Textbook of High Risk Pregnancy Hemant Deshpande
INDEX
A
Abnormal
demands 12
trophoblastic 24
ABO incompatibility 166
Acquired
coagulation disorders in pregnancy 110
hemophilia 116
Activated protein C 113
Active intervention 210
Actual management (protocol) 152
Acute renal failure 99
Advanced maternal age 148
Advantages of
hypervolemia 2
polyclonal anti-D 179
Adverse effects of intravenous B-sympathomimetics 142
Age at pregnancy 139
Aggressive treatment of cervical and vaginal infections 139
Aim of tocolysis 140
Albumin 72
Amniocentesis 170
Amnionicity 215
Amnionicity and clinical importance 217
Amniotic fluid
analysis 174
embolism 111
Anatomic abnormalities
leading to recurrent pregnancy loss 248
of uterus 137
Anemia 220
in pregnancy 1
Antenatal
care 124
corticosteroids 144
management 19
Antepartum management 48
Antibiotic prophylaxis 54
Anticoagulant regime 109
Anticonvulsant treatment 34
Anti-D preparations 179
Antiepileptic drugs (AEDs) 121
Antihypertensive
agents in acute hypertension 28
management 37
Antimalarial in pregnancy 135
Antiphospholipid antibody syndrome 105
Antiretroviral
drug resistance testing 85
therapy 85
Aortic
incompetence 51
stenosis 51
Approach in the antenatal period 97
Assessment of fetal well-being 68
Assisted reproduction technology 214
Asymptomatic bacteriuria 97
Augmentation of labor 247
Autoimmune
or connective tissue disease 107
thrombocytopenic purpura 115
Avoidance of multiple elective terminations of pregnancy 139
B
B-thalassemia 19
Bacterial vaginosis 138
B-adrenergic receptor agonist 141
Benson and Durfee's transabdominal cerclage 191
Bergmans Balloon test 184
Bimanual examination 243
Bleeding pattern 155
Blood glucose monitoring 60
Blood transfusion 9
Bone marrow 6
Breastfeeding and puerperium 126
C
Calcium channel blockers 143
Cardiac arrhythmias 46, 53
Cardiac
diseases in pregnancy 46
hypertrophy 66
Cardiovascular
disease 66
Case of anemia pernicious 16
Catamenial epilepsy 119
Catastrophic antiphospholipid syndrome 109
Cause of anemia 5
Causes of
antepartum hemorrhage 146
bleeding in placenta previa 149
decreased variability 254
failure of oral iron therapy 8
hydrops fetalis 168
increased prevalence in pregnancy 4
increased variability 254
intrauterine growth restriction 194
maternal alloimmunization 166
preterm labor 136
Cerebral edema 38
Cervical incompetence 137, 182
Cesarean
delivery indications 153
Changes in hypertension 22
Chemoprophylaxis 134
Chloroquine resistant
P. falciparum 134
P. vivax 134
Chloroquine sensitive
Chorioamnionitis 137
Chorionicity 215
Chronic
autoimmune thyroiditis 74
fetal distress 194
hypertension 41
hypertension in pregnancy 39
renal insufficiency 101
Cigarette smoking 156
Classification of
acardius 222
antiphospholipid syndrome 106
diabetes complicating pregnancy 56
gestational diabetes mellitus 56
pelvic shapes 240
Clinical
features of megaloblastic anemia 14
Clonic stage 33
Clot observation test 159
Coagulation studies 27
Cocaine abuse 156
Color Doppler flow study 151
Complete
blood count 26
hydatidiform mole coexisting fetus 228
Complications of
abruptio placentae 160
eclampsia and pre-eclampsia 37
Computer interpretation 257
Conditions with placental abruption 156
Conduct of trial of labor 246
Confirmation of diagnosis 150
Congenital
abnormality 226
heart disease 46, 51
hemolytic anemia 169
malformation 64
Conjoined twins 226
Consequences of iodine deficiency 72
Consumptive coagulopathy 160
Contraception in women with diabetes 69
Contracted
pelvic outlet 245
pelvis and cephalopelvic disproportion 239
Contraindications
of oral iron 8
to use of tocolytic agents 140
Cord compression pattern— true knot 258
Cordocentesis 171
Coronary artery disease 46, 53
Cortical necrosis 100
Couvelaire uterus or uteroplacental apoplexy 161
Criteria for delivery in mild pre-eclampsia 28
Curative treatment 7
Cutis graft technique 188
D
Daily iron requirement 5
Decreased maternal activity and bed rest 229
Defective
absorption 12
intestinal absorption 14
Degree of anemia 5
Degrees of alloimmunization 165
Delayed complications 178
Determinants of vertical transmission 80
Determination of fetomaternal hemorrhage 173
Development of seizure in pregnancy 127
Diabetes
in pregnancy 55
Diabetic
nephropathy 67
neuropathy 66
retinopathy 67
Diagnosing GDM 59
Diagnosis of
chorionicity and amnionicity by ultrasound examination 218
GDM based on OGTT 59
IUGR 199
Diagnostic
criteria and evaluation of antiphospholipid syndrome 107
criteria for severe pre-eclampsia 26
Dichorionic-diamniotic 217
Dietary prescription 7
Digital examination of cervix 186
Dilemma in equivocal controversial or nonreassuring findings 202
Dimorphic anemia (macrocytic hypochromic anemia) 17
Direct Coomb's test 176
Discordant growth 220
Disorders in fetal growth 65
Disseminated
intravascular coagulation 110
intravascular coagulation (DIC) 110
Divalent metal transporter 1 (DMT1) 3
Dizygotic twins 215
Doppler studies of placental anastomosis 225
Double trouble 129
Down's syndrome 195
Drugs producing thrombocytopenia 117
Dystocia dystrophia syndrome 242
E
Early
exchange transfusion 177
onset severe pre-eclampsia 107
Education about preterm labor 139
Effect of
B12 deficiency during pregnancy 14
drug disposition 123
epilepsy on pregnancy 121
fetus and newborn 133
HIV on pregnancy 83
intrauterine growth restriction (IUGR) 198
iodine deficiency on fetus 74
pregnancy on anemia 5
pregnancy on epilepsy 120
pregnancy on HIV 82
pregnancy on renal function 101
renal insufficiency on pregnancy 102
Effects on pregnant woman 133
Eisenmenger's syndrome 51
Endocrine
abnormalities 248
changes 219
Endothelial
and oxidant stress dysfunction 42
dysfunction seen in pre-eclampsia 23
Enterobacter 98
Environmental causes 195
Epilepsy in pregnancy 118
Erythropoiesis 3
Escherichia coli 98
Estimation of
anti-D levels 174
gestational age 209
Estriol 207
Ethanol 144
Evaluation of nutritional status and screening for anemia 139
Examination of placenta 217
Exchange transfusion 177
Expectant management 152
Extent of placental separation 155
Extraplacental bleeding 146
F
Factors influencing alloimmunization 165
Fallacies of test 173
False positive serological test for syphilis 107
Fatty liver of pregnancy 220
Female sex 94
Fertility and pregnancy in thalassemia 19
Fetal
and neonatal hypothyroidism 76
anticonvulsant syndrome 123
asphyxia 208
blood typing 170
bradycardia 253
causes of IUGR 195
complications unique in multiple gestations 220
fibronectin (FFN) 138
morbidity and mortality 221
response 168
Fetomaternal unit 195
Fetoplacental unit dysfunction 42
FIGLU test 16
First stage of labor 125
Flow cytometry 173
Fluid replacement in coagulation failure 112
Freda's method 171
G
Gametocytes of plasmodium species 131
Gastrointestinal system 219
Generalized tonic clonic seizure (GTCS) during labor 126
Genesis of pre-eclampsia as a two-stage disorder 25
Genetic
counseling 230
predisposition 24
Gestational
diabetes 220
epilepsy 127
goitrogenesis 73
hypertension 39
thrombocytopenia 114
Glomerular endotheliosis 38
Grades of incompetence 184
Grandmal 118
H
Hegar test 184
Hellin's law 214
HELLP syndrome 30
Hematological indices 6
Hepatitis
A (HAV) and pregnancy 90
B virus (HBV) 89
C (HCV) 89, 94
E (HCE) 94
E virus (HEV) 89
Herniation of bag of membranes 185
HIV
in pregnancy 78
screening during pregnancy 82
HIV/AIDS nephropathy 102
Home uterine monitoring 229
Hospitalized bed rest 230
Hydrops fetalis 168
Hydroxychloroquine 109
Hyperbilirubinemia 66
Hypertension in pregnancy 156
Hypertensive disorders in pregnancy 21
Hyperthyroidism and pregnancy 76
Hypervolemia of pregnancy 1
Hypocalcemia and hypomagnesemia 66
Hypoglycemia 65
Hypothesis 132
Hypothyroidism and pregnancy 75
Hysterosalpingography 184
I
Icteric phase 89
Icteric phase: Jaundice occurs 89
Icterus gravis neonatorum 169
Idiopathic hypertrophic subaortic stenosis (IHSS) 51
Immunological factors 24
Immunosuppressive drugs in pregnancy 103
Inadequate
intake 12
trophoblastic invasion 23
Increased
blood flow 23
prevalence in tropical developing countries 4
Indications for
evaluation of antiphospholipid antibodies 107
indications for cesarean delivery in women with GDM 64
parenteral iron therapy 9
valvotomy 49
Indications of MTP 49
Indirect Coombs’ test 174
Indomethacin 143
Induction at term reduces incidence of postdate pregnancy 209
Inevitable antepartum hemorrhage 146
Infections outside the uterus 137
Inhibition of thrombin activated protein C 113
Injection anti-D immunoglobulin 178
Insulin 62, 67
Interfering influence of bacteria and parasites 14
Interlocking twins 236
Intermediate disease 168
Intermittent therapy 8
Intranatal management 20
Intrapartum fetal blood sampling (FFS) 116
Intrapartum monitoring 145
Intrauterine fetal death 65
Intrauterine fetal demise of one twin 221
Intrauterine growth restriction (IUGR) 193
Intrauterine transfusion (IUT) 176
Intrauterine transmission 81
Invasive measures 84
Invasive methods for diagnosing monoamniotic pregnancy 218
Investigation protocol during pregnancy 125
Investigations in megaloblastic anemia 15
Iron balance during pregnancy 3
Iron metabolism 3
Iron sources and balance during pregnancy 3
ISBT numeric terminology 165
Isoxsuprine hydrochloride 141
Issues concerning pregnancy 80
J
Jaundice occurs 89
K
Ketoacidosis 66
Klebsiella 98
Kleihauer Betke test 173
L
Laboratory testing in HIV infected pregnant women 86
Lash and lash procedure 187
Length of cervix 184
Less placental blood flow 24
Liley's curve 170
Liver
function tests 27
rupture 38
Localization of placenta 150
Long-term consequences 66
Low
birth weight (LBW) 194
dose aspirin 109
molecular weight heparin 109
dose insulin infusion 68
Lower genital tract infections 137
M
Macrocytic
classification 11
hypochromic anemia 17
Macrosomia 61, 208
Magnesium sulfate 143
Major malformations 123
Malaria in pregnancy 129
Management
during labor 10
in group A—fetus with suspected dysmaturity syndrome 210
in group B—fetus with suspected macrosomia 212
Management of
gestation with high fetal number 236
heart disease 48
hepatitis in pregnancy 93
HIV infection during pregnancy 83
HIV positive pregnant women 83
labor 125
mild anemia 7
moderate anemia 7
pregnancy 103
preterm labor 139
Rh-immunized gravida 174
Rh-negative immunized patient 174
Rh-negative nonimmunized gravida 174
severe anemia 7
thalassemia 19
trap 223
Management strategy 133
Maneuvers to help in shoulder dystocia 212
Manifestation of HAV infection during pregnancy 90
Mann's isthmic cerclage 187
Marfan's syndrome 51
Maternal
adaptation 218
age, race, parity and ehthnicity 215
and fetal complications 60
and fetal effects 40
changes during pregnancy 22
complications 219
complications 66
medical disorders 137
response 167
smoking and alcohol intake 137
McDonald's cerclage 190
Mechanism of DIC during pregnancy 110, 111
Meconium aspiration 208
Megaloblastic anemia 11, 16
Metabolism of folic acid 11
Milestones in the history of Rh-alloimmunization 163
Minor anomalies 123
Miscellaneous drugs 144
Mitral incompetence 50
Moderate sources 11
Modifications of standard regimens 35
Monitoring of patient on intravenous B-sympathomimetics 142
Monoamniotic twins 226, 235
Monochorionic-diamniotic 217
Monoclonal injection anti-D 179
Morbidly restricted 194
Mother-to-child transmission (MTCT) 80
Multidrug resistant P. falciparum 134
Multifetal gestation 214
Munro Kerr Muller method 243
Mycobacterium avium complex 83
N
Neonatal management 87
Nevirapine 86
Newer antiepileptic agents 122
Nifedipine 143
Nitric oxide donors 142
Nitroglycerine 142
Nonpharmacological interventions 44
Nonreactive NST 255, 256
Nonreassuring NST 211
Nonresponders 166
Non-stress test 250
Normal
hemodynamic changes during pregnancy 47
maternal changes for fetal growth 22
physiologic changes during pregnancy 46
trophoblastic invasion 23
values in pregnancy 96
NST in special situations 256
NST vs other surveillance tests 258
Nutrition and weight gain 219
Nutritional
interventions 44
sources of folate 11
status 80
therapy 67
NYHA classification 48
O
Obstetric
complications 108
management 37, 63, 64, 104
measures 84
perspective of epilepsy 119
Occupational factors 137
Oligohydramnios 211
Optic density curve 170
Oral
hypoglycemics 62
iron therapy 7
Oxytocin antagonist 144
P
Paired gene theory 165
Parenteral iron therapy 9
Patau's syndrome 195
Pathogenesis of maternal alloimmunization 166
Pathophysiology
and mechanism 106
of anemia in B12 and folic acid deficiency 12
Per speculum examination 150
Per vaginal examination 150
Percutaneous umbilical blood sampling (PUBS) 116
Perinatal asphyxia 65
Periodic FHR changes 254
Peripartum cardiomyopathy 46, 52
Peripheral blood smear 6
Petit mal 118
Pharmacological interventions 44
Physiological
hypervolemia of pregnancy 2
jaundice 169
Physiological changes
during pregnancy 123
Pitfalls in sonographic diagnosis 185
Placenta previa 146
inevitable antepartum hemorrhage 146
Placenta previa and abruptio placentae 152, 220
Polyclonal injection anti-D 179
Polyhydramnios 65, 220
Positive autoantibodies tests 107
Postconceptional
cerclage 188
diagnosis 184
Postmaturity syndrome 208
Postpartum
hemorrhage 220
idiopathic ARF 100
management 64
thyroiditis (PPT) 75
Potassium channel openers 144
Potential mechanism of anticonvulsant embryopathy 124
Precautions while doing cesarean section 153
Preconception risk factors 42
Preconceptional
counseling 119, 139
therapy 40
Predictors and biochemical markers for preterm labor 138
Predictors of complications 53
Predisposing factors 148
Pregestational diabetes 64
Pregnancy and cardiac surgery 52
Pregnancy in patients
after transplantation 103
receiving dialysis 102
Pregnancy
in pre-existing renal disease 100
induced hypertension 220
morbidity 107
Pregnant woman with prosthetic valves 52, 46
Premature rupture of membranes 138
Premonitory stage 33
Presence and amount of virus in the genital tract 80
Preterm
delivery 65, 136
labor 136, 220
premature rupture of membranes 231
Prevention of preterm birth in multiple gestations 229
Previous preterm birth and abortions 137
Primary
antiphospholipid syndrome 106
pulmonary hypertension 51
Prior cesarean delivery 148
Pritchard's protocol 35
Production of procoagulant 111
Progesterone 144
Prolonged coagulation studies 107
Prophylactic
anticonvulsant therapy 29
supplementation 17
tocolysis 229
treatment 7
Prostaglandin synthetase inhibitors 143
Proteus 98
Psychological stress 137
Pulmonary
and tricuspid valve diseases 51
edema 37
stenosis 51
Q
Quintero's classification of the severity of TTTS 225
R
Radiopelvimetry 245
Rates of HIV transmission 78
RBC versus lymphocyte 16
Reactive NST 255
Recombinant factor VIIA 114
Recommended criteria for HELLP syndrome 31
Recurrent pregnancy loss 107, 248
Red cell antigen 164
Release of thromboplastins 110
Renal
complications of pre-eclampsia 38
disease in pregnancy 95
failure 161
functions 219
Replacement of blood products 112
Respiratory functions 219
Retained dead fetus 112
Retarded growth 194
Rh
alloimmunization in pregnancy 163
antigen 164
blood group system 164
factor 164
negative nonimmunized patient 173
Rheumatic heart disease 46, 48
Risk of antiphospholipid syndrome and pregnancy 108
Risks during pregnancy 12
Ritodrine 141
Role of folic acid in prevention of embryopathy 124
Rosenfield system 165
Rosetting test 173
Routes of delivery 233
Rupture of membranes 80
S
Safety of newer antimalarials 135
Saltatory pattern 253, 254
Screening for
chromosomal anomalies 230
GDM 57
Second stage of labor 125, 145
Secondary
antiphospholipid syndrome 106
immune response 166
prevention 84
Selection of cases for expectant treatment 152
Sensitization phenomenon 168
Sequential events 13
Serial ultrasound examination 140
Serum
electrolytes 27
levels of magnesium toxicity 34
Shirodkar’s
cerclage 188
operation 189
Silicone plastic cuff 188
Small for gestational age (SGA) 194
Smoking and illicit drug use 80
Socioeconomic causes 136
Specific causes of preterm labor 137
Spectrophotometry 170
Spontaneous abortion 64, 220
Standard doses regimen of chloroquine 134
Sudden uterine decompression 157
Superfecundation 215
Superimposed pre-eclampsia 40
Systolic blood pressure (SBP) 21
T
Temporary blindness (amaurosis) 39
Teratogenic risks from AEDs 123
Tetralogy of Fallot 51
Thalassemia 18
Therapeutic termination of pregnancy 127
Threatened preterm 136
Thrombocytopenia 114
Thrombophilias 156
Thrombotic
complications 108
microangiopathies 100
thrombocytopenic purpura (TTP) 115
Thyroglobulin 72
Thyroid
binding globulin (TBG) 72
disorders in pregnancy 70
function in normal pregnancy 70
hormone transport proteins 72
hormones and disorders 71
storm or heart failure 77
Total body iron 3
Transperineal
sonography (TPS) 151
hemorrhage (TPH) 166
Transthyretin (prealbumin). 72
Transvaginal sonography (TVS) 150
Trauma 156
Treatment of
anemia 7
antiphospholipid syndrome 108
established deficiency 17
heart failure 54
IUGR 202
lower genital tract infections 139
pulmonary edema 54
Trigger mechanisms 110
Trust your vaginal ultrasound 185
Tubulointerstitial 103
Twin a
nonvertex-twin B others 235
vertex-twin B
nonvertex 234
vertex 233
Twin
monitoring 257
reversed arterial perfusion (TRAP) 222
to twin transfusion syndrome 223
Types of
anemia 5, 6
abruptio placentae 155
placenta previa 147
U
Ultrasonography 228
Umbilical cord
and lower segment 149
dimensions 207
problems 227
Unexplained
bleeding 146
fetal growth restriction 107
second or third trimester loss 107
Universal precautions 87
Unprotected sexual intercourse 80
Urinary tract infections 97
Urine examination 26
USG and chorionicity 218
Uterine
artery Doppler 201
leiomyomas 157
overdistention 138
V
Vaccine against malaria in pregnancy 135
Vaginal
delivery 84, 159
examination 244
pessary 187
Vascular endothelial injury 110
Venous or arterial thrombosis 107
Viagra for the treatment of IUGR 204
Vibroacoustic stimulator 257
Viral load 80
Vitamin
B12 and folate levels 16
K supplementation 124
Vulval inspection 150
W
Warning hemorrhage 149
Width of internal OS 185
Wurm's stitch/hefner stitch 191
×
Chapter Notes

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1Textbook of High-Risk Pregnancy2
3Textbook of High-Risk Pregnancy
Hemant Deshpande MBBS MD Professor and Head Department of Obstetrics and Gynecology Padmashree Dr DY Patil Medical College and Hospital Pimpri, Pune, Maharashtra, India
4
Published by
Jaypee Brothers Medical Publishers (P) Ltd
Corporate Office
4838/24, Ansari Road, Daryaganj, New Delhi 110 002, India, Phone: +91-11-43574357, Fax: +91-11-43574314
Offices in India
Overseas Offices
Textbook of High-Risk Pregnancy
© 2011, Jaypee Brothers Medical Publishers
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 editor and the publisher.
First Edition: 2011
9789350250389
Typeset at JPBMP type setting unit
Printed at
5Dedication to
Shri Guru Raghvendra Swamiji with who's blessings this book has come into reality
6
7Contributors 9Foreword
It is a great honor to endorse book on High-Risk Pregnancy particularly as the first ideas regarding this book are addressed to the need of Maternal and Child Welfare Program. The maternal mortality rate is very high in many parts of the world. The common causes of maternal mortality include hemorrhage, toxemia, anemia, sepsis and unsafe termination of pregnancy. All these and many more factors including diabetes, thyroid disorders, renal diseases, malaria, hepatitis and others have been scholarly dealt with by a galaxy of authors.
The pedagogic idea of the authors is to harmonize the main aim of providing guidelines in uncommon situations for fruitful and happy outcome of pregnancy. The most appropriate methodology for diagnosis and therapy at the right time, at right place, at reasonable cost with convincing applications that the benefits of prompt treatment outweigh the potential risk to the mother and the child.
I congratulate Prof Hemant Deshpande and other authors for their timely and stupendous task.
KC Singhal md
Vice Chancellor
NIMS University
Jaipur, Rajasthan, India
10
11Foreword
This innovative book on high-risk pregnancy is a welcome addition to the field of obstetrics and gynecology. An excellent textbook on clinical approach to the subject was long overdue. This important publication is timely and meets the needs of students and practicing physicians. It is a sincere effort to initiate students to learn obstetrics and gynecology in the proper perspective.
The contributors to this volume have focused as much on the subject as on the central theme of learning clinical skills. The book is edited by Dr Hemant Deshpande, Prof and HOD, in Obstetrics and Gynecology of Padmashree Dr DY Patil Medical College, Pimpri, Pune, Maharashtra. He is a committed, hard working and a conscientious medical teacher. This institution is well known for bringing about innovations in medical education. Indeed the book makes a valuable contribution towards highlighting both the critical needs of clinical skill development and necessary strategies for providing quality reproductive health services for high-risk cases in obstetrics.
The editor must be complimented for his excellent work. It is fervently hoped that this brilliant publication will be widely used by undergraduate and postgraduate students and practicing obstetricians and gynecologists.
Amarjit Singh md
Dean, Padmashree Dr DY Patil Medical College
Hospital and Research Center
Pimpri, Pune, Maharashtra, India
12
13Preface
You see things; and you say ‘Why?’
But I dream things that never were; and I say ‘Why not?’
—George Bernard Shaw
Medical knowledge is constantly changing. In this constant changing world, it gives me an immense pleasure to introduce the first edition of my book Textbook of High-Risk Pregnancy. Editing and publishing the first edition of the book has been, to me, just like bringing a new life into this world. Though there have been constant changes in the treatment, procedures and other protocols in managing the patients with high-risk all over the world and in this book I have tried to incorporate all the basic facts along with the recent knowledge.
This book is aimed for not only undergraduates and postgraduates but also for the practicing clinicians who also encounter these complications in their day-to-day practice.
The contributors of this book are highly acclaimed obstetricians from renowned medical institutions, who have acclaimed their fort in this field.
Over the course of 24 chapters, most of the clinically important aspects of pregnancy - associated risks are covered, ranging through the overall a ntenatal till the puerperal and further management of the same. It is clear that the book has been written by all experienced obstetricians, as the topics are organized in a fashion that illuminates the principle of thinking and application correlation, which is the tool with which obstetricians approach clinical problems.
I am deeply honored and thankful to all my colleagues who have taken out time from their busy schedules and contributed their part in this book and to my family for their utmost support and p atience.
I have been very careful and have tried to make this book very informative, but all suggestions will be welcomed.
Hemant Deshpande