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A. Overviewnavigator

  1. Ectopic Pregnancy
  2. Breech Birth (see below)
  3. Postpartum Psychiatric Disorders [1]
    1. Postpartum Depression (see below)
    2. Postpartum Psychosis
    3. Disorders of Mother-Infant Relationship
    4. Post-Traumatic Stress Disorder (PTSD)
    5. Peripartum Anxiety Disorders
  4. Uterine Rupture [2,3]
    1. >90% of cases related to labor trial after previous Cesarean delivery
    2. Complete uterine rupture associated with maternal blood transfusion, neonatal hypoxia
    3. Incomplete rupture, also called uterine dehiscence, has much less morbidity
    4. A trial of labor after prior cesarean delivery lead to 0.7% symptomatic uterine rupture
    5. Endometritis was 2.9% with labor trial after prior cesarean delivery versus repeat cesarean delivery
  5. Bladder Incontinence [6]
    1. Overall incontinence prevalence is 10.1% in nulliparous women
    2. In women who have undergone Cesarean (C-) section, prevalence 15.9%
    3. In women with history of vaginal deliveries, prevalence is 21%
  6. Bleeding
    1. First 20 weeks
    2. Final 20 weeks
    3. Peripartum Hemorrhage
  7. Hypertension
    1. Pregnancy Induced Hypertension
    2. Preeclampsia - hypertension, proteinuria, edema
    3. Microangiopathic Hemolytic Anemia (HELLP Syndrome)
    4. Eclampsia - preeclampsia with seizure
    5. May be associated with flare of systemic lupus
  8. Diabetes mellitus / Gestational diabetes
  9. Venous Thromboembolic Disease
    1. Mainly deep vein thrombosis (DVT)
    2. Pulmonary Embolism
  10. Peripartum Cardiomyopathy
  11. Liver and Gastrointestinal Disease
    1. Hyperemesis Gravidarum
    2. Acute Fatty Liver of Pregnancy
    3. Gallstones and other Cholestatic Liver Disease
    4. Hepatitis (HELLP Syndrome)
    5. Viral Hepatitis - particularly Hepatitis B
  12. Generalized Weight Gain
    1. Increased risk of diabetes
    2. Low back pain
  13. Autoimmune Disease
    1. Increased risk of developing autoimmune diseases 3-12 weeks post-partum [8]
    2. Increased risk of flare of systemic lupus erythematosus (SLE) including nephritis
    3. Systemic Sclerosis - fetal cells circulating in maternal system may play role
    4. Immune thrombocytopenia purpura (ITP; see below)
  14. Stillbirth [5]
    1. Occurs in ~1 per 200 pregnancies in developed countries
    2. Nulliparity, advanced age, obesity, smoking are most common risk factors
    3. Small for gestational age (SGA) is a major risk factor
    4. Abnormally elevated maternal hemoglobin antepartum is a ~2X risk for stillbirth [19]
    5. Low pregnancy associated plasma protein A (PAPP) in first trimester associated with ~40X increased risk of stillbirth associated with growth retardation [32]
    6. Elevated levels of amniotic fluid S100B protein strongly associated with mid-gestation and intrauterine fetal death [31]
    7. Placental dysfunction likely responsible for most stillbirths
    8. Hypertensive disorders, diabetes mellitus, systemic lupus, chronic renal disease, and thyroid disorders associated with increased risk of stillbirths [5]
    9. Currently no effective screening test
  15. Meconium Stained Amniotic Fluid [33]
    1. Occurs in ~15% of term births
    2. Increased in premature infants and in cystic fibrosis
    3. Aspiration of meconium leading to pneumonitis occurs in ~20% of meconium staining
    4. Case fatality rate in meconium aspiration syndrome ~22%
    5. Prophylactic pharyngeal suction and tracheal aspiration do not reduce syndrome risk
    6. Amnioinfusion (transcervical infusion of saline to amniotic cavity) did not reduce risk of moderate to severe meconium aspiration syndrome in women with meconium staining [33]
  16. Spontaneous Abortion
  17. Infection
  18. Sleep Disorders [20]
    1. Estrogen and progesterone both affect many stages of sleep
    2. Estrogen reduces REM sleep
    3. Progesterone increases non-REM sleep (perhaps through GABA receptor agonism)
    4. All stages of pregnancy have decreased stage 3 and 4 non-REM sleep
    5. First trimester: increased total sleep time with naps, increased nocturnal insomnia
    6. Second trimester: normalization of total sleep time but with increased awakening
    7. Third trimester: decreased total sleep time, increased insomnia and nocturnal awakening
    8. In addition, sleep disordered breathing occurs in pregnancy (increased small airway closure)
    9. Zolpidem (Ambien®) or diphenhydramine (Benadryl®) can be used during pregnancy
    10. May be a component of postpartum depression
    11. Pregnancy associated sleep disorder is clearly recognized
  19. Increased Levothyroxine Requirements [29]
    1. In women with hypothyroidism on levothyroxine replacement therapy
    2. Levothyroxine requirements increase during pregnancy by up to 30%
    3. Levothyroxine dose adjustments should be made from 5th week gestation onward
  20. Postpartum aortic dissection - rare but well described [28]
  21. Preterm Labor / Premature Infants
  22. History of invasive treatment for cervical pre-/cancerous lesions associated with 2-3X increased risk of premature delivery, low birth weight, and caesarian section [4]
  23. Women whose infants die from SIDS have increased ~2X risk of subsequent pregnancy complications including preterm birth, small for gestational age [35]

B. Ectopic Pregnancy navigator

  1. About 0.5% of all births in USA are ectopic
  2. Defined as any implantation that develops outside of the endometrium
  3. About 95% occur in fallopian tube, 80% at ampulla
    1. Most often associated with previous gynecologic infection (which caused scarring)
    2. Tubal wall is thin, and easily invaded with bleeding occurring
    3. Tubal rupture usually occurs by the 12th week of gestation
  4. Progression of Condition
    1. Major problem is invasion of structure by trophoblast
    2. This leads to bleeding into peritoneum, often with rapid blood loss
    3. Tubal rupture is life threatening and may lead to hemorrhagic shock
    4. Abdominal pain is major initial complaint
    5. Medical emergency
  5. Fallopian Tube Blood is Ectopic Pregnancy until proven otherwise
    1. Diagnosis made with hCG and ultrasound or diagnostic laparoscopy
    2. Non-clotting blood into peritoneum (due to exhaustion of clotting factors)
    3. Medical emergency
  6. Termination
    1. Methotrexate (MTX) is current mainstay of therapy
    2. Up to three doses of intramuscular methotrexate (50mg/m2) are used
    3. Women with HCG >10,000 mIU/mL have high failure rates with methotrexate [13]
    4. MTX + Misoprostal is more effective than MTX alone for terminating pregnancies
    5. Vaginal misoprostal is preferred over oral route
    6. These agents may be also be used for elective abortions
    7. Combination of agents is more effective than misoprostal alone
    8. RU486 (mifepristone) is also effective but not approved in USA
    9. Surgery may be required, usually with HCG levels >10,000 at initiation of treatment

C. Breech Birth [17,23] navigator

  1. About 4% of term pregnancies have fetus in breech presentation
  2. Planned Caesarean (C-) section is usually preferred method for delivery
  3. In women with breech presentation and planned vaginal delivery, >40% required C-section
  4. Perinatal and neonatal mortality are less with planned C-section versus planned vaginal
  5. Reduced incidence of maternal incontinence following planned C-section versus urgent
  6. Serious neonatal morbidity is also less with planned C-section versus planned vaginal
  7. Maternal mortality or serious morbidity do not differ with these methods

D. Postpartum Depression [21,25] navigator

  1. Likely caused by rapid decline in reproductive hormones
    1. Nonpsychotic major depression occurs in 10-15% within 6 months of giving birth
    2. Psychotic major depression (hallucinations, delusions) occurs less frequently
  2. Risk Factors include
    1. History of major depression
    2. Premenstrual dysphoric disorder
    3. Psychosocial stress and inadequate social support also risk factors
  3. Postpartum psychosis usually a manifestation of bipolar disorder
  4. High risk for doing harm to infants, particularly with psychotic symptoms
  5. Immediate referral for any patient with suicidal or thought of harm to infant
  6. Treatment
    1. Initial treatment with agent which has previously been effective should be used
    2. Sertraline or fluvoxamine, paroxetine recommended for lactating mothers
    3. Citalopram, desipramine, venlafaxine are acceptable second line for lactating mothers
    4. Electroconvulsive therapy (ECT) very effective for refractory depression
    5. Psychotherapy + fluoxetine no better than fluoxetine alone

E. Venous Thromboembolic (VTE) Disease [18,34] navigator

  1. Pregnancy induces a hypercoagulable state
    1. VTE risk is increased about 2 fold during pregnancy
    2. VTE risk is increased >5 fold in peripartum period, mainly in the month after delivery
    3. Incidence of VTE in pregnant or postpartum women is ~200 per 100,000 women-years [34]
    4. DVT incidence is ~3X higher than PE incidence in this population
  2. Underlying coagulopathy (thrombophilia) is usually found in pregnancy associated VTE [11]
  3. Underlying Thrombophilias [11,18]
    1. About 20% of pregnant women with VTE have Factor V Leiden
    2. Acquired or genetic Protein S deficiency is fairly common
    3. Antithrombin (AT3) or protein C deficiencies
    4. Prothrombin (Factor II) mutation G20210A
    5. Antiphospholipid (anticardiolipin) antibodies [7]
    6. Methylenetetrahydrofolate reductase (MTHFR) mutations
    7. These mutations may also predispose to other pregnancy complications [11]
  4. Factor V Leiden (FVL) and Prothrombin G20210A mutations [14,18]
    1. FVL increases risk of DVT during pregnancy by >9X
    2. FVL + prothrombin G20210A has increases risk of DVT during pregancy >100X
    3. Screening for FVL + prothrombin mutations in pregnant women with DVT history is strongly advocated; primary screening is of unclear benefit
  5. Prophylaxis in Pregnant Women with a History of VTE [18]
    1. Recurrence of pregnancy associated VTE in women with history is 0-13% (~6%)
    2. Warfarin is usually given for 4-6 weeks post-partum to INR of 2.0-3.0
    3. Warfarin may NOT be given during pregnancy
    4. Standard or low molecular weight heparin may be given during pregnancy
    5. However, routine antepartum prophylaxis with heparin is not warrented [18]
    6. Postpartum prophylaxis with warfarin is warrented due to increased risk

F. Infection and Pregnancy navigator

  1. "TORCHS" Diseases and Intrauterine Infections are major concerns
  2. "TORCHS" Diseases primarily affect the Fetus
    1. Toxoplasmosis
    2. Other: pelvic inflammatory disease, bacterial vaginitis (increased risk of prematurity)
    3. Rubella
    4. Cytomegalovirus (CMV)
    5. Herpes Simplex Virus (HSV) and Human Immunodeficiency Virus (HIV)
    6. Syphylis
  3. Screening
    1. Rubella titers should be obtained during first or second trimesters
    2. Screening for evidence of active syphilis with RPR is usually done
    3. In immunodeficient persons, toxoplasmosis and CMV are major concers
    4. HIV testing is strongly recommended in ALL pregnant women
    5. This is particularly critical because zidovudine reduces fetal transmission and is safe
  4. Congenital CMV [26]
    1. Sensorineural hearing loss (leading cause in USA)
    2. Cognitive impairment
    3. Cerebral palsy
    4. Visual impairment
    5. Virus transmitted to fetus during primary maternal infection during pregnancy
    6. Naturally acquired immunity leads to ~70% reduction in risk of congenital CMV infection
  5. Genital HSV During Pregnancy
    1. About 2% of women aquire genital HSV during pregnancy
    2. Main problem is active HSV infection (or other disease) during delivery
    3. Examination of genitalia prior to deliver is important
    4. Strongly consider Cesarean Section in acutely HSV infected
    5. Consider acyclovir treatment in infected persons and in potentially infected newborns
  6. Parvovirus B19 [12]
    1. Infection during pregnancy may increase risk of fetal death
    2. Most often contracted from exposure to mother's household children
    3. Nursery school teachers also have increased risk
  7. Group B Streptococcus (GBS) [36]
    1. Major cause of sepsis and meningitis in newborn infants in USA
    2. Pregnancy-related morbidity and mortality including prematurity
    3. All pregnant women should be tested [3]
    4. Patients testing positive tests should receive antibiotic prophylaxis
    5. Antibiotic prophylaxis for group B strep infections in pregnancy reduced disease []
  8. Bacterial Vaginosis in Pregnancy [9,10]
    1. Most common lower genital tract syndrome among women of reproductive age
    2. Lower genital tract infections associated with increased risk of preterm delivery
    3. Randomized trial data recommend against routine screening for bacterial vaginosis in asymptomatic women at low risk for preterm delivery
  9. HIV and Pregnancy
    1. Course of HIV disease is not affected by pregnancy
    2. Antiretroviral therapy is not associated with increased pregnancy complications [24]
  10. Intrauterine Infections
    1. Likely cause PROM and premature births [15]
    2. Chorioamnionitis is a risk factor (1.6-4.7X) for cerebral palsy [16]
    3. Early detection of infection in amniotic fluid is critically important
    4. Elevated levels of calgranulin B and a fragment of IGF-1 found in intra-amniotic infection [30]
  11. Hepatitis E Virus can cause fulminant hepatic failure in pregnant women
  12. Post-partum Fever

G. ITP in Pregnancy [22] navigator

  1. Incidence is 0.1-0.2% of pregnancies
  2. Thrombocytopenia in Pregnancy: Differential Diagnosis
    1. HELLP Syndrome
    2. Benign thrombocytopenia of pregnancy (gestational thrombocytopenia)
  3. Treatment
    1. Generally for symptomatic disease or platelets <20K/µL
    2. Glucocorticoids avoided if possible (gestational diabetes, hypertension)
    3. IVIg is currently treatment of choice in pregnant women
  4. Epidural anesthesia is contraindicated for platelets <50-100K/µL
  5. Monitor newborn platelet levels which are often reduced

References navigator

  1. Brockington I. 2004. Lancet. 363(9405):303 abstract
  2. Kieser KE and Baskett TF. 2002. Obstet Gynecol. 100(4):749 abstract
  3. Landon MB, Hauth JC, Leveno KJ, et al. 2004. NEJM. 351(25):2581 abstract
  4. Kyrgiou M, Koliopoulos G, Martin-Hirsch P, et al. 2006. Lancet. 367(9509):489 abstract
  5. Smith GC and Fretts RC. 2007. Lancet. 370(9600):1715 abstract
  6. Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S. 2003. NEJM. 348(10):900 abstract
  7. Magee CC. Coggins MP, Foster CS, et al. 2008. NEJM. 358(3):275 (Case Record) abstract
  8. Williams WW, Ecker JL, Thadhani RI, Rahemtullah A. 2005. NEJM. 353(24):2590 (Case Record) abstract
  9. US Preventive Services Task Force. 2008. Ann Intern Med. 148(3):214 abstract
  10. Nygren P, Fu R, Freeman M, et al. 2008. Ann Intern Med. 148(3):220 abstract
  11. Kupferminc MJ, Eldor A, Steinman N, et al. 1999. NEJM. 340(1):1
  12. Valeur-Jensen AK, Pedersen CB, Westergaard T, et al. 1999. JAMA. 281(12):1099 abstract
  13. Lipscomb GH, McCord ML, Stovall TG, et al. 1999. NEJM. 341(26):1974 abstract
  14. Gerhardt A, Scharf RE, Beckmann MW, et al. 2000. NEJM. 342(6):374 abstract
  15. Goldenberg RL, Hauth JC, Andrews WW. 2000. NEJM. 342(20):1500 abstract
  16. Wu YW and Colford JM Jr. 2000. JAMA. 284(11):1417 abstract
  17. Hannah ME, Hannah WJ, Hewson SA, et al. 2000. Lancet. 356(9239):1375 abstract
  18. Brill-Edwards P, Ginsberg JS, Gent M, et al. 2000. NEJM. 343(20):1439 abstract
  19. Stephansoon O, Dickman PW, Johansson A, Cnattingius S. 2000. JAMA. 284(20):2611 abstract
  20. Santiago JR, Nolledo MS, Kinzler W, Santiago TV. 2001. Ann Intern Med. 134(5):396 abstract
  21. Miller LJ. 2002. JAMA. 287(6):762 abstract
  22. Cines DB and Blanchette VS. 2002. NEJM. 346(13):995 abstract
  23. Hannah ME, Hannah WJ, Hodnett ED, et al. 2002. JAMA. 287(14):1822 abstract
  24. Tuomala RE, Shapiro DE, Mofenson LM, et al. 2002. NEJM. 346(24):1863 abstract
  25. Wisner KL, Parry BL, Piontek CM. 2002. NEJM. 347(3):194 abstract
  26. Fowler KB, Stagno S, Pass RF. 2003. JAMA. 289(8):1008 abstract
  27. O'Gara PT, Greenfield AJ, Afridi NA, Houser SL. 2004. NEJM. 350(16):1666 (Case Record) abstract
  28. Alexander EK, Marqusee E, Lawrence J, et al. 2004. NEJM. 351(3):241 abstract
  29. Gravett MG, Novy MJ, Rosenfeld RG, et al. 2004. JAMA. 292(4):462 abstract
  30. Florio P, Michetti F, Bruschettini M, et al. 2004. Lancet. 364(9340):270
  31. Smith GCS, Crossley JA, Aitken DA, et al. 2004. JAMA. 292(18):2249 abstract
  32. Fraser WD, Hofmeyr J, Lede R, et al. 2005. NEJM. 353(9):909 abstract
  33. Heit JA, Kobbervig CE, James AH, et al. 2005. Ann Intern Med. 143(10):697 abstract
  34. Smith GC, Wood Am, Pell JP, Dobbie R. 2005. Lancet. 366(9503):2107 abstract
  35. Gibbs RS and Roberts DJ. 2007. NEJM. 357(9):918 (Case Record) abstract
  36. Schrag SJ, Zell ER, Lynfield R, et al. 2002. NEJM. 347(4):233 abstract