (LBW)
Battaglia
Gruenwald
CANS Score
Normal Fetal Growth and Placentation
Fetal Composition of Fat and Protein
Placental Histopathology
Immunobiology of Pregnancy
Etiology
Risk Factors for FGR
Etiologic Factors
Fetal Factors
Placental Factors
Maternal Factors
Maternal Infections
Chronic Hypoxia
Renal Disease
Environmental
Pathophysiology
Infancy, Childhood and Adolescence
Poor Growth: Short Stature
Infant Behavior
Neurologic Defects
Complications
Intrauterine Death
Fetal Distress
Neonatal
Hypertension
Adulthood
Syndrome X
Screening and Early Diagnosis
Accurate Determination of Gestational Age
Maternal Weight Gain in Pregnancy
Clinical Estimation
Serial Fundal Height Estimation on Palpation and Symphysis
Ultrasonographic Biometry
Qualitative Amniotic Fluid Volume
Placental Grade
Doppler Studies
Investigations
Prevention
Management
General Management
Bed Rest
Maternal Dietary Supplementation
Other Non-dietary Methods
Low Dose Aspirin
Steroids to Accelerate Lung Maturity
Fetal Surveillance
Cardiff Count to 10 Method
Non-Stress Test
Contraction Stress Test
Biophysical Profile
Serial Fetal Biometry
Doppler Velocimetry
Indications for Hospitalization
When to Deliver
Indications for Elective Cesarean Section
Monitored Induction of Labor
Intrapartum Management
Risk Assessment and Counseling
Neonatal Resuscitation
48:
Prophylaxis for Pregnancy-induced Hypertension and Intrauterine Growth Restriction with Low-Dose Aspirin
Introduction
Etiopathology of PIH
The Use of Aspirin
Predictions of Pre-eclampsia and Indications for Low-Dose Aspirin in Pregnancy
Pressor Tests
Doppler Velocimetry
Laboratory Methods
Pharmacokinetics
Pathophysiology and Mechanism of Action
Clinical Trials
Complications of Aspirin and Fetal Effects
49:
Postdatism
Introduction
Etiology and Associations
Pathophysiology
Amniotic Fluid
Placenta
Fetus
Changes During Pregnancy
Changes During Labor
Perinatal Morbidity
Maternal Morbidity
Prevention
Management
Antepartum Fetal Surveillance
Induction of Labor
Role of Intrapartum Saline Amnioinfusion in Thick Meconium
SECTION EIGHT: DRUGS AND ENVIRONMENT
50:
Teratology
Introduction
Scenario in Developing Countries
The Critical Period
Wilson Six Principles of Teratology
Genetic and Physiological Mechanisms of Teratogenesis
Teratogenic Agents
Physical Agents
Ionizing Radiations
Biological Agents
Chemical Agents
Drugs
Drugs that are Potentially Harmful to the Embryo or Fetus
Anticonvulsants
Thalidomide
Psychotropic Drugs
Anticoagulants
Hormones
Retinoids
Antineoplastics
Antibiotics
Use of Other Common Medications in Pregnancy
Antimicrobials
Antifungal Agents
Antiviral Agents
Antibacterial Agents
Antiprotozoal Agents
Antihelminthics
Analgesics
Cardiovascular Drugs
Respiratory Drugs
Antidiabetic Drugs
Antithyroid Drugs
Vaccines
Herbal Remedies
Prevention of Teratogen-induced Anomalies
Counseling the Patient
Conclusion
51:
Hazards of Drug Usage in Pregnancy and Lactation
Introduction
Pharmacokinetics During Pregnancy
Drug Absorption
Drug Distribution
Drug Metabolism and Excretion
Drug Transfer Across the Placenta
Fetal/Neonatal Pharmacology
Effects of Drugs on Pregnancy
Teratogenicity
Teratogenic Effects
Mechanism
Teratogen Testing and Labeling
Principles of Drug Usage in Pregnancy
Risk Factors
Drugs With Deleterious Effects
Cytotoxic Drugs
Thalidomide
Corticosteroids
Anticonvulsants
DES
Isotretinoin
Antibiotics
Tetracyclines
Chloramphenicol
Antithyroid Drugs
Antituberculous Drugs
Oral Anticoagulants
Drugs Causing Neonatal Jaundice and Kernicterus
Long Acting Sulphonamides
Hormones
Hypotensive Agents
Prostaglandin Synthesis Inhibitors
Antiretrovirals
Conditions of Special Concern during Pregnancy
Diabetes
Epilepsy
Addictions in Pregnancy
Narcotic Addiction
Diagnosis of Early Pregnancy
Antepartum Management
Rehabilitation and Drug Withdrawal
Newborn Withdrawal
Smoking
Mechanism
Maternal Effect
Nicotine and Lactation
Risk of Alcohol in Pregnancy
Lactation and Drugs
Mechanism of Drug Excretion
Conclusion
Take Home Message
52:
Substance Abuse in Pregnancy
Introduction
Definitions
Effects of Substance Abuse During Pregnancy
Pregnancy Outcome
Prevalence of Substance Abuse During Pregnancy
Sociolegal Aspects
Medical Aspects
Managing Substance Abuse in Pregnancy
Antenatal Care
Intrapartum Care
Postnatal Care
Specific Substances and their Management Strategies
Tobacco
Management of Smoking in Pregnancy
Alcohol
Management
Reproductive Outcome
Neonatal Effects
Management of Pregnant Alcoholic patients
Cocaine
Management of Cocaine Addicts
Heroin/Opiates
Management of Opiate Addicts
Amphetamine
Management of Pregnant Amphetamine Addicts
Benzodiazepines
Marijuana
Caffeine
Conclusion
53:
Fetal Dysmorphology
Introduction
Classification of Fetal Dysmorphology
Clinical Approach
Prenatal Diagnosis
Fetal Structural Anomalies: System-Wise
Central Nervous System Anomalies
Important Points
Specific Anomalies
Cardiac Anomalies
Important Points
Specific Anomalies
Thoracic/Pulmonary Anomalies
Important Points
Specific Anomalies
Gastrointestinal and Abdominal Anomalies
Important Points
Specific Anomalies
Renal System Anomalies
Important Points
Specific Anomalies
Facial Anomalies
Important Points
Specific Anomalies
Neck Anomalies
Important Points
Specific Anomalies
Skeletal System Anomalies
Important Points
Simplified Classification of Skeletal Dysplasia
Specific Anomalies
Genital Anomalies
Important Points
Specific Anomalies
Twin Pregnancy Anomalies
Important Points
Anomalies specific to Monochorionic Twins
Miscellaneous
Abnormalities of Amniotic Fluid
Abnormalities of Placenta
Specific Anomalies
Abnormalities of Umbilical Cord
Important Points
Specific Anomalies
Role of Fetal Autopsy
Etiology of Fetal Dysmorphogenesis
Understanding Teratogenic Insult
Concluding Remarks
54:
Impact of Environment on Reproductive Health
Introduction
Endocrine Disruptors
Physical Factors and Reproductive Health
Chemicals and Drugs
Lead
Mercury
Pesticides (Fig. 54.4), Fungicides and Organic Solvents
Lifestyle of People Creating Environmental Pollution
Tobacco, Alcohol and Narcotic Drugs
Impact of Drugs Used in Clinical Practice
Conclusion
SECTION NINE: FETAL THERAPY
55:
Medical Therapy to the Fetus
Introduction
Prevention of Respiratory Distress Syndrome
Management of Fetal Hydrops
Prevention of Mother to Child Transmission of HIV
Prevention of Neural Tube Defects
Prevention of Fetal Growth Retardation
Maternal Treatment with Phenobarbitone for Prevention of Neonatal Jaundice
Prenatal Vitamin K1 Supplementation to Prevent Neonatal Hemorrhagic Disease
Treatment of Fetal Cardiac Arrhythmias
Antenatal Medical Management of Metabolic Defects
Congenital Adrenal Hyperplasia (CAH)
Multiple Carboxylase Deficiency and Methylmalonic Acidemia
Galactosemia
Fetal Thyroid Disorders
Fetal Hypothyroidism
Fetal Hyperthyroidism
Fetal Immune Thrombocytopenia
Prenatal Hematopoietic Stem Cell Transplantation
56:
Fetal Surgery
Introduction
History
Types
Open Fetal Surgery
Defects Sometimes Treated by Open Fetal Surgery
Minimally Invasive Fetal Surgery
Description
Diagnosis/Preparation
Aftercare
Risks
Normal Results
Morbidity and Mortality Rates
Alternatives
Sacrococcygeal Teratoma
Diagnosis
Management of Fetal SCTs
Complications
Spina Bifida
Diagnosis of the Different Types
Spina Bifida Occulta
Spina Bifida Cystica
Meningocele
Meningomyelocele
Pathophysiology
Diagnosis of Myelomeningocele33
Prenatal Treatment for Myelomeningocele
Fetal Surgery Clinical Trials
Epidemiology
Prevention
Pregnancy Screening
Congenital Diaphragmatic Hernia
Bochdalek Hernia
Pathophysiology
Presentation and Diagnosis
Morbidity and Mortality
Morgagni's Hernia
Diaphragm Eventration
Congenital Cystic Adenomatoid Malformation
Diagnosis
Treatment
Urinary Tract Dilation Obstruction
Diagnosis
Treatment
Surgical Care
Medication
Fetal Hydrothorax
Hydrocephalus
Stenosis of the Semilunar Valves
Pulmonary Sequestration
Treatments
Abdominal Wall Defects
Fetal Cleft Lip and Palate
The Impact of Genomics and Stem Cell Research on Fetal Medicine
Fetal Surgery Advances Spur New Ethical Questions
Conclusion
57:
Prenatal Interventional Procedures
Introduction
Types of Fetal Interventions
Indications for Prenatal Diagnosis
Fetal Diagnostic Procedures
Amniocentesis
Timing of Amniocentesis
Technique of Amniocentesis
Complications
Chorionic Villus Sampling
Technique
Transabdominal CVS6,7
Transcervical
Deciding the Route of CVS (Fig. 57.6)
Complications of CVS8–10
Amniocentesis and Chorionic Villus Sampling RCOG Guidelines
Guideline No. 8
1. Rates of Miscarriage
2. Timing of Amniocentesis and CVS
3. Consent
4. Method
5. Skill of the Operator
6. Audit of Practice is the Best Way to Assess Competency
7. Multiple Pregnancies
8. Control of Infection
Fetal Blood Sampling
Technique
Complications
Fetal Skin Biopsy
Indications
Technique
Complications
Fetal Liver Biopsy
Fetal Brain Biopsy
Fetal Therapeutic Procedures
Rh Isoimmune Disease
Technique
Complications
Fetal Arrhythmias
Management of Fetal SVT and Flutter 34,35
Goiter
Fetal Therapy in Multiple Gestations
Treatment and Outcomes36
Amnioreduction
Septostomy
Laser Ablation
Selective Feticide
Stage-based Treatment
Future Developments
Twin Reversed Arterial Perfusion Sequence
Treatment Options
Fetal Shunts
Type of Pathology and the Type of Shunt used
Contraindications to Shunt Insertions
Fetal Hydrothorax
Aims of Thoracoamniotic Shunting
Posterior Urethral Valves
Aims of Vesicoamniotic Shunt31,32
Multifetal Reduction
Transabdominal Technique
Selective Feticide
Preoperative Counseling
Risks of the Procedure
Justification of Fetal Reduction
Technical Problems
Methods to Avoid the Procedure Related Problems
58:
Obstetric Decisions for Fetal Malformations
Gastrointestinal Anomalies
Esophageal Atresia
Duodenal Atresia
Abdominal Wall Defects
Gastroschisis
Omphalocele
Cardiac Malformations
Congenital Hydronephrosis and Obstructive Uropathy
Prognostic Evaluation of the Fetus
Congenital Diaphragmatic Hernia (CDH)
Sacrococcygeal Teratoma
Follow-up after Termination of Pregnancy
Summary
SECTION TEN: OBSTETRIC COMPLICATIONS
59:
Pregnancies at Extremes of Reproductive Age
Introduction
Too Young: Adolescent/ Teenage Pregnancies
Causes of Teenage Pregnancies
Outcomes of Teenage Pregnancies
Too Old: Pregnancy in the Older Age Group
Decrease in Fertility with Increasing Age
Increased Risk of Birth Defects
Increased Risk of Miscarriage
Increased Risk of Medical Disorders
Multiple Pregnancies
Preterm Birth
Increased Risk of Intervention
Increased Risk of Placenta Previa and Abruption
Risk of Congenital Malformations due to ART
Stillbirths
Increased Maternal Mortality
Summary
60:
Placenta Previa
Introduction
Classification
Etiology
Differential Diagnosis
Clinical Features
The Double Set-up Examination
Diagnosis
Placental Migration
Transabdominal Sonography (TAS)
Transvaginal Sonography (TVS)
Transvaginal Color Doppler
Magnetic Resonance Imaging (MRI)
Diagnosis of Suspected Placental Invasion
Antenatal Management
Expectant Management
Rationale
Conservative Management: Inpatient versus Outpatient Care
Tocolysis
Cervical Cerclage
Acceleration of Fetal Lung Maturation
Other Measures
Delivery
Timing of Delivery
Route of Delivery
Choice of Anesthesia
Operative Details
Control of Hemorrhage
Management Strategies for Adherent Placenta
Conclusion
61:
Pregnancy Following ART
Early Pregnancy Loss in ART
Ectopic Pregnancy
Late Pregnancy Loss
Obstetrical, Perinatal and Long-term Outcomes
Ovarian Stimulation
IVF with or without ICSI
Perinatal Outcomes
Singleton Pregnancy
Multiple Pregnancy
Long-term Outcomes
Structural Abnormalities
Chromosomal Disorders
Imprinting Disorders
Management of ART Pregnancy
Conclusion
62:
Abruptio Placentae
Introduction
Pathophysiology
Gene Defect Behind Abruptio Placentae
Causes of Abruption
Symptoms
Clinicopathological Classification
Classification of Degree of Placental Abruption
Diagnosis
Vaginal Bleeding
Uterine Tenderness
Uterine Contractions
Proteinuria
Management
Principles of Management
General Measures
Investigations and Work-up
Timing and Method of Delivery
Fetal Monitoring
Prevention, Early Diagnosis and Treatment of Complications
Perinatal Mortality and Morbidity
Maternal Mortality
Conclusion
63:
Preterm Premature Rupture of Membranes
Introduction
Etiopathogenesis
Risk Factors Associated with Preterm PROM
Natural Course of Pregnancies Complicated with Preterm PROM
Complications of pPROM
Diagnosis
Differential Diagnosis
Management of Preterm PROM
General Principles of Management
Confirmation of Diagnosis and Gestational Age of the Fetus
Assessment and Surveillance of Maternal and Fetal Condition
Prevention of Ascending Infection
Acceleration of Fetal Lung Maturity
Deciding the Optimum Time and Mode of Delivery
Conclusion
64:
Etiology and Early Diagnosis of Preterm Labor
Introduction
Etiology
Infections of the Genital Tract
Inflammation
Alterations in the Fetal Membranes
Changes in Cervical Competence
Genetic Factors
Early Diagnosis of Preterm Labor
Standard Primary Predictors of Preterm Labor
Cervical Ultrasound
Fetal Fibronectin
Salivary Estriol
Other Biological Markers
Use of Multiple Markers
Diagnosis of Threatened and Established Preterm Labor
Conclusion
65:
Prevention of Preterm Labor
Introduction
Definition/Incidence
Goals of Management
Early Identification of Risk Factors Associated with Preterm Birth
Identifying the Etiology of Preterm Labor and Timely Diagnosis of Preterm Labor
Maternal/Fetal Stress
Pathway Specific Markers
Decidual-amnion Chorion Inflammation
Pathway Specific Markers
Abruption-associated PTD
Pathway Specific Markers
Mechanical Stretching of Uterus from Polyamnios/Multifetal Gestation inducing Oxytocin Receptors and COX-2 Expression
Final Common Pathway
Pathway Specific Markers
Fetal Fibronectin—as a Marker for Predicting PTD
Cervical Length Measure—as a Marker for Predicting PTD
Interventions
Primary Interventions (Aimed at all Women)
Preconceptional
During Pregnancy
Screening of Low-risk Women
Self-care
Secondary Interventions (Reducing Existing Risks)
During Pregnancy
Antibiotics
Progesterone
Cervical Cerclage
Tertiary Interventions (Preterm Birth Imminent)
Glucocorticosteroids
Tocolysis
Conclusion
66:
Pregnancy Loss in the Second Half of Gestation
67:
Hydramnios
Introduction
Pathophysiology
Definition and Diagnostic Criteria
Clinical Manifestations
Causes of Hydramnios
Fetal Conditions
Maternal Conditions
Placental Causes
Chorioangioma
Idiopathic Polyhydramnios and Chromosomal Abnormalities
Severity of Hydramnios
Mild Hydramnios
Moderate Polyhydramnios
Severe Polyhydramnios
Acute Hydramnios
Complications of Hydramnios
Investigations
Management
Indomethacin Therapy
68:
Rh-Isoimmunization
Introduction
Genetics of the Rh-Antigen
The Pathological Picture in Rh-Isoimmunization
Factors Affecting Rh-Isoimmunization
Evaluation of the Rh-Isoimmunized Pregnancy
Fetal Transfusions
Alternative Therapies
The Rh-Isoimmunized Neonate
Passive Immunization
The Future
69:
Nonimmune Hydrops Fetalis
Introduction
Definition
Incidence
Etiology
Pathogenesis
Anemia
Cardiac Failure
Reduced Osmotic Pressure
Impaired Lymphatic Drainage
Obstruction of Venous Return
Maternal Complications
Perinatal Complications
Investigations
Management
Transplacental Drug Therapy
Direct Fetal Drug Therapy
Invasive Procedures
Drainage Procedures
Fetal Surgery
Obstetric Management
Conclusion
70:
Pregnancy with Prolapse
Etiology
Clinical Presentation
Complications
Management
Bed Rest with Head Low Position
Pessary
Mode of Delivery
An Alternative Option
Procedure of Introital Tightening
Advantages
71:
Benign Adnexal Masses in Pregnancy
Introduction
Frequency and Natural History
Diagnosis
Tumor Markers in Pregnancy
Treatment
Timing of Surgery
Surgery versus Observation
Role of Ultrasound-guided Cyst Aspiration
Surgery in a Pregnant Patient
Laparoscopic Approach
Conclusions
SECTION ELEVEN: LABOR AND DELIVERY IN PREGNANCY AT RISK
72:
Induction of Labor
Introduction
Historical Background
Induction in Modern Practice
Physiological Basis for Induction of Labor
Risks of Induction
Failed Induction
Prematurity
Unforeseen Disproportion
Sepsis
Partial Placental Detachment and ‘Bloody Tap’
Antepartum Hemorrhage
Fetal Pneumonia
Cord Accidents
Amniotic Fluid Embolism
Neonatal Jaundice
Maternal and Neonatal Outcome
Selection Criteria for Cases
Indications for Induction of Labor
Fetal Indications
Maternal Indications
Logistic Indications
Contraindications for Induction of Labor
Methods of Induction of Labor
Methods Involving the Use of Oxytocin
Pharmacology
Advantage of Amniotomy Combined with Oxytocin Infusion
Pulsatile versus Continuous Oxytocin Infusion
Computer-controlled Oxytocin Infusion
Complications due to Use of Oxytocin
Methods not Involving the Use of Oxytocin
Prostaglandins
Pharmacology
Routes of Administration
Mifepristone (Roussel Uclaf 486)
Breast Pump
Corticosteroids to Induce Labor
Surgical Methods of Induction
Amniotomy
Hindwater Rupture
Mechanical Methods
Stripping of Membranes
Mechanical Cervical Dilators
Misoprostol
Non-recommended Methods (NICE Guideline)
Pharmacologic Methods
Nonpharmacological Methods
Surgical Methods
Mechanical Methods
Induction of Labor in Pregnancies at Risk
Prolonged Pregnancy
Abnormal Fetal Growth
Pre-eclampsia and Eclampsia
Unstable Lie
Anencephaly
Breech Presentation
Previous Cesarean Section
Induction for Social Reasons
Criticisms of Induction
Conclusion
73:
Labor Analgesia in High-Risk Pregnancy
Introduction
Non-Pharmacological Methods
Lamaze
Acupuncture
Transcutaneous Electrical Nerve Stimulation (TENS)
Hypnosis
Massage
Intracutaneous Sterile Water Blocks
Water Immersion
Pharmacological Methods
Systemic Analgesia
Opioid
Ketamine
Inhalation Analgesia
Regional Analgesia
Local Blocks
Central Neuroaxial Block
Pain Relief Options
High Risk from Obstetric View Point
Prematurity or IUGR
Previous Cesarean Delivery (VBAC)
Breech Presentation
Multiple Gestation
Pregnancies with Altered Physiology
Pregnancy-induced Hypertension
Diabetic Gestation
Obese Patient
Pregnancies with Systemic Diseases
Cardiovascular Diseases
Asthma
Coagulopathy
Thyroid Diseases
Adrenal Diseases
Renal Diseases
Hepatic Diseases
Hematological Diseases
Neurological Diseases
Acquired Immunodeficiency Syndrome (AIDS)
Conclusion
74:
Intrapartum Fetal Distress
Introduction
Pathophysiological Basis
Significance of Meconium Staining of Amniotic Fluid
Intrapartum Fetal Monitoring
The Management of Fetal Distress
Alteration of Maternal Position
Hydration
Use of Oxygen
Use of Intravenous Hypertonic Dextrose
Amnioinfusion
Technique
Complications
Tocolysis
The Decision to Delivery Interval
Fetal Distress in the Public Health Perspective
75:
Dysfunctional Labor
Introduction
Normal Labor
Normal Labor: Standards for Definition of Progress
Lack of Progress of Labor—Power, Pelvis and the Passenger
Primigravidae and Multigravidae
Labor Abnormalities
Latent Phase Disorders
Management of Prolonged Latent Phase
Prognosis of Prolonged Latent Phase
Active Phase Disorders
Management of Prolonged Active Phase of Labor
Prognosis of Active Phase Disorders
Active Management of Labor
Secondary Arrest in Second Stage of Labor
Management of Second Stage Descent Disorders
Prognosis for Second Stage Disorders
Intrapartum Strategies to Reduce the Risk of Dystocia
Conclusion
76:
Contemporary Instrumental Delivery
Conclusion
77:
Breech Presentation
Introduction
Types of Breech
Complete Breech
Incomplete Breech
Incidence of Breech
Etiology
Clinical Features
Diagnosis
Management of Breech
Antenatal Period
Procedure of ECV
Technique of ECV
ECV before Term
Internal Podalic Version
Induction of Labor in Breech
Decision on Mode of Delivery
Selection of Cases for Vaginal Delivery
Conduct of Vaginal Breech Delivery
Assessment of the Newborn
Problems that may Come up during Vaginal Breech Delivery
Delay at the Level of the Breech
Extended Lower Limbs
Problems at the Shoulder
Extended Arm
Problems with the Delivery of the Head
Occiput Posterior Position
Dead Fetus
Breech Presentation in Multiple Pregnancy
Cesarean Section for Breech
Our Experience
Conclusion
78:
Cesarean Section in Present Day Practice
Introduction
Incidence
Reasons for Rising Rates of CS
Indications
Reasons Related to the Baby
Reasons Related to the Mother
Problems with Labor or Delivery
Problems with the Placenta or Umbilical Cord
Problems Related to Training of Obstetricians
Improper Use of Technology (Electric Fetal Monitoring [EFM])16
Vaginal Birth after Cesarean Section (VBAC)
External Cephalic Version
Technique of Cesarean Section
79:
Modern Management of Obstructed Labor
Definition
Incidence
Etiology
Pathophysiology
Diagnosis
Prognosis
Prophylaxis
Management
General Measures
Delivery of the Fetus
Exploratory Laparotomy
Cesarean Section
Vaginal Delivery
Reducing the Fetal Size
Enlarging the Pelvis by Symphysiotomy
Removing the Cause of Obstruction
Management of Third Stage of Labor
Care of the Neonate
Puerperium
After Care and Late Complications
Conclusion
80:
Postpartum Hemorrhage
Introduction
Types
Immediate
Delayed
Causes
Uterine Atony
Etiology
Genital Tract Lacerations and Hematomas
Hematomas
Broad Ligament and Retroperitoneal Hematomas
Uterine Rupture
Retained Placenta
Uterine Inversion
Bleeding Disorders
Preventive Aspects
Management
General Management
Specific Management
Uterine Atony
Traumatic Postpartum Hemorrhage
Retained Placenta
Conclusion
81:
Sudden Postpartum Collapse
Introduction
Massive Postpartum Hemorrhage
Acute Puerperal Uterine Inversion
Total Inversion
Pathophysiology
Diagnosis
Management
Manipulative Replacement (Johnson, 1949)9
Hydrostatic Replacement (O'Sullivan)
Pulmonary Embolism
Amniotic Fluid Embolism (AFE)
Pathophysiology
Clinical Features
Diagnosis
Management
Hematological Support
Pulmonary Thromboembolism (PE)
Clinical Features
Management
Thrombolysis
Surgery
Inferior Vena Cava Filter (Greenfeld Filter)
Air Embolism
Eclampsia
Causes Related to Anesthesia
Anesthesia Toxicity
Clinical Features
Management
Mendelson's Syndrome
Pathophysiology
Clinical Features
Management
Prevention
Acute Tension Pneumothorax
Other Anesthetic Problems
Cardiac Causes
Heart Failure (Acute Pulmonary Edema)
Arrhythmias
Acute Myocardial Infarction
Clinical Features
Management
Cardiac Arrest
Intracranial Hemorrhage
Management
Miscellaneous
Septic Shock
Anaphylactic Shock
Acute Adrenocortical Insufficiency (Addisionian Crisis)
Conclusion
82:
Rupture Uterus
Uterine Rupture in Modern Obstetrics
Incidence
Traditional Classification (Fig. 82.1)
Etiological Classification (Table 82.3)
Pathological Anatomy
Spontaneous Rupture (Fig. 82.2)
Scar Rupture (Fig. 82.2)
Traumatic Rupture
Diagnosis (Fig. 82.3)
Spontaneous Rupture during Pregnancy
Scar Rupture During Pregnancy (Fig. 82.2)
Spontaneous Rupture during Labor
Scar Rupture during Labor
Treatment (Fig. 82.4)
Obstetric Hysterectomy
Rupture Repair
Repair with Sterilization
Prognosis
Prophylaxis
Antenatal Care
High Risk Cases
VBAC and Uterine Rupture
Sonographic Evaluation of Previous Cesarean Scar before VBAC (Fig. 82.5)
Conclusion
83:
Management of Critically Ill Patients in Labor
Introduction
CVS Changes in Pregnancy (Adapted from Koszaike 1997)6
Intrapartum CVS Changes
Coagulation Changes
Pulmonary Edema
Common Life-threatening Problems
Collapse
Principles of Critical Care
Principles of Management
Monitoring
Clinical
Respiratory Support
Invasive Hemodynamic Monitoring
Pulmonary Edema
Oliguria
Hemorrhagic Shock
Septic Shock
IYHA Class III and IV Cardiac Disease
Respiratory Distress of Unknown Cause
Does SwanGanz Catheter Improve Outcome?
Respiratory Support
Hypovolemic Shock
Commonly Used Vasoactive Drugs
Fetal Response
Conclusion
84:
Obstetric Patient in ICU
Introduction
Assessing the Patient
Monitoring
Ventilator Therapy
Fetal Considerations
Maternal Cardiorespiratory Arrest
Drugs in ICU
Fetal Effects
Nutrition
Hypertensive Disorders of Pregnancy
Hemorrhagic Disorders of Pregnancy
Postpartum Hemorrhage
Consumptive Coagulopathy/ DIC
Septic Shock
Anaphylaxis
Amniotic Fluid Embolism (AFE)
Trauma
Key Points in Management
85:
Fluid and Electrolyte Balance in Pregnancy and Labor
Introduction
Fluid Balance
Hypovolemia
Hypervolemia
Electrolyte Disturbances
Hyponatremia
Hypernatremia
Hypokalemia
Hyperkalemia
Intravenous Fluids: Daily Requirements
Conclusion
SECTION TWELVE: MULTIPLE PREGNANCIES
86:
Embryo Reduction
Introduction
Indications for Multifetal Reduction
Quadriplets and Higher Order
Advantages
Disadvantages
Triplets
Twins with One Abnormal Fetus
Heterotrophic Pregnancy
Technique
Advantages
Disadvantages of Late MFR
Transvaginal Early KCl Injection
Advantages
Disadvantages
Conclusion
87:
Managing Multiple Pregnancies
Introduction
Incidence
Management
First Trimester
Antenatal Care
Second Trimester
Antenatal Care during the Second Trimester
Third Trimester
Management
Fetal Complications in Third Trimester
Labor and Delivery of a Twin Pregnancy
Role of Cesarean Section
88:
Twin to Twin Transfusion Syndrome
Introduction
Monochorionicity and TTTS
Pathophysiology1–3
Diagnosis
Doppler in TTTS
Staging
Differential Diagnosis
Treatment Options
Amniodrainage17,18
Fetoscopic Laser Ablation19,24
Septostomy (Intentional Rupture of Intervening Membrane)20
Selective Umbilical Cord Ligation
Amniocentesis vs Fetoscopic Laser Ablation
Complications and Sequelae
89:
High Order Pregnancy
Introduction
Epidemiology and Predisposing Factors
Frequency
Ethnicity
International Data
Age of the Mother
High Parity
Hereditary Factors
Ovulation Inducing Agents
History
Complications
Increased Maternal Morbidity
Pre-eclampsia
Gestational Diabetes
Placental Abruption
Anemia
Hyperemesis Gravidarum
Postpartum Hemorrhage
Prematurity and Preterm Labor
Low Birth Weight Babies
Spontaneous Abortion
Vanishing Twin Syndrome
Intrauterine Growth Restriction (IUGR)
Hyaline Membrane Disease
Birth Asphyxia/Perinatal Depression
Increased Neonatal Mortality
Twin to Twin Transfusion Syndrome (TTTS)
Operative Manipulations
Birth Defects
Lifelong Disability
Prevention
Monitoring in the Antenatal Period
Screening for Downs Syndrome
Prophylactic Intervention to Reduce Preterm Labor
Antenatal Corticosteroids
Management
ACOG Committee Opinion
Hospitalization and Bed Rest for Multiple Pregnancy
90:
Rural Obstetrics
The Definition of Rural
Incidence of Maternal Mortality
Comparison of MMR in Different Parts of India
Maternal Mortality Ratios
Causes of Maternal Mortality
Direct Maternal Mortality Causes
Indirect Maternal Mortality Causes
Incidental or Contributory Cause of Maternal Mortality
Preventing and Social Measures
Antenatal Care
Rural Area
Intranatal and Postnatal Care
Safe Motherhood
Measures Recommended for Implementing Safe Motherhood
Removal of Social Inequalities for Women
Ensuring Easy Access for Family Planning and MTP Services
Developing Community—Basic Maternal Care
Referral System
International Commitment to Maternal and Child Health
Health Personnel in India
Rural
Urban
Training Program for the Grassroots Level Health Workers
Traditional Birth Attendants (TBAs Or ‘Dais’)
Profile of TBAs
Training of Community Health Volunteers
Training of Health Assistants (female)
Training of Multipurpose Health Workers (Female) – MPW-F or ANM
Training of the Medical Officers at PHCs
Undergraduate and Postgraduate Medical Education
Tribals in Rural Area
91:
High-Risk Pregnancy in Low Resource Settings
Introduction
Challenges
Pregnancy-related Risks
Puerperal Infection
Abortion and Post-abortion Complications
Pre-eclampsia and Eclampsia
Obstructed Labor
Culture and Environment
Anemia
Birthing Location
Birth Attendants
Potential Solutions
Emergency Care
Training of Birth Attendants
Appropriate Technologies for Low-Resource Settings
Balancing Short-term Costs and Long-term Benefits
Identifying Technology-Based Solutions
Comment
SECTION THIRTEEN: MISCELLANEOUS
92:
Preconceptional Counseling and Antenatal Care
93:
High-Risk Neonate
Identifying the High-Risk Neonate
Newborn Groups Based on Weights and Gestations
The Preterm Neonates (< 34 weeks)
The Late Preterm Neonates (34–37 weeks)
Medically Indicated Preterm
Iatrogenic Prematurity
The Small-for-Gestation Age (SGA) Newborn
The Large-for-Gestation Newborn
Postmature Infants
The Elective Cesarean Section
Meconium Stained Amniotic Fluid
Congenital Malformations
Multiple Births
94:
Gestational Trophoblastic Disease
95:
The Role of Stress in First Trimester Miscarriage
96:
Surrogacy
Introduction
Indications for Surrogacy
Screening of the Surrogate
Endometrial Preparation
Psychosocial Aspects
Perinatal Outcome
Ethical Issues
Conclusion
97:
Perinatal Asphyxia and Hypoxic-ischemic Encephalopathy
Introduction
Incidence
Risk Factors
Pathophysiology
Pathology
Detection of Infants at Risk of Perinatal Asphyxia
Antepartum Monitoring
Intrapartum Monitoring
Clinical Manifestations
Investigations
Ultrasonography
EEG or aEEG
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
Magnetic Resonance Spectroscopy
Evoked Potentials
Management
Medical Management
Brain Specific Therapy
Therapeutic Hypothermia
Criteria for Starting Cooling
Exclusion Criteria
Prediction of Outcome
Mortality/Morbidity
98:
Neurologic Outcome and Fetal Well-Being
Introduction
Physiology of Gas Exchange in Fetus
Fetal Adaptive Mechanisms
Intrapartum Asphyxia and Neurologic Injury in the Fetus
Comment
Intrapartum Assessment of Fetal Well Being
Newborn Assessment of Fetal Oxygenation/Acid-base Status
Apgar Scores
Umbilical Arterial Cord Gases
Conclusion
99:
Management of Autoimmune Thrombocytopenic Purpura in Pregnancy
Medical Aspects
Diagnosis
Differential Diagnosis
Normal Platelet Count in Pregnancy
ITP in Pregnancy
Diagnosis
Management
Recommendation for Modality of Treatment for ITP in Pregnancy (Flow chart 99.1)
Corticosteroids
Intravenous Immunoglobulins
Platelet Transfusion
Splenectomy
IV Anti-D
Antenatal Monitoring of Patients with ITP
First Trimester
Second Trimester
Third Trimester
Management Before 36 Weeks
Asymptomatic Patients
Symptomatic Patients
Severely Thrombocytopenic Patients (platelet count < 10 × 109/L)
Recommendations for Treatment
Management After 36 Weeks
Recommended Mode of Delivery
Management in Labor
Safe Platelet Thresholds for Delivery
Fetal Assessment
Neonatal Care
100:
Fetal Monitoring—Revisited
Introduction and History
Pathophysiology of Control of Fetal Heart Rate (FHR)
Biophysical Techniques of Fetal Monitoring
Maternal Assessment of Fetal Activity or Movements
Non-Stress Test (NST)
Admission Test
Vibroacoustic Stimulation Test (VAST)
Contraction Stress Test- CST/Oxytocin Challenge Test—OCT
Biophysical Profile/BPP
Modified Biophysical Profile
Doppler Ultrasound
Fetal Surveillance in Gestational Diabetes Mellitus
Conclusion
Pitfalls in Fetal Monitoring
Case 1
Case II
Case III
Case IV
Case V
101:
Laparoscopy in Pregnancy
Introduction
Indications for Laparoscopy in Pregnancy
Contraindications of Laparoscopy or Laparoscopic Surgery in Pregnancy
Hemodynamics in Pregnancy
Technique of Laparoscopic Surgery in Pregnancy
Common Laparoscopic Surgery during Pregnancy and Simple Technical Minute
Advantages of Laparoscopy in Pregnancy
General
Disadvantages
Conclusion
INDEX
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