The impact of teenage pregnancy and subsequent childbirth on parents, child and society reaches far and wide and has negative consequences to all involved. Too many teenagers become parents either they cannot envision another positive future direction to their lives, or because they lack concrete educational or employment goals and opportunities that would convince them to delay parenthood. No single or simple approach has successfully reduced the teen pregnancy rate; much more study and efforts are required. Other industrialized countries have much lower teen pregnancy and abortion rates than USA. There is few, if any other social problem that has a greater impact on us as a nation. It will take the involvement and efforts on the part of families, society and government to negotiate a change in the right direction. As physicians, we are in a unique position to take a leadership role in the decision making process, at all levels.Read More

The ideal time to address medication exposure and consider alternative treatment is prior to conception. Many pharmacologic agents have teratogenic potential as well as the potential to induce fetal harm later in gestation with effects that may be lethal or cause long-term handicaps. Many women will present already pregnant, thus providing a narrow window of time in which to evaluate the fetal risks and weigh them against the maternal benefits of continuing the medication. This chapter reviews the risks of commonly used medications during pregnancy, highlights medications with particularly high risk, and reviews the evaluation of fetuses who are exposed.Read More

Multiple pregnancies are fascinating and challenging situations. It requires early detection and identification of number of pregnancies, early detection of the complications and their proper management. Multiple births are more common nowadays, owing to over-stimulation of ovulation that occurs when ovulation stimulation is done in cases of women with infertility because of ovulatory failure. Moreover, although the dizygotic twinning rate varies widely under different circumstances, the monozygotic twinning rate is "remarkably constant", usually between 3.5 to 4 per 1,000. Premature babies need prolonged and expensive care. Patient education and availability of trained healthcare providers in the area can reduce the mortality and morbidity. There are support groups for the parents of multiple births available at almost all the area hospitals, which deal with high-risk deliveries.Read More

The goal of antepartum fetal surveillance is to prevent fetal death. Several antepartum fetal surveillance techniques or tests are in use. These include fetal movement assessment, non-stress test (NST), contraction stress test (CST), biophysical profile (BPP), and umbilical artery Doppler velocimetry. Antepartum fetal surveillance techniques are now routinely used to assess the risk of fetal death in pregnancies complicated by preexisting maternal conditions, as well as those in which complications have developed. Identification of suspected fetal compromise provides the opportunity to intervene before progressive metabolic acidosis can lead to fetal death. Identification of suspected fetal compromise provides the opportunity to intervene before progressive metabolic acidosis can lead to fetal death. In both animals and humans, fetal heart rate pattern, level of activity, and degree of muscular tone are sensitive to hypoxemia and academia. Recent, normal antepartum fetal test results should not preclude the use of intrapartum fetal monitoring.Read More

Shoulder dystocia is most often defined as a delivery that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders. It is most often an unpredictable and unpreventable obstetric emergency. Failure of the shoulders to deliver spontaneously places both the pregnant woman and fetus at risk for injury. Shoulder dystocia is caused by the impaction of the anterior fetal shoulder behind the maternal pubis symphysis. It also can occur from impaction of the posterior fetal shoulder on the sacral promontory. Several maneuvers to release impacted shoulders have been developed, and they are described below. The purpose of this chapter is to provide clinicians with information regarding management of deliveries at risk for or complicated by shoulder dystocia.Read More

Preterm labor is the leading cause of neonatal mortality in the United States and accounts for about 11.5% of all live births. It is responsible for three quarters of neonatal mortality and one half of long-term neurologic impairments in children. Despite the numerous management methods proposed, the incidence of preterm birth has changed little over the past 40 years. Uncertainty persists about the best strategies for managing preterm labor. The purpose of this document is to discuss the various methods proposed to manage preterm labor and the evidence for their roles in clinical practice. The information is designed to aid practitioners in making decisions about appropriate obstetrical care. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.Read More

The risk of symptomatic venous thrombosis during pregnancy is between 0.5 and 3.0 per 1,000 women. Pulmonary embolism (PE) is a leading cause of maternal deaths in the United States. During pregnancy women have a five-fold increased risk of venous thromboembolism (VTE), compared to non-pregnant women. The prevalence and severity of this condition warrants consideration of anticoagulant therapy in pregnancy for women at risk for VTE. The purpose of this document is to review the current literature on the prevention and management of thromboembolism in obstetric patients. It offers evidence-based recommendations to address the most clinically relevant issues in the management of these patients.Read More

Gestational Trophoblastic disease comprises a spectrum of interrelated conditions originating from the placenta. Approximately 20% of patients will develop malignant sequelae requiring administration of chemotherapy after evacuation of hydatidiform moles. Most patients with post-molar gestational trophoblastic disease will have non-metastatic molar proliferation or invasive moles, but gestational choriocarcinomas and metastatic disease can develop in this setting. The purpose of this document is to address current evidence regarding the diagnosis, staging, and management of gestational trophoblastic disease. Other terms often used to refer to these conditions include gestational trophoblastic neoplasia and gestational trophoblastic tumor. At present, with sensitive quantitative assays for beta-hCG and current approaches to chemotherapy, most women with malignant gestational trophoblastic disease can be cured and their reproductive function preserved. Histologically distinct disease entities encompassed by this general terminology include complete and partial hydatidiform moles, invasive moles, gestational choriocarcinomas, and placental site trophoblastic tumors.Read More

Bleeding in the second half of pregnancy and in labor due to placental abnormalities include placenta previa, abruptio placentae, placenta accreta and vasa previa. Third-trimester bleeding complicates about 3.8% of all pregnancies. The purpose of this document is to present evidence-based approach to the management of placental abnormalities and major obstetric hemorrhage. Attention to improving the hospital systems is necessary for the care of women at risk for major obstetric hemorrhage. It is important in the effort to decrease maternal mortality from hemorrhage. Multidisciplinary team implementation systemic changes are also discussed. It is the responsibility of the physician to decide without delay whether the cause is benign or potentially life-threatening to the mother, fetus, or both. The potential harm from either procrastination or unnecessary intervention may be extreme.Read More

An abnormally adherent placenta, although an uncommon condition, assumes considerable significance clinically because of morbidity and at times mortality from severe hemorrhage, uterine perforation, and infection. The incidence of placenta accreta, increta and percreta has increased because of the increased cesarean delivery rate. This document reflects emerging clinical and scientific advances on this subject. If the diagnosis or a strong suspicion is formed before delivery, the patient should be counseled about the likelihood of hysterectomy and blood transfusion.Read More