Queenan's Management of High-Risk Pregnancy E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Queenan's Management of High-Risk Pregnancy The new edition of the long-standing classic text, covering all areas of perinatal medicine Continuing to set the standard for maternal-fetal practice, the seventh edition of Queenan's Management of High-Risk Pregnancy provides practical, clinically useful information on the full spectrum of perinatal care. Focused on clinical decision-making, this invaluable reference contains authoritative, evidence-based information on the factors of high-risk pregnancy, biochemical and biophysical monitoring, maternal disease, obstetric complications, patient safety in labor and delivery, and more. With more than 50 concise chapters, this text has been written by leading experts, and contains evidence-based protocols, algorithms, case studies, potential outcome measures, medications, and illustrative case reports to ensure the best possible outcomes for fetal and maternal patients. This text offers clear guidance on the common problems encountered in the day-to-day management of high-risk pregnancies. The seventh edition of Queenan's Management of High-Risk Pregnancy includes new and updated chapters with the most current evidence-based information and protocols available on topics such as infectious diseases in pregnancy, vaping, operative vaginal delivery, postpartum hemorrhage, pregnancies in women with disabilities, maternal anemia, malaria, and HIV infection. Queenan's Management of High-Risk Pregnancy: An Evidence-Based Approach, Seventh Edition, remains an indispensable reference and guide for obstetricians, gynecologists, OB/GYN trainees, midwives, and primary and general practitioners.
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Seitenzahl: 1779
Veröffentlichungsjahr: 2023
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
List of Contributors
Foreword
Preface
Acknowledgments
Chapter 1: Overview of High‐Risk Pregnancy
Chapter 2: Nutrition in Pregnancy
Fetal growth
Body mass index, weight gain, and adverse pregnancy outcomes
Obesity
Nutrition assessment and counseling
Food security
Energy intake during pregnancy
Healthy dietary pattern in pregnancy
Multivitamins
Micronutrients in pregnancy
Vitamin toxicity
Caffeine consumption in pregnancy
Seafood consumption in pregnancy
Multifetal pregnancy
Nutrition during lactation
Conclusion
References
Chapter 3: Alcohol and Substance Use Disorder
Introduction
Screening and testing for substance use disorder
Alcohol
Opioids
Cannabis
Stimulants
Vaping (E‐cigarettes)
Benzodiazepines
References
Chapter 4: Environmental Agents and Reproductive Risk
Background incidence of adverse outcome
Biologic evidence of toxicity
General principles
Specific agents
References
Chapter 5: Genetic Screening for Mendelian Disorders
Family history
Mendelian inheritance
Carrier screening
Hemoglobinopathies
Cystic fibrosis
Spinal muscular atrophy
Fragile X syndrome
Jewish genetic diseases
Prenatal diagnosis
Newborn screening
References
Chapter 6: Screening for Congenital Heart Disease
Introduction
Screening low‐risk populations
Benefits of cardiac screening
High‐risk populations for fetal echocardiography
Normal fetal heart anatomy
Technique
Color Doppler imaging
Expectations from cardiac screening
Conclusion
References
Chapter 7: First‐ and Second‐Trimester Screening for Fetal Aneuploidy and Neural Tube Defects
First‐trimester sonographic screening
Combined first‐trimester serum and sonographic screening
First‐trimester cystic hygroma
Second‐trimester sonographic screening
Second‐trimester serum screening
Combined first‐ and second‐trimester screening
Screening in multiple gestations
Screening for neural tube defects
Cell‐free fetal DNA (cffDNA) screening for fetal aneuploidy
References
Chapter 8: Sonographic Dating and Standard Fetal Biometry
Pregnancy dating
First trimester
Second and third trimesters
Estimation of fetal weight
Macrosomia
Fetal growth restriction
References
Chapter 9: Antepartum Fetal Monitoring
Nonstress test
Biophysical profile
Modified biophysical profile (NST/amniotic fluid volume)
Doppler velocimetry
References
Chapter 10: Interpreting Intrapartum Fetal Heart Tracings
Components of EFM documentation
Interpretation of EFM
Management of FHR abnormalities in labor
Future directions
References
Chapter 11: Sickle Cell Anemia
Hemoglobin SCD
Hemoglobin S/β‐thalassemia disease
Management during pregnancy
Fetal assessment
Labor and delivery
Genetic evaluation
References
Chapter 12: Anemia
Consequences
Causes of anemia in pregnancy
Diagnostic workup and treatment
Macrocytic anemia
Normocytic anemia
Microcytic anemia
Iron supplementation in pregnancy
Treatment of iron deficiency anemia
References
Chapter 13: Thrombocytopenia
Maternal thrombocytopenia
Fetal thrombocytopenia
References
Chapter 14: Inherited and Acquired Thrombophilias
Overview of hemostasis changes during pregnancy
Inherited thrombophilias
Factor V Leiden
Prothrombin gene mutation (G2021A)
Protein C deficiency
Protein S deficiency
Antithrombin deficiency
Acquired thrombophilia
Management considerations in patients with inherited or acquired thrombophilia
Summary
References
Chapter 15: Thromboembolic Disorders
Physiology of hemostasis
Pathophysiology of and risk factors for thrombosis in pregnancy
Diagnosis of venous thromboembolism
Conclusion
References
Chapter 16: Cardiac Disease in Pregnancy
Risk assessment and risk‐appropriate care
Antenatal care and optimization
Multidisciplinary delivery planning
Postpartum and interconception care
Conclusion
References
Chapter 17: Renal Disease
Physiological changes in renal function during pregnancy
Anatomic changes in the urinary tract during pregnancy
Renal disease in pregnancy
Renal dialysis
Renal transplantation
Management of pregnancies complicated by renal disease
Conclusion
References
Chapter 18: Pregnancy in Transplant Patients
Prepregnancy assessment and counseling
Antepartum care
Review of common agents for maintenance immunosuppression
Kidney transplant
Other organ transplant patients
Intrapartum management
Obstetric emergencies
The baby
References
Chapter 19: Gestational Diabetes Mellitus
Risk factors for gestational diabetes
Therapeutic modalities in gestational diabetes
Antenatal testing
Delivery: when and how to deliver
Postpartum considerations
References
Chapter 20: Diabetes Mellitus
Initial evaluation
Regulating maternal glycemia
Management during pregnancy
Management of insulin during labor
References
Chapter 21: Thyroid Disorders
Diagnosis
Hypothyroidism
Hyperthyroidism
Thyroid storm management [3,4,10]
References
Chapter 22: Asthma
Definition of asthma
Effect of pregnancy on the course of asthma
Effect of asthma on pregnancy
Diagnosis of asthma during pregnancy
Management
Assessment and monitoring
Control of factors contributing to severity
Patient education
Pharmacologic therapy
Chronic asthma
Acute asthma
Management during labor and delivery
Conclusion
References
Chapter 23: Epilepsy
Contraception
Fertility
Preconception counseling
Folic acid
Seizures during pregnancy
ASM risks: Structural and neurodevelopmental teratogenicity
Management during pregnancy
Peripartum care
Postpartum care
Summary
References
Chapter 24: Chronic Hypertension
Definition
Diagnosis
Preconceptional counseling
Morbidity and mortality
Diagnosis and evaluation in pregnancy
Treatment during pregnancy
Antepartum fetal assessment
Delivery
Postpartum care
References
Chapter 25: Systemic Lupus Erythematosus
Epidemiology
Etiology
Pathogenesis
Differential diagnosis
Morbidity
Management during pregnancy
Antiphospholipid antibodies
References
Chapter 26: Perinatal Infections
Parvovirus B
19
Rubella
Syphilis
Toxoplasmosis
Herpes simplex infection
Cytomegalovirus
Varicella zoster virus
Group B
Streptococcus
References
Chapter 27: Malaria
Clinical features
Diagnosis
Treatment
Complications
Prevention
References
Chapter 28: Hepatitis in Pregnancy
Hepatitis A
Hepatitis E
Hepatitis B
Hepatitis D
Hepatitis C
Hepatitis G
References
Chapter 29: HIV Infection
Identifying infected patients
Posttest counseling of pregnant patients with HIV
Laboratory assessment of the pregnant patient with HIV
Recommended immunizations for pregnant patients with HIV
Antiretroviral treatment in pregnancy
Labor and delivery care for pregnant patients living with HIV
Postpartum care for pregnant patients living with HIV
Ethical and legal considerations
Conclusion
References
Chapter 30: Pregnancy in Women with Disabilities
General considerations
Psychosocial risk factors
Pregnancy outcomes
Intellectual and developmental disabilities
Sensory disabilities
Breastfeeding
Conclusion
References
Chapter 31: COVID‐19 in Pregnancy
Pathophysiology of COVID in pregnancy
Epidemiology
Screening and Prevention
Vaccination
Clinical course
Vertical transmission
Clinical management
Treatment
Postpartum care and newborns
References
Chapter 32: Recurrent Pregnancy Loss
Factors contributing to recurrent pregnancy loss
Immunologic factors
Hematologic factors
Inherited thrombophilias
Evidence‐based evaluation of couples experiencing recurrent pregnancy loss
References
Further reading
Chapter 33: Cervical Insufficiency
Syndrome of spontaneous preterm birth
How can we make the clinical diagnosis of cervical insufficiency, and how effective is cerclage for a history indication?
Should insufficiency be a sonographic diagnosis?
Can ultrasound replace the history indication?
What is acute cervical insufficiency and how effective is a physical exam‐indicated cerclage?
Can acute cervical insufficiency be predicted and managed?
When should cerclage be placed in a twin gestation?
How should women with a prior failed vaginal cerclage be managed?
Do cervical procedures cause insufficiency?
What surgical techniques are used for history or ultrasound‐indicated vaginal cerclage?
Should postcerclage activity restrictions be recommended?
When should a cerclage be removed?
Cerclage complications
Adjunctive management strategies for cervical insufficiency
Conclusion
References
Chapter 34: Gestational Hypertension, Preeclampsia, and Eclampsia
Pathophysiology
Diagnosis
Management
Postpartum management
Follow up and maternal counseling
References
Chapter 35: Postpartum Hemorrhage
Hematologic parameters
Defining excessive blood loss
Prevention
Risk factors and etiologies
Treatment
Complications
Conclusion
References
Chapter 36: Emergency Care
Timely and dynamic assessment of trauma
Cardiac arrest in pregnancy
Stabilization and resuscitation
Optimizing resource use in emergency care
Suggested readings
Chapter 37: Rh and Other Blood Group Alloimmunizations
Prophylaxis
Methods of surveillance
Overall clinical management
Outcome
References
Chapter 38: Multiple Gestations
Impact on perinatal outcomes
Zygosity and chorionicity
Fetal complications and multiple gestations
Complications unique to monochorionicity
Maternal obstetric complications
Antepartum management of multiple gestations
Intrapartum period
Conclusion
References
Chapter 39: Polyhydramnios and Oligohydramnios
Normal amniotic fluid composition and volume
Dynamics of amniotic fluid turnover
Fetal urine
Fetal lung fluid
Fetal swallowing
Intramembranous flow
Amniotic fluid turnover
Clinical measurement of amniotic fluid
Polyhydramnios
Oligohydramnios
Conclusion
References
Chapter 40: Pathogenesis and Prediction of Preterm Delivery
Etiology and pathogenesis of spontaneous preterm delivery
Idiopathic and stress‐associated premature activation of the maternal‐placental–fetal hypothalamic–pituitary–adrenal axis
Decidual‐amnion‐chorion inflammation
Abruption‐associated preterm delivery
Mechanical stretching of the uterus
Final common pathway of preterm delivery
Prediction of preterm delivery: interpretation of test results
Pathway‐specific markers
Biomarkers of decidual hemorrhage and dysregulation in coagulation pathways
References
Chapter 41: Preterm (Prelabor) Premature Rupture of Membranes
Mechanisms
Prediction and prevention
Diagnosis
Clinical course
Evaluation
Management
Preterm premature rupture of membranes at 32 to 36 weeks of gestation
Premature rupture of membranes before 32 weeks of gestation
Previable premature rupture of membranes before the limit of viability
Special circumstances
References
Chapter 42: Management of Preterm Labor
Evaluation: history, physical exam, and screening tests
Initial assessment
Management
Nontocolytic interventions
Tocolysis
Mode of delivery
References
Chapter 43: Placenta Previa and Related Disorders
Placenta previa
Vasa previa
Placenta accreta spectrum
Conclusion
References
Chapter 44: Fetal Growth Restriction
Definition of fetal growth restriction
Epidemiology
Perinatal morbidity and mortality
Etiologies
Diagnosis
Management of FGR
Antenatal surveillance
Timing of delivery in FGR
References
Chapter 45: Induction of Labor
Indications and contraindications to labor induction
Medically indicated delivery timing
Elective induction of labor
Predicting a successful induction
Defining failed induction
Preinduction considerations
Cervical ripening
Risks associated with labor induction
Additional considerations
Conclusion
References
Chapter 46: Cesarean Delivery
Maternal and perinatal morbidity and mortality
Evidence‐based operative considerations
Preoperative considerations
Intraoperative considerations
Postoperative considerations
Potential risks of repeat cesarean delivery
Current indications for cesarean delivery
Repeat cesarean
References
Chapter 47: Vaginal Birth after Cesarean Delivery
Trends in vaginal birth after cesarean‐trial of labor
Candidates for trial of labor
Factors affecting the success rates for trial of labor
Risks of vaginal birth after cesarean‐trial of labor
Management of vaginal birth after cesarean‐trial of labor
Counseling for vaginal birth after cesarean‐trial of labor
References
Chapter 48: Breech Delivery
Types of breech
Diagnosis
Prevention
Complications of vaginal breech delivery
Approach to management
External cephalic version at or near term
Planned mode of delivery
Delivery planning
Vaginal breech delivery
Cesarean breech delivery
Complications to anticipate
Twin pregnancy with leading breech presentation
Noncephalic second twin
Internal podalic version and total breech extraction for cephalic second twins
Preterm breech birth
Training
Conclusion
Acknowledgments
References
Chapter 49: Operative Vaginal Delivery
Prerequisites and indications
Classification
Instrument selection
Site of delivery
Technique
Outcomes
Training
Conclusion
References
Chapter 50: Obstetric Analgesia and Anesthesia
Labor and vaginal delivery
Cesarean delivery
Compromised coagulation and neuraxial regional analgesia and anesthesia
References
Chapter 51: Quality and Patient Safety
Patient safety in obstetrics
How to measure safety
Tools to improve patient safety
Evidence to support improvement tools
Beyond safety and quality
References
Chapter 52: Genetic Amniocentesis, Chorionic Villus Sampling, Intrauterine Transfusion, and Shunts
Prenatal diagnosis
Chorionic villus sampling
Amniocentesis
Diagnostic studies
Intrauterine Transfusion
Fetal shunts
References
Chapter 53: Fetal Surgery
Different fetal techniques
Specific diseases
Fetal molecular therapies
Conclusion
References
Index
Supplemental Images
End User License Agreement
List of Tables
Chapter 2
Table 2.1
Sources of
weight gain in pregnancy
Table 2.2 Factors associated with fetal growth
Table 2.3 Obstetric history and birthweight
Table 2.4 Recommended total weight gain during pregnancy
Table 2.5 The prevalence of adverse pregnancy outcomes associated with meeti...
Chapter 3
Table 3.1 Specific substances and their associations with fetal, neonatal, a...
Table 3.2 Examples of patient presentation associated with underlying alcoho...
Table 3.3 Potential phenotype of fetal alcohol syndrome
Chapter 4
Table 4.1 Reproductive toxicology sources
Chapter 5
Table 5.1 Mendelian disorders frequent among individuals of Ashkenazi Jewish...
Chapter 6
Table 6.1 Detection of major congenital heart disease
Chapter 7
Table 7.1 Likelihood ratios for Down syndrome when an isolated minor sonogra...
Chapter 9
Table 9.1 Orders for fetal diagnostic testing
Chapter 11
Table 11.1 Pregnancy outcomes in women with and without sickle cell disease ...
Table 11.2 Pregnancy morbidity with hemoglobin SS and SC disease
Chapter 12
Table 12.1 Changes in laboratory hematologic indices in pregnancy
Table 12.2 Electrophoresis results consistent with beta thalassemia or hemog...
Table 12.3 Oral preparations for therapy of iron deficiency anemia
Table 12.4 Intravenous preparations for therapy of iron deficiency anemia...
Chapter 14
Table 14.1 Inherited thrombophilia, personal history of VTE and pregnancy VT...
Table 14.2 Inherited thrombophilia and pregnancy complications (odds ratio [...
Table 14.3 Anticoagulation considerations in pregnancy: indications, dosing,...
Chapter 15
Table 15.1 Fetal radiation exposure of various ionizing modalities
Chapter 16
Table 16.1 Framework for risk‐appropriate care according to cardiovascular r...
Chapter 17
Table 17.1 Classification of chronic kidney disease
Table 17.2 Classification of chronic kidney disease
Table 17.3 Pregnancy‐related outcomes by chronic kidney disease stage
Chapter 18
Table 18.1 Common transplant maintenance immunosuppressive medications
Table 18.2 Transplant Pregnancy Registry International: Newborn outcomes acr...
Chapter 19
Table 19.1 Diagnostic thresholds for gestational diabetes
Chapter 20
Table 20.1 Risk of major malformation in fetuses of women with insulin‐depen...
Chapter 21
Table 21.1 Diagnosis of thyroid disorders
Chapter 22
Table 22.1 Stepwise approach for managing asthma during pregnancy in patient...
Table 22.2 Assessment of asthma control in pregnant women
Table 22.3 Safety of commonly used medications for the treatment of asthma d...
Table 22.4 Clinically comparable doses of inhaled corticosteroids
Table 22.5 Steps of asthma therapy during pregnancy
a
Chapter 23
Table 23.1 Interactions between antiseizure medication (ASM) and exogenous s...
Table 23.2 Total antiseizure medication (ASM) serum decreases during pregnan...
Table 23.3 Median percentage of infant‐to‐mother antiseizure medication (ASM...
Chapter 24
Table 24.1 Criteria for diagnosis of hypertension
Table 24.2 Adverse outcomes associated with chronic hypertension
Table 24.3 Commonly used oral antihypertensive medications for chronic hyper...
Table 24.4 Antihypertensive agents for acute blood pressure control in pregn...
Chapter 25
Table 25.1 Systemic lupus erythematosus and pregnancy
Table 25.2 Systemic lupus erythematosus therapeutic agents
Chapter 26
Table 26.1 Oral desensitization protocol for penicillin‐allergic patients...
Chapter 28
Table 28.1 Viral hepatitis in pregnancy: summary of key facts
Table 28.2 Nucleos(t)ide analogs recommended for treatment of chronic hepati...
Chapter 29
Table 29.1 Preferred antiretroviral regimens for initiation in ART‐naïve pre...
Chapter 30
Table 30.1 Weighted unadjusted prevalence estimates of disability among US w...
Chapter 32
Table 32.1 Comparison of the elements of RPL by international guidelines
Table 32.2 Management guidelines summary of uterine anomalies for patients w...
Chapter 34
Table 34.1 Drugs used to treat hypertension in pregnancy
Table 34.2 Protocols for treatment of severe hypertension (SBP ≥160 or DP ≥1...
Chapter 35
Table 35.1 Normal reference ranges in pregnant women compared to nonpregnant...
Table 35.2 Selected risk factors for postpartum hemorrhage
Chapter 36
Table 36.1 Primary survey with considerations for the pregnant trauma patien...
Table 36.2 Components of secondary survey with associated diagnostic testing...
Table 36.3 Reversible causes of cardiac arrest with pulseless electrical act...
Table 36.4 Anticipated hemodynamic parameters according to type of shock
Table 36.5 Therapies for resuscitation in hemorrhagic shock
Table 36.6 Vasopressors and inotropes for use in shock
Chapter 37
Table 37.1 Indications for administration of Rhesus immunoglobulin
Table 37.2 Peak systolic middle cerebral artery values
Table 37.3 Red blood cell antibodies associated with hemolytic disease of th...
Chapter 38
Table 38.1 Staging of twin–twin transfusion syndrome
Chapter 39
Table 39.1 Polyhydramnios: associated conditions
Chapter 46
Table 46.1 Incidence of morbidly adherent placenta in the setting of placent...
Chapter 47
Table 47.1 Success rates for trial of labor
Table 47.2 Success rates for trial of labor with two prior cesarean deliveri...
Table 47.3 Risk of uterine rupture with trial of labor
Table 47.4 Comparison of maternal complications in trial of labor vs. electi...
Chapter 52
Table 52.1 Complications of amniocentesis and CVS
List of Illustrations
Chapter 2
Figure 2.1 Fetal weight gain in grams among singleton and twin pregnancies....
Figure 2.2 Perinatal mortality rates by prepregnancy weight and height (Metr...
Figure 2.3 Guide for safe seafood consumption during pregnancy from the US F...
Chapter 6
Figure 6.1 (A) Transverse two‐dimensional ultrasound of the abdomen of a fet...
Figure 6.2 (A) Three‐vessel view demonstrating the left (LPA) and right bran...
Figure 6.3 A simple stepwise approach to the fetal heart can help to standar...
Figure 6.4 A sagittal sweep from right‐to‐left allows assessment of the supe...
Chapter 7
Figure 7.1 Sonographic examination at 12 weeks and 4 days gestation demonstr...
Figure 7.2 Second‐trimester sonographic measurement of the fetal nuchal fold...
Chapter 8
Figure 8.1 Normal Doppler waveforms obtained from the umbilical artery in th...
Figure 8.2 Reversed end‐diastolic velocity is noted in the umbilical circula...
Figure 8.3 Axial view of the fetal head in the second trimester with color D...
Figure 8.4 Doppler velocity waveforms of the ductus venosus in a normal fetu...
Figure 8.5 Doppler velocity waveforms of the inferior vena cava (IVC) in a n...
Chapter 10
Figure 10.1 The patient progressed to 10 cm and had severe variable decelera...
Figure 10.2 Forceps‐assisted vaginal delivery was performed from +3 station....
Chapter 12
Figure 12.1 Causes of maternal anemia, classified by mean corpuscular volume...
Chapter 14
Figure 14.1 Coagulation pathway [2].
Chapter 15
Figure 15.1 An outline of the mechanisms defining the careful balance of thr...
Figure 15.2 Diagnostic algorithm for the diagnosis of deep venous thrombosis...
Figure 15.3 Diagnostic algorithm for the diagnosis of pulmonary embolism in ...
Figure 15.4 Diagnostic algorithm for the diagnosis of pulmonary embolism in ...
Chapter 16
Figure 16.1 Risk‐based approach to antenatal care for cardiac disease in pre...
Chapter 23
Figure 23.1 Degree of structural teratogenicity, from the lowest (on the lef...
Chapter 26
Figure 26.1 Algorithm for evaluation and management of parvovirus B19 infect...
Figure 26.2 Characteristics of CMV infection in pregnancy.CMV, cytomegal...
Chapter 28
Figure 28.1 CDC‐recommended diagnostic algorithm for identifying current HCV...
Chapter 30
Figure 30.1 Risk of experiencing any pregnancy or labor, delivery, or postpa...
Chapter 31
Figure 31.1 Management algorithm for pregnant patients with COVID‐19 illness...
Figure 31.2 Therapeutic management of COVID‐19 in pregnancy. IM, intramuscul...
Chapter 33
Figure 33.1 Short cervix, measured before cerclage (2.06 cm).
Figure 33.2 Short cervix, with suture visible, measured after ultrasound‐ind...
Chapter 34
Figure 34.1 Signs and symptoms of preeclampsia and organ dysfunction. CNS, c...
Figure 34.2 Recommended management of gestational hypertension or preeclamps...
Figure 34.3 Recommended management of preeclampsia with severe features or s...
Chapter 35
Figure 35.1 Parkland Hospital postpartum hemorrhage checklist. Used with per...
Chapter 36
Figure 36.1 Focused assessment with sonography for trauma.
Figure 36.2 High‐yield principles for the management of cardiac arrest in pr...
Figure 36.3 Principles of crisis resource management to optimize outcomes fo...
Chapter 38
Figure 38.1 Lambda or twin peak sign in dichorionic diamniotic pregnancy.
Chapter 39
Figure 39.1 Normal amniotic fluid (AF) volumes are plotted against weeks of ...
Chapter 40
Figure 40.1 Pathogenesis of preterm delivery (PTD). COX‐2, cyclooxygenase 2;...
Figure 40.2 Algorithm for using fetal fibronectin (fFN) and/or cervical ultr...
Chapter 42
Figure 42.1 Preterm labor management algorithm.CL, cervical length; fFN,...
Chapter 43
Figure 43.1 Transvaginal sonogram of a placenta previa (placenta marked “p”)...
Figure 43.2 Transvaginal sonogram of a posterior low‐lying placenta previa (...
Figure 43.3 Grayscale transvaginal sonogram showing circular hypoechoic stru...
Figure 43.4 Color Doppler of vasa previa showing flow through a vessel runni...
Figure 43.5 Sinusoidal fetal heart rate tracing in a patient with a ruptured...
Figure 43.6 Grayscale sonogram of placenta accreta. Note the prominent lacun...
Chapter 44
Figure 44.1 (A) UA Dopplers demonstrating normal results. The UA PI is 0.91,...
Chapter 46
Figure 46.1 Population‐level, cause‐specific proportionate pregnancy‐related...
Chapter 48
Figure 48.1 For the Mauriceau‐Smellie‐Veit method, support the baby’s body a...
Figure 48.2 For the Burns‐Marshall method, grasp the baby’s ankles with the ...
Chapter 49
Figure 49.1a Luikart forceps. The key features of pseudofenestrated blades, ...
Figure 49.1b Simpson forceps. In contrast to the Luikart forceps, these forc...
Figure 49.2 Lines of axis traction at different planes of the pelvis.
Figure 49.3 The Pajot‐Saxtorph maneuver. In the photo downward traction is a...
Chapter 51
Figure 51.1 Yale‐New Haven Hospital quarterly obstetric Adverse Outcome Inde...
Chapter 52
Figure 52.1 Transcervical chorionic villus sampling.
Figure 52.2 Transabdominal chorionic villus sampling (CVS) performed: (A) in...
Figure 52.3 Amniocentesis performed with ultrasound guidance.
Figure 52.4 Technique of amniocentesis in twin gestations, performed under c...
Figure 52.5 This figure illustrates the general principle underlying compara...
Supplemental Images
Plate 6.1 (A) A transverse view through the fetal chest demonstrating an api...
Plate 6.2 (A) Long‐axis view of the left ventricular outflow tract (LVOT). N...
Plate 6.3 (A) Short‐axis view of the right ventricular outflow tract (RVOT) ...
Plate 6.4 (A) Three‐vessel trachea view demonstrating the ductus arteriosus ...
Plate 7.1 Septated cystic hygroma at 11 weeks’ gestation: midsagittal view d...
Plate 7.2 Ductus venosus flow velocity waveform with reversed a‐wave. The Do...
Plate 43.1 Vasa previa shown after cesarean delivery. In this case, the diag...
Plate 43.2 Transvaginal sonogram demonstrating a vasa previa. Pulse wave Dop...
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
List of Contributors
Foreword
Preface
Acknowledgments
Begin Reading
Index
Supplemental Images
WILEY END USER LICENSE AGREEMENT
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Queenan’s Management of High‐Risk Pregnancy
An Evidence‐Based Approach
EDITED BY
CATHERINE Y. SPONG
Professor and ChairDepartment of Obstetrics and GynecologyPaul C. MacDonald Distinguished Chair in Obstetrics and GynecologyUniversity of Texas Southwestern Medical CenterDallas, TX, USAEditor‐in‐Chief Contemporary OB/GYN
CHARLES J. LOCKWOOD
DeanMorsani College of MedicineExecutive Vice PresidentUSF HealthExecutive Vice PresidentTampa General HospitalProfessor of Obstetrics, Gynecology and Public HealthUniversity of South FloridaTampa, FL, USA
SEVENTH EDITION
This edition first published 2024© 2024 John Wiley & Sons Ltd
Edition History[Blackwell Science, Inc., 4e, 1999], [Blackwell Publishing Ltd., 5e, 2007], [John Wiley & Sons Ltd., 6e, 2012]
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List of Contributors
Pouya AbhariDepartment of Obstetrics, Gynecology and Reproductive SciencesUniversity of Miami/Jackson Memorial HospitalMiami, FL, USA
Alfred Abuhamad Department of Obstetrics and GynecologyEastern Virginia Medical SchoolNorfolk, VA, USA
Richard M.K. AdanuSchool of Public HealthUniversity of GhanaGhana College of Physicians and SurgeonsAccra, Ghana
Emily H. AdhikariDepartment of Obstetrics and GynecologyUniversity of Texas Southwestern Medical CenterDallas, TX, USA
Maria AndrikopoulouDepartment of Obstetrics and GynecologyColumbia University Irving Medical CenterColumbia Presbyterian HospitalNew York, NY, USA
Sami BackleyDepartment of Obstetrics, Gynecology and Reproductive SciencesMcGovern Medical SchoolThe University of Texas Health Sciences CenterHouston, TX, USA
Martina L. BadellDepartment of Gynecology and ObstetricsEmory University School of MedicineAtlanta, GA, USA
Michal Fishel Bartal Department of Obstetrics, Gynecology and Reproductive SciencesMcGovern Medical SchoolThe University of Texas Health Science CenterHouston, TX, USADepartment of Obstetrics and GynecologySheba Medical CenterTel HashomerSackler School of MedicineTel Aviv, Israel
Ron BelooseskyDepartment of Obstetrics and GynecologyRuth and Bruce Rappaport Faculty of MedicineTechnionHaifa, Israel
Vincenzo BerghellaDepartment of Obstetrics and GynecologyThomas Jefferson UniversityPhiladelphia, PA, USA
Katherine H. BligardDepartment of Obstetrics and GynecologyWashington University School of Medicine in St. LouisSt. Louis, MO, USA
Angela R. Boyd Department of Obstetrics and GynecologyJoe R. and Teresa Lozano Long School of MedicineSan Antonio, TX, USA
Ann M. BrunoDepartment of Obstetrics and GynecologyUniversity of Utah School of MedicineSalt Lake City, UT, USA
Catalin S. BuhimschiDepartment of Obstetrics and GynecologyUniversity of Illinois College of MedicineChicago, IL, USA
Elizabeth O. BuschurDepartment of Internal MedicineThe Ohio State University College of MedicineColumbus, OH, USA
Alison G. CahillDepartment of Women’s HealthDell Medical SchoolUniversity of Texas at AustinAustin, TX, USA
Serban ConstantinescuTransplant Pregnancy Registry InternationalPhiladelphia, PA, USADepartment of MedicineSection of Nephrology, Hypertension and Kidney TransplantationLewis Katz School of Medicine at Temple UniversityPhiladelphia, PA, USA
Deborah L. ConwayDepartment of Obstetrics and GynecologyJoe R. and Teresa Lozano Long School of MedicineSan Antonio, TX, USA
Lisa A. CosciaTransplant Pregnancy Registry InternationalPhiladelphia, PA, USA
Mary E. D’AltonDepartment of Obstetrics and GynecologyColumbia University Irving Medical CenterColumbia Presbyterian HospitalNew York, NY, USA
Ronan DalyDepartment of Obstetrics and GynaecologyRoyal College of Surgeons in IrelandRotunda HospitalDublin, Ireland
Cara D. DolinDepartment of Obstetrics and GynecologyWomen’s Health InstituteCleveland Clinic Lerner College of MedicineCleveland, OH, USA
Georgios DoulaverisDepartment of Obstetrics & Gynecology and Women's HealthMontefiore Medical CenterAlbert Einstein College of MedicineBronx, NY, USA
Deborah A. DriscollDepartment of Obstetrics and GynecologyPerelman School of Medicine at the University of PennsylvaniaPhiladelphia, PA, USA
Carolynn M. DudeDepartment of Gynecology and ObstetricsEmory University School of MedicineAtlanta, GA, USA
Lorraine DugoffDepartment of Obstetrics and GynecologyPerelman School of Medicine at the University of PennsylvaniaPhiladelphia, PA, USA
Elaine L. DuryeaDepartment of Obstetrics and GynecologyUniversity of Texas Southwestern Medical CenterDallas, TX, USA
Sarah Rae EasterDepartment of Obstetrics and GynecologyDepartment of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalHarvard Medical SchoolBoston, MA, USA
Ann ErickstadDepartment of Obstetrics and GynecologyTexas Tech University Health Sciences CenterLubbock, TX, USA
Kelly S. GibsonDepartment of Reproductive BiologyCase Western Reserve UniversityMetroHealth Medical CenterCleveland, OH, USA
Laura GoetzlDepartment of Obstetrics, Gynecology and Reproductive SciencesMcGovern Medical SchoolThe University of Texas Health Sciences CenterHouston, TX, USA
Gilbert J. GrantDepartment of Anesthesiology, Perioperative Care and Pain MedicineGrossman School of MedicineNew York UniversityNew York, NY, USA
Christina S. HanDepartment of Obstetrics and GynecologyUniversity of California at Los AngelesLos Angeles, CA, USA
Lorie M. HarperDepartment of Women’s HealthDell Medical SchoolUniversity of Texas at AustinAustin, TX, USA
Christina L. HerreraDepartment of Obstetrics and GynecologyUniversity of Texas Southwestern Medical CenterDallas, TX, USA
G.J. HofmeyrDepartment of Obstetrics and GynaecologyUniversity of BotswanaGaborone, BotswanaUniversity of the WitwatersrandJohannesburg, South AfricaWalter Sisulu UniversityEast London, South Africa
Denise J. JamiesonVice President for Medical Affairs and Dean of the Roy J. and Lucille A. Carver College of MedicineUniversity of IowaIowa City, IA, USA
Anthony M. KendleDepartment of Obstetrics and GynecologyMorsani College of MedicineUniversity of South FloridaTampa, FL, USA
Michelle A. KominiarekDepartment of Obstetrics and GynecologyNorthwestern University Feinberg School of MedicineChicago, IL, USA
Mark B. LandonDepartment of Obstetrics and GynecologyOhio State University College of MedicineColumbus, OH, USA
Hanmin LeeDepartment of SurgeryUniversity of California, San FranciscoSan Francisco, CA, USA
Regan J. LemleyDepartment of NeurologyBrigham and Women’s HospitalHarvard Medical SchoolBoston, MA, USA
Fergal D. MaloneDepartment of Obstetrics and GynaecologyRoyal College of Surgeons in IrelandRotunda HospitalDublin, Ireland
Ann McHughDepartment of Obstetrics and GynecologyColumbia University Irving Medical CenterNew York, NY, USA
Brian M. MercerDepartment of Reproductive BiologyCase Western Reserve UniversityThe MetroHealth SystemCleveland, OH, USA
Audrey A. MerriamDepartment of Obstetrics, Gynecology and Reproductive SciencesYale University School of MedicineNew Haven, CT, USA
Russell S. MillerDepartment of Obstetrics and GynecologyColumbia University Irving Medical CenterNew York, NY, USA
Kenneth J. Moise Jr. Department of Women’s HealthDell Medical SchoolUniversity of Texas at AustinThe Comprehensive Fetal Care CenterDell Children’s Medical CenterAustin, TX, USA
Michael J. MoritzTransplant Pregnancy Registry InternationalPhiladelphia, PA, USADeparment of SurgeryLehigh Valley Health NetworkAllentown, PA, USAMorsani College of MedicineUniversity of South FloridaTampa, FL, USA
Andrew MyersDepartment of Internal MedicineUSF Health Morsani College of MedicineTampa, FL, USA
Michael NageotteMiller Children’s and Women’s HospitalLong Beach, CA, USAUniversity of CaliforniaIrvine, CA, USA
Jennifer NamazyDepartment of Allergy and ImmunologyScripps ClinicSan Diego, CA, USA
M.N. NassaliDepartment of Obstetrics and GynaecologyUniversity of BotswanaGaborone, Botswana
David B. NelsonDepartment of Obstetrics and GynecologyUniversity of Texas Southwestern Medical CenterDallas, TX, USA
Anna Hayes NutterDepartment of Obstetrics and GynecologyEastern Virginia Medical SchoolNorfolk, VA, USA
Sarah G. ObicˇanDepartment of Obstetrics and GynecologyUniversity of South FloridaTampa, FL, USA
Anthony O. OdiboDepartment of Obstetrics and GynecologyWashington University School of Medicine in St. LouisSt. Louis, MO, USA
John OwenDepartment of Obstetrics and GynecologyThe University of Alabama at BirminghamBirmingham, AL, USA
Asa OxnerDepartment of Internal MedicineUSF Health Morsani College of MedicineTampa, FL, USA
Yinka OyeleseObstetric ImagingBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, MA, USA
Michael J. PaidasDepartment of Obstetrics, Gynecology and Reproductive SciencesMiller School of MedicineUniversity of MiamiUniversity Health TowerJackson Health SystemMiami, FL, USA
Shivani PatelDepartment of Obstetrics and GynecologyUniversity of Texas Southwestern Medical SchoolDallas, TX, USA
Christian M. PettkerDepartment of Obstetrics, Gynecology and Reproductive SciencesYale University School of MedicineNew Haven, CT, USA
Michael RichleyDepartment of Obstetrics and GynecologyUniversity of California at Los AngelesLos Angeles, CA, USA
Scott RobertsDepartment of Obstetrics and GynecologyUniversity of Texas Southwestern Medical CenterDallas, TX, USA
Stephanie T. RosDepartment of Obstetrics and GynecologyUniversity of South FloridaTampa, FL, USA
Michael G. RossDepartment of Obstetrics and GynecologyGeffen School of MedicineDepartment of Community Health SciencesFielding School of Public HealthUniversity of California at Los Angeles (UCLA)Harbor‐UCLA Medical CenterTorrance, CA, USA
George R. SaadeDepartment of Obstetrics and GynecologyEastern Virginia Medical SchoolNorfolk, VA, USA
Michael SchatzDepartment of AllergyKaiser Permanente Medical CenterSan Diego, CA, USA
Rachel C. SchellDepartment of Obstetrics and GynecologyUniversity of Texas Southwestern Medical CenterDallas, TX, USA
Claudio V. SchenoneDepartment of Obstetrics and GynecologyUniversity of South TampaTampa, FL, USA
Marisa Eve SchwabDepartment of SurgeryUniversity of California, San FranciscoSan Francisco, CA, USA
Baha M. SibaiDepartment of Obstetrics, Gynecology and Reproductive SciencesMcGovern Medical SchoolThe University of Texas Health Science CenterHouston, TX, USA
Caroline SignoreEunice Kennedy Shriver National Institute of Child Health and Human DevelopmentBethesda, MD, USA
Robert M. SilverDepartment of Obstetrics and GynecologyUniversity of Utah School of MedicineSalt Lake City, UT, USA
Lynn L. SimpsonDepartment of Obstetrics and GynecologyColumbia University Irving Medical CenterNew York, NY, USA
Rachel SinkeyDepartment of Obstetrics and GynecologyThe University of AlabamaBirmingham, AL, USA
Stephen F. ThungDepartment of Obstetrics, Gynecology and Reproductive SciencesYale School of MedicineNew Haven, CT, USA
P. Emanuela VoinescuDepartment of NeurologyBrigham and Women’s HospitalHarvard Medical SchoolBoston, MA, USA
Michelle E. WhittumDepartment of Obstetrics and GynecologyUniversity of South FloridaTampa, FL, USA
Edward R. YeomansDepartment of Obstetrics and GynecologyTexas Tech University Health Sciences CenterLubbock, TX, USA
Foreword
I am delighted – indeed tickled – to pen this foreword for the Seventh Edition of Queenan’s Management of High‐Risk Pregnancy! The book is now edited by my esteemed colleagues, Dr. Charles J. Lockwood and Dr. Catherine Y. Spong, with whom I have had the good fortune to have worked on prior editions of this textbook as well as our co‐edited textbooks Protocols of High Risk Pregnancy: Evidence Based Management. We share a common academic lineage as successive editors‐in‐chief of Contemporary ObGyn. I recall the conversations at meetings and at airports with Drs. Lockwood and Spong inviting them to join me as editors in the previous editions, all with the fervent hope that one day they would carry the book forward to future generations. That time has arrived!
Looking back to the origins of this book, in the 1980s I had the good fortune to assemble chapters derived from terrific articles by esteemed authors in Contemporary ObGyn. This book was successful because these chapters were succinct, evidence based, up to date, and easy to understand – the perfect management tool for the busy practitioner. They included clinical vignettes to highlight important concepts. I never had difficulty getting the leading authors to participate in this project and I recognize this was because they were also passionate educators, master clinicians, and incredible colleagues with collaborative willingness to work together.
I had always hoped this book would serve all levels of trainees as well as busy practitioners and established colleagues. With ever‐changing evidence in obstetrics and maternal fetal medicine, it has been critical to ensure that chapters were up to date and new chapters were added to address topics previously undescribed. For example, this edition includes SARS CoV2 virus, vaping, and various advances in obstetrical management to name a few.
Over the past 40 years plus we have seen extraordinary advances in prenatal screening and diagnosis. The seventh edition, under the leadership of Drs. Lockwood and Spong, upholds the textbook’s place as a classic, outlining a practical approach to management for physicians and trainees. I am honored to have my name as part of the title.
John T. Queenan
Professor and Chairman Emeritus of Obstetrics and GynecologyGeorgetown University School of MedicineWashington, DC
Preface
The seventh edition of Queenan’s Management of High‐Risk Pregnancy, like its predecessors, is directed to all health professionals involved in the care of women with high‐risk pregnancies. This book has its origins from a series of articles appearing in Contemporary OB/GYN that were the inspiration for the first edition in 1980. Contemporary OB/GYN, was in turn, the inspiration of John T. Queenan. Its legacy was carried forward first by Charles J. Lockwood and now by Catherine Y. Spong. As with prior editions, Queenan’s Management of High‐Risk Pregnancy contains clear, concise, practical material presented in an evidence‐based manner. Each chapter is followed by an illustrative case report to help put the subject in perspective.
In this new edition we have focused on including topics most critical to providing good care, each written by outstanding authorities on the subject to ensure they are focused, timely, and authoritative. This dynamic process requires adding new chapters as the evidence dictates and eliminating others so that the reader is presented with the most clinically useful contemporary information. We are delighted to ensure John T. Queenan’s legacy continues in this latest edition, as we are committed to his vision and inspiration to have clear, concise protocols that ensure that busy practitioners have needed information at their fingertips.
The seventh edition comes at a time when health care has experienced a pandemic, virtual visits and encounters are increasingly common, and health care settings continue to rapidly evolve. We continue to emphasize evidence‐based information and clinical practicality and included chapters addressing timely topics such as infectious diseases in pregnancy, vaping, operative vaginal delivery, postpartum hemorrhage, and pregnancies in women with disabilities. To ensure applicability for health professionals in developing countries we have protocols on maternal anemia, malaria, and HIV infection.
We are committed to bringing the busy practitioner the best possible clinical information. As a reader if you find an area that needs correction or modification or have comments to improve this effort, we welcome your feedback.
Catherine Y. Spong and Charles J. Lockwood
Acknowledgments
We are fortunate to work in cooperation with a superb editorial staff at Wiley Blackwell Publishing under the direction of our publisher. Commissioning editor Sophie Bradwell, managing editor Harini Arumugam, and content refinement specialist Praveen Kumar Bondili have also provided guidance and editorial skills that are evident in this edition.
It is vital that we also acknowledge with great appreciation and admiration our authors, experts with busy schedules who took the time to ensure their protocols are evidence‐based, clear, concise, and practical. Their contributions to this book are in the best traditions of academic medicine and we hope that they will be translated into a considerable decrease in morbidity and mortality for mothers and infants.
We also hope that by using this book, you will improve the delivery of care for your patients. Your dedication to women’s health has made it a joy to prepare this resource.
Chapter 1Overview of High‐Risk Pregnancy
Catherine Y. Spong1 and Charles J. Lockwood2
1Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
2Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
We live in an era of dynamic change, where the accelerating pace of information accretion touches all aspects of our lives. Nowhere is this acceleration of knowledge more dynamic or more critical than in medicine. Obstetrics has seen extraordinary changes in practice with enormous gains in molecular genetics, imaging, and evidence‐based management of both common and uncommon conditions. And despite the acquisition of these powerful tools, we live at a time of rising maternal mortality and morbidity, rising rates of preterm birth, a chronic opioid crisis, serial viral pandemics, and the increasing politicization of obstetrical practice. In addition, the business of medicine grows ever more complex, and the amount of non‐value‐added work is accelerating. All this poses serious challenges for the busy clinician and are the ingredients of professional burnout. In the edition of Queenan’s classic textbook, as we have in the prior six editions, we try to simplify the work of busy obstetricians by distilling the latest and most rigorous evidence on the management of high‐risk pregnancies.
We provide new insights into the management of maternal substance use, simplify approaches to prenatal screening and diagnosis of fetal genetic abnormalities, provide indications for fetal surgery and cover the range of established perinatal pathogens such as group B beta‐hemolytic streptococcus, malaria, hepatitis, and HIV – and emerging infections such as Zika and COVID‐19. We also cover the evidence‐based management of common obstetrical complications such as preterm birth, preeclampsia, recurrent pregnancy loss, breech presentation, and postpartum hemorrhage. The latest in diagnosis and treatment of serious maternal pre‐existing medical conditions including cardiac and renal disease, systemic lupus erythematosus, chronic hypertension, diabetes, thromboembolism, thrombocytopenia, and anemia are described. Indications, risks, and techniques for a full range of obstetrical procedures are also explored from operative vaginal delivery to induction of labor, fetal monitoring, and fetal diagnostic procedures.
We have assembled a very talented team of experts on all these topics who distill volumes of new data leavened with their own extensive clinical experience to provide management pearls and algorithms. All this is in keeping with the philosophy of the founding editor, Dr. John Queenan, a towering figure in American obstetrics and gynecology and a founding father of modern maternal–fetal medicine. Through his textbooks and long‐standing editorship of Contemporary Ob/Gyn, John focused on the “doctors in the trenches” and sought to enhance their practice while saving them time and effort. We are honored to continue John’s legacy in this seventh edition.
Chapter 2Nutrition in Pregnancy
Cara D. Dolin1 and Michelle A. Kominiarek2
1Department of Obstetrics and Gynecology, Women’s Health Institute, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
2Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
The study of nutrition in pregnancy begins with natural experiments during war and famine. Classic studies from Holland and Leningrad during World War II suggest that when caloric intake during pregnancy was acutely restricted to <800 kcal/day, birthweights were reduced [1]. Exposure to famine conditions during the second half of pregnancy had the greatest adverse effect on birthweight and placenta weight whereas birth length, head circumference, and postpartum weight were effected to a lesser extent [2,3]. With the progressive loss of calories, maternal weight was lost until a critical threshold was met. Once maternal weight loss stabilized, the placenta and then fetal weights were reduced. When the rationing to 800 kcal/day stopped, maternal weight was the first to recover, followed by placenta weight and finally birthweight.
Although these studies are used as prima facie evidence of a link between nutrition and fetal development, a more discerning examination reveals that many common factors are associated with nutrition and fetal development. Although the onset of food rationing was distinct and the birthweight and other anthropomorphic measurements were recorded reliably, other factors were not identified. For example, menstrual data were notoriously unreliable and accurate gestational dating was challenged by the stress of war. Furthermore, in Holland and Leningrad, the stress of war may have been associated with both preterm delivery and reduced birthweight.
In more recent times, the “fetal origins hypothesis” suggests that nutrition during pregnancy not only is associated with birthweight, but also has lifelong effects on metabolism and risk for chronic disease in adulthood [4]. For example, studies have described associations between birthweight and hypertension, diabetes, and coronary heart disease. These studies were also limited by selection bias and failure to account for factors such as socioeconomic status in the pathway of fetal and adult health [5–8].
Today, social determinants of health, including economic stability, education access and quality, healthcare access, neighborhood and built environment, and social and community contexts are key considerations in the study of pregnancy and nutrition [9]. For example, people may live in an environment with access to food but may have limited access to healthy foods. A person’s diet in wartime Europe or the lack of adequate access to healthy food today is challenging to evaluate but likely depends on both the quantity (e.g. total kilocalories) and overall quality. Body mass index (BMI) is used to categorize people according to their height and weight and predict their associated health outcomes [10]. Measures than can complement BMI to determine risk for health outcomes include waist circumference, body fat analysis, and other metabolic markers such as inflammatory status and insulin resistance [11]. In pregnancy, BMI is the anthropomorphic measure that is most readily available. A person’s prepregnancy weight or BMI along with their weight changes during pregnancy may estimate nutritional status but are not replacements for measures of diet quantity and quality.
The purpose of this chapter is to review the associations between nutrition and perinatal outcomes. We summarize the basic concepts of fetal growth, the multiple predictors of fetal growth, gestational weight gain, adverse perinatal outcomes related to either inadequate or excessive weight gain, and recommendations for caloric, vitamin, mineral, and other supplements during pregnancy.
Fetal growth
After the first trimester, estimated fetal weight is derived from ultrasound biometry (i.e. head circumference, femur length, abdominal circumference) and referenced to either population or customized growth standards to create a weight percentile. The term fetal growth restriction is used to describe a fetus with an ultrasound estimated fetal weight <10th% for gestational age or having an abdominal circumference <10th% as determined by ultrasound [12]. According to birth and death certificates from 2 288 806 births in California from 1970–1976, birthweight was used as a proxy for fetal growth rates whereby the growth peaked at 250 g per week at 33 weeks and then declined to 75 g per week at 40 weeks (Figure 2.1). The comparison of coincidental estimated fetal weight and birthweight reveals a relatively large error; 20% of estimated fetal weights will differ from the actual weight by one standard deviation or more, 400‐600 g at term [13].
Twin pregnancies have a proportionately lower rate of growth, reaching a maximum at 175 g per week at 31 weeks (Figure 2.1) [14]. A study of live births of twins delivered between 1990 and 1996 evaluated birthweights according to type of placentation. Between 30 and 40 weeks, twins with dichorionic placentation were heavier than those with a monochorionic placentation [15]. There is still controversy as to whether singleton or separate twin standards should be the comparison reference in multifetal pregnancies. A prospective cohort study of 171 dichorionic twins evaluated the fetal growth trajectory and compared the findings to a singleton growth standard. By 35 weeks of gestation, nearly 40% of twins would be classified as small for gestational age with the use of a singleton, non‐Hispanic White reference [16].
It is important to study the extremes of fetal growth as growth restriction is associated with increased risk for stillbirth, acidosis, and neonatal intensive care unit admissions whereas macrosomia (i.e. birthweights greater than 4500 g) is associated with an increased risk for abnormal labor, cesarean delivery, birth injury, >30 minutes of assisted ventilation, and infant mortality [17]. The velocity of fetal growth may inform the mechanisms of abnormal growth [18]. Fetal length peaks earlier than weight, as the fetus stores fat and hepatic glycogen, which contribute to increasing abdominal circumference in the third trimester. When an exposure occurs early in pregnancy, such as with alcohol exposure, severe starvation, smoking, perinatal infection (i.e. cytomegalovirus infection), chromosomal or developmental disorders, or chronic vasculopathies (i.e. diabetes, autoimmune disease, chronic hypertension), the result is a fetus with similarly reduced growth of its length, head circumference, and abdominal circumference [19].
Figure 2.1 Fetal weight gain in grams among singleton and twin pregnancies.
When the exposure occurs after the peak in the velocity of length growth, the result is a disproportionately reduced body‐length ratio, with a larger head circumference relative to abdominal circumference. This pattern usually is the result of new onset or developing vasculopathy (i.e. placental thrombosis/infarcts, preeclampsia) or a reduction of the absorptive capacity of the placenta (i.e. postdate pregnancy). Although the classification of symmetrical vs. asymmetrical fetal growth restriction has been referenced to the timing of an exposure and proposed etiologies, more recent studies suggest growth and developmental delay from birth until 4 years of age are similar in symmetrical and asymmetrical growth restriction. Furthermore, ratios of head and abdominal circumferences did not independently predict adverse outcomes [20,21].
Fetal growth requires the transfer of nutrients as building blocks and the transfer of oxygen to support fetal growth and development. Maternal pulmonary, gastrointestinal, and cardiac systems adapt for fetal and placental needs. These adaptations are partially driven through placenta hormones (i.e. human placental lactogen). The central role of the placenta in the production of pregnancy hormones, the transfer of nutrients, and fetal respiration is demonstrated by the fact that 20% of the oxygen supplied to the fetus is diverted to the metabolic activities of the placenta and placental oxygen consumption at term is about 25% higher than the amount consumed by the fetus as a whole. The absorptive surface area of the placenta is strongly associated with fetal growth; the chorionic villus surface area grows from about 5 m2 at 28–30 weeks to 10 m2 by term.
The measured energy requirement of pregnancy totals 55 000 kcal for an 11 800 g of weight gain or 4.7 kcal/g of weight gain [22]. This value is considerably less than the 8.0 kcal/g required for weight gain in nonpregnant people. This discrepancy is likely due to the poorly understood relationship between pregnancy hormones (i.e. human placental lactogen, corticosteroids, sex steroids) and the pattern of nutrient distribution. Table 2.1 describes the work as measured by weight that occurs to produce an appropriately grown fetus at term. Weight gain is essentially linear throughout the second and third trimesters of pregnancy [23].
Table 2.1Sources of weight gain in pregnancy
Maternal gains
Fetal gains
Blood volume
2 kg (4.4 lb)
Fetus
3.5 kg (7.7 lb)
Uterine size
1 kg (2.2 lb)
Placenta
0.6 kg (0.7 lb)
Breast size
1 kg (2.2 lb)
Amniotic fluid
1.2 kg (2.6 lb)
Fat increase
3 kg (6.6 lb)
Total (maternal + fetal) weight gain
12.3 kg (27 lb)
Table 2.2 Factors associated with fetal growth
Factors
Clinical examples
Genetics
Parental anthropometrics Chromosomal disorders Congenital anomalies
Uterine volume
Müllerian duct abnormalities Fibroids
Maternal intake
Eating disorders (anorexia) Inadequate or excessive weight gain Iron deficiency anemia Micronutrient deficiencies (folic acid)
Maternal absorption
Inflammatory bowel disease Bariatric surgery
Maternal hyper metabolic states
Hyperthyroidism Adolescent pregnancy Extreme exercise
Maternal cardiorespiratory function
Cardiac disease Sarcoidosis Asthma
Uterine blood flow
Hypertension/preeclampsia β‐adrenergic blockers Diabetic vasculopathy Autoimmune vasculopathy Smoking (nicotine) Chronic environmental stress
Placental transfer
Diabetes Smoking (carbon monoxide)
Placental absorption
Placental infarcts or thrombosis
Fetal blood flow
Congenital heart disease Increased placental resistance Polycythemia
Fetal metabolic state
Drug effects (amphetamines) Genetic metabolic disease
Reduced fetal cell numbers
Alcohol Chromosomal disorders
Many factors affect the transfer of nutrients and oxygen to the fetus.
