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Obstetrics

• Editor's Note
• List of Articles

List of Articles

• Iron Deficiency Anemia in Pregnancy
  Today, iron is the world’s most common micronutrient deficiency, estimated to affect 3 billion people and more than half of pregnancies worldwide, with higher prevalence in under-resourced countries. To make a significant impact, it is likely that a combination of key programs that address the determinants of low blood hemoglobin concentrations will be required. These strategies should be tailored to local conditions, taking into account the specific etiology and prevalence of anemia in a given setting and population group, and should be built into the primary healthcare systems and existing programs. The first-line treatment or iron deficiency anemia is oral iron. New evidence suggests that intermittent dosing is as effective as daily or twice-daily dosing with fewer side effects. For patients who cannot tolerate, absorb, or do not respond to oral iron, intravenous iron is preferred in the third trimester and sometimes as early as the second trimester. Iron supplementation decreases the prevalence of maternal anemia at delivery. Iron deficiency anemia during pregnancy has been associated with an increased risk of low birth weight, preterm delivery, and perinatal mortality. Severe anemia with maternal hemoglobin levels less than 6 g/dL has been associated with abnormal fetal oxygenation resulting in non-reassuring fetal heart rate patterns, reduced amniotic fluid volume, fetal cerebral vasodilatation, and fetal death. Thus, maternal transfusion should be considered for fetal indications.
  
  
• Prevention of Group B Streptococcal Disease in Newborns: Perinatal Management
  Group B streptococcus (GBS) is the leading cause of newborn infection. it is a common commensal in the gut of humans and in the lower genital tract in women, remains an important cause of neonatal mortality and morbidity. This review identifies limitations of current strategies for antepartum and intrapartum prophylaxis of neonatal early-onset GBS infection. The present guidelines are designed to lower the risk of GBS early-onset-disease, which is the most common cause of early-onset neonatal sepsis. Most individuals who report a penicillin allergy are neither truly allergic nor at risk of a developing a hypersensitivity reaction after exposure to penicillin. Approximately 80 – 90% of persons with a history penicillin allergy are actually penicillin tolerant. We advocate for wider consideration and adoption of penicillin allergy testing in pregnant women specifically and the female population in general cared for by providers of obstetrics and gynecology. Vaccines that would prevent GBS colonization are the subject of ongoing research but are not yet applicable in clinical practice.
  
  
• Critical Care in Obstetrics: Disseminated Intravascular Coagulation Syndromes
  Disseminated intravascular coagulation (DIC) is a life-threatening situation that can arise from a variety of obstetrical and non-obstetrical causes. DIC is a syndrome that can be initiated by a myriad of medical, surgical, and obstetric disorders. Also known as consumptive coagulopathy, defibrination syndrome and generalized intravascular coagulation, it is not a disease per se, but rather a clinicopathologic syndrome that can be initiated by a myriad of underlying diseases, conditions, or disorders. The purpose of this review is to discuss the pathophysiology of DIC syndromes, focusing on the triad represented by exaggerated activation of coagulation, consumption of coagulopathy, and impaired synthesis coagulation as well as anticoagulation proteins. The diagnosis of DIC with special attention to the available scores adding prognostic value to the laboratory parameters in patients with this dangerous condition or are at risk for its development are also reviewed. The principles of the treatment of DIC is discussed extensively from the literature. In recent years, novel diagnostic scores and treatment modalities along with bedside point-of-care tests were developed and may assist the clinician in the diagnosis and management of DIC. Team work and prompt treatment are essential for the successful management of patients with DIC. The management of DIC in obstetrics remains a major clinical challenge. The inciting disease-specific syndrome may be complex and require directed management strategies for correction of the underlying disorders. Equally important is treatment of frequently concomitant massive blood loss that worsens the coagulopathy. With limited clinically proven management strategies available, the need for future studies is obvious. We look forward to these studies designated to address our numerous evidence-based deficits, especially regarding management of obstetric DIC syndromes.
  
  
• Marijuana and Pregnancy Implications
  This review is intended to provide practicing clinicians with an understanding of existing literature and recommendations for managing women who use marijuana during pregnancy because this will be an increasingly encountered clinical scenario. Marijuana is the most common illicit drug used in pregnancy, with a prevalence of use ranging from 3% to 30% in various populations. Marijuana freely crosses the placenta and is found in breast milk. It may have adverse effects on both perinatal outcomes and fetal neurodevelopment. Specifically, marijuana may be associated with fetal growth restriction, stillbirth, and preterm birth. There is an emerging body of evidence indicating that marijuana may cause problems with neurological development, resulting in hyperactivity, poor cognitive function, and changes in dopaminergic receptors. In addition, contemporary marijuana products have higher quantities of Delta-9-tetrahydrocannabinol (THC) than in the 1980s when much of the marijuana research was completed. The effects on the pregnancy and fetus may therefore be different than those previously seen. Further research is needed to provide evidence-based counseling of women regarding the anticipated outcomes of marijuana use in pregnancy. In the meantime, women should be advised not to use marijuana in pregnancy or while lactating. We recommend screen all women verbally for marijuana use at intake to obstetrical care and consider rescreening later in pregnancy. The review suggests a need for healthcare provider training on potential consequences of perinatal marijuana use and communication skills for counseling patients about perinatal marijuana. An increasing number of states are passing or considering medical marijuana laws. The goal of this document is to address the public health system's responsibility to educate physicians and public about the impact of marijuana on pregnancy and to establish guidelines that discourage the use of medical marijuana by pregnant women or women considering pregnancy.
  
  
• Non-Invasive Prenatal Genetic Testing for Fetal Anomalies
  Non-invasive prenatal testing that uses cell-free fetal DNA (cfDNA) from the plasma of pregnant women offers tremendous potential as a screening tool for fetal aneuploidy. Recently, a number of groups have validated a technology known as massively parallel genomic sequencing, which uses a highly sensitive assay to quantify millions of DNA fragments in biological samples in a span of days and has been reported to accurately detect trisomy 13, trisomy 18 and trisomy 21 as early as the 10th week of pregnancy with results available approximately 1 week after maternal sampling. cfDNA has a very high detection rate for trisomy 21: 99% or 100%. It does not replace the precision obtained with diagnostic tests, such as chorionic villus sampling (CVS) or amniocentesis, and currently does not offer other genetic information. Given that the fetus is the source of perhaps 5% of cfDNA in maternal plasma, blood from a mother carrying a trisomy 21 pregnancy should have 2.5% more chromosome 21 sequences than if her fetus were not trisomic. cfDNA analysis will remain a screen, not a test requiring no additional assays before a management decision. Expert patient counseling may be important before and after testing. Metabolomic analysis could lead to the development of additional biochemical markers to improve Down syndrome screening. Metabolomics provide insights into the cellular dysfunction in Down syndrome. Clinical management guidelines and education are essential. As with all new screening tests and technologies, the expanded panel should be appropriately studied before it replaces current standard of care and changes clinical practice.
  
  
• Postpartum Hemorrhage
  The purpose of this document is to review the etiology, evaluation, and management of postpartum hemorrhage. Although many risk factors have been associated with postpartum hemorrhage, it often occurs without warning. Attention to improving the hospital systems necessary for the care of women at risk for major obstetric hemorrhage is important in the effort to decrease maternal mortality from hemorrhage. The creation of a patient safety team that works to improve the hospital systems for caring for women at risk for major obstetric hemorrhage can help to identify and manage these situations and save lives. Development of clinical pathways, guidelines and protocols designed to provide early diagnosis of patients at risk for major obstetric hemorrhage and for streamlined care in emergency situations are essential. A multidisciplinary patient safety team that includes individuals from the Division of Obstetric Anesthesiology, Maternal Fetal Medicine, Neonatology, and the Blood Bank as well as Departments of Nursing, Communication, and Administration and quarterly mock drills of rapid response team, helps to respond to these situations effectively.
  
  
• Nausea and Vomiting in Pregnancy
  Without a doubt, nausea and vomiting are common side effects of pregnancy. Hyperemesis gravidarum is a rare and severe complication of pregnancy that requires appropriate diagnosis and management to improve the patient’s quality of life and provide best possible maternal and neonatal outcomes. Physicians must appreciate the magnitude of the condition given its widespread implications – economic costs, decreased quality of life, maternal psychological effects, and risks to mother and fetus. Common maternal complications include dehydration, weight loss, and nutrient deficiencies. Current strategies include dietary modification, antiemetic therapy, and in certain situations, alimentary support. Use caution when prescribing phenothiazines because dystonia and extrapyramidal symptoms can occur with prolonged use and high dose. Future strategies should include more randomized controlled trials therapies that are safe for both mother and fetus, and effective treatment to prevent hospitalization and offer alternatives for nutritional support.
  
  
• Stillbirth: Evaluation and Management
  Despite improvements in antenatal and intrapartum care, stillbirth, defined as in utero fetal death at 20 weeks of gestation or greater, remains and important, largely unstudied, and poignant problem in obstetrics. This review discusses known and suspected causes of stillbirth including genetic abnormalities, infection, fetal-maternal hemorrhage, and a variety of medical conditions in the mother. The proportion of stillbirths that have a diagnostic explanation is higher in centers that conduct a defined and systemic evaluation. The most important test in the evaluation of a stillbirth is fetal autopsy; examination of the placenta, cord and membranes; and karyotype evaluation. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, religious leader, peer support group, or mental health professional may be advisable for management of grief and depression.
  
  
• Exercise During Pregnancy and Postpartum Period
  The aim of this review is to highlight exercise guidelines in pregnancy in concise format for obstetricians and gynecologists and other healthcare providers who provide prenatal and postpartum care. These recommendations provide evidence that increasing weekly physical-activity expenditure while incorporating vigorous exercise provides optimal health outcomes for pregnant women and their fetuses, and also suggest light strength training during the second and third trimesters does not negatively affect newborn body size and overall health. Women of childbearing age are at increased risk of gestational diabetes mellitus (GDM), which has been linked strongly to obesity. Weight gain during pregnancy can be excessive, and some women tend to retain that weight after delivery. Gaining excessive weight during pregnancy can result in obesity-associated comorbidities, which are a major health concern in the United States.
  
  
• Recurrent Pregnancy Loss
  Recurrent pregnancy loss (RPL) is a frustrating problem for both the patients and physicians. Pregnancy is a complicated process involving many intricate interactions between the fetus and the maternal environment. Pregnancy loss can result from any number of genetic, anatomic, endocrine, immune, or thrombotic disorders, as well as from unknown causes. The purpose of this document is to outline the causes of recurrent pregnancy loss and their potential therapies, where applicable. Traditionally RPL refers to the loss of three or more consecutive pregnancies; however, many clinicians will begin the evaluation of RPL after two losses, because the risk of a third loss after two miscarriages is approximately 30%, whereas the risk after three losses is about 33%. This approach may be especially useful in older women. It is important to remember that couples who are being evaluated for RPL have high levels of depression and stress. Some studies have indicated that psychological support may decrease the rates of unexplained miscarriage. Finally, patients should be reassured that even without treatment, successful pregnancy occurs in the majority of cases. This review can serve as a useful resource when counseling patients regarding treatment options.
  
  
• Healthy Mother Healthy Infant Through Nutrition
  Maternal nutritional status not only influences fetal development and overall health but also significantly affects long-term risk for chronic childhood and adult diseases. Many pregnant and lactating women may not achieve optimum levels of important nutrients, as evidenced by the proportion of women throughout the US population and in the world, whose nutritional levels do not meet documented standards for many vitamins, minerals, and other essential nutrients. Women's Health and Education Center (WHEC) places emphasis on specific nutrients essential for optimal fetal development, notably folic acid, calcium, vitamin D, and omega-3 fatty acids; these are often consumed at levels below the recommended requirements. Maternal/infant morbidity and mortality are age-old and worldwide problems. There are many factors that influence the ultimate outcome of pregnancy, including the absence or presence of access to prenatal care, maternal stress (physical and psychological), comorbid diseases, and maternal nutrition -- both before and during pregnancy. Good nutrition is much more than just the food we eat.
  
  
• Intrapartum Electronic Fetal Heart Rate Monitoring
  The purpose of this document is to: 1) review nomenclature for fetal heart rate assessment, 2) review the data on the efficacy of electronic fetal monitoring (EFM), and 3) delineate the strengths and shortcomings of EFM. It also compares international three-tier systems for fetal heart rate tracing, including the National Institute of Child Health and Human Development (NICHD), Society of Obstetricians and Gynecologists of Canada (SOGC) and the Royal College of Obstetricians and Gynecologists (RCOG, United Kingdom). The collaboration of practitioners in defining the interpretation and implementing is critical for improved care for women and children. Realizing that this information deserves wide dissemination, Women's Health and Education Center (WHEC) encourages its translations and adaptations.
  
  
• Amniotic Fluid Disorders
  Amniotic fluid is seldom considered important until polyhydramnios or oligohydramnios occurs, either of which may significantly impact perinatal survival. Amniotic fluid is dynamic, with large volume flows into and out of the amniotic compartment each day. This document explores what is known about the normal mechanisms affecting the formation and removal of amniotic fluid, including fetal urination, swallowing, lung liquid and intramembranous absorption. In addition, the changes in amniotic fluid volume and composition across gestation, in order to help us understand its normal regulation are examined. The various treatment options available for amniotic fluid volume abnormalities are discussed. The goal of this review is to offer the reader a complete understanding of the known mechanisms and functioning of amniotic fluid volume regulation, and their connection with disease states.
  
  
• Genetic Counseling and Genetic Screening
  The review discusses the principles of genetic counseling and genetic screening. Disorders amenable to genetic screening and prenatal diagnosis are also enumerated. Salient principles of the genetic counseling process are described. A variety of molecular diagnostic tests are available to determine whether an individual or fetus has inherited a disease-causing gene mutation. It can identify other family members or relatives at risk for the disorder or at risk for being a carrier. The gift of life can be "perfect" even in the presence of serious problems.
  
  
• HELLP Syndrome - Diagnosis and Management
  Intravascular hemolysis, elevated liver function tests and low platelets counts (thrombocytopenia) also known as HELLP syndrome has been recognized as a complication of severe preeclampsia and eclampsia for many decades. The purpose of this document is to describe the pathogenesis, diagnosis and management of this syndrome. The presence of this syndrome is associated with increased risk of adverse outcome for both mother and fetus. This review will explain the controversies surrounding the diagnosis and management of this syndrome. Recommendations for the counseling of these women are also provided based on the results of recent studies.
  
  
• Normal Values in Pregnancy
  The physiologic, biochemical, and anatomic changes that occur during pregnancy are extensive and may be systemic or local. However, most systems return to pre-pregnancy status between the time of delivery and 6 weeks postpartum. Major adaptation in maternal anatomy, physiology, and metabolism are required for a successful pregnancy. Hormonal changes, initiated before conception, significantly alter maternal physiology, and persist through both pregnancy and initial postpartum period. A full understanding of physiologic changes is necessary to differentiate between normal alterations and those that are abnormal. This document describes maternal adaptations in pregnancy. An understanding of the normal physiologic changes and values induced by pregnancy is essential in understanding coincidental disease processes. Many laboratory values are dramatically altered from non-pregnant values. We hope this provides a valuable tool to manage your patients effectively.
  
  
• Ectopic Pregnancy
  Ectopic pregnancy is a condition in which an early embryo (fertilized egg) implants outside the normal site for implantation (uterus). The purpose of the document is to diagnose early, and to understand conservative medical and surgical treatments that are now widely available for ectopic pregnancies. Methotrexate, a folinic acid antagonist, has been used to treat patients with small unruptured tubal pregnancies. Evidence, including risks benefits, about methotrexate as an alternative treatment for selected ectopic pregnancy is also discussed. Early detection may make it possible for some patients to receive medical therapy instead of surgery.
  
  
• Female Genital Cutting: Impact on Maternal and Neonatal Outcomes
  Female genital cutting (FGC) is the collective name given to traditional practices that involve partial or total cutting away of the female external genitalia whether for cultural or other non-therapeutic reasons. These beliefs and practices can damage the health of both mother and child in various ways. FGC, for instance, leads to scarification and later complications in childbirth. Female genital cutting/mutilation has no known health benefits. On the contrary, it is known to be harmful to girls and women in many ways. First and foremost, it is painful and traumatic. The removal of or damage to healthy, normal genital tissue interferes with the natural functioning of the body and causes several immediate and long-term health consequences. Babies born to women who have undergone female genital mutilation suffer a higher rate of neonatal death compared with babies born to women who have not undergone the procedure. Girls have the right to grow to womanhood without harm to their bodies. We know what has to be done to abandon this harmful practice, strong support from governments encouraging communities and individuals to make the healthiest choices possible for girls will save lives and greatly benefit families and communities.
  
  
• Neural Tube Defects Screening
  Neural tube defects (NTDs) are congenital structural abnormalities of the brain and vertebral column that occur either as an isolated malformation, along with other malformations, or as a part of genetic syndrome. The purpose of this document is to review prenatal screening, diagnosis that are widely available and prenatal therapy is being investigated. Neural tube defects (NTDs) are among the few birth defects for which primary prevention is possible. Yet identification of selected anomalies, such as ventriculomegaly and spina bifida, remains a challenge in many cases. Anencephaly accounts for one half of all cases of NTDs and is incompatible with life; with treatment, 80-90% of infants with spina bifida survive with varying degrees of disability. In this chapter, the sonographic investigation, screening for NTDs and role of folic acid are also reviewed.
  
  
• Premature Rupture of Membranes: Diagnosis and Management
  Premature rupture of the fetal membranes (PROM) is one of the most common and controversial problems facing the obstetric clinician. The fetal membranes and the amniotic fluid that they encase have functions that are critical for normal fetal protection, growth, and development. The purpose of this document is to review the current understanding of premature rupture of membranes (PROM) and to provide management guidelines that have been validated by appropriately conducted outcome-based research. There is some controversy over the optimal approaches to clinical assessment and treatment of women with term and preterm PROM. Management hinges on knowledge of gestational age and evaluation of the relative risks of preterm birth versus infection, abruptio placentae, and cord accident that could occur with expectant management. The risk factors, diagnosis, and management of PROM are discussed here. Additional guidelines on the basis of consensus and expert opinion also are included.
  
  
• Breastfeeding Guidelines for Healthcare Providers
  The promotion of breastfeeding is an ongoing priority of the Women's Health and Education Center (WHEC). The purpose of this document is to promote breastfeeding and work with national and international organizations dedicated to promoting the health of infants worldwide to formulate guidelines for breastfeeding. Where breastfeeding practices are suboptimal, simple one-encounter antenatal education and counseling significantly improve breastfeeding practice up to 3 months after delivery. Healthcare providers should make every effort to have at least one face-to-face encounter to discuss breastfeeding with expectant mothers before they deliver. Human milk provides developmental, nutritional, and immunologic benefits to the infant that cannot be duplicated by formula feeding.
  
  
• The Ethical Concept of the Fetus as a Patient
  Ethics is an essential dimension of obstetrical practice. In this paper, authors have developed a framework for clinical judgment and decision-making about the ethical dimensions of the obstetrician-patient relationship. Authors emphasize a preventive ethics approach that appreciates the potential for ethical conflict and adopts ethically justified strategies to prevent those conflicts from occurring.  First defined are ethics, medical ethics, and the fundamental ethical principles of medical ethics, beneficence and respect for autonomy. Authors then show how these two principles should interact in obstetric judgment and practice, with emphasis on the core concept of the fetus as a patient.
  
  
• Immunization During Pregnancy
  The purpose of this document is to understand immunization during pregnancy. Immunization saves lives and prevents disease. There are many national resources available to help you fine-tune your vaccination practices. If you have not yet incorporated vaccination into your practices, now would be a great time to start. Immunizations are considered one of the major medical achievements of the 20th century. However, inadequate vaccination remains an important public health problem. This document reflects emerging clinical and scientific advances and current information on the safety of vaccines given during pregnancy. The benefits of immunization to the pregnant woman and her neonate usually outweigh the theoretic risk of adverse effects. The theoretic risks of the vaccination of pregnant women with killed virus vaccines have not been identified. Preconceptional immunization of women to prevent disease in the offspring, when practical, is preferred to vaccination of pregnant women with certain vaccines.
  
  
• Pregnancy and Nutrition
  There have always been differing approaches, even controversies with regard to the role of food intake during pregnancy. Traditional beliefs from a wide variety of cultures present divergent approaches. At present, nutritional care during pregnancy is based on the following general premises: women are encouraged to eat a variety of foods "to appetite", to achieve adequate weight gain as determined by their pre-pregnancy body mass index, and to breast-feed their infants after birth. Nutritional problems can be found in women of every socioeconomic status and range from an inability to acquire and prepare food to eating disorders. If the women cannot afford a sufficient supply of food, she should be referred to food pantries and soup kitchens in her area. All low-income women should receive information about the Special Supplemental Food Program for Women, Infants and Children (WIC) and food stamp program. All WIC programs have nutritionists who are required to counsel patients on these matters. Poor weight gain also may reflect substance abuse, domestic violence, or depression.
  
  
• Preeclampsia and Eclampsia
  Hypertensive disease occurs in approximately 12-22% of pregnancies, and it is directly responsible for 17.6% of maternal deaths in the United States. However, there is confusion about the terminology and classification of these disorders. We hope to provide guidelines for the diagnosis and management of hypertensive disorders unique to pregnancy (preeclampsia and eclampsia), as well as the various associated complications. The purpose this document is to provide guidelines for the diagnosis and management of hypertensive disorders unique to pregnancy -- preeclampsia and eclampsia. Various associated complications are also discussed. Expectant management should be considered for women remote from term who have mild preeclampsia. For the prevention and treatment of seizures in women with severe preeclampsia or eclampsia magnesium sulfate is the drug of choice. Practitioners should be aware that various laboratory tests may be useful in the management of women with preeclampsia. The differential diagnosis is also discussed. It is important that clinician make the accurate diagnosis when possible because the management and complications from these syndromes may be different.
  
  
• Mapping the Theories of Preeclampsia
  Preeclampsia is a major cause of maternal and perinatal mortality and morbidity worldwide. Its etiology is elusive and theories abound regarding its pathogenesis. Preeclampsia can cause changes in virtually all organ systems. Several organ systems are consistently and characteristically involved. The pathologic findings indicate that the pathogenetic factor of primary importance is not blood pressure elevation, but rather poor tissue perfusion. The histologic data support the clinical impression that the poor perfusion is secondary to profound vasospasm, which also increases total peripheral resistance and blood pressure. Preeclampsia is not merely an alternate form of malignant hypertension. Recently homocysteine, a metabolite of the essential amino acid methionine has been postulated to produce oxidative stress and endothelial cell dysfunction, alterations associated with preeclampsia. The studies examining the relationship between serum homocysteine concentrations and preeclampsia are also discussed.
  
  
• Teen Pregnancy: Understanding the Social Impact
  The impact of teenage pregnancy and subsequent childbirth on parents, child and society reaches far and wide and has negative consequences to all involved. Too many teenagers become parents either they cannot envision another positive future direction to their lives, or because they lack concrete educational or employment goals and opportunities that would convince them to delay parenthood. No single or simple approach has successfully reduced the teen pregnancy rate; much more study and efforts are required. Other industrialized countries have much lower teen pregnancy and abortion rates than USA. There is few, if any other social problem that has a greater impact on us as a nation. It will take the involvement and efforts on the part of families, society and government to negotiate a change in the right direction. As physicians, we are in a unique position to take a leadership role in the decision making process, at all levels.
  
  
• Drugs in Pregnancy and Lactation
  The ideal time to address medication exposure and consider alternative treatment is prior to conception. Many pharmacologic agents have teratogenic potential as well as the potential to induce fetal harm later in gestation with effects that may be lethal or cause long-term handicaps. Many women will present already pregnant, thus providing a narrow window of time in which to evaluate the fetal risks and weigh them against the maternal benefits of continuing the medication. This chapter reviews the risks of commonly used medications during pregnancy, highlights medications with particularly high risk, and reviews the evaluation of fetuses who are exposed.
  
  
• Multiple Pregnancies
  Multiple pregnancies are fascinating and challenging situations. It requires early detection and identification of number of pregnancies, early detection of the complications and their proper management. Multiple births are more common nowadays, owing to over-stimulation of ovulation that occurs when ovulation stimulation is done in cases of women with infertility because of ovulatory failure. Moreover, although the dizygotic twinning rate varies widely under different circumstances, the monozygotic twinning rate is "remarkably constant", usually between 3.5 to 4 per 1,000. Premature babies need prolonged and expensive care. Patient education and availability of trained healthcare providers in the area can reduce the mortality and morbidity. There are support groups for the parents of multiple births available at almost all the area hospitals, which deal with high-risk deliveries.
  
  
• Antepartum Fetal Surveillance
  The goal of antepartum fetal surveillance is to prevent fetal death. Several antepartum fetal surveillance techniques or tests are in use. These include fetal movement assessment, non-stress test (NST), contraction stress test (CST), biophysical profile (BPP), and umbilical artery Doppler velocimetry. Antepartum fetal surveillance techniques are now routinely used to assess the risk of fetal death in pregnancies complicated by preexisting maternal conditions, as well as those in which complications have developed. Identification of suspected fetal compromise provides the opportunity to intervene before progressive metabolic acidosis can lead to fetal death. Identification of suspected fetal compromise provides the opportunity to intervene before progressive metabolic acidosis can lead to fetal death. In both animals and humans, fetal heart rate pattern, level of activity, and degree of muscular tone are sensitive to hypoxemia and academia. Recent, normal antepartum fetal test results should not preclude the use of intrapartum fetal monitoring.
  
  
• Shoulder Dystocia
  Shoulder dystocia is most often defined as a delivery that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders. It is most often an unpredictable and unpreventable obstetric emergency. Failure of the shoulders to deliver spontaneously places both the pregnant woman and fetus at risk for injury. Shoulder dystocia is caused by the impaction of the anterior fetal shoulder behind the maternal pubis symphysis. It also can occur from impaction of the posterior fetal shoulder on the sacral promontory. Several maneuvers to release impacted shoulders have been developed, and they are described below. The purpose of this chapter is to provide clinicians with information regarding management of deliveries at risk for or complicated by shoulder dystocia.
  
  
• Preterm Labor Management
  Preterm labor is the leading cause of neonatal mortality in the United States and accounts for about 11.5% of all live births. It is responsible for three quarters of neonatal mortality and one half of long-term neurologic impairments in children. Despite the numerous management methods proposed, the incidence of preterm birth has changed little over the past 40 years. Uncertainty persists about the best strategies for managing preterm labor. The purpose of this document is to discuss the various methods proposed to manage preterm labor and the evidence for their roles in clinical practice. The information is designed to aid practitioners in making decisions about appropriate obstetrical care. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.
  
  
• Thromboembolism in Pregnancy
  The risk of symptomatic venous thrombosis during pregnancy is between 0.5 and 3.0 per 1,000 women. Pulmonary embolism (PE) is a leading cause of maternal deaths in the United States. During pregnancy women have a five-fold increased risk of venous thromboembolism (VTE), compared to non-pregnant women. The prevalence and severity of this condition warrants consideration of anticoagulant therapy in pregnancy for women at risk for VTE. The purpose of this document is to review the current literature on the prevention and management of thromboembolism in obstetric patients. It offers evidence-based recommendations to address the most clinically relevant issues in the management of these patients.
  
  
• Gestational Trophoblastic Disease: A Comprehensive Review
  Gestational Trophoblastic disease comprises a spectrum of interrelated conditions originating from the placenta. Approximately 20% of patients will develop malignant sequelae requiring administration of chemotherapy after evacuation of hydatidiform moles. Most patients with post-molar gestational trophoblastic disease will have non-metastatic molar proliferation or invasive moles, but gestational choriocarcinomas and metastatic disease can develop in this setting. The purpose of this document is to address current evidence regarding the diagnosis, staging, and management of gestational trophoblastic disease. Other terms often used to refer to these conditions include gestational trophoblastic neoplasia and gestational trophoblastic tumor. At present, with sensitive quantitative assays for beta-hCG and current approaches to chemotherapy, most women with malignant gestational trophoblastic disease can be cured and their reproductive function preserved. Histologically distinct disease entities encompassed by this general terminology include complete and partial hydatidiform moles, invasive moles, gestational choriocarcinomas, and placental site trophoblastic tumors.
  
  
• Placental Abnormalities & Major Obstetric Hemorrhage
  Bleeding in the second half of pregnancy and in labor due to placental abnormalities include placenta previa, abruptio placentae, placenta accreta and vasa previa. Third-trimester bleeding complicates about 3.8% of all pregnancies. The purpose of this document is to present evidence-based approach to the management of placental abnormalities and major obstetric hemorrhage. Attention to improving the hospital systems is necessary for the care of women at risk for major obstetric hemorrhage. It is important in the effort to decrease maternal mortality from hemorrhage. Multidisciplinary team implementation systemic changes are also discussed. It is the responsibility of the physician to decide without delay whether the cause is benign or potentially life-threatening to the mother, fetus, or both. The potential harm from either procrastination or unnecessary intervention may be extreme.
  
  
• Placenta Accreta
  An abnormally adherent placenta, although an uncommon condition, assumes considerable significance clinically because of morbidity and at times mortality from severe hemorrhage, uterine perforation, and infection. The incidence of placenta accreta, increta and percreta has increased because of the increased cesarean delivery rate. This document reflects emerging clinical and scientific advances on this subject. If the diagnosis or a strong suspicion is formed before delivery, the patient should be counseled about the likelihood of hysterectomy and blood transfusion.
  
  

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