Antenatal Disorders for the MRCOG and Beyond

Description

During pregnancy, most women remain well and require little formal medical input, while a much smaller group develop complications with significant morbidity and mortality for their baby and, occasionally, for themselves. Providers of antenatal care must be able to distinguish between these two groups of women and arrange with them an appropriate and personalised plan of care. This book covers all aspects of identifying and caring for women who develop disorders during their pregnancies. This second edition has been comprehensively updated to reflect changes in clinical practice and new research since publication of the previous edition. The contents take into account that care of such women is provided by multidisciplinary teams of physicians, obstetricians, general practitioners and midwives. The book covers the curriculum for the antenatal disorders section of the Part 2 MRCOG, so is a key examination preparation test Approximately 2000 candidates sit the Part 2 MRCOG each year - this is the final stage of becoming a member of the RCOG In addition to being of interest to Part 2 candidates, the book provides a useful update for all healthcare professionals involved in caring for women who develop disorders during pregnancy: physicians, obstetricians, general practitioners and midwives Cover Half-title Title page Copyright information Table of contents LIst of contributors Preface 1 Antenatal care and risk assessment Introduction What is the purpose of antenatal care? Antenatal risk assessment Who should see women at antenatal visits, and where? Antenatal interventions which are not routinely recommended Who should provide antenatal care? Basic principles of antenatal care Organization and content of the antenatal visit Frequency of antenatal visits First contact with a healthcare professional The booking visit Follow-up visits General lifestyle advice during pregnancy Pre-pregnancy counselling and care Key summary points References 2 Antepartum haemorrhage Introduction General management principles Placental abruption Pathophysiology Aetiology Clinical presentation Management Fluid management of hypovolaemia Coagulopathy/disseminated intravascular coagulation (DIC) Placenta praevia Aetiology and risk factors Diagnosis Clinical presentation Management Delivery Vasa praevia Clinical presentation Risk factors Diagnosis Management and prognosis Marginal bleed Uterine rupture Risk factors Clinical presentation Management Unexplained bleeding Management Key summary points References Further reading 3 Multiple pregnancy Prevalence and epidemiology Classification of multiple pregnancy Complications Twin-to-twin transfusion syndrome Discordant growth Monofetal death Selective fetal reduction Higher-order multiple pregnancies Antenatal care Mode and timing of delivery Intrapartum care Key summary points References 4 Hypertensive disorders in pregnancy Introduction Definitions (NICE 2010) Degrees of hypertension Significant proteinuria Measurement of blood pressure Measurement of proteinuria (NICE 2010) Why is hypertensive disease in pregnancy important? Maternal mortality and morbidity Perinatal mortality and morbidity Pre-conception care Antihypertensive medication Antihypertensive medication and breastfeeding Outpatient management of hypertensive disorders in pregnancy Management of chronic hypertension Management of gestational hypertension Antepartum care Timing of delivery Care in labour Postnatal care Long-term significance of hypertension in pregnancy Pre-eclampsia Aetiology and pathogenesis Prediction of pre-eclampsia Reducing the risk of pre-eclampsia Management of pre-eclampsia Maternal monitoring and management of hypertension (NICE 2010) Fetal monitoring Timing of delivery Management of delivery Seizure prophylaxis Postpartum care Eclampsia Management HELLP syndrome Laboratory diagnosis Differential diagnosis Complications of HELLP Management Postpartum hypertension Aetiology of hypertension in the postpartum Why detect and treat postpartum hypertension? Antihypertensive treatment Key summary points References 5 Prematurity Introduction Pathogenesis Antenatal management Risk assessment Investigations Cervical length scanning Infection screening Fetal fibronectin (FFN) Other technologies Preventive treatment Cerclage Progesterone Cervical pessary Bed rest Multiple pregnancy and preterm birth prophylaxis Symptomatic women Assessment Fetal fibronectin Actim Partus Cervical length scanning Treatment Tocolysis Steroids In-utero transfer Magnesium sulphate for fetal neuroprotection Management of women with PPROM Perinatal issues Parental counselling Mode of delivery Key summary points References Further reading RCOG Green-top Guidelines RCOG Scientific Impact Papers NICE guidance 6 Previous caesarean section Introduction Antenatal care for a woman who has had a previous caesarean delivery Morbidly adherent placenta Options for birth after previous caesarean section Vaginal birth after caesarean section (VBAC) Contraindications to VBAC Risks of VBAC versus elective LSCS Planned repeat caesarean section Special circumstances Preterm delivery Multiple pregnancy Induction and augmentation of labour External cephalic version (ECV) after previous LSCS When there is disagreement between the clinician and woman regarding mode of delivery after previous caesarean section Delivery after intrauterine fetal death in the second trimester, or termination of pregnancy in the second trimester, in a woman with a previous LSCS Reviewing local practice Key summary points References Further reading 7 Common medical disorders in pregnancy 7.1 Anaemia Background and clinical relevance Treatment Oral iron supplements Parenteral iron Serum ferritin Blood transfusion Megaloblastic anaemias Key summary points References 7.2 Endocrine disorders Diabetes Background Effect of pregnancy on diabetes Effect of diabetes on pregnancy Management of diabetic pregnancy Pre-pregnancy care Antenatal management Intrapartum management Gestational diabetes Screening at first antenatal visit Screening later in pregnancy Diagnosis of gestational diabetes Importance of gestational diabetes Key summary points Thyroid disease Physiology Hyperthyroidism Effect of pregnancy on hyperthyroidism Effect of hyperthyroidism on pregnancy Management of hyperthyroidism Hypothyroidism Effect of pregnancy on hypothyroidism Effect of hypothyroidism on pregnancy Management of hypothyroidism Key summary points Prolactinoma Effect of pregnancy on prolactinoma Effect of prolactinoma on pregnancy Management of prolactinoma Key summary points References Further reading 7.3 Gastrointestinal and hepatic disease Physiological changes during pregnancy Reflux oesophagitis Peptic ulcer disease Inflammatory bowel disease (Crohn’s disease and ulcerative colitis) Intrahepatic cholestasis of pregnancy Acute fatty liver of pregnancy Key summary points References 7.4 Haematological disorders Introduction Haemoglobinopathies Sickle cell disease Beta-thalassaemia Antenatal screening Management of sickle cell disease in pregnancy Pre-conception care Antenatal care Intrapartum care Postpartum care Sickle cell crisis Thrombocytopenia Immune thrombocytopenic purpura (ITP) Thrombotic thrombocytopenic purpura (TTP) Neonatal alloimmune thrombocytopenia (NAIT) Thrombophilia Key summary points References 7.5 Malignancy Introduction Cervical cancer Previous treatment Breast cancer Ovarian cancer Melanoma Acute leukaemia Pregnancy following previous chemotherapy Gestational trophoblastic disease Key summary points References 7.6 Obesity The scale of the problem Pre-pregnancy counselling Antenatal care Intrapartum care Postnatal care The future Key summary points References 7.7 Kidney disease Physiological changes in renal function with pregnancy Effect of chronic kidney disease on pregnancy Effect of pregnancy on chronic kidney disease Women on dialysis and with transplant Management Pre-pregnancy Antepartum Postpartum Key summary points References 7.8 Skin disorders Introduction Physiological changes in pregnancy Atopic eruption of pregnancy (AEP) Polymorphic eruption of pregnancy (PEP) Pemphigoid gestationis (PG) Key summary points References 8 Cardiac disease in pregnancy Introduction Principles of management Specific heart diseases Key summary points References 9 Alloimmunization in pregnancy Introduction Prediction Prevention Silent sensitization Consent and refusal Fetal genotyping Treatment Red blood cell alloimmunization Investigation Ultrasound monitoring Cordocentesis and intrauterine transfusion Planning for delivery Platelet alloimmunization Key summary points References Further reading 10 Maternal mental health disorders Introduction Psychiatric disorders in pregnancy Depression in pregnancy Incidence Onset Risk factors Clinical features Treatment Psychosis in pregnancy Clinical features Treatment Postnatal psychiatric disorders Postpartum blues Incidence Onset Clinical features Prognosis Treatment Postnatal depression Incidence Onset Risk factors Clinical features Treatment Postpartum (puerperal) psychosis Incidence Onset Risk factors Clinical features Treatment Conclusion Key summary points References Further reading 11 Drug and alcohol misuse in pregnancy Introduction What is substance misuse? Accepted definitions of substance misuse How common is substance misuse in pregnancy? Substances of misuse Effects of substances of misuse on pregnancy Alcohol Associated problems Cannabis Associated problems Heroin Associated problems Methadone Buprenorphine Codeine Benzodiazepines Associated problems Cocaine/crack cocaine, amphetamines and mephedrone Associated problems Ketamine Ecstasy Solvents ‘Legal’ highs General principles of management Philosophy of care Attitude Holistic care Comorbid medical problems Social problems Engagement Communication Model of care Pre-conception care Antenatal care Identification of patients Management of substance misuse Assessment Antenatal screening and investigations Drug screening Harm reduction advice Facilitating change Safeguarding Obstetric care Venous damage and thromboembolic disease Management Blood-borne viruses and sepsis Management Placental problems and preterm delivery Management Mental health problems Management Complex social factors Chaos Management Family planning Management Planning intrapartum and postnatal care Intrapartum care Postnatal care Neonatal and infant problems Maternal health Key summary points References Further reading 12 Screening for fetal anomalies Introduction Screening for structural anomalies Diagnostic value of the routine scan during pregnancy Screening for Down’s syndrome The provision of Down’s syndrome screening during antenatal care Key summary points References Index