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The sympathetic nerves are a reserve mechanism to improve the pumping activity of the heart during intermittent stressful situations. The waning enthusiasm for midpelvic forceps deliveries has contributed to the increased number of cesarean deliveries in the "dystocia" category. These agents act to relax smooth muscle in the bronchial tree, blood vessels, and myometrium through stimulation of the -receptors. Among the 51 infants delivered vaginally, there were 4 deaths, 3 of which were the result of tentorial tears. Proteinuria in the presence of hypertension is the most reliable indicator of fetal jeopardy. The rationale for this calculation, commonly known as the Fick principle, is as follows. Barr M: Teratogen update: angiotensinconverting enzyme inhibitors, Teratology 50: 399, 1994. Pregnancy introduces an additional challenge to this system because the risk of hemorrhage during placentation and the third stage of labor is high. The mechanisms by which treatment for pre-invasive disease increases the risk for prematurity are unclear. Adverse event reports summarized in the product labeling indicates that of 77 pregnancies exposed to mycophenolate, 25 spontaneously aborted, and 14 resulted in a malformed infant or fetus. This success has been attributed to many factors: the movement of most births to hospitals, improved hygiene and aseptic technique, common use of prenatal care including screening for preeclampsia, the introduction of blood transfusions and antibiotics, widespread availability of obstetric anesthesia, an increase in training and expertise of obstetric providers, and an improvement in the overall health of the population. Most studies of maternal mortality categorize maternal deaths by the causal pathway, regardless of the final event that led to cessation of heart and lung function, so the latter may not appear on the death certificate. Myatt L, Brewer A, Brockman D: the action of nitric oxide in the perfused human fetalplacental circulation, Am J Obstet Gynecol 164:687, 1991. American College of Obstetricians and Gynecologists: Prevention of early-onset group B streptococcal disease in newborns. General endotracheal anesthesia is used, taking advantage of the myorelaxant and uterine contraction suppression qualities of halogenated anesthetic gases. Whether induction is elective or indicated, adequate stimulation of uterine contractions is important in reducing the incidence of failed induction of labor. For example, in D-type transposition of the great vessels, the aorta arises from the right ventricle, and the pulmonary artery from the left. Overall, recurrent hydrops fetalis is unusual, and for most families the prognosis is good for a normal pregnancy in the future. Therefore, splitting of the second heart sound is paradoxical and is heard in expiration instead of inspiration. If an abnormality is found or these measurements are abnormal in a particular fetus, that fetus is selected for reduction. Pinto N, Keenan H, Minich L, et al: Barriers to prenatal detection of congenital heart disease: a population based study, Ultrasound Obstet Gynecol 40:418, 2012.

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Peak systolic measurements should be made with electronic calipers; automated software to trace the waveform typically underestimates the true peak velocity. This score was not predictive of outcome in this series, as the overall perinatal mortality rate was close to 100%. Cesarean delivery rates vary widely worldwide, from as low as 5% in Bolivia to as high as 40% in Chile. Moreover, should the space around the heart be filled with fluid, either circumferentially or with a depth of greater than 2 mm, further evaluation may be indicated. Since licensure of the first measles vaccine in 1963, the incidence of infection has decreased by almost 99%. Predictive values, unlike sensitivity and specificity, depend on the prevalence of the outcome in the population tested. Doppler velocimetry is not recommended unless fetal growth restriction is observed. Nicholson and colleagues134 and Caughey and colleagues135 questioned the conventional wisdom that induction is a risk factor for abdominal delivery. The infant mortality rate is the number of deaths of liveborn infants before 1 year of age per 1000 live births; stillbirths are not included in the denominator. Gordon A, Raynes-Greenow C, McGeechan K, et al: Stillbirth risk in a second pregnancy, Obstet Gynecol 119:509, 2012. Life-threatening umbilical cord stump hemorrhage has occurred in affected newborns. In late pregnancy, uterine and placental blood flow is reduced profoundly by postural effects on uterine perfusion. It summarized all published studies with the highest level of evidence and concluded that umbilical arterial Doppler studies significantly decreased the likelihood of perinatal death, cesarean delivery, and labor induction. The record above the aortic pressure tracing is a phonocardiogram showing the systolic murmur. Two thirds of eclampsia cases occur in first pregnancies, but two thirds of maternal deaths due to eclampsia occur in pregnancies other than the first pregnancy, in which underlying hypertension is a more common disposing factor. In addition to labor and delivery personnel, emergency department staff and primary care providers must also recognize that women who present in the third trimester with nausea, vomiting, or malaise should have a complete blood count including platelets, and liver function tests should be completed before discharge home. This finding raises interesting questions regarding the role of the gut microbiota in early life and the risk of later obesity. These findings indicate that vasopressin probably participates in fetal circulatory responses to stress not only directly but also by enhancing pressor responses to other vasoactive substances. One major disadvantage of epidural block for cesarean delivery is the time required for the onset of operative anesthesia, which could preclude its use in many emergency situations. However, it is the multiplanar data that often contributes the most information diagnostically. Most of the fluid moves rapidly into the interstitial spaces and then directly into the pulmonary vasculature, with clearance of less than 20% of the fluid by pulmonary lymphatics. This panel was initially composed of pan-ethnic detection of 25 mutations, but in 2004 the number was reduced to 23. For a woman who is contemplating pregnancy, the need for aortic valve replacement constitutes the grounds on which the medical advisor should caution against pregnancy and make the patient fully understand the consequences of choosing otherwise. A group of nulliparas and a group of multiparas were selected who had no apparent complications of labor and who delivered normal infants. This, in turn, would expose placental antigens to a more cytotoxic maternal immune response. However, with the definition of a probability value in mind (see preceding paragraph), readers should wonder whether a probability value of 0. Bartels I, Hansmann I, Holland U, et al: Down syndrome at birth not detected by firsttrimester chorionic villus sampling, Am J Med Genet 34:606, 1989.

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• Life-threatening allergic reaction
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The rate of infusion should be modified for patients with compromised renal function. Hemminki E: Impact of caesarean section on future fertility: a review of cohort studies, Paediatr Perinat Epidemiol 10:366, 1996. After completion of the fetal portion of the procedure, the uterus is closed in two layers with resorbable sutures, amniotic fluid volume is restored, intra-amniotic antibiotics are administered, and magnesium sulfate is initiated. After pressure has been applied, and three measurements that fully satisfy the criteria in the table have been obtained that vary by less than 10%, the shortest of these is chosen and recorded as the "shortest best. Michelfelder E: Doppler echocardiographic characterization of the fetus in distress, Prog Pediatr Cardiol 22:31, 2006. At the other end of the spectrum is the case of a footling breech presentation or genital herpes simplex infection, in which the operation is performed entirely for the benefit of the fetus, with no advantages to the mother apart from the reassurance that it may help her infant. A host of sociodemographic factors have been associated with an increased risk for stillbirth. All pregnant women with known underlying cardiac disease should have a consultation with and be co-managed by a maternal-fetal medicine specialist and a cardiologist. Because previous studies had associated short- and long-term follow-up characteristics to distinct placental lesions,510-513 the results of histologic examination of the placenta (as performed by a perinatal pathologist) was used as an intermediate-outcome variable when evaluating performance of new diagnostic tests. Cates W Jr: Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. Antiphospholipid antibodies are immunoglobulins directed against proteins bound to negatively charged (anionic) phospholipids. Serial reduction amniocenteses were suggested as a path to equilibrate amniotic fluid volume across the dividing membrane and to reduce overall intrauterine pressure. Therefore, focusing solely on heavily colonized women in preventive approaches is inadequate. The generally downward trend in the syphilis rate was temporarily interrupted in the late 1970s and early 1980s when the rates of primary and secondary syphilis began increasing, in large part due to increases among men having sex with men. Most recent studies using molecular genetic testing have estimated a prevalence of 1 in 4000 males. Warburton D, Kline J, Stein Z, et al: Does the karyotype of a spontaneous abortion predict the karyotype of a subsequent abortion Uehara S, Yaegashi N, Maeda T, et al: Risk of recurrence of fetal chromosomal aberrations: analysis of trisomy 21, trisomy 18, trisomy 13, and 45,X in 1,076 Japanese mothers, J Obstet Gynaecol Res 25:373, 1999. Women with normally functioning biologic valve replacements tolerate pregnancy well. Multiple Gestations the diagnosis of cervical insufficiency cannot be made reliably in women with multiple gestations. The oxygen saturation of blood in the hepatic veins reflects this difference in perfusion saturation. The 95% confidence intervals are also interpreted in the same fashion as those for relative risks. Atosiban has minimal maternal side effects and an efficacy that is comparable with that of other tocolytics. Persistent masses are more likely to result in torsion (1%22%), rupture (0%-9%), or obstruction of labor (2%-17%). A recent retrospective, multicenter study showed newborn survival rates of 97% in prenatally detected cases of vasa previa and a fetal loss rate of 56% in cases not identified before the commencement of labor. Although 9 of the 12 fetuses with prenatal intervention survived until birth (mean gestational age at birth, 33 weeks), 6 of the 7 cases with hydrops at presentation resulted in fetal or neonatal demise. A positive test is believed to indicate disruption of the maternal-fetal decidual attachment. Ultrasound gel is placed on a transvaginal probe before covering it with a condom or specialized probe cover.

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During the third trimester, this right-sided predominance may become more pronounced. In this closely monitored environment, expectant management of severe preeclampsia remote from term may be considered, with particular attention to laboratory studies, fetal well-being, and blood pressures. Because peripheral blood leukocytosis occurs commonly in normal labor, a high white blood cell count (>15,000/mL) supports, but is not diagnostic of, infection. Another limitation is the inability to evaluate an agent for a spectrum of outcomes that have not been identified as part of the anomaly pattern. Brain sparing is seen as progressive abnormalities in umbilical artery circulation. Co-twin survival was just under 90%, with a median gestational age at birth of 36 weeks. Minor fetal complications include cephalhematomas and retinal hemorrhages, which are usually benign and self-limited. The fetal head is imaged in a transverse plane, the plane used to measure the biparietal diameter. However, in our experience, it has been useful to evaluate the intracranial anatomy using multiplanar displays, including obliteration of the fourth ventricle, in first-trimester fetuses with Chiari malformation. This technology identifies submicroscopic deletions and duplications that may be associated with human disease. If cesarean delivery is performed after an extended period of labor and ruptured membranes, the incidence of endometritis is approximately 30% to 35% without antibiotic prophylaxis and approximately 10% or even less with prophylaxis. Also, antenatal corticosteroids have similar maturational effects on other organs including the brain, kidneys, and gut. Kaar K, Joupilla P, Kuikka J, et al: Intervillous blood flow in normal and complicated late pregnancy measured by means of an intravenous Xe133 method, Acta Obstet Gynecol Scand 59:7, 1980. Their normative data will likely be of particular value in the evaluation for Down syndrome markers in late-to-care gestations. Placental separation usually is complete by the time two contractions have occurred, although several additional contractions may be necessary to accomplish expulsion of the placenta from the uterus. The lung microvasculature continues to increase, as does the gas-exchange surface area of the lung. Gembruch U, Niesen M, Hansmann M, et al: Listeriosis: a cause of non-immune hydrops fetalis. Many states have adopted systems of regionalized perinatal care in recognition of the advantages of concentrating care for preterm infants, especially those born before 32 weeks. The higher incidence of neonatal respiratory morbidity associated with repeat cesarean delivery in patients not in labor compared with those who are in labor suggests that labor is the signal that crucial physiologic changes have occurred to prepare a fetus for extrauterine life. Color flow Doppler imaging may be necessary to distinguish cysts from vascular structures. Vitamin K antagonists should be avoided in pregnancy because they are associated with congenital malformations (especially with exposure from 6 to 12 weeks) and with fetal and neonatal hemorrhage after second- and third-trimester exposure. Notably, it is accepted that some conditions such as bronchogenic cysts and bronchial atresia may be difficult to distinguish until resection. These common risk factors may include human papilloma viruses and other microbial infections in the cervix, or defects in the immune response. Approximately 50% to 60% of women of reproductive age have evidence of prior infection, and immunity is long-lasting. Bonduelle M, Lissens W, Goossens A, et al: Lysosomal storage diseases presenting as transient or persistent hydrops fetalis. Present recommendations are that invasive prenatal diagnosis be offered at this cutoff. Levels of team performance are seen to deteriorate during periods of low and high workload.

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Because of the ample collateral circulation, there appear to be no long-term consequences of hypogastric artery ligation, and women have delivered normal infants in subsequent pregnancies after undergoing this procedure. The characteristic lesion of rheumatic heart disease is mitral stenosis, and the next most common manifestation is the combination of mitral stenosis with aortic regurgitation. Actual measurements of immune complexes in preeclampsia are inconsistent because of widely different methodologies and definitions of preeclampsia. Page E: the relation between hydatid moles, relative ischemia of the gravid uterus, and pla- 36. Because of the important role of hormones in pregnancy establishment and maintenance, polymorphisms in genes encoding hormones and hormone receptors have been evaluated. The primary impact on perinatal mortality rate, however, comes from improvements in neonatal care. Duley L, Henderson-Smart D: Magnesium sulphate versus phenytoin for eclampsia, Cochrane Database Syst Rev (10):D000128, 2003. These include ventriculomegaly, microcephaly, frontal bone scalloping (lemon sign), and obliteration of the cisterna magna with either an "absent" cerebellum or an abnormal anterior curvature of the cerebellar hemispheres (banana sign). Cervical cytology screening for premalignant lesions of the cervix is an example of a successful screening program that fulfills all of these criteria. More chorionic tissue is obtained by the transcervical method, but the proportion of cases in which less than 10 mg is obtained is similar in both groups. Efstratiou A, Singh B: Combined spontaneous postpartum coronary artery dissection and pulmonary embolism with survival, Cathet Cardiovasc Diagn 31:29, 1994. Third, the pathogenetic changes of preeclampsia occur long before manifestation of clinical criteria leading to the diagnosis. Visualization of the two needle tips on alternate sides of the membrane confirms sampling of both fetuses. For binary risk factors that are either present or absent, likelihood ratios are determined by comparing the frequency of positive tests in affected pregnancies to the frequency in normal pregnancies. The fetal heart rate should be monitored intermittently with Doppler or real-time scanning. Chitkara U, Cogswell C, Norton K, et al: Choroid plexus cysts in the fetus: a benign anatomic variant or pathologic entity In alobar, the most severe type, there is complete lack of division of the forebrain with absent midline structures. Although abnormalities of the female (X) and male (Y) sex chromosomes are frequently lethal (80% to 95% result in firsttrimester spontaneous abortions), they could be a cause of growth restriction in a newborn. However, an antistaphylococcal antibiotic should be added to the treatment regimen. Because most early pregnancy losses are associated with aneuploidy, thrombophilias are unlikely to play a role. Deprest J, Ville Y, Barki G, et al: Endoscopy in fetal medicine, Tuttlingen, Germany, 2004, Endopress. American College of Obstetricians and Gynecologists, Committee on Ethics: Committee opinion no. However, because no other thrombophilias were associated with stillbirth, the authors concluded that routine thrombophilia testing after stillbirth is not warranted. Restriction of the duration of treatment to less than 24 hours, careful ongoing attention to fluid status, and detection of complicating conditions such as intrauterine infection may reduce this risk. Blood or semen contamination, alkaline antiseptics, and bacterial vaginosis can cause false-positive nitrazine test results. Renal failure with a marked rise in serum creatinine concentration by 1 mg/dL over baseline or urine output less than 0. Recognizing the influence of human error and interpersonal interactions in airline accidents, the aviation industry took an early lead in adverse outcome reduction in the 1980s. Because no dye marker is available to ensure retrieval from a gestation, a backup amniocentesis should be offered if there is any suspicion that two separate samples have not been obtained and if the fetal sexes are concordant. This is usually associated with reduced uteroplacental blood flow and impaired villous growth and development. Society for Maternal-Fetal Medicine Publications Committee: Doppler assessment of the fetus with intrauterine growth restriction, Am J Obstet Gynecol 206:300, 2012. This infection typically develops within the first 10 days of life and results from transplacental transmission of the virus.

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After a desired effect has been safely achieved, digoxin is administered orally two to four times daily, usually at 0. Geiger J-M, Baudin M, Saurat J-H: Teratogenic risk with etretinate and acitretin treatment, Dermatology 189:109, 1994. The frequency of seroconversion during pregnancy is approximately 5%, and about 3 in 1000 infants show evidence of congenital infection. Host factors linked to both subfertility and preterm birth, and medication effects, are other possible explanations for these associations. Daily, or twice-daily, fetal testing should be performed in cases of absent or reversed end-diastolic flow until delivery is accomplished. Pathologic Fetal Acidemia What level of umbilical artery pH should be considered abnormal, pathologic, or clinically significant Evidence suggests that significant morbidity is more likely among neonates with umbilical artery pH values lower than 7. The aspirin and calcium data suggest that initiation of therapy before disease is clinically evident may be successful in appropriately selected subjects. Starting a pregnancy under these circumstances is not advisable, and aggressive treatment (including coronary angiography followed by percutaneous coronary intervention or coronary artery bypass surgery) is recommended. Before viability, in utero therapy can be offered in cases of "imminent" or evident fetal heart failure consisting of intrauterine fetal transfusion168,169 with or without interruption of the vascular supply, documented by either ultrasound-guided170-171 or endoscopic166,176-178 techniques. Therefore, percutaneous coronary intervention (with stenting) is probably the procedure of choice. A segment of 10 to 20 cm of umbilical cord may then be clamped and cut separately. Serologic tests suggestive of an acute infection include identification of IgM-specific antibody, demonstration of an extremely high IgG antibody titer, and documentation of IgG seroconversion from negative to positive. Ulm and associates2 reported that the chance for hydrops fetalis was increased 13-fold in RhD-positive male fetuses compared with their female counterparts; the adjusted odds ratio for perinatal mortality was 3. These placental changes are seen in one of seven primiparous women at the time of first-trimester abortion,105,106 suggesting that disordered placentation precedes the clinical presentation of preeclampsia. Because of the complexity of various forms of fetal structural heart defects, as well as their common association with maternal or extracardiac fetal disease, a multidisciplinary team. Negative pressure is applied by means of the syringe, and the catheter is removed slowly. However, early care can create opportunities to identify risk factors and overcome obstacles to performing cervical sonography or beginning progesterone prophylaxis. Inflation is more uniform because low surface tensions make aeration of airways less dependent on airway size. However, many of these conditions are common in the general population, and most women with these conditions have uncomplicated pregnancies, making interpretation of a positive test difficult. Smoking Cessation Smoking cessation programs are more likely to be well received among pregnant than among nonpregnant women. The growth-restricted fetus is at higher risk for perinatal morbidity and mortality, the risk rising with the severity of the restriction. The chance of recurrence decreases as the likelihood of true preeclampsia increases and increases when the disease occurs in the late second or early third trimester. The mutation detection rate and carrier frequency among different ethnic or racial groups for some of these disorders may not be well established, requiring a discussion about the lack of a precise residual risk in the case where the nonJewish partner is negative on mutation analysis. Experience in hydropic fetuses indicated that the absorption of transfused red cells from the peritoneal cavity is compromised. Despite these advantages, several limitations of existing data must be considered when assessing such studies. This method fares poorly in the diagnosis of cleft palate, with the evaluation being greatly impaired by bony shadowing on the standard oblique face view. Tongsong T, Sittiwangkul R, Wanapirak C, et al: Prenatal diagnosis of isolated tricuspid valve atresia, J Ultrasound Med 23:945, 2004.

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A series of physiologic adaptive responses in each of these compartments can also be triggered by stress subsequent to malnutrition, infection, ischemia, vascular damage, and psychosocial factors. Rosen M: Paracervical block for labor analgesia: a brief historic review, Am J Obstet Gynecol 186:D127, 2002. In the case of monozygotic twins, the hydrops is probably related to abnormal vessels in the placenta, resulting in twin-to-twin transfusion syndrome. Right atrial pressure is also higher than left atrial pressure because of the greater volume of flow through the right atrium. Therefore, maternal alloimmunization to non-RhD antigens continues to contribute to the occurrence of stillbirth. Cardiotocography is an integral part of the evaluation for late pregnancy bleeding. Because thalassemia is also common in individuals of African heritage, carrier testing should be offered to all African Americans. The systemic venous return passes from right atrium to left ventricle to pulmonary artery, and the pulmonary venous return passes from left atrium to right ventricle to aorta. Susceptibility to teratogenic agents varies with the developmental stage at the time of exposure. This is contrary to most other methods, which prescribe initial volume acquisition in the midsagittal plane. Review of the literature investigating associations between low birth weight and insulin resistance shows that people who are light at birth generally have an adverse profile of later glucose and insulin metabolism, which is related to insulin resistance rather than altered insulin secretion. Lewi L, Gratacos E, Ortibus E, et al: Pregnancy and infant outcome of 80 consecutive cord coagulations in complicated monochorionic multiple pregnancies, Am J Obstet Gynecol 194:782, 2006. In the fetus with complete heart block, the atrial rate remains normal but atrial contractions do not conduct to the ventricles. Cruikshank and White217 reported that, of 32 compound presentations, the presenting extremity could be manually replaced in 16 cases, resulting in uneventful vaginal delivery in 15 of the patients. Predictive accuracy according to score composition, Am J Obstet Gynecol 162:918, 1990. Retrospective observational studies are more likely to be biased than prospective studies (although bias can still occur in prospective observational studies). Tricuspid atresia represents the most basic form of single ventricle and generally carries the best long-term prognosis among single-ventricle disorders. In addition, women with a breast abscess should be hospitalized for intravenous antibiotic therapy and surgical drainage. Bleeding during the second half of pregnancy complicates about 6% of all pregnancies. Whittemore R, Wells J, Castellsague X: A second-generation study of 427 probands with congenital heart defects and their 837 children, J Am Coll Cardiol 23:1459, 1994. Regardless of the counseling approach, understanding the concept of screening is difficult for many patients. B, Pulsed Doppler image of the same patient in which two separate heart rates are clearly visible within the Doppler gate. Cervical mucus should be avoided during sampling because it can also yield a ferning pattern on microscopy. Heart rate and stroke volume are significantly increased in gravidas with twins during the third trimester, leading to a significant increase in cardiac output and cardiac index compared with singleton pregnancies. Surgeon General has recommended that the safest course is to avoid ethanol entirely during pregnancy. Both pregnancy and aortic regurgitation contribute to hypervolemia and peripheral vasodilation. For several of these disorders, the gene responsible has been identified, and detection of the genetic abnormality in fetal or neonatal tissue specimens can therefore be accomplished. Because the methylation pattern is predictive of gene function, it is occasionally used to make the distinction between a large premutation and a small full mutation. Such complexities show the inadvisability of embryologic speculation based on pathologic appearance.

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Depending on the nature of the exposure and timing during gestation, adverse outcomes may encompass effects ranging from spontaneous abortion or stillbirth to major and minor structural defects, prenatal or postnatal growth deficiency, preterm delivery, and functional deficits or learning disabilities. The prognosis is particularly bleak in women with a history of repeated syncopal episodes, a hematocrit level greater than 60%, or a right ventricular systolic pressure greater than 120 mm Hg. Table 55-1 lists laboratory studies frequently used in the evaluation of an anemic patient. Second, the lowest portion of the atrial septum, just above the insertion point of the mitral valve, should always be visualized. The leaflets may remain coapted during systole, or they may separate, causing a variable degree of mitral regurgitation. In animal experiments, estrogen enhances the growth of strains of Escherichia coli that cause pyelonephritis and predispose to renal leukocyte migration, phagocytosis, and complement activity. In 1997, B-Lynch and colleagues118 described a "brace" suturing technique that results in closure of the uterine blood supply. This is similar to the study of movement activity in the ovine fetus with graded reductions in oxygenation29 and suggests the need for heightened surveillance in the extremely high risk pregnancy because metabolic deterioration may occur rapidly as acidemia worsens. For example, growth restriction associated with preeclampsia may antedate the appearance of hypertension or proteinuria by several weeks. Hill and coworkers143 examined the incidence of risk factors among women with acute antepartum pyelonephritis. Unlike aortic stenosis, however, critical pulmonary stenosis does not require valve replacement or open repair. Counseling should include information on basic inheritance patterns, the variable nature of disease expression, the risk of occurrence, and the diagnostic and therapeutic options available. These can effect local quality improvements, but also, more importantly, as happened in the 1930s, they can help create a public agenda for improving the care of women and infants. As techniques have improved, cytogenetic results can be obtained in almost 90% of cases. The dosage should be the minimal effective dosage needed to avoid excessive slowing of the fetal heart. The skin and underlying lymphatic fluid in the fetal neck can now be seen with ultrasound at as early as 10 to 12 weeks of gestation. The technique of sonographic measurement of cervical length does not differ from that described for singleton gestations (see Chapter 41). He concluded that detection of maternal bacteriuria would identify patients at risk for pyelonephritis and premature delivery and maintained that pyelonephritis in pregnancy could be prevented by detection and treatment of bacteriuria in early pregnancy. There have been significant changes in how the data are collected and analyzed, with corresponding changes in the rates reported. However, the presence of antibodies is not perfectly protective against either reinfection or vertical transmission of infection from mother to fetus. Nifedipine may be used in doses of 10 mg orally, with repeat doses every 30 minutes as needed. One disadvantage of the tocodynamometer is that it works best with the mother in the supine position. There are probably substantial differences among mammals in the permeability of the placental barrier to bicarbonate ions. Lipitz S, Reichman B, Uval J, et al: A prospective comparison of the outcome of triplet pregnancies managed expectantly or by multifetal reduction to twins, Am J Obstet Gynecol 170:874, 1994. Its deficiency disrupts lipid transport and lamellar body formation, resulting in severe surfactant deficiency. However, should nutritional status be surprisingly good, the poor capacity of the muscle to take up glucose could eventually contribute to development of the insulin resistance of type 2 diabetes. Numerous trials of various agents (low-dosage aspirin,334,335 antioxidant vitamins C and E,336 and fish oil337,338) have been conducted to test their effects on the rates of preeclampsia, fetal growth restriction, and preterm birth. Moreover, evolving technology allows the 3D visualization of color-flow jets in volume-rendered displays or as stand-alone "angiograms. Intrafetal coagulation techniques constitute a good alternative and may be the preferred method when access is difficult because of a short umbilical cord or placental location.

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Long-term complications include vesicoureteric reflux, recurrent infection, and hypertension. Prenatal stress increases not only prostaglandin levels but also that of maternal circulating inflammatory markers. Magnesium is more effective than phenytoin or benzodiazepine to treat eclamptic seizures. Smith R, Comstock C, Kirk J, et al: Ultrasonographic left cardiac axis deviation: a marker for fetal anomalies, Obstet Gynecol 85:187, 1995. The well-illustrated publication by Piper and Bachman,204 describing the use of the forceps designed by Piper and presenting in detail the method of breech delivery, should be standard reading for all physicians planning to assist in the vaginal delivery of a breech presentation. Three mechanisms have been postulated to explain the development of aplastic anemia: (1) insufficient stem cells resulting from an intrinsic defect or a reduction in number after exposure to a noxious agent, (2) the presence of a suppressor substance that inhibits maturation of the hematopoietic stem and progenitor cells, and (3) development of an autoimmune reaction that causes death of the stem cells. The risk for early birth rises with the number of fetuses, suggesting uterine overdistention and fetal signaling as potential pathways to early initiation of labor (Table 40-3). Larsen L, Peterson O, Norrild K, et al: Strain rate derived from color Doppler myocardial imaging for assessment of fetal cardiac function, Ultrasound Obstet Gynecol 27:210, 2006. Ultrasoundimage,coronalview,showing interocular distance (x) as well as binocular distance (calipers, +) decreasedproportionally. Because serum magnesium concentrations decrease with increased urinary output, it is extremely unlikely that serum magnesium concentrations are therapeutic at usual doses in the setting of puerperal diuresis. Glucose uptake by the fetus is critical, because there is the suggestion that little glucogenesis occurs in the normal fetus. Some physicians recommend continuing therapy for longer than 24 hours in selected patients, but it is difficult to determine the basis on which this selection can be made. The third stage of labor and the immediate puerperal recovery period are a crucial time for the parturient. Coinfection with hepatitis G does not adversely affect the prognosis of these other infections. Single nucleotide probe arrays can also detect uniparental disomy and consanguinity. Case reviews have documented the difficulty in recognizing the signs and symptoms of pulmonary embolism in pregnant and postpartum women because of the overlap with normal pregnancy symptoms. Accurate measurement of the umbilical artery Doppler is complicated by fetal breathing or fetal movement and is optimally done when the fetus is at rest. From the clinical perspective, this means that conclusions drawn from one type of study must be interpreted with caution until they are confirmed or refuted by other types of studies. Other Placental Abnormalities Umbilical cord abnormalities, such as single umbilical artery, varices and aneurysms, thrombosis of umbilical vessels, hematoma, abnormal insertion of the blood vessels, and excessive coiling, knots, and entanglement of the cords, in monoamniotic twin pregnancies can be associated with abnormal fetal growth, development, and behavior that can contribute to premature delivery. Another difficulty is the possible crosscontamination of samples when both placentas are on the same uterine wall. The tracing exhibits a normal rate (about 130 beats/min), normal variability (amplitude range about 15 beats/min), and absence of periodic changes. A report on 20 sets of monoamniotic twins found no fetal deaths after 32 weeks, suggesting that prophylactic early delivery was not needed. It affords an opportunity to compare obstetric dating with fetal biometric measures, and it permits, prior to fetal viability, identification of important structural abnormalities that may significantly alter neonatal prognosis and management. In Fraccaro M, Brambati B, Simoni G, editors: First trimester fetal diagnosis, Heidelberg, 1985, Springer-Verlag. This ratio yields a likelihood ratio of 50 but includes fetuses with more than one marker. An important feature in many cases is obstruction of the space between the ventricular septum and the anterior leaflet of the mitral valve. The trophoblasts invade the decidua and myometrium to anchor the placenta, and a subpopulation of cytotrophoblasts invades the uterine blood vessels at the implantation site, resulting in extensive remodeling of the vessels. If available iron stores are insufficient to meet the demands of pregnancy, irondeficient erythropoiesis results. Iannucci T, Besinger R, Fisher S, et al: Effect of dual tocolysis on the incidence of severe intraventricular hemorrhage among extremely low-birth-weight infants, Am J Obstet Gynecol 175:1043, 1996.

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Riebel T, Nasir R, Weber K: Choroid plexus cysts: a normal finding on ultrasound, Pediatr Radiol 22:410, 1992. Formal fetal echocardiography involves evaluation of the fetal heart and cardiovascular system using several modalities: 2D imaging, color flow imaging, spectral or continuous wave Doppler evaluation, quantitative assessment of ventricular function, and 3D imaging. Sagittal view demonstrates expanded, echogenic lungs (asterisk) and a flattened hemidiaphragm. Factor V Leiden mutation, protein C deficiency, and the presence of antiphospholipid antibodies were significant factors for perinatal stroke. Hamilton B, Martin J, Ventura S: Births: preliminary data for 2007, Hyattsville, Md, 2009, National Center for Health Statistics. The white blood cell count initially may be decreased in septic shock but subsequently becomes elevated. Frequently, these patterns of growth abnormality merge, particularly after long-standing fetal nutritional deprivation. Untreated vesicoureteral reflux can lead to recurrent renal infections, parenchymal scarring, and ultimate renal failure. If this type of regimen is followed closely and is expertly supervised, maternal mortality is low. The answer to the question of whether placental O2 transport is blood flow limited should be that it is flow dependent but not flow limited. Changes in the cervix preceding myometrial activation may be used to identify women in whom the parturitional process has begun. However, a simple calculation demonstrates that it must be similar to that of the fetal lamb. Continuous electronic fetal heart rate monitoring is used only if there is meconium-stained amniotic fluid and after the fetal scalp pH has been determined to rule out fetal acidosis. Nonetheless, the overall growth trajectory closely resembled that found in India among men and women who developed insulin resistance or diabetes in adulthood. Cesarean section for the routine obstetric indications or macrocephaly However, in cases of severe hydrocephaly, cephalocentesis can be performed to decompress the head and achieve vaginal delivery. There is little evidence that therapeutic efforts alter the underlying pathophysiology of preeclampsia. A sterile speculum examination should be performed to provide confirmatory evidence of membrane rupture and to inspect for cervicitis and for umbilical cord or fetal prolapse, to assess cervical dilation and effacement, and to obtain cultures, including endocervical N. If antiarrhythmic drugs must be used, whenever possible they should be those that have been used for several decades, allowing prediction of the fetal risk. The "team" consisted of nurses, available attending obstetricians, anesthesia, pediatricians, and obstetric residents. Although the specific endocrine and biomolecular mechanisms of cervical ripening (including the role of prostaglandins) are not fully understood, the result of this phenomenon is softening, thinning, and early dilation of the cervix. Under ultrasound guidance, a portion of the umbilical cord is grasped, and coagulation is begun at low power, approximately 20 W for approximately 15 seconds, with progressive increments until the appearance of turbulence and steam bubbles, indicating local heat production and, hence, tissue coagulation (usually between 27 and 45 W). When indicated, and only in the absence of any contraindication, treatment may begin with a digoxin load, using 0. Hyaline membrane disease and the need for neonatal exchange transfusions for the treatment of hyperbilirubinemia were common. In utero surgery has proved feasible in animal models, reversing deleterious effects of the condition.