Queenan's Management of High-Risk Pregnancy

An Evidence-Based Approach

John T. Queenan, Catherine Y. Spong, Charles J. Lockwood, John T. Queenan, Catherine Y. Spong, Charles J. Lockwood

• Publisher: Wiley-Blackwell
• Year: 2011
• Print ISBN: 9780470655764
• eBook ISBN: 9781119963769
• Edition: 6
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

Changing demographics and evolving technology continuously affect maternal-fetal medicine

Increasing maternal age and weight during pregnancy, higher rates of pregnancies conceived by artificial reproductive technologies and growing numbers of cesarean deliveries have led to a rise in the incidence of complicated pregnancies. The options have also increased for monitoring maternal and fetal health throughout a pregnancy, and identifying and managing risk earlier.

For the maternal-fetal physician, constant vigilance throughout a pregnancy remains essential. But continuous change makes this an increasing challenge. Queenan's Management of High-Risk Pregnancy covers the full spectrum of perinatal care. It guides you through the tough and complex decisions needed to protect the health of both your fetal and the maternal patients.

New material in the 6th edition covers contemporary issues such as:

• Iron-deficient anemia
• Malaria
• Pregnancy in the disabled woman
• Placenta accreta
• Induction of labor
• Operative vaginal delivery
• Patient safety in labor and delivery

The stellar cast of expert authors provide evidence, algorithms, case studies and potential outcome measures to ensure that Queenan's Management of High-Risk Pregnancy continues to set the bar for maternal-fetal practice.

Titles of Related Interest

Stillbirth
Edited by Catherine Y. Spong
ISBN 978-1-4443-3706-8

The Placenta: From Development to Disease
Edited by Helen Kay, D. Michael Nelson and Yuping Wang
ISBN 978-1-4443-3366-4

Pregnancy in the Obese Woman: Clinical Management
Edited by Deborah E. Conway
ISBN 978-1-4051-9648-2

Chapter 1

Overview of High-Risk Pregnancy

John T. Queenan¹, Catherine Y. Spong² and Charles J. Lockwood³

¹Department of Obstetrics and Gynecology, Georgetown University School Medicine, Washington, DC, USA

²Bethesda, MD, USA

³Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA

With the changing demographics of the United States population, including increasing maternal age and weight during pregnancy, higher rates of pregnancies conceived by artificial reproductive technologies and increasing numbers of cesarean deliveries, complicated pregnancies have risen. Although most pregnancies are low risk with favorable outcomes, high-risk pregnancies – the subject of this book – may have potentially serious occurrences. We classify any pregnancy in which there is a maternal or fetal factor that may adversely affect the outcome as high risk. In these cases, the likelihood of a positive outcome is significantly reduced. In order to improve the outcome of a high-risk pregnancy, we must identify risk factors and attempt to mitigate problems in pregnancy and labor.

Many conditions lend themselves to identification and intervention before or early in the perinatal period. When diagnosed through an appropriate work-up before pregnancy, conditions such as rhesus (Rh) immunization, diabetes, and epilepsy can be managed to minimize the risks of mortality and morbidity to both mother and baby. It is not possible, however, to predict other conditions, such as multiple pregnancies, preeclampsia, and premature rupture of membranes prior to pregnancy. To detect and manage these challenging situations, the obstetrician must maintain constant vigilance once pregnancy is established.

Although much progress has been made since the 1950s, there is still much to accomplish. Fifty years ago, the delivering physician and the nursing staff were responsible for newborn care. The incidence of perinatal mortality and morbidity was high. Pediatricians and pediatric nurses began appearing in the newborn nursery in the 1950s, taking responsibility for the infant at the moment of birth. This decade of neonatal awareness ushered in advances that greatly improved neonatal outcome.

Many scientific breakthroughs directed toward evaluation of fetal health and disease occurred in the 1960s, which is considered the decade of fetal medicine. Early in that decade, the identification of patients with the risk factor of Rh immunization led to the prototype for the high-risk pregnancy clinic. Rh-negative patients were screened for antibodies, and if none were detected, these women were managed as normal or “low-risk” cases. Those who developed antibodies were enrolled in a high-risk pregnancy clinic, where they could be carefully followed by specialists with expertise in Rh immunization. With the advent of scientific advances such as amniotic fluid bilirubin analysis, intrauterine transfusion, and, finally, Rh immune prophylaxis, these often perilous high-risk pregnancies generally became success stories.

A note of caution is in order. The creation of special Rh clinics for Rh-immunized mothers in the early 1960s was a logical strategy since the Rh-immunized mother with an Rh-positive fetus had a 50% chance of losing her baby either in utero or in the nursery. With increasing technologic and scientific advances physicians achieved markedly better outcomes. We are sensitive to the use of the term “high-risk pregnancy” and believe it should be avoided in patient counseling as it can cause unnecessary anxiety for the parents.

During the 1970s, the decade of perinatal medicine, pediatricians and obstetricians combined forces to continue improving perinatal survival. Some of the most significant perinatal advances are listed in Box 1.1. Also included are the approximate dates of these milestones and (where appropriate) the names of investigators who are associated with the advances.

Box 1.1 Milestones in perinatology

Before 1950s

Neonatal care by obstetricians and nurses

1950s: Decade of Neonatal Awareness

Pediatricians entered the nursery
1950	Allen and Diamond	Exchange transfusions
1953	du Vigneaud	Oxytocin synthesis
1954	Patz	Limitation of O2 to prevent toxicity
1955	Mann	Neonatal hypothermia
1956	Tjio and Levan	Demonstration of 46 human chromosomes
1956	Bevis	Amniocentesis for bilirubin in Rh immunization
1958	Donald	Obstetric use of ultrasound
1958	Hon	Electronic fetal heart rate evaluation
1959	Burns, Hodgman, and Cass	Gray baby syndrome

1960s: Decade of Fetal Medicine

Prototype of the high-risk pregnancy clinic
1960	Eisen and Hellman	Lumbar epidural anesthesia
1962	Saling	Fetal scalp blood sampling
1963	Liley	First intrauterine transfusion for Rh immunization
1964	Wallgren	Neonatal blood pressure
1965	Steele and Breg	Culture of amniotic fluid cells
1965	Mizrahi, Blanc, and Silverman	Necrotizing enterocolitis
1966	Parkman and Myer	Rubella immunization
1967		Neonatal blood gases
1967		Neonatal transport
1967	Jacobsen	Diagnosis of cytogenetic disorders in utero
1968	Dudrick	Hyperalimentation
1968	Nadler	Diagnosis of inborn errors of metabolism in utero
1968	Stern	NICU effectiveness
1968	Freda et al	Rh prophylaxis

1970s: Decade of Perinatal Medicine

Refinement of NICU
Regionalization of high-risk perinatal care
1971	Gluck	L:S ratio and respiratory distress syndrome
1972	Brock and Sutcliffe	α-Fetoprotein and neural tube defects
1972	Liggins and Howie	Betamethasone for induction of fetal lung maturity
1972		Neonatal temperature control with radiant heat
1972	Quilligan	Fetal heart rate monitoring
1972	Dawes	Fetal breathing movements
1972	Ray and Freeman	Oxytocin challenge test
1972	ABOG	Maternal-Fetal Medicine Boards
1973	Sadovsky	Fetal movement
1973		Real-time ultrasound
1973	Hobbins and Rodeck	Clinical fetoscopy
1975	ABP	Neonatology Boards
1976	Schifrin	Nonstress test
1977	March of Dimes	Towards Improving the Outcome of Pregnancy I
1977	Kaback	Heterozygote identification (Tay–Sachs disease)
1978	Bowman	Antepartum Rh prophylaxis
1978	Steptoe and Edwards^*	In vitro fertilization
1979	Boehm	Maternal transport

1980s: Decade of Progress

Technologic progress
1980	Bartlett	ECMO
1980	Manning and Platt	Biophysical profile
1981	Fujiwara, Morley, and Jobe	Neonatal surfactant therapy
1982	Harrison and Golbus	Vesicoamniotic shunt for fetal hydronephrosis
	Bang, Brock and Toll	First fetal transfusion under ultrasound guidance
1983	Kazy, Ward, and Brambati	Chorionic villus sampling
1985	Daffos, Hobbins	Cordocentesis
1986		DNA analysis
1986	NICHD	MFMU network established
1986	Michaels et al	Cervical ultrasound and preterm delivery

1990s: Decade of Managed Care

Managed care alters practice patterns
1991	Lockwood et al	Fetal fibronectin and preterm delivery
1993	March of Dimes	Towards Improving the Outcome of Pregnancy II
		Fetal therapy
		Preimplantation genetics
		Stem cell research
1994	NIH Consensus Conference	Antenatal corticosteroids

2000s: Decade of Evidence-Based Perinatology

2000	Mari	Middle cerebral artery monitoring for Rh disease
2002	CDC	Group B streptococcus guidelines
	MFMU	Antibiotics for PPROM
2003	MFMU	Progesterone to prevent recurrent prematurity
2006	Merck	Immunization against human papillomavirus
2008	MFMU	Magnesium for prevention of cerebral palsy
2009	MFMU	Gestational diabetes trial

2010s: Current Decade

2010	NIH	Consensus conference on VBAC
2011	MOMS	Fetal surgery improves outcome for myelomeningocele

ABOG, American Board of Obstetrics and Gynecology; ABP, American Board of Pediatrics; CDC, Centers for Disease Control; ECMO, extracorporeal membrane oxygenation; L:S, lecithin:sphingomyelin ratio; MFMU, Maternal-Fetal Medicine Units; MOMS, Management of Myelomeningocele Study: NICU, neonatal intensive care unit; NICHD, National Institute of Child Health and Human Development; NIH, National Institutes of Health; PPROM, preterm premature rupture of membranes; VBAC, vaginal birth after cesarean.

* Recipient of the 2010 Nobel Prize in Medicine.

Among the advances in perinatal medicine that occurred during the 1980s were the development of comprehensive evaluation of fetal condition with the biophysical profile, the introduction of cordocentesis for diagnosis and therapy, the development of neonatal surfactant therapy, antenatal steroids and major advances in genetics and assisted reproduction. These technologic advances foreshadowed the “high-tech” developments of the 1990s. Clearly, the specialty has come to realize that “high tech” must be accompanied by “high touch” to ensure the emotional and developmental well-being of the baby and the parents. This decade was one of adjusting to the challenges of managed care under the control of “for profit” insurance companies.

The new millennium brought the decade of evidence-based perinatology. Clinicians became aware of the value of systematic reviews of the Cochrane Database. Major perinatal research projects by the Maternal-Fetal Medicine Units network of the Eunice Kennedy Shriver National Institute of Child Health and Human Development answered many clinical questions.

The future will bring better methods of determining fetal jeopardy and health. Continuous readout of fetal conditions will be possible during labor in high-risk pregnancies. Look for the new advances to be made in immunology and genetics. Immunization against group B streptococcus and eventually human immunodeficiency virus will become available. Preimplantation genetics will continue to provide new ways to prevent disease. Alas, prematurity and preeclampsia with their many multiple etiologies may be the last to be conquered.

New technology will increase the...

Table of contents

• Cover
• Title page
• Copyright page
• List of Contributors
• Foreword
• Preface
• Acknowledgments
• List of Abbreviations
• Part 1: Factors of High-Risk Pregnancy
• Part 2: Genetics
• Part 3: Monitoring: Biochemical and Biophysical
• Part 4: Maternal Disease
• Part 5: Obstetric Complications
• Part 6: Complications of Labor and Delivery
• Part 7: Procedures
• Index
• Color Plates