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Perinatal Infections and Chorioamnionitis

Definitions and Epidemiology Chorioamnionitis (or intra-amniotic infection) is a major cause of fetal, neonatal, and maternal morbidity and mortality. There are strong associations between chorioamnionitis and maternal morbidity, preterm birth, early-onset neonatal sepsis, bronchopulmonary dysplasia, retinopathy of prematurity, and diffuse white matter injury. The literature supporting these associations has been inconsistent, largely because of lack of precision in the diagnosis of chorioamnionitis. Potential sites of microbial…

Amniotic Fluid Volume

Amniotic fluid surrounds the developing embryo throughout gestation, protecting the fetus and umbilical cord from trauma while allowing mobility to facilitate structural growth and development. The underlying forces that regulate amniotic fluid are exceedingly complex and dynamic, synchronizing volumes within relatively narrow ranges and providing an indirect measure of fetal well-being. Understanding the pathways of water and solute exchange provides the physiologic basis of the pathologic…

Immune and Nonimmune Hydrops Fetalis

Hydrops fetalis (HF) is defined as the presence of excessive fetal fluid in two or more of the following spaces: abdominal ascites, pleural effusion, pericardial effusion, skin edema, polyhydramnios, or placentomegaly. The diagnosis is made by ultrasound imaging evaluating body cavities, the placenta, and the amniotic fluid volume. Classically, HF has been classified into two categories based on etiology: Immune HF accounts for an estimated 10%-24%,…

Obstetric Management of Multiple Gestation and Birth

The human female is programmed by nature to mono-ovulate, to nurture one fetus, and to take care of one neonate at a time. This natural pattern results in the relatively rare birth of twins (about 1 per 80 to 100 births) and in the extremely rare occurrence of high-order multiple gestations. The rarity of high-order multiple gestations can be appreciated by the quasi-mathematical Hellin-Zellany rule for…

Fetal Effects of Autoimmune Disease

Placental Transfer: General Remarks The maternal-fetal interface is quite efficient in its selective exclusion of substances during the transport process from the maternal to the fetal circulation. At the same time, the placenta selectively transfers other substances, a process that is facilitated by the proximity of the respective maternal-fetal vascular systems within the placental cotyledons. Although there is no mixing of the maternal and fetal blood,…

Obstetric Management of Prematurity

Preterm birth is defined as a delivery that occurs at 20 weeks’ gestation or later but prior to 37 weeks’ gestation (from the first day of the last menstrual period). Although advancements in neonatology and obstetrical interventions have dramatically improved outcomes and reduced the burden associated with prematurity, the rate of preterm birth itself has not changed substantially over the past 40 years. From 1990-2006, the…

Pregnancy Complicated by Diabetes Mellitus

In the United States, depending on the applied diagnostic criteria, 135,000-200,000 women develop gestational diabetes mellitus (GDM) annually, adding to the number of pregnant women diagnosed with either type 1 or type 2 diabetes. Of greater concern may be the fact that approximately 80% of these mothers will develop type 2 diabetes and metabolic syndrome, both of which are associated with high mortality and morbidity. Furthermore,…

Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy consist of a broad spectrum of medical complications, including gestational hypertension, preeclampsia, eclampsia, and pregestational hypertension. The incidence is estimated to be between 3% and 10% of all pregnancies. Worldwide, preeclampsia and related conditions are among the leading causes of maternal mortality. Although maternal death caused by preeclampsia is less common in developed countries, maternal morbidity remains high. Hypertensive disorders of pregnancy…

Developmental Origins of Adult Health and Disease

Fetal Origins of Adult Disease Concept The concept of fetal origins of adult disease popularized by Barker arose from a robust association between small size at birth and the risk of chronic adult diseases, such as coronary artery disease, hypertension, stroke, type 2 diabetes mellitus, and osteoporosis. These original epidemiologic observations have been extensively replicated by multiple groups in varying populations of different ethnicities employing birth…

Intrauterine Growth Restriction

Summary Intrauterine growth restriction (IUGR) broadly encompasses pregnancies complicated by poor fetal growth, where the fetus's growth is less than its genetic potential. IUGR is an important condition to recognize, as it is a common complication of pregnancy that has both short- and long-term sequelae for offspring. This is a particularly difficult diagnosis to manage in both the prenatal and postnatal periods for a number of…

Adverse Exposures to the Fetus and Neonate

Exposure to environmental toxicants during pregnancy may have a significant impact on the developing fetus. Fetal adverse exposures are growing in importance as our population expands and the number of women participating in the workforce continues to rise. In 2015, women comprised 47% of the workforce in the United States, and 73.5 million women aged 16 and over were employed. Approximately 75% worked full time. In…

Surgical Treatment of the Fetus

Summary Over the past half-century, implementation of high-resolution screening prenatal imaging, coupled with increasingly nuanced understanding of embryology and human fetal development, have created a new surgical patient: the fetus. Through decades of rigorous scientific investigation and technical innovation, congenital anomalies that previously carried a grim prognosis are now candidates for fetal intervention. As experience has grown with fetal surgical intervention, we have been able to…

Estimation of Fetal Well-Being

In high-risk populations at increased risk of perinatal mortality, antenatal fetal surveillance is often employed in an attempt to prevent stillbirth. Pregnancies at risk for progressive deterioration of placental function leading to fetal hypoxemia and acidosis are most likely to benefit from the methods currently in use. The various modalities, including non-stress test (NST), contraction stress test (CST), biophysical profile, and Doppler velocimetry, rely on fetal…

Perinatal Ultrasound

Ultrasound has permanently changed imaging in perinatology, increasing expectations of success and improving outcomes in maternal and neonatal care. The method is safe, real time, relatively inexpensive, and readily available in hospitals and clinics worldwide. Fetal imaging is the most common ultrasound study. Identifying anomalies related to fetal and placental development or dating errors is crucial. Sonographic genetic screening, cervical assessment, Doppler vascular measurements, and three-dimensional…

Genetic Aspects of Perinatal Disease and Prenatal Diagnosis

The genetic basis of human disorders is a fundamental cornerstone of modern medicine. Recent advances in our understanding of complex genetic disorders coupled with technical developments have allowed genetics to become an invaluable part of clinical practice. This chapter highlights essential concepts regarding the genetic basis of disease and issues surrounding prenatal evaluation and diagnosis. Principles of inheritance, teratogens, genetic screening, and diagnostic modalities are discussed.…

Social and Economic Contributors to Neonatal Outcome in the United States

Epidemiology of Health Disparities in Neonatal and Perinatal Medicine While there have been significant improvements in neonatal and infant mortality in the United States over the past 50 years, compared to other high income countries in the world, the United States alarmingly lags behind these other countries in infant mortality rates. Infant mortality and morbidity rates are commonly used as an important indicator worldwide of overall…

Perinatal and Neonatal Care in Developing Countries

The science and practice of modern neonatology evolved as a medical specialty in the United States and the Western world over the last 70 years. Neonatology as a specialty in developing countries is still evolving. The increased attention to improving newborn care at a global level can be traced to the recognition by the World Health Organization (WHO) of unacceptably high infant mortality in low- and…

Practicing Evidence-Based Neonatal-Perinatal Medicine

This chapter focuses on five strategic processes in practicing evidence-based, neonatal-perinatal medicine: (1) asking a focused clinical question; (2) searching MEDLINE, the Cochrane Library, and other sources for high-quality evidence (primary reports and systematic reviews); (3) critically appraising the retrieved evidence for its validity; (4) extracting the data; and (5) applying the results to patient care. The role of the Cochrane Collaboration in the preparation, dissemination,…

Simulation and Debriefing in Neonatal-Perinatal Medicine

Introduction Whereas teaching is something that is (passively) done to trainees, learning is something that trainees must (actively) do themselves. Because not everything that is taught is necessarily learned , programs that best facilitate skill acquisition in trainees are those that focus on learning rather than on teaching. Traditional didactic programs are passive by nature, and the settings in which they are held are typically isolated…