Part 1 of ebook Gabbe’s obstetrics essentials: Normal and problem pregnancies provide readers with content about: placental anatomy and physiology; placental anatomy and physiology; maternal physiology; maternal-fetal immunology; developmental origins of adult health and disease; prenatal care; nutrition during pregnancy; drugs and environmental agents in pregnancy and lactation - teratology and epidemiology; genetic screening and prenatal genetic diagnosis;... Please refer to the ebook for details!
Gabbe’s Obstetrics Essentials Normal and Problem Pregnancies Mark B Landon, MD Richard L Meiling Professor and Chair, Department of Obstetrics and Gynecology, Ohio State University College of Medicine, Columbus, Ohio Henry L Galan, MD Professor, Department of Obstetrics and Gynecology, University of Colorado School of Medicine Co-Director, Colorado Fetal Health Center, Aurora, Colorado Eric R.M Jauniaux, MD,PhD, FRCOG Professor of Obstetrics and Fetal Medicine, EGA Institute for Women’s Health, Faculty of Population Health Sciences, University College London, London, United Kingdom Deborah A Driscoll, MD Luigi Mastroianni Professor and Chair, Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Vincenzo Berghella, MD, FACOG Professor, Department of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania William A Grobman, MD, MBA Arthur Hale Curtis Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois Steven G Gabbe, MD Emeritus Chief Executive Officer, Ohio State University Wexner Medical Center, Professor of Obstetrics and Gynecology, Ohio State University College of Medicine, Columbus, Ohio Jennifer R Niebyl, MD Professor, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, Iowa City, Iowa Joe Leigh Simpson, MD Senior Vice President for Research and Global Programs, March of Dimes Foundation, White Plains, New York Professor of Obstetrics and Gynecology, Professor of Human and Molecular Genetics, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida Table of Contents Cover image Title page Copyright Contributors PART I Physiology Chapter Placental Anatomy and Physiology Placental Anatomy Placental Histology Placental Physiology Chapter Fetal Development and Physiology Umbilical Blood Flow Amniotic Fluid Volume Fetal Growth and Metabolism Fetal Cardiovascular System Fetal Kidney Fetal Gastrointestinal System Fetal Adrenal and Thyroid Glands Fetal Central Nervous System Chapter Maternal Physiology Overview Cardiovascular System Hematologic Changes Respiratory System Urinary System Body Water Metabolism Alimentary Tract Endocrine Changes Pancreas and Fuel Metabolism Skeleton Skin Central Nervous System Lower Reproductive Tract Microbiome Chapter Maternal-Fetal Immunology Introduction Immune System Overview: Innate and Adaptive Immunity Innate Immunity: First Line of Host Defense Adaptive Immunity Regulatory T Cells Fetal Immune System Maternal Tolerance of the Fetus Solid Organ Transplantation in Pregnancy Amelioration of Rheumatoid Arthritis in Pregnancy Chapter Developmental Origins of Adult Health and Disease Introduction Epigenetics and Programming Fetal Nutrition and Growth Energy-Balance Programming Maternal Stress and Anxiety Glucocorticoids and Prematurity Immune Function Other Programming PART II Prenatal Care Chapter Preconception and Prenatal Care Definition and Goals of Prenatal Care Components of Preconception Care and Well-Woman Visits Preconception Health Counseling Screening for Chronic Disease, Optimizing Care, and Managing Medication Exposure Prenatal Care Components of the Postpartum Visit Chapter Nutrition During Pregnancy Overview Integrating Nutrition Into the Obstetric History Maternal Weight Gain Recommendations Maternal Weight Gain Recommendations for Special Populations Maternal Nutrient Needs: Current Recommendations Vitamin and Mineral Supplementation Guidelines Nutrition-Related Problems During Pregnancy Special Nutritional Considerations During Pregnancy Chapter Drugs and Environmental Agents in Pregnancy and Lactation: Teratology and Epidemiology Overview Basic Principles of Teratology Medical Drug Use Drugs of Abuse Drugs in Breast Milk Occupational and Environmental Hazards Chapter Obstetric Ultrasound: Imaging, Dating, Growth, and Anomaly Biophysics of Ultrasound Optimizing the Ultrasound Image Special Ultrasound Modalities Scanning Technique First-Trimester Ultrasound Second- and Third-Trimester Ultrasound Components of the Examination Ultrasound for Determining Gestational Age Safety of Ultrasound Ultrasound Diagnosis of Malformations “Entertainment” Ultrasound Examinations Chapter 10 Genetic Screening and Prenatal Genetic Diagnosis Genetic History Genetic Counseling Chromosome Abnormalities Single-Gene or Mendelian Disorders Multifactorial and Polygenic Disorders Procedures for Prenatal Genetic Diagnosis Preimplantation Genetic Diagnosis Chapter 11 Antepartum Fetal Evaluation Defining the Problem of Perinatal Mortality Potential Utility of Antepartum Fetal Testing What Do These Tests Tell Us About the Fetus? Biophysical Techniques of Fetal Evaluation Clinical Application of Tests of Fetal Well-Being PART III Intrapartum Care Chapter 12 Normal Labor and Delivery Labor: Definition and Physiology Mechanics of Labor Cardinal Movements in Labor Normal Progress of Labor Spontaneous Vaginal Delivery Delivery of the Placenta and Fetal Membranes Episiotomy and Perineal Injury and Repair Ultrasound in Labor and Delivery Chapter 13 Abnormal Labor and Induction of Labor Diagnosis Induction of Labor Techniques for Cervical Ripening and Labor Induction Chapter 14 Operative Vaginal Delivery Operative Vaginal Delivery Operative Vaginal Delivery Instruments Risks of Operative Vaginal Delivery Chapter 15 Intrapartum Fetal Evaluation Direct Fetal Heart Rate and Uterine Activity Monitoring Indirect Fetal Heart Rate and Uterine Activity Monitoring Physiologic Basis for Electronic Fetal Heart Rate Monitoring Summary of Placental Causes of Interrupted Oxygenation 10 fetuses are particularly affected by maternal alloimmunization to D antigen Transfusion 1999;39(2):169– 173 Prenatal antibody screening and use of Rho (D) immune globulin (human) American College of Obstetricians and Gynecologists Technical Bulletin 1970:13 The selective use of Rho(D) immune globulin (RhIG) American College of Obstetricians and Gynecologists Technical Bulletin Update 1981:61 Prevention of RhD alloimmunization American College of Obstetricians and Gynecologists Practice Bulletin 1999:4 Bowman J.M Controversies in Rh prophylaxis Who needs Rh immune globulin and when should it be given? Am J Obstet Gynecol 1985;151(3):289–294 10 Levitt J Standards for Blood Banks and Transfusion Services 29th ed Bethesda, MD: American Association of Blood Banks; 2014 11 Cannon M, Pierce R, Taber E.B, Schucker J Fatal hydrops fetalis caused by anti-D in a mother with partial D Obstet Gynecol 2003;102(5 Pt 2):1143–1145 12 Chitty L.S, Finning K, Wade A, et al Diagnostic accuracy of routine antenatal determination of fetal RHD status across gestation: population based cohort study BMJ 2014;349 g5243 13 Nicolaides K.H, Soothill P.W, Clewell W.H, Rodeck C.H, Mibashan R.S, haemoglobin measurement in the assessment of red cell isoimmunisation Lancet 1988;1(8594):1073–1075 14 Yinon Y, Visser J, Kelly E.N, et al Early intrauterine transfusion in severe red blood cell alloimmunization Ultrasound Obstet Gynecol 2010;36(5):601–606 15 Copel J.A, Grannum P.A, Green J.J, et al Fetal cardiac output in the isoimmunized pregnancy: a pulsed Dopplerechocardiographic study of patients undergoing intravascular intrauterine transfusion Am J Obstet Gynecol 1989;161(2):361–365 16 Mari G, for the Collaborative Group for Doppler 596 Assessment of the Blood Velocity in Anemic Fetuses, Noninvasive diagnosis by Doppler ultrasonography of fetal anemia due to maternal red-cell alloimmunization N Engl J Med 2000;342:9–14 17 Nicolini U, Santolaya J, Ojo O.E, et al The fetal intrahepatic umbilical vein as an alternative to cord needling for prenatal diagnosis and therapy Prenat Diagn 1988;8(9):665– 671 18 Moise Jr K.J, Mari G, Fisher D.J, Huhta J.C, Cano L.E, Carpenter Jr R.J fetal hemodynamic alterations after intrauterine transfusion for treatment of severe red blood cell alloimmunization Am J Obstet Gynecol 1990;163(3):776–784 19 Lindenburg I.T, van Kamp I.L, van Zwet E.W, Middeldorp J.M, Klumper F.J, Oepkes D Increased perinatal loss after intrauterine transfusion for alloimmune anaemia before 20 weeks of gestation BJOG 2013;120(7):847–852 20 Lindenburg I.T, Smits-Wintjens V.E, van Klink J.M, et al Long-term neurodevelopmental outcome after intrauterine transfusion for hemolytic disease of the fetus/newborn: the LOTUS study Am J Obstet Gynecol 2012;206(2) 141.e1–e8 21 Ruma M.S, Moise Jr K.J, Kim E, et al Combined plasmapheresis and intravenous immune globulin for the treatment of severe maternal red cell alloimmunization Am J Obstet Gynecol 2007;196(2) 138.e1–e6 22 Hall A.M, Cairns L.S, Altmann D.M, Barker R.N, Urbaniak S.J Immune responses and tolerance to the RhD blood group protein in HLA-transgenic mice Blood 2005;105(5):2175–2179 23 Nielsen L.K, Green T.H, Sandlie I, Michaelsen T.E, Dziegiel M.H In vitr assessment of recombinant, mutant immunoglobulin G anti-D devoid of hemolytic activity for treatment of ongoing hemolytic disease of the fetus and newborn Transfusion 2008;48(1):12–19 24 Brecher M.E Technical Manual of the American Association of 597 Blood Banks 15th ed Bethesda, MD: American Association of Blood Banks; 2005 598 CHAPTER 35 Amniotic Fluid Disorders William M Gilbert KEY POINTS • AF is dynamic, with large volume flows into and out of the amniotic compartment each day • Clinical estimates of actual AFV based on ultrasound measurements of the AFI or MVP are not accurate in predicting true volume • In the presence of intrauterine growth restriction or a prolonged gestation, oligohydramnios is associated with significant increases in perinatal morbidity and mortality • Preterm or term isolated oligohydramnios is not associated with an increase in perinatal morbidity or mortality with an otherwise normal fetus • Early-onset or severe polyhydramnios is associated with aneuploidy, congenital malformations, preterm delivery, and an increased perinatal mortality rate • The cause of mild polyhydramnios, especially in the latter part of the third trimester, is usually idiopathic or related to diabetes mellitus and has little impact on perinatal survival • AFV as estimated by the AFI may be expanded with increased 599 maternal oral ingestion of water and/or bed rest in the left lateral recumbent position • Short-term use of indomethacin decreases fetal urine production and can reduce AFV within 24 hours of administration; prolonged use should be avoided because of the risk of premature closure of the ductus arteriosus and renal abnormalities in the newborn Overview ▪ Abnormalities of amniotic fluid volume (AFV) raise the concern for an underlying fetal or maternal complication during pregnancy or fetal/neonatal compromise The perinatal mortality rate approaches 90% to 100% with severe oligohydramnios in the second trimester and can exceed 50% with significant polyhydramnios in midpregnancy Amniotic Fluid Volume ▪ From 22 through 39 weeks of gestation, the average volume of amniotic fluid (AF) (Fig 35.1) remains unchanged despite an increase in fetal weight from about 500 g to 3500 g, a sevenfold increase Ultrasound Assessment of Amniotic Fluid Volume ▪ Polyhydramnios may be present if the maternal uterus is large for gestational age or if the fetus cannot be easily palpated or is ballotable The diagnosis of oligohydramnios is a consideration when the fundal height is small for gestational age or the fetus is easily palpated 600 601 FIG 35.1 Nomogram showing amniotic fluid volume as a function of gestational age The black dots are the mean for each 2-week interval Percentiles are calculated from a polynomial regression equation and standard deviation of residuals From Brace RA, Wolf EJ Normal amniotic fluid volume throughout pregnancy Am J Obstet Gynecol 1989;161:382 602 FIG 35.2 Ultrasound image demonstrates measurement of the maximum vertical pocket (MVP) within the uterus by holding the transducer perpendicular to the floor and determining the MVP of amniotic fluid in centimeters ▪ Early ultrasound estimations of AFV were made by measuring the maximum vertical pocket (MVP) of AF (Fig 35.2) ▪ Subsequently, a four-quadrant assessment of AF referred to as the amniotic fluid index (AFI) was introduced into practice (Fig 35.3) The sum of the MVP in each quadrant equals the AFI 603 FIG 35.3 Schematic diagram of the technique for measuring the four-quadrant amniotic fluid index ▪ Although the MVP appears to be the preferred method to diagnose oligohydramnios near term, the vast majority of research on ultrasound measurement of AFV utilizes the AFI ▪ When the MVP is less than cm, a marked increase in perinatal morbidity and mortality has been reported that persisted even after correcting for birth defects Amniotic Fluid Formation 604 ▪ The main source of amniotic fluid is fetal urination Human fetal urine-production rate appears to be approximately 1000 to 1200 mL/day at term, which suggests that the entire AFV is replaced more frequently than every 24 hours (Fig 35.4) ▪ Fetal lung liquid also plays an important role in amniotic fluid formation Amniotic Fluid Removal ▪ In the human, fetal swallowing begins early in gestation and contributes to the removal of amniotic fluid Fetal swallowing does not remove the entire volume of fluid that enters the amniotic compartment from fetal urine production and lung liquid; therefore other mechanisms of amniotic fluid removal such as intramembranous absorption must occur ▪ Researchers have noted that 200 to 500 mL/day leaves the amniotic compartment under normal physiologic conditions Intramembranous absorption could easily explain this movement Oligohydramnios ▪ In clinical practice, an MVP less than to cm or an AFI less than cm are commonly used as criteria for the diagnosis of oligohydramnios ▪ AF is required for fetal lung development during certain periods of early and mid-gestation ▪ Although the evidence for induction in the prolonged pregnancy is solid (see Chapter 36), the term or preterm patient with isolated oligohydramnios may not need immediate delivery ▪ All cases with oligohydramnios should be evaluated for evidence of intrauterine growth restriction and should be followed with antepartum testing 605 606 FIG 35.4 All known pathways for fluid and solute entry and exit from the amniotic fluid in the fetus near term Arrow size is relative to associated flow rate Brown arrows represent directly measured flows, whereas the blue arrows represent estimated flows The numbers represent volume flow in milliliters per day The curved portion of the double arrow represents lung fluid that is directly swallowed after leaving the trachea, whereas the straight portion represents lung fluid that enters the amniotic cavity from the mouth and nose From Gilbert WM, Moore TR, Brace RA Amniotic fluid volume dynamics Fetal Med Review 1991;3:89 B O X 1 Fetal and Maternal Causes of Oligohydramnios Fetal Conditions ▪ Renal agenesis ▪ Obstructed uropathy ▪ Spontaneous rupture of the membranes 607 ▪ Premature rupture of the membranes ▪ Abnormal placentation ▪ Prolonged pregnancy ▪ Severe intrauterine growth restriction Maternal Conditions ▪ Dehydration-hypovolemia ▪ Hypertensive disorders ▪ Uteroplacental insufficiency ▪ Antiphospholipid syndrome Evaluation and Treatment of Oligohydramnios ▪ When the diagnosis of oligohydramnios is made in the second trimester, it is vitally important to obtain a complete history and physical exam and to perform a targeted ultrasound to help identify a cause (Box 35.1) ▪ Several investigators have attempted to treat oligohydramnios with the oral administration of water in the hope of “hydrating” the fetus through the mother ▪ Groups have demonstrated that the AFI can be influenced by increasing or decreasing water intake orally B O X 2 Fetal and Maternal Causes of Polyhydramnios Fetal Conditions Congenital anomalies ▪ Gastrointestinal obstruction, central nervous system abnormalities, cystic hygroma, 608 nonimmune hydrops, sacrococcygeal teratoma, cystic adenoid malformations of lung Aneuploidy Genetic disorders ▪ Achondrogenesis type 1-B ▪ Muscular dystrophies ▪ Bartter syndrome Twin-to-twin transfusion syndrome Infections ▪ Parvovirus B-19 Placental abnormalities ▪ Chorioangioma Maternal Conditions Idiopathic Poorly controlled diabetes mellitus Fetomaternal hemorrhage Oligohydramnios in Labor ▪ Although most report a decrease in the frequency of variable decelerations with amnioinfusion in the setting of oligohydramnios, few have demonstrated any decrease in perinatal morbidity or mortality or in the cesarean delivery rate ▪ Based on a large multicenter trial, ACOG recommends against routine prophylactic amnioinfusion for the dilution of meconium-stained amniotic fluid Polyhydramnios ▪ Many authors define polyhydramnios as an MVP of greater than cm, whereas others use an AFI of 25 cm or greater ▪ Severe polyhydramnios in the second trimester has a 609 significant perinatal mortality rate due to prematurity or aneuploidy Evaluation and Treatment of Polyhydramnios ▪ The pregnant woman who presents with a rapidly enlarging uterus in mid pregnancy, with or without preterm labor, needs to be evaluated to identify a cause (Box 35.2) Ultrasound examination should be performed to measure the AFV and assess fetal anatomy ▪ When polyhydramnios occurs in the third trimester of pregnancy, it is usually mild and is not associated with a structural defect ▪ With severe polyhydramnios associated with preterm labor, one medical treatment option involves the administration of a prostaglandin inhibitor such as indomethacin, which decreases fetal urine production 610 ... 18 00 Philadelphia, PA 19 10 3-2 899 GABBE’S OBSTETRICS ESSENTIALS: NORMAL AND PROBLEM PREGNANCIES ISBN: 97 8-0 -3 2 3-6 097 4-6 Copyright © 2 019 by Elsevier, Inc All rights reserved No part of this publication... Cataloging-in-Publication Data Names: Landon, Mark B., editor Title: Gabbe’s obstetrics essentials : normal and problem pregnancies / [edited by] Mark B Landon [and others] Other titles: Obstetrics. . .Gabbe’s Obstetrics Essentials Normal and Problem Pregnancies Mark B Landon, MD Richard L Meiling Professor and Chair, Department of Obstetrics and Gynecology, Ohio State