Disseminated intravascular coagulation (DIC) is a life-threatening situation that can arise from a variety of obstetrical and non-obstetrical causes. DIC is a syndrome that can be initiated by a myriad of medical, surgical, and obstetric disorders. Also known as consumptive coagulopathy, defibrination syndrome and generalized intravascular coagulation, it is not a disease per se, but rather a clinicopathologic syndrome that can be initiated by a myriad of underlying diseases, conditions, or disorders. The purpose of this review is to discuss the pathophysiology of DIC syndromes, focusing on the triad represented by exaggerated activation of coagulation, consumption of coagulopathy, and impaired synthesis coagulation as well as anticoagulation proteins. The diagnosis of DIC with special attention to the available scores adding prognostic value to the laboratory parameters in patients with this dangerous condition or are at risk for its development are also reviewed. The principles of the treatment of DIC is discussed extensively from the literature. In recent years, novel diagnostic scores and treatment modalities along with bedside point-of-care tests were developed and may assist the clinician in the diagnosis and management of DIC. Team work and prompt treatment are essential for the successful management of patients with DIC. The management of DIC in obstetrics remains a major clinical challenge. The inciting disease-specific syndrome may be complex and require directed management strategies for correction of the underlying disorders. Equally important is treatment of frequently concomitant massive blood loss that worsens the coagulopathy. With limited clinically proven management strategies available, the need for future studies is obvious. We look forward to these studies designated to address our numerous evidence-based deficits, especially regarding management of obstetric DIC syndromes.Read More

This review is intended to provide practicing clinicians with an understanding of existing literature and recommendations for managing women who use marijuana during pregnancy because this will be an increasingly encountered clinical scenario. Marijuana is the most common illicit drug used in pregnancy, with a prevalence of use ranging from 3% to 30% in various populations. Marijuana freely crosses the placenta and is found in breast milk. It may have adverse effects on both perinatal outcomes and fetal neurodevelopment. Specifically, marijuana may be associated with fetal growth restriction, stillbirth, and preterm birth. There is an emerging body of evidence indicating that marijuana may cause problems with neurological development, resulting in hyperactivity, poor cognitive function, and changes in dopaminergic receptors. In addition, contemporary marijuana products have higher quantities of Delta-9-tetrahydrocannabinol (THC) than in the 1980s when much of the marijuana research was completed. The effects on the pregnancy and fetus may therefore be different than those previously seen. Further research is needed to provide evidence-based counseling of women regarding the anticipated outcomes of marijuana use in pregnancy. In the meantime, women should be advised not to use marijuana in pregnancy or while lactating. We recommend screen all women verbally for marijuana use at intake to obstetrical care and consider rescreening later in pregnancy. The review suggests a need for healthcare provider training on potential consequences of perinatal marijuana use and communication skills for counseling patients about perinatal marijuana. An increasing number of states are passing or considering medical marijuana laws. The goal of this document is to address the public health system's responsibility to educate physicians and public about the impact of marijuana on pregnancy and to establish guidelines that discourage the use of medical marijuana by pregnant women or women considering pregnancy.Read More

Non-invasive prenatal testing that uses cell-free fetal DNA (cfDNA) from the plasma of pregnant women offers tremendous potential as a screening tool for fetal aneuploidy. Recently, a number of groups have validated a technology known as massively parallel genomic sequencing, which uses a highly sensitive assay to quantify millions of DNA fragments in biological samples in a span of days and has been reported to accurately detect trisomy 13, trisomy 18 and trisomy 21 as early as the 10th week of pregnancy with results available approximately 1 week after maternal sampling. cfDNA has a very high detection rate for trisomy 21: 99% or 100%. It does not replace the precision obtained with diagnostic tests, such as chorionic villus sampling (CVS) or amniocentesis, and currently does not offer other genetic information. Given that the fetus is the source of perhaps 5% of cfDNA in maternal plasma, blood from a mother carrying a trisomy 21 pregnancy should have 2.5% more chromosome 21 sequences than if her fetus were not trisomic. cfDNA analysis will remain a screen, not a test requiring no additional assays before a management decision. Expert patient counseling may be important before and after testing. Metabolomic analysis could lead to the development of additional biochemical markers to improve Down syndrome screening. Metabolomics provide insights into the cellular dysfunction in Down syndrome. Clinical management guidelines and education are essential. As with all new screening tests and technologies, the expanded panel should be appropriately studied before it replaces current standard of care and changes clinical practice.Read More

The purpose of this document is to review the etiology, evaluation, and management of postpartum hemorrhage. Although many risk factors have been associated with postpartum hemorrhage, it often occurs without warning. Attention to improving the hospital systems necessary for the care of women at risk for major obstetric hemorrhage is important in the effort to decrease maternal mortality from hemorrhage. The creation of a patient safety team that works to improve the hospital systems for caring for women at risk for major obstetric hemorrhage can help to identify and manage these situations and save lives. Development of clinical pathways, guidelines and protocols designed to provide early diagnosis of patients at risk for major obstetric hemorrhage and for streamlined care in emergency situations are essential. A multidisciplinary patient safety team that includes individuals from the Division of Obstetric Anesthesiology, Maternal Fetal Medicine, Neonatology, and the Blood Bank as well as Departments of Nursing, Communication, and Administration and quarterly mock drills of rapid response team, helps to respond to these situations effectively.Read More

Without a doubt, nausea and vomiting are common side effects of pregnancy. Hyperemesis gravidarum is a rare and severe complication of pregnancy that requires appropriate diagnosis and management to improve the patient’s quality of life and provide best possible maternal and neonatal outcomes. Physicians must appreciate the magnitude of the condition given its widespread implications – economic costs, decreased quality of life, maternal psychological effects, and risks to mother and fetus. Common maternal complications include dehydration, weight loss, and nutrient deficiencies. Current strategies include dietary modification, antiemetic therapy, and in certain situations, alimentary support. Use caution when prescribing phenothiazines because dystonia and extrapyramidal symptoms can occur with prolonged use and high dose. Future strategies should include more randomized controlled trials therapies that are safe for both mother and fetus, and effective treatment to prevent hospitalization and offer alternatives for nutritional support.Read More

Despite improvements in antenatal and intrapartum care, stillbirth, defined as in utero fetal death at 20 weeks of gestation or greater, remains and important, largely unstudied, and poignant problem in obstetrics. This review discusses known and suspected causes of stillbirth including genetic abnormalities, infection, fetal-maternal hemorrhage, and a variety of medical conditions in the mother. The proportion of stillbirths that have a diagnostic explanation is higher in centers that conduct a defined and systemic evaluation. The most important test in the evaluation of a stillbirth is fetal autopsy; examination of the placenta, cord and membranes; and karyotype evaluation. Patient support should include emotional support and clear communication of test results. Referral to a bereavement counselor, religious leader, peer support group, or mental health professional may be advisable for management of grief and depression.Read More

The aim of this review is to highlight exercise guidelines in pregnancy in concise format for obstetricians and gynecologists and other healthcare providers who provide prenatal and postpartum care. These recommendations provide evidence that increasing weekly physical-activity expenditure while incorporating vigorous exercise provides optimal health outcomes for pregnant women and their fetuses, and also suggest light strength training during the second and third trimesters does not negatively affect newborn body size and overall health. Women of childbearing age are at increased risk of gestational diabetes mellitus (GDM), which has been linked strongly to obesity. Weight gain during pregnancy can be excessive, and some women tend to retain that weight after delivery. Gaining excessive weight during pregnancy can result in obesity-associated comorbidities, which are a major health concern in the United States.Read More

Recurrent pregnancy loss (RPL) is a frustrating problem for both the patients and physicians. Pregnancy is a complicated process involving many intricate interactions between the fetus and the maternal environment. Pregnancy loss can result from any number of genetic, anatomic, endocrine, immune, or thrombotic disorders, as well as from unknown causes. The purpose of this document is to outline the causes of recurrent pregnancy loss and their potential therapies, where applicable. Traditionally RPL refers to the loss of three or more consecutive pregnancies; however, many clinicians will begin the evaluation of RPL after two losses, because the risk of a third loss after two miscarriages is approximately 30%, whereas the risk after three losses is about 33%. This approach may be especially useful in older women. It is important to remember that couples who are being evaluated for RPL have high levels of depression and stress. Some studies have indicated that psychological support may decrease the rates of unexplained miscarriage. Finally, patients should be reassured that even without treatment, successful pregnancy occurs in the majority of cases. This review can serve as a useful resource when counseling patients regarding treatment options.Read More

Maternal nutritional status not only influences fetal development and overall health but also significantly affects long-term risk for chronic childhood and adult diseases. Many pregnant and lactating women may not achieve optimum levels of important nutrients, as evidenced by the proportion of women throughout the US population and in the world, whose nutritional levels do not meet documented standards for many vitamins, minerals, and other essential nutrients. Women's Health and Education Center (WHEC) places emphasis on specific nutrients essential for optimal fetal development, notably folic acid, calcium, vitamin D, and omega-3 fatty acids; these are often consumed at levels below the recommended requirements. Maternal/infant morbidity and mortality are age-old and worldwide problems. There are many factors that influence the ultimate outcome of pregnancy, including the absence or presence of access to prenatal care, maternal stress (physical and psychological), comorbid diseases, and maternal nutrition -- both before and during pregnancy. Good nutrition is much more than just the food we eat.Read More

The purpose of this document is to: 1) review nomenclature for fetal heart rate assessment, 2) review the data on the efficacy of electronic fetal monitoring (EFM), and 3) delineate the strengths and shortcomings of EFM. It also compares international three-tier systems for fetal heart rate tracing, including the National Institute of Child Health and Human Development (NICHD), Society of Obstetricians and Gynecologists of Canada (SOGC) and the Royal College of Obstetricians and Gynecologists (RCOG, United Kingdom). The collaboration of practitioners in defining the interpretation and implementing is critical for improved care for women and children. Realizing that this information deserves wide dissemination, Women's Health and Education Center (WHEC) encourages its translations and adaptations.Read More