The purpose of this document is to understand immunization during pregnancy. Immunization saves lives and prevents disease. There are many national resources available to help you fine-tune your vaccination practices. If you have not yet incorporated vaccination into your practices, now would be a great time to start. Immunizations are considered one of the major medical achievements of the 20th century. However, inadequate vaccination remains an important public health problem. This document reflects emerging clinical and scientific advances and current information on the safety of vaccines given during pregnancy. The benefits of immunization to the pregnant woman and her neonate usually outweigh the theoretic risk of adverse effects. The theoretic risks of the vaccination of pregnant women with killed virus vaccines have not been identified. Preconceptional immunization of women to prevent disease in the offspring, when practical, is preferred to vaccination of pregnant women with certain vaccines.Read More

There have always been differing approaches, even controversies with regard to the role of food intake during pregnancy. Traditional beliefs from a wide variety of cultures present divergent approaches. At present, nutritional care during pregnancy is based on the following general premises: women are encouraged to eat a variety of foods "to appetite", to achieve adequate weight gain as determined by their pre-pregnancy body mass index, and to breast-feed their infants after birth. Nutritional problems can be found in women of every socioeconomic status and range from an inability to acquire and prepare food to eating disorders. If the women cannot afford a sufficient supply of food, she should be referred to food pantries and soup kitchens in her area. All low-income women should receive information about the Special Supplemental Food Program for Women, Infants and Children (WIC) and food stamp program. All WIC programs have nutritionists who are required to counsel patients on these matters. Poor weight gain also may reflect substance abuse, domestic violence, or depression.Read More

Hypertensive disease occurs in approximately 12-22% of pregnancies, and it is directly responsible for 17.6% of maternal deaths in the United States. However, there is confusion about the terminology and classification of these disorders. We hope to provide guidelines for the diagnosis and management of hypertensive disorders unique to pregnancy (preeclampsia and eclampsia), as well as the various associated complications. The purpose this document is to provide guidelines for the diagnosis and management of hypertensive disorders unique to pregnancy -- preeclampsia and eclampsia. Various associated complications are also discussed. Expectant management should be considered for women remote from term who have mild preeclampsia. For the prevention and treatment of seizures in women with severe preeclampsia or eclampsia magnesium sulfate is the drug of choice. Practitioners should be aware that various laboratory tests may be useful in the management of women with preeclampsia. The differential diagnosis is also discussed. It is important that clinician make the accurate diagnosis when possible because the management and complications from these syndromes may be different.Read More

Preeclampsia is a major cause of maternal and perinatal mortality and morbidity worldwide. Its etiology is elusive and theories abound regarding its pathogenesis. Preeclampsia can cause changes in virtually all organ systems. Several organ systems are consistently and characteristically involved. The pathologic findings indicate that the pathogenetic factor of primary importance is not blood pressure elevation, but rather poor tissue perfusion. The histologic data support the clinical impression that the poor perfusion is secondary to profound vasospasm, which also increases total peripheral resistance and blood pressure. Preeclampsia is not merely an alternate form of malignant hypertension. Recently homocysteine, a metabolite of the essential amino acid methionine has been postulated to produce oxidative stress and endothelial cell dysfunction, alterations associated with preeclampsia. The studies examining the relationship between serum homocysteine concentrations and preeclampsia are also discussed.Read More

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