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Amniotic Fluid Disorders

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…

Red Cell Alloimmunization

Key Points Alloimmunization to the RhD, Kell (K1), and Rhc red cell antigens is the main cause of HDFN. Despite the widespread use of rhesus immune globulin (RhIG), approximately six cases of RhD alloimmunization occur annually per 1000 live births in the United States. Hydrops fetalis is defined as extracellular fluid in two or more fetal compartments; it represents the end-stage of fetal anemia in HDFN.…

Intrauterine Growth Restriction

Key Points Although the terms intrauterine growth restriction (IUGR), fetal growth restriction (FGR), and small for gestational age (SGA) are used interchangeably, IUGR and FGR identify pathologically small fetuses, whereas SGA indicates a fetus below a specific cutoff without designation of pathology. IUGR is a major cause of perinatal morbidity, perinatal mortality, and both short-term and life-long morbidities. Although IUGR is currently defined by fetal size…

Multiple Gestations

Key Points Twinning is one of the most common high-risk conditions in all of obstetrics with a reported rate of 33.1 per 1000 births in 2012. Both maternal and perinatal morbidity and mortality are significantly higher in multifetal gestations than in singleton pregnancies. Chorionicity is a critical determinant of pregnancy outcome and management, and as such it should be ascertained by ultrasound as early in gestation…

Preeclampsia and Hypertensive Disorders

Key Points Hypertension is the most common medical complication during pregnancy. Preeclampsia is a leading cause of maternal mortality and morbidity worldwide. The pathophysiologic abnormalities of preeclampsia are numerous, but the etiology is unknown. At present, there is no proven method to prevent preeclampsia. However, low-dose aspirin may have a role in certain women. HELLP syndrome may develop in the absence of maternal hypertension and proteinuria.…

Premature Rupture of the Membranes

Key Points PROM complicates about 8% to 10% of pregnancies and is a significant cause of gestational age–dependent and infectious perinatal morbidity and mortality. Latency from membrane rupture to delivery is typically brief and decreases with increasing gestational age at membrane rupture. Chorioamnionitis is common after PPROM and increases in frequency with decreasing gestational age at membrane rupture. Women with a prior preterm birth due to…

Preterm Labor and Birth

Key Points More than 70% of fetal, neonatal, and infant morbidity and mortality occurs in infants born preterm. The rate of PTB peaked in 2006 as the result of the increased use of assisted reproductive technology, ultrasound dating, and indicated preterm births. It has since declined largely because of the adoption of fertility practices to reduce the multifetal gestations associated with infertility treatment. Major risk factors…

Cervical Insufficiency

Key Points Cervical insufficiency is primarily a clinical diagnosis characterized by recurrent painless dilatation and spontaneous midtrimester loss. Cervical insufficiency is rarely a distinct and well-defined clinical entity, but only one component of the larger and more complex spontaneous preterm birth syndrome. Current evidence suggests that cervical competence functions along a continuum, influenced by both endogenous and exogenous factors, such as uterine contractions and decidual/membrane activation.…

Early Pregnancy Loss and Stillbirth

Key Points About 50% to 70% of conceptions are lost, most in the first trimester. Losses in preimplantation embryos are especially high: 25% to 50% of morphologically normal and 50% to 75% of morphologically abnormal embryos. Sporadic pregnancy loss is age dependent, and 40-year-old women have twice the loss rate of 20-year-old women. Most of these pregnancies are lost before 8 weeks’ gestation. At least 50%…

Trauma and Related Surgery in Pregnancy

Key Points Maternal trauma is the most frequent cause of nonobstetric maternal death. In cases of significant trauma, such as motor vehicle accidents, maternal stabilization and evaluation in the emergency department should occur prior to transfer to labor and delivery. Fetal monitoring should occur as soon as possible while maternal evaluation takes place. Abruptio placentae complicates 1% to 2% of cases of minor blunt abdominal trauma…

Surgery During Pregnancy

Key Points Care of the pregnant surgical patient requires a multidisciplinary approach with an understanding of the physiologic changes that accompany normal pregnancy. Expansion of maternal blood volume during pregnancy may mask signs of maternal hemorrhage, and clinically significant blood loss can occur before hemodynamic changes are evident. Delay in surgical intervention can result in increased maternal and fetal morbidity and mortality, which significantly increases the…

Lactation and Breastfeeding

Key Points The WHO, the U.S. Surgeon General, the American Academy of Pediatrics, the American Academy of Family Practice, ACOG, and the Academy of Breastfeeding Medicine endorse breastfeeding as the gold standard for infant feeding. Breastfeeding accrues many health benefits for the infant, including protection against infection, fewer allergies, better growth, better neurologic development, and lower rates of chronic diseases, such as type 1 diabetes and…

Postpartum Care and Long-Term Health Considerations

Key Points By 6 weeks postpartum, only 28% of women have returned to their prepregnant weight. About 50% of parturients experience diminished sexual desire during the 3 months that follow delivery. Postpartum uterine bleeding of sufficient quantity to require medical attention occurs in 1% to 2% of parturients. Of patients who require curettage, 40% will be found to have retained placental tissue. Long-acting reversible contraceptive methods…

The Neonate

Key Points Surfactant maintains lung expansion on expiration by lowering surface tension at the air-liquid interface in the alveolus. Antenatal corticosteroids accelerate fetal lung maturation and decrease neonatal mortality and RDS in preterm infants. In addition, corticosteroids are associated with a decrease in intracranial hemorrhage and necrotizing enterocolitis. Transition from intrauterine to extrauterine life requires removal of fluid from the lungs, switching from fetal to neonatal…

Placenta Accreta

Key Points Prior CD is the most important factor associated with PA, and the risk of PA increases with the number of prior CDs. Suspected PA on prenatal imaging allows planned management of the condition and has been associated with a reduced rate of maternal morbidity. Ultrasound imaging is superior to MRI for routine screening of PA in at-risk women, but the degree of invasion to…

Vaginal Birth After Cesarean Delivery

Key Points VBAC rates have plummeted from a peak of approximately 30% in 1996 to 5% in 2010. Two-thirds of women with a prior low transverse CD are candidates for TOLAC and should be counseled about and offered this option. The success rate for TOLAC is influenced by prior indication for cesarean delivery, history of vaginal delivery, demographic characteristics such as maternal age and body mass…

Antepartum and Postpartum Hemorrhage

Key Points Understanding the hemodynamic changes of pregnancy and the physiologic responses that occur with hemorrhage assists in appropriate management. Clinicians should recognize the four classes of hemorrhage to allow for rapid intervention. Placental abruption is diagnosed primarily by clinical findings and is confirmed by radiographic, laboratory, and pathologic studies. Management of placental abruption is dependent on the severity, gestational age, and maternal-fetal status. Placenta previa…

Malpresentations

Key Points Fetal lie refers to the orientation of the fetal spine relative to that of the mother. Normal fetal lie is longitudinal and by itself does not connote whether the presentation is cephalic or breech. Fetal malpresentation requires timely diagnostic exclusion of major fetal or uterine malformations and/or abnormal placentation. A closely monitored labor and vaginal delivery is a safe possibility with face or brow…

Obstetric Anesthesia

Key Points Analgesia during labor can reduce or prevent potentially adverse stress responses to the pain of labor, including postpartum depression. Parenteral opioids for labor analgesia work primarily by sedation and, except at high doses, result in minimal reduction of maternal pain. Side effects include maternal nausea and respiratory depression in both the mother and newborn. The routine use of promethazine in conjunction with opioids should…