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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Mount Sinai Expert Guides
- Sprache: Englisch
Mount Sinai Expert Guides: Obstetrics and Gynecology provides specialty trainees and junior physicians with an extremely clinical, affordable and accessible handbook covering the key and hot topics in this complex field with focus throughout on clinical diagnosis and effective patient management. Used as a point-of-care resource in the hospital and clinical setting, it present sthe very best in expert information in an attractive, quick and easy to navigate informative and well-structured manner, with features such as key points, potential pitfalls, management algorithms, and national/international guidelines on treatment.
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Veröffentlichungsjahr: 2020
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MOUNT SINAI EXPERT GUIDES
Obstetrics and Gynecology
EDITED BY
Rhoda Sperling
Icahn School of Medicine at Mount SinaiNew York, NY, USA
This edition first published 2020© 2020 John Wiley & Sons, Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.
The right of Rhoda Sperling to be identified as the author(s) of the editorial material in this work has been asserted in accordance with law.
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Library of Congress Catalgoing-in-Publication DataNames: Sperling, Rhoda, editor.Title: Obstetrics and gynecology / edited by Rhoda Sperling.Description: Hoboken, NJ : Wiley-Blackwell, 2020. | Series: Mount Sinai expert guides | Includes bibliographical references and index.Identifiers: LCCN 2020010613 (print) | LCCN 2020010614 (ebook) | ISBN 9781119450115 (library binding) | ISBN 9781119450108 (adobe pdf) | ISBN 9781119450078 (epub)Subjects: LCSH: Obstetrics–Handbooks, manuals, etc. | Gynecology–Handbooks, manuals, etc.Classification: LCC RG531 .O27 2020 (print) | LCC RG531 (ebook) | DDC 618.2–dc23LC record available at https://lccn.loc.gov/2020010613LC ebook record available at https://lccn.loc.gov/2020010614
Cover image: © Raycat/Getty ImagesCover design by Wiley
Set in 8.5/12pt FrutigerLTStd by Aptara Inc., New Delhi, India
CONTENTS
Cover
Title Page
Copyright
Contributors
Series Foreword
Preface
About the Companion Website
Part 1 Obstetrics
Chapter 1 Multiple Gestations
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Images
Chapter 2 Preeclampsia/Eclampsia
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Evidence
Chapter 3 Gestational Diabetes
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Evidence
Chapter 4 Viral Infections and Pregnancy
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Evidence
Chapter 5 Placenta Previa and Morbidly Adherent Placenta
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Chapter 6 Gastrointestinal Disorders and Pregnancy
Background
Prevention
Diagnosis
Treatment
Reading list
Chapter 7 Ultrasound in Pregnancy
Background
Indications
Procedure (transvaginal ultrasound)
Procedure (transabdominal ultrasound)
Ultrasound-guided procedures
3D/4D ultrasound
Reading list
Guidelines
Images
Chapter 8 Carrier Screening and Aneuploidy Screening
Carrier screening
Aneuploidy screening and diagnostic testing
Invasive/diagnostic testing
Reading list
Guidelines
Chapter 9 Preterm Birth
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Chapter 10 Abnormal Labor
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Evidence
Chapter 11 Cesarean Delivery and Operative Vaginal Delivery
Background
Prevention
Diagnosis
Reading list
Guidelines
Chapter 12 Intrapartum and Postpartum Hemorrhage
Background
Prevention
Diagnosis
Treatment
Reading list
Guidelines
Chapter 13 Intraamniotic Infection
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Evidence
Images
Chapter 14 Liver Disease and Pregnancy
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Chapter 15 Thyroid Disease and Pregnancy
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Evidence
Chapter 16 Perinatal Mood and Anxiety Disorders
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Part 2 Gynecology
Chapter 17 Surgical Site Infections
Background
Prevention
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Chapter 18 Vaginitis, Cervicitis, and Pelvic Inflammatory Disease
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Images
Chapter 19 Abnormal Uterine Bleeding
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Images
Chapter 20 Fibroids
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Images
Chapter 21 Pelvic Organ Prolapse
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Chapter 22 Stress Incontinence
Background
Prevention
Diagnosis
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Chapter 23 Adnexal Mass
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Images
Chapter 24 Endometriosis
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Chapter 25 Anogenital HPV
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Images
Chapter 26 Genitourinary Syndrome of Menopause
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Chapter 27 Menopausal Hot Flashes
Background
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Chapter 28 Urinary Tract Infection
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Chapter 29 Ectopic Pregnancy
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Chapter 30 Osteoporosis
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Chapter 31 Genital Ulcer Disease
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Chapter 32 Vulvodynia
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Part 3 Reproductive Endocrinology
Chapter 33 Evaluation of the Infertile Couple
Background
Diagnosis
Reading list
Guidelines
Chapter 34 Ovulation Induction/ART/IVF/ICSI
Indications
Procedure
Management of complications
Follow-up
Miscellaneous
Reading list
Chapter 35 Polycystic Ovary Syndrome
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Images
Chapter 36 Recurrent Pregnancy Loss
Background
Diagnosis
Treatment
Reading list
Guidelines
Chapter 37 Fertility Preservation
Indications
Procedures
Management of complications
Follow-up
Reading list
Part 4 Gyn Oncology
Chapter 38 Ovarian Cancer
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Images
Chapter 39 Cervical Cancer
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Images
Chapter 40 Endometrial Cancer
Background
Prevention
Diagnosis (Algorithm 40.1)
Treatment (Algorithm 40.2)
Special populations
Prognosis
Reading list
Guidelines
Evidence
Images
Chapter 41 Gestational Trophoblastic Disease
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Evidence
Chapter 42 Vulvar Cancer
Background
Prevention
Diagnosis
Treatment
Prognosis
Reading list
Guidelines
Evidence
Part 5 Family Planning
Chapter 43 Unintended Pregnancy
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Chapter 44 Pregnancy Prevention
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Chapter 45 Early Pregnancy Failure
Background
Prevention
Diagnosis
Treatment
Special populations
Prognosis
Reading list
Guidelines
Evidence
Index
End User License Agreement
List of Tables
Chapter 15
Table 15.1
Table 15.2
Chapter 21
Table 21.1
Table 21.2
Chapter 38
Table 38.1
Table 38.2A
Table 38.2B
Table 38.3
Table 38.4
Table 38.5
Table 38.6
Chapter 40
Table 40.1
Table 40.2
List of Illustrations
Chapter 1
Figure 1.1 “Twin peak” or Lambda sign characteristic of a dichorionic diamniotic gestation...
Figure 1.2 “T sign” characteristic of monochorionic diamniotic gestation. This sonographic...
Chapter 7
Figure 7.1 First trimester fetus in sagittal plane with crown-rump length (CRL) measuremen...
Figure 7.2 Nuchal translucency (NT) measurement with amnion/amniotic membrane and nasal bo...
Figure 7.3 Cervical length measured using transvaginal ultrasound between the internal (*)...
Figure 7.4 Transvaginal ultrasound image of cervix with placental edge (arrow) overlying t...
Figure 7.5 Dichorionic diamniotic twin pregnancy with lambda sign/twin peak sign (arrow).
Figure 7.6 Monochorionic twin pregnancy with intervening membrane and “T” sign (arrows).
Figure 7.7 Axial view of the fetal cranium at the level of the cavum septum pellucidum (CS...
Figure 7.8 Axial view of the fetal abdomen at the level of the stomach (*) and the umbilic...
Figure 7.9 Longitudinal view of the fetal femur. The femur length (FL) is measured as the ...
Figure 7.10 Maximal vertical pocket (MVP) measured between calipers. See color version on w...
Figure 7.11 3D image of the third trimester fetal face. See color version on website.
Chapter 11
Figure 11.1 Mushroom-shaped cups are a hybrid of the stainless steel and plastic devices: K...
Chapter 13
Figure 13.1 Acute chorioamnionitis showing inflammation. Source: https://upload.wikimedia.o...
Figure 13.2 Potential sites of bacterial infection within the uterus. From: https://clinica...
Chapter 18
Figure 18.1 Bacterial vaginosis – presence of gram negative rods and absence of lactobacill...
Figure 18.2 Vulvovaginal candidiasis (yeast and hyphae) on a 10% hydrogen peroxide wet moun...
Figure 18.3 Trichomonas vaginalis on wet mount. From...
Chapter 19
Figure 19.1 Abnormal uterine bleeding - Submucosal leiomyoma. Courtesy of UpToDate....
Chapter 20
Figure 20.1 Leiomyomas - Hysterectomy specimens. Reproduced with permission from Aron Schuf...
Figure 20.2 Leiomyomas - Hysterectomy specimens. Reproduced with permission from Aron Schuf...
Chapter 21
Figure 21.1 The POPQ system. Courtesy of AUGS (American Urogynecologic Society), https://ww...
Chapter 22
Figure 22.1 Likelihood of stress incontinence or detrusor overactivity being the predominan...
Chapter 23
Figure 23.1 a. Normal follicle – anechoic (Courtesy of Dr. Thomas Shipp); b. Simple ovarian...
Figure 23.2 Benign mature ovarian teratoma – hyperechogenic areas representing hair (Courte...
Figure 23.3 Endometrioma with color flow Doppler (Courtesy of Dr. Thomas Shipp). See color ...
Figure 23.4 a. Ultrasound image of the pelvis of a 24-year-old woman with intermittent pelv...
Chapter 25
Figure 25.1 Visual inspection – Condyloma acuminata. See color version on website.
Figure 25.2 Colposcopy – Cervical dysplasia. See color version on website.
Figure 25.3 High-resolution anoscopy – Anal dysplasia. See color version on website.
Chapter 34
Figure 34.1 Schematic representation and description of IVF procedure. Photo courtesy of Re...
Figure 34.2 ICSI. An oocyte is stabilized by a holding pipette. The injection pipette cont...
Chapter 35
Figure 35.1 A stereotypical image of a polycystic ovary on transvaginal ultrasound, with en...
Figure 35.2 Modified Ferriman-Gallwey scoring for hirsutism. Scores from 0–4 are assigned a...
Chapter 38
Figure 38.1 Susceptibility genes and their prevalence in hereditary ovarian syndromes. From...
Chapter 39
Figure 39.1 Global distribution of cervical cancer cases in 2018. Available from: http://gl...
Figure 39.2 Progression from benign cervical lesion to invasive carcinoma. Courtesy of Nati...
Figure 39.3 Cervical cancer seen on colposcopic examination (personal collection). See colo...
Chapter 40
Figure 40.1 Endometrial cancer. Courtesy of Dr. Tamara Kalir, Department of Pathology, Icah...
Figure 40.2 Photomicrograph of a well-differentiated endometrioid endometrial adenocarcinom...
Guide
Cover
Table of Contents
Contributors
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Contributors
Omara Afzal, DO
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Devora Aharon, MD
Reproductive Medicine Associates of New York
Division of Reproductive Endocrinology and Infertility
Icahn School of Medicine at Mount Sinai, New York, NY
Charles Ascher-Walsh, MD
Division of Female Pelvic Medicine and Reconstructive Surgery
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Ann Marie Beddoe, MD
Division of Gynecologic Oncology
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Eric P. Bergh, MD
Maternal-Fetal Medicine Subspecialist
UT Health – McGovern Medical School
Division of Maternal-Fetal Medicine, Houston, TX
Veerle Bergink, MD, PhD
Department of Psychiatry and Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Neha R. Bhardwaj, MD, MS
Division of Family Planning
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Angela Bianco, MD
Division of Maternal-Fetal Medicine
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Catherine A. Bigelow, MD
Maternal-Fetal Medicine Subspecialist
Minnesota Perinatal Physicians
Allina Health, Minneapolis, MN
Stephanie V. Blank, MD
Division of Gynecologic Oncology
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Karen F. Brodman, MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Danielle Brooks, MD
Department of Medicine
Division of Endocrinology, Diabetes, and Metabolism
Icahn School of Medicine at Mount Sinai, New York, NY
Lois Brustman, MD
Division of Maternal-Fetal Medicine
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Laudy Burgos, LCSW
Department of Social Work Services
MSH, NERA-Undergraduate Behavioral Health Fellowship Program
Icahn School of Medicine at Mount Sinai, New York, NY
Francesco Callipari, MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Woojin Chong, MD
Urogynecologist, Inspira Health, Vineland, New Jersey, NJ
Division of Female Pelvic Medicine and Reconstructive Surgery
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Garfield Clunie, MD
Maternal-Fetal Medicine
The Brooklyn Hospital Center
Division of Maternal-Fetal Medicine
Icahn School of Medicine at Mount Sinai, New York, NY
Carmel J. Cohen, MD
Division of Gynecologic Oncology
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Katherine A. Connolly, MD
Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
University of California, San Francisco, CA
Alan B. Copperman, MD
Reproductive Medicine Associates of New York
Division of Reproductive Endocrinology and Infertility
Icahn School of Medicine at Mount Sinai, New York, NY
Lisa Dabney, MD
Division of Female Pelvic Medicine and Reconstructive Surgery
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Gillian Dean, MD, MPH
Planned Parenthood Federation of America
Division of Family Planning
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Andrew Ditchik, MD
Department of Obstetrics and Gynecology
Elmhurst Hospital Center, Queens, NY
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Matthew Dominguez, MD
Department of Psychiatry
Icahn School of Medicine at Mount Sinai, New York, NY
Janine A. Doneza, MD
Robotic and Minimally Invasive Gynecologic Surgery
MIGS/Urogynecology Fellowship Program Fibroid Center
Bronxcare Hospital, Bronx, NY,
Icahn School of Medicine at Mount Sinai, New York, NY
Peter Dottino, MD
Division of Gynecologic Oncology
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Keith Eddleman, MD
Division of Maternal-Fetal Medicine
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
John A. Fantl, MD
Division of Female Pelvic Medicine and Reconstructive Surgery
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Suzanne S. Fenske, MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Lauren Ferrara, MD
Division of Maternal-Fetal Medicine
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Geetha N. Fink, MD, MPH
Division of Family Planning
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Eric Flisser, MD
Reproductive Medicine Associates of New York
Division of Reproductive Endocrinology and Infertility
Icahn School of Medicine at Mount Sinai, New York, NY
Faith J. Frieden, MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Elissa Gretz Friedman, MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Frederick Friedman Jr., MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Eric M. Ganz, MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Sharon Gerber, MD
Division of Family Planning
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Jeannette Guziel, MD
Hematology/Medical Oncology
Kaiser Permanente
Southern California Permanente Medical Group, Woodland Hills, CA
Anne Hardart, MD
Division of Female Pelvic Medicine and Reconstructive Surgery
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Nola S. Herlihy, MD
Reproductive Endocrinology and Infertility
IVIRMA, New Jersey, NJ
Karina Hoan, MD
FMIGS Faculty, Division of Minimally Invasive Gynecology
The Portland Clinic, Portland, OR
Adam Jacobs, MD
Division of Family Planning
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Nina S. Jacobson, MD
Division of Female Pelvic Medicine and Reconstructive Surgery
Department of Obstetrics and Gynecology
Jersey Shore University Medical Center, Neptune City, NJ
Tamara Kolev, MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Anna Kremer, MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Rashmi Kudesia, MD, MSc
Houston Methodist Hospital, CCRM Fertility, Houston, TX
Tatyana Kushner, MD
Department of Medicine
Division of Liver Diseases
Icahn School of Medicine at Mount Sinai, New York, NY
Carol Levy, MD
Department of Medicine
Division of Endocrinology, Diabetes, and Metabolism
Icahn School of Medicine at Mount Sinai, New York, NY
Holly C. Loudon, MD, MPH
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Britt Lunde, MD, MPH
Division of Family Planning
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Laura MacIsaac, MD, MPH
Division of Family Planning
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Rachel Masch, MD, MPH
Division of Family Planning
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Peter G. McGovern, MD
Division of Reproductive Endocrinology and Infertility
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Maria Teresa Mella, MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Keerti Murari, MD
Department of Medicine
Division of Endocrinology and Metabolism
Yale School of Medicine, New Haven, CT
Navya Nair, MD, MPH
Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
Louisiana State University School of Medicine, New Orleans, LA
Taraneh Gharib Nazem, MD
Reproductive Medicine Associates of New York
Division of Reproductive Endocrinology and Infertility
Icahn School of Medicine at Mount Sinai, New York, NY
Annacecilia Peacher, MD
Division of Female Pelvic Medicine and Reconstructive Surgery
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Elena Pereira, MD
Gynecologic Oncology
Department of Obstetrics and Gynecology
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New York, NY
Jamal Rahaman, MD
Division of Gynecologic Oncology
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Andrei Rebarber, MD
Maternal Fetal Medicine Associates New York, NY
Division of Maternal-Fetal Medicine
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Patricia Rekawek, MD
Maternal-Fetal Medicine
New York University Long Island School of Medicine, NYU Winthrop Hospital, Mineola, NY
V. Ord Sarabanchong, MD, MPH
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Fahimeh Sasan, DO
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Melissa Schwartz, MD
Division of Gynecologic Oncology
Department of Obstetrics, Gynecology and Women's Health
Saint Louis University School of Medicine, St. Louis, MO
Lucky Sekhon, MD
Reproductive Medicine Associates of New York
Division of Reproductive Endocrinology and Infertility
Icahn School of Medicine at Mount Sinai, New York, NY
Kathryn L. Shaia, MD, MHA
Duke Fertility Center
Division of Reproductive Endocrinology and Infertility
Department of Obstetrics and Gynecology
Duke University School of Medicine, Durham, NC
Amanda M. Silbermann, MD
Department of Obstetrics and Gynecology
New York University School of Medicine, New York, NY
Marti Soffer, MD
Division of Maternal Fetal-Medicine
Department of Obstetrics and Gynecology
Massachusetts General Hospital, Boston, MA
Rhoda Sperling, MD
Department of Obstetrics, Gynecology and Reproductive Science
Department of Medicine, Division of Infectious Diseases
Icahn School of Medicine at Mount Sinai, New York, NY
Daniel E. Stein, MD
Reproductive Medicine Associates of New York
Division of Reproductive Endocrinology and Infertility
Icahn School of Medicine at Mount Sinai, New York, NY
Joanne L. Stone, MD
Division of Maternal-Fetal Medicine
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Noel Strong, MD
Division of Maternal-Fetal Medicine
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Jian Jenny Tang, MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Dyese Taylor, MD
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Amy Tiersten, MD
Department of Medicine
Division of Hematology and Medical Oncology
Icahn School of Medicine at Mount Sinai, New York, NY
Shannon Tomita, MD
Division of Gynecologic Oncology
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Luciana Vieira, MD
Division of Maternal-Fetal Medicine
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Brian Wagner, MD
Division of Maternal-Fetal Medicine
Department of Obstetrics, Gynecology and Reproductive Science
Icahn School of Medicine at Mount Sinai, New York, NY
Elizabeth Yoselevsky, MD
Division of Maternal-Fetal Medicine
Department of Obstetrics, Gynecology, and Reproductive Biology
Brigham and Women's Hospital, Boston, MA
Series Foreword
Now more than ever, immediacy in obtaining accurate and practical information is the coin of the realm in providing high quality patient care. The Mount Sinai Expert Guides series addresses this vital need by providing accurate, up-to-date guidance, written by experts in formats that are accessible in the patient care setting: websites, smartphone apps, and portable books. The Icahn School of Medicine, which was chartered in 1963, embodies a deep tradition of preeminence in clinical care and scholarship that was first shaped by the founding of the Mount Sinai Hospital in 1855. Today, the Mount Sinai Health System, comprised of seven hospitals anchored by the Icahn School of Medicine, is one of the largest health care systems in the United States, and is revolutionizing medicine through its embracing of transformative technologies for clinical diagnosis and treatment. The Mount Sinai Expert Guides series builds upon both this historical renown and contemporary excellence. Leading experts across a range of disciplines provide practical yet sage advice in a digestible format that is ideal for trainees, mid-level providers, and practicing physicians. Few medical centers in the United States could offer this type of breadth while relying exclusively on its own physicians, yet here no compromises were required in offering a truly unique series that is sure to become embedded within the key resources of busy providers. In producing this series, the editors and authors are fortunate to have an equally dynamic and forward-viewing partner in Wiley Blackwell, which together ensures that health care professionals will benefit from a unique, first-class effort that will advance the care of their patients.
Scott Friedman MD
Series Editor
Dean for Therapeutic Discovery
Fishberg Professor and Chief, Division of Liver Diseases
Icahn School of Medicine at Mount Sinai
New York, NY, USA
Preface
Designed for both trainees and practitioners, this Expert Guide explores the wide breadth of topics that define the discipline of obstetrics and gynecology. This Expert Guide is dedicated to Dr. Michael Brodman, Chair of the Department of Obstetrics, Gynecology and Reproductive Sciences at the Icahn School of Medicine at Mount Sinai; his tireless efforts have built a strong, innovative, and diverse faculty whose expertise are now showcased in these chapters.
Rhoda Sperling, MD
Department of Obstetrics, Gynecology and Reproductive Science
Department of Medicine
Division of Infectious Diseases
Icahn School of Medicine at Mount Sinai,
New York, NY
About the Companion Website
This series is accompanied by a companion website:
www.wiley.com/go/sperling/mountsinai/obstetricsandgynecology
The website includes:
Advice for patients
Case studies with interactive MCQs
ICD codes
Color versions of images
PART 1Obstetrics
CHAPTER 1Multiple Gestations
Katherine A. Connolly1 and Joanne L. Stone2
1Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, San Francisco, CA
2Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
Overall Bottom Line
The incidence of twin gestation has risen due to advancing maternal age and the use of assisted reproductive techniques (ART).
There are increased risks of a twin gestation, including preterm labor, preterm delivery, low birth weight, fetal growth restriction, gestational diabetes, preeclampsia, and need for cesarean delivery.
Twin gestations require increased surveillance due to these increased risks.
Background
Definition of disease
Twin gestation refers to an intrauterine gestation of two fetuses.
Disease classification
Dizygotic twins occur after ovulation and fertilization of two different oocytes. This type of twins has two placentas and two amniotic sacs (
Figure 1.1
).
Monozygotic twins result from ovulation and fertilization of one single oocyte, with subsequent division. Depending on what day the embryo splits, these monozygotic twins are further classified as the following:
Dichorionic/diamniotic (Day 1–3)
Monochorionic/diamniotic (Day 4–8) (
Figure 1.2
)
Monochorionic/monoamniotic (Day 8–13)
Conjoined twins (Day 13–15)
Incidence/prevalence
The natural incidence of twins is 1/80.
The incidence of multiple gestation increased by 76% from 1980 to 2009 due to ART and has since stabilized.
Twins now account for 3% of live births.
Economic impact
Twin gestations are associated with higher cost, which is mostly related to the increased rate of preterm delivery. The cost of a premature infant is up to 10 times greater than that of a term infant in the first year.
Predictive/risk factors
Risk factor
Contribution
Assisted reproductive technology
Accounts for 1/3 of all twin pregnancies
Maternal age
Fourfold increase from age 15 to age 35
Family history
Increased risk of dizygotic twins
Prevention
Bottom Line/Clinical Pearls
The incidence of twin gestation has stabilized over time as the number of embryos transferred with ART has decreased. Single embryo transfer has become an increasingly common practice.
Screening
Ultrasound in the first or early second trimester is essential in diagnosing twin gestation and establishing chorionicity (
Figures 1.1
and
1.2
).
Primary prevention
Single embryo transfer to decrease the number of twin gestations that result from in vitro fertilization is an important prevention method. Splitting of an embryo into a monozygotic twin gestation, whether spontaneous or after ART, is not preventable.
Secondary prevention
After a twin gestation is diagnosed, a multifetal pregnancy reduction procedure can be performed, resulting in a single fetus and improved pregnancy outcomes.
Multifetal pregnancy reduction to a singleton gestation is associated with higher birth weights and lower rates of preterm deliveries.
Diagnosis
Bottom Line/Clinical Pearls
The diagnosis of twins is made with ultrasound.
This ultrasound should be done in the first or early second trimester in order to most accurately establish chorionicity, which has important implications for the pregnancy.
Typical presentation
Twin gestation may be suspected if uterine size measures larger than would be expected for a given gestational age.
Diagnosis can be confirmed only with ultrasound.
Clinical diagnosis
History
Age
Family history of twin gestation
Use of ART
Physical examination
Clinical examination of uterine size with bimanual exam and measurement of fundal height
Laboratory diagnosis
List of diagnostic tests
The risk of aneuploidy is higher in dizygotic twins. The mathematical probability that a single fetus is affected is doubled in a twin gestation.
The chance that a 33-year-old with twins has one fetus with Down syndrome is equivalent to the chance that a 35-year-old has a singleton fetus with Down syndrome.
All pregnant patients are counseled on options for genetic screening (serum screening such as sequential or quad screen) or diagnostic testing (chorionic villus sampling or amniocentesis).
Even in a singleton pregnancy, serum screening is never diagnostic, but this screening is even further limited in twin gestations.
Analyte levels in maternal serum for twins are estimated using mathematical models.
Analyte levels in maternal serum from each fetus are averaged together, possibly normalizing the levels and masking an affected fetus.
First trimester serum screening combined with nuchal translucency measurements identifies 75–85% of pregnancies with Down syndrome and 66% of pregnancies with trisomy 18 in twins.
Second trimester serum screening identifies 63% of pregnancies with Down syndrome in twins.
Noninvasive prenatal screening (NIPS), which analyzes cell-free fetal DNA in maternal serum, is not recommended for multiple gestations.
Invasive testing with chorionic villus sampling (CVS) or amniocentesis remain the only two options for diagnostic testing.
CVS samples the chorionic villi and may be performed as early at 9 weeks.
CVS may be more technically challenging in a twin gestation. There is an approximately 1% rate of sampling error, meaning that one fetus was sampled twice.
Amniocentesis is performed by sampling the amniotic fluid and is done after 15 weeks.
To avoid sampling error, once a needle is inserted into the first amniotic sac, indigo carmine is injected into this sac, which results in blue colored fluid. This needle is then removed and a second needle inserted into the second sac. If the fluid is clear, it is confirmed that the second sac has been entered. If the fluid is blue, this indicates that the same sac has just been entered a second time.
There is approximately a 1.8% pregnancy loss rate prior to 24 weeks after amniocentesis in twins.
List of imaging techniques
Ultrasound is the primary imaging modality used in the surveillance of all pregnancies, including twin gestation.
Potential pitfalls/common errors made regarding diagnosis of disease
Ultrasound should be performed in the first or early second trimester for the most accurate determination of chorionicity. It is essential that chorionicity is accurately established, as monochorionic twins and dichorionic twins are at risk for different complications and need to be monitored and managed differently.
Treatment
Treatment rationale
There have been several interventions that have been studied in an attempt to decrease the rate of preterm delivery in twins that have not found to be beneficial:
Prophylactic cerclage: not beneficial, not recommended
Cerclage for short cervix: not only not beneficial but actually DOUBLES the rate of spontaneous preterm delivery and is therefore not recommended
Bed rest: not beneficial, not recommended
Prophylactic tocolytics: not beneficial, not recommended
Prophylactic pessary: not beneficial, not recommended
Prophylactic use of progesterone: not beneficial, not recommended
Twin pregnancies require increased surveillance to detect signs of preterm labor. There are several beneficial interventions if a patient is found to be in preterm labor that are discussed in the following sections.
When to hospitalize
There are several indications for hospitalization of twins:
Preterm labor, advanced cervical exam, preeclampsia/gestational hypertension, bleeding, fetal growth restriction
Twins are at higher risk for all of the aforementioned complications, but once they are diagnosed, they are often managed similarly to the way singletons are managed.
Managing the hospitalized patient
Management of preterm labor in twin gestation:
Tocolytics: Data are limited in twin gestations, though a 48-hour course to enable the administration of corticosteroids seem to be beneficial in twins as well. First-line agents include calcium channel blockers and nonsteroidal anti-inflammatory agents (indomethacin).
Corticosteroids: Administration of steroids between 24 and 34 weeks has been shown to decrease the incidence of neonatal death, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis in singleton gestations. Based on this evidence, the National Institutes of Health recommends that they should be administered in multiple gestations as well.
Magnesium sulfate: Administration has been shown to reduce the incidence of cerebral palsy when given prior to delivery when it is occurs less than 32 weeks.
Table of treatment
Treatment
Comments
Medical
When a patient with twins is admitted for preterm labor, administration of corticosteroids (if between 24–34 weeks), tocolytics (if between 24–34 weeks), and magnesium sulfate prior to delivery (if less than 32 weeks) is recommended.
Surgical
Cerclage is not recommended in twin gestations, as it leads to worse outcomes.
There is a higher rate of cesarean delivery in twin gestations, although vaginal delivery is possible if the presenting fetus (typically fetus A) is in cephalic presentation.
Radiological
The use of ultrasound is essential to the management of twin gestation. Early ultrasound to establish chorionicity, then second trimester anatomic survey, and then serial growth ultrasounds to look for growth restriction or twin to twin transfusion syndrome are employed.
Psychological (includes cognitive, behavioral, etc., therapies)
Mothers who give birth to twins are at increased risk of postpartum depression; therefore, it is important to administer a depression scale at their postpartum visit and treat as necessary.
Prevention/management of complications
Prevention is aimed at early identification of complications for which twins are at risk.
Preterm delivery: cervical length screening to identify patients at risk for preterm delivery is reasonable in order to optimize outcomes with steroids and magnesium sulfate if preterm delivery is imminent.
Preeclampsia: blood pressure should be taken at each visit and patients counseled on signs and symptoms of preeclampsia.
Gestational diabetes: all patients should be screened for gestational diabetes and early screen should be considered in patients with risk factors.
Twin to twin transfusion syndrome: this complication is unique to monochorionic twins. Screening for this is with ultrasound that is performed every 2 weeks starting at 16 weeks in monochorionic gestations.
Growth discordance/restriction: all twin gestations should be followed with serial growth ultrasounds to detect differences in weight or selective growth restriction.
Clinical Pearls
Chorionicity is best established in the first or early second trimester.
Twin gestations are at an increased risk for spontaneous abortion, genetic abnormalities, growth restriction, preeclampsia, gestational diabetes, and cesarean delivery and patients should be counseled accordingly.
Multifetal pregnancy reduction has been shown to improve outcomes and may be offered to patients with multiple gestation.
Prognosis
Bottom Line/Clinical Pearls
Twins are at increased risk for preterm delivery and the neonatal complications that accompany it. Twin gestations delivery earlier on average, even with treatment of preterm labor.
The following table compares delivery timing and infant morbidity in singleton versus twin gestation.
Outcomes in singleton versus twin gestations
Singletons
Twins
Mean gestational age at delivery
38.7 weeks
35.3 weeks
Mean birth weight
3296 g
2336 g
Percentage who deliver <32 weeks
1.6
11.4
Percentage who deliver <37 weeks
10.4
58.8
Rate of cerebral palsy (per 1000 live births)
1.6
7
Reading list
American College of Obstetricians and Gynecologists. Multifetal gestations: twin, triplet and higher-order multifetal pregnancies. Practice bulletin no. 169.
Obstet Gynecol
2016;e131-46.
Society for Maternal Fetal Medicine Publications Committee. Prenatal aneuploidy screening using cell-free DNA. Consult series no. 36.
Am J Obstet Gynecol
2015;212:711-6.
Stone J, Ferrara L, Kamrath J, et al. Contemporary outcomes with the latest 1000 cases of multifetal pregnancy reduction (MPR).
Am J Obstet Gynecol
2008 Oct;199(4):408.e1-4. doi: 10.1016/j.ajog.2008.05.020
Suggested websites
American College of Obstetricians and Gynecologists.
www.acog.org
Society for Maternal-Fetal Medicine.
www.smfm.org
Guidelines
National society guidelines
Title
Source
Date/full reference
Multifetal gestations: twin, triplet, and higher-order multifetal pregnancies
American College of Obstetricians and Gynecologists
American College of Obstetricians and Gynecologists. Multifetal gestations: twin, triplet and higher-order multifetal pregnancies. Practice bulletin no. 169.
Obstet Gynecol
2016;e131-46.
Images
Figure 1.1 “Twin peak” or Lambda sign characteristic of a dichorionic diamniotic gestation. This sonographic sign is used to help establish chorionicity. Another sonographic feature of a dichorionic diamniotic gestation is two placentas. If the fetal sex is discordant, the pregnancy is dichorionic.
Figure 1.2 “T sign” characteristic of monochorionic diamniotic gestation. This sonographic feature is 100% sensitive and >98% specific for the diagnosis of monochorionic gestation.
Additional material for this chapter can be found online at: www.wiley.com/go/sperling/mountsinai/obstetricsandgynecology
This includes multiple choice questions, advice for patients, and ICD codes.
CHAPTER 2Preeclampsia/Eclampsia
Patricia Rekawek1 and Brian Wagner2
1Maternal-Fetal Medicine, New York University Long Island School of Medicine, NYU Winthrop Hospital, Mineola, NY
2Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY
Overall Bottom Line
Preeclampsia is a disorder characterized by the development of hypertension and either proteinuria or end-organ dysfunction after 20 weeks gestation in a previously normotensive woman.
Preeclampsia should be differentiated from other hypertensive disorders of pregnancy including chronic hypertension, gestational hypertension, preeclampsia superimposed on chronic hypertension, hemolysis elevated liver enzymes and low platelets (HELLP) syndrome, and eclampsia.
Women with preeclampsia are at increased risk of the development of end-organ damage including placental abruption, kidney injury, hepatic failure, pulmonary edema, cardiac failure, stroke, and eclampsia. Additionally, these women are at increased risk for future cardiovascular disease.
Pregnancy complications may include fetal growth restriction, preterm delivery, and stillbirth.
Delivery remains the treatment for preeclampsia.
Background
Definition of disease
Preeclampsia is a progressive disease defined as the new onset of hypertension and either proteinuria or other signs of end-organ dysfunction after 20 weeks gestation in a previously normotensive patient.
Hypertension is defined as systolic blood pressure (BP) ≥140 mm Hg or diastolic BP ≥ 90 mm Hg on two occasions at least 4 hours apart and proteinuria is defined as ≥ 0.3 g in a 24-hour urine collection or a ratio of urine protein to creatinine of > 0.3 mg/dL.
Disease classification
Some clinical findings increase the risk of morbidity and mortality and these indicate a severe form of preeclampsia, known as preeclampsia with severe features.
These findings include severe range blood pressure, defined as systolic BP ≥ 160 mm Hg or diastolic BP ≥ 110 mm Hg on two occasions at least 4 hours apart and/or thrombocytopenia, impaired liver function, renal insufficiency, pulmonary edema, and cerebral or visual disturbances (see disease severity classification).
Incidence/prevalence
Worldwide, 4.6% of pregnancies are complicated by preeclampsia.
The prevalence of preeclampsia in the United States is approximately 3.4%; however, this varies by gestational age.
Variances in prevalence are likely due to differences in maternal age and percentage of nulliparous pregnant women among worldwide populations.
Etiology
A clear cause for preeclampsia has yet to be elucidated.
It is thought that preeclampsia may be due to placental and maternal vascular dysfunction. Although incompletely understood, it is thought that impaired remodeling of uterine spiral arteries leads to reduced placental perfusion.
This leads to increased inflammation, increased production of antiangiogenic factors, and resultant maternal endothelial cell damage that manifest in the signs and symptoms of preeclampsia.
Pathology/pathogenesis
The pathophysiology of preeclampsia involves abnormal placental development. Spiral arteries abnormally invade the myometrium, which creates hypoxic trophoblast tissue, thereby resulting in a state of placental oxidative stress.
Placental villous angiogenesis is thereby altered resulting in increased secretion of placental antiangiogenic factors such as soluble fms-like tyrosine kinase (sFlt-1) and endoglin.
This further leads to widespread maternal vascular dysfunction, which leads to end-organ damage and manifests clinically as hypertension, proteinuria, or signs of renal/liver/cerebral damage.
Predictive/risk factors
Risk factor
Relative risk
History of preeclampsia
7.19
Antiphospholipid antibodies
9.72
Pregestational diabetes
3.56
Nulliparity
2.91
Family history of preeclampsia
2.90
Prevention
Bottom Line/Clinical Pearls
Low-dose aspirin (81 mg) has been shown to be the only effective pharmacologic agent that reduces the risk of preeclampsia.
Recent studies have shown that the effect of aspirin on preventing preeclampsia in high-risk pregnancies is greatest when initiated at less than 16 weeks gestation and that the optimal dose is 100–150 mg.
Anticoagulation does not prevent recurrence.
Screening
Women at high risk for preeclampsia include the following:
Previous pregnancy with preeclampsia; most significantly with early onset and with adverse outcome
Multifetal gestation
Chronic hypertension
Type 1 or type 2 diabetes mellitus
Chronic kidney disease
Autoimmune disorders such as antiphospholipid syndrome or systemic lupus erythematous
Primary prevention
Low-dose aspirin (81 mg) during pregnancy has been shown to modestly reduce the risk of preeclampsia and adverse pregnancy outcomes in high-risk women.
These include multifetal gestation, type 1 or 2 diabetes, chronic hypertension, autoimmune disease, and chronic kidney disease.
Recent data suggest that doses up to 150 mg of aspirin may be more effective at reducing risk of recurrent preeclampsia.
Obese women who lose weight prior to becoming pregnant may reduce their risk of developing preeclampsia.
Secondary prevention
Low-dose aspirin (81 mg) during pregnancy has been shown to modestly reduce the risk of recurrent preeclampsia and adverse pregnancy outcomes especially in patients with early onset and severe disease.
Weight loss in obese women between pregnancies may reduce the risk of recurrent disease.
Diagnosis
Bottom Line/Clinical Pearls
Clinical symptoms of preeclampsia include persistent and/or severe headache, visual abnormalities, upper abdominal or epigastric pain, altered mental status, and dyspnea or retrosternal chest pain.
Exam findings may include generalized hyperreflexia, peripheral edema, pulmonary edema, or oliguria (urine output < 500 mL/24 hours).
Laboratory findings include proteinuria, elevated creatinine level, thrombocytopenia, elevated transaminase levels, hemolysis, and/or hemoconcentration.
Differential diagnosis
Differential diagnosis (see
Algorithms 2.1
and
2.2
)
Features
Chronic hypertension
Defined as systolic blood pressure ≥ 140 mm Hg and/or diastolic ≥ 90 mm Hg, present before 20 weeks gestation and persists longer than 12 weeks postpartum
Chronic hypertension with superimposed preeclampsia
New onset of either proteinuria or end organ dysfunction after 20 weeks in women with chronic hypertension
Gestational hypertension
Hypertension developing after 20 weeks gestation in a previously normotensive woman with no proteinuria and no signs of end-organ damage
HELLP syndrome
Defined as hemolysis, elevated liver enzymes, and low platelets. This is characterized as a more severe form of preeclampsia, although it can be diagnosed without hypertension or proteinuria.
Eclampsia
Grand mal seizures in a woman with preeclampsia
Preeclampsia
Systolic blood pressure ≥ 140 mm Hg or diastolic blood pressure ≥ 90 mm Hg on two occasions at least four hours apart after 20 weeks gestation in a previously normotensive patient.
If systolic BP ≥ 160 mm Hg or diastolic blood pressure is ≥ 110 mm Hg, confirmation within minutes is sufficient.
AND
Proteinuria
≥0.3 g in a 24-hour urine specimen or
Urine protein to creatinine ratio ≥ 0.3 mg/Dl
Urine dip ≥ 1+, if quantitative measurements are unavailable
OR
New-onset hypertension with the onset of any of the following (with or without proteinuria)
Serum transaminase concentration ≥ 2 times upper limit of normal range
Thrombocytopenia defined as platelets < 100°000/microL
Serum creatinine > 1.1 mg/dL or doubling of serum creatinine concentration
Liver transaminase levels at least twice the upper limit of normal
Pulmonary edema
Cerebral or visual symptoms
Data from American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013;122:1122.
Algorithm 2.1 Diagnostic algorithm for preeclampsia
Preeclampsia with severe features (based on the presence of one or more of the following)
Severe blood pressure elevation
Systolic blood pressure ≥ 160 mm Hg and/or diastolic blood pressure ≥ 110 mm Hg on two occasions at least 4 hours apart while patient is on bedrest.
Symptoms of central nervous system dysfunction
New-onset cerebral or visual disturbance, such as:
Photopsia, scotomata, cortical blindness, retinal vasospasm
Severe headache or headache that persists and progresses despite analgesia
Altered mental status
Hepatic abnormality
Severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by an alternative diagnosis; or
Serum transaminase concentration ≥ 2 times upper limit of normal range
Thrombocytopenia
<100°000 platelets/microL
Renal abnormality
Progressive renal insufficiency such as serum creatinine > 1.1 mg/dL; or
Doubling of serum creatinine concentration in absence of other renal disease
Pulmonary edema
Adapted from Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstetic Gynecol 2013;122:1122.
Algorithm 2.2 Diagnostic algorithm for preeclampsia with severe features
Typical presentation
The typical presentation of preeclampsia is of a nulliparous patient with new-onset hypertension and proteinuria ≥ 34 weeks gestation. The degree of maternal hypertension and proteinuria or additional signs of end-organ damage can be quite variable.
Clinical diagnosis
History
The clinician should inquire about symptoms suggestive of preeclampsia. These clinical symptoms include persistent and/or severe headache not responsive to analgesia, visual abnormalities (blurred vision, scotomata, photophobia, or temporary blindness), upper abdominal or epigastric pain, altered mental status, or dyspnea or retrosternal chest pain.
Physical examination
Physical examination findings include tenderness to palpation of epigastrium, generalized hyperreflexia, peripheral edema, pulmonary edema, oliguria, or gross neurologic deficits to suggest stroke.
Disease severity classification
The disease is classified as preeclampsia with severe features if the following occur:
Mild range blood pressures with signs/symptoms of end-organ injury (+/-proteinuria):
Thrombocytopenia (<100°000 platelets/microL)
Impaired liver function (serum transaminase concentration ≥ 2 times upper limit of normal)
Progressive renal insufficiency (serum creatinine > 1.1 mg/dL or doubling of serum creatinine in absence of other renal disease)
Pulmonary edema
New-onset neurologic or visual disturbances
Severe persistent right upper quadrant or epigastric pain unresponsive to medication
Severe hypertension defined as systolic BP ≥ 160 mm Hg and/or diastolic BP ≥ 110 mg Hg with proteinuria and/or signs of end-organ injury as noted previously.
Laboratory diagnosis
List of diagnostic tests
Proteinuria
Persistent ≥ 1+ (30 mg/dL) on paper test strip
Confirmed by random urine ratio of protein to creatinine ≥ 0.3 mg/dL
Diagnostic test is ≥ 0.3 g protein in a 24-hour urine collection
Elevated creatinine
Creatinine level > 1.1 mg/dL or doubling from baseline
Thrombocytopenia
Platelet count < 100°000/microL
Elevated transaminase levels
Twice the upper limit of normal
Hemolysis
Schistocytes and helmet cells on peripheral blood smear
Hemoconcentration
List of imaging techniques
Fetal ultrasound is used to assess for adequate growth as preeclampsia can result in reduced uteroplacental perfusion and subsequent fetal growth restriction.
Testing of fetal well-being can be performed including a biophysical profile.
Umbilical artery Doppler is used to measure the impedance of flow in the umbilical arteries that results from abnormalities in uteroplacental development. This can be used to guide management particularly in fetuses with growth restriction. Absent and reversed end-diastolic flow is associated with a poor perinatal prognosis.
Maternal echocardiography can be used to assess for changes in cardiac function and morphology as the disease progresses in severity.
Maternal right upper quadrant (RUQ) sonography can be used to assess liver capsule if hematoma is suspected.
Potential pitfalls/common errors made regarding diagnosis of disease
Delay in diagnosis can result in significant maternal and/or fetal morbidity and mortality.
Atypical presentations should be considered. This includes those with severe features of preeclampsia without hypertension, which can occur in up to 15% of patients with HELLP syndrome and in some with eclampsia.
Treatment
Treatment rationale
Definitive treatment of preeclampsia is delivery. This prevents progression of disease and resultant maternal and/or fetal morbidity and mortality.
All women diagnosed with preeclampsia at ≥ 37 weeks should undergo delivery.
All women diagnosed with preeclampsia with severe features at ≥ 34 weeks should undergo delivery.
In a tertiary care setting, expectant antepartum management is an option for women diagnosed with preeclampsia before these gestational ages.
Antihypertensive therapy is indicated for treatment of severe hypertension to prevent maternal cerebrovascular complications (see table of treatment).
Antenatal glucocorticoids, to promote fetal lung maturity, are recommended for women with a diagnosis of preeclampsia < 34 weeks.
Magnesium sulfate is recommended intrapartum and postpartum for seizure prophylaxis for women with preeclampsia with severe features.
See also
Algorithm 2.3
.
When to hospitalize
Hospitalization is indicated for women with the diagnosis of preeclampsia with severe features who are being expectantly managed and remote from term (<34 weeks gestational age).
Managing the hospitalized patient
The hospitalized patient is managed by serial blood pressure assessment, serial laboratory assessment, and monitoring for features of severe disease.
Fetal well-being should be assessed with a combination of tests (nonstress test, biophysical profile, umbilical artery Doppler, fetal growth) as dictated by the clinical picture.
Table of treatment
Treatment
Side effects
Medical
Acute management of severe hypertension
Labetalol IV 10–20 mg over 2 minutes; 20–80 mg every 20 to 30 minutes to maximum 300 mg
Avoid in asthma, heart disease, or congestive heart failure
May cause neonatal bradycardia
Hydralazine IV 5 mg over 1 to 2 minutes; 5–10 mg every 20 to 40 minutes
Associated with increase in maternal hypotension
Nifedipine orally 10 mg; repeat in 30 minutes
Causes reflex tachycardia and overshoot hypotension
Concern for neuromuscular blockade and severe hypotension when combined with magnesium sulfate
Longer-term blood pressure control
Labetalol 100 mg orally bid; increase by 100 mg twice-daily as needed; maximum dose 2400 mg daily
Nifedipine extended release 30 to 60 mg orally qd; maximum dose 120 mg daily
Methyldopa 250 mg orally bid to tid; maximum dose 3000 mg daily
Hydralazine 10 mg orally qid; 200 mg maximum dose
Seizure prophylaxis
Magnesium sulfate 4 g IV loading dose followed by 2 g IV per hour
Contraindicated in myasthenia gravis
Side effects include diaphoresis, flushing, warmth, nausea/vomiting
Delivery
Preeclampsia without severe features
Delivery indicated at 37 weeks
Preeclampsia with severe features
Delivery indicated at 34 weeks or earlier in the case of worsening progression of disease (consultation with maternal-fetal medicine specialist recommended)
Prevention/management of complications
Magnesium toxicity:
This is uncommon in women with adequate renal function. Toxicity correlates with level of serum magnesium concentration:
Loss of deep tendon reflexes occurs at 7 to 10 mEq/L
Respiratory paralysis at 10 to 13 mEq/L
Cardiac conduction is altered at > 15 mEq/L
Cardiac arrest occurs at > 25 mEq/L
Calcium gluconate is administered as an antidote to severe cardiac toxicity related to hypermagnesemia
Diagnosis of preeclampsia
What is the gestational age?
<24 weeks – consider termination of pregnancy
≥37 weeks – recommend delivery; antihypertensive therapy and magnesium sulfate for seizure prophylaxis as needed for severe features
24–37 weeks
Is there evidence of severe disease or contraindications to expectant management?
No – outpatient expectant management; twice-weekly office visits to assess maternal and fetal status
Yes –
Admit
Admit for preeclampsia with severe features?
Is the maternal and fetal status stable? Are there contraindications to expectant management?
No – delivery
Yes – daily assessment of maternal and fetal status; antenatal corticosteroids; magnesium sulfate during initial assessment
Worsening of maternal and/or fetal status?
Yes – delivery; recommend magnesium sulfate for seizure prophylaxis; antihypertensives as needed
No – continue expectant management; plan for delivery at 34 weeks
Algorithm 2.3 Management and treatment of preeclampsia
Clinical Pearls
Delivery remains the definitive treatment of preeclampsia. This depends on the severity of preeclampsia, maternal/fetal condition, and gestational age at diagnosis. Delivery is recommended at ≥ 37 weeks. Close outpatient expectant management can be performed if diagnosed at earlier gestational ages.
Delivery is recommended in preeclampsia with severe features at ≥ 34 weeks. Expectant management is an option for women diagnosed at earlier gestational ages. This requires hospitalization and close assessment of maternal and fetal status to monitor for worsening disease that would necessitate delivery.
To prevent maternal cerebrovascular complications, antihypertensive therapy is indicated for treatment of severe hypertension.
To prevent seizures/eclampsia, magnesium sulfate is recommended for seizure prophylaxis intrapartum and postpartum in women with severe features.
Prognosis
Bottom Line/Clinical Pearls
There is an associated increased risk of preeclampsia in subsequent pregnancies.
The American Heart Association regards a history of preeclampsia or pregnancy-induced hypertension as a major risk for development of cardiovascular disease in the future.
