Pregnancy at Risk: A Practical Approach to High Risk Pregnancy and Delivery Usha Krishna, Duru Shah, Vinita Salvi, Nozer Sheriar
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1Pregnancy at Risk
3Pregnancy at Risk: A Practical Approach to High Risk Pregnancy and Delivery
FIFTH EDITION
Editors Usha Krishna MD DGO FICS FICOG Past president, FOGSI, MOGS, Ex-Hon. Prof. KEM Hospital and GS Medical College Consultant, Obstetrician and Gynecologist, Bhatia General Hospital Director, Clinic for Women, Laburnum Road, Gamdevi, Mumbai, Maharashtra, India Duru Shah MD FRCOG FCPS FICS FICOG FICMCH DGO DFP Chairman: Gynaecworld Professor and Consultant Obstetrician and Gynecologist Breach Candy Hospital and Research Center Jaslok Hospital and Research Center Sir Hurkisondas Nurrotumdas Hospital and Research Center Mumbai, Maharashtra, India Vinita Salvi MD DNBE FCPS DGO DFP Consultant Obstetrician and Gynecologist SevenHills Hospital, Mumbai Ex-Professor of Obstetrics and Gynecology and Officer in-Charge ICMR Regional Center for Research in Human Reproduction Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India Nozer Sheriar MD DNBE FCPS DGO Consultant Obstetrician and Gynecologist Breach Candy, Holy Family, Masina and Parsee General Hospitals Gynecological Endoscopist, Bhatia and BARC Hospitals Deputy Secretary General: FOGSI Mumbai, Maharashtra, India Kaizad R Damania MD DNBE FCPS DGO DFP Professor of Obstetrics and Gynecology Seth GS Medical College and Nowrosjee Wadia Maternity Hospital, Mumbai, Maharashtra, India
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Pregnancy at Risk: A Practical Approach to High Risk Pregnancy and Delivery
© 2010, The Federation of Obstetric and Gynaecological Societies of India
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the editors and the publisher.
This book has been published in good faith that the material provided by the contributors is original. Every effort is made to ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.
First Edition: 1993
Second Edition: 1995
Third Edition: 1997
Fourth Edition: 2001
Reprint: 2004
Fifth Edition: 2010
9788184489590
Typeset at JPBMP typesetting unit
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5CONTRIBUTORS 15Preface to the Fifth Edition
While pregnancies and child birth are natural events, they often require medical interaction and intervention. It would be fair to say that every pregnancy has some degree of potential risk. To paraphrase George Orwell, in clinical practice some pregnancies are more at risk than others. This book is about these Pregnancies at Risk, where medical understanding, vigilance and care is the difference between safety and catastrophe.
Pregnancy at Risk – Current Concepts was first published in 1993 as a companion volume to a landmark conference of the same name organized by FOGSI. The volume had a series of upgrades over the years that also expanded its scope and coverage of topics. That it is in its fifth edition, stands testimony to its continued relevance and popularity for practitioners and students of obstetrics. It aims to cover a focused clinical area—high-risk pregnancy—by amalgamating evidence and practices, giving the benefits of a monogram and handbook rolled into one.
This fifth edition of Pregnancy at Risk – A Practical Approach to High Risk Pregnancy and Delivery is published to keep our readers, practicing colleagues and postgraduate students alike updated with the most recent developments in what is now differentiated and defined as perinatology. Its purpose is to provide and ensure pregnant women under our care the very best of available treatment. The scope of the book continues to extend beyond routine obstetrics. It continues this by a coverage of various subjects such as genetics, infections, and medical complications as also problems and risks related to labor and delivery. It does this with a special emphasis on understanding their most recent clinical concepts and technological advances that are applicable for diagnosis and management.
In spite of the rapid technological progress in recent years, the role of interpersonal interaction and clinical acumen remains central to patient care. The importance of an insightful history, thorough examination and proper counseling with genuine involvement of patients and their families is even more essential as we deal with high-risk pregnancy and delivery. Technology is no substitute for a caring, empathetic and conscientious physician. Interaction starts early with preconception counseling, continues with vigilant antepartum care and carries forward to appropriate and judicious intrapartum management of normal and abnormal labor. A team approach with selected professional colleagues is an asset in providing multidimensional care and is essential to manage potential medical and surgical complications. The team could include physicians and intensivists, surgeons and anesthetists, neonatologists and perinatologists, endocrinologists and immunologists, pathologists and sonologists, psychiatrists and counselors as required. Their experience and inputs help to give the best well-rounded professional care in Pregnancies at Risk.
We owe this publication to and are most grateful to each of our handpicked contributors who have put in unstinted effort to contribute chapters, appropriately referenced and embellished with personal experiences. This is a multiauthored book and the views expressed herein are those of the authors. We acknowledge the support and commitment of our publishers over the years for making this, one of their first publications for FOGSI so successful. We would also like to acknowledge the support of our families for allowing us to take time away from them to give to this academic endeavor.
For us, editing this volume has been a labor of love. It is our tribute to the brave women who put themselves at risk as they give birth to the next generation. To them, we dedicate this book.
Usha Krishna
Duru Shah
Vinita Salvi
Nozer Sheriar
Kaizad R Damania
16
17Preface to the First Edition
Pregnancy and childbearing are attended by certain risks to the mother as well as the fetus. The aim is to improve our management of the high risk situations and optimize the outcome of pregnancy. This book covers various factors which put the fetus at risk and presents the current concepts in evaluation, monitoring and management of various medical disorders in pregnancy, perinatal infections, placental insufficiency and the immunological, endocrine and anatomical disorders.
Fetomaternal medicine is under constant discussion, experimentation and evaluation. There is a revolution in the care of the fetus and the newborn. New options are being developed in gene control, drug therapy and immunotherapy. The womb is no longer considered an isolated dark chamber. The fetus is accessible today with increasing clarity with sophisticated monitoring tools such as ultrasonography, magnetic resonance imaging, chorion villus sampling, amniotic fluid studies, Doppler blood flow studies, etc. The concept of the fetus as “The unborn patient” has elevated the importance of prenatal diagnosis and treatment.
There are many ethical considerations in the practice of fetomaternal medicine. Our objective is to avoid preventable death, disease or disability in children. However, we have to remember that the benefit to the mother will remain our primary obligation. It is only with the agreement of the pregnant woman that the physician should make the decisions.
We must also remember that diagnostic machines cannot substitute a good physician. A pregnant patient is in a sensitive phase of her life, therefore, an excellent rapport and an empathetic attitude are most essential. Counseling is an important aspect of management of a high risk pregnancy. It is not only the investigations and assessment but the compliance and cooperation of the patient which are necessary for good results.
In most of the high risk pregnancies, good antenatal care and close monitoring of the factors arising during labor and just after, give rewarding results. In the better equipped centers with sophisticated monitoring tools, the cardiovascular status—both structural and functional can be assessed. Biomarkers for assessing fetal and maternal therapy can be studied.
Low dose aspirin for prophylaxis in pre-eclampsia and intrauterine growth retardation, glucocorticoid therapy for fetal lung maturation, maternal immunization to prevent fetal and neonatal infection and pharmacologic therapy for fetal arrhythmias are now well established. However, we still have limitations to fetal therapy specially in the area of fetal surgery. The greatest success of fetal therapy is in the area of rhesus immunization.
Rapid progress in the understanding of the etiopathology, neonatal management and prophylaxis in high risk pregnancy is due to the teamwork of hematologists, sonologists as well as obstetricians and pediatricians. Success in fetomaternal medicine can be achieved only by the collaborative efforts of physicians, microbiologists, biochemists as well as the experts in imaging science and laboratory medicine.
In spite of the technical developments there has been some disillusionment with the results of their clinical application. Proper interpretation with clinical correlation and consideration of many factors are necessary for decision making. We must therefore consider each case carefully and individually before undertaking any aggressive management or invasive procedure.
We are conscious that in a developing country like ours, the majority of the deliveries are conducted by traditional birth attendants. The “Safe Motherhood” programs therefore envisage training and equipping these traditional birth attendants, so that they become able to identify high risk pregnancies and refer them in time to the appropriate hospitals.
We are most grateful to all the contributors for sparing their valuable time to write these chapters. This is multiauthored book and the views expressed herein are those of the authors. We have tried to select the chapters and contributors to offer the reader a comprehensive view of the growing experience in investigations and management. 18We specially thank the co-editors, Duru Shah, Nozer Sheriar, Vinita Salvi and Kaizad R Damania who have spared no pains to help us with all the aspects of publication of this book. It is the cooperation and goodwill of all our colleagues and some silent workers which has made it possible to compile this book. We hope this book will stimulate the interest of the readers in minimizing every possible risk in pregnancy and childbirth. We also hope that the book is constantly updated as “current concepts” will always keep changing.
Usha Krishna
Shirish Daftary