Оглавление
Группа авторов. Protocols for High-Risk Pregnancies
Table of Contents
List of Tables
List of Illustrations
Guide
Pages
Protocols for High‐Risk Pregnancies. An Evidence‐Based Approach
Preface
Reference
List of Contributors
PROTOCOL 1 Alcohol Use in Pregnancy and Lactation
Overview
Alcohol use during pregnancy
Alcohol use during lactation
Screening for alcohol use
Intervention and referral to treatment
Conclusion
Suggested reading
PROTOCOL 2 Smoking, Vaping, and Nicotine Exposure
Clinical significance
Pathophysiology
Screening for tobacco, nicotine, and vaping exposure
Interventions
Pharmacotherapy
Complications
Follow‐up and prevention
Suggested reading
PROTOCOL 3 Opioid Use, Misuse, and Addiction in Pregnancy and Postpartum
Overview
Opioid use and misuse
Screening and diagnosis
Management
Labor and delivery
Postpartum
Conclusion
Suggested reading
PROTOCOL 4 Depression
Clinical significance
Pathophysiology
Diagnosis
Management
Follow‐up
Conclusion
Suggested reading
PROTOCOL 5 Prenatal Testing for Chromosomal Abnormalities
Overview
Pathophysiology
Diagnosis and screening protocols
Prenatal diagnostic testing
Cell‐free DNA screening
First‐trimester combined screening
Nuchal translucency sonography
First‐trimester PAPP‐A and hCG
Secondary sonographic markers
Second‐trimester screening
Sonographic detection of major malformations
Sonographic detection of minor features of aneuploidy
Second‐trimester AFP, hCG, uE3, and inhibin‐A
Combined first‐ and second‐trimester screening
Conclusion
Suggested reading
PROTOCOL 6 Fetal Echocardiography
Overview
Pathophysiology
Structural heart disease. Diagnosis and work‐up
Management
Fetal arrhythmias. Diagnosis and management
Follow‐up
Suggested reading
PROTOCOL 7 Clinical Use of Doppler
Overview
Pathophysiology. Normal fetal circulation
Fetal growth restriction
Fetal anemia
Preterm labor
Cardiac abnormalities
Diagnosis. Doppler techniques and measurements
Cardiac flow velocities
Prediction of adverse pregnancy events
Fetal growth restriction
Rh sensitization
Management. Congenital heart disease and arrhythmia
Fetal growth restriction
Fetal anemia
Preterm labor
Summary
Suggested reading
PROTOCOL 8 Antepartum Testing
Nonstress test
Biophysical profile
Modified biophysical profile
Contraction stress test
Umbilical Artery Doppler Velocimetry
Indications for antepartum fetal surveillance
Suggested reading
PROTOCOL 9 Fetal Blood Sampling and Transfusion
Clinical significance
Cytogenetic diagnosis
Fetal infection
Fetal anemia
Procedure‐related risks
Long‐term effects
Technique. Fetal blood sampling
Fetal blood transfusion
Postprocedure care
Future directions
Suggested reading
PROTOCOL 10 Preconception Genetic Screening
Overview
Cystic fibrosis. Clinical significance
Genetic etiology
Screening
Spinal muscular atrophy. Clinical significance
Genetic etiology
Screening
Hemoglobinopathies. Clinical significance
Genetic etiology
Screening
Fragile X syndrome. Clinical significance
Genetic etiology
Screening
Tay–Sachs disease and other disorders more prevalent in individuals of Ashkenazi Jewish descent. Clinical significance
Genetic etiology
Screening
Management and follow‐up
Conclusion
Suggested reading
PROTOCOL 11 Maternal Anemia
Definition
Consequences
Diagnostic work‐up and treatment
Macrocytic anemia
Normocytic anemia
Microcytic anemia
Iron supplementation in pregnancy
Treatment of iron deficiency anemia
Suggested reading
PROTOCOL 12 Hemoglobinopathies in Pregnancy
Clinical significance
Sickle cell disease
Thalassemias
Pathophysiology
Diagnosis
Role of transfusion therapy
Pregnancy management of sickle cell disease. Preconception counseling
Antenatal management
Antepartum management (acute pain crisis)
Intrapartum management
Postpartum management
Pregnancy management of thalassemias
Suggested reading
PROTOCOL 13 Fetal and Neonatal Alloimmune Thrombocytopenia
Introduction
Diagnosis
Management. Antenatal
Stratum 1 (low risk)
Stratum 2 (medium risk)
Stratum 3 (high risk)
Stratum 4 (extremely high risk)
Delivery
Postnatal
Conclusion
Suggested reading
PROTOCOL 14 Rheumatological Disorders
Introduction
Systemic lupus erythematosus. Overview
Pathophysiology
Diagnosis
Effect of pregnancy on SLE
Effect of SLE on pregnancy
Evaluation
Treatment
Antepartum SLE flare (Table 14.2)
Timing of delivery. Uncomplicated SLE
In the presence of deteriorating maternal or fetal health. Beyond 34 weeks of gestation
At 28–34 weeks of gestation
At 24–28 weeks of gestation
At less than 24 weeks of gestation
Postpartum care
Rheumatoid arthritis. Overview
Pathophysiology
Diagnosis
Effect of pregnancy on RA
Effect of RA on pregnancy
Management
Scleroderma. Overview
Pathophysiology
Effect of pregnancy on scleroderma
Effect of scleroderma on pregnancy
Management
Suggested reading. Systemic lupus erythematosus
Rheumatoid arthritis
Scleroderma
PROTOCOL 15 Antiphospholipid Syndrome
Overview
Pathophysiology
Diagnosis
Effect on pregnancy
Antepartum management. Baseline information
Medical therapy (anticoagulation and immunosuppressive therapy)
Pregnancy monitoring
Timing of delivery
Postpartum management
Conclusion
Suggested reading
PROTOCOL 16 Inherited Thrombophilias
Overview
Mechanisms of hemostasis
Mechanisms of thrombosis
Genetic risk factors for thrombosis
Adverse pregnancy outcome
Evaluation and treatment
Suggested reading
PROTOCOL 17 Valvular Heart Disease in Pregnancy
Introduction
Clinical implications of the physiological changes of pregnancy
Diagnosis and work‐up
Etiology of VHD
Maternal risk stratification
Stages of progression of valvular heart disease
Cardiac medications in pregnancy
Stenotic versus regurgitant valve lesions
Stenotic lesions. Tricuspid stenosis
Pulmonary stenosis
Mitral stenosis
Aortic stenosis
Regurgitant lesions. Tricuspid regurgitation
Pulmonic regurgitation
Mitral regurgitation
Aortic regurgitation
Mixed anomalies
Artificial valves
Cardiac surgery in pregnancy
Preconception and early pregnancy counseling
Antepartum management
Anticoagulation
Delivery planning
Medications on L&D
Delivery and the immediate postpartum period
Prophylactic antibiotics
Anesthesia
Follow‐up
Suggested reading
PROTOCOL 18 Peripartum Cardiomyopathy
Peripartum cardiomyopathy and the obstetric care provider
Clinical presentation and diagnosis
Differential diagnosis
Etiopathogenesis of peripartum and other cardiomyopathies. Dilated cardiomyopathy
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy
Stress cardiomyopathy
Stabilization and treatment
Stabilization of acute heart failure
Location and timing of delivery
Chronic therapy and long‐term follow‐up
Cardiomyopathy pearls for the obstetric care provider
Suggested reading
PROTOCOL 19 Thromboembolism
Introduction
Hemostasis changes during pregnancy
Clinical risk factors for thromboembolism associated with pregnancy
Inherited thrombophilias
Acquired thrombophilia
Diagnosis and management of venous thromboembolism associated with pregnancy. Deep venous thrombosis
Acute pulmonary embolism
Radiation considerations in pregnancy
Treatment of venous thromboembolism
Anticoagulation management considerations in the peripartum and postpartum periods
Postpartum anticoagulation
Anticoagulation prophylaxis considerations for women at risk for pregnancy‐related venous thromboembolism. Antepartum period
Postpartum period
Summary
Suggested reading
PROTOCOL 20 Renal Disease
Overview
Pre‐pregnancy counseling
Management
Suggested reading
PROTOCOL 21 Obesity
Clinical significance
Diagnosis
Treatment
Pregnancy and obesity
Prenatal care
Intrapartum care
Postpartum care
Conclusion
Suggested reading
PROTOCOL 22 Diabetes Mellitus
Overview
Pathophysiology
Pregestational diabetes mellitus. Risk assessment
Prepregnancy care. Objectives
Detection and evaluation of malformations
Antepartum care: regulation of maternal glycemia
Fetal evaluation
Delivery. Timing
Method
Intrapartum glycemic control
Contraception for the woman with type 1 or type 2 diabetes mellitus. Combination oral contraceptives
Progestin‐only pills
Etonogestrel implants
Mechanical or barrier methods
Intrauterine device
Sterilization
Gestational diabetes mellitus. Definition
Consequences: why bother to screen?
Screening and diagnosis. Detection
High risk
Average risk: two‐step process
Definitive diagnosis
Other diagnostic criteria
Antepartum management. Program of care
Dietary recommendations in pregnancy
Exercise
Surveillance of maternal diabetes
Delivery
Postpartum care. Evaluation for persistent carbohydrate intolerance
Effects of oral contraceptives
Recurrence risk in subsequent pregnancies
Suggested reading. Type 1 and type 2 diabetes mellitus in pregnancy
Gestational diabetes mellitus
PROTOCOL 23 Thyroid Disorders
Overview
Diagnosis
Additional studies
Hypothyroidism
Implications for pregnancy
Treatment
Hyperthyroidism
Implications for pregnancy
Management
Thyroid storm management
Suggested reading
PROTOCOL 24 Hepatitis in Pregnancy
Hepatitis A in pregnant and breastfeeding women
Hepatitis B in pregnant and breastfeeding women
Interaction of HBV with the physiology of the pregnant immune system
Maternal screening
Prevention of HBV infection
Treatment of mothers with HBV
Elective cesarean versus vaginal delivery
Breastfeeding
Hepatitis C in pregnant and breastfeeding women
Epidemiology
Screening
Diagnostic algorithm
Additional monitoring and management considerations during pregnancy
Treatment
Breastfeeding
Hepatitis D in pregnant and breastfeeding women
Hepatitis E in pregnant and breastfeeding women
Suggested reading. Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
PROTOCOL 25 Asthma
Overview
Pathophysiology
Diagnosis
Management. General
Chronic asthma
Acute asthma
Follow‐up
Conclusion
Suggested reading
PROTOCOL 26 Epilepsy
Overview
Pathophysiology and risks. Inheritance
Seizure threshold
Fetal risks
Maternal risks
Antiepileptic drugs
Teratogenicity
Risks associated with specific medications
Pregnancy management
Pre‐pregnancy
First trimester
Second trimester
Third trimester
First seizure during pregnancy
Intrapartum
Postpartum
Suggested reading
PROTOCOL 27 Chronic Hypertension
Definition and diagnosis
Etiology and classification
Maternal–perinatal risks
Treatment
Suggested management
Evaluation and classification
Low‐risk hypertension
High‐risk hypertension
Summary
Suggested reading
PROTOCOL 28 Cytomegalovirus, Genital Herpes, Rubella, and Toxoplasmosis
Cytomegalovirus
Diagnosis
Management
Genital herpes simplex virus
Diagnosis
Management. Antepartum management
Intrapartum management
Rubella
Diagnosis
Management
Toxoplasmosis
Diagnosis
Treatment
Suggested reading. Cytomegalovirus
Genital herpes simplex virus
Rubella
Toxoplasmosis
PROTOCOL 29 Syphilis
Epidemiology
Pathophysiology and clinical manifestations
Congenital syphilis
Diagnosis in pregnancy
Ultrasound
Management
Response to treatment
Suggested reading
PROTOCOL 30 Vector‐Borne Diseases in Pregnancy: Zika, West Nile, and Chagas Disease
Zika virus
Clinical significance
Congenital Zika syndrome
Pathophysiology
Diagnosis and management
Follow‐up
West Nile virus
Pathophysiology
Clinical findings
Diagnosis
Treatment
Complications
Prevention
Chagas disease
Pathophysiology
Clinical findings
Diagnosis
Treatment
Prevention
Suggested reading
PROTOCOL 31 Influenza
Overview
Pathophysiology
Diagnosis
Treatment
Complications
Prevention
Suggested reading
PROTOCOL 32 Malaria
Overview
Life cycle of the parasite
Clinical significance and pathophysiology
Epidemiology
Diagnosis
Prevention
Management
Travel to endemic areas
Conclusion
Suggested reading
PROTOCOL 33 Human Immunodeficiency Virus Infection
Epidemiology
Pathophysiology
Screening in pregnancy
Diagnosis
Initial counseling
Initial laboratory assessment
Treatment
Follow‐up
Intrapartum management
Postpartum management
Conclusion
Suggested reading
PROTOCOL 34 Parvovirus B19
Overview
Epidemiology
Pathophysiology
Clinical features
Erythema infectiosum
Arthropathy
Transient aplastic crisis
Pure red blood cell aplasia
Fetal infection
Diagnosis. Maternal diagnosis
Fetal diagnosis
Management
Ultrasound surveillance
Fetal transfusion
Intravenous immune globulin
Delivery considerations
Follow‐up
Prevention
Screening
Summary
Suggested reading
PROTOCOL 35 Group B Streptococcus
Clinical significance
Pathophysiology
Diagnosis
Treatment
Preterm labor
Preterm prelabor rupture of the membranes
Bacteriuria
Cesarean delivery
Penicillin allergy
Unknown GBS status
Prevention
Conclusion
Suggested reading
PROTOCOL 36 Biliary, Liver, and Pancreatic Disease
Chronic calculus cholecystitis/biliary dyskinesia. Clinical significance
Pathophysiology
Diagnosis
Treatment
Complications
Acute cholecystitis. Clinical significance
Pathophysiology
Diagnosis
Treatment
Complications
Choledocholithiasis. Clinical significance
Pathophysiology
Diagnosis
Treatment
Complications
Intrahepatic cholestasis of pregnancy. Clinical significance
Pathophysiology
Diagnosis
Treatment
Complications
Acute fatty liver of pregnancy. Clinical significance
Pathophysiology
Diagnosis
Management
Follow‐up and conclusion
Acute pancreatitis during pregnancy. Clinical significance
Pathophysiology
Diagnosis
Management
Follow‐up and conclusion
Suggested reading. Biliary disease
Intrahepatic cholestasis
Acute fatty liver
Pancreatitis
PROTOCOL 37 Cervical Insufficiency
Overview
Diagnosis
Management in singleton pregnancy
History‐indicated cerclage (HIC) Recurrent second‐trimester loss
Cerclage in prior pregnancy
Cervical anomaly
Progesterone
Short transvaginal ultrasound cervical length. Ultrasound‐indicated cerclage. Prior preterm birth
No prior preterm birth
Progesterone. Prior preterm birth
No prior preterm birth
Pessary
Cervical dilation on physical exam. Physical exam‐indicated cerclage
Progesterone
Pessary
Surgical technique for cerclage placement. Transvaginal cerclage
Transabdominal cerclage
Cerclage removal
Complications
Contraindications
Management in twin pregnancy
Ultrasound diagnosis
Physical exam diagnosis
Suggested reading
PROTOCOL 38 Nausea and Vomiting
Clinical significance
Diagnosis and pathophysiology
Differential diagnosis
Treatment
Pharmacotherapy
Complications
Recurrence risk
Conclusion
Suggested reading
PROTOCOL 39 Fetal Death and Stillbirth
Overview
Pathophysiology and etiology
Diagnosis
Treatment
Expectant management
Dilation and curettage (uterus 12 weeks of gestation in size or less)
Dilation and evacuation (uterus between 13 and 22 weeks of gestation in size)
Induction of labor
Fetal demise (uterus less than 28 weeks of gestation in size)
Fetal demise (uterus greater than 28 weeks of gestation in size)
Diagnostic evaluation
Follow‐up
Suggested reading
PROTOCOL 40 Abnormal Amniotic Fluid Volume
Overview
Physiology of normal amniotic fluid volume
Amniotic fluid production
Amniotic fluid removal
Oligohydramnios. Overview
Complications
Diagnosis
Evaluation. Physical examination
Sonography
Laboratory screening
Amniocentesis
Treatment options. Delivery
Amnioinfusion
Maternal hydration
Summary
Polyhydramnios. Overview
Diagnosis
Evaluation
Sonography
Laboratory screening
Amniocentesis
Treatment options
Amnioreduction
Indomethacin
Follow‐up. Antepartum management
Labor management
Complications
Summary
Suggested reading
PROTOCOL 41 Fetal Growth Restriction
Definition and clinical significance
Etiology
Screening
Surveillance
Management
Outcome
Prevention
Conclusion
Suggested reading
PROTOCOL 42. Rh and Other Blood Group Alloimmunizations
Overview
Pathophysiology
Management of the first alloimmunized pregnancy (Figure 42.1)
Management of a subsequent alloimmunized pregnancy
Treatment
Outcome and follow‐up
Prevention
Conclusion
Suggested reading
PROTOCOL 43 Preterm Labor
Clinical significance
Pathophysiology
Diagnosis
Treatment
Minimize interventions
Optimize fetal status. Transfer
Corticosteroids for fetal maturity
Tocolysis
Magnesium for neuroprotection
Other interventions
Complications
Follow‐up
Conclusion
Suggested reading
PROTOCOL 44 Prevention of Preterm Birth
Clinical significance
Pathophysiology and antecedents of preterm birth
Management
Population‐based interventions. Midwife‐led continuity of care models
Screening for infection
Smoking cessation
Nutritional supplementation
Immediate postpartum contraception
Interventions for women at high risk of preterm birth. Risk stratification for preterm birth
Specialist antenatal care
Aspirin
Treatment options for women at high risk of preterm birth with a short cervix
Transvaginal cervical cerclage
Expectant management
Progesterone
Cervical pessary
Second‐line treatment: transabdomnial cervical cerclage
Women with multiple pregnancy
Conclusion
Suggested reading
PROTOCOL 45 Premature Rupture of the Membranes
Overview
Pathophysiology
Clinical implications
Diagnosis
Evaluation
Management
Term PROM (at 37 weeks or more)
Preterm PROM (at 34 weeks–36 weeks 6 days)
Preterm PROM (at 32 weeks–33 weeks 6 days)
Preterm PROM (at 23 weeks–31 weeks 6 days)
Preterm PROM (prior to 23 weeks)
Special circumstances. Cervical cerclage
Herpes simplex virus
Human immunodeficiency virus
Resealing of the membranes
Prevention of recurrent preterm PROM
Suggested reading
PROTOCOL 46 Indicated Late‐Preterm and Early‐Term Deliveries
Clinical significance
Pathophysiology
Diagnosis
Management
Complications
Follow‐up and prevention
Conclusion
Suggested reading
PROTOCOL 47 Chorioamnionitis
Overview
Definitions and clinical presentation
Isolated maternal fever
Epidemiology
Pathophysiology
Risk factors
Management. Triple I ‐ term ( ≥ 37 weeks)
Triple I – preterm (<34 weeks)
Preterm labor/PPROM without clinical signs or symptoms of Triple I
Preterm labor/PPROM with symptoms of Triple I or confirmed Triple I
Triple I – late preterm (34–37 weeks)
Fever of unknown origin
Isolated intrapartum maternal fever
Complications
Prevention
Conclusion
Suggested reading
PROTOCOL 48 Third‐Trimester Bleeding
Introduction
Etiology
Placenta previa
Placenta accreta spectrum
Vasa previa
Placental abruption
Uterine rupture
Other causes of third‐trimester bleeding
Work‐up of third‐trimester bleeding
General management considerations
Potential complications
Conclusion
Suggested reading
PROTOCOL 49 Amniotic Fluid Embolism
Overview
Pathogenesis
Clinical presentation
Management
Published guidelines
Conclusion
Suggested reading
PROTOCOL 50 Preeclampsia
Overview
Pathophysiology
Diagnosis
Gestational hypertension
Severe gestational hypertension
Proteinuria
Edema
Preeclampsia
Preeclampsia with severe features
Eclampsia
Management
Initial evaluation
Gestational hypertension and preeclampsia without severe features
Management of gestational hypertension or preeclampsia without severe features. 37 weeks or more
Less than 37 weeks
Preeclampsia with severe features
Management of preeclampsia with severe features
Blood pressure control
Indications for delivery
HELLP
Eclampsia
Intrapartum management
Postpartum management
Complications of preeclampsia and HELLP
Follow‐up and maternal counseling
Suggested reading
PROTOCOL 51 Elective Induction of Labor
Overview
Cervical ripening agents. Mechanical agents. Membrane stripping
Intracervical balloon catheter placement
Pharmacological agents
Prostaglandin E1
Prostaglandin E2
Recommendations for fetal surveillance after prostaglandin use
Labor‐inducing procedures and agents. Amniotomy
Oxytocin
Failed induction
Conclusion
Acknowledgment
Suggested reading
PROTOCOL 52 Electronic Fetal Heart Rate Monitoring
Overview
Physiology of fetal heart rate patterns
Baseline fetal heart rate
Variability
Accelerations
Early deceleration
Late deceleration
Variable deceleration
Prolonged deceleration
Sinusoidal pattern
Fetal oxygenation and its interruption
A simplified, standardized approach to management
Confirm fetal heart rate and uterine activity
Evaluate FHR components
A: Assess the oxygen pathway and consider other causes of FHR changes
B: Begin corrective measures as indicated
Reevaluate the FHR tracing
C: Clear obstacles to rapid delivery
D: Determine decision‐to‐delivery time
Delivery
Conclusion
Suggested reading
PROTOCOL 53 Breech Delivery
Overview
Diagnosis
Management. Antepartum management
External cephalic version
Delivery
Breech delivery at cesarean
Conclusion
Suggested reading
PROTOCOL 54 Vaginal Birth After Cesarean
Overview
Prelabor counseling
Criteria most predictive of a safe and successful TOLAC
Potential contraindications
Management of labor and delivery
Uterine rupture
Diagnosis
Management
Conclusion
Suggested reading
PROTOCOL 55 Placenta Accreta Spectrum
Overview and clinical significance
Pathophysiology and risk factors
Diagnosis
Complications
Management
Antepartum obstetric care (suspected PAS with previa)
Surgical (suspected PAS)
Surgical (unsuspected accreta)
Conservative management
Prevention
Follow‐up
Conclusion
Suggested reading
PROTOCOL 56 Shoulder Dystocia
Overview
Pathophysiology and diagnosis
Management
Extraordinary maneuvers
Gaskin maneuver
Axillary traction
Cephalic replacement (Zavanelli maneuver)
Abdominal rescue
Documentation
Suggested documentation for shoulder dystocia
Suggested reading
PROTOCOL 57 Twins, Triplets, and Beyond
Clinical significance
Pathophysiology
Placentation
Diagnosis
Determining chorionicity
Management. Antepartum. Early ultrasonography
Medications and nutritional requirements
Prenatal diagnosis. Aneuploidy screening
Maternal serum alpha‐fetoprotein screening to determine neural tube defect (NTD) risk
Congenital anomalies
Preterm birth prevention
Diabetes screening
Fetal growth assessment
Antepartum testing
Delivery. Timing of delivery
Mode of delivery
Vertex/vertex
Vertex/nonvertex
Nonvertex presenting twin
Triplets and beyond
Other considerations
Complications
Monoamniotic pregnancies
Monochorionic‐diamniotic pregnancies
Twin‐to‐twin transfusion syndrome. Screening and diagnosis
Management and treatment
Single fetal demise
Multifetal pregnancy reduction
Selective termination
Conclusion
Suggested reading
PROTOCOL 58 Postpartum Hemorrhage
Clinical significance
Definition
Pathophysiology
Diagnosis
Management
Surgical treatment
Complications
Follow‐up
Reporting
Prevention
Conclusion
Suggested reading
Appendix A. Evaluation of Fetal Health and Defects
Index
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