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Assessment of Fetal Well-Being

Key Points Fetal assessment demands a view into the somewhat inaccessible intrauterine environment; the primary tools are ultrasound and fetal heart rate monitoring. It is important to make the distinction between intrapartum (during labor) and antepartum (before labor) fetal assessment; the latter is the focus of this chapter. Current debate centers on who should undergo sonographic examination and what type of evaluation these patients should have.…

Intrauterine Drug Exposure: Fetal and Postnatal Effects

Key Points Substance use remains at epidemic proportions, both nationally and globally. Increasing legalization of marijuana has resulted in new concerns for fetal and infant exposure, with limited understanding of the short- and long-term effects in this population. The recent focus of perinatal substance use has grown to include widely prescribed substances, including opioids and other psychotropic drugs. The importance of establishing and maintaining consistent protocols…

Hypertensive Complications of Pregnancy

Key Points Hypertensive disorders of pregnancy are classified as chronic hypertension, gestational hypertension, preeclampsia with and without severe features, and chronic hypertension with superimposed preeclampsia. Pharmacologic management of chronic hypertension should be reserved for women with sustained elevations in blood pressure at or greater than 160 mm Hg systolic or 110 mm Hg diastolic. Magnesium sulfate administration to prevent eclampsia is used for those preeclampsia cases…

Maternal Medical Disorders of Fetal Significance

Key Points Diagnostic imaging carries a risk of fetal radiation exposure. However, in most cases the actual fetal dose is low. While x-ray and computed tomography imaging should be avoided during pregnancy if possible, these studies are not contraindicated if needed. Adverse pregnancy outcomes in patients with lupus are more frequently seen in those with renal disease, antiphospholipid antibody syndrome, thrombocytopenia, and active disease. Cardiovascular disease…

Maternal Diabetes

Key Points The incidence of diabetes in pregnancy is steadily rising, likely in parallel with the rising incidence of obesity among pregnant patients. Pregnant patients with diabetes are at increased risk for fetal complications (such as congenital malformations, fetal growth abnormalities, and stillbirth) and perinatal/neonatal complications (such as prematurity, respiratory distress, and metabolic abnormalities, including hypoglycemia and electrolyte derangements). Tight maternal glycemic control, achieved preconception and…

Nonimmune Hydrops

Key Points Nonimmune hydrops fetalis results from many etiologies. Management involves correcting the underlying cause. The condition is associated with significant morbidity and mortality. Some etiologies are amenable to treatment in utero. A newborn with hydrops has an abnormal accumulation of fluid. The condition varies from mild, generalized edema to massive anasarca with effusions in multiple body cavities and with peripheral edema so severe that the…

Prematurity and Stillbirth: Causes and Prevention

Key Points Preterm birth, defined as birth prior to 37 weeks gestation, is the leading cause of under-five child mortality worldwide. Preterm birth can be spontaneous or medically indicated, in which cesarean delivery or induction of labor is performed to avoid the risks of continued pregnancy. Preterm birth and stillbirth should be considered as occurring on a spectrum rather than distinct entities, due to overlapping physiology…

Multiple Gestations and Assisted Reproductive Technology

Key Points The multiple birth rate has increased by 76% in the past three decades; however, it has recently started to stabilize or even decline. Increased utilization of assisted reproductive technologies and women delaying childbearing are the main contributors to the high rate of multiples. Multiple gestations are at high risk for both maternal and fetal morbidity and mortality, which increase as fetal number increases. Most…

Abnormalities of Fetal Growth

Key Points Normal fetal growth is determined by a number of factors. The pattern of normal fetal growth involves rapid increases in fetal weight, length, and head circumference during the last half of gestation. Year-over-year increases in birth weight for gestational age are attributed to improvements in living conditions and maternal nutrition as well as changes in obstetric management. Variations in fetal growth have been identified…

Development, Function, and Pathology of the Placenta

Key Points The placenta is the first organ to form in mammals and is required for establishment of a maternal–fetal vascular interface capable of supplying the bioenergetic needs of the developing conceptus. Multiple placental cell types engage in highly varied functions, from attachment, invasion, and vascular remodeling to cell fusion, hormone production, and nutrient transport. Multiple mechanisms allow transport of waste and nutrients across the placenta,…

Ethics, Data, and Policy in Newborn Intensive Care

Key Points Increasingly available data in neonatal intensive care may help guide ethical decision-making about sick infants. Despite better ability to predict outcomes for sick infants, prognostic efforts are imperfect. When using data to guide decision-making in the neonatal intensive care unit, it is important to choose appropriate outcomes that match families’ values. There are policy implications to both limited data, as in predicting outcomes for…

Neonatal and Perinatal Epidemiology

Key Points Maternal and child health in the population have traditionally been assessed by monitoring two key statistics—the maternal mortality ratio and the infant mortality rate. The infant mortality rate is the sum of the neonatal mortality and post-neonatal mortality rates. Due to improvements in income, housing, birth spacing, and nutrition, along with public health interventions to produce cleaner food and water, improve maternal and infant…

Acute Frostbite

Skin and soft tissue are readily susceptible to injury at either end of the temperature spectrum. With exposure to cold, unprotected tissues can readily become frostbitten and/or hypothermic (aka frostnip); these are two distinct but often linked injuries. In the past, skin, limbs, and digits sustaining severe frostbite injury had predictable outcomes: sloughing or amputation. The only question was how long to wait to amputate. Essentially,…

Spinal Cord Injury

Introduction Spinal cord injury (SCI) is a devastating, life-altering event for patients and their families. In spite of decades of innovative research in the field, no pharmacologic “silver bullet” has been developed that can mitigate or cure the extent of neurologic impairment in SCI patients. Preservation of function by providing early stability to the injured spine followed by neurorehabilitation remains the current standard of care. Surgical…

Cervical Spine Fractures

The purpose of this chapter is to outline a stepwise approach to C-spine fractures to aid in the safe and expedient work-up for these potentially complex injuries. The inclusion of some of the specific classifications employed by spine surgeons and the stepwise progression through localization, anatomy, neurologic status, stability, and disposition allow the reader to critically evaluate the nuances of the injury in anticipation of definitive…