Arias' Practical Guide To High-risk Pregnancy And Delivery

Front cover
Front matter
Copyright
Dedication
Preface
Contributors
Table of contents
1 Prenatal diagnosis of chromosomal abnormalities
	Introduction
	Types of chromosomal abnormalities
		Numerical abnormalities
		Structural changes
	Screening
		First trimester
			Nuchal translucency
			Maternal age
			Biochemical markers
			Additional first trimester ultrasound markers for chromosomal abnormalities
			Special circumstances
				Women with HIV
		Second trimester screening
			Biochemical markers
				Beta-hcg
				Alpha fetoprotein
				Free estriol
				Inhibin a
			Comprehensive ultrasound
				Triple test
				Quadruple test
	Diagnostic testing
		Chorionic villus sampling
		Amniocentesis
		Non-invasive prenatal testing
		Multiple pregnancy
			Twin pregnancies
			Triplet pregnancies
	Indian experience of chromosomal abnormalities
	References
2 Fetal dysmorphology
	Introduction
	Central nervous system abnormalities
		Neural tube defects
		Anencephaly
		Spina bifida
		Ventriculomegaly
		Holoprosencephaly
		Agenesis of corpus callosum
	Abnormalities of the neck
		Cystic hygroma
		Cardiac abnormalities
		Ventricular septal defect
		Atrio-ventricular septal defects
		Atrial septal defect
		Hypoplastic left heart syndrome
		Tetralogy of fallot
		Double outlet right ventricle
		Ebstein’s anomaly
		Coarctation of aorta
		Transposition of great arteries
		Cardiomyopathies
		Fetal arrhythmias
		Cardiac tumours
	Thoracic abnormalities
		Congenital diaphragmatic hernia
		Congenital cystic adenoid malformation of the lungs
		Bronchopulmonary sequestration
		Hydrothorax (fig. 2.8)
	Abdominal abnormalities
		Gastroschisis
		Exomphalos
	Abnormalities of the urinary tract
		Hydronephrosis
		Obstructive uropathy
		Multicystic dysplastic kidneys
		Autosomal recessive (infantile) polycystic kidney disease
		Adult pckd
	Skeletal abnormalities
		Lethal skeletal dysplasias
			Thanatophoric dysplasias
			Achondrogenesis
			Osteogenesis imperfecta type 2
		Non-lethal skeletal dysplasias
			Achondroplasia
			Sacro-coccygeal teratoma
	Miscellaneous
		Oligohydramnios
		Polyhydramnios
		Non-immune hydrops
	Environmental fetal risks
		Diagnostic radiation in pregnancy
		Alcohol and recreational drug use
		Substance misuse
			Cocaine
			Benzodiazepines
			Opiates including heroine
		Medications in pregnancy
			Anti-epileptic drugs (aeds)
			Antidepressants
			Progesterone
			Steroids
			Antimicrobials
			Metronidazole
			Antihypertensives
				Diuretics
				Beta-blockers
			Antimalarials
			Antituberculosis agents
			Anticancer drugs
				Methotrexate
				Azathioprine
			Aspirin
	Indian experience of fetal dysmorphology
		Liquor amnii and its significance in monitoring fetal health
			Hydramnios
	References
3 Impact of advances in genetics on prenatal diagnosis
	Introduction
	Methods of prenatal diagnosis
		Non-invasive procedures
		Invasive procedures
	Confirmatory tests for prenatal diagnosis
		Chromosome abnormalities1
		Single gene analysis
			Chorionic villus sampling
			Amniocentesis
			Fetal blood sampling
	Chromosome analysis
		Standard karyotype (fig. 3.1)
		Karyotype nomenclature
			Translocation
				Robersonian translocation
				Balanced reciprocal translocation (fig. 3.5)
			Inversions
		Chromosome deletions and duplications
		Marker chromosomes
		Chromosome mosaicism
		Molecularly based karyotype tests
		Quantitative fluorescent polymerase chain reaction
	Techniques for identification of smaller chromosome abnormalities
		Fluorescent in situ hybridisation (fish) (fig. 3.9)
		Multiple ligation probe amplification (mlpa) (fig. 3.10)
		Prenatal bacterial artificial chromosomes on beads (bobs)
		Comparative genomic hybridization (cgh)
		Free fetal DNA (fig. 3.12)
	Single gene disorders
		Inheritance patterns
			Pedigree drawing symbols (fig. 3.13)
		Molecular techniques for identifying mutations in single gene disorders
			Sanger sequencing (fig. 3.18)
			Amplification refractory mutations system (arms) test
			Next generation sequencing (ngs)
			Free fetal DNA (ffdna) and single gene analysis
		Indications for invasive prenatal diagnosis
		Maternal screening
		Mutation identification
			Single mutation causing the disease
			Small number of mutations cause the majority of disease
			Diseases caused by multiple mutations in multiple genes
		Non-invasive methods of prenatal diagnosis
			Ultrasound
			Fetal dysmorphology
			Fetal MRI
	Databases and useful resources
	References
	Further reading
4 Fetal infections
	Introduction
	Cytomegalovirus (cmv)
		Virology
		Epidemiology
		Implication for fetal infection
		Ultrasound signs and symptoms
		Laboratory investigation
		Management
		Postnatal management
		Cmv infection: Indian experience
	Toxoplasmosis
		Microbiology
		Epidemiology
		Implications for fetal infections
		Ultrasound signs and symptoms
		Laboratory investigation
		Management
		Postnatal management
		Toxoplasmosis: Indian experience
	Rubella (german measles)
		Virology
		Epidemiology
		Implications for fetal infection
		Ultrasound signs and symptoms
		Laboratory investigations
		Management
		Post-natal management
		Rubella epidemiology: Indian experience
	Parvovirus b19 (pb19)
		Virology
		Epidemiology
		Implications of fetal infection
		Ultrasound signs and symptoms
		Laboratory investigations
		Management
		Post-natal management
	Varicella zoster (chickenpox)
		Virology
		Epidemiology
		Implications of fetal infection
		Ultrasound signs and symptoms
		Laboratory investigations
		Management
		Post-natal management
	Syphilis
		Microbiology
		Epidemiology
		Implication for fetal infection
		Ultrasound signs and symptoms
		Laboratory investigations
		Management
		Postnatal management
	Group b streptococcus
		Risk factors for early onset gbs sepsis
		Maternal and neonatal colonization and infection
		Screening
		Prevention of neonatal infection
		Treatment of maternal infection
		Immunization
		Group b streptococci infection: Indian experience
	Viral hepatitis
		Hepatitis A
		Hepatitis B
			Virology
			Epidemiology
			Maternal infection
			Implications for fetal infection
			Ultrasound signs and symptoms
			Laboratory investigations
			Management
			Postnatal management
		Hepatitis C
		Viral hepatitis: Indian experience
	Genital herpes (hsv)
		Virology
		Maternal infection
		Implication for fetal infection
		Ultrasound signs and symptoms (box 4.14)
		Laboratory investigations
		Management
		Hsv infection: Indian experience
	Human immunodeficiency virus infection
		Virology
		Epidemiology
		Maternal infection
		Implications for fetal infection
		Diagnosis
		Ultrasound signs and symptoms
		Management
		Postnatal management
		HIV in pregnancy: Indian experience
	Malaria
		Microbiology
		Epidemiology
		Implication for maternal and fetal infection
		Ultrasound signs and symptoms
		Laboratory investigation
		Management
		Infection as a possible cause following ultrasound scan findings
		Positive torch test result
	References
5 Fetal growth restriction
	Concept
	Definition
	Type of smallness
		Error in pregnancy dating
			Symmetry and asymmetry
		Constitutionally small fetuses
			Structural or chromosomal abnormality
		Fetal infection
		Placental insufficiency
	Risk factors
		Maternal characteristics (assessed at booking and during pregnancy)
		Maternal medical history (assessed at booking)
		Obstetric history (assessed at booking)
		Current pregnancy findings/complications
		Substance abuse (assessed at booking and during pregnancy)
	Screening for sga due to placental insufficiency
		Uterine artery doppler
	Diagnosis
		Ultrasound biometry
		Clinical examination
		Biophysical tests
		Investigations to be undertaken for differential diagnosis
			Invasive prenatal diagnosis
		Test for maternal/fetal infection
		Doppler assessment
	Fetal surveillance
		Fetal biometry
		Doppler assessment
			Uterine artery doppler
			Umbilical artery doppler
			Middle cerebral artery and ductus venosus doppler
		Amniotic fluid volume
		Biophysical profile
		Cardiotocography
	Interventions in preterm sga
	Prevention of sga
	Timing of delivery
	Fetal and neonatal problems associated with fgr
		Fetal hypoxia and acidosis
		Stillbirth
		Oligohydramnios
		Intrapartum complications
		Neonatal complications
		Respiratory distress syndrome (rds)
		Meconeum aspiration syndrome
		Persistent fetal circulation
		Intraventricular haemorrhage (ivh)
		Newborn encephalopathy
		Hypoglycaemia
		Hypocalcaemia
		Hyperviscosity syndrome
	Long-term outcome
	Indian experience of fetal growth restriction
	References
6 Early pregnancy complications
	Introduction
	Presentation-based approach to complications in early pregnancy
	Bleeding in early pregnancy
		Causes of bleeding in early pregnancy
		Clinical evaluation of a woman with early pregnancy bleeding
		Blood investigations in early pregnancy bleeding
		Transvaginal ultrasound in early pregnancy bleeding
	Miscarriage – clinical terminologies
	Management of threatened miscarriage (viable intrauterine pregnancy with bleeding)
	Management of other miscarriage scenarios (nonviable intrauterine pregnancy)
	Management of tubal ectopic pregnancy
		Medical therapy – methotrexate
		Surgical therapy
		Future fertility after ectopic pregnancy
	Management of ectopic pregnancy (nontubal sites)
	Gestational trophoblastic disease (gtd)
	Nausea, vomiting and hyperemesis in early pregnancy
	Lower abdominal and pelvic pain in early pregnancy
		Adnexal torsion
		Ovarian hyperstimulation syndrome (ohss)
	Physiological changes and symptoms mimicking complications
	Indian perspective
	References
7 Identification and antepartum surveillance of high risk pregnancy
	Maternal mortality and perinatal mortality
		Maternal mortality
		Perinatal mortality
			Causes of perinatal mortality
	Antenatal evaluation
		Preconception counselling
	Identifying high risk factors
		High risk factors
			Medical high risk
			Obstetric high risk
	Fetal high risk evaluation
		Clinical assessment of fetal well-being
		Cardiotocography (ctg)
			Nonstress test (nst)
			Contraction stress test (cst)
			Computerized ctg (cctg)
		Biophysical profile (bpp)
			Physiology
			Modified biophysical profile
		Ultrasonographic evaluation
			Determination of gestation age by ultrasonography
			Ultrasound in detecting chromosomal and other targeted anomalies
			Assessing fetal growth
		Fetal echocardiography
		Doppler velocimetry
			Intrauterine growth restriction
			Rhesus alloimmunization
			Monitoring fetuses on indomethacin therapy for tocolysis or polyhydramnios
			Fetal cardiac abnormalities
		Chorionic villus sampling and amniocentesis
			Chorionic villus sampling (cvs)
			Amniocentesis
		Fetal blood sampling (fbs)
	Recent advances in fetal surveillance
	Indian perspective
	References
8 Preterm birth
	Introduction
	Implications of preterm birth
	Aetiology of preterm birth
		Cervical insufficiency
	Management of asymptomatic high-risk women
		Patient selection
		Microbiological screening
		Cervical length scan
		Fetal fibronectin
	Prevention of preterm labour
		Progesterone
		Cervical cerclage
	Management of preterm labour
		Tocolytics
		Antenatal corticosteroids administration
		Antibiotics
		Magnesium sulphate for neuroprotection
	Mode of delivery
	References
9 Post term and prolonged pregnancy
	Introduction
	Incidence
	Aetiology
	Diagnosis
	Pathophysiological changes seen in prolonged gestation
		Amniotic fluid changes
		Placental changes
	Fetal, neonatal and maternal complications
		Fetal and neonatal
			Perinatal death
			Fetal asphyxia
			Meconium aspiration
			Fetal trauma
			Postmaturity syndrome
		Maternal complications
	Management
		Antepartum management
			Fetal surveillance for prolonged pregnancy
			Induction of labour
			Methods of induction
			Prostaglandins
		Intrapartum care
			Abnormal cardiotocography (ctg)
			Meconium aspiration
			Shoulder dystocia
			Fetal trauma
			Maternal perineal injuries
	Indian perspective
	References
10 Antepartum haemorrhage
	Antepartum haemorrhage
		Management of antepartum haemorrhage
	Placenta praevia
		Classification
		Aetiology and associated factors
		Clinical presentation and diagnosis
		Management
	Placental abruption
		Pathology and aetiology
		Clinical presentation
		Management
	Placenta accreta
	Bleeding of indeterminate origin
	Vasa praevia
	Indian experience of third trimester bleeding
	References
11 Venous thromboembolism in pregnancy
	Introduction
	Pathophysiology
	Pathogenesis
	Risk factors
		Pre-existing risk factors
		Transient or new onset factors
	Preventing dvt
	Thromboprophylaxis
		Noninvasive and mechanical methods
		Drugs for thromboprophylaxis
			Unfractionated heparin
			Low molecular weight heparin
		Duration of thromboprophylaxis
		Thromboprophylaxis in the peripartum period
	Clinical features of vte in pregnancy
	Diagnostic testing for vte
	Treatment of acute vte
	Fetal surveillance in patients with vte
	Indian perspective
	References
12 Multiple pregnancy
	Introduction
	Incidence and epidemiology
		Ethnic variation
		Geographical variation
		Advanced maternal age
		Assisted reproductive techniques
	Mechanism of twinning
		Zygosity
		Chorionicity and amnionicity
	Complications of multifetal pregnancy
		Maternal morbidity
		Perinatal mortality and morbidity
		Preterm birth
		Fetal growth restriction and discordant fetal growth
		Complications of monochorionicity
			Twin-to-twin transfusion syndrome
			Selective fetal growth restriction (sfgr)
			Single fetal demise
			Monoamniotic twins
			Twin reversed arterial perfusion (trap)
			Conjoined twins (siamese twins)
			Fetus in fetu
	Antepartum management
		Gestational age determination
		Chorionicity determination
		Systematic labelling of twins
		Screening for chromosomal aneuploidy
		Prediction and prevention of preterm labour
		Antepartum fetal surveillance
		Screening for complications in monochorionic twins
		Fetal growth and well-being assessment
		Summary of antepartum management
	Management of labour and delivery
		Timing of delivery
		Malpresentations
		Mode of delivery
	Management of higher order multiple pregnancy
		Multifetal pregnancy reduction
	References
13 Hypertensive disorders in pregnancy
	Introduction
	Definitions
		Hypertension
		Proteinuria
	Classification of hypertensive disorders in pregnancy
	Gestational hypertension
		Classification
		Maternal and perinatal outcome
		Management
			Initial evaluation
			Gestational hypertension without risk factors
			Gestational hypertension with risk factors
		Delivery
		Long-term prognosis
	Chronic hypertension and pregnancy
		Aetiology
		Pathophysiology
		Effect of chronic hypertension on pregnancy
		Effect of pregnancy on chronic hypertension
		Management of chronic hypertension in pregnancy
			Initial evaluation (preconception or early in pregnancy)
			Prepregnancy counseling
			General care during pregnancy
			Severity assessment
			Nonpharmacologic therapy
				Bed rest
				Salt restriction
				Weight gain and exercise
			Antihypertensive therapy
				Beta-blockers
				Nifedipine (calcium channel blocker)
				Methyldopa (central acting adrenergic agonist)
				Diuretics
				Hydralazine (peripheral vasodilator)
				Prazosin
			Delivery
		Postnatal investigation, monitoring and treatment
	Preeclampsia
		Atypical preeclampsia
		Epidemiological risk factors
		Aetiopathogenesis
			Two-stage disorder hypothesis37
			Vascular endothelial activation
			Angiogenic imbalance
			Genetic factors
			Increased pressor response
			Nitric oxide
			Prostaglandins
		Maternal changes in preeclampsia
			Haemodynamic changes
			Changes in intravascular volume
			Changes in peripheral vascular resistance
			Haematological abnormalities
			Renal changes
			Hepatic changes
			Brain
		Clinical diagnosis
			Blood pressure elevation
			Proteinuria
			Excessive weight gain and oedema
		Signs and symptoms
		Laboratory findings
			Altered renal function
			Changes in liver function test
			Haematologic abnormalities
			Ophthalmic assessment
			Fetal growth assessment
		Classification
		Management
			Mild preeclampsia
				Initial evaluation
				General measures
				Antihypertensive treatment
				Role of glucocorticoids for fetal lung maturity
				Delivery
			Severe preeclampsia
				Gestational age ≥ 34 weeks
				Prevention of seizures
					Magnesium sulfate 
					Phenytoin 
				Antihypertensive treatment for acute management of severe hypertension
					Labetalol 
					Hydralazine 
					Nifedipine 
					Other antihypertensive agents 
				Gestational age < 24 weeks
				Gestational age 25–33 weeks
				Expectant management of severe preeclampsia at ,34 weeks gestation
				Delivery
				Postpartum care
	Eclampsia
		Pathophysiology
		Maternal and perinatal outcome
		Diagnosis
		Management
			Control of convulsion
			Treatment of hypertension
			Diuretics
			Fetal response to maternal seizures
			Delivery of the fetus
		Postpartum care
		Prevention
		Long-term prognosis
	Hellp syndrome
		Diagnosis
		Maternal and perinatal outcome
		Management
	Severe complications of preeclampsia
		Pulmonary oedema
		Acute renal failure
		Intracranial bleeding
		Visual disorders
		Abruption placentae
	Long-term prognosis of preeclampsia and eclampsia
	Prediction of preeclampsia
		Provocative pressor tests
			Angiotensin sensitivity test
			Roll-over test
			Isometric exercise test (hand grip test)
		Mean blood pressure in the second trimester
		Urinary calcium
		Fibronectin
		Uterine artery doppler
	Prevention of preeclampsia
		Low dose aspirin
		Calcium
		Antioxidant
	Indian experience of hypertensive disorders in pregnancy
		Predictive test
		Clinical aspects of pregnancy-induced hypertension
		Indian experience with chronic hypertension and pregnancy
	References
14 Haematological disorders and red-cell alloimmunization in pregnancy
	Introduction
	Physiological changes in pregnancy
	Anaemia in pregnancy
		Physiology
		Clinical features
		Iron-deficiency anaemia
			Iron metabolism
			Iron requirements during pregnancy
			Diagnosis and laboratory assessments
			Treatment
		Megaloblastic anaemia
			Diagnosis
			Treatment
		Haemolytic anaemia
		Aplastic anaemia
	Haemoglobinopathies
		Sickle cell disease
			Management
		Sickle cell trait
		Thalassaemias
			Alpha thalassaemia and alpha thalassaemia trait
			Beta thalassaemia trait and beta thalassaemia major
			Diagnosis
			Management
	Platelet disorders
		Thrombocythaemia
		Thrombocytopaenia
		Gestational thrombocytopaenia
		Immune thrombocytopaenia
	Bleeding disorders
		Von willebrand disease
		Haemophilia a and b
	Red cell alloimmunization
		Introduction
		Pathophysiology
		Genetics
		Diagnosis
		Management
		Management of rh-negative non-immunized women
		Detection of rh alloimmunization
		Prevention of rhesus alloimmunization
			Antenatal and postnatal prophylaxis
		Management of rh-negative immunized women
		Paternal rh phenotype and genotype
		Fetal blood group
		First affected pregnancy
		Ultrasound assessment
		Middle cerebral artery-peak systolic velocity (mca-psv)
		Fetal blood sampling (fbs) and intrauterine transfusion (iut)
		Care at delivery
	Alloimmunization to non-rhesus-d antigens
	Fetal and neonatal alloimmune thrombocytopaenia (fnait)
	Indian experience of erythroblastosis fetalis
	References
15 Diabetes in pregnancy
	Introduction
	Classification of diabetes
	Carbohydrate metabolism in pregnancy
	Complications of diabetes mellitus
	Gestational diabetes mellitus
	Screening and diagnosis of gdm
	Effects of diabetes on pregnancy
		Maternal effects
		Fetal and neonatal effects
			Growth abnormalities
			Chemical imbalances
			Fetal oxygenation problems
			Long-term sequelae
	Management options
		Prepregnancy
			Antenatal management
				Self-monitoring of blood glucose (smbg)
				Medical nutrition therapy (mnt)
				Exercise
				Pharmacotherapy
					Insulin
					Oral hypoglycemic agents (oha)
				Fetal surveillance in diabetes
					First trimester
					Second trimester
					Third trimester
					Timing and mode of delivery
	Management during labour
	Precautions during caesarean
	Postpartum management
	Management of diabetic ketoacidosis
	Contraceptive advice
	Gestational diabetes: Indian perspective
	References
16 Cardiac disease and pregnancy
	Preconceptional counselling
	Haemodynamic changes during pregnancy
		During pregnancy
		During labour and delivery
	Effects of maternal cardiac disease on pregnancy
	Effects of maternal cardiac disease on the fetus
	General measures for the care of pregnant patients with heart disease
		Monitoring cardiac function during pregnancy
			Evaluation of patient
		Measures and medications frequently used in women with heart disease and pregnancy
			Antepartum
			During labour and delivery
	Treatment of acute CHF during pregnancy
	Acute pulmonary edema during pregnancy
	Specific cardiac conditions and pregnancy
		Valvular lesions
			Mitral stenosis
			Aortic stenosis
			Pulmonic stenosis (ps)
			Mitral regurgitation
			Aortic regurgitation
		Women with prosthetic heart valves
		Left to right shunts
		Cyanotic congenital heart diseases: Right to left shunts
		Infective endocarditis
			Prophylaxis for infective endocarditis
		Myocardial conditions
			Peripartum cardiomyopathy
			Ischemic heart disease
	Other cardiac conditions of importance during pregnancy
		Aortic coarctation
		Eisenmenger syndrome
		Primary pulmonary hypertension
		Marfan syndrome
		Cardiac arrhythmias during pregnancy
	Indian perspective
	References
17 Other medical disorders in pregnancy
	Dermatological disorders in pregnancy
		Physiologic skin changes in pregnancy
		Pre-existing skin diseases affected by pregnancy
		Eczema (atopic dermatitis)
			Acne vulgaris
			Psoriasis
			Malignant melanomas
		Pruritus in pregnancy
		Specific dermatoses of pregnancy
		Pemphigoid (herpes) gestationis
			Pruritic urticarial papules and plaques of pregnancy (puppp)
			Prurigo of pregnancy
		Pruritic folliculitis of pregnancy
	Autoimmune diseases in pregnancy
		Systemic lupus erythematosus (sle) in pregnancy
			Diagnosis
			Sle and pregnancy
				Sle exacerbation (sle flare)
			Lupus nephritis in pregnancy
			Obstetric complications of sle in pregnancy25
				Preeclampsia
				Pregnancy loss
				Preterm birth
				Iugr
				Neonatal lupus26-28
			Management of sle
				Management of sle flare in pregnancy
		Antiphospholipid antibody syndrome in pregnancy
			Antiphospholipid antibodies33
			Pathogenesis of aps
			Diagnostic criteria for aps
			Aps in pregnancy
				Thrombotic complications
			Obstetric complications
				Preeclampsia
				Iugr and preterm birth
				Pregnancy loss
				Catastrophic aps
			Treatment of aps in pregnancy
			Management strategies in women with aps
	Neurologic complications in pregnancy
		Epilepsy in pregnancy
			Management
		Status epilepticus (se)
		Cerebral venous thrombosis
		Migraine in pregnancy
	Respiratory disorders in pregnancy
		Asthma in pregnancy
			Management of asthma in pregnancy53
				Pregnancy
				Labour and delivery
				Postnatal
			Asthma medications
		Tuberculosis in pregnancy
			Effect of TB on pregnancy
			Management
		Pneumonia in pregnancy
			Effect of pneumonia on pregnancy
			Management
		Pulmonary edema and acute respiratory distress syndrome
			Management
	Renal disorders in pregnancy
		Urinary tract infection in pregnancy
		Acute pyelonephritis
		Acute renal failure during pregnancy
			ARF in preeclampsia
		Chronic renal failure in pregnancy
		Chronic dialysis in pregnancy
		Renal transplant and pregnancy
	Other medical disorders: An indian perpective
	References
18 Tropical diseases in pregnancy
	Malaria in pregnancy
		The malarial parasite
		Pathology
		Clinical features
		Diagnosis
		Effects of malaria during pregnancy
			Maternal effects
			Fetal and perinatal effects
		Effects of pregnancy on malaria
		Prognostic parameters
		Management
		Preventative treatment
		Congenital and neonatal malaria
	Dengue fever in pregnancy
		Causative organism
		Pathology
		Clinical features
		Diagnosis
		Maternal risks
		Fetal risks
		Management
	Intestinal parasitic infestations in pregnancy
		Amebiasis in pregnancy
			Definition
			Pathology
			Clinical features
			Diagnosis
			Maternal effects
			Fetal effects
			Treatment
		Giardiasis in pregnancy
			Definition
			Pathology
			Clinical features
			Diagnosis
			Maternal effects
			Fetal effects
			Treatment
		Helminthiasis in pregnancy
			Hookworm infestation
				Background
				Clinical features
				Diagnosis
				Effects on the mother
				Effects on the fetus
				Treatment
			Ascariasis (roundworm infection)
				Background
				Clinical features
				Diagnosis
				Effects on the mother
				Effects on the fetus
				Treatment
			Enterobiasis (E. vermicularis; threadworm, pinworm, and oxyuria infection)
				Background
				Clinical features
				Diagnosis
				Effects on the mother
				Effects on the fetus
				Treatment
			Strongyloides (s. stercoralis)
				Background
				Clinical features
				Diagnosis
				Maternal effects
				Fetal effects
				Treatment
			Trichuriasis (t. trichiura; whipworm infestation)
				Background
				Clinical features
				Diagnosis
				Maternal effects
				Fetal effects
				Treatment
			Cestode (tapeworm infestations)
				Background
				Clinical features
				Diagnosis
				Maternal effects
				Fetal effects
				Treatment
			Hydatid disease (echinococcosis)
				Background
				Clinical features
				Diagnosis
				Maternal effects
				Fetal effects
				Treatment
			Trematodes (schistosomiasis)
				Background
				Clinical features
				Diagnosis
				Maternal effects
				Fetal effects
				Treatment
			Tissue nematodes (filariasis)
				Background
				Clinical features
				Diagnosis
				Maternal effects
				Fetal effects
				Treatment
	Hepatitis in pregnancy
		Hepatitis A virus (infectious hepatitis) in pregnancy
			Background
			Clinical features
			Laboratory diagnosis
			Prevention
			Pregnancy
			Management
		Hepatitis B virus in pregnancy
			Background
			Prevention
			Clinical features
			Diagnosis
			Pregnancy
			Effects on the mother
			Effects on the fetus
			Management
		Hepatitis C virus in pregnancy
			Background
			Prevention
			Clinical features
			Laboratory diagnosis
			Pregnancy
			Effects on the mother
			Effects on the fetus
			Management
		Hepatitis D virus in pregnancy
			Background
			Prevention
			Clinical features
			Laboratory diagnosis
			Pregnancy
			Management
		Hepatitis E virus in pregnancy
			Background
			Prevention
			Clinical features
			Laboratory diagnosis
			Pregnancy
			Maternal effects
			Fetal effects
			Management
		Hepatitis g in pregnancy
		Indian contribution to hepatitis in pregnancy
	Tuberculosis complicating pregnancy
		Background
		Clinical features
		Investigations
		Diagnosis
		Effect of pregnancy on the disease
		Effects on the mother
		Effects on the fetus
		Prevention
		Management
	References
19 Abnormal labour
	Introduction
	Background
	Normal labour – clinical assessment
	The friedman curve and the partogram
	Progress in labour – revising normal definitions
	Dysfunctional labour
		Causes of labour dysfunction
	The first stage - latent phase
		Managing the prolonged latent phase
	The first stage – active phase
		Diagnosing delay in the first stage of labour
		Management of primary dysfunctional labour
		Management of secondary arrest
	The second stage
	Effectiveness of other interventions in dysfunctional labour
	Managing dysfunctional labour – the future
	Summary
	References
20 Fetal surveillance in labour
	Introduction
	Indications for continuous electronic fetal monitoring
	Intermittent auscultation
	Continuous cardiotocography (ctg) / electronic fetal heart rate monitoring (efm)
	Admission ctg
		Features of the ctg
	Fetal scalp blood sampling
	Fetal scalp lactate
	Fetal pulse oximetry
	Fetal ECG waveform – ST segment analysis (stan)
	Fetal stimulation tests
	References
21 Birth asphyxia
	Introduction
	Magnitude of the problem
	Definition of birth asphyxia
	Hypoxic ischemic encephalopathy (hie) – grading, imaging and clinical course
	Pathophysiology of brain damage in hie
	Management
	Long-term sequelae and prognosis
	Medico-legal issues surrounding birth asphyxia
	Birth asphyxia and the challenge of intrapartum fetal monitoring
		Intermittent auscultation (IA)
		Cardiotocography (ctg)
		Clinical interpretation of ctgs – adhering to standards
		Patterns of hypoxia and nature of birth injury
			Long standing or chronic hypoxia
			Gradually developing hypoxia
			Acute hypoxia
			Subacute hypoxia
	Best practice clinical recommendations for intrapartum fetal surveillance
		Intermittent auscultation
		Cardiotocography
	Conclusion
	References
22 Operative delivery
	Introduction
	Definitions
	Malpresentation (breech, face, brow, shoulder) in labour
		Breech presentation
			Incidence and aetiology
			Diagnosis
			Management in the antenatal period
			Management in labour
			Conclusion
		Brow presentation
		Face presentation
		Shoulder presentation
	Cephalopelvic disproportion
	Instrumental vaginal deliveries (ivd)
		The debate as to the instrument for safe assisted delivery
		Direct traction forceps delivery
		Rotational forceps delivery
			Complications of forceps delivery
		Vacuum-assisted vaginal delivery
		Trial of instrumental delivery
	Shoulder dystocia
		Definition, incidence and associations
		Diagnosis and management
	Caesarean section
		Indications for cs
		Types of caesarean section
			Lower uterine segment incision
			Midline longitudinal incision
		Complications associated with cs
	Episiotomy and perineal lacerations
		Episiotomy
		Perineal repair
		Third and fourth degree tears
	Conclusions
	References
23 Postpartum haemorrhage
	Introduction
	Definition
	Aetiology
		Uterine atony
		Genital tract trauma
		Retained placental tissue (and membranes)
		Coagulopathy
		Causes of secondary postpartum haemorrhage
	Diagnosis of postpartum haemorrhage
		Visual estimation of blood loss
		Direct measurement
		Shock index
		Golden first hour and the rule of 30
		Signs and symptoms
	Management
		Fluid therapy
		Assessing the cause
		Mechanical methods
		Pharmacological methods
			Uterotonic agents
		Shifting to the theatre or transferring to tertiary referral centre
		Tamponade test
		Haemostatic uterine compression sutures
		Systematic pelvic devascularization
		Interventional radiology
		Peripartum hysterectomy
		Women refusing blood transfusion
		What is new in the management of post-partum haemorrhage?
			Transfusion strategies
			Massive transfusion/trauma exsanguination protocols
			Use of fibrinogen
			Thromboelastograph (teg)
			Tranexamic acid
			Recombinant factor VII a
			Triple p procedure
			Role of monitoring
	References
Index
	A
	B
	C
	D
	E
	F
	G
	H
	I
	K
	L
	M
	N
	O
	P
	Q
	R
	S
	T
	U
	V
	W
	X
	Z