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Respiratory Diseases in Pregnancy

Proper functioning of the cardiorespiratory system is imperative to achieve adequate oxygenation of maternal and fetal tissues. The maternal cardiorespiratory system undergoes significant changes during gestation to optimize oxygen delivery to the fetus and maternal tissues. Pulmonary disease is one of the most frequent maternal complications during pregnancy, and it may result in significant morbidity or mortality for the mother and her fetus. Depending on the…

Renal Disorders

Pregnancy induces many changes to both renal function and physiology. Physiologic adaptations to the renal system that occur in normal pregnancy are the subject of Chapter 9 . The focus of this chapter is to describe the effects of various preexisting renal conditions in pregnancy and discuss the implications of various obstetrical conditions on the renal system. Although women with preexisting chronic kidney disease typically have…

Malignancy and Pregnancy

Overview of Cancer in Pregnancy It is estimated that 1 in 1000 pregnancies are complicated by a diagnosis of cancer. Approximately 30% of pregnancy-associated cancers are diagnosed antepartum, with the remainder diagnosed in the postpartum period. Of women with cancer identified during pregnancy, more than 50% are identified in the first trimester. The incidence of pregnancy-associated cancer is expected to continue to rise with the ongoing…

Anemia and Pregnancy

Anemia is defined as a hemoglobin (Hb) value less than the lower limit of normal not explained by the state of hydration. This definition has physiologic validity, in that it is the amount of Hb per unit volume of blood that determines the oxygen-carrying capacity of blood. The normal Hb level for the adult female is 14.0 ± 2.0 g Defining anemia as a Hb level…

Thromboembolic Disease in Pregnancy

The Centers for Disease Control and Prevention (CDC) Pregnancy Mortality Surveillance System reports that pregnancy-related deaths in the United States have risen from 7.2 per 100,000 live births in 1987 to 17.3 per 100,000 live births in 2013 and stabilized through 2015. Although the plurality of such deaths can now be attributed to cardiac disease, venous thromboembolism (VTE) accounts for almost 10% of pregnancy-related deaths in…

Coagulation Disorders in Pregnancy

Acquired and inherited disorders of the hemostatic system can produce hemorrhage and thrombosis. , Inherited and acquired thrombophilias are associated with venous thromboembolism (VTE), a leading cause of maternal death in the United States, and may be associated with recurrent pregnancy loss and severe placenta-mediated pregnancy complications. The hemostatic system and its modulators are reviewed in this chapter. We discuss inherited and acquired disorders of platelet…

Cardiac Diseases

Diagnosis of Heart Disease in Pregnancy Pregnant women with heart disease are at higher risk for cardiovascular complications during pregnancy and also have a higher incidence of neonatal complications. However, the significant hemodynamic changes that accompany pregnancy make the diagnosis of certain forms of cardiovascular disease difficult. During normal pregnancies, women frequently experience dyspnea, orthopnea, easy fatigability, dizzy spells, and occasionally even syncope. On physical examination,…

Maternal-Fetal Infections

Select infections during pregnancy carry risks to pregnant individuals, the pregnancy itself, the fetus, and the neonate. The term TORCH, ( t oxoplasmosis, o ther, r ubella, c ytomegalovirus, h erpes simplex virus) was coined in 1971 to categorize pathogens that can traverse the maternal-fetal interface and cause clinical congenital malformations. These pathogens display remarkable heterogeneity in transmission efficacy and presentation ( Table 51.1 ). Some…

Sexually Transmitted Diseases

Rates of sexually transmitted diseases are increasing in women of reproductive age. Thus, pregnancies complicated by these infections have and will continue to become more prevalent. A number of these infections, such as gonorrhea, chlamydia, herpes simplex virus, and syphilis, can have a significant impact on both the woman’s overall health and that of her pregnancy. Others, such as trichomoniasis and bacterial vaginosis, don’t pose significant…

Maternal and Fetal Viral Infections

Acknowledgment We would like to acknowledge the work of Patrick Duff, MD, whose previous chapter on Maternal and Fetal Infections served as the template for this chapter and has been edited accordingly. – Infectious diseases are among the most common problems encountered by obstetricians. Pregnancy is a period of immune reshaping, with alterations in the maternal immune system aimed at protecting the fetus from rejection potentially…

Bacterial and Parasitic Infections in Pregnancy

Infectious disease is frequently encountered by the obstetrician. Some conditions, such as urinary tract infections, endometritis, wound infection, and mastitis, pose a risk primarily to the mother. Other disorders, such as group B streptococci (GBS) infection and toxoplasmosis, are of principal concern because of the risk of fetal or neonatal complications. Still others, such as syphilis and malaria, can cause serious morbidity for both mother and…

Maternal Mortality

Acknowledgment The authors would like to acknowledge Elliott K. Main, MD, for his work on the previous edition of this chapter. Quality Improvement Maternal mortality is a tragedy for the woman and her family, as well as for health care providers and society. Reports of trends or causes of maternal mortality invariably receive much attention in the media and on the Internet. Although the maternal mortality…

Patient Safety and Quality Improvement in Obstetrics

Physicians have always striven to provide patients with the very best care and outcomes. However, in the past 40 years, health care has become progressively more complex, increasingly dependent on technology, and reliant on more team members to provide care. The physician is still the ultimate leader of the team, and yet more than a dozen staff, including physicians, nurses, social workers, therapists, and trainees at…

Pregnancy-Related Hypertension

Acknowledgments We would like to thank Kara Beth Markham and Edmund Funai for drafting and maintaining this chapter over the course of the previous editions. Classification of Hypertensive Disorders Interpretation of available data regarding hypertension in pregnancy is difficult because of inconsistent terminology. Although imperfect, the American College of Obstetricians and Gynecologists (ACOG) nomenclature is straightforward and available worldwide. , The classification system includes the following…

Fetal Growth Restriction

Initial evaluation of suspected fetal growth abnormality includes accurately determining gestational age and then distinguishing between a fetus that is constitutionally small but normal and a fetus with true fetal growth restriction (estimation of fetal weight usually <3rd percentile, evidence of abnormal umbilical artery diastolic flow impedance). A detailed anatomic survey should be performed to detect the presence of any structural abnormalities. If there is any…

Placenta Previa and Accreta, Vasa Previa, Subchorionic Hemorrhage, and Abruptio Placentae

Bleeding in the later stages of pregnancy has been described as “third-trimester bleeding” or “antepartum hemorrhage.” Late-pregnancy bleeding is a significant cause of maternal and fetal morbidity, fetal mortality, and preterm delivery. Traditional accounts of such bleeding have addressed placenta previa, abruptio placentae, and vasa previa, although in fact the only thing these clinical problems have in common is that they are all concerned with hemorrhage.…

Stillbirth

Epidemiology Stillbirth, defined as fetal death at 20 weeks’ gestation or more, is one of the most common adverse pregnancy outcomes, with an estimated 2.6 million stillbirths at 28 weeks’ gestation or more occurring worldwide annually. , It has been estimated that 98% of all stillbirths occur in low- and middle-income countries. , In the United States, stillbirth occurs in 1 in 165 pregnancies, and 21,500…

Recurrent Pregnancy Loss

Pregnancy loss is the most common complication of pregnancy; up to 70% of all fertilized eggs and approximately 20% of all clinically recognized pregnancies will not result in a live birth. Recurrent pregnancy loss (RPL) affects 1% to 2% of all couples trying to conceive, with 80% of pregnancy losses occurring in the first trimester. RPL is often a physical and emotional ordeal for the woman…

Clinical Aspects of Normal and Abnormal Labor

Acknowledgment This work was supported in part by the Intramural Research Program at the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health. The views expressed in this chapter are those of the authors and do not reflect the official policy or position of the NICHD. Normal Labor and Its Limits The proper management of labor and delivery depends…

Premature (Prelabor) Rupture of the Membranes

Rupture of the fetal membranes is an integral part of parturition at term and is anticipated in the processes of both spontaneous term and preterm birth. Spontaneous rupture of the membranes at term and preterm can occur any time before or after the onset of contractions. When membrane rupture occurs before the onset of contractions, it is referred to as premature or prelabor rupture of the…