Professor, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas Parkland Health and Hospital System. Faculty Associate, Department of Obstetrics and Gynecology at Texas Southwestern Medical Center in Dallas.
APPENDIX
PREFACE
Specifically, we mention the entire Department of Maternal-Fetal Medicine, whose professors, in addition to providing professional content, kindly helped us cover clinical obligations when writing and editing were particularly time-consuming. Thanks to generous funding from The McGraw-Hill Companies, this 24th edition now includes more than 200 color illustrations.
ACKNOWLEDGMENTS
It was truly fortuitous for us to have access to a pantheon of contributors here as well as from other academic medical centers. Finally – but certainly not least – we acknowledge our significant debt to the women who have allowed us to participate in their care.
OVERVIEW
Number of stillbirths per 1000 births, including live births and stillbirths. A newborn born at any time after 37 completed weeks of pregnancy and up to 42 completed weeks of pregnancy (260 to 294 days).
PREGNANCY IN THE UNITED STATES
The death of a woman, from any cause, while she is pregnant or within 1 calendar year after the termination of pregnancy, regardless of the duration and place of.
MEASURES OF OBSTETRICAL CARE
For example, 55 percent of all infant deaths in 2005 were in the 2 percent of babies born before 32 weeks' gestation. As shown in Figure 1-4, maternal mortality rates in the United States declined rapidly during the 20th century.
TIMELY TOPICS IN OBSTETRICS
Rising costs, inconsistent quality, and patient safety issues are significant challenges to the delivery of health care in the United States. According to the American College of Obstetricians and Gynecologists (2011): "The most effective way to reduce the number of abortions is to prevent unwanted and unintended pregnancies." Importantly, the negative attitudes, beliefs, and policies toward family planning services and sexuality education discussed above have contributed to the more than 800,000 abortions performed annually in the United States.
Van der Kooy J, Poeran J, de Graaf JP, et al: Planned home births versus planned hospital births in the Netherlands. Wapner RJ, Martin CL, Levy B, et al: Chromosome microarray versus karyotyping for prenatal diagnosis.
MATERNAL ANATOMY AND PHYSIOLOGY
ANTERIOR ABDOMINAL WALL
In contrast, the inferior "deep" epigastric vessels and the deep circumflex iliac vessels are branches of the external iliac vessels. In contrast, the iliohypogastric and ilioinguinal nerves originate from the anterior shoulder of the first lumbar spinal nerve.
EXTERNAL GENERATIVE ORGANS
The superficial space of the anterior triangle is bounded deeply by the perineal membrane and superficially by Colles fascia. The internal anal sphincter (IAS) is a distal continuation of the rectal circular smooth muscle layer.
INTERNAL GENERATIVE ORGANS
The blood supply to the pelvis is mainly supplied by the branches of the internal iliac artery. Others arise from the plexus surrounding the ovarian branch of the uterine artery.
MUSCULOSKELETAL PELVIC ANATOMY
Clinically, three diameters of the pelvic opening are usually described - anteroposterior, transverse and posterior sagittal. Barber MD, Bremer RE, Thor KB, et al: Innervation of the female levator ani muscles.
GENITOURINARY TRACT DEVELOPMENT
The development of the genitals begins when the Müllerian ducts, also called paramesonephric ducts, form lateral to each mesonephros. The uterus is formed by this union of the two Müllerian ducts around the 10th week (Fig. 3-1E).
MESONEPHRIC REMNANTS
As the distal end of the fused Müllerian ducts contacts the urogenital sinus, this induces endodermal outgrowths called the sinovaginal bulbs. The close association between the mesonephric (wolffian) and paramesonephric (müllerian) ducts explains why there are commonly concomitant abnormalities involving these structures.
BLADDER AND PERINEAL ABNORMALITIES
Intra-abdominal wolf remains in the female include some blind tubules in the mesovarium - epoöphoron -. Epoöphoron or paroöphoron can develop into clinically recognizable cysts and are included in the differential diagnosis of an adnexal mass (Chap. 63, p. 1226).
DEFECTS OF THE HYMEN
MÜLLERIAN ABNORMALITIES
These anomalies can be suspected on pelvic examination by identifying a longitudinal vaginal septum and two cer-. Although an abnormality can be identified with HSG, MR imaging or 3-D sonography is typically required to distinguish this from a bicornuate uterus (see Fig. 3-3).
UTERINE FLEXION
Chan YY, Jayaprakasan K, Tan A, et al: Reproductive outcomes in women with congenital uterine anomalies: a systematic review. Seubert DE, Puder KS, Goldmeier P, et al: Colonoscopic liberation of the incarcerated gravid uterus.
REPRODUCTIVE TRACT
This dextrorotation is probably caused by the rectosigmoid on the left side of the pelvis. Remember that blood flow in a vessel increases in proportion to the fourth power of the radius.
BREASTS
SKIN
Occasionally, the muscles of the abdominal wall cannot withstand the tension they are exposed to. If severe, a significant portion of the anterior uterine wall is covered only by a layer of skin, weakened fascia, and peritoneum to form a ventral hernia.
METABOLIC CHANGES
HEMATOLOGICAL CHANGES
Moderate erythroid hyperplasia is present in the bone marrow and the reticulocyte count is slightly elevated in normal pregnancy. This contributes greatly to the striking increase in erythrocyte sedimentation rate as discussed earlier.
CARDIOVASCULAR SYSTEM
Upon standing up, cardiac output falls to the same level as in non-pregnant women (Easterling, 1988). It has also been implicated in the angiotensin resistance characteristic of normal pregnancy (Friedman, 1988).
RESPIRATORY TRACT
The increased oxygen demands and possibly increased critical closure volume imposed by pregnancy make respiratory disease more serious. The amount of oxygen delivered to the lungs by the increased tidal volume clearly exceeds the oxygen demands imposed by pregnancy.
URINARY SYSTEM
One unusual feature of the changes in renal excretion caused by pregnancy is the greatly increased amount of various nutrients lost in the urine. A dilated tract can cause errors related to both retention—hundreds of milliliters of urine remain in the dilated tract—and time—the remaining urine may have formed hours before collection.
GASTROINTESTINAL TRACT
Continuing this process until the end of pregnancy leads to a marked deepening and widening of the trigonus. In addition, elevated progesterone levels and genetic factors are involved in the pathogenesis (Lammert, 2000).
ENDOCRINE SYSTEM
At the beginning of the first trimester, levels of the main carrier protein – thyroxine-binding globulin (TBG) – rise, peak at about 20 weeks – and stabilize at about double baseline levels by the end of pregnancy. This scenario results in an increase in the plasma level of angiotensin II, which acts on the zona glomerulosa of the maternal adrenal glands and is responsible for the markedly increased secretion of aldosterone.
MUSCULOSKELETAL SYSTEM
The levels of deoxycorticosterone and its sulfate in fetal blood are significantly higher than those in maternal blood, suggesting transfer of fetal deoxycorticosterone to the maternal compartment. The source of this increased C19 steroid production is unknown, but it probably originates in the ovary.
CENTRAL NERVOUS SYSTEM
Pitkin RM, Reynolds WA, Williams GA, et al: Calcium metabolism in normal pregnancy: a longitudinal study. Powers RW, Majors AK, Kerchner LJ, et al: Renal treatment of homocysteine during normal pregnancy and preeclampsia.
PLACENTATION, EMBRYOGENESIS, AND FETAL DEVELOPMENT
THE OVARIAN–ENDOMETRIAL CYCLE
The hormone secretion pattern of the corpus luteum differs from that of the follicle (see Fig. 5-1). During the early part of the proliferative phase, the endometrium is usually less than 2 mm thick.
THE DECIDUA
Early in pregnancy, an impressive abundance of large, granular lymphocytes called decidual natural killer (NK) cells are present in the decidua. This may explain the different mechanisms regulating expression in the decidua versus the pituitary (Christian, 2002a,b).
IMPLANTATION AND EARLY TROPHOBLAST FORMATION
As the blastomeres continue to divide, a solid mulberry-like ball of cells—the morula—forms. The opposite, thicker wall comprises two zones - trophoblasts and the inner cell mass that forms the embryo.
PLACENTA AND CHORION DEVELOPMENT
Low estradiol levels in the first trimester are critical for trophoblast invasion and remodeling of the spiral veins. In the remaining 35 percent, the veins radiate to the edge of the placenta without narrowing.
THE AMNION
Early in human embryogenesis, the amniotic mesenchymal cells lie immediately adjacent to the basal surface of the amnion epithelium. Synthesis of interstitial collagens that compose the compact layer of the amnion—the main source of its tensile strength—occurs in mesenchymal cells (Casey, 1996).
THE UMBILICAL CORD
Although collagen III provides some amnion extensibility, elastin microfibrils have also been identified (Bryant-Greenwood, 1998). From the above it is clear that the amnion is more than a simple avascular membrane containing amniotic fluid.
PLACENTAL HORMONES
The pattern of appearance of hCG in the blood of the fetus is similar to that of the mother. For each, there is an analogous hormone produced in the human placenta (Petraglia, 1992; Siler-Khodr, 1988).
FETAL ADRENAL GLAND–PLACENTAL INTERACTIONS
Maaskant RA, Bogic LV, Gilger S, et al: Fudhata piroolaaktiin namaa meembraanota daa’imaa, decidua, fi placenta keessatti. Thiruchelvam U, Dransfield I, Saunders PTK, fi kkf: Gahee maakrofeejii endometrium namaa keessatti.
HISTOPATHOLOGICAL EXAMINATION
NORMAL PLACENTA
ABNORMALITIES OF THE PLACENTA
The chorionic plate usually extends to the circumference of the placenta and has a diameter similar to that of the basal plate. Large tumors, typically those measuring > 5 cm, may be associated with significant arteriovenous shunting within the placenta that may cause fetal anemia and hydrops.
ABNORMALITIES OF THE MEMBRANES
Bleeding, preterm delivery, amniotic fluid abnormalities and fetal growth restriction can also complicate large tumors (Sepulveda, 2003a; Zalel, 2002). As a result, metastasis to the fetus is uncommon, but is most often seen in melanoma (Alexander, 2003; Altman, 2003).
ABNORMALITIES OF THE UMBILICAL CORD
Jauniaux E, De Munter C, Vanesse M, et al: Embryonic remnants of the umbilical cord: morphological and clinical aspects. Weber MA, Sau A, Maxwell DJ, et al: Third-trimester intrauterine fetal death due to umbilical cord arterial aneurysm.
EMBRYO-FETAL GROWTH AND DEVELOPMENT
A quick estimate of the date of pregnancy based on menstruation data can be done as follows: add 7 days to the first day of the last menstruation and subtract 3 months. In these cases, the sonographic evaluation is usually done a few days later than that determined by the last period.
GESTATIONAL AGE VARIOUSLY DEFINED
Lateral view of embryo-fetus at 56 days, which marks the end of the embryonic period and the beginning of the fetal period. In contrast, after 36 weeks, fetal crown-rump length averages about 32 cm and weight is approximately 2500 g.
PLACENTAL PHYSIOLOGY AND FETAL GROWTH
Short-term uteroplacental blood flow is estimated to be 700 to 900 ml/min, with most blood apparently going to the intervillous space. Due to the continuous passage of oxygen from the maternal blood in the interspace to the fetus, its oxygen saturation resembles that in the maternal capillaries.
FETAL NUTRITION
Fatty acids transferred to the fetus can be converted to triacylglycerols in the fetal liver. Zinc concentrations in fetal plasma are also greater than those in maternal plasma.
FETAL ORGAN SYSTEM DEVELOPMENT
Plasma Proteins
Two primitive urinary systems - the pronephros and the mesonephros - develop before the development of the metanephros, which forms the terminal kidney (chap. At this stage, respiratory bronchioles give rise to primitive lung alveoli - terminal sacs.
DEVELOPMENT OF GENITALIA
Pulmonary lecithin synthesis in the human fetus and neonate and etiology of respiratory distress syndrome. Schwartz R, Gruppuso PA, Petzold K, et al: Hyperinsulinemia and macrosomia in the fetus of the diabetic mother.
PRECONCEPTIONAL AND PRENATAL CARE
However, there are prospective observational and case-control studies that demonstrate the success of preconceptional counseling. Moos and colleagues (1996) assessed the effectiveness of a preconception counseling program administered during routine health care in reducing unintended pregnancies.
COUNSELING SESSION
MEDICAL HISTORY
In this study, increased malformation rates could only be detected in the offspring of women who had been exposed to anticonvulsant treatment. They identified an increased malformation risk only in women exposed to valproic acid (5.6 percent) and polytherapy (6.1 percent).
GENETIC DISEASES
The American College of Obstetricians and Gynecologists (2013b) recommends that individuals of high-risk ancestry be offered carrier screening to allow them to make informed decisions regarding reproduction and prenatal diagnosis. One method—preimplantation genetic diagnosis—discussed in Chapter 14 (p. 301)—is available for patients at risk for certain thalassemia syndromes (Chen, 2008; Kuliev, 2011).
REPRODUCTIVE HISTORY
Most individuals of Jewish descent in North America are descended from Ashkenazi Jewish communities and are at increased risk of having offspring with one of several autosomal recessive disorders.
PARENTAL AGE
Other obstetric morbidities, such as placenta previa and abruption, are also risks associated with ART (Fong, 2014). In this analysis, after adjustment for maternal age and other risk factors, intracytoplasmic injection was still associated with a significantly increased risk of malformations, but in vitro fertilization was not.
SOCIAL HISTORY
According to the American College of Obstetricians and Gynecologists (2012a), approximately 324,000 pregnant women are abused each year. As discussed in Chapter 47 (p. 951), intimate partner violence has been associated with an increased risk for several pregnancy-related complications, including hypertension, vaginal bleeding, hyperemesis gravidarum, preterm birth, and low birth weight infants. birth (Silverman, 2006).
SCREENING TESTS
Davies MJ, Moore VM, Willson KJ, et al: reproductive technologies and the risk of birth defects. Johnson K, Posner SF, Biermann J, et al: Recommendations to improve preconception health and health care - United States.
DIAGNOSIS OF PREGNANCY
As discussed in Chapter 1 (p. 5), the relatively low current maternal mortality rate of approx. 10 to 15 per 100,000 probably associated with the high utilization of prenatal care (Xu, 2010). A second antibody is then added, binds to a different site on the hCG molecule, and "sandwiches" the bound hCG between the two antibodies.
INITIAL PRENATAL EVALUATION
As such, only about 15 percent of pregnancies could be diagnosed at the time of the missed period. Gestational or menstrual age is thus the number of weeks since the beginning of the last period.
SUBSEQUENT PRENATAL VISITS
Selected Genetic Screening
Some examples include testing for Tay-Sachs disease in persons of Eastern European Jewish or French Canadian descent; β-thalassemia in persons of Mediterranean, Southeast Asian, Indian, Pakistani or African descent; α-thalassemia in individuals of Southeast Asian or African descent. ; sickle cell anemia for people of African, Mediterranean, Middle Eastern, Caribbean, Latin American, or Indian descent; and trisomy 21 for those with advanced maternal age.
NUTRITIONAL COUNSELING
Later intellectual development was studied by Stein and associates (1972) in young male adults whose mothers had starved during pregnancy in the famine winter. Not all weight gained during pregnancy is lost during and immediately after birth (Hytten, 1991).
