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
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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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.
First Edition: 1993
Second Edition: 1995
Third Edition: 1997
Fourth Edition: 2001
Reprint: 2004
Fifth Edition: 2010
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Typeset at JPBMP typesetting unit
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5CONTRIBUTORS
- Abhishek Pachchigar MBBS DMRD
- Fellow in Ultrasound and Doppler
- Department of Radiology
- KEM Hospital and GS Medical College
- Parel, Mumbai
- Maharashtra, India
- Adarsh Bhargava MS (OBS/GYN) FICOG FIMCH
- Visiting Faculty, Rajasthan University of Health Science
- Advisor, Govt, IVF and Stemcell Research Center
- SMS Medical College, Jaipur
- Retired Head of Department (Obs/Gyn)
- SMS Medical College, Jaipur
- Rajasthan, India
- Adi E Dastur MD FICOG FCPS DGO DFP
- Medical Head
- Nowrosjee Wadia Maternity Hospital and Former
- Honorary Professor of Obstetrics and Gynecology
- Seth GS Medical College and Nowrosjee Wadia
- Maternity Hospital
- Mumbai
- Maharashtra, India
- Ajanta Narvekar
- Consultant Gynecologist and Infertility Specialist
- Narvekar Infertility and Endoscopy Clinic
- Patel Chambers, Opera House
- Mumbai
- Maharashtra, India
- Ajay Mehta MD DGO
- Consulting Obstetrician and Gynecologist, Mumbai
- Visiting Sonologist
- Nowrosjee Wadia Maternity Hospital, Mumbai
- Maharashtra, India
- Alka Gogate MD
- Professor and Head
- Department of Microbiology, LTM Medical College and
- General Hospital, Mumbai, Maharashtra, India
- Alka Kriplani MBBS MD FICOG FICMCH FIMSA
- Professor and Head Unit II
- Department of Obstetrics and Gynaecology
- All India Institute of Medical Sciences
- New Delhi, India
- Alokendu Chatterjee FRCOG FICS
- Formerly, Head, Department of Obstetric
- and Gynecology
- NRS Medical College, Kolkata, West Bengal, India
- Ambrish Dalal MD
- Honorary Sonologist
- Bombay Hospital, Mumbai, Maharashtra, India
- Ameet Patki MD DNB FCPS FICOG FRCOG (UK)
- Medical Director – ReGenesis, Center for Assisted Reproduction, Endoscopy and Fetal Medicine
- Reliance Life Sciences, Mumbai
- Hon Associate Professor
- Mumbai, Maharashtra, India
- Ameya C Purandare MD DNBE FCPS DGO DFP MNAMS MICOG
- Assistant Honorary Obstetrician and Gynecologist
- K J Somaiya Medical College and Hospital, Mumbai
- Masina Hospital, Mumbai
- Naigaon Municipal Maternity Hospital
- Mumbai, Maharashtra, India
- Amit Chakravarty MSC PhD MSCG (USA)
- Consultant Geneticist
- Birth Defects Center
- Mumbai, Maharashtra, India
- Amit Sudhakar Kulkarni DPM DNB
- Consultant Psychiatrist Research officer
- Dr RN Cooper Municipal General Hospital
- Mumbai, Maharashtra, India
- Anahita Chauhan MD DGO
- Associate Professor of Obstetrics and Gynecology
- Seth GS Medical College and KEM Hospital
- Mumbai, Maharashtra, India
- Anita Soni MD DNB FCPS DGO
- Consultant Obstetrician and Gynecologist
- LH Hiranandani Hospital
- Mumbai, Maharashtra, India
- Anirudh Kohli MD DNB DMRD
- Breach Candy Hospital
- Mumbai, Maharashtra, India
- Ashwini Bhalerao Gandhi MD DGO DFP FCPS DNB FICOG
- Consultant Gynecologist
- PD Hinduja National Hospital and Medical Research Center, Mahim, Mumbai, Maharashtra, India
- Ex Associate Professor
- TN Medical College and BYL Nair Hospital
- Chairperson, Adolescent Health Committee of FOGSI (2004–08)
- Secretary, Mumbai Obstetrics and Gynecology Society
- Mumbai, Maharashtra, India
- Ashwita Aiyer MBBS
- Chowpatty Medical Center
- Mumbai, Maharashtra, India
- Avan Dadina
- Consultant Obstetrician and Gynecologist
- Mumbai, Maharashtra, India
- Basil T Lyngdoh
- Senior Resident
- Department of Obstetrics and Gynecology
- All India Institute of Medical Sciences
- New Delhi, India
- Bhaskar Pal MD DGO DNBE MRCOG
- Consultant Obstetrician and Gynecologist
- Apollo Gleneagles Hospital
- Kolkata, West Bengal, India
- Bhavisha Bafna
- MSc in Pharmaceutical Sciences with Management Studies
- Senior Research Officer
- Chowpatty Medical Center
- Mumbai, Maharashtra, India
- Behram S Anklesaria MD DGO DFP ATMF (USA)
- Honorary Professor of Obstetrics and Gynecology
- LG Hospital NHL Medical College and
- KM School of Postgraduate Medicine
- Ahmedabad
- Gujarat, India
- B Shakuntala Baliga MD (AIIMS) FICOG
- Professor of Obstetrics and Gynecology
- Lady Hardinge Medical College
- New Delhi, India
- Chabra S
- Director and Professor
- Obstetrics and Gynecology
- MGIMS, Sevagram
- Wardha, Maharashtra, India
- Chander Lulla
- Consultant Sonologist
- Ria Clinic, Mumbai, Maharashtra, India
- Chinmayee Patra
- Senior Resident
- TNMC and BYL Nair Ch. Hospital
- Mumbai, Maharashtra, India
- Chittaranjan N Purandare MD (BOM), MA OBST (IRELAND), DGO, DFP, D. OBST. RCPI (DUBLIN), FICOG, FICMCH, PGD, MLS (LAW)
- President FOGSI, Assoc. Editor Journal FOGSI
- Consultant Obstetrics and Gynecology
- St. Elizabeth Hospital and BSES Hospital, Mumbai
- Ex. Hon. Professor Obstetrics and Gynecology
- Grant Medical College and JJ Hospital
- Mumbai, Maharashtra, India
- Chopra S MBBS
- Resident, Obstetrics and Gynecology
- Dilip R Karnad MD FACP FRCP (GLASG)
- Consultant, Critical Care Medicine
- SevenHills Hospital, Mumbai
- Adjunct Professor of Medicine
- Baylor College of Medicine, Houston, Texas
- Divakar H MD
- Consultant Obstetrician
- Divakars Speciality Hospital
- JP Nagar II Phase
- Bengaluru, Karnataka, 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
- Feroze R Soonawala MD
- Consultant Obstetrician and Gynecologist
- Mumbai, Maharashtra, India
- Firuza R Parikh MD DNBE FCPS DGO
- Director, Department of Assisted Reproduction and Genetics
- Jaslok Hospital and Research Center
- Mumbai, Maharashtra, India
- Visiting Associate Professor of Obstetrics and Gynecology
- Yale University School of Medicine
- New Haven, USA
- Gautam N Allahbadia MD DNBE FCPS DGO
- Honorary Assistant Obstetrician and Gynecologist
- Bombay Hospital Institute of Medical Sciences
- Mumbai, Maharashtra, India
- Geetha Balsarkar MD FCPS DGO DNB
- Associate Professor
- Nowrosjee Wadia Maternity Hospital and
- Seth GS Medical College, Parel
- Mumbai, Maharashtra, India
- Gita Arjun FACOG
- Chennai, India
- Harshad Parasnis MD DNB FCPS DGO FICOG
- Consultant Gynecologic Oncologist
- Hon. Associate Professor
- Bharati Vidyapeeth's Medical College
- Pune
- Chairman, Oncology and Trophoblastic Tumours Committee, FOGSI
- Vice President
- Pune Obstetrics and Gynecology Society, India
- Hema Purandare MBBS MS MSCG (USA)
- Consultant Geneticist
- Birth Defects Center
- Mumbai, Maharashtra, India
- Hetal H Parekh MD DNB
- Associate Consultant
- Center for Human Reproduction
- Dr LH Hiranandani Hospital, Powai
- Mumbai, Maharashtra, India
- Himangi Sudhakar Warke
- Lecturer, Department of Obstetrics and Gynecology
- Seth GS Medical College, KEM Hospital
- Parel, Mumbai, Maharashtra, India
- Hiralal Konar MBBS (CAL), MD (PGI), DNB MNAMS FACS FRCOG (London)
- Department of Obstetrics and Gynecology
- NRS Medical College and Hospital
- Vice President, FOGSI, 2008
- Kolkata, West Bengal, India
- Hosamani P
- Clinical Research Co-ordinator
- Divakars Speciality Hospital
- JP Nagar II Phase
- Bengaluru, Karnataka, India
- Hrishikesh Pai MD FCPS MS CLINICAL EMBRYOLOGY (USA)
- Consultant Gynecologist- Babies an US
- IVF Centers, Mumbai
- Consultant Gynecologist
- Fortis La Femme Hospital
- Delhi, Chandigarh, India
- Indrani Lodh MS
- Senior Consultant Gynecologist and Laparoscopic Surgeon
- Apollo Gleneagles Hospital
- Kolkata, West Bengal, India
- Indrani Suresh MD
- Associate Director
- Mediscan Systems
- Diagnostic Ultrasound and Research Center
- Chennai, TN, India
- Ishita Pateria BA (Psy)
- Research Coordinator
- Department of Psychiatry Research
- Jaslok Hospital and Research Center
- Jaideep Malhotra MD FICMCH FICOG
- Consultant Obstetrician and Gyecologist
- Center for woman Care and Research
- Agra, UP, India
- Jasmine Lopez MD (BOM) DGO
- Dean, Padmashri Dr DY Patil Education
- Enterprises Pvt Ltd, Mumbai
- Ex. Associate Professor and Unit Incharge
- Grant Medical College and
- JJ Group of Hospitals
- Mumbai, Maharashtra, India
- Jaydeep D Tank MD DNBE FCPS DGO
- Asstt Honorary Consultant (Obstetrics and Gynecology)
- KJ Somaiya Medical College and Research Center
- Mumbai
- Consultant
- Ashwini Maternity and Surgical Hospital
- Center for Endoscopy and IVF
- Mumbai, Maharashtra, India
- JB Sharma MD FRCOG
- Associate Professor
- Department of Obstetrics and Gynecology
- All India Institute of Medical Sciences
- 9/22 AIIMS
- New Delhi, India
- Jesse M Levi MD FCPS DGO DFP
- Consultant Obstetrician and Gynecologist
- Mumbai, Maharashtra, India
- Joshita Singh DNB DMRD
- Breach Candy Hospital
- Mumbai, Maharashtra, India
- Joydev Mukherjee MD
- Formerly, Head, Department of Obstetrics
- and Gynecology, RG Kar Medical College
- Kolkata, West Bengal, 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
- Kaushal Kadam MD
- Rotunda-CHR, Bandra
- Mumbai, Maharashtra, India
- Kedar N Ganla MD DNBE FCPS DGO DFP
- Consultant (Infertility), Hiranandani Hospital
- Mumbai, Maharashtra, India
- Ketan S Parikh
- Consultant Anesthetist
- Mumbai, Maharashtra, India
- KP Sanghavi
- Neonatologist
- Jaslok Hospital and Research Center
- Prince Aly Khan Hospital
- Saifee Hospital, Mumbai
- Maharashtra, India
- K Coyaji MD
- Director and Head
- Department of Obstetrics and Gynecology
- KEM Hospital Pune/Honorary Professor
- Department of Obstetrics and Gynecology
- BJ Medical College
- Pune, Maharashtra, India
- Krishnakumar S MD DGO
- Consultant, Gynecologist and Obstetrician
- IVF Specialist
- Wockhardt Hospital
- Kumars’ Maternity and Surgical Nursing Home, Dombivli (E)
- Nirmiti Fertility and IVF Center, Thane (W)
- Mumbai, Maharashtra, India
- Kuldeep Singh MBBS FAUI FICMCH
- Consultant Ultrasonologist
- Special interest in Obstetric Sonology in detailed Fetal Anomaly
- Scanning and Color Doppler for management and Gynecological Scanning
- Dr Kuldeep's Ultrasound and Color Doppler Clinic
- 266, Prakash Mohalla
- East of Kailash
- New Delhi, India
- Kumud M Ingle
- Ex-Dean
- Nowrosjee Wadia Maternity Hospital
- Mumbai, Maharashtra, India
- Kurush P Paghdiwalla MD DNBE
- Honorary Assistant Obstetrician and Gynecologist
- Parsee General Hospital and Masina Hospital
- Mumbai, Maharashtra, India
- Madhavi Panpalia
- Clinical Assistant
- Department of Assisted Reproduction and Genetics
- Jaslok Hospital and Research Center
- Mumbai, Maharashtra, India
- Mahendra N Parikh MD DGO DA FICOG
- Professor Emeritus
- Obstetrics and Gynecology
- Seth GS Medical College and Nowrosjee Wadia Maternity Hospital
- Mumbai, Maharashtra, India
- Mahesh Balsekar MD DCH
- Consultant Pediatrician
- Breach Candy Hospital
- Sir Hurkisondas Hospital
- Mumbai, Maharashtra, India
- Mala Arora FRCOG (UK), FICOG, FICMCH, DA (UK), D'OBST (IRE)
- Chairperson FOGSI Quiz Committee
- President Faridabad Obstetrics and
- Gynecological Society
- Director Noble Hospital
- Sector-14, Faridabad, Haryana, India
- Mandakini Megh MD
- Professor of Obstetrics and Gynecology
- Grant Medical College
- Medical Superintendent
- Cama and Albless Hospital
- Mumbai, Maharashtra, India
- Mangala Ketkar MBBS DGO
- Obstetrics and Gynecologist
- Ketkar Hospital, Nagpur, Maharashtra, India
- Manju Puri
- Professor, Department of Obstetrics and Gynecology
- Lady Hardinge Medical College and Smt SK Hospital
- New Delhi, India
- Manorama Purwar MD DGO MS (USA)
- Project coordinator and Liaison officer
- WHO PLGF TRIAL OBGY
- GMCH Nagpur, Maharashtra, India
- Mansi Parikh MS (OBGY) DNB
- Consultant Obstetrician and Gynecologist
- Dr. Medhekar's Clinic
- Mahim, Mumbai, Maharashtra, India
- Meena S Bhattacharya MS
- Ex-Professor and Head
- Department of Obstetrics and Gynecology
- Seth GS Medical College and Nowrosjee Wadia Maternity Hospital, Mumbai, Maharashtra, India
- Milind R Shah MD DGO DFP
- 2nd Vice President Elect FOGSI 2001
- Past Chairman-Rural Obstetrics Committee of FOGSI-2004-2008
- Prof. and HOD, Department of OBGY, Gandhi Natha Medical College, Solapur
- Naval Nursing Home, 199, South Kasba
- Solapur, Maharashtra, India
- Mirudhubashini Govindarajan FRCSC
- Honorary Professor of Obstetrics and Gynecology
- Institute of Medical Sciences and Research
- Coimbatore, TN, India
- MJ Jassawalla MD FCPS DGO DFP
- Honorary Assistant Professor of Obstetrics and Gynecology
- Seth GS Medical College and
- Nowrosjee Wadia Maternity Hospital, Mumbai
- Honorary Obstetrician and Gynecologist
- Parsee General Hospital and Masina Hospital
- Mumbai, Maharashtra, India
- MS Nanawati MD MNAMS FCPS DGO DFP
- Honorary Associate Professor of Obstetrics and Gynecology
- Seth GS Medical College and
- Nowrosjee Wadia Maternity Hospital
- Mumbai, Maharashtra, India
- Mumtaz Sharif MD DNB
- Assistant Professor
- DY Patil Medical College
- Neural, Navi Mumbai
- Maharashtra, India
- Nadeem Rais MD
- Consultant Endocrinologist
- Breach Candy Hospital
- Mumbai, Maharashtra, India
- Nalini S Shah
- Professor and Head
- Department of Endocrinology
- Seth GS Medical College and KEM Hospital
- Mumbai, Maharashtra, India
- Narendra Malhotra MD FRSH
- Consultant Obstetrician and Gynecologist
- Center for Women Care and Research
- Agra
- UP, India
- Narhari Malegaonkar MD DGO
- Clinical Fellow –ReGenesis
- Reliance Life Sciences
- Mumbai, Maharashtra, India
- Nayna A Dastur MD FICOG DGO DFP
- Former Professor, Obstetrics and Gynecologist
- Seth GS Medical College
- Honorary Consultant, Obstetrician and Gynecologist
- Nowrosjee Wadia Maternity Hospital
- Consultant, Sir HN Hospital
- Breach Candy Hospital
- Mumbai, Maharashtra, India
- Neetha N Pujari MD MRCOG
- Lecturer
- Department of Obstetrics and Gynecology
- Seth GS Medical College and KEM Hospital
- Mumbai, Maharashtra, India
- Nisha Sana Ahmad
- Chief of Lab Services
- Metropolis Health Services
- Nitin Narvekar
- Hon. Associate Obstetrician and Gynecologist Nowrosjee Wadia Maternity Hospital
- Hon. Associate Professor of Obstetrics and Gynecology
- Seth GS Medical College
- Hon. Endoscopic Surgeon Bhatia General Hospital and Jagjivan Ram Hospital
- NK Hase
- Professor and Head Department of Nephrology
- Seth GS Medical College and KEM Hospital
- Parel, 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
- Pakhee Aggarwal MD
- Senior Resident
- Department of Obstetrics and Gynecology
- All India Institute of Medical Sciences
- New Delhi, India
- Paresh P Choksi MD
- Lecturer of Obstetrics and Gynecology
- KJ Somaiya Medical College and Research Center
- Mumbai, Maharashtra, India
- Parikshit D Tank MD DNBE FCPS DGO DFP MNAMS MICOG MRCOG
- Honorary Clinical Associate
- Nowrosjee Wadia Maternity Hospital
- Parel, Mumbai
- Consultant
- Ashwini Maternity and Surgical Hospital, Center for Endoscopy and IVF, Mumbai, Maharashtra, India
- Partha Guha Roy MD DGO
- Senior consultant
- Fertility Clinic and IVF Center
- Mumbai, Maharashtra, India
- Piclu Choudhury MD
- Assistant Professor, Chittaranjan Seva Sadan
- Kolkata, West Bengal, India
- Piyush Jain DM NEONATOLOGY
- Consultant Neonatologist
- Department of Neonatology
- Fortis Hiranandani Hospital
- Navi Mumbai, Maharashtra, India
- PK Shah MD FCPS DGO DFP
- Professor of Obstetrics and Gynecology
- Seth GS Medical College and KEM Hospital
- Mumbai, Maharashtra, India
- Pradnya Parulekar MD DGO
- Consulting Obstetrician and Gynecologist
- Bhatia Hospital and Raheja Fortis Hospital
- Prakash Pispati MD FRSM (LONDON)
- Senior Consultant Rheumatologist– Jaslok
- (Head of the Department) and Saifee Hospitals
- Mumbai, Maharashtra, India
- Master and Honorary Member- Asia Pacific League of Associations for Rheumatology (APLAR)
- Past President- APLAR and Indian Rheumatology Association
- Prakash Trivedi
- Prof and Head of Department Rajawadi Hospital and DY Patil Medical College, Mumbai
- Director: NILES and Aakar IVF ICSI Center
- Dr Trivedi's Total Health Care Centre, Mumbai
- Chief Gynaec Endoscopist: Jaslok and BARC Hospital
- Mumbai, Maharashtra, India
- Pranay Shah MD DGO
- Consultant Obstetrician and Gynecologist
- Mumbai
- Maharashtra, India
- Pratap Kumar MD DGO FICS FICOG FICMCH
- Professor of Obstetrics and Gynecology
- Kasturba Hospital
- Manipal, Karnataka, India
- Pratima Anjaria MD DGO
- Consultant Obstetrician and Gynecologist
- Mumbai, Maharashtra, India
- Pravin N Mhatre MD FCPS DGO DFP
- Honorary Associate Professor of Obstetrics
- and Gynecology
- Seth GS Medical College and Nowrosjee Wadia Maternity Hospital
- Mumbai, Maharashtra, India
- Prerna Gupta MD DNB
- Senior Resident
- Department of Obstetrics and Gynecology
- All India Institute of Medical Sciences
- New Delhi, India
- Purnima Satoskar MD DNBE MRCOG
- Professor of Obstetrics and Gynecology
- Seth GS Medical College and KEM Hospital
- Mumbai
- Maharashtra, India
- Rachita Nanda MBBS MD
- Assistant Professor
- Department of Clinical Biochemistry
- SCB Medical College
- Cuttack, Orissa, India
- Rajen Y Daftary MD DA
- Consultant Anesthesiologist, Breach Candy Hospital
- Masina Hospital
- Mumbai, Maharashtra, India
- Rajesh M Parikh MD DNBE DPM FICP
- Consultant Psychiatrist and Neuropsychiatrist
- Jaslok Hospital and Research Center
- Mumbai, Maharashtra, India
- Rajesh V Darade DNB MD FCPS FICMCH FICS (USA), DGO DFP DGOCPS (MUM) MNAMS MICOG (IND)
- Associate Professor Department of Obstetrics and Gynecology
- Government Medical College
- Latur, Maharashtra, India
- Rakhi Sahu
- Lecturer, Department of Obstetrics and Gynecology
- Seth GS Medical College, N Wadia Hospital
- Mumbai, Maharashtra, India
- Rama Vaidya MD DGO DFP PhD
- Consultant Reproductive Endocrinologist
- SPA Research Center
- Mumbai, Maharashtra, India
- Ramesha KN
- Kerala Registry of Epilepsy and Pregnancy
- Department of Neurology
- Sree Chitra Tirunal Institute
- Thiruvananthapuram
- Kerala and Indian Epilepsy Society
- New Delhi, India
- Rana J Khan FCPS DGO DFP
- Clinical Assistant
- PD Hinduja Hospital and Research Center, Mahim
- Mumbai, Maharashtra, India
- Rashid Merchant MD
- Consulting Neonatologist, Nanavati Hospital
- Mumbai, Maharashtra, India
- Reena J Wani MD MRCOG FICOG DNBE DFP DGO FCPS
- Associate Professor, I/C Family Welfare Program
- TNMC and BYLNair Ch. Hospital
- Mumbai, Maharashtra, India
- Reva Tripathi MD
- Professor of Obstetrics and Gynecology
- MAM College, Delhi, India
- Rishma Dhillon Pai MD DNB DGO FICOG
- Consultant Gynecologist
- Jaslok and Lilavati Hospitals, Mumbai
- Medical Director- Every woman Cliniqs
- Mumbai, Maharashtra, India
- Ritu Joshi
- Head of the Department, Gynecology and Obstetrics
- Monilek Hospital and Research Center, Jaipur
- Chair-person Family Welfare Com. FOGSI (09–12)
- Rohit V Bhatt MD DCH FAMS FICOG
- Chief Department of Obstetrics and Gynecology
- Bhailal Amin General Hospital
- Vadodara, Gujarat, India
- Ruchita Sarda DNB DGO
- Obstetrician and Gynecologist
- Planet Women Hospital
- Ahmedabad
- Gujarat, India
- Rupinder Kaur Ruprai
- Ass. Professor
- Department of Obstetrics and Gynecology
- Kasturba Hospital
- Manipal, Karnataka, India
- Rustom P Soonawala MD FRCS
- Emeritus Professor of Obstetrics and Gynecology
- Seth GS Medical College and Nowrosjee Wadia Maternity Hospital, Mumbai
- Consultant Obstetrician and Gynecologist
- Breach Candy Hospital
- Mumbai, Maharashtra, India
- Sadhana Desai MD FRCOG DGO
- Professor and Head
- Department of Obstetrics and Gynecology
- Bombay Hospital Institute of Medical Sciences
- Mumbai, Maharashtra, India
- Sakshi Tomar
- Agra, UP, India
- Samir R Shah MD DM (Gastro)
- Consultant Gastroenterologist
- Jaslok Hospital and Research Center
- Breach Candy Hospital
- Mumbai, Maharashtra, India
- Samir S Shah
- Consultant hematologist
- Kokilaben Dhirubhai Hospital
- Sanjay Rao MD DNBE MRCOG FCPS DGO
- Consultant Obstetrician and Gynecologist
- Sanjeev V Thomas
- Department of Neurology
- Sree Chitra Tirunal Institute for Medical Sciences
- and Technology, Thiruvananthapuram, Kerala, India
- Saradha Jaganathan MD DNB FNB
- Consultant in Obstetrics
- Gynecology and Feto-Maternal Medicine
- Women's Center, Coimbatore
- Tamil Nadu, India
- Sarita Bhalerao MD DGO FCPS DNB DFP MRCOG
- Obstetrician and Gynecologist
- Bhatia, Saifee, Wadia Maternity Hospitals
- Mumbai
- Chairperson FOGSI Quiz Committee 2009 – 2010
- Seeru Agarwal MBBS DGO
- Obstetrician and Gynecologist
- Mumbai, Maharashtra, India
- Shailesh Kore MD DNB MNAMS FCPS DGO DFP DICOG MICOG
- Associate Professor and Unit Head
- LTM Medical College
- Sion, Mumbai, Maharashtra, India
- Shakun Tyagi
- Assistant Professor, Department of Gynecology
- LN Hospital, New Delhi, India
- Shalini Fusey MBBS MD DGO
- Associate Professor
- Department of Obstetrics and Gynecology
- Government Medical College and Hospital
- Nagpur, Maharashtra, India
- Shamsah Sonawalla
- Consultant, Jaslok Hospital
- Mumbai, Maharashtra, India
- Sharad Gogate MD FCPS DGO DFP FICS
- Consultant Obstetrician and Gynecologist
- Mumbai, Maharashtra, India
- Sharda Patra
- Assistant Professor
- Department of Obstetrics and Gynecology
- Lady Hardinge Medical College and Smt SK Hospital
- New Delhi, India
- Shefali Pandey
- Global hospital and Research Center
- Andheri (W), Mumbai
- Maharashtra, India
- Shyam Vijay Desai MD DGO DFP FCPS MNAMS
- Honorary Associate Professor of Obstetrics and Gynecology
- Grant Medical College and Nowrosjee Wadia Maternity Hospital, Parel, Mumbai
- Maharashtra, India
- Smriti Agarwal MD (OBS/GYN), DNB
- Senior Research Associate
- Department of Obstetric and Gynecology
- CSM Medical University (KGMC)
- Lucknow, UP, India
- Subhas Nargolkar MD DGO FICOG FICMCH
- Consultant Obstetrician and Gynecologist
- Pune, Maharashtra, India
- Suchitra N Pandit MD DNBE FRCOG FICOG MNAMS
- Consultant Kokilaben Dhirubhai Ambani Hospital
- Suhas Otiv
- Associate Consultant Obstetrician and Gynecologist
- KEM Hospital, Pune
- Maharashtra, India
- Sukhpreet Patel MD DNB FCPS DGO PGDMLS
- Program Director, Gynaecworld Assisted Fertility Unit
- Consultant Obstetrician and Gynecologist
- Gynaecworld
- Sukirti Jain MBBS DNB (Obstetrics and Gynecology)
- Assistant Professor
- Department of Obstetrics and Gynecology at Terna Medical College and Mother and Child Hospital
- Navi Mumbai, Maharashtra, India
- Sulbha Arora
- Deccan Fertility Clinic and Keyhole Surgery Center
- Shivaji Park, Mumbai
- Maharashtra, India
- Suneeta Mittal MD FAMS FICOG FRCOG FIMSA FICMCH
- Head, Department of Obstetrics and Gynecology and Director In-charge
- WHO-CCR in Human Reproduction
- All India Institute of Medical Sciences
- New Delhi, India
- S Suresh MD
- Director
- Mediscan Systems
- Diagnostic Ultrasound and Research Center
- Chennai, Tamil Nadu, India
- Sushil Shah MD DPB
- Fellow of Cornell Medical Centre (USA)
- Consultant Pathologist
- Breach Candy Hospital and Research Center, Mumbai
- Chairman, Metropolis Health Services
- Suvarna S Khadilkar MD DGO FICOG
- Associate Professor and Head of the Unit in Obstetrics and Gynecology
- Grant Medical College and Cama and Albless Hospital
- Mumbai
- Secretary, Mumbai Chapter, Indian Menopause Society
- Assistant Secretary, Editorial Board
- Journal of Obstetrics and Gynecology of India, FOGSI
- Chairperson Menopause Committee, MOGS
- Joint Secretary AMWI, Mumbai
- Maharashtra, India
- SV Kotwaliwale MS FAIMS
- Consultant Geneticist
- Genetic Diagnostic Center
- Mumbai, Maharashtra, India
- Swati G Allahbadia MD DGO
- NWMH, Parel, Mumbai
- Asian Heart Research Institute, BKC
- Bandra (E), Mumbai
- Rotunda Nursing Home, Wadala
- Mumbai, Maharashtra, India
- Swati R Daftary MD DA
- Consultant Anaesthesiologist
- Jaslok Hospital, Mumbai, Maharashtra, India
- Tambe P MD
- Consultant, Gynecologist and Obstetrician
- IVF Specialist
- Nirmiti Fertility and IVF Center, Thane (W)
- Kumars’ Maternity and Surgical Nursing Home, Dombivli (E)
- Mumbai, Maharashtra, India
- Tejas C Purandare
- Obstetrician and Gynecologist
- Bhatia Hospital, Tardeo
- Mumbai, Maharashtra, India
- Trupti Nadkarni MD DNB DGO FCPS
- Lecturer – Nowrosjee Wadia Maternity Hospital
- Mumbai, Maharashtra, India
- Tushar R Bandgar
- Associate Professor
- Department of Endocrinology
- Seth G S Medical College and KEM Hospital
- Mumbai, Maharashtra, India
- Umakanta Nanda MBBS MS FICS FICMCH
- Former Professor and Head
- Department of Obstetrics and Gynecology
- Medical College of Cuttack
- Behrampur and Burla, Orissa, India
- Usha B Saraiya MD DGO FIAC FICS FICOG
- Former Professor of Obstetrics and Gynecoloy
- Cama and Albless Hospital, Mumbai
- President FOGSI 2002
- Chairman ICOG 2006–9
- 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
- Vanaj Mathur
- Consultant
- Agra, UP, India
- Vandana Bansal MD DGO DNB MRCOG FNB
- (High Risk Pregnancy and Perinatology)
- Lecturer, Obstetrics and Gynecology
- Seth GS Medical College and
- Nowrosjee Wadia Maternity Hospital
- Mumbai, Maharashtra, India
- Vandana R Walvekar
- Former Dean Nowrosjee Wadia Maternity Hospital
- Professor, Seth GS Medical College, Parel
- Mumbai
- Honorary Consultant, Bhatia Hospital
- Tardeo
- Mumbai, Maharashtra, India
- Vanita S Raut MD DGO
- Consultant Obstetrician and Gynecologist
- Hiranandani Hospital
- Ex Professor of Obstetrics and Gynecology
- Seth GS Medical College and KEM Hospital
- Mumbai, Maharashtra, India
- Vasanthi Jayaraj MD
- Consultant Mother Hospital
- Thrissur 12, Kerala, India
- Veerbala N Parikh MD FICOG
- Consultant Obstetrician and Gynecologist
- NM Wadia Charitable Hospital, Solapur
- Maharashtra, India
- Vihang N Vahia MD DPM MAPA
- Consultant Psychiatrist Breach Candy
- Lilavati and Hurkisondas Hospitals, Mumbai
- Formerly Professor and HOD Psychiatry
- Dr RN Cooper Hospital and Seth GS Medical College
- Mumbai, Maharashtra, India
- Vinita Das
- Professor and Head of Department of Obstetrics and Gynecology
- King George Medical College
- Lucknow, UP, 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
- Vinod Saxena MD
- Medical Advisor
- Reckitt and Colman of India Ltd
- New Delhi, India
- VN Purandare MD FRCS (EDIN) FICOG
- Professor Emeritus Obstetrics and Gynecology
- Seth G S Medical College and KEM Hospital
- Mumbai
- Editor Emeritus Journal of Obstetrics and
- Gynecology of India
- VP Paily MD FRCOG
- Professor of Obstetrics and Gynecology
- Jubilee Mission Medical College Hospital
- Thrissur, Kerala
- Consultant Mother Hospital
- Thrissur 12, Kerala
- Yasmin Kazi
- Consultant Obstetrician and Gynecologist
- Mumbai, Maharashtra, India
- YS Nandanwar
- Professor and Head
- Department of Obstetrics and Gynecology
- (ISO 9001-2000 Certified), LTMMG College
- Sion, Mumbai, Maharashtra, India
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
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